NCLEX Fundamentals

A client receiving treatment for hypertension is scheduled to receive hydrochlorothiazide 25 mg orally. Based on the label on the bottle, how many tablets should the nurse administer? Each tablet contains hydrochlorothiazide 50 mg. Ans:______ tab

0.5 ((25 mg ÷ 1) × (1 tab ÷ 50 mg) 25 ÷ 50 = 0.5 tab)

An elderly, bed-bound client receiving G-tube feedings at home is transported to the emergency department after onset of behavioral changes and hallucinations. Which nursing action is priority while diagnostic testing is underway? 1. Initiate seizure precautions 2. Monitor for signs of increased intracranial pressure 3. Orient to time, place, and person 4. Obtain vital signs q 15 minutes

1. Initiate seizure precautions (1. Correct: Feeding tube clients tend to get dehydrated, especially clients on bed rest, because bed rest induces diuresis. If the client is already having neurological signs, a grand-mal seizure may be next. Take seizure precautions while awaiting the serum sodium results. 2. Incorrect: When hypernatremia is present, the brain cells shrink because when the body is dehydrated, water is drawn from the cells into the vascular space. 3. Incorrect: Until serum sodium is corrected, the client will be unable to process information regarding time, place, and person. The brain does not like it when the sodium is abnormal. 4. Incorrect: While you're taking vital signs, your client is having a seizure. Don't delay care.

How should the nurse assist a post-operative client in transferring from the bed to a chair? 1. Have the client look down and watch their feet as they move. 2. Tell the client to bend at the waist to lower the center of gravity. 3. Place a walker away from the bed so the client can lean forward while standing. 4. Ensure the client's feet are as wide apart as the hips.

4. Ensure the client's feet are as wide apart as the hips. (4. Correct: This maintains the client's horizontal center of gravity. 1. Incorrect: Looking down shifts the client's center of gravity and moves the client out of alignment. 2. Incorrect: Bending at the waist will shift the client's center of gravity. This will not assist the client in tranferring. 3. Incorrect: Placing a walker away from the bed will shift the client's center of gravity. This could cause a fall.)

Which action by a nurse would require the charge nurse to intervene? 1. Walking in the hallway outside the operating room without a hair covering. 2. Putting on a surgical mask, gown and cap shoe cover before entering the operating room (OR). 3. Wearing a surgical mask into the holding area. 4. Wearing scrubs from home into the nursing station.

1. Walking in the hallway outside the operating room without a hair covering. (1. Correct: The hallway outside the OR is restricted to personnel with surgical attire and coverings. This area requires boot covers and hair covering. 2. Incorrect: Putting on a surgical mask, gown, cap and shoe covers are all required prior to entering the OR. You are walking into a sterile area that requires these coverings. 3. Incorrect: Surgical mask may be worn in the holding area, but is not required. This area is a clean area, but not sterile. 4. Incorrect: Wearing scrubs into a nursing station is appropriate. This area is not considered part of the surgical suite.)

The nurse is discharging the client after removing sutures from an abdominal wound. Which instructions should the nurse give the client at the time of discharge to reduce the risk of complications? 1. inspect the wound daily for any changes 2. Resume normal activities when you go home. 3. Keep the incision covered at all times. 4. Follow up with primary healthcare provider when scheduled.

1. inspect the wound daily for any changes (1. Correct: The wound should be inspected daily for any signs of infection once the client goes home. Healing has only just begun by discharge. Signs of wound infection include: Increased pain, swelling, redness, or warmth around the affected area; Red streaks extending from the affected area; Drainage of pus from the area; Fever. 2. Incorrect: The client may be restricted in some activities, such as lifting, that would place undue strain on the suture line. 3. Incorrect: It is likely that the incision can be uncovered, but the primary healthcare provider prescription would apply here. Look for words like "all" which generally make the option wrong. Things are not that definite. 4. Incorrect: This is true; however, the signs and symptoms of infection should be given to the client. If signs/symptoms develop, the primary healthcare provider should be notified prior to the next appointment.)

An occupational health nurse is planning to teach a group of manufacturing workers how to prevent back injuries. What teaching points should the nurse plan to include? Select all that apply 1. Wear comfortable, low-heeled shoes. 2. When sitting, keep knees slightly lower than the hips. 3. Avoid movements that require spinal flexion with straight legs. 4. Squarely face the direction of anticipated movement. 5. Pivot to turn while holding an object.

1. Wear comfortable, low-heeled shoes. 3. Avoid movements that require spinal flexion with straight legs. 4. Squarely face the direction of anticipated movement. 5. Pivot to turn while holding an object.

The nurse, performing an initial physical assessment on a client determines that the client has difficulty hearing questions. The nurse also notices an empty eyeglass case. Based on this information, which action should first be taken by the nurse? 1. Determine which ear the client hears best from or if there is a hearing deficit is bilateral. Then ask about the empty eyeglass case. 2. Ask client about use of any assistive devices and document the client's response. 3. Look through client's belongings to determine if there is a pair of glasses and a hearing aid. 4. Notify the primary healthcare provider of client's difficulty hearing and the empty eyeglass case.

1. Determine which ear the client hears best from or if there is a hearing deficit is bilateral. Then ask about the empty eyeglass case. (1. Correct: Determine out of which ear the client hears best or if there is a hearing deficit is bilateral. Ask if the client uses glasses and how often the glasses are used at home. Assessment is a first action many times. 2. Incorrect: Documenting the client's response is not going to intervene. 3. Incorrect: Inappropriate to look through client's belonging without asking. This is an invasion of privacy unless the client gives permission to do so. This should not be the first action either. Assessment should be first. 4. Incorrect: This is not first action to be taken by the nurse. Notifying the physician should not be the first action. The nurse should take steps to help the client directly.)

Prior to removal of cataracts, the client is to receive eye drops in both eyes. The nurse knows what action takes priority? 1. Remove any exudate around eyes with warm water. 2. Instill exact number of drops into lower conjunctival sac. 3. Instruct client to look upward when drops are instilled. 4. Avoid dropping the medication directly on the cornea.

4. Avoid dropping the medication directly on the cornea. (4. Correct: The most important safety consideration when instilling eye drops is to avoid dropping the medication directly onto the cornea. The extreme sensitivity of the cornea before, and after, eye surgery could cause serious eye problems if meds were dropped onto the cornea. 1. Incorrect: It is important to clean away any exudate prior to instilling eye drops to maintain aseptic technique and decrease chance of infection. Though this is an important action, there is another task which takes priority. 2. Incorrect: Instilling the exact number of drops is appropriate when implementing written prescriptions from the primary healthcare provider. This is an important nursing action but not the priority. 3. Incorrect: Instructing the client to look upward helps prevent drops from running out of the eye but there is another issue more important.)

A nurse is performing eye care for an unconscious client. Which interventions should the nurse include? Select all that apply. 1. Clean eyes with saline and cotton balls, wiping from outer to inner canthus. 2. Use a new cotton ball for each cleansing wipe. 3. Instill artificial tears into the lower eye lids as prescribed. 4. Protect the eyes with a protective shield. 5. Monitor eyes for redness, and exudate.

2. Use a new cotton ball for each cleansing wipe. 3. Instill artificial tears into the lower eye lids as prescribed. 4. Protect the eyes with a protective shield. 5. Monitor eyes for redness, and exudate. (2., 3., 4., & 5. Correct: All of these interventions are appropriate for eye care of the comatose client. These actions will prevent infection, keep eyes moist, and protect the eyes from injury. 1. Incorrect: Clean the eyes with saline solution and cotton balls. Wipe from the inner to outer canthus. This prevents debris from being washed into the nasolacrimal duct.)

A primary healthcare provider has prescribed the insertion of a nasogastric (NG) tube. In what order should the nurse perform this procedure? Place actions in the correct order. Secure NG tube. Have client swallow ice as NG tube advances into stomach. Measure distal NG tube from nose tip to earlobe to xiphoid process. Advance NG tube upward and backward. Lubricate 2-3 inches (5.08-7.62 cm) of distal NG tube. Rotate catheter and pass the tube into nasopharynx. Elevate head of bed to Fowler's position. Insert NG tube into unobstructed naris.

Elevate head of bed to Fowler's position. Measure distal NG tube from nose tip to earlobe to xiphoid process. Lubricate 2-3 inches (5.08-7.62 cm) of distal NG tube. Insert NG tube into unobstructed naris. Advance NG tube upward and backward. Rotate catheter and pass the tube into nasopharynx. Have client swallow ice as NG tube advances into stomach. Secure NG tube. (First, raise the client's head of bed to fowler's position Second, measure the distal NG tube from the nose tip to the earlobe to the xiphoid process. Third, lubricate 2-3 inches (5.08-7.62 cm) of the distal NG tube. Fourth, insert the NG tube into unobstructed naris. Fifth, advance NG tube upward and backward. Sixth, rotate catheter and advance into nasopharynx. Seventh, have client swallow ice to pass the NG tube into the stomach. Eighth, secure the NG tube. During this process, the tube is advanced past the nasopharynx. The client is then asked to take sips of water or swallow ice chips to help with tube advancement into the stomach. Finally, the tube is taped once placement is assured. The core issue of the question is knowledge of the insertion procedure for a nasogastric tube. Use nursing knowledge to sequence the steps that the nurse needs to take. Visualize the procedure to aid in answering the question.)

The nurse is caring for a client that requires lifting. What techniques should the nurse utilize to prevent injury to self and potentially the client? Select all that apply 1. Tighten stomach muscles. 2. Keep the knees straight. 3. Keep weight to be lifted close to body. 4. Bend at the waist. 5. Avoid twisting the body.

1. Tighten stomach muscles. 3. Keep weight to be lifted close to body. 5. Avoid twisting the body. (1., 3., & 5. Correct: Tightening the stomach muscles provides stability for the movement. Keeping the weight close to the body provides additional support and reduces the risk of a stretching type injury. When the body is in alignment, it is considered to be balanced. Therefore, twisting motions cause the body to be off balanced and make the nurse more susceptible to injury. 2. Incorrect: The trunk should be kept straight, and the knees should be bent. This provides an upright posture to maximize stability and reduce risk of injury. 4. Incorrect: The trunk should be kept straight, and the knees should be bent. This provides an upright posture to maximize stability and reduce risk of injury. Bending at the knees helps prevent back injuries.)

The nurse assesses a diabetic client in the emergency department and notes a blood glucose of 400 mg/dL (22.2 mmol/L), muscle twitching, and an increased respiratory rate. What is the nurse's priority concern? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

3. Metabolic acidosis (3. Correct: Metabolic acidosis. Look at the hints you have been given. Diabetes, blood sugar of 400 mg/dL (22.2 mmol/L), muscle twitching, and increased respirations. This client is going into diabetic ketoacidosis (DKA), which leads to metabolic acidosis. 1., & 2. Incorrect: The problem is not a respiratory problem, so respiratory acidosis in not correct. 4. Incorrect: This client would be breaking down body fat, which produces ketones. Ketones are an acid, so the client would be in metabolic acidosis, not metabolic alkalosis.)

Which nursing statements about a client reflect correct documentation in the hospital medical record? Select all that apply 1. 20% of breakfast consumed. 2. 4 inch by 2 inch wound noted on right arm. 3. Enema administered. 4. Appears upset at spouse. 5. Lying in bed.

1. 20% of breakfast consumed. 2. 4 inch by 2 inch wound noted on right arm. (1. & 2. Correct: The nurse should record findings or observations precisely and accurately. Percent of breakfast eaten is accurate documentation. An arm wound should include its exact size and location. 3. Incorrect: Documentation of enema administered should also include type of solution, amount and results. 4. Incorrect: Documenting observed behaviors or conversations is appropriate; however, drawing conclusions about feelings is not. A better notation would be to describe facial expression and any emotions exhibited,( i.e. crying, laughing, etc.). 5. Incorrect: This documentation does not give body position and does not provide pertinent information about the position of bed and side rails or light placement.)

The nurse instructs a client about deep breathing and coughing exercises that will be performed postoperatively. Which statement by the client indicates that teaching has been effective? 1. "Coughing and deep breathing should be performed hourly to prevent pneumonia." 2. "Coughing and deep breathing are needed to prevent blood clots." 3. "Coughing and deep breathing will aide with healing by increasing available oxygen." 4. "Coughing and deep breathing will help resolve any blood clots that have formed. "

1. "Coughing and deep breathing should be performed hourly to prevent pneumonia." (1. Correct: Coughing and deep breathing exercises are done to expand the lungs and prevent pneumonia and atalectasis. After surgery, due to the pain, clients are prone to shallowly breath which can lead to atelectasis and thick secretions and increased risk of pneumonia. 2. Incorrect: Coughing and deep breathing exercises are done to expand the lungs and prevent pneumonia and atalectasis after surgery. Coughing and deep breathing will not prevent blood clots. 3. Incorrect: Coughing and deep breathing will increase available oxygen. The main reason client's should cough and deep breath however, is for lung expansion and pneumonia prevention. 4. Incorrect: Coughing and deep breathing exercises are done to expand the lungs and prevent pneumonia and atalectasis after surgery. Coughing and deep breathing will not resolve blood clots.)

The community health nurse is presenting information about birth control measures to a group of young females. The nurse explains that an intrauterine device (IUD) is most appropriate for what individuals? Select all that apply 1. A mother of a toddler who wants another child in three years. 2. The client with a recent exacerbation of sickle cell anemia. 3. A client with stage II breast cancer who has finished chemotherapy. 4. An adolescent who has recently become sexually active. 5. The client with a double mastectomy seven years ago.

1. A mother of a toddler who wants another child in three years. 5. The client with a double mastectomy seven years ago. (1 & 5. Correct: An IUD is a surgically placed method of birth control in which a small, t-shaped piece of plastic, or even copper, is inserted into the uterus to decrease the chance of pregnancy. The client must be very healthy, emotionally amenable to a foreign body to prevent pregnancy, and aware that an IUD is not 100% fail-proof. The mother of a toddler who would like to have another child in a few years is an excellent candidate for the use of an IUD. Also, a client who had a double mastectomy over seven years ago is a good candidate, since treatment that long ago means the client would no longer be receiving any type of immunosuppressant therapy. 2. Incorrect: A client who has had a recent exacerbation of sickle cell anemia is at high risk for several complications, including infection and clots. This is a foreign body in an already compromised client, leading to many potential complications. 3. Incorrect: The client being actively treated for cancer is also immunosuppressed and would not be a good choice for an IUD. The risk of infection is much too high. 4. Incorrect: An adolescent does not have regular menstrual cycles yet, and can experience intermittent bleeding. Many primary healthcare providers argue that the use of an IUD may be safer since the client would not have to remember a pill, a ring, or a patch. But an even greater concern is the fact that an IUD is not 100% effective, still presenting the risk of an unwanted pregnancy. Also, an IUD does not protect against sexually transmitted disease (STDs), which is often a concern in those who have become sexually active.)

The nurse is teaching a community education course regarding complementary and/or alternative therapies. Which therapies would the nurse include in the course as complementary and/or alternative therapies? Select all that apply 1. Acupuncture 2. Yoga 3. Tai chi 4. Reiki 5. Zumba

1. Acupuncture 2. Yoga 3. Tai chi 4. Reiki (1., 2, 3, & 4. Correct: All are considered complementary and/or alternative therapies. Acupuncture involves stimulating specific points on the body. This is most often done by inserting thin needles through the skin, to cause a change in the physical functions of the body. Research has shown that acupuncture reduces nausea and vomiting after surgery and chemotherapy. It can also relieve pain. The practice of yoga makes the body strong and flexible, and improves the functioning of the respiratory, circulatory, digestive, and hormonal systems. Yoga brings about emotional stability and clarity of mind. Tai chi is an ancient Chinese discipline involving a continuous series of controlled usually slow movements designed to improve physical and mental well-being. Reiki is a healing technique based on the principle that the therapist can channel energy into the client by means of touch, to activate the natural healing processes of the body and restore physical and emotional well-being. 5. Incorrect: Zumba is a type of dance exercise and is not considered a form of alternative therapy.)

A client with a suprapubic catheter is admitted for surgery and requires a catheter change before that procedure. What is the most important action for the nurse to take prior to changing this catheter? 1. Check size of existing catheter and balloon. 2. Ask client when the catheter was last changed. 3. Clamp and empty the present catheter bag. 4. Gather clean gloves and basin of hot soapy water.

1. Check size of existing catheter and balloon. (1. Correct: It is important to maintain the same catheter size as the one currently in use since the surgical opening does not increase in size like a urethral opening. If the balloon is too small, urine can leak through the opening. If the balloon is too big, urine will not drain properly, leaving residual and the potential for infection. 2. Incorrect: Though obtaining information directly from the client is often a good choice, the individual may not be able to recall a precise date or time. When a catheter change is scheduled at specific time intervals, the nurse needs to verify the correct time line. Generally, the primary healthcare provider can provide a current order to facilitate the changing of the catheter. 3. Incorrect: Although the nurse may empty a catheter bag, if the client uses one, there is no need to clamp a suprapubic catheter. The standard procedure for replacing a suprapubic catheter does not include clamping since the catheter does not require long tubing like a regular catheter. Also, urine bags are generally emptied at scheduled times each shift. 4. Incorrect: Replacing a suprapubic catheter requires the use of sterile gloves both while cleaning and inserting the new catheter. Also, care of the insertion site is completed with sterile normal saline before and after the reinsertion.)

The family of an elderly woman is concerned that their mother is not getting restful sleep. As a result, the family members' sleep is disturbed. Which questions would be important for the nurse to ask? Select all that apply 1. Has there been any change in your mother's state of health? 2. Can family members take naps during the day? 3. Does she take routine diuretics? 4. Has there been an increase in noise levels? 5. Can the family take turns in managing the mother's sleep problems?

1. Has there been any change in your mother's state of health? 3. Does she take routine diuretics? 4. Has there been an increase in noise levels? (1., 3. & 4. Correct: There may be a physical reason for the difficulty sleeping, perhaps pain or presence of an infection. Diuretics should be scheduled early in the day so as not to interfere with sleep. Perhaps there has been a change in medication schedule. Changes in the sleep environment, such as an additional TV in the home or other noise, may impact sleep. 2. Incorrect: This may be necessary; however, the nurse is working toward helping the mother of the family to sleep better. 5. Incorrect: The family may need to do this over time; however, the focus is to help the mother of the family to sleep better.)

When disposing of waste in a client's room, the nurse would place which item(s) in a biohazard red bag? Select all that apply 1. Chest drainage unit 2. Doxorubicin IV bag and tubing 3. Staples removed from an abdominal incision 4. Tramadol 50 mg tablet prescribed but refused by client 5. Soiled dressing 6. Paper trash with identifying client information

1. Chest drainage unit 5. Soiled dressing (1., & 5. Correct: Chest drainage units should be capped and placed in a large red biohazard bag for disposal. Dressings soiled with human waste, blood or body fluids should be disposed of in a red biohazard bag. 2. Incorrect: Doxorubicin is an intravenous antineoplastic chemotherapy agent. IV bags and tubing used to administer chemotherapy medications should be disposed of intact and placed in a yellow or purple chemotherapy waste container with a lid. 3. Incorrect: Client staples are considered a "sharp" and should be disposed of in a red biohazard sharps container. 4. Incorrect: Tramadol is a non-hazardous waste medication, but it is also a Schedule IV narcotic. Narcotics should be disposed of in an irretrievable medicinal waste container or sharps container according to hospital policy. No matter the type of container used, for narcotics, it should be irretrievable. 6. Incorrect: Paper trash containing client information should be disposed of in a manner that it is no longer readable, cannot be reconstructed and cannot be retrieved.)

The nurse is planning care for four clients with different medical issues. With which diagnosis would a client benefit most from an integrative medicine healthcare strategy? 1. Chronic fatigue syndrome who has had no relief of fatigue. 2. Diabetes whose blood sugars are out of control and refuses to take the prescribed oral and injection medications. 3. Cholecystitis who wants surgery to treat the symptoms definitively. 4. Productive cough with green sputum, fever of 104.2 degrees Fahrenheit (40.1 degrees C), and chest pain.

1. Chronic fatigue syndrome who has had no relief of fatigue. (1. Correct: Chronic fatigue syndrome is a chronic health problem that is difficult to treat using only traditional medicine and responds well to the use of an integrative medicine healthcare strategy by using a combination of traditional and holistic therapies. Integrative medicine is an approach to care that puts the patient at the center and addresses the full range of physical, emotional, mental, social, spiritual and environmental influences that affect a person's health. 2., 3., & 4. Incorrect: Clients with acute illness symptoms are more appropriately treated with traditional medicine strategies.)

Which action by a nurse would indicate that this nurse is following standard precautions? 1. Clean gloves while performing a heel stick on an infant. 2. Sterile gloves to empty a indwelling urinary catheter bag. 3. Shoe covers when entering the room of a client with influenza. 4. Clean gloves while inserting a urinary catheter.

1. Clean gloves while performing a heel stick on an infant. (1. Correct: Standard precautions when drawing blood is to wear gloves so blood will not get on the nurse's hands. Clean gloves are appropriate. 2. Incorrect: Clean gloves for the nurse's protection are needed. Sterile gloves are not needed as part of standard precautions. 3. Incorrect: Shoe covers are not a standard precaution and not needed when entering the room of a client with influenza. 4. Incorrect: Sterile gloves are needed to insert a urinary catheter. Standard precautions are meant to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources. They are the basic level of infection control precautions which are to be used, as a minimum, in the care of all clients. ASSESS THE RISK of exposure to body substances or contaminated surfaces BEFORE any health-care activity. Make this a routine! Select PPE based on the assessment of risk: clean non-sterile gloves, clean, non-sterile fluid-resistant gown, mask and eye protection or a face shield.)

A client who was diagnosed with amyotropic lateral sclerosis (ALS) has been immobile for 2 weeks. Which of the nursing interventions would the nurse implement? Select all that apply. 1. Explore diversional activities. 2. Perform range of motion exercises. 3. Maintain the feet in dorsiflexion position. 4. Assess pressure points for skin changes. 5. Encourage a fluid intake of 1500 mL/24 hours.

1. Explore diversional activities. 2. Perform range of motion exercises. 3. Maintain the feet in dorsiflexion position. 4. Assess pressure points for skin changes. (1., 2., 3., & 4. Correct: The client's immobility may lead to apathy and isolation. The nurse should explore diversional activities which can reduce the frustration and depression of being immobile. Immobility will result in muscle weakness and decreased venous return. The client is encouraged to perform active range of motion exercises. Also passive range of motion exercises should be performed if the client cannot perform the active exercises themselves. Due to the client's decreased movement of the ankles, the client's feet should be positioned in the dorsiflexion position to prevent plantar flexion contractures. A bed board should be positioned to the foot of the bed. Active and passive range of motion exercises to the ankle and foot will promote proper joint movement. An immobile client's skin is affected by extrinsic, intrinsic, and shear forces. A decrease in the client's perfusion and peripheral circulation are intrinsic factors. The immobile client is experiencing the extrinsic factor of increased skin temperature at the skin pressure points. Moving the immobile client may result in a shearing force on the skin. 5. Incorrect: The effects of immobility on the urinary system may include urinary retention, renal calculi, and urinary tract infections. Also the immobile client may experience constipation if the fluid intake decreases. The fluid intake for a healthy adult is recommended at 2200 - 2700 mL per 24 hours.)

When inspecting the equipment in a client's room, what would the nurse recognize as electrical safety hazard(s)? Select all that apply. 1. Flickering overhead light 2. Ground-fault circuit interrupter electrical sockets 3. Hospital labeled UL power strip 4. Bent electrical bed cord 5. Cracked electrical socket

1. Flickering overhead light 4. Bent electrical bed cord 5. Cracked electrical socket (1, 4, & 5. Correct: Dim or flickering lights are indications that there is a possible electrical wiring problem. Use of a damaged electrical cord or socket increases the risk of an electrical fire, shock, or burn. 2. Incorrect: Ground-fault circuit interrupter (GFCI) electrical sockets should be in place in hospital and healthcare facilities. A GFCI socket will immediately cut off power if it detects someone receives a shock, helping prevent serious injury. 3. Incorrect: While power strips are not ideal in the hospital setting, power strips that have been inspected and tagged with a hospital label may be used when multiple electrical outlets are required. Additionally, only power strips with the Underwriters Laboratories (UL) seal should be used.)

A new nurse is documenting in a client's electronic record. Which documentation would the charge nurse evaluate as appropriate documentation by the nurse? Select all that apply 1. Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services. 2. Appears to be having abdominal discomfort. 3. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon. 4. Pre-op diazepam 10.0 mg given po 5. Transferred to surgical suite per stretcher with side rails up, in stable condition.

1. Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services. 3. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon. 5. Transferred to surgical suite per stretcher with side rails up, in stable condition. (1., 3., & 5. Correct. These are written correctly. The first entry provides the age, provides the diagnosis, room number, and plan for care. this gives a "snap shot" of the admission. Option 3 is documentation of informed consent for surgery. It states that the consent is signed, the surgery to be performed, and very importantly, that the client is consenting to surgery after the surgeon discussed the procedure. Option 5 appropriately documents a transfer. It presents where the client was transferred, how they were transported, and the condition upon their transfer. 2. Incorrect. "Appears" is subjective. Pain should be assessed in an objective manner, such as by using a pain scale. The nurse should not use subjective documentation of the client's pain. 4. Incorrect. Do not use trailing zeros after a decimal point. Always lead a decimal point with a zero (0.5). These are safety issues. Trailing zeros are identified on the Joint Commission on the Accreditation of Hospitals Organization (JCAHO) "Do Not Use" list. The placement of a zero after a decimal point could lead to the inadvertent administration of a medication ten times the prescribed dose if the decimal point was not noted or could not be seen. Nurses should always follow JCAHO standards and guideline for documentation and nursing care.)

A primary healthcare provider prescribes contact precautions for a newly admitted client. What equipment does the nurse need to place outside of the client's room for use when entering the room? Select all that apply 1. Gown 2. Gloves 3. Goggles 4. Surgical mask 5. N95 respirator

1. Gown 2. Gloves (1. & 2. Correct: Healthcare personnel caring for clients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the client or potentially contaminated areas in the client's environment. 3. Incorrect: Goggles are not required with contact precautions.It is used when splashing is anticipated. 4. Incorrect: A surgical mask is not required with contact precautions. It would be used for droplet precautions. 5. Incorrect: A N95 respirator is not required with contact precautions. It is used for airborne precautions.)

The client reports having trouble sleeping at night. "My mind is constantly working, and I can't fall asleep until 2:00 or 3:00 a.m."Which behaviors found in the assessment are likely to contribute to sleep difficulty? Select all that apply 1. Performs office work before going to bed. 2. Watches night-time drama shows on TV. 3. Drinks caffeine after dinner each evening. 4. Reads for pleasure before going to bed. 5. Exercises 45 minutes at 5 pm each evening.

1. Performs office work before going to bed. 2. Watches night-time drama shows on TV. 3. Drinks caffeine after dinner each evening. (1., 2. & 3. Correct: Working on job-related tasks before bedtime may increase anxiety and contribute to difficulty sleeping. Suspenseful night-time drama TV shows may be too stimulating prior to going to bed. Caffeine following dinner may interfere with sleep. 4. Incorrect: Quiet reading is likely to ease the transition from wakefulness to sleep and may be an important intervention to promote sleep. 5. Incorrect: Exercising early in the evening may be an effective intervention. If exercise is performed prior to going to bed, it may interfere with falling asleep.)

After assessing a client, the nurse determines that the client has incomplete emptying of the bladder with reports of dribbling, hesitancy, and frequency. Which interventions would the nurse include for this client? Select all that apply 1. Have client attempt to void again (double voiding). 2. Encourage the client to void every 8 hours. 3. Perform Credé method. 4. Have client listen to sound of running water. 5. Teach intermittent catheterization for retention, if needed.

1. Have client attempt to void again (double voiding). 3. Perform Credé method. 4. Have client listen to sound of running water. 5. Teach intermittent catheterization for retention, if needed. (1., 3., 4. & 5. Correct: Have client attempt to void again. This is called double voiding. This can improve bladder emptying. Place bedpan, urinal, or bedside commode within reach. Provide privacy. Have client listen to sound of running water or place hands in warm water and/or pour warm water over perineum to stimulate urination. Offer fluids before voiding. Perform Credé method over bladder to increase bladder pressure. If these methods are unsuccessful, the client will need education on intermittent catheterization. 2. Incorrect: Encourage client to void every 4 hours. We do not want urine to sit in the bladder for long periods of time. Stagnant urine can create infection.)

The nurse tries to notify the primary healthcare provider (PHP) that the dosage of newly prescribed medication is higher than recommended. The PHP cannot be located and the medication is scheduled to be administered in 30 minutes. Which intervention should the nurse implement next? 1. Inform the charge nurse. 2. Administer the medication as prescribed. 3. Document the prescribed medication dosage in the nursing notes. 4. Administer the recommended dosage until the PHP is contacted.

1. Inform the charge nurse. (1. Inform the charge nurse. 2. Administer the medication as prescribed. 3. Document the prescribed medication dosage in the nursing notes. 4. Administer the recommended dosage until the PHP is contacted.)

The home health nurse is caring for a client who is identified as high risk for falls. What evaluation would indicate a therapeutic response to home fall prevention education? Select all that apply 1. Installs a grab bar in the tub. 2. Turns night lights on at bedtime. 3. Only uses assistive devices when leaving home. 4. Goes barefoot while in the home. 5. Uses throw rugs in walking areas to prevent slipping.

1. Installs a grab bar in the tub. 2. Turns night lights on at bedtime. (1. & 2. Correct: Placing a grab bar in a slippery tub can assist the client in getting into and out of the tub. Turning on night lights at night ensures that the client can navigate safely, thus reducing the risk of falls. 3. Incorrect: If the adult has an assistive device, it should be used inside and outside the home. The client should be encouraged to use assistive devices, such as canes or walkers, at all times. 4. Incorrect: The client should always wear properly fitting shoes that have nonskid protection. The client increases their risk for injury when properly fitting shoes are not worn. 5. Incorrect: Throw rugs actually may increase the risk of tripping.)

The client with a new diagnosis of hypertension has been instructed to maintain a low sodium diet. Which foods does the nurse plan to teach the client to include on a low sodium diet? Select all that apply 1. Lemonade 2. Broccoli 3. Apple 4. Smoked sausage 5. Boiled shrimp 6. Tomato soup

1. Lemonade 2. Broccoli 3. Apple (1, 2, & 3. Correct: Lemonade has about 5 mg of sodium. Broccoli and apples have 0 mg of sodium per serving. 4. Incorrect: Sausage is made from ground meat such as pork, beef, or veal with salt and other spices added. A serving of sausage can have 644 mg of sodium. 5. Incorrect: Shellfish or shrimp are high in sodium. A serving of boiled shrimp can have 111 mg of sodium. Also, the seasoning for the shrimp has sodium added. 6. Incorrect: Processed foods are high in sodium unless the food label states "low sodium". Even though the food may read "low sodium", the client should read the food label to evaluate the sodium content.)

Which assessments will provide the nurse with the most information regarding a client's neurologic function? Select all that apply 1. Level of consciousness 2. Doll's eyes reflex 3. Babinski reflex 4. Reaction to painful stimuli 5. Verbal ability

1. Level of consciousness 5. Verbal ability (1. & 5. Correct: If the client is alert and oriented, that indicates high brain functioning. As level of consciousness decreases, so is brain function. If the client can speak and answer questions appropriately, this indicates neuro function level, versus, incoherent speech or no speech at all. 2. Incorrect: No, only helps with the determination of brain death. 3. Incorrect: Identifies diseases of the brain and spinal cord. 4. Incorrect: Clients who are awake and alert will withdraw from a painful stimuli. This is done as a last resort and only if the client does not respond to other stimuli.)

The housekeeper and a nurse, having lunch together in the staff lounge, begin discussing the housekeeper's neighbor who has been admitted to the floor. The housekeeper occasionally helps the neighbor with shopping and cleaning. The conversation is overheard by the unit secretary, though no names were mentioned. The conversation is reported to the nurse manager, who determines the situation reflects what HIPAA criteria? 1. Not permissible because the housekeeper is not medical personnel. 2. Is permissible since the housekeeper does help care for the neighbor. 3. Not permissible despite family stating housekeeper is "like family". 4. Is permissible given that no other family members are available now.

1. Not permissible because the housekeeper is not medical personnel. (1. Correct: A client's medical diagnosis or treatments can only be discussed with those hospital personnel involved directly with that individual's care. The housekeeper does not meet these criteria, and this conversation is not permissible since it violates HIPAA regulations. 2. Incorrect: Despite the fact the housekeeper provides assistance to the neighbor at home, sharing private medical details is definitely not permitted, even if there were no names heard by the unit secretary. 3. Incorrect: An individual considered "like family" is still not legally entitled to discuss any medical details unless the client gives specific written permission to do so. Additionally, a family member is not permitted to give consent for medical facts to be revealed without the client's direct consent. 4. Incorrect: Whether family members are available or not, only the client or the client's designated power of attorney may give permission to reveal medical data to anyone not directly involved with the client's care.)

While making evening rounds, the nurse discovers an elderly, confused client standing next to the bed with the IV pulled out, gown wet with urine and the side rails still in the up position. The client's arm band is on the floor. To ensure client safety, what is the most important intervention for the nurse to include in the plan of care? 1. Provide for scheduled toileting intervals. 2. Apply a restraining vest on the client at night. 3. Cover the IV site with a gauze dressing. 4. Remind client to ring call bell for the nurse.

1. Provide for scheduled toileting intervals. (1. Correct: The client is confused and likely will not remember any verbal instructions. Therefore, the safest priority action would be to check on the client at regular intervals and assist the client with any bathroom needs at those times. 2. Incorrect: A restraining vest would not guarantee client safety. This client was able to crawl out of bed over a raised side rail; therefore, this client could struggle against the vest with the potential to get entangled and become seriously injured. 3. Incorrect: Placing gauze over the IV site does not address client safety. The issue is we do not want the client to fall. 4. Incorrect: This action would not ensure safety because the client is confused. So, it is very unlikely the client would remember to ring for the nurse before getting out of bed.)

A nurse is attempting to help a client who has self-care difficulty due to left sided paralysis. Which intervention should the nurse plan to include? Select all that apply. 1. Provide the client with a button hook for dressing. 2. Provide brush for client to brush own hair. 3. Offer to place the client on the toilet every 2 hours during the day. 4. Identify client preferences for personal care items and food. 5. Have client pivot on left foot to sit in chair placed on right side parallel to the bed.

1. Provide the client with a button hook for dressing. 2. Provide brush for client to brush own hair. 3. Offer to place the client on the toilet every 2 hours during the day. 4. Identify client preferences for personal care items and food. (1., 2., 3. & 4. Correct: The use of a button hook or loop and pile closure on clothes may make it possible for a client to continue independence in this self-care activity. This is a one handed task that will enable the client to maintain autonomy for as long as possible. Having client brush own hair helps maintain autonomy. Identifying the client's food and personal care item preferences supports the client's independence. Offer bedpan or place client on toilet every 2 hours during the day and three times during the night. 5. Incorrect: Have client pivot with the right foot with the chair placed on the left side parallel to the bed. The nurse shouldn't place the chair on right side or perpendicular to the bed because the client won't be able to support the body weight on the left leg.)

An intubated client admitted to the intensive care unit appears anxious and fearful of the equipment in the room. The nurse observes this and takes the time to explain each piece of equipment and its role in providing care to the client. How does this action demonstrate client advocacy? Select all that apply 1. Providing information to the client. 2. Promoting client compliance. 3. Providing emotional support. 4. Ensuring the client's wishes for treatment are followed. 5. Fostering a sense of security.

1. Providing information to the client. 3. Providing emotional support. 5. Fostering a sense of security. (1., 3. & 5. Correct: Client advocacy has been described in many different ways and involves many things such as assistance in gaining needed healthcare, assuring quality of care, protection of client's rights, and simply serving as a mediator between the client and the healthcare system as a whole. Client advocacy involves regular communication in which the nurse explains what is being done or likely to happen, reasons for tests or procedures, and simplifying medical terminology into words that can be easily understood. Emotional support is also an aspect of client advocacy that the nurse should employ. The nurse acts as a client advocate by providing information to the client to alleviate fear of the unfamiliar equipment and by fostering a sense of security. 2. Incorrect: This question addressing client advocacy is not related to client compliance. Client compliance may improve if the nurse served as an appropriate client advocate. However, promotion of compliance is not a basic part of advocacy. 4. Incorrect: This question addressing client advocacy is not related to client's healthcare treatment wishes. This would be related to the client's advance directive.)

An unconscious client is admitted to the ICU with a closed head injury suffered in a fall. Despite aggressive efforts, the client expired within 24 hours. The nurse must complete postmortem care while awaiting the coroner. The nurse knows what action is not appropriate in this situation? Select all that apply 1. Remove indwelling catheter 2. Disconnect the ET tube from ventilator 3. Remove hospital ID band 4. Cap all intravenous lines 5. Wash body head to toe

1. Remove indwelling catheter 3. Remove hospital ID band 5. Wash body head to toe (1., 3., & 5.Correct: The client expired of injuries within 24 hours of being admitted to the hospital, which requires investigation by a coroner. It must be determined if death resulted from fall injuries, or whether any action, or lack thereof, by medical personnel contributed to the client's demise. When completing postmortem care on a "coroner's case", the nurse must leave all invasive lines and tubes in place for investigative purposes. Therefore, it would not be appropriate for the nurse to remove the foley catheter, although the urine can be emptied from the bag. It is also incorrect to remove any hospital identification bands. Washing the body should never be done since evidence could be disturbed or even removed. 2. Incorrect: This action is acceptable since the client would not be transported while still attached to a ventilator. However, the endotracheal tube itself must remain taped in place when the client is transported to the coroner's facility. 4. Incorrect: It is not necessary to leave the IV bags attached to intravenous catheters. The tubing and bags may be removed as long as the intravenous catheter itself remains intact on the client. Any variation of this standard procedure would be determined by the facility or coroner in advance.)

While making rounds, the nurse discovers a small fire in a client's room. What should the nurse do first? 1. Remove the client from the room immediately. 2. Leave the client's room to obtain a fire extinguisher. 3. Instruct the unlicensed assistive personnel (UAP) to pull the fire alarm. 4. Evacuate all clients from the unit.

1. Remove the client from the room immediately. (1. Correct: Rescue/Remove the client; first step in Rescue, Alarm, Contain, Extinguish (RACE). 2. Incorrect: Never leave the client in an unsafe environment. Remove the client from the area. 3. Incorrect: Not first action in RACE. Get the client out of the area first. The UAP may need to help you with this. Don't send the UAP away. 4. Incorrect: Not first action in RACE. Remove the client in immediate danger first. All clients may not have to be evacuated if the fire is contained and extinguished.)

The client has been prepared for surgery. As the nurse is discussing the post-op expectations, the client says to the nurse, "I am not sure what other options are available to me." What should the nurse do? 1. Request the surgeon visit the client again before surgery. 2. Check client records to see if the client signed the consent form. 3. Explain that the surgery is scheduled for 30 minutes from now. 4. Tell the client that the surgeon explained those options yesterday.

1. Request the surgeon visit the client again before surgery. (1. Correct: The surgeon is responsible for informing the client about the surgical procedure, the options available,and the benefits and risks of each treatment modality. So, if the client has concerns the surgeon should be told and requested to see the client again prior to surgery. Surgery should be delayed until the client is sure of decision. 2. Incorrect: The consent form signature is important; however, the client has the right to have questions answered and to change his mind. 3. Incorrect: The client should not be encouraged to have the surgery if he still has questions about other options. The consent must be informed, so the client must have all questions answered. The surgery can be delayed until the client's concerns are addressed. 4. Incorrect: The surgeon may have explained the options, however; it is obvious that the client did not understand the options. The client's concerns must be addressed prior to surgery.)

The nurse has been teaching a client diagnosed with diabetes about self-administration of regular insulin. The first injection was given at the right upper abdomen. The nurse knows that education regarding site rotation was successful when the client chooses which site next? 1. Right upper abdomen 2. Left upper abdomen 3. Upper arm 4. Buttocks

1. Right upper abdomen (1. Correct: Regular insulin is a short acting insulin that is absorbed best in the abdomen. The first injection was given in the right upper abdomen, so the next injection should be given approximately 1 inch from the first one. 2. Incorrect: Although this site is in the abdomen, it is best to follow a more specific pattern. Move 1 inch from the previous injection site. Done properly, there will be approximately 24 days for each site to heal prior to another injection. 3., & 4. Incorrect: For best results, it is important to stick with a consistent body part for injections to avoid variations in insulin action.)

A client receiving 50 mL/hr of enteral feedings has a gastric residual volume of 200 mL and is reporting nausea. What is the appropriate nursing intervention? 1. Stop the feeding and assess gastric residual volume in 1 hour. 2. Reduce the infusion rate to 25 mL/ hour and reevaluate residual volume in 4 hours. 3. Change the feeding schedule from continuous to intermittent delivery. 4. Discard the 200 mL and continue the feedings at the same rate.

1. Stop the feeding and assess gastric residual volume in 1 hour. (1. Correct: The safest response is to stop the feedings and re-assess in 1 hour. Nausea may be a sign of intolerance. Continuing the feeding may also result in vomiting with possible aspiration. 2. Incorrect: Reducing the rate requires a primary healthcare provider's prescription and does not fix the problem. 3. Incorrect: Changing the feeding schedule requires a primary healthcare provider's prescription and does not fix the problem. 4. Incorrect: Do not discard residual volumes. Discarding residual volumes can disrupt a client's fluid and electrolyte balance. Standard practice is to give it back. Discarding the residual requires a prescription. Continuing at the same rate is not safe when you have high residuals. The feedings should be stopped.)

The employee health nurse is designing a health promotion plan for a group of workers who have neck and back strain symptoms and repetitive movement pain from long periods of computer work. Which interventions should be included in the plan to reduce these symptoms? Select all that apply 1. Suggest that the workers place the keyboard and mouse close to the body. 2. Adjust computer screen to below eye level. 3. Drop and roll shoulders periodically. 4. Type with forearms parallel to the floor. 5. Keep elbows at the side when typing.

1. Suggest that the workers place the keyboard and mouse close to the body. 3. Drop and roll shoulders periodically. 4. Type with forearms parallel to the floor. 5. Keep elbows at the side when typing. (1., 3., 4. & 5. Correct: Keeping the keyboard and mouse close keeps the body in a more neutral position. Dropping the shoulders puts them in a relaxed position. As tension increases, the shoulders tend to rise. This position keeps the neck and back from being stretched and keeps the body in a more neutral position. This allows the shoulders to stay in a more neutral position. 2. Incorrect: The computer screen should be at eye level so that the neck does not become strained as easily.)

The nurse is preparing a client for transport to the radiology department for a left lung tissue biopsy. Which actions should the nurse make certain have been completed? Select all that apply 1. The consent form is signed. 2. The operative site is prepped with a razor. 3. The most recent lab work is on the chart. 4. Any preoperative medication is given as prescribed. 5. Person performing the procedure has marked the site.

1. The consent form is signed. 3. The most recent lab work is on the chart. 4. Any preoperative medication is given as prescribed. 5. Person performing the procedure has marked the site. (1., 3., 4. & 5. Correct: The client has the legal right to sign a consent form prior to any invasive procedure such as a lung biopsy. The client's physical status should be evaluated prior to the biopsy. The client's lab reports are a vital part the physical assessment. Many medications are administered during the perioperative period. The last dose if ordered is usually taken with a sip of water within 2 hours prior to the procedure. Also other medications may be ordered that are specific to the client's procedure and the client's diagnoses. The operative site is marked by the person who is ultimately accountable for the procedure and will be present when the procedure is performed. 2. Incorrect: The site should be prepped with clippers as opposed to a razor, which can cause injury to the client. The goal of preoperative skin preparation is to decrease bacteria without injuring the skin.)

A 70 year-old client reports not sleeping well at night, having trouble staying asleep, and awakening about 4:00 a.m. What should the nurse teach the client about sleep patterns in the elderly? 1. Don't worry about a few hours of lost sleep. 2. Elders need as much sleep as younger adults. 3. Caffeine and some medications may interfere with sleep. 4. Elders sleep more than younger adults.

3. Caffeine and some medications may interfere with sleep. (3. Correct: Caffeine and some medications may interfere with sleep. 1. Incorrect. The client is concerned about the sleep problem, and the nurse should address the client's concerns. Sleep disturbances can also indicate depression. This option is denying their concerns. 2. Incorrect. Elders actually require less sleep because they are less active. Elderly do not need as much sleep. 4. Incorrect. Elders are likely to have more disturbed sleep. They usually do not need more sleep.)

A client with cancer refuses treatment and asks about options for hospice home care. The client's daughter asks the case manager to talk the client into agreeing to cancer treatment. The nurse explains to the daughter that this violates which client right? Select all that apply 1. To self-determination 2. To decline participation in research studies and experimental treatments 3. To expect reasonable continuity of care 4. To make decisions about the plan of care 5. To advocacy

1. To self-determination 4. To make decisions about the plan of care (1., & 4. Correct: Under the Patient Self-Determination Act (PSDA), healthcare institutions provide clients with a summary of their rights when making health care decisions as well as the facility's policies regarding recognition of advanced directives. The client is advised of the right to consent to or refuse treatment. Client rights refer to such matters as access to care, dignity, confidentiality, and consent to treatment. The competent adult client has the right to participate in the plan of care, to refuse a proposed treatment, and to accept alternative care and treatment. Documentation should be made that the client fully understands the risks and benefits of their decision. 2. Incorrect: The right to decline participation in research or experimental studies is incorrect because no research or experimental treatment is proposed to the client. 3. Incorrect: The right to expect reasonable continuity of care appears to be a possible correct answer, but is incorrect because the client has not been transferred to hospice home care. Attempting to convince the client to agree to cancer treatment would not be pertinent to continuity of care in this situation. 5. Incorrect: The right to advocacy relates to the right to have another person present during interviews or examinations. This right would not be violated by the nurse if attempts were made to convince the client to have cancer treatment.)

The nurse is assisting the client on the correct procedure for applying anti-embolism stockings. Which statement by the client indicates that the client understands the procedure? Select all that apply 1. "The stockings should be applied when my legs are swollen." 2. "I will apply the anti-embolism stockings before getting out of bed." 3. "I will apply cortisone-10 ointment to skin on both legs every day." 4. "Prior to applying the stockings, I will look for reddened areas on my skin." 5. "When pulling up the stockings, I will allow for an extra roll of the stocking at my calves."

2. "I will apply the anti-embolism stockings before getting out of bed." 4. "Prior to applying the stockings, I will look for reddened areas on my skin." (2., & 4. Correct: To promote increased blood flow in the legs, anti-embolism stockings should be applied before getting out of bed. After keeping the legs elevated during sleeping, the legs should be less swollen. The compression of the deep venous system will be more effective if swelling is decreased prior to applying the stockings. Both legs should be assessed for any reddened skin areas prior to applying the stockings. If reddened areas are noted, the cause of the reddened areas should be evaluated and treatment initiated, if appropriate. Client's symptoms should be addressed prior to the application of the stockings. 1. Incorrect: The purpose of the anti-embolism stockings is to promote increased blood flow in the legs. To promote the increase blood flow in the legs, anti-embolitism stockings should not be applied when the legs are swollen. If the legs are swollen when applying the stockings, the compression to the deep venous system is reduced. 3. Incorrect: Unless prescribed, the stockings should not be applied over any ointment that has been applied to the legs. The legs and feet should be dry. The stockings are to be worn over an extended period. If there is a skin condition that warrants treatment, the stockings may reduce the effectiveness of the treatment. 5. Incorrect: The client's leg should be measured to ensure that the correct size of the anti-embolism stockings is applied. An extra roll of the stocking at the calves would decrease the appropriate deep venous pressure and could also cause a pressure area on the calves.)

The nurse is discussing foot care with a client who was recently diagnosed with diabetes. Which statement by the client indicates an understanding of foot care? 1. "I will soak my feet for 30 minutes a day." 2. "I will avoid using a heating pad on my feet." 3. "I can use scissors to remove the corns on my toes." 4. "I enjoy walking without my shoes around the house."

2. "I will avoid using a heating pad on my feet." (2. Correct: One of the long-term complications of diabetes is peripheral neuropathy. As the neuropathy progresses the feet have reduced sensation and may eventually become numb. The client should avoid using heating pads and hot water bottles. Due to the decrease sensation of the feet, the client is in danger of blistering and burning the feet. 1. Incorrect: A complication of diabetes is an increased risk of foot infections. The client is immunocompromised which impairs the leukocytes that destroy bacteria. The client should not allow moisture to accumulate between the toes. 3. Incorrect: Due to the possibility of the client experiencing peripheral neuropathy, the client should not remove any corns from their toes. If a cut occurs while removing the corn, the client is a risk for an ulcer developing. A primary healthcare provider should prescribe the appropriate treatment for corns. 4. Incorrect: Walking without appropriate shoes is dangerous for the client diagnosed with diabetic peripheral neuropathy. After stepping on an object, the client cannot feel the damage to the skin which could result in a scratch or cut.)

A home health nurse is educating a female client about home care considerations for intermittent catheterization. Which statement by the client would let the nurse know that the client understands what has been taught? 1. "After insertion, I will tape the tubing to my lower abdomen." 2. "I will wash the rubber catheter thoroughly with soap and water after use." 3. "It is important that I keep the drainage bag below the level of my bladder." 4. "Catheterization should be done hourly."

2. "I will wash the rubber catheter thoroughly with soap and water after use." (2. Correct: For intermittent catheterization in the home, the client should follow clean technique. Wash rubber catheters thoroughly with soap and water after use, then dry and store in a clean place. 1. Incorrect: There is no drainage bag for intermittent catheterization. If there was an indwelling catheter, it would be secured to the woman's upper thigh. 3. Incorrect: With intermittent catheterization, there is no drainage bag. This would be an incorrect comment if made by the client. 4. Incorrect: Intermittent catheterization should be done first thing in the morning and just before going to bed at night. In most cases, self catheterization should be done every 4 to 6 hours. The client may need to self catheterize more frequently if oral intake of fluids has increased.)

Which client is legally able to sign a consent for surgery? Select all that apply 1. An 86 year old client who is disoriented. 2. A 62 year old client who speaks only Spanish. 3. A 41 year old client who just received midazolam. 4. A 17 year old client needing an emergency appendectomy whose parents cannot be contacted. 5. A 44 year old with schizophrenia who is hallucinating.

2. A 62 year old client who speaks only Spanish. 4. A 17 year old client needing an emergency appendectomy whose parents cannot be contacted. (2., & 4. Correct: The Spanish speaking client should have a trained medical interpreter, either in person,by telephone, or by video conference, but the client can still sign the consent. The 17 year old client is considered a minor, however, since the parents are not available, the emergency exception rule, known as "implied consent" would be followed. The primary healthcare provider must document the nature of the emergency, the reason why immediate treatment is required, and the attempts to obtain consent from the minors parents or legal guardian. 1. Incorrect: The 86 year old client who is disoriented is not considered capable of making an informed decision. 3. Incorrect: Midazolam is a benzodiazepine administered for preoperative sedation/amnesia. For a consent to be legally valid, the consent must be signed prior to being administered preoperative medication or other mind-altering medications. 5. Incorrect: This client with schizophrenia who is hallucinating does not have the ability at this time to understand explanations, understand risks and benefits, and communicate a decision based on that understanding.)

The charge nurse is reviewing multiple events reported by staff during morning shift. The nurse is aware which event requires a written incident report? 1. A client yells loudly throughout the night shift. 2. A nurse discusses client's prognosis with family. 3. An unlicensed assistive personnel (UAP) spills water pitcher onto client. 4. A nurse tears sterile gloves and applies new gloves.

2. A nurse discusses client's prognosis with family. (2. Correct: The purpose of an incident report is to document any incident or unusual event inconsistent with routine operations of hospital or staff routine and resulting in injury, or potential liability, for clients, family, or staff. The nurse has violated HIPAA regulations by discussing a client's medical prognosis with family members. The primary healthcare provider is responsible to discuss prognosis with client and only those individuals designated by the client. 1. Incorrect: Although this client may disturb other clients at night, this event does not meet the criteria for an incident report. 3. Incorrect: This event requires the UAP to intervene, providing clean clothes for the client. However, while an unfortunate occurrence, this incident would not require an incident report. 4. Incorrect: Damaged sterile gloves must be removed and replaced immediately to prevent contamination of the field. The nurse followed the correct procedure and no report is needed.)

Eight hours after a cholecystectomy a male client has tried unsuccessfully to urinate using a urinal in bed. Which nursing interventions would the nurse implement? Select all that apply 1. Insert a straight catheter. 2. Administer the prescribed PRN analgesic. 3. Assist the client to stand at the bedside to void. 4. Emphasize that the client must void within 2 hours. 5. Encourage the client to increase fluid intake to 500 mL/hr. 6. Assist the client to the bathroom and turn on running water.

2. Administer the prescribed PRN analgesic. 3. Assist the client to stand at the bedside to void. 6. Assist the client to the bathroom and turn on running water. (2., 3., & 6. Correct: The pain level of the client should be assessed. When the client is experiencing pain, the client's anxiety level will increase. The prescribed PRN analgesic should be administered to decrease the client's pain and anxiety levels. Though there is no posture-related differences when men void in the lying position versus the standing position, the male client sometimes prefers voiding in the standing position. The sound of the water can stimulate the central nervous system to facilitate the voiding process. 1. Incorrect: In and out catheter will not assist the client to void. 4. Incorrect: Giving the client a time limit to void is a not a helpful technique. The nurse is telling the client what to do. This will increase client's anxiety which will decrease the client's ability to void. 5 Incorrect: Increasing the intake amount will cause the bladder to expand further, but the client is having difficulty initiating the voluntary opening of the sphincter.)

An Asian client, who cannot speak or comprehend English, is brought to the emergency department by family. One family member is able to understand simple sentences of English. How would the nurse best explain how to obtain a clean catch urine to the client? 1. Have the family member repeat the nurse's explanation to the client. 2. Contact Social Services to find an authorized interpreter. 3. Use simple hand motions to explain the procedure to the client. 4. Draw a diagram to demonstrate the use of the sterile cup when obtaining the specimen.

2. Contact Social Services to find an authorized interpreter. (2. Correct: Hospitals must have a means of communicating with a variety of non-English speaking clients, as well as deaf clients. It is vital to have interpreters that are capable of translating medical terms or instructions correctly and also to relay the client's specific concerns back to medical staff. Because of the importance of accuracy, only trained and qualified interpreters should be used when communicating with those who do not understand English. 1. Incorrect: Although the family is present and may be able to translate information from the nurse to the client, the accuracy of that information cannot be guaranteed since the family member has a limited understanding of English and no medical knowledge. It is vital that the procedure be clearly explained to the client, since test results will be affected if the specimen is not correctly collected. 3. Incorrect: The use of hand motions does not ensure that the client will understand the procedure correctly, and in this particular situation, demonstrating some of the steps could be embarrassing to this client. Hand motions do not provide a means for the client to ask questions about anything that is not clearly understood. 4. Incorrect: Although there may be circumstances in which a nurse can use alternative methods of communication, such as picture boards or hand gestures, this situation calls for clear instructions on the proper method for obtaining a clean catch urine so that test results are accurate. Additionally, a picture does not allow the client to confirm understanding of the process.)

An elderly client has been admitted to the hospital with a diagnosis of cerebral vascular accident (CVA) with right-sided paralysis. When the nurse instructs staff to reposition client every two hours, the family asks about the purpose of this action. What is the best explanation by the nurse? 1. Improves circulation to the affected side of the body. 2. Decreases potential skin breakdown from immobility. 3. Prevents blood stasis in the client's lower extremities. 4. Alleviates sensory deprivation by varying environment.

2. Decreases potential skin breakdown from immobility. (2. Correct: An immobile client is subjected to sheering forces and tissue breakdown because of prolonged contact between the skin and linens. Pressure sores can develop quickly when a client remains in one position over long periods of time, particularly on protruding areas of the body such as hips, elbows, sacrum or heels. Repositioning the client every two hours decreases the potential for skin breakdown and allows for inspection of all vulnerable body areas. 1. Incorrect: While moving a paralyzed client might stimulate the overall circulation, and even allow for passive range of motion, repositioning a client does not specifically increase blood flow to one side of the body. 3. Incorrect: Though moving a client can stimulate the circulation, repositioning every two hours is not sufficient to prevent blood stasis in lower extremities, particularly when this client cannot move the right side independently. 4. Incorrect: Sensory deprivation is not a major concern for the client initially and repositioning is not meant to address sensory needs. The purpose of repositioning is prevention of skin breakdown.)

What should the nurse monitor for when caring for a client receiving an IV of ½ Normal Saline at 100 mL/hr? 1. Hypertension 2. Fluid volume deficit 3. Hypernatremia 4. Pulmonary edema

2. Fluid volume deficit (2. Correct: ½ Normal Saline is a hypotonic solution. Monitor for cellular edema because the fluid is moving out to the cell which could lead to fluid volume deficit and decreased blood pressure. 1. Incorrect: Hypertension can occur with isotonic and hypertonic IV solutions. Hypotension can occur with hypotonic IV solutions such as ½ Normal Saline. 3. Incorrect: Hypernatremia can occur with isotonic and hypertonic sodium solutions. 4. Incorrect: This is a nursing alert for hypertonic IV solutions.)

Where should a nurse place the stethoscope when auscultating heart sounds? Select all that apply 1. First intercostal space left of the sternum to hear sounds from the pulmonic valve area. 2. Fourth intercostal space to the left of the sternum to hear sounds from the tricuspid area. 3. Second intercostal space to the right of the sternum to hear sounds from the aortic valve area. 4. Fifth intercostal space left side of sternum to hear sounds from the mitral area. 5. Apex of the heart to hear the loudest 2nd heart sound (S2).

2. Fourth intercostal space to the left of the sternum to hear sounds from the tricuspid area. 3. Second intercostal space to the right of the sternum to hear sounds from the aortic valve area. (2., & 3. Correct: These are correct locations to listen to heart sounds. 1. Incorrect: Second intercostal space left of the sternum to hear sounds from the pulmonic valve 4. Incorrect: The fifth intercostal space in the midclavicular line is where you will hear sounds in the mitral area. 5. Incorrect: This is where you will hear the loudest 1st heart sound (S1). Listen at the base to hear S2 the loudest.)

A client has developed preeclampsia at 30 weeks' gestation. The nurse is instructing the client on an appropriate diet for preeclampsia. The nurse knows the teaching was successful when the client selects what menu? Select all that apply 1. Caesar salad with feta cheese 2. Grilled cheese with tomatoes 3. Chipped ham on a croissant roll 4. Hot dog with a glass of soda pop 5. Chicken sandwich on wheat toast

2. Grilled cheese with tomatoes 5. Chicken sandwich on wheat toast (2 and 5. Correct: A high protein, calcium rich diet is most important for the preeclampsia client who is losing protein in urine. Grilled cheese is an excellent selection for lunch, especially since it contains tomato slices, which adds another level of nourishment and vitamins. Additionally, a chicken sandwich, particularly on whole wheat toast, is very appropriate for this preeclampsia client. 1. Incorrect: Caesar dressing is made with raw eggs, exposing the client to the potential for salmonella. Pregnant woman should not eat raw foods, including eggs, fish, or meat. Additionally, feta cheese is a 'soft cheese', exposing the client to another bacterium known as listeria. Although a salad could be a good choice, this particular salad is not healthy. 3. Incorrect: The need to restrict salt is not a priority for preeclampsia clients, but chipped ham is a processed meat containing less protein than other meats and increasing the risk for contracting listeria. The croissant roll is made of refined white flour and sugar. The client would benefit more from whole grain products. 4. Incorrect: Processed meats, such as hot dogs, are not the healthiest choice for the client, as they increase the risk for listeria. Also, a client with preeclampsia should avoid alcohol, caffeine, and refined sugar to help control the blood pressure. The glass of soda pop is not a healthy selection.)

A client shares with the nurse that they are having difficulty staying asleep. Which sleep hygiene intervention would the nurse share with the client to promote falling asleep? 1. Take a cool bath. 2. Include a daytime exercise plan. 3. Take an antihistamine at bedtime. 4. Scan the news feeds on the computer.

2. Include a daytime exercise plan. (2. Correct: Including a daytime exercise program is a sleep hygiene recommendation that will increase the quality of sleep. The exercise program increases metabolism and reduces stress. Activities after 1700 should be avoided if they a strenuous. 1. Incorrect: As the cycle of falling to sleep begins, the temperature of the hands and feet increases and the core temperature decreases. When the client takes a warm bath or shower, this will increase the temperature of the hands and feet. It is the cooling down of the body after the warm bath that promotes sleep. By taking a cool bath the temperature of the hands and feet will decrease at a faster pace. 3. Incorrect: Antihistamine are drugs that counteract histamine in the body. A side effect of histamines is sleepiness, which might assist one to fall asleep. Routine use of antihistamines is not recommended for insomnia, since tolerance for the antihistamines can occur and the medication is intended for short term use. 4. Incorrect: Scanning the news feeds on the computer is not a sleep hygiene recommendation. The news feeds can be disturbing and the light from the computer has a stimulating effect .)

A client enters the post-anesthesia care unit with a three way indwelling urinary catheter that has a continuous irrigation of normal saline infusing. The urine in the indwelling urinary catheter bag, is dark red. Which action should the nurse take first? 1. Chart the drainage color and amount. 2. Increase the flow rate of the irrigation solution until the urine is a light pink. 3. Notify the primary healthcare provider of the dark red drainage. 4. Pull traction on the indwelling tubing and tape the indwelling tubing to the client's leg.

2. Increase the flow rate of the irrigation solution until the urine is a light pink. (2. Correct: Continuous bladder irrigation is used following surgery to ensure that the bladder remains clear of blood clots.The nurse would need to increase the irrigation rate until the urine becomes light pink. 1. Incorrect: If the urine is not diluted, the client could form clots in the urine that could obstruct the urine flow. Charting the drainage color and amount would not address the issue. 3. Incorrect: Dark red color to the urine would warrant an increase in irrigation. There is no need to call the primary healthcare provider. If the color of urine doesn't clear or the vital sign show signs of shock (increased heart rate and decreased blood pressure) then notifying the primary healthcare provider would be needed. 4. Incorrect: This is the intervention that would be carried out if the client is hemorrhaging from the prostate. The balloon on the catheter would be used to apply pressure to the prostate and decrease bleeding. If there was more evidence of hemorrhage such as a decrease in blood pressure or increase in heart rate this type traction would be initiated. There is not enough evidence of hemorrhage at this point to initiate traction, therefore, more assessments should be performed.)

A nurse auscultates the bowel sounds of a client suspected of having a bowel obstruction in the transverse colon. What sounds would the nurse expect to hear in the abdominal quadrants? Select all that apply 1. Absent RLQ 2. Increased RLQ 3. Decreased RLQ 4. Increased LLQ 5. Decreased LLQ

2. Increased RLQ 5. Decreased LLQ (2. & 5. Correct: Peristalsis should increase in the ascending colon (RLQ) in an attempt to clear the blockage resulting in hyperactive bowel sounds. There will be little or no peristalsis distal to the obstruction (LLQ) resulting in decreased or absent bowel sounds. 1. Incorrect: Bowel sounds should be present proximal to the blockage (RLQ). 3. Incorrect: Peristalsis will increase proximal (RLQ) to the obstruction. 4. Incorrect: Peristalsis will be decreased or absent distal to the obstruction (LLQ).)

The charge nurse is observing a nurse perform a dressing change on a client with a Stage III pressure ulcer. What observation by the charge nurse would indicate a need for further teaching? 1. Irrigates the pressure ulcer with 50 mL normal saline. 2. Irrigates the pressure ulcer with half-strength hydrogen peroxide. 3. Packs the wound with sterile gauze soaked in normal saline. 4. Applies a hydrocolloid dressing over the wound after cleansing.

2. Irrigates the pressure ulcer with half-strength hydrogen peroxide. (2. Correct: Pressure ulcers should not be cleaned with substances that are cytotoxic such as hydrogen peroxide, betadine or Dakin's solution. Cytotoxic means toxic to cells, or cell-killing. Any agent or process that kills cells. These solutions can kill or damage cells, especially fibroblasts. Dakin's solution is a type of hydrochlorite solution. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine is the active ingredient in Dakin's solution. 1. Incorrect: Normal saline is an appropriate solution and is used to clean pressure ulcers. This does not kill or damage cells. 3. Incorrect: Normal saline is an appropriate solution and pressure ulcers may be packed with sterile gauze. This helps remove necrotic tissue. 4. Incorrect: The wound should be covered with an appropriate dressing after cleaning. Hydrocolloid dressings support healing in clean granulating wounds and autolytically debride necrotic wounds. Hydrocolloid dressings are occlusive, so they provide a moist healing environment, autolytic debridement, and insulation.)

A new nurse has a prescription to insert a feeding tube. The new nurse has never performed the procedure, but learned how to do it while in nursing school. What would be the best action by this new nurse? 1. Ask to observe another nurse perform the procedure. 2. Look up how to perform the procedure in the policy and procedure manual. 3. Tell the charge nurse that someone else will have to insert the feeding tube. 4. Insert the feeding tube as learned in nursing school.

2. Look up how to perform the procedure in the policy and procedure manual. (2. Correct: The best action for the nurse, is to look up how the procedure is done in the agency policy and procedure manual. The nurse could then discuss the procedure with a fellow nurse and ask them to observe during the procedure. 1. Incorrect: This is passive and will not give the new nurse the experience they need. The best action would be to look up how to do the procedure. Then the new nurse could discuss with another nurse, and have that nurse observe the insertion of the feeding tube by the new nurse. 3. Incorrect: This is not the best option. The new nurse needs to learn how to insert a feeding tube. This will not help the new nurse learn. Actually doing the procedure after checking the policy and procedures manual will give the new nurse the experience they need. 4. Incorrect: Nursing school knowledge is needed but also check agency policy and procedure manuals. Then the new nurse can discuss the procedure with a fellow nurse and ask the them to observe the feeding tube insertion.)

The nurse is providing discharge dietary instructions to a client diagnosed with full thickness burns to the right hand. To promote tissue healing, which food examples should the nurse provide to the client? Select all that apply 1. Pasta 2. Oranges 3. Brown rice 4. Chicken breast 5. Electrolyte drink

2. Oranges 4. Chicken breast (2., & 4. Correct: During the healing process vitamin C intake will promote collagen synthesis, increase healing time and decrease capillary fragility. An orange is high in vitamin C. The body requires an increased consumption of protein during the wound healing process. The increased protein intake results in greater collagen formation. 80% of the calories of a chicken breast are from protein. 1. Incorrect: Due to the low level of protein, pasta is not the correct choice for food that promotes wound healing. 3. Incorrect: The intake of brown rice will not promote tissue healing. There is no protein or Vitamin C here. 5. Incorrect: One cup of an electrolyte drink does not contain protein or vitamin C.)

A hospitalized client reports needing scented candles to aid sleep. The nurse informs client lit candles are not permitted in the facility. What appropriate alternatives could the nurse suggest to the client to assist with the sleep process? Select all that apply 1. Use an electric potpourri burner. 2. Place dry potpourri in nightstand. 3. Bring in live flowers to keep in room. 4. Spray scented air freshener frequently. 5. Dab scented oil on corner of the sheets.

2. Place dry potpourri in nightstand. 5. Dab scented oil on corner of the sheets. (2 and 5. Correct: The nurse must provide the client with alternatives methods to aid sleep that do not present a safety hazard. Potpourri is fragrant dried flowers or plant stems which emit a smell based on the assortment. Sprinkling a small amount inside the nightstand drawer would allow the scent to gently permeate the area next to the client's bed without presenting a safety hazard and the aroma would be consistent over long periods of time. Also, a tiny drop of an essential oil dabbed on the corner of the pillow case or sheet would also provide the client with desired needed sleep enhancement without impacting health or safety issues. 1. Incorrect: Hospitals have specific regulations about outside electronics, requiring most to be checked by maintenance staff prior to use in the facility. An electric potpourri burner melts scented wax in a small open ceramic dish, providing odor as it dissipates. An open container of hot wax plus the need to keep the burner plugged in all night are extreme safety hazards to client and staff. 3. Incorrect: This inefficient and costly method to aid client sleep is impractical on several levels. The fragrance of flowers rapidly fades, based on ambient temperature and room size. Additionally, the inconsistency of smell would not provide the same restful level of sleep during the night. 4. Incorect: Spraying non-hospital approved air freshener could prove problematic for other clients, since that odor would not be confined to just the client's room. Secondly, the quick dissipation of the spray would not provide an entire night of restful sleep.)

The nurse is teaching a client about the use of a cane. Which is the correct cane technique? 1. Place the cane on weaker side of the body to support the weaker leg. Using the cane for support, the client should step forward with strong leg, and then move the weaker leg and cane forward to the strong leg. 2. Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time. 3. Place cane on weaker side of body. The cane is placed forward 6 to 10 inches while the client advances weaker leg to the cane. 4. Place cane on stronger side of body to help support weaker leg. Using cane for support, step forward with the strong leg and then move the weaker leg and the cane forward to the strong leg.

2. Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time. (2. Correct: Place the cane on the stronger side of the body. The cane is placed forward 6 to 10 inches while the client advances the weak leg at the same time. The body weight is divided between the strong leg and the cane. 1. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling. 3. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling. 4. Incorrect: The cane should be on the stronger side of the body to create a wider base for balance as the client advances the strong leg and must use the weaker leg for support with the cane. If the cane is placed on the weaker side of the body, this would create a narrower base for support and balance and increase the risk of falling.)

The nurse is assisting a client with right-sided weakness to transfer from the hospital bed to a wheelchair. The client has an IV attached to an IV pole on the right side of the bed. How should the nurse complete this transfer? Select all that apply 1. Place the wheelchair on the left side of the bed. 2. Place the wheelchair on the right side of the bed. 3. Face the wheelchair toward the foot of the bed. 4. Face the wheelchair toward the head of the bed. 5. Have client grab the wheelchair with the right arm. 6. Have client grab the wheelchair with the left arm.

2. Place the wheelchair on the right side of the bed. 4. Face the wheelchair toward the head of the bed. 6. Have client grab the wheelchair with the left arm. (2., 4., & 6. Correct: The wheelchair should be placed on the right side of the bed where the equipment is located. It needs to face the head of the bed so the client can reach the chair with the strong left arm to help with the transfer. The client should grab the wheelchair arm with the strong left arm. 1. Incorrect: Since the IV and IV pole are on the right side of the bed, the wheelchair should be placed on the right side rather than the left side of the bed. There would not be enough slack in the IV tubing to get out on the left side. 3. Incorrect: If the wheelchair faces the foot of the bed, then the client would not be able to reach with the wheelchair arm with the strong left arm. The client needs to be able to use the left arm for stability. 5. Incorrect: The client should grab the wheelchair arm with the strong left arm. The right side is weak and grabbing with this side puts the client at an increased risk for falls and injury.)

Which action by two unlicensed nursing personnel (UAPs), while moving the client back up in bed, would require intervention by the nurse? 1. Lowers the side rails closest to them. 2. Places hands under client's axilla. 3. Lowers the head of bed. 4. Raises the height of the bed.

2. Places hands under client's axilla. (2. Correct: This action is not appropriate and requires intervention by the nurse. This could damage the brachial plexus nerves under the axilla. Use a draw sheet to prevent this from occurring. 1. Incorrect: This is a correct action. The UAPs will need to lower the side rails closest to them to safely move the client up in bed. Not lowering the rails could injury the UAPs back. 3. Incorrect: This action is correct. Moving the client upward with the head of the bed raised works against gravity, requires more force and can cause back strain. 4. Incorrect: This action is appropriate and would not require intervention by the nurse. Raising the height of the bed brings the client close to the UAPs center of gravity and decreases the chance of back injury.)

The nurse is making a home assessment for the purpose of preventing injury for a visually impaired elderly client who also has diabetes. Which findings are important for the nurse to include in this assessment? Select all that apply 1. Episodes of mild anxiety 2. Rugs secured to the floor 3. Adequate lighting 4. Functional eye glasses 5. Client is wearing well-fitting closed toe shoes

2. Rugs secured to the floor 3. Adequate lighting 4. Functional eye glasses 5. Client is wearing well-fitting closed toe shoes (2., 3., 4. & 5. Correct: Throw rugs may cause falls, as the client may trip. Diabetes may also impact sensation to know there is a rug in place. Adequate lighting is important so that the client does not bump into furniture or miss a step when navigating stairs. The visually impaired client needs functioning glasses to maximize sight and safety within the home. Diabetic clients do not need open toed shoes, as injury may occur to the foot and the client may not actually be aware of it. Also, wearing sandals is a risk to the person who is visually impaired and elderly, as the shoe may come off unexpectedly. 1. Incorrect. While depression is common and may result in self harm for elderly clients, anxiety is not likely to result in injury. Depression assessment should be performed on all elderly clients.)

While programming the client's IV infusion pump the nurse notes that the display screen on the infusion pump is cracked. What is the best action for the nurse to take? 1. Continue to use the infusion pump and request a replacement pump. 2. Stay with the client and monitor the infusion while another staff member obtains a replacement pump. 3. Clamp and disconnect the infusion tubing prior to obtaining a replacement pump. 4. Slow the infusion to a keep-open rate and obtain a replacement pump.

2. Stay with the client and monitor the infusion while another staff member obtains a replacement pump. (2. Correct: The safest action is to stay with the client while a new infusion pump is obtained by another staff member. 1. Incorrect: When the screen on an infusion pump is cracked, water or other liquids can enter the case causing the pump to malfunction resulting in over-infusion or under-infusion. Defective infusion pumps should be locked out, tagged, and replaced immediately. 3. Incorrect: You should not completely clamp and disconnect the infusion tubing until a replacement pump is obtained. 4. Incorrect: While slowing the infusion sounds correct, the pump is cracked and you cannot ensure that it will maintain the set rate. Staying with the client until a replacement pump is obtained is the safest option.)

A recently hired primary healthcare provider from India has started working at the local hospital. When receiving new phone prescriptions, the nurse is unable to understand the primary healthcare provider's thick accent. Which comment by the nurse is most likely to successfully resolve the issue? 1. "I'll have to get someone who can understand you." 2. "I can't understand you. You need to say it again." 3. "Can you please repeat that prescription again slowly? " 4. "I don't know what you are trying to say."

3. "Can you please repeat that prescription again slowly? " (3. Correct: The issue involves difficulty understanding the verbal phone prescriptions rom the new primary healthcare provider. Any comment by the nurse must be both professionally worded and culturally sensitive. In this statement, the nurse is asking for the orders to be repeated and indicating the need to speak slowly. This does not place blame on the healthcare provider but does suggest a process to resolve the situation in a professional manner. 1. Incorrect: This response is not the best. It may imply cultural insensitivity and that the inability to communicate is solely the fault of the primary healthcare provider. 2. Incorrect: This may be a truthful statement, but it is not professionally stated. This phrasing by the nurse suggests that the problem is the fault of the primary healthcare provider. Additionally, the manner in which the nurse asks the prescription to be repeated sounds abrupt and demanding. 4. Incorrect: There is no attempt by the nurse to resolve the situation with any suggestions, which is both culturally insensitive and unprofessional. A tone of frustration would not help the nurse to clarify the prescription.)

A client diagnosed with glaucoma is being instructed on self-instillation of eye drops. What statement by the client would indicate to the nurse that teaching was successful? 1. "I should look into the mirror to be sure I am getting the drops in." 2. "I will put all drops in my eyes and then close eyes for 5 minutes." 3. "I have to be sure not to touch the dropper to any part of my eye." 4. "I have to pull down the upper lid when putting the eye drops in."

3. "I have to be sure not to touch the dropper to any part of my eye." (3. Correct: The client is correctly stating the importance of not contaminating the eye drop bottle by touching it to the eye. This statement indicates teaching was successful. 1. Incorrect: Instilling eye drops cannot be accomplished with a mirror because the client will need to look up toward the ceiling when placing drops into the eye. 2. Incorrect: Only one drop is instilled at a time, even when multiple drops are prescribed by the primary healthcare provider. The client needs to instill one drop, wait approximately 5 minutes and then instill the next drop of the same medication. 4. Incorrect: It is not possible to instill eye drops if the client pulls down the upper lid. The eye would be closed with no access for drops.)

An adolescent is being instructed on the proper way to use crutches following knee surgery. The nurse knows that teaching has been successful when the client makes what statement? 1. "The weight of the crutches should be on my shoulders." 2. "It's ok to lean against the crutches if I am standing still." 3. "If going up the stairs, my non-operative leg goes up first." 4. "When sitting down, first lean crutches against the wall."

3. "If going up the stairs, my non-operative leg goes up first." (3. Correct: It is evident that the client has understood the nurse's instructions with this statement. When going up stairs with crutches, the unaffected (non-operative) leg goes up first. The strong leg bears the body weight and therefore provides a solid base while the client lifts up the weaker leg. 1. Incorrect: The correct position for crutches should be about 2 inches below the axilla and never directly up into the arm pit. Body weight is carried by the hands on the hand-grips, which means the force to push comes from the forearms and biceps, not the shoulders. Bearing weight in the axilla can cause severe damage to the axillary nerves and muscles. 2. Incorrect: Crutches are an ambulatory aid only and, if not used correctly, can actually be a safety hazard. Even if the client is standing still, it is unsafe to use crutches as a leaning support. Additionally, even resting on the crutches can cause trauma to the axillary area. 4. Incorrect: When sitting in a chair, the client should back up to the chair until the back of the knees gently touches the chair seat. The client should then reach back and grab the arm of the chair while holding both crutches in the other hand. Once seated, the client can then lean the crutches upright nearby. They will balance better if stood upside down.)

The nurse is preparing to administer a hepatitis B vaccine 1 mL IM to a client. Which syringe should the nurse use to administer this vaccine? 1. 1 mL syringe. 2. Orange capped syringe. 3. 3mL syringe. 4. 10 mL syringe.

3. 3mL syringe. (3. Correct: The nurse needs to give 1 mL of vaccine IM to a client. Therefore, the appropriate size syringe would be a 3 mL syringe. 1. Incorrect: The syringe holds up to 1 mL, which is what is needed for the vaccine to be given. However, you do not want to fill the syringe to capacity, when there is another option. 2. Incorrect: This is an insulin syringe and should be used when administering insulin subcutaneously. IM injections should not be administered using this syringe. 4. Incorrect: Now this syringe holds up to 10 mL. You only need to give 1 mL. It will be harder to get a precise measurement of 1 mL with this syringe.

A nurse is evaluating an unlicensed assistive personnel (UAP) for proper body mechanics while lifting a heavy object off of the floor. What action by the UAP would indicate a need for further instruction by the nurse? 1. Testing the weight to determine if additional assistance is needed. 2. Keeping the feet shoulder width apart. 3. Bending from the waist to pick up the object. 4. Holding the object close to the body upon rising.

3. Bending from the waist to pick up the object. (3. Correct: You should not bend at the waist. This will injure your back. Lower your knees, and stay close to the object to use thigh muscles. 1. Incorrect: This is correct. If it is too heavy do not attempt to lift alone. 2. Incorrect: This is correct and will help maintain balance as you lower yourself to the floor. 4. Incorrect: This is correct. Holding close to the center of gravity will help prevent injury to your back and arms. Body mechanics describes the ways we move as we go about our daily routine. Poor body mechanics are often the cause of back problems. When we don't move correctly and safely, the spine is subjected to abnormal stresses that over time can lead to degeneration of spinal structures. The process of lifting places perhaps the greatest loads on the low back and therefore, has the highest risk of injury. Use of proper lifting mechanics and posture is critical to prevent injury. How to lift safely: Place the load immediately in front of you. Bend the knees to a full squat or lunge position. Bring the load towards your chest. Assume a neutral position with your back. Tighten the lumbar and buttocks muscles to "lock" the back. Lift now from the legs to the standing position DO NOT Lift from a twisted / sideways position. DO NOT Lift from a forward stooped / imbalanced position.)

A client is brought to the emergency room following a serious motor vehicle accident. Standing orders include initiating an IV line and inserting a foley catheter. What action should the nurse take first? 1. Obtain all supplies for the procedures. 2. Explain the procedure to the client. 3. Check the client's identification band. 4. Verify client has signed consent forms.

3. Check the client's identification band. (3. Correct: Even in an emergency, the nurse follows the nursing process by initially gathering data, including identifying the client before beginning any ordered interventions. The client's identity must always be verified before any procedure or treatment. 1. Incorrect: It is important to make sure all necessary supplies are present before beginning an intervention. Stopping in the middle of a procedure to get supplies could expose the client to infection or other complications. However, gathering supplies is an action, which is not the first step when providing care to any client. 2. Incorrect: While it is important to explain any procedure to the client, the scenario does not indicate if this client is even conscious. The nurse has another important priority. 4. Incorrect: When stabilizing an injured client, consent is implied for life-saving procedures such as initiating an IV or applying oxygen. Additionally, obtaining or verifying consent is not a nursing responsibility.)

What action should the nurse take when testing a client's near vision? 1. Have client read a Snellen chart from 20 feet away. 2. Have client read Ishihara plates (see image) at 30 inches (75 cm). 3. Have client read a newspaper at 14 inches (36 cm). 4. Have client alternate gaze from a near object to a distant object.

3. Have client read a newspaper at 14 inches (36 cm). (3. Correct: The nurse can get a general idea of near visual acuity by asking the client to read from a newspaper. The newspaper should be held 14 inches from the eyes. This exam can also be done with the Jaeger chart containing a few short lines or paragraphs of printed text. The size of the print gradually gets smaller. The client is asked to hold the card about 14 in. (36 cm) from the face and read aloud the paragraph containing the smallest print he/she can comfortably read. Both eyes are tested together, with and without corrective lenses. This test is routinely done after age 40, because near vision tends to decline as one ages (presbyopia). 1. Incorrect: The Snellen chart is used to test distant vision. To test distance vision, individuals stand 20 feet from the Snellen eye chart, cover one eye, read aloud the smallest line they can clearly see, and then repeat this process with the other eye. After performing an eye test, a person's visual acuity is written as a fraction. Normal vision is defined as 20/20 visual acuity, which means at 20 feet away from the eye chart, the person is able to read the line that most human beings with normal vision can read at 20 feet away.​ 2. Incorrect: Ishihara plates are used to assess color blindness, and are not used to test near vision. 4. Incorrect: Having the client alternate their gaze from a near object to a distant object tests for accommodation. It does not test for near vision.)

Prior to signing a consent form for surgery, the client states, "I am not sure that I understand the possible risks for this surgery and what the alternative treatments are." What should the nurse do first? 1. Clarify any questions that the client may have and then share the client's concern with the primary healthcare provider. 2. Reinforce that it is not unusual for clients to have questions about surgery. 3. Inform the primary healthcare provider that the client has concerns about the surgery. 4. Use open ended questions to explore client's concerns.

3. Inform the primary healthcare provider that the client has concerns about the surgery. (3. Correct: The nurse should call the primary healthcare provider. Further discussion with the client is warranted from the primary healthcare provider that has scheduled and most likely will be performing the surgery. This also provides the client the opportunity to ask questions appropriately. 1. Incorrect: The client has the right to make informed decisions. The client should not sign until all questions are answered by the primary healthcare provider. 2. Incorrect: Recognizes client concerns, but does not take care of problem. The nurse has a responsibility to be an advocate for the client and practice within the law. 4. Incorrect: The informed consent comes from discussion between the primary healthcare provider and the client. The nurse can do this, but it doesn't fix the problem.)

A nurse is caring for client with a left above the knee amputation 48 hours postop. The client is experiencing left lower leg pain on a scale of 6 out of 10. Which pain relief intervention would the nurse implement? 1. Position the client in a supine position. 2. Rewrap the ace bandage on the stump. 3. Instruct the client in guided imagery techniques. 4. Initiate range of motion exercises to the knee.

3. Instruct the client in guided imagery techniques. (3. Correct: Phantom limb pain (PLP) may be experienced in the amputated part after surgery. The client may describe the PLP as crushing, cramping, and burning. Complementary therapy is a non-pharmacological comfort measure that can be utilized to reduce the client's PLP. Instructing the client to implement guided imagery techniques will assist the client in reducing PLP. 1. Incorrect: Placing the client in various positions in bed by the nurse will not reduce the client's PLP. The client's PLP can be addressed with complementary therapy and medications such as calcitonin, beta-blockers, antiepileptics, antispasmodics or antidepressant medications. 2 Incorrect: Rewrapping the ace bandage on the stump by the nurse will not reduce the phantom limb pain. Wrapping the stump will decrease edema, secure the dressing, and assist in shrinking the limb. 4. Incorrect: Range of motion exercises will decrease the possibility of flexion contractures of the hip and knee. The improved flexion of the hip and knee with range of motion will not decrease PLP.)

A nurse is feeding a client diagnosed with a stroke who is exhibiting dysphagia. Which action by the nurse would be appropriate? 1. Elevate the head of the bed to 15 degrees. 2. Request the client to not hold food in their mouth. 3. Monitor for frequent throat clearing after eating. 4. Orient the client to the location of food on their plate.

3. Monitor for frequent throat clearing after eating. (3. Correct: When helping to feed a client with dysphagia, the nurse should monitor for signs of aspiration such as frequent throat clearing during and after meals. The client is trying to move the bolus of food down esophagus. Aspiration is a condition where food, liquids or saliva moves into the lungs instead of the esophagus during eating. 1. Incorrect: The client should be sitting upright or a high-fowlers position. This position allows for more flexibility of neck movement to promote swallowing. The nurse can keep the client's neck in the neutral position or their chin lowered to their chest. 2. Incorrect: Why is the client holding food in their mouth? Are they disoriented or with a cognitive impairment? Asking a client who is disoriented or with a cognitive impairment to not hold food in their mouth is not an effective intervention. 4. Incorrect: Does the location of the food on the plate affect how a client swallows the food. The location of the food will not affect the possibility of the client aspirating during swallowing food.)

The circulating nurse prepares the sterile field in the operating room (OR). Fifteen minutes later, the nurse is informed the surgery will be delayed for 20 minutes because the surgeon is working at another hospital. Which is the best action for the nurse to take? 1. Cover the sterile field with a sterile drape until the surgery is about to begin. 2. Close and tape the OR doors so that no one may enter. 3. Monitor the sterile field while awaiting the surgeon. 4. Tear down the sterile field until the surgeon arrives in the OR.

3. Monitor the sterile field while awaiting the surgeon. (3. Correct: The nurse should monitor the sterile field while awaiting the surgeon. This means keeping the sterile field in your site. 1. Incorrect: Sterile fields should not be covered. Although there are no research studies to support or discount the practice, removing a table cover may result in a part of the cover that was below the table level being drawn above the table level or air currents drawing microorganisms from a nonsterile area to the sterile field. It is important to continuously monitor all sterile areas for possible contamination.​ 2. Incorrect: There is no specified amount of time designated that a room can remain open and not used and still be considered sterile. The sterility of an open sterile field is event-related. An open sterile field requires continuous visual observation. Direct observation increases the likelihood of detecting a breach in sterility.​ 4. Incorrect: It is unnecessary to tear down the sterile field as the delay is minimal. This is also an added cost to discard materials and redo the sterile field when it has not been contaminated. Sterile fields should be prepared as close as possible to the time of use. The potential for contamination increases with time because dust and other particles present in the ambient environment settle on horizontal surfaces over time. Particulate matter can be stirred up by movement of personnel when opening the room and also can settle on opened sterile supplies.)

A client is scheduled for surgery today. As the nurse prepares the pre-op medication, the client says, "I have changed my mind. I don't want to go through with the surgery." What should the nurse do first? 1. Convince the client to proceed with the plans for surgery. 2. Notify the surgery department to cancel surgery. 3. Notify the primary healthcare provider of the client's decision. 4. Suggest that the client talk over the decision with family members.

3. Notify the primary healthcare provider of the client's decision. (3. Correct: The client has the right to make decisions about their care. The primary healthcare provider should be notified about the client's decision to not have the surgery. 1. Incorrect: The nurse should not try to convince the client into having the surgery. If the nurse tries to have the client do something they do not want to do, the client is being coerced to make a decision by the nurse. This breaches the client's rights. 2. Incorrect: The primary healthcare provider should be notified prior to the surgery department being notified. The primary healthcare provider will need to review the client's plan of care with the client. 4. Incorrect: The client has informed the nurse of their decision. The nurse should not suggest any further action related to the client's decision. The client has the right to make decisions autonomously.)

When preparing to administer the client a dose of intravenous (IV) antibiotics, the nurse notes that the IV pump cord is frayed with wiring visible. What priority action should the nurse take? 1. Notify maintenance to come and check the pump immediately. 2. Continue to use the IV pump and fill out an equipment maintenance request. 3. Obtain a replacement pump. 4. Tag the equipment for maintenance.

3. Obtain a replacement pump. (3. Correct: Removing potentially hazardous equipment is priority. Continued use of a faulty IV pump could lead to client endangerment such as electrical shock or fire. 1. Incorrect: Maintenance should be notified, but after equipment is removed from client care and properly tagged. Do not leave potentially hazardous equipment in patient's reach. 2. Incorrect: The equipment maintenance request should be filled out but after the equipment is removed from client care. The nurse needs to get a properly working IV pump to administer the antibiotics. 4. Incorrect: This should occur after it has been removed from the client's room. Patient safety is always the priority.)

The nurse in the pediatric intensive care unit (PICU) is caring for a preschool child three days after open heart surgery. What assessment finding should the nurse report immediately to the primary healthcare provider? 1. Increased episodes of fussy crying. 2. A hacking, non-productive cough. 3. Oral temperature of 100.9°F (38.3°C). 4. Chest tube draining 30 mL per shift.

3. Oral temperature of 100.9°F (38.3°C). (3. Correct: An oral temperature of 100.9°F (38.3°C) is considered too elevated for 3 days post-op. An oral body temperature greater than 100.5°F (38.1°C) indicates the potential for infection. Although no other vital signs are given in the scenario, a temperature this elevated would need to be reported immediately by the nurse to the primary healthcare provider. 1. Incorrect: Increasing episodes of crying could indicate many things in a preschool child, including pain, fear, loneliness, or even elevated body temperature. While this change in the client's status will need to be investigated further, the nurse would not need to report this behavior at this time. 2. Incorrect: A hacking, non-productive cough, even several days after open heart surgery, could be attributed to the effects of intubation, anesthesia, or even certain cardiac medications. Clients are always encouraged to cough and deep breathe in order to prevent pulmonary complications. If the cough becomes productive or breathing becomes labored, the nurse would need to report this to the primary healthcare provider. This is not an urgent concern for the nurse. 4. Incorrect: Chest tube drainage is common following open-heart surgery, even three days later. It is impossible to evaluate whether 30 mL in one shift is a change since there are no parameters to compare the previous shift's output. The nurse would not need to report this drainage at this time.

The nurse is caring for a client in the Emergency Department (ED) who reports a migraine headache unrelieved by over the counter medications. This is the 4th visit to the ED for this problem in 6 weeks. What is the priority nursing intervention? 1. Refer the client to their primary healthcare provider in the morning. 2. Make the client an appointment with the chronic pain clinic. 3. Rate the client's pain using the pain scale used in the ED. 4. Perform a visual acuity test.

3. Rate the client's pain using the pain scale used in the ED. (3. Correct: Just because a client is a frequent visitor to the emergency department reporting migraines does not mean that the client is addicted to narcotics or that the client is not really experiencing the pain. Pain is what the client says it is and assessment is priority. 1. Incorrect: This is delay of treatment and does not address the pain. The nurse should have the client rate the pain in order to become objective data. 2. Incorrect: This is the primary healthcare provider's decision and also indicates you think the pain is not real. Assessment by the nurse and primary healthcare provide are warranted. Don't delay treatment. 4. Incorrect: Assessment of the eyes could be an option since eye strain can lead to headaches. Rating their pain would be the priority assessment however.)

The client who is scheduled for a cholecystectomy asks the nurse about her opinion on the surgeon who is going to perform the surgery. The nurse says to the client, "You should get a second opinion because your surgeon has been involved in several client lawsuits." Because the surgeon has not been involved in any client lawsuits, the nurse has initiated which tort? 1. Assault 2. Libel 3. Slander 4. Negligence

3. Slander (3. Correct: Slander is sharing verbal untruths that will harm the reputation of the surgeon being accused of untrue rumors. The nurse is verbally defaming the surgeon about possible lawsuits. 1. Incorrect: Assault is a physical attack on another person. The nurse is not physically touching the client or the surgeon, but is verbally accusing the surgeon of untrue rumors. 2. Incorrect: Libel is the defamation of character by print or pictures. The nurse is not writing her statement about the surgeon, but verbally expressing rumors about the surgeon. 4. Incorrect: Negligence is the commission of an act that of reasonably prudent nurse would not do under similar situation. The nurse slandered the surgeon, but did not fail to do an act that another nurse would do under the same situation.)

A client is sedated. His wife asks the nurse about her husband's test results. The client does not have a healthcare proxy or durable power of attorney executed at this time. How should the nurse respond in compliance with HIPAA (Health Insurance Portability and Accountability Act) regulations regarding the confidentiality of the sedated client's health information? 1. I can't give you those results. You should ask his primary healthcare provider the next time that he comes in to examine your husband. 2. Those test results are confidential, but since you are his wife I can give them to you. Let me look them up in the computer system. 3. The health information of all clients is confidential and is protected by law. Those test results cannot be released without the consent of the client in order to protect the client's right to choose who receives health information. 4. Your husband is only lightly sedated. I can wake him up and ask him if it is all right to release these test results to you.

3. The health information of all clients is confidential and is protected by law. Those test results cannot be released without the consent of the client in order to protect the client's right to choose who receives health information. (3. Correct: Each client's health information is confidential and protected by law. The nurse should inform the client's wife of this fact, and explain the rationale for health information confidentiality. Family members are often offended or angry upon learning that health information cannot be released to them without the client's consent , but healthcare employees are bound by law to confidentiality. 1. Incorrect: The wife is not automatically able to receive personal health information about her husband.The husband has to list the wife as a person who can receive personal health information. The Healthcare employees, including primary healthcare providers, are bound by law to keep health information confidential without the client's consent. 2. Incorrect: Healthcare employees, including primary healthcare providers, are bound by law to keep health information confidential without the client's consent. 4. Incorrect: A client who has received sedative medications cannot give legal consent, as these medications alter a client's level of consciousness and impair the ability to make informed decisions.)

The nursing unit manager is reviewing cardiopulmonary resuscitation protocols with a group of new nurses. When the unit manager asks for an indication of effective CPR on an adult, what new nurse response would be most accurate? 1. Chest wall visibly rises with rescue breathing. 2. Skin color and temperature becomes pink and warm. 3. There is a palpable femoral pulse with a compression. 4. A sinus beat appears on monitor during compression.

3. There is a palpable femoral pulse with a compression. (3. Correct: Cardiopulmonary resuscitation is considered effective if the nurse or medical personnel can palpate a femoral pulse with each chest compression. Though the lay person is taught to assess a carotid pulse, the femoral pulse is utilized in a hospital setting. 1. Incorrect: While it is true that the chest should visibly rise during effective rescue breathing, the question is asking about cardiopulmonary resuscitation, not rescue breathing. 2. Incorrect: Chest compressions during cardiopulmonary resuscitation are designed to keep vital internal organs oxygenated until an AED or defibrillator is available to restart the heart. Skin is not considered a vital organ and therefore skin color and temperature does not change unless a heartbeat is restored. 4. Incorrect: Any complex or rhythm noted on the monitor during chest compressions indicates only electrical impulses within the heart muscle and does not actually indicate a contraction unless accompanied by a pulse. This is referred to as 'pulseless electrical activity', and CPR should continue.)

A client asks, "I would like to view my medical records." Which response made by the nurse is most appropriate? 1. You will first need to contact your primary healthcare provider. 2. You may view your electronic health records on a weekly basis. 3. You have the right to view the medical records that pertain to your care. 4. You want to view your medical records?

3. You have the right to view the medical records that pertain to your care. (3. Correct: According to the Client's Bill of Rights, the client has the right to view medical records pertaining to the client's care and to have those records explained if necessary. 1. Incorrect: The client may contact medical records and does not need to first contact the primary healthcare provider. 2. Incorrect: The electronic health record can be made available to the client when requested. 4. Incorrect: This is an open ended question, but the client may view this as challenging their desire to view the medical records.)

A client scheduled for an amniocentesis expresses concerns about the procedure to the nurse, despite having signed the consent form. What statement by the nurse would be most appropriate for the client? 1. "Don't worry, it's a very simple procedure." 2. "You have already signed the consent form." 3. "I will tell the doctor you need to talk more." 4. "Can you tell me what most concerns you?"

4. "Can you tell me what most concerns you?" (4. Correct: The client is obviously having second thoughts and needs further clarification or discussion. Even though a consent form was signed, the client has the legal right to withdraw that consent at any time. This open-ended question by the nurse is an appropriate approach to encourage the client to express concerns, allowing the nurse to gather further information and formulate a suitable plan to proceed. 1. Incorrect: A nurse should not use the words "don't worry" to a client. Doing so dismisses both the client's feelings and the right to request further information. This is not a "very simple procedure", and has definite, potentially serious complications. This comment by the nurse does not employ any appropriate therapeutic communication techniques. 2. Incorrect: This comment by the nurse is not true, since a client can withdraw consent for a procedure at any time, including just before the actual procedure. The client is expressing concerns about the amniocentesis now. "Patient Rights" always assure clients the ability to question any and all proposed treatments at any time. 3. Incorrect: Since the client needs more information, it would be important to notify the primary healthcare provider. However, it is not appropriate on the NCLEX to transfer care of the client to someone else initially. The client is anxious and worried; therefore, the nurse should use therapeutic communication techniques to encourage the client to talk.)

A client with a history of deep vein thrombosis (DVTs) is being instructed on how to apply compression stockings prior to discharge. What statement alerts the nurse the client may be noncompliant when at home? 1. "I will follow the special diet in order to lose weight." 2. "I should walk a little every few hours after sitting." 3. "My husband can help remind me not to cross my legs." 4. "The stockings are too difficult to put on every morning."

4. "The stockings are too difficult to put on every morning." (4. Correct: Compression stockings are used to prevent the formation of blood clots, reduce the diameter of distended veins and decrease stasis. Usually these stockings are ordered to be applied upon rising in the morning and removed at night, depending on the disease process. The client's comment suggests the difficulty of putting the hose on may lead to not wearing the stockings consistently. 1. Incorrect: This statement by the client indicates a positive attitude about the need to lose weight and the intention of following the prescribed diet. Obesity is one of several main factors that can lead to the development of DVTs. 2. Incorrect: Prolonged sitting, or even lying down, can increase the incidence of blood clots or DVTs. If the client does a lot of sitting during the day, it is advisable to walk around every few hours to reduce stasis. The client is acknowledging the need to increase mobility regularly, which is an indication of compliance. 3. Incorrect: Placing pressure directly on vessels by crossing the legs compresses both veins and arteries, thus increasing the potential for blood clots or dislodging an unknown clot. The client has acknowledged the need to keep legs uncrossed and the benefit of having family provide reminders.)

A nurse delegates an unlicensed assistive personnel (UAP) to transfer a client from the bed to a wheelchair with a mechanical lift. The UAP states "It has been a long time since I used the lift." To ensure that the UAP can properly operate the mechanical lift, which intervention would the nurse implement? 1. Assign the client to another UAP. 2. Verbally discuss the procedure for the lift. 3. Instruct the UAP to physically transfer the client. 4. Ask the UAP to demonstrate how to use the lift.

4. Ask the UAP to demonstrate how to use the lift. (4. Correct: The UAP should demonstrate how to transfer a client with a mechanical lift. The demonstration will assess the UAP's knowledge and skill to safely transfer the client using the mechanical lift. 1. Incorrect: Assigning another UAP to use the mechanical lift is not the appropriate solution to determining the skill of the current UAP. The nurse is directly responsible for ensuring that delegated interventions are safely performed. 2. Incorrect: The psychomotor skill of demonstrating the proper use of the mechanical lift should be initiated so the UAP can practice these skills safely. The verbal discussion related to the mechanical lift can be utilized in the evaluation phase. 3. Incorrect: Best practices reflect that the use of a mechanical lift for transfers is safer for both the client and the UAP than a physical transfer. Also the nurse has not identified that the UAP can safely transfer a client with a mechanical lift.)

At a summer pool party, an adult client is found unconscious in the water. Someone calls 911, and a nurse present at the party immediately initiates what priority action? 1. Initiate chest compressions. 2. Assess client for any injuries. 3. Wrap client in warm blankets. 4. Check for any respirations.

4. Check for any respirations. (4. Correct: In any emergency situation, the nurse must still adhere to Maslow hierarchy and follow current American Heart Association guidelines when assessing a client. Once the client has been pulled from the water, the first action is to open the airway and check for the presence of spontaneous respirations. 1. Incorrect: While this client will most likely require cardiopulmonary resuscitation, the nursing process requires assessment prior to initiating any action. Additionally, checking for any respirations must be done before starting chest compressions. 2. Incorrect: There is no information on whether the client fell into the pool or was already in the pool; therefore, the client will need to be assessed for injuries at some point. However, that particular assessment is not the initial priority action. 3. Incorrect: The client's core body temperature may be decreased. However, hypothermia is not an initial concern with this client, and in fact, hypothermia can sometimes be beneficial in a drowning situation.)

A nurse has received morning report on multiple clients. What client should the nurse assess first? 1. Client on 2/L min, of oxygen by nasal cannula with pneumonia. 2. Client with Crohn's disease reporting two semi-loose stools. 3. Client one day post-appendectomy reporting abdominal cramps. 4. Client on heparin drip reporting bleeding gums when brushing teeth.

4. Client on heparin drip reporting bleeding gums when brushing teeth. (4. Correct: This client is currently on a heparin drip, possibly for a DVT. Bleeding gums sometimes occurs in those who brush teeth too vigorously; however, bleeding in a client on a heparin drip could indicate a serious side effect. This client should be seen immediately. 1. Incorrect: It is not unusual for a client with pneumonia to need supplemental oxygen by nasal cannula and 2L/min, is a very small amount. Although this client will definitely need a respiratory assessment, there is no indication that any complications are occurring. This client is not a priority. 2. Incorrect: Crohn's disease is an auto-immune process in which inflammation of the large and small bowel causes pain and diarrhea. Reporting loose stools would not be unexpected for this client; therefore, this client would not need to be the first assessment. 3. Incorrect: One-day after an appendectomy, it would not be unusual for a client to have some abdominal pain or cramping. Although the nurse will need to assess for bowels sounds and inspect the dressing, this client is not a priority.)

The nurse is preparing to bathe a client who is confined to the bed. Which action by the nurse is important to preserve client's self-esteem as the task is completed? 1. Closes the door for privacy. 2. Introduces self and explains the procedure. 3. Bathes the client without the help of others. 4. Covers the client with a bath blanket.

4. Covers the client with a bath blanket. (4. Correct: The client does not have to be exposed during the bed change and should be covered with a bath blanket as the top sheet is removed. A bath blanket covers the client as once section at a time of the body is exposed and bathed. This allows for the most privacy and protects self-esteem. 1. Incorrect: Closing the door is very important but the client's privacy should be maintained at all times even from the nurse administering the bath. A bath blanket promotes privacy and protects the self-esteem. 2. Incorrect: Introducing yourself to the client and explain procedures shows respect. These two actions do not provide for privacy and preserve the self-esteem of the client. 3. Incorrect: If help is needed during an occupied bed bath to protect the client and provide for safety, help should be obtained. The nurse should use measures to protect privacy and preserve the client's self-esteem.)

Preparing to administer a bolus enteral feeding to a client who is receiving a proton pump inhibitor, a nurse checks the pH of aspirated gastric fluid to determine feeding tube placement. The pH reading is 6. Which action should the nurse take next? 1. Initiate the tube feeding. 2. Replace the feeding tube. 3. Notify the primary healthcare provider of the assessment finding. 4. Inspect the aspirated contents for color and consistency.

4. Inspect the aspirated contents for color and consistency. (4. Correct: The nurse should inspect the aspirated stomach contents for color and consistency to determine correct feeding tube placement. The normal stomach pH value is 1 to 4; however, when a client is receiving medications to decrease stomach acidity, the pH of the gastric aspirate may be as high as 6 and similar to the pH of respiratory secretions. Small intestines aspirates can also have a pH equal to or higher than 6. A pH of 6 does not confirm correct tube placement. Gastric contents are cloudy, green, tan, or off white, bloody or brown. 1. Incorrect: The tube feeding should not be initiated until feeding tube placement has been confirmed. 2. Incorrect: It is not necessary to replace the feeding tube at this time. Look at the aspirated contents for color and consistency. 3. Incorrect: Further data should be collected before notifying a primary healthcare provider.)

What personal protective equipment should the nurse wear into the room of a client who has been placed on droplet precaution? 1. Gloves 2. Gown 3. Goggles 4. Mask

4. Mask (4. Correct: For a client on droplet precautions, a facemask is worn for close contact with the client. 1. Incorrect: The only requirement for droplet precautions is that a mask needs to be worn. However, if there is a reasonable expectation of contact with secretions, such as through contact or spraying, additional standard precautions would be needed, such as gown, gloves, and goggles. There is not indication in this stem about additional precautions needed. 2. Incorrect: The only requirement for droplet precautions is that a mask needs to be worn. However, if there is a reasonable expectation of contact with secretions, such as through contact or spraying, additional standard precautions would be needed, such as gown, gloves, and goggles. There is not indication in this stem about additional precautions needed. 3. Incorrect: The only requirement for droplet precautions is that a mask needs to be worn. However, if there is a reasonable expectation of contact with secretions, such as through contact or spraying, additional standard precautions would be needed, such as gown, gloves, and goggles. There is not indication in this stem about additional precautions needed.)

A client arrives in the emergency department reporting signs and symptoms of nausea, numbness, prolonged muscle spasms, muscle twitching, and hand tremor. Current medications include furosemide 40 mg by mouth every morning. What acid/base imbalance does the nurse anticipate for this client? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

4. Metabolic alkalosis (4. Correct: This client's condition indicates pending metabolic alkalosis. Hypokalemia related to potassium loss with a loop diuretic is a cause of metabolic alkalosis. 1. Incorrect: This client has no respiratory symptoms. This is not respiratory acidosis. 2. Incorrect: This client has no respiratory symptoms. This is not respiratory alkalosis. 3. Incorrect: This client's condition is related to hypokalemia. Acidosis is related to hyperkalemia. This client is on a loop diuretic and the signs and symptoms point to hypokalemia.)

The nurse asks if the client has an advance directive. The client responds by saying, "What is an advance directive?" What is the nurse's best response to the client's question? Select all that apply 1. Specifies your wishes regarding your personal effects and finances should you become unable to make decisions. 2. Specifies your wishes regarding healthcare and your finances should you become incapacitated. 3. Similar to a will, it specifies your wishes for burial should you die during hospitalization. 4. Specifies your wishes regarding healthcare and treatment options should you become incapacitated. 5. The person signing the advanced directive must be competent.

4. Specifies your wishes regarding healthcare and treatment options should you become incapacitated. 5. The person signing the advanced directive must be competent. (4. & 5. Correct: An advance directive is a legal document prepared by a competent individual that specifies what treatments, if any, the client desires should the client become incapacitated or unable to make informed healthcare decisions in the future. The person signing the advance directive must be able to understand and agree with the document. 1. Incorrect: An advance directive does not address client personal effects and finances. These might be included in a last will and testament but are not part of an advance directive. 2. Incorrect: An advance directive does not address client personal effects and finances. These might be included in a last will and testament but are not part of an advance directive. 3. Incorrect: An advance directive does not address burial wishes.)

An unlicensed assistive personnel (UAP) is asked to transfer a client with left hemiplegia from the bed to a wheelchair. The nurse tells the UAP the safest approach for this transfer is what method? 1. Lift client from edge of bed, supporting under arms and pivot to chair. 2. Utilize a slide board to transfer client from bed to the wheelchair. 3. Apply an ambulation belt around client's waist and pull into the chair. 4. Use a mechanical lift to move client from the bed into the wheelchair.

4. Use a mechanical lift to move client from the bed into the wheelchair. (4. Correct: When transferring a large or physically impaired client out of bed to a wheelchair, safety for both staff and client is most important. The UAP should use a mechanical lift, first rolling the client onto the sling, attaching the lift loops, and allowing the machine to do the work of lifting the client. This provides a safe, gentle lift for the client and protects the UAP from injury. 1. Incorrect: This is not appropriate for a client with hemiplegia. Because the client has no sensation or control over the left side, managing that extra dead weight will be placed on the UAP. Trying to lift the client under the arms and pivot into the chair is extremely risky, putting both the client and UAP in danger of being injured. 2. Incorrect: A slide board is utilized when a client is lying flat and needs transferred between two flat surfaces, such as bed to stretcher. A slide board requires several people to utilize safely, and is not appropriate from bed to chair. 3. Incorrect: An ambulation belt is a wide, flexible belt of heavy cotton webbing that is placed around a client's waist to assist when moving from a standing position, whether walking or sitting in chair. In order to correctly utilize this belt, the client needs to be able to stand. This client has hemiplegia and would not be able to stand independently.)

A six month old infant has been admitted with a diagnosis of meningococcal meningitis. The primary healthcare provider has written multiple stat prescriptions. In what priority order should the nurse implement these prescriptions? Prepare client for lumbar pucture. Start IV of D5¼NS at 25 mL/hr. Place client on droplet precautions. Administer ceftriaxone 250 mg IV TID. Draw blood cultures every 8 hours ×3.

Place client on droplet precautions. Start IV of D5¼NS at 25 mL/hr. Draw blood cultures every 8 hours ×3. Prepare client for lumbar pucture. Administer ceftriaxone 250 mg IV TID. (First: This nurse's first priority must focus on safety for the greatest number of individuals, including staff and other clients. Because bacterial meningitis is highly contagious, the child should immediately be placed in isolation with droplet precautions. Second: The remaining prescriptions are all stat, so the nurse must consider which is most beneficial to the child, such as reducing the risk of further infection. Multiple needle sticks place the child at increased risk for infection, and even sepsis. In order to minimize the situation, the nurse should start the intravenous line of D5¼NS because another prescription can be completed simultaneously - drawing the blood! Third: Blood work can be drawn when the IV is started, thus decreasing the number of needle sticks. The IV site may also be used to administer a small amount of sedation prior to the prescribed lumbar puncture. Fourth: Prepare for lumbar puncture. Fifth: After that procedure, the first dose of ceftriaxone can be administered via the IV route.)

During night time rounds, the nurse finds a client has cigarettes in bed and the room is filled with smoke. In what order should the nurse perform the following actions? Remove client from room. Close the client's door. Pull the fire alarm handle. Get the fire extinguisher. Notify hospital operator.

Remove client from room. Pull the fire alarm handle. Notify hospital operator. Close the client's door. Get the fire extinguisher. (Anytime an internal disaster is suspected, client safety is always the first concern. National Fire Safety codes refer to the pneumonic "R-A-C-E" (rescue -alarm-contain-extinguish). If the area is safe for the nurse to enter, removing the client from that environment would be the first action. Secondly the nurse must activate the EMS alarm system so that emergency personnel are en route. Additionally, the hospital must be alerted by contacting the hospital operator to activate appropriate internal alarm systems. Closing the client's door will help contain any fire or smoke. Finally, the nurse should obtain the closest fire extinguisher appropriate for the type of fire.)

The nurse is removing the client's peripheral IV line prior to discharge. The nurse completes the appropriate steps in what order? Stabilize cannula with one hand. Loosen tape and tegaderm cover. Wash hands and apply gloves. Clamp IV line closed securely. Apply gauze and tape tightly.

Wash hands and apply gloves. Clamp IV line closed securely. Stabilize cannula with one hand. Loosen tape and tegaderm cover. Apply gauze and tape tightly. (When preparing to remove a peripheral IV line, the nurse begins by washing hands and applying non-sterile gloves. Next, the clamp is closed on the IV line or saline lock extension to prevent fluid or blood from leaking during process. Third, the nurse needs to stabilize the cannula with one hand to prevent trauma at the insertion site. Fourth, carefully begin to loosen all the tape on the site. The bottom dressing or tegaderm, is loosened last. Lastly, the nurse will place large, folded gauze square over the insertion site and gently pull the cannula out of the skin, while placing pressure on that gauze. After holding the gauze in place for a few moments, and checking for excess bleeding, the nurse will tightly tape that gauze square in place, providing pressure over the site. The client should be instructed to keep that dressing in place for at least one hour.)