PN Fundamentals Online Practice Test A 2023

A nurse is caring for a client who has metastatic cancer and practices Catholicism. The client asks the nurse to discuss the afterlife with them. Which of the following statements by the nurse assists in meeting the client's spiritual needs?

"Tell me what the afterlife means to you." Rationale: This statement respects the client's spiritual needs by using open-ended therapeutic communication to assist the client to talk about their concerns.

A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of the following instructions should the nurse include?

"When lifting a heavy object, keep it close to your body." Rationality: The nurse should instruct the client to keep the object as close to their body as possible to increase stability and decrease back strain when lifting a heavy object.

A nurse is reinforcing dietary teaching with a client who has chronic kidney disease and requires a low-potassium diet. Which of the following food choices by the client demonstrates an understanding of the teaching?

1 cup of applesauce Rationality: The nurse should determine that applesauce is the best food choice because 1 cup of applesauce contains 184 mg of potassium per serving. Therefore, the client's food choice of applesauce demonstrates an understanding of the teaching. The nurse should recommend that the client choose a different food that contains less potassium. One cup of cantaloupe contains 473 mg of potassium. The nurse should recommend that the client choose a different food that contains less potassium. One large baked potato contains 1,630 mg of potassium. The nurse should recommend that the client choose a different food that contains less potassium. Four ounces of banana chips contains 608 mg of potassium.

A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication?

Ask the client close-ended questions. Rationality: Clients who have aphasia can have difficulty forming words. Therefore, the nurse should ask the client questions that can be answered with a "yes" or "no" because the client can respond to these close-ended questions by shaking or nodding their head.

A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Assist a client to get out of bed after a breathing treatment. Rationality: The nurse should delegate assisting a client to get out of bed because this task requires little technical skill or judgment and is within the AP's range of function.

A nurse is assisting with the care of a recently deceased client. Which of the following actions should the nurse complete prior to the family viewing the body?

Clean soiled areas of the body. Rationality: A complete bath is not necessary because the body will be washed by the mortician. The nurse should cleanse any soiled areas prior to the family viewing the body, make sure dentures are in place if applicable, and comb the client's hair.

A nurse has delegated various client care tasks to the assistive personnel (AP) on the care team. Which of the following actions by the AP should the nurse identify as correct?

Donning a mask to measure the vital signs of a client who has pertussis Rationality: Caring for clients who have pertussis requires droplet precautions. Therefore, the AP should wear a mask when within 1 m (3.3 feet) of the client.

A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of the following actions should the nurse take to prevent client musculoskeletal injury?

Internally rotate the client's hips by using a trochanter roll rationality: The nurse should place trochanter rolls at the proximal end of each of the client's legs to maintain a neutral or internal rotation of the client's hips and to prevent external rotation of the hips, which can cause injury when the client is supine.

A client who has advanced cancer tells the nurse that they have a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication?

Let the client know that, as their nurse, they are available and willing to listen. - Rationality: Active listening conveys the nurse's respect and acceptance for the client's feelings and gives the client an opportunity to express their thoughts and needs.

A nurse at a long-term care facility is caring for a client who is alert. Which of the following actions should the nurse take to protect the client's privacy?

Speak with the client about their condition after visitors have left. Rationality: The nurse should ensure a private environment before discussing the client's condition with them.

A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching?

The client advances the unaffected leg first while climbing stairs. Rationality: When ascending stairs, the client should first advance the unaffected leg. The nurse should reinforce with the client that their axilla should not bear any weight while in the tripod position because this can cause pressure injury formation. The client should bear their weight with their arms and hands.

A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include?

Young adults should receive a dental assessment every 6 months. Ratinality: The nurse should include the recommendation for young adults to receive a dental assessment twice per year. Young adult males should have a testicular examination annually. Young adult females should have a routine physical examination every 1 to 3 years. Young adults who have an increased risk of exposure should receive a tuberculosis skin test every 2 years.

A nurse is calculating the intake and output for a client over the last 8 hr. The client is receiving a continuous IV infusion at 150 mL/hr and had 4 oz of juice and 0.5 L of water. How many mL of fluid should the nurse document as the client's intake for the last 8 hr? (Round your answer to the nearest whole number.)

1820 mL Rationality: First, calculate the intake separately for the continuous IV infusion, the juice, and the water, converting to mL as needed: Continuous IV infusion: 150 mL × 8 hr = 1,200 mL Juice: 1 oz = 30 mL4 oz × 30 mL = 120 mL of juice Water: 1 L = 1,000 mL 0.5 L × 1,000 mL = 500 mL of water Then, add all three together to find the total fluid intake: IV infusion + Juice + Water = Total fluid intake 1,200 + 120 + 500 = 1,820 mL

A nurse is reviewing the vital signs of four adult clients. Which of the following findings requires further data collection by the nurse?

A client who has a pulse rate of 110/min Rationality: This client's heart rate is above the expected reference range of 60 to 100/min. Therefore, the nurse should collect further data to determine the cause of the tachycardia. client's temperature is within the expected reference range of 36° to 38° C (96.8° to 100.4° F). Therefore, the nurse does not need to collect further data.

A nurse is providing wound care for a group of clients. Which of the following wounds should the nurse identify as healing by secondary intention?

A stage 3 pressure injury on the coccyx Rationality: The nurse should identify a pressure injury and other wounds with edges that are not approximated as healing by secondary intention. The nurse should identify a wound that is sutured as healing by primary intention. The nurse should identify a surgical wound that has intact staples as healing by primary intention. The nurse should identify a contaminated wound that is left open for monitoring and then closed after several days as healing by tertiary intention.

A nurse is assisting with the plan of care for a client who has a bacterial infection and a persistent oral temperature of 38.9° C (102° F). Which of the following interventions should the nurse include in the plan of care to treat the fever?

Administer acetaminophen Rationality: The nurse should administer acetaminophen or an NSAID such as ibuprofen to the client to reduce the body's temperature. Acetaminophen inhibits the synthesis of prostaglandins, resulting in a reduced fever. The nurse should maintain the room temperature between 21.1° to 26.7° C (70° to 80° F). A room temperature that is too low can lead to shivering, which increases the client's body temperature. The nurse should not apply ice packs to the client's axillae or groin because this measure can lead to shivering, which increases the client's body temperature. The nurse should limit the client's physical activity to decrease body heat production.

A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take?

Assign the client to a negative-pressure airflow room. Rationality: The nurse should assign the client to a negative-pressure airflow room to ensure that the air from the client's room is not circulated throughout the facility. The nurse should have the client wear a surgical mask whenever they leave their room to prevent transmitting bacteria to others.

A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess?

BUN 8mg/dl Rationality: A BUN of 8 mg/dL is below the expected reference range of 10 to 20 mg/dL. With fluid volume excess, the nurse should expect the client's BUN to be below the expected reference range due to hemodilution. A hematocrit of 42% is within the expected reference range of 37% to 47% for females and 42% to 52% for males. With fluid volume excess, the nurse should expect the client's hematocrit to be below the expected reference range due to hemodilution

A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age-related changes?

Circulation becomes less efficient with age. Rationality: Older adults have an increased sensitivity to temperature extremes due to decreased cardiac output. Poor cardiac output leads to less efficient circulation of blood to the tissues. Older adults have a decreased ability to regulate body temperature due to poor control of vasoconstriction and vasodilation. Older adults also have a reduced ability to shiver to increase body temperature. Older adults have a decreased body temperature due to a decrease in metabolic rate. Older adults will have a decrease in sweat gland activity, which affects body temperature regulation.

A nurse is preparing to remove a client's peripheral IV catheter. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first?

Clamp the infusion tubing. Rationality: Evidence-based practice indicates that the nurse should first clamp the infusion tubing after applying clean gloves. This action stops the flow of the IV fluid and prevents it from leaking out during the IV removal.

A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit? (Select all that apply.)

Cool extremities Orthostatic hypotension Flat neck veins rationality: Full bounding pulse is incorrect. A full bounding pulse indicates fluid volume excess. The nurse should expect a weak peripheral pulse in a client who has fluid volume deficit. Cool extremities is correct. Cool extremities can indicate fluid volume deficit. Moist crackles in the lungs is incorrect. Moist crackles in the lungs indicate fluid volume excess. The nurse should expect clear lungs in a client who has fluid volume deficit. Orthostatic hypotension is correct. Orthostatic hypotension indicates fluid volume deficit. Flat neck veins is correct. Flat neck veins indicate fluid volume deficit.

A nurse is caring for a client who is receiving continuous NG tube feedings. The nurse listens to the client's bowel sounds. Which of the following actions should the nurse take? (Click on the audio button to listen to the clip.)

Decrease the rate of the feeding - Rationality: The nurse should expect to hear bowel sounds every 5 to 35 seconds. This audio clip indicates hypermotility because there are greater than 40 bowel sounds/min. Hypermotility leads to diarrhea and is an indication of intolerance to the enteral feeding. Therefore, the nurse should slow the rate of the feeding to promote the client's tolerance of the feeding. The nurse should maintain a client who is receiving continuous NG tube feedings in a position with the head of the bed elevated 30° to 45° to prevent aspiration of the formula.

A nurse is preparing to palpate a client's pulse. The nurse should recognize that which of the following pulses is located on the top of the client's foot?

Dorsalis pedis Rationality: The nurse should document palpating the dorsalis pedis pulse on the top of the foot The popliteal pulses are located behind the knees. The brachial pulses are located at the inner aspect of the biceps muscles. The posterior tibial pulses are located on the inner side of the ankle below the medial malleolus.

A nurse is planning care for a client who is disoriented and at risk for falls. Which of the following interventions should the nurse include? (Select all that apply.)

Ensure that the client is wearing nonskid slippers. Rationality: Nonskid slippers provide better traction and can help prevent slipping and falling. Place the client in a room near the nurses' station. Keeping the client close to the nurses' station allows for more frequent observation to help identify actions that increase the risk for falls. Reinforce teaching about how to use the call bell. Rationality: Even if the client is confused, it is important to reinforce the use of the call bell for assistance to help prevent the client from attempting actions that could increase the risk for falls.

A nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care?

Ensure that the client wears a surgical mask during transportation throughout the facility. rationality: Streptococcal pharyngitis requires droplet precautions. The nurse should instruct the client to wear a surgical mask when outside of the room to prevent the spread of infection. Staff should make every attempt to limit the client's movement outside of the room. The nurse should provide a room with negative-pressure airflow for clients who require airborne precautions.

A nurse is caring for a client who has a Clostridium difficile infection. Which of the following solutions should the nurse use to perform hand hygiene while caring for this client?

Mild soap Rationality: The CDC recommends using soap and water for handwashing when caring for clients who have a C. difficile infection. C. difficile is a spore-forming bacterium that is difficult to kill with disinfectants. Chlorhexidine solution is effective against bacteria and viruses. However, this solution does not kill the spores of C. difficile. Triclosan is effective against some bacteria. However, this solution does not kill the spores of C. difficile. Isopropyl alcohol is an active ingredient in the alcohol-based cleansing solutions nurses use to perform hand hygiene when in contact with bacteria, fungi, and viruses. However, alcohol does not kill C. difficile

A nurse is preparing to administer oxygen to a client who has heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client?

Nonrebreather mask Rationality: A nonrebreather mask provides the highest percentage of oxygen concentration without intubation and mechanical ventilation. A Venturi mask can be adjusted to provide a consistent lower oxygen concentration. A simple face mask can be adjusted for short-term delivery of low to medium oxygen concentration. A nasal cannula provides a low oxygen concentration.

A nurse is caring for a client who has a COPD Exhibit 1 -Nurses notes 1000: Client admitted with a productive cough of thick yellow sputum. Breath sounds with crackles heard in left upper lobe and decreased breath sounds at bases bilaterally Exhibit 2: Vital Signs 1000: Temperature 38.6° C (101.5° F)Blood pressure 114/56 mm HgHeart rate 99/minRespiratory rate 32/minOxygen saturation 85% on room air Exhibit 3: Diagnostic Results 1200:Chest x-ray shows lung hyperinflation and left upper lobe pneumonia. Select the 3 findings that require follow-up.

Rationality: Select the 3 findings that require follow-up. temperature, oxygen saturation, breath sounds. Exhibit 1 answer: Breath sounds. Crackles are caused by mucous in the airways and are a manifestation of pneumonia. Decreased breath sounds indicate decreased ventilation and require follow-up by the nurse. Exhibit 2 Oxygen saturation. The client's oxygen saturation is below the expected reference range of 95% to 100%, indicating hypoxia. Therefore, this finding requires follow-up by the nurse. Exhibit 3 Temperature. The client's temperature is greater than the expected reference range, which indicates an infection. Therefore, this finding requires follow-up by the nurse.

A nurse is preparing to transfer a client from an acute care facility to a long-term care facility. Which of the following information should the nurse plan to include in the transfer report?

Resolved health conditions rationality: The nurse should report both unresolved and resolved health conditions to promote continuity of care. The nurse should report ongoing interventions, rather than completed interventions.

A nurse is taking notes of client information on a piece of paper while receiving report. Which of the following actions should the nurse take to dispose of the paper?

Shred the paper in a secure container. Rationality: The nurse should shred any written information in a secure container after use to protect the client's privacy and adhere to HIPAA guidelines.

A nurse is collecting data on four clients. Which of the following findings should the nurse report to the provider?

Urine output of 200 mL over 8 hr Rationality: A urinary output of less than 30 mL/hr can indicate low blood volume or kidney malfunction. The nurse should report an output that averages 25 mL/hr to the provider.

A nurse is caring for a client who has a prescription for a potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles?

beneficence Rationality: The nurse is demonstrating beneficence by acting in the client's best interest to make it possible for the client to swallow the medication. Nonmaleficence: means to avoid harm or injury to the client. This situation does not involve a choice among potentially painful interventions. Justice: refers to fairness in client care. A nurse demonstrates fairness by dividing their time among assigned clients to ensure all clients have their needs met. Autonomy: The nurse is not demonstrating autonomy. The nurse is attempting to compromise, rather than simply accepting the client's refusal of the medication.

A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching?

"I will be sure to keep the crutch tips dry." Rationality: The nurse should instruct the client to inspect the crutch tips frequently and keep them dry at all times to decrease the risk for slipping. The nurse should instruct the client to place their weight on the handgrips. Weight should never be borne on the axillae as this can damage the brachial plexus nerve bundle.

A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make?

"I see that you are angry. Let's sit down and talk." Rationality: This is an example of the therapeutic communication technique of offering self. It provides an opportunity for the nurse to understand the reason for the client's anger and provides a means for further communication.

A nurse is reinforcing teaching with a client about living wills. Which of the following client statements indicates an understanding of the teaching?

"The living will directs my medical care when I am unable to make decisions." Rationality: The living will provides specific directions for a client's medical treatment when the client is unable to make decisions due to their health status. Medicare requires health care facilities to inform clients about advance directives and about their right to make their own choices regarding living wills.

A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make?

"The reduced muscle tone has relaxed the jaw muscles." Rationality: Prior to death, decreased muscle tone causes jaw muscles to relax, resulting in an open mouth. Applying a chin strap is a postmortem action that the nurse can take to keep the mouth closed.

A nurse is reinforcing preoperative teaching with a client about how to turn, cough, and deep breathe. Which of the following statements by the client indicates an understanding of the teaching?

"This can help prevent pneumonia." Rationality: The purpose of turning, coughing, and breathing deeply is to reduce the risk of respiratory complications such as atelectasis, which can lead to pneumonia. This helps to maximize lung expansion and assist with the removal of pulmonary secretions. Turning, coughing, and deep breathing can reduce the risk of developing a pulmonary embolus, rather than prevent nausea. The nurse should instruct the client to turn, cough, and deep breathe every 1 to 2 hr to promote lung expansion. Turning, coughing, and deep breathing can reduce the risk of developing a thrombus formation, rather than tachycardia.

A nurse is reinforcing teaching about hospice care measures with the family of a client who is dying. Which of the following statements by a member of the client's family indicates an understanding of the teaching?

"We will keep her room cool to help her breathe better." Rationality: Clients who are dying will have thick secretions and decreased muscle tone, which can make breathing more difficult. Keeping the air in the room cool will ease the work of breathing.

A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse?

"When I look at myself in the mirror, I don't know if I can go on." Rationality: This statement shows sadness and a decreased initiative. The greatest risk to this client is injury from suicidal ideation. Therefore, the priority action is for the nurse to immediately contact the client's provider regarding this statement. It is important to acknowledge the client's feelings; however, another statement requires immediate action. It is important to ensure that the client has an accurate understanding of their condition; however, another statement requires immediate action.

A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take?

Administer an analgesic 30 min before starting the procedure. Rationality: The nurse should administer an analgesic to promote pain control, which allows the client to move more easily and be positioned to facilitate the irrigation procedure. The nurse should hold the syringe 2.5 cm (1 in) above the upper end of the wound and over the area they are cleaning to prevent syringe contamination and unsafe pressure of flowing solution. The nurse should place the irrigation solution in a basin of hot water to warm the solution to body temperature. This action will reduce vasoconstriction of the tissues. The nurse should use a 35-mL syringe with a 19-gauge needle or an angiocatheter to ensure an irrigation pressure within the correct range.

A nurse is caring for four clients who are required to provide informed consent for treatment. The nurse should identify that which of the following clients is able to provide informed consent?

An 18-year-old client who has acute appendicitis Raionality: A competent 18-year-old client who has acute appendicitis is able to provide informed consent for treatment. 16 years old - This client is considered a minor and is not old enough to provide informed consent. Therefore, this client is not able to provide informed consent. A parent or legal guardian should provide informed consent for this client.

A nurse is caring for a postoperative client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to an assistive personnel (AP)?

Apply thromboembolic stockings. Rationality: The application of thromboembolic stockings is within the range of function of an AP and does not require further data collection by the nurse. Reinforcing teaching is not within the range of function of an AP because it requires the knowledge and skills of the nurse.

A nurse is using Maslow's hierarchy of needs in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client?

Attend an exercise program Rationality: When using Maslow's hierarchy of needs, the nurse should determine that the priority activity is to fulfill the client's physiological needs for activity. Therefore, the nurse should recommend exercise and help the client select a suitable exercise program.

A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principles?

Autonomy Rationality: Autonomy is an ethical principle that refers to protecting a client's independence and right to make decisions about care. Nonmaleficence is an ethical principle that refers to the avoidance of causing harm.

A nurse is assisting with the admission of a client who has brought their medications to the facility. Which of the following actions should the nurse take?

Compare the medications the provider has prescribed with the client's medications from home. - Rationality: During admission, the nurse should compare the medications that the provider has prescribed with the medications that the client is taking at home to decrease the risk of medication error. The nurse should include this information in the client's medical record as a resource for other health care personnel.

A nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify correct placement of the NG tube?

Check the pH of the gastric aspirate rationality: The nurse should check the pH of the gastric contents to verify tube placement. A pH greater than 6 is an indication that the nurse has aspirated respiratory contents or that the tube is in the intestine, and that the nurse should withhold the feeding. The nurse should not auscultate over the epigastrium because this is not a reliable indication that the tube is in place. The nurse should measure the length of the inserted NG tube immediately after insertion of the tube. However, measuring the length of the tube at this point is not a reliable indication that the tube is in place.

A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care?

Compare the client's pedal pulses bilaterally every 4 hr. Rationality: The nurse should compare the pedal pulses bilaterally every 4 hr to check for adequate circulation for a client who has elastic bandages on their lower extremities. The nurse should remove the elastic bandages daily to inspect for skin breakdown. The nurse should check capillary refill distally every 4 hr for a client who has elastic bandages on their lower extremities. The nurse should elevate the client's legs for at least 20 min before applying the elastic bandages.

A nurse is preparing to administer a topical medication to a client. Which of the following actions should the nurse take?

Compare the label of the medication container with the medication administration record three times. Rationality: When preparing medication from a bottle or container, the nurse should compare the label of the medication container with the medication administration record three times to ensure it is the correct medication.

A nurse is caring for a client who is refusing medical treatment. Which of the following actions should the nurse take?

Document the client's refusal of the treatment. Rationality: The nurse is responsible for notifying the provider when a client refuses a treatment or procedure and documenting the client's decision. The provider is responsible for explaining the negative consequences of the client's refusal. The nurse should ensure that the client has been fully informed. However, the client has the right to refuse treatment.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infections?

Drain urine from the tubing before ambulation Rationality: Draining urine from the tubing before ambulation will prevent backflow of urine into the bladder. The nurse should hang the drainage bag below the level of the client's bladder to prevent backflow of urine into the bladder.

A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Evacuate clients from the area is the first step. Rationality: The first action the nurse should take when using the RACE protocol is to "rescue" or evacuate the clients from the area to prevent harm. Pull the lever on the fire alarm box is the second step. Rationality: For the next step, "alarm," the nurse should activate the facility fire alarm and call to report the fire to the facility emergency extension. Close the fire doors on the unit is the third step. Rationality: Close the fire doors on the unit is the third step. For the third step, "confine," the nurse should close the unit fire doors to prevent the fire from spreading. Use a fire extinguisher to put out the fire is the fourth step. Rationality: For the final step, "extinguish," the nurse should use a fire extinguisher to put out the fire by aiming the nozzle at the base of the fire and using a sweeping motion.

A nurse is reinforcing teaching with a client who has a partial hearing loss about how to modify the home environment. Which of the following is a priority modification that the nurse should include?

Flashing smoke alarm Rationality: The greatest risk to the client's safety is injury from a fire. Therefore, the priority modification is to install flashing smoke alarms because this allows the client to see when the alarm is activated rather than having to hear it.

A nurse is caring for a client who is postoperative following abdominal surgery. Exhibit 1: Nurses Notes 1100:Client received from PACU; initial vital signs recorded. Client drowsy but arouses to verbal stimuli. Client is oriented to person, place, and time. Client can move all extremities. Hypoactive bowel sounds. Abdominal dressing is intact with drainage noted and marked. Indwelling urinary catheter is in place and draining yellow urine. Infusing lactated Ringer's at 100 mL/hr to the right forearm. Client positioned for comfort and side rails are up x 2. Call light is within reach of client. 1115:Provider prescriptions reviewed. 1200:Upon waking, client reports nausea and rates pain as 6 on a scale of 0 to 10. Abdominal dressing intact; no further drainage noted. Urine output of 15 mL since 1100. Morphine 4 mg IV bolus and metoclopramide 10 mg IV bolus administered by charge nurse. 1230:Client reports relief from nausea, but not pain. Client rates pain as 8 on a scale of 0 to 10. No additional urine output since 1200. Repositioned client for comfort. Exhibit 2 Medication Administration Record Morphine 4 mg IV bolus every 4 hr PRN painMetoclopramide 10 mg IV bolus every 6 hr PRN nausea/vomiting Exhibit 3 Vital Signs 1100:Temperature 36.2° C (97.2° F)Heart rate 76/minRespiratory rate 18/minBlood pressure 122/68 mm HgOxygen saturation 95% on room air1200:Temperature 36.8° C (98.2° F)Heart rate 116/minRespiratory rate 20/minBlood pressure 112/68 mm HgOxygen saturation 93% on room air

Neurological findings Incisional drainage Urinary output Reported pain level Gastrointestinal findings Vital signs Urinary output - A client who has an indwelling urinary catheter should produce at least 30 to 50 mL/hr of urine. The client's output is less than the expected volume. The nurse should review the catheter's placement and the potential for blockage due to the client's reduced urine output. This finding should be reported to the provider. Reported pain level - The client's pain has not been relieved with the administration of morphine. According to the client's report, their pain level is increasing. This finding should be reported to the provider. Vital signs are - The client's heart rate and respiratory rate have increased, and their blood pressure and oxygen saturation levels have decreased. These findings should be reported to the provider. A nurse in an emergency department is caring for a client. Physical Examination 1200:Influenza with nausea/vomiting and diarrhea for 3 daysClient is tachycardic, hypotensive, and tachypneic, with weak pulses, dry mucous membranes, poor turgor, and oliguria.Plan: Admit for IV fluids. Vital Signs 1200:Temperature 38.4° C (101.1° F)Pulse rate 126/minRespiratory rate 28/minBlood pressure 92/54 mm HgOxygen saturation 93% on room air Nurses Notes 1900:Client is disoriented, confused. When attempting to get out of bed without assistance, client stated, "I'm going home." Returned client to bed and attempted to reorient them to time, place, and circumstances. Call placed to client's family, no answer, message left.1915:Client remains disoriented. Attempting to pull out IV line. Family returned call, updated on situation. Medication Administration Record Dextrose 5% in 0.45% sodium chloride IV at 125 mL/hrPromethazine 25 mg IV bolus every 4 to 6 hr PRN nausea/vomitingDiphenoxylate 5 mg PO 4 times dailyAcetaminophen 625 mg PO every 6 hr PRN temperature greater than 38.6° C (101.5° F Rationality: Review the medications that may be causing the client's confusion is correct. When using the nursing process, the nurse should first collect data and attempt to determine the cause of the client's confusion. Using alternative methods to keep the client safe is correct. After collecting data to determine the cause of the client's confusion, the nurse should use alternative methods to keep the client safe. Instead of using restraints to prevent the client from pulling out their IV, the nurse should first attempt to camouflage the IV lines or ask a family member to stay with the client. The use of restraints should be avoided if possible.

A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan?

Pad bony prominences on the wrist Rationality: The nurse should pad bony prominences on the wrist to prevent skin breakdown caused by the restraint rubbing against the client's skin. The nurse should remove the restraint every 2 hr. A knot that tightens when pulled could injure the client. The nurse should use a quick-release knot or buckle to secure the restraint. The nurse should tie the restraint to the part of the bedframe that moves when raising or lowering the head of the bed. The restraint should not be tied to the siderails or the immovable part of the bedframe.

A nurse is moving a client up in bed with the assistance of a second nurse. Which of the following actions should the nurse take?

Place feet apart with the foot nearest the head of the client's bed in front of the other foot. Rationality: Placing the feet apart provides a wide base of support, which improves balance. Additionally, a forward-backward stance enables the nurse to shift their weight as the client moves up in bed.

A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicates hypomagnesemia?

Positive Chvostek's sign - Rationality: To elicit Chvostek's sign, the nurse should tap the client's facial nerve near the ear. If the client's facial muscles contract, the sign is positive, indicating low serum magnesium or calcium levels. The nurse should identify decreased bowel motility as a finding associated with hypokalemia.

A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of health behavior change?

Precontemplation Rationality: According to evidence-based practice, the nurse should identify that precontemplation is the first stage the client will experience when using the stages of health behavior change. In this stage, the client avoids discussing the behavior and does not intend to make a change in behavior. The stages of health behavior change are precontemplation, contemplation, preparation, action and the maintenance stage. The nurse should identify that preparation is the third stage the client will experience when using the stages of health behavior change. In this stage, the client plans to make minor changes to behavior. However, according to evidence-based practice, another stage occurs prior to the preparation stage. The nurse should identify that maintenance is the last stage the client will experience when using the stages of health behavior change. In this stage, the client sustains changes to behavior. However, according to evidence-based practice, another stage occurs prior to the maintenance stage. The nurse should identify that action is the fourth stage the client will experience when using the stages of health behavior change. In this stage, the client actively changes behavior. However, according to evidence-based practice, another stage occurs prior to the action stage.

A nurse is reinforcing preoperative teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

Provide handouts written in the client's primary language. Rationality: The nurse should provide handouts that are easy to read in the client's primary language to promote learning. The nurse should plan teaching sessions that are short in length to promote learning. The nurse should request a certified interpreter to deliver the instructions to the client. The nurse should not ask the client's family members to interpret because they are not trained in medical terminology. The nurse should provide the most important information first while the client is receptive to learning.

A nurse is preparing to collect data from a client for a health assessment. Which of the following actions should the nurse take?

Provide privacy for the client. Rationality: The nurse should promote a therapeutic environment by providing privacy while data is being collected for a health assessment.

A nurse is assisting with the care of a client who is receiving a unit of packed RBCs. Exhibit 1: Nurses Notes 0800:Packed RBCs initiated by the charge nurse through an 18-gauge peripheral IV to infuse over 2 hr.0815:Client reports itching and anxiety. Client's face is flushed and has hives. Exhibit 2 Vital Signs 0800:Blood pressure 112/64 mm HgHeart rate 80/minRespiratory rate 18/minTemperature 37.1° C (98.8° F)Oxygen saturation 97% on room air0815:Blood pressure 106/54 mm HgHeart rate 100/minRespiratory rate 22/minTemperature 37° C (98.6° F)Oxygen saturation 95% on room air Complete the following sentence by using the lists of options. The client has manifestations of an allergic reaction _____ as evidenced by the client's_____

Rationality: Dropdown 1: Allergic reaction is correct. The nurse should identify that the client has manifestations of an allergic reaction, as evidenced by the itching, flushing of the face, anxiety, and urticaria. The nurse should stop the transfusion and notify the charge nurse. Dropdown 2 Itching is correct. The nurse should identify that itching, flushing of the face, anxiety, and urticaria are manifestations of an allergic reaction to the blood transfusion. The nurse should stop the transfusion and notify the charge nurse.

A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching?

Remove polish from the client's fingernail before applying the oximetry probe. Rationality: The nurse should instruct the AP to remove the client's fingernail polish on at least one finger before placing the probe on that finger because the sensor needs to detect a pulsating vascular bed to produce a reading. The nurse should instruct the AP to select an alternate site to place the probe if the capillary refill is greater than 2 seconds because of the inability of the sensor to detect a pulsating vascular bed to produce a reading.

A nurse is collecting data from an older adult client. Which of the following findings should the nurse report to the provider?

The client reports urinary incontinence. Rationality: Aging is a risk factor for urinary incontinence as older adult males can experience hypertrophy of the prostate gland, and older adult females can experience stress incontinence with laughing, sneezing, or coughing. Urinary incontinence is an abnormal condition that can impact the quality of life for older adults. Urinary incontinence should be investigated; therefore, the nurse should report this finding to the provider. Interventions can be reinforced to the client to promote improved urinary function.

A nurse is caring for a client who has just died and practiced the Islamic faith. Which of the following cultural practices should the nurse expect?

The client's face should be turned toward Mecca. Rationality: Following death, it can be a practice of the Islamic faith to turn the face of a deceased person toward Mecca. It can be a Hispanic and Latino cultural practice to adorn the body of a deceased person with amulets or rosary beads. It can be a Chinese cultural practice for the oldest child to bathe the body of a deceased person under the direction of an older relative or priest. It can be a practice of the Hindu faith to place the body of a deceased person on the floor.