Safety HESI prep Adult Care

A nurse caring for a newly admitted client is reviewing the medication prescription sheet in preparation for administering medications to the client. The nurse notes that the health care provider has prescribed a dose that is twice the amount that the client has reported taking before admission. What is the most appropriate nursing action? a) Contact the health care provider directly. b) Administer the medication as prescribed. c) Question the client if the reported dosage is accurate. d) Call the hospital pharmacy to clarify the prescription.

a) Contact the health care provider directly.

A registered nurse (RN) asks a licensed practical nurse (LPN) to set up a hospital room for a client who is being admitted with a diagnosis of tonic-clonic seizures and asks the LPN to institute seizure precautions. The RN checks the client's room before the arrival of the client and determines that which item placed in the room by the LPN is unsafe? a) Restraints b) Nasal cannula c) Suction catheter d) Padding for side rails

a) Restraints Rationale: Seizure precautions include keeping side rails up and padded if the client has tonic-clonic seizures, ensuring that suction and oxygen equipment is available, and disabling the locks on the bathroom and room doors. Restraints are not used and can result in client injury.

The nurse is providing instructions to an unlicensed assistive personnel (UAP) who is assigned to care for a client with hemiparesis of the right arm and leg. Where should the nurse instruct the UAP to place personal articles for morning care? a) Within the client's reach on the left side b) Within the client's reach on the right side c) Just out of the client's reach on the left side d) Just out of the client's reach on the right side

a) Within the client's reach on the left side Rationale: Hemiparesis is weakness of the face, arm, and leg on one side. The nurse would instruct the unlicensed assistive personnel to place objects on the unaffected side and within reach of the client.

The nurse is preparing medications for administration. In addition to the right medication, the nurse adheres to which additional rights of medication administration? Select all that apply. 1. The right dose 2. The right route 3. The right time 4. The right client 5. The right staff member 6. The right documentation

1. The right dose 2. The right route 3. The right time 4. The right client 6. The right documentation Rationale: There are six rights to administering medications: the right medication, the right client, the right dose, the right route, the right time, and the right documentation. The right staff member is not a right of medication administration.

The nurse is admitting a homeless man who was brought to the emergency department by paramedics. He was found unresponsive next to the back door of a restaurant, was unkempt in appearance, and had various scratches on his body. The nurse develops a plan of care for the client. Which priority client problems apply? Select all that apply. 1. Confusion because of homelessness 2. Risk for unsafe conditions because of homelessness 3. Anxiety when consciousness is regained because of the unfamiliar surroundings 4. Lack of knowledge regarding hygiene because of the client's unkempt condition 5. Risk for infection because of his unkempt condition, various scratches, and homelessness

2. Risk for unsafe conditions because of homelessness 3. Anxiety when consciousness is regained because of the unfamiliar surroundings 5. Risk for infection because of his unkempt condition, various scratches, and homelessness Rationale: Infection is a priority because of the client's poor hygiene, altered skin integrity, and being homeless. Injury is also a concern because of the client's situation (homelessness). Waking up in an unfamiliar place can lead to anxiety. No data in the question indicate that the client has confusion or lacks knowledge.

The nursing student develops a plan of care for a client with paraplegia who is at risk for injury related to spasticity of the leg muscles. On reviewing the plan, the co-assigned licensed nurse identifies which action as an incorrect intervention? a) Using prescribed muscle relaxants as needed b) Using padded restraints to immobilize the limb c) Performing range-of-motion exercises to the affected limbs d) Removing potentially harmful objects near the spastic limbs

b) Using padded restraints to immobilize the limb Rationale: Use of limb restraints will not alleviate spasticity and could harm the client. Use of muscle relaxants is indicated if the spasms cause discomfort to the client or pose a risk to the client's safety. Range-of-motion exercises are beneficial in stretching muscles, which may diminish spasticity. Removing potentially harmful objects is a good safety measure.

The nurse teaches skin care to a client receiving external radiation therapy. Which client statement indicates the need for further instruction? a) "I will handle the area gently." b) "I will wear loose-fitting clothing." c) "I will avoid the use of deodorants." d) "I will limit sun exposure to 1 hour daily."

d) "I will limit sun exposure to 1 hour daily." Rationale: The client needs to be instructed to avoid exposure to the sun. Because of the risk of altered skin integrity, options 1, 2, and 3 are accurate measures in the care of a client receiving external radiation therapy.

A nurse is making a note in the care plan for a client who has a multilumen central venous catheter. The nurse should write to change the injection caps on the lumens at which times? a) Once a week b) At the change of each shift c) After administration of each medication d) Whenever blood is drawn from the lumen

d) Whenever blood is drawn from the lumen Rationale: Changing the injection caps is done to reduce systemic infection, which can be caused by contaminated caps. The injection cap should be discarded and a new one applied once it has been removed from the actual lumen. It is removed whenever blood work is drawn from the lumen. Once a week is too infrequent. At the change of shift is too frequent. It is not necessary to change the injection caps after administration of each medication because it is unnecessary to remove the cap to administer medication. In addition, agencies have policies that guide the frequency of routine injection cap changes (often every 48 hours). Agency policies should always be followed.

A client has a fiberglass cast applied to the lower leg. The client asks the nurse when the client will be able to walk using the casted leg. The nurse replies that the client will be able to bear weight on the casted leg in which time period? a) In 24 hours b) In 48 hours c) In about 8 hours d) Within 20 to 30 minutes of application

d) Within 20 to 30 minutes of application Rationale: A fiberglass cast is made of water-activated polyurethane materials that are dry to the touch within minutes and reach full rigid strength in about 20 minutes. Because of this, the client can bear weight on the cast within 20 to 30 minutes. Therefore, the remaining options are incorrect.

The nurse is inserting an indwelling urinary catheter into the urethra of a male client. As the nurse inflates the balloon, the client complains of discomfort. The nurse should take which appropriate action? a) Aspirate the fluid, remove the catheter, and insert a new catheter. b) Aspirate the fluid, advance the catheter farther, and reinflate the balloon. c) Remove the syringe from the balloon; discomfort is normal and temporary. d) Aspirate the fluid, withdraw the catheter slightly, and reinflate the balloon.

b) Aspirate the fluid, advance the catheter farther, and reinflate the balloon. Rationale: If the balloon is positioned in the urethra, inflating the balloon could produce trauma, and pain will occur. If pain occurs, the fluid should be aspirated and the catheter inserted a little farther into the bladder to provide sufficient space to inflate the balloon. The balloon of the catheter is behind the opening at the insertion tip. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra. There is no need to remove the catheter and insert a new one. Pain when the balloon is inflated is not normal.

A client is being transferred to the nursing unit after receiving a radiation implant for bladder cancer. The nurse should take which priority action in the care of this client? a) Encourage the family to visit. b) Assign the client to a private room. c) Place the client on protective isolation. d) Encourage the client to take frequent rest periods.

b) Assign the client to a private room.

The nurse has administered diazepam (Valium) 5 mg by the intravenous (IV) route to a client. The nurse should plan to maintain the client on bed rest for at least how long? a) 1 hour b) 3 hours c) 12 hours d) 30 minutes

b) 3 hours Rationale: The client should remain in bed for at least 3 hours after a parenteral dose of diazepam. The medication is a centrally acting skeletal muscle relaxant and has antianxiety, sedative-hypnotic, and anticonvulsant properties. Cardiopulmonary adverse effects of the medication include apnea, hypotension, bradycardia, and cardiac arrest. For this reason, resuscitative equipment also is kept nearby.

A client has been taught to use a walker to aid in mobility after internal fixation of a hip fracture. The nurse determines that further teaching is required if the client performs which action? a) Holds the walker using the hand grips b) Advances the walker with reciprocal motion c) Leans forward slightly when advancing the walker d) Supports body weight on the hands while advancing the weaker leg

b) Advances the walker with reciprocal motion Rationale: A disadvantage of the walker is that it does not allow for reciprocal walking motion. If the client were to try to use reciprocal motion with a walker, the walker would advance forward one side at a time as the client walks; thus the client would not be supporting the weaker leg with the walker during ambulation. The client should use the walker by placing the hands on the hand grips for stability. The client lifts the walker to advance it and leans forward slightly while moving it. The client walks into the walker, supporting the body weight on the hands while moving the weaker leg.

The nurse is preparing to administer an intramuscular (IM) injection to a client receiving a continuous heparin infusion. Which action should the nurse prepare to do? a) Use a ⅝-inch needle for the injection. b) Apply prolonged pressure to the IM site after the injection. c) Apply a 4 × 4 pressure dressing at the IM site after the injection. d) Decrease the rate of the heparin infusion for 1 hour before and 1 hour after the injection.

b) Apply prolonged pressure to the IM site after the injection. Rationale: Heparin is an anticoagulant that increases the risk of bleeding. Prolonged pressure over the site of an IM injection will lessen the chance of having an increase of bleeding into the tissue. It is not necessary to apply a pressure dressing to the IM site of injection. A ⅝-inch needle is not an appropriate size needle for an IM injection. The heparin infusion is not decreased before an injection, and the rate is not adjusted unless specifically prescribed by a health care provider.

A client has a prescription for an injection to be administered by the intradermal route. The nurse should avoid which action when administering this medication? a) Injecting the medication slowly b) Massaging the area after removing the needle c) Inserting the needle at a 10- to 15-degree angle d) Making a circular mark around the injection site

b) Massaging the area after removing the needle Rationale: An intradermal injection is administered with the needle bevel facing upward at a 10- to 15-degree angle. The medication is injected slowly, and a bleb should form under the skin with injection. After withdrawal of the needle, the area may be patted dry with a 2 × 2 sterile gauze. The area should not be rubbed, to prevent the spread of the medication beyond the area of injection. All equipment is then disposed of, and the area of injection is outlined (circled) for later reference.

The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at the top of the solution. The nurse should take which action? a) Rolls the bottle of solution gently b) Obtains a different bottle of solution c) Shakes the bottle of solution vigorously d) Runs the bottle of solution under warm water

b) Obtains a different bottle of solution Rationale: Fat emulsion (lipids) is a white, opaque solution administered intravenously during parenteral nutrition therapy to prevent fatty acid deficiency. The nurse should examine the bottle of fat emulsion for separation of emulsion into layers of fat globules or for the accumulation of froth. The nurse should not hang a fat emulsion if any of these are observed and should return the solution to the pharmacy. Therefore the remaining options are inappropriate actions.

The nurse orientee is preparing to insert a nasogastric tube, and the nurse educator is observing the procedure. Which item, if obtained by the nurse orientee, would indicate a need for further teaching regarding this procedure? a) Half-inch tape b) Oil-soluble lubricant c) A 50-mL catheter tip syringe d) A glass of tap water with a straw

b) Oil-soluble lubricant Rationale: Water-soluble lubricant is used to lubricate 3 to 4 inches of the tube at the insertion end. An oil lubricant is not used because if the tube accidentally goes into the bronchus, pneumonia can develop. Half-inch tape is used to secure the tube after correct placement is verified. A 50-mL catheter tip syringe is used to aspirate gastric contents to help verify placement. Only a chest x-ray can confirm placement. The client will be asked to take a sip of water through a straw to help with the passage of the tube.

The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client? a) Side-lying on the operative side b) On the nonoperative side with the legs abducted c) Side-lying with the affected leg internally rotated d) Side-lying with the affected leg externally rotated

b) On the nonoperative side with the legs abducted Rationale: Positioning following a total hip replacement depends on the surgical techniques used, the method of implantation, the prosthesis, and health care provider's (HCP's) preference. Abduction is maintained when the client is in a supine position or positioned on the nonoperative side. Internal and external rotation, adduction, or side-lying on the operative side (unless specifically prescribed by the HCP) is avoided.

The community health nurse is conducting an education session for community members regarding measures to prevent skin cancer and is providing instructions for use of sunscreen protection. The nurse determines that teaching was effective if a community member states that chemical sunscreens are most effective when applied at what time? a) Immediately after swimming b) One hour before exposure to the sun c) Immediately before exposure to the sun d) Five minutes before exposure to the sun

b) One hour before exposure to the sun Rationale: Sunscreens are most effective when applied about 30 minutes to 1 hour before exposure to the sun, so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating.

The nurse develops a plan of care for a client with a cervical-uterine radiation implant. Which intervention would be appropriate for the nurse to include in the plan? a) Restrict all visitors. b) Place a lead shield at the bedside. c) Keep the client's room door open. d) Place the client in a semi-private room.

b) Place a lead shield at the bedside.

The nurse is caring for an older client following surgical repair of a hip fracture. On assessment of the client, the nurse notes that the client is disoriented and is attempting to get out of bed. Which is the most appropriate initial nursing intervention? a) Apply restraints to the client. b) Place a mattress sensor pad on the bed. c) Collaborate with the health care provider (HCP) for a prescription for a sedative. d) Have the unlicensed assistive personnel (UAP) check the client every half hour.

b) Place a mattress sensor pad on the bed. Rationale: A client should not be placed in a physical restraint or sedated just because they are older and disoriented. Alternative methods should be used before applying any type of restraints. For example, a mattress sensor pad will alert the nursing staff of movement. Physical restraints may cause further disorientation and should not be applied unless specifically prescribed. Agency policies and procedures should be followed before the application of restraints.

When administering an intramuscular (IM) injection in the gluteal muscle, how should the nurse position the client to best relax the muscle? a) Sims with a toe-in position b) Prone with a toe-in position c) On the side with the knee of the uppermost leg flexed d) On the side with the knee of the lowermost leg flexed

b) Prone with a toe-in position Rationale: A prone toe-in position will promote internal rotation of the hips, which will relax the muscle, thereby making the injection less painful.

The nurse is administering ear drops to a 2-year-old child. To follow the correct administration procedure, the nurse should perform which action? a) Pulls the pinna of the ear back and up b) Pulls the pinna of the ear back and down c) Places the child in a prone position with the ear to receive the drop facing downward d) Places the child in a side-lying position with the ear to receive the drop facing downward

b) Pulls the pinna of the ear back and down Rationale: Because of the internal anatomy of the ear, if the child is 3 years of age or younger, the pinna of the ear is pulled back and down. If the child is older than 3 years, the pinna of the ear is pulled back and up. The child should lie on the unaffected side with the ear to receive the drop facing upward.

The nurse is caring for a client with impaired mobility that occurred as a result of a stroke. The client has right-sided arm and leg weakness. Which assistive device should the nurse suggest that the client use to provide the best stability for ambulating? a) Walker b) Quad cane c) Crutches d) Single straight-legged cane

b) Quad cane Rationale: Crutches and a walker can be difficult to maneuver for a client with weakness on one side. A cane is better suited for the client with weakness of the arm and leg on one side; however, the quad cane would provide the most stability because of the structure of the cane and because a quad cane has four legs.

A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action? a) Induce vomiting. b) Call an ambulance. c) Call the Poison Control Center. d) Bring the child to the emergency department.

c) Call the Poison Control Center. Rationale: If a poisoning occurs, the Poison Control Center should be contacted immediately. Vomiting should not be induced if the victim is unconscious or if the substance ingested is a strong corrosive or petroleum product. Bringing the child to the emergency department or calling an ambulance would not be the initial action because this would delay treatment. The Poison Control Center may advise the mother to bring the child to the emergency department and, if this is the case, the mother should call an ambulance.

A client has an impairment of cranial nerve II. To maintain safety in the home, the nurse should teach the spouse to implement which measure? a) Speak to the client in a loud voice. b) Serve food that is not too hot or too cold. c) Keep traveled paths in the home free of clutter. d) Lower the temperature setting of the hot water heater.

c) Keep traveled paths in the home free of clutter. Rationale: Cranial nerve II is the optic nerve, which governs vision. The nurse can promote safety by encouraging the family to keep pathways free of clutter to prevent falls. Speaking to the client in a loud voice may help compensate for a deficit of cranial nerve VIII (vestibulocochlear). Cranial nerves VII (facial) and IX (glossopharyngeal) control taste from the anterior two thirds and posterior one third of the tongue, respectively. Lowering the temperature of the hot water heater would be useful if the client had peripheral nerve damage.

The registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action? a) Mark the tube at 10 inches. b) Mark the tube at 32 inches. c) Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process. d) Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum.

c) Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process. Rationale: Measuring the length of a nasogastric tube needed is done by placing the tube at the tip of the client's nose and extending the tube to the earlobe and then down to the xiphoid process. The average length for an adult is about 22 to 26 inches. The remaining options identify incorrect procedures for measuring the length of the tube.

The pediatric nurse educator provides a teaching session to parents regarding the substances that cause lead poisoning. Which item, if identified by a parent as a known environmental substance that can cause lead poisoning, indicates a need for further education? a) Paint chips b) Vinyl blinds c) Properly glazed pottery d) Solder used in plumbing

c) Properly glazed pottery Rationale: Paint chips, soil contaminated with lead, lead solder user in plumbing, vinyl blinds, and improperly glazed pottery can be the source of toxic exposure in lead poisoning.

The nurse is preparing a plan of care for a postpartum client who is at risk for postpartum endometritis. Which intervention should the nurse include in the plan of care to minimize this risk? a) Encourage early ambulation. b) Discuss the resumption of home care and other activities with the client. c) Review hand washing techniques and pericare procedures with the client. d) Instruct the client in proper positioning of the newborn to facilitate breast-feeding.

c) Review hand washing techniques and pericare procedures with the client. Rationale: Postpartum endometritis frequently is associated with the invasion of bacteria that may arise from the gastrointestinal tract or from the lower genital tract. Reviewing appropriate hand washing techniques and pericare with clients during the postpartum period will reduce the risk of possible bacterial invasion. Options 1, 2, and 4 are unrelated to this postpartum complication.

The nurse is providing mouth care to an unconscious client. The nurse should avoid which action during this procedure? a) Turning the head to one side b) Using oral suction equipment c) Rinsing with a large volume of fluid d) Using a bite stick or padded tongue blade

c) Rinsing with a large volume of fluid Rationale: The client who is unconscious is at great risk of aspiration. The nurse assesses the client for the presence of a gag reflex. The nurse turns the client's head to the side and places an emesis basin underneath the mouth. A bite stick or padded tongue blade is used to open the mouth; use of the nurse's gloved fingers is avoided to prevent injury to the nurse. Small volumes of fluid are used in rinsing the mouth, and oral suctioning is used to prevent aspiration.

The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy? a) Restrict all visitors. b) Restrict fluid intake. c) Teach the client and family about the need for hand hygiene. d) Insert an indwelling urinary catheter to prevent skin breakdown.

c) Teach the client and family about the need for hand hygiene. Rationale: In the neutropenic client, meticulous hand hygiene education is implemented for the client, family, visitors, and staff. Not all visitors are restricted, but the client is protected from persons with known infections. Fluids should be encouraged. Invasive measures such as an indwelling urinary catheter should be avoided to prevent infections.

The home care nurse visits a client at home who has been experiencing increased weakness. The client tells the nurse that he is using a cane that was purchased at a local pharmacy. The home care nurse assesses the client's use of the cane and determines that the cane is sized correctly if which observation is made? a) The handle of the cane is even with the client's waist. b) The client's elbow is straight when ambulating with the cane. c) The client's elbow is flexed at a 15- to 30-degree angle when ambulating with the cane. d) The client's elbow is flexed at a 50- to 75-degree angle when ambulating with the cane.

c) The client's elbow is flexed at a 15- to 30-degree angle when ambulating with the cane. Rationale: The height of a cane should be even with the greater trochanter. This allows the elbow to be held at approximately 15 to 30 degrees of flexion. The flexion is necessary to allow the client to push off without bending over when ambulating. Options 1, 2, and 4 are incorrect and present an unsafe situation.

The nurse is caring for an older client with dysphagia who is at risk for aspiration. When preparing the client for eating, the nurse should place the client in which position to minimize the risk for aspiration? a) Low Fowler's b) On the left side c) Upright in a chair d) On the right side

c) Upright in a chair Rationale: It is best to assist the client who is at risk for aspiration and is dysphagic to sit upright in a chair for meals. This position facilitates chewing and swallowing and prevents reflux of stomach contents. Options 1, 2, and 4 are not the best positions to prevent aspiration of food and fluids.

The nurse is supervising an unlicensed assistive personnel (UAP) performing mouth care on an unconscious client. The nurse should intervene if the UAP is observed taking which action? a) Turning the client's head to one side b) Using small volumes of fluid to rinse the mouth c) Using a gloved finger to open the client's mouth d) Placing an emesis basin under the client's mouth

c) Using a gloved finger to open the client's mouth Rationale: The client who is unconscious is at great risk for aspiration. The UAP turns the client's head to the side and places an emesis basin underneath the mouth. A bite stick or a padded tongue blade is used to open the mouth, not a gloved finger, to prevent injury to the caregiver. Small volumes of fluids are used to rinse the mouth.

An unconscious client has an impaired corneal reflex on one side. The nurse should demonstrate the best understanding of how to protect the client's eye by performing which action? a) Placing an eye patch b) Taping the eye shut during the day c) Using sterile saline drops every few hours to keep the eye moist d) Wiping inside the lower eyelid with a cotton-tipped applicator three times a day

c) Using sterile saline drops every few hours to keep the eye moist Rationale: With loss of the corneal (blink) reflex, the client is at risk for eye dryness and also for corneal abrasions if foreign matter comes in contact with the eye. Use of sterile saline drops is indicated to keep the eyes lubricated. An eye patch would have to be used carefully because corneal abrasion could result if the cornea comes in contact with the patch. Taping the eye shut is inappropriate and could impair the conscious client's vision, putting the client at risk for other injury, such as from falls. Introduction of a cotton-tipped applicator (foreign object) inside the lower eyelid also risks corneal abrasion.

The nurse is providing instructions to the unlicensed assistive personnel (UAP) who will be caring for a client with hand restraints. The nurse asks the UAP to repeat the instructions to ensure that the UAP understands the care. Which statement, if made by the UAP, indicates an understanding of the care for this client? a) "I need to remove the restraints every 4 hours." b) "I need to make sure that the restraints are securely tied to the side rails." c) "If the family comes in to visit, I can tell them to take the restraints off if they want to." d) "I need to remove the restraints at least every 2 hours to perform range-of-motion exercises."

d) "I need to remove the restraints at least every 2 hours to perform range-of-motion exercises." Rationale: The nurse should instruct the UAP to check restraints, circulatory status, and skin integrity every 30 minutes. Additionally, restraints need to be removed at least every 2 hours to permit muscle exercise and promote circulation. Restraints are not to be secured to the bedrails because this could cause injury to the client if the rails are lowered. The responsibility of the client should not be placed on the family members. Agency guidelines regarding the use of restraints should always be followed.

The nurse is providing instructions to a client regarding the use of a walker. Which statement by the client would indicate the need for further instruction? a) "I need to inspect the rubber tips daily." b) "I need to wear shoes when ambulating." c) "I need to pick up the walker and move it forward, and then walk into the walker, one step at a time." d) "The walker height should allow for about 45 degrees of flexion at my elbow so that the height of the walker will be safe."

d) "The walker height should allow for about 45 degrees of flexion at my elbow so that the height of the walker will be safe." Rationale: In a standing position, there should be 25 to 30 degrees of flexion at the client's elbow. A walker of incorrect height will not allow the client's line of gravity to go through his or her base of support. The other options regarding the use of a walker are correct statements.

The nurse is preparing to care for a client with esophageal varices who needs a Sengstaken-Blakemore tube inserted because other treatments were unsuccessful. The nurse gathers supplies, knowing that which item must be kept at the bedside at all times? a) An obturator b) A Kelly clamp c) An irrigation set d) A pair of scissors

d) A pair of scissors Rationale: The Sengstaken-Blakemore tube is a triple-lumen gastric tube that may be used to treat bleeding esophageal varices if other interventions are contraindicated or are ineffective. The tube has an inflatable esophageal balloon, an inflatable gastric balloon, and a gastric aspiration lumen. The gastric balloon applies pressure at the cardioesophageal junction to compress gastric varices directly and decrease blood flow to esophageal varices. Traction is applied to maintain the gastric balloon in place. When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the client's bedside at all times. The client must be observed for sudden respiratory distress, which occurs if the gastric balloon ruptures and the entire tube moves upward. If this occurs, the nurse immediately cuts all balloon lumens and removes the tube. An obturator and a Kelly clamp are kept at the bedside of a client with a tracheostomy. An irrigation set may be kept at the bedside, but it is not the priority item.

The nurse is instructing a client to perform a two-point gait for crutch walking. The nurse should tell the client to perform which action? a) Advance the right foot and then the left foot, followed by both crutches. b) Advance both crutches forward, followed by the left foot and then the right foot. c) Move the left foot and then the left crutch forward, followed by the right crutch and then the right foot. d) Advance the right crutch and the left foot forward, followed by advancing the right foot and the left crutch forward.

d) Advance the right crutch and the left foot forward, followed by advancing the right foot and the left crutch forward. Rationale: The two-point gait is used when weight bearing is allowed on both feet. Only two points are in contact with the floor. The two-point gait closely resembles normal walking. Options 1 and 2 describe three points of contact. Option 3 describes four points of contact.

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? a) Call for help. b) Extinguish the fire. c) Activate the fire alarm. d) Confine the fire by closing the room door.

d) Confine the fire by closing the room door. Rationale: The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire then is confined by closing all doors and, finally, the fire is extinguished. RACE- rescue, alarm, confine, extinguish PASS- pull the pin, aim at the base, squeeze the handle, sweep side to side.

A client with right leg hemiplegia has a problem with mobility. The nurse determines a need for reinforcement of teaching the client and the client's family if the nurse observes which action being done by the family? a) Applying a premolded splint b) Active range of motion to the affected leg c) Passive range of motion to the affected leg d) Encouraging the client to stand unassisted on the leg

d) Encouraging the client to stand unassisted on the leg Rationale: Depending on the client's functional ability, either passive or active range of motion is indicated to keep the joint moving freely. Application of a premolded splint also would keep the limb aligned and in good position. The client should not attempt to stand unsupported on a weak or paralyzed limb. The inability to bear weight will cause the client to fall.

A nurse is developing a plan of care for a client with a diagnosis of early-stage Alzheimer's disease. The plan of care should include nursing interventions that address which early characteristic of Alzheimer's disease? a) Confusion is common. b) The client may wander. c) The client may be easily frustrated. d) Forgetfulness interferes with the daily routine.

d) Forgetfulness interferes with the daily routine. Rationale: In early Alzheimer's disease, forgetfulness begins to interfere with daily routines. The client has difficulty concentrating and difficulty learning new material. Options 1, 2, and 3 are characteristics of this disorder but occur later as the disease progresses.

The nurse is assessing a confused older client admitted to the hospital with a hip fracture. Which data obtained by the nurse increases the safety of the client? a) Eyeglasses left at home b) Unfamiliar hospital setting c) Stress induced by the fracture d) Hearing aid available and in working order

d) Hearing aid available and in working order Rationale: Confusion in the older client with a hip fracture could result from the unfamiliar hospital setting, stress owing to the fracture, concurrent systemic diseases, cerebral ischemia, or side/adverse effects of medications. Use of the hearing aids will enhance the client's interaction with the environment and can reduce disorientation. Eyeglasses left at home may increase the risk for disorientation and injury.

A home care nurse provides medication instructions to a client. What is the appropriate nursing action to ensure safe administration of medication in the home? a) Conduct pill counts on each home visit. b) Demonstrate the proper procedure to take prescribed medications. c) Instruct the client to double up on medications if a dose has been missed. d) Observe the client verbalize and demonstrate the correct administration procedures

d) Observe the client verbalize and demonstrate the correct administration procedures Rationale: To ensure safe administration of medication, the nurse allows the client to verbalize and demonstrate correct procedure and administration of medications. Demonstrating the proper procedure for the client does not ensure that the client can safely perform this procedure. It is not acceptable to double up on medication, and conducting a pill count on each visit is not realistic or appropriate.

The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate nursing action? a) Quickly insert the tube. b) Notify the health care provider immediately. c) Remove the tube and reinsert when the respiratory distress subsides. d) Pull back on the tube and wait until the respiratory distress subsides.

d) Pull back on the tube and wait until the respiratory distress subsides. Rationale: During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. It is not necessary to notify the health care provider immediately or remove the tube completely. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus.

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position? a) Prone b) Reverse Trendelenburg's c) Supine, with the amputated limb flat on the bed d) Supine, with the amputated limb supported with pillows

d) Supine, with the amputated limb supported with pillows Rationale: The amputated limb is usually supported on pillows for the first 24 hours following surgery to promote venous return and decrease edema. After the first 24 hours, the amputated limb usually is placed flat on the bed to reduce hip contracture. Edema also is controlled by limb-wrapping techniques. In addition, it is important to check health care provider prescriptions regarding positioning following amputation.

The nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tubing change? a) Breathe normally. b) Turn the head to the right. c) Exhale slowly and evenly. d) Take a deep breath, hold it, and bear down.

d) Take a deep breath, hold it, and bear down. Rationale: The client should be asked to perform the Valsalva maneuver during tubing changes. This helps avoid air embolism during tubing changes. The nurse asks the client to take a deep breath, hold it, and bear down. If the intravenous line is on the right, the client turns his or her head to the left. This position increases intrathoracic pressure. Breathing normally and exhaling slowly and evenly are inappropriate and could enhance the potential for an air embolism during the tubing change.

The nurse is preparing to initiate an intravenous (IV) puncture on a client and obtains the prescribed solution of 1000 mL of normal saline for the infusion. The nurse sets up the IV infusion and checks which before performing the venipuncture? a) The client's temperature b) The client's blood pressure c) The client's electrolyte values d) The IV solution for particles or contamination

d) The IV solution for particles or contamination Rationale: All IV solutions should be free of particles or precipitates and should be assessed before initiation of an IV line. Although the client's vital signs and laboratory values may be assessed, these actions are unrelated to performing the venipuncture.

While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action? a) Call the health care provider (HCP). b) Reinsert the implant into the vagina. c) Pick up the implant with gloved hands and flush it down the toilet. d) Pick up the implant with long-handled forceps and place it in a lead container.

d) Pick up the implant with long-handled forceps and place it in a lead container. Rationale: In the event that a radiation source becomes dislodged, the nurse would first encourage the client to lie still until the radioactive source has been placed in a safe closed container. The nurse would use a long-handled forceps to place the source in the lead container that should be in the client's room. The nurse should then call the radiation oncologist and then document the event and the actions taken. It is not within the scope of nursing practice to insert a radiation implant.

The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention if noted in the plan indicates the need for revision of the plan? a) Wearing gloves when emptying the client's bedpan b) Keeping all linens in the room until the implant is removed c) Wearing a lead apron when providing direct care to the client d) Placing the client in a semiprivate room at the end of the hallway

d) Placing the client in a semiprivate room at the end of the hallway Rationale: A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent accidental exposure of other clients to radiation. The remaining options identify accurate interventions for a client with an internal radiation implant and protect the nurse from exposure.

The nurse is performing discharge teaching for a client with a peripherally inserted central catheter (PICC). Which instructions should the nurse include? Select all that apply. 1. Wear a Medic-Alert tag or bracelet. 2. Report redness or swelling at the catheter insertion site. 3. Have a repair kit available in the home for use if needed. 4. Keep activity level to a minimum while this catheter is in place. 5. Cover the PICC dressing with plastic when in the shower or bath.

1. Wear a Medic-Alert tag or bracelet. 2. Report redness or swelling at the catheter insertion site. 3. Have a repair kit available in the home for use if needed. 5. Cover the PICC dressing with plastic when in the shower or bath. Rationale: The client should be taught that there are only minor activity restrictions with this catheter. The client should protect the site during bathing and should carry Medic-Alert identification. The client should have a repair kit in the home for PRN use, because it is a long-term catheter. Redness or swelling at the catheter insertion site needs to be reported because this could indicate a sign of infection.

A client is being transferred from the intensive care unit to a step-down unit. The nurse is performing a final assessment of the client before moving the client to the new unit. The priority components of this final assessment should include which parameters? Select all that apply. 1. The client's weight 2. The client's vital signs 3. The client's dietary orders 4. The client's level of consciousness 5. The patency of intravenous (IV) lines

2. The client's vital signs 4. The client's level of consciousness 5. The patency of intravenous (IV) lines Rationale: Assessment of the client's vital signs, level of consciousness, and patency of IV lines are priority parameters when transferring a client to another unit or area. Assessing these can help reduce the risk of complications during the transfer. Client's weight and dietary orders, although important in the client's care, are not an immediate priority.

The nurse is caring for a child who will require the use of an apnea monitor when discharged from the hospital. Which information should the nurse provide to the child's caregiver about the use of an apnea monitor? Select all that apply. 1. Keep leads on the child at all times. 2. Place the monitor inside the child's crib. 3. Adjust the monitor to eliminate false alarms. 4. Sleep in the same bed as the monitored infant. 5. Keep pets and children away from the monitor. 6. Keep emergency rescue numbers near the telephone.

5. Keep pets and children away from the monitor. 6. Keep emergency rescue numbers near the telephone. Rationale: An apnea monitor should not be adjusted to eliminate false alarms; adjustments could compromise the monitor's effectiveness. The monitor should be placed on a firm surface away from the crib and drapes. The caregiver should not sleep in the same bed as a monitored infant. Pets and children should be kept away from the monitor and infant. Emergency rescue numbers should be kept near phones in the home. Leads should be removed when the infant is not attached to the monitor.

The nurse is preparing to discontinue a client's nasogastric (NG) tube. The client is positioned properly and the tube has been flushed with 15 mL of air to clear secretions. Which statement should the nurse make to the client before removing the tube? a) "Take a deep breath when I tell you, and hold it while I remove the tube." b) "Take a deep breath when I tell you, and bear down while I remove the tube." c) "Take a deep breath when I tell you, and slowly exhale while I remove the tube." d) "Take a deep breath when I tell you, and breathe normally while I remove the tube."

a) "Take a deep breath when I tell you, and hold it while I remove the tube." Rationale: The client should take a deep breath because the client's airway will be temporarily obstructed during tube removal. The client is then told to hold the breath while the tube is removed. The nurse should remove the tube slowly and evenly over the course of 3 to 6 seconds. Bearing down could inhibit the removal of the tube. Exhaling and breathing normally could result in aspiration of gastric secretions during inhalation.

The nurse has a prescription to give 30 mL of an antacid to a client through a feeding tube. Which is the priority nursing action? a) Assess tube placement. b) Flush with 30 mL of sterile saline. c) Aspirate to determine residual volume. d) Administer the antacid by gravity flow.

a) Assess tube placement.

A nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse should document in the medical record that which occurred? a) Phlebitis of the vein b) Infiltration of the IV line c) Hypersensitivity to the IV solution d) Allergic reaction to the IV catheter

a) Phlebitis of the vein Rationale: Phlebitis at an IV site can be distinguished by client discomfort at the site, as well as redness, warmth, and swelling proximal to the catheter. The IV line should be discontinued, and a new line should be inserted at a different site. The remaining options are incorrect occurrences.

The health care provider (HCP) has written a prescription to start progressive ambulation as tolerated in a hospitalized client who experiences periods of confusion because of bed rest and prolonged confinement to the hospital room. Which nursing intervention would be appropriate when planning to implement the HCP's prescription and address the needs of the client? a) Progressively ambulate the client in the hall three times daily. b) Ambulate the client in the room for short distances frequently. c) Ambulate the client to the bathroom in his or her room three times daily. d) Assist with range-of-motion exercises three times daily to increase strength.

a) Progressively ambulate the client in the hall three times daily. Rationale: The cause of the confusion in this situation is bed rest and decreased sensory stimulation resulting from prolonged confinement; therefore it is best to ambulate the client in the hall. This will increase sensory stimulation and may decrease confusion. Ambulating in the room and to the bathroom in the client's room will not address the client's need for sensory stimulation. Range-of-motion exercises is an action that should have been performed in preparation for ambulation while the client was on bed rest.

A client is in the bathroom when the nurse arrives at his room with his scheduled medications. The client calls to the nurse, "Just leave my medication on the bedside table like the rest of the nurses, and I will take it when I get finished." What is the nurse's best action? a) Tell the client you will be back when he is finished. b) Leave the medication at the bedside as the client requested. c) Let another nurse who is not busy give the client his medication when he is finished. d) Tell the unlicensed assistive personnel (UAP) to give it to the client when he is finished.

a) Tell the client you will be back when he is finished. Rationale: The best action is to tell the client that you will return with his medication once he is finished. It is inappropriate to leave a medication in a client's room. Another nurse should not administer a medication that he or she did not prepare. It is not within a UAP's scope of practice to administer medications.

The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions? a) "I should not sleep on my left side." b) "I should not sleep on my right side." c) "I should not sleep with my head elevated." d) "I should not wear my glasses at any time."

b) "I should not sleep on my right side." Rationale: After cataract surgery, the client should not sleep on the side of the body that was operated on to prevent edema formation and intraocular pressure. The client also should be placed in a semi-Fowler's position to assist in minimizing edema and intraocular pressure. During the day, the client may wear glasses or a protective shield; at night, the protective shield alone is sufficient.

The nurse is assessing the intravenous (IV) dressing of a client with a peripheral IV infusion running. The date on the dressing is 7/25 (July 25). The nurse documents on the client's record that the dressing should be changed on which date? a) 7/26 b) 7/28 c) 7/30 d) 8/1

b) 7/28 Rationale: IV site dressings should be changed every 48 to 72 hours, which is every 2 to 3 days. With an insertion date of 7/25, the due date for change, depending on agency policy, would be 7/27 or 7/28. It would be unnecessary, uncomfortable, and not cost effective to change the site dressing daily (option 1). Changing the site dressing every 5 or 7 days (options 3 and 4) would place the client at greater risk for infection or other catheter complications.

A nurse discovers a fire in the trash basket in a client's bathroom. The nurse assists the client out of the hospital room to a safe place and takes which action next? a) Extinguishes the fire b) Activates the fire alarm c) Pulls the pin on the fire extinguisher d) Closes the doors to the other clients' rooms

b) Activates the fire alarm RACE

A nurse is preparing to administer 1 mg of hydromorphone (Dilaudid), a Schedule II opioid. The medication is available in a premeasured syringe of 2 mg/mL. Which action by the nurse is correct? a) Return the unused portion of the medication to the pharmacy. b) Ask a second nurse to witness disposal of the unused portion. c) Administer the 1-mg dose and save the remainder for the next dose. d) Administer the 1-mg dose and discard the unused portion of medication.

b) Ask a second nurse to witness disposal of the unused portion. Rationale: The Controlled Substances Act requires a nurse to have a second nurse witness disposal of unused scheduled medications. Both nurses will document on the required form. Unused portions are not saved or reused.

The nurse has admitted a client to the clinical nursing unit following a right-sided mastectomy. The nurse should plan to place the right-sided arm in which position? a) Elevated above shoulder level b) Elevated on one or two pillows c) Level with the right-sided atrium d) Dependent to the right-sided atrium

b) Elevated on one or two pillows Rationale: The client's operative arm should be positioned so that it is elevated on one or two pillows and does not exceed shoulder elevation. This promotes optimal drainage from the limb without impairing the circulation to the arm. If the arm is positioned flat (option 3) or dependent (option 4), this could increase the edema in the arm, which is contraindicated because of lymphatic disruption caused by surgery.

The nurse is preparing the morning medications to be administered to her assigned clients and is reviewing the health care provider's prescriptions. Which medication prescription should the nurse question? a) Lanoxin (Digoxin) 0.25 mg orally daily b) Hydrochlorothiazide (HCTZ) orally twice daily c) Docusate sodium (Colace) 100 mg orally twice daily d) Enoxaparin sodium (Lovenox) 20 mg subcutaneously daily

b) Hydrochlorothiazide (HCTZ) orally twice daily Rationale: The prescription for the HCTZ is incomplete because the dosage is missing. The prescriptions in the other options are complete prescriptions.

A nurse is assessing the intravenous (IV) line of a client who is receiving a chemotherapy infusion. The assessment reveals coolness and swelling around the IV insertion site. What should the nurse do next? a) Notify the prescriber. b) Stop the IV infusion. c) Obtain a prescription for a chest x-ray. d) Apply cold compresses to the insertion site.

b) Stop the IV infusion. Rationale: The assessment indicates that infiltration of the IV solution has occurred, and the infusion must be stopped immediately to prevent further infiltration of the chemotherapy fluid. The nurse next notifies the health care provider of the occurrence. The health care provider needs to prescribe the treatment for the insertion site. There is no useful reason for doing a chest x-ray.

A client is scheduled for insertion of a peripherally inserted central catheter (PICC) and the nurse explains the advantages of this catheter. Which statement by the client indicates a need for follow-up? a) "It is reasonable in cost." b) "This type of catheter is very reliable." c) "It is specifically designed for short-term use." d) "I should not have pain or discomfort with this catheter."

c) "It is specifically designed for short-term use." Rationale: PICCs are intended to be used for clients who need long-term catheter placement. They can be left in place for several months. It is reasonable in cost because the catheter does not need routine replacement, as do traditional peripheral IV catheters. The catheter is more comfortable for the client because there is no repeated venipuncture with catheter change. The catheter is also very reliable. It is less likely to infiltrate and can be used for administration of a number of different types of medications.

The nurse is preparing to administer an intramuscular (IM) injection to a 4-year-old child. The nurse plans to administer the injection in the ventral gluteal muscle, knowing that which indicates the maximum amount of medication volume that can be safely injected? a) 0.5 mL b) 1.0 mL c) 1.5 mL d) 2.0 mL

c) 1.5 mL Rationale: In a young child, ages 3 to 6 years, the maximum volume of medication that can be safely injected into the ventral gluteal muscle is 1.5 mL.

The nurse is giving a change-of-shift report. What is the primary purpose of a change-of-shift report? a) Assess the client's status. b) Plan care for the next shift. c) Ensure continuity of care for the client. d) Document the client's care for that shift.

c) Ensure continuity of care for the client. Rationale: Change-of-shift report is given from one caregiver to another caregiver who is taking on responsibility for the client's care in order to ensure continuity of care. Report includes many relevant areas of information and is not limited to assessment of a client or planning care. Documentation is not a part of change-of-shift report.

A nursing student is caring for a client with a stroke (brain attack) who is experiencing unilateral neglect. The nurse would intervene if the student plans to use which strategy to help the client adapt to this deficit? a) Telling the client to scan the environment b) Placing the bedside articles on the affected side c) Approaching the client from the unaffected side d) Moving the commode and chair to the affected side

c) Approaching the client from the unaffected side Rationale: Unilateral neglect is an unawareness of the paralyzed side of the body, which increases a client's risk for injury. The nurse's role is to refocus the client's attention to the affected side. The nurse moves personal care items and belongings to the affected side, as well as the bedside chair and commode. The nurse teaches the client to scan the environment so as to become aware of the affected half of the body. The nurse approaches the client from the affected side to increase awareness further.

A filled blood specimen tube was dropped and broken in the client's room. Which action performed by the unlicensed assistive personnel (UAP) to clean up the blood spill is incorrect? a) Uses tongs to collect any broken glass b) Wears gloves for the cleaning procedure c) Blots up the spill with a face cloth or cloth towel d) Disinfects the area of the blood spill with a dilute bleach solution

c) Blots up the spill with a face cloth or cloth towel Rationale: The unlicensed assistive personnel should blot the spill with an absorbent disposable material, such as paper towels or terry wipes, but not with a face cloth or cloth towel. Gloves are worn for the procedure, and tongs are used to pick up any broken glass. The area is disinfected with a dilute bleach solution or an agency-approved product.

A nurse is caring for a client who is on strict bed rest. The nurse develops a plan of care and develops goals related to the prevention of deep vein thrombosis (DVT) and pulmonary emboli. Which nursing action is most helpful to prevent these disorders from developing? a) Restricting fluids b) Placing a pillow under the knees c) Encouraging active range-of-motion exercises d) Applying a heating pad to the lower extremities

c) Encouraging active range-of-motion exercises Rationale: Clients at greatest risk for DVT and pulmonary emboli are immobilized clients. Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat should not be applied without a health care provider's prescription.

Treatment for a client with bleeding esophageal varices has been unsuccessful and the health care provider decides to insert a Sengstaken-Blakemore tube. What is the priority nursing action? a) Request an obturator. b) Obtain a Kelly clamp. c) Place a pair of scissors at client's bedside. d) Pour sterile water in the irrigation set basins.

c) Place a pair of scissors at client's bedside.

The health care provider writes a prescription to apply a heating pad to a client's back. Which intervention is contraindicated and is unsafe? a) Setting the heating pad on a low setting b) Assessing the skin frequently for burns c) Placing the heating pad under the client d) Using tape to hold heating pad in place

c) Placing the heating pad under the client Rationale: The heating pad should never be placed under the client, but it should be placed lightly against or on top of the involved area. Burns to the skin can occur when the client lies on the pad.

The nurse is preparing medications when a pill pops out of the medication container and falls onto the countertop. What action should the nurse take? a) Promptly pick up the pill and put it into the medicine cup. b) Promptly pick up the pill, blow off the dust, and then put it into the medicine cup. c) Promptly pick up the pill, dispose of it properly, and obtain a new one from the pharmacy. d) Promptly pick up the pill, use an alcohol swab to clean it off, and put it into the medicine cup.

c) Promptly pick up the pill, dispose of it properly, and obtain a new one from the pharmacy. Rationale: Medication that is dropped on any surface is considered contaminated and should not be administered; therefore the remaining options are incorrect.

A client who is receiving therapy with a hypothermia blanket starts to shiver. The nurse raises the blanket temperature and monitors the client. After 15 minutes the client's temperature has not increased and the client is still shivering. What should the nurse do next? a) Apply a smaller heating pad to the client's axillae and neck areas. b) Wait 10 more minutes and then check the client's temperature again. c) Remove the hypothermia blanket and notify the client's health care provider (HCP). d) Increase the blanket's temperature again and recheck the client's temperature in 15 minutes.

c) Remove the hypothermia blanket and notify the client's health care provider (HCP). Rationale: Shivering is not a desired outcome of therapy with a hypothermia blanket. Even though shivering increases the body's metabolic rate and heat production, oxygen consumption is also increased. Another adverse effect is that shivering can cause vasoconstriction, which may injure areas in distal parts of the body. If shivering cannot be stopped, then the therapy with the warming blanket must be stopped and the client's HCP notified. Waiting and rechecking the client's temperature delays necessary treatment. Applying a heating pad to the axillae and neck also delays necessary treatment. Additionally, it could cause a burn.

The emergency department nurse is caring for a client who has been identified as a victim of physical abuse. In planning care for the client, which is the priority nursing action? a) Adhering to the mandatory abuse reporting laws b) Notifying the case worker of the family situation c) Removing the client from any immediate danger d) Obtaining treatment for the abusing family member

c) Removing the client from any immediate danger Rationale: Whenever an abused client remains in the abusive environment, priority must be placed on ascertaining whether the client is in any immediate danger. If so, emergency action must be taken to remove the client from the abusive situation. Options 1, 2, and 4 may be appropriate interventions but are not the priority.

A nurse is assessing the extremities of a client who had wrist restraints applied 2 hours ago. Which assessment finding, if present, is of greatest concern? a) The client is able to wiggle the fingers. b) The restraint is secured to the bed's frame. c) The skin of the hand feels cool to the touch and is pale. d) The nurse is able to insert two fingers under the restraints between the restraint and the client's skin.

c) The skin of the hand feels cool to the touch and is pale. Rationale: When an extremity restraint, such as a wrist restraint, is properly applied, the nurse should be able to insert two fingers under the restraint, next to the client's skin. Restraints that are tied too tightly will interfere with circulation and may cause neurovascular injury. The nurse should assess proper placement of the restraint, skin integrity, pulses, temperature, color, and sensation of the wrist and hand, and the client should be able to move the fingers. The restraints are secured to the bed's frame, not to the side rails.

The nurse has given a client with a leg cast instructions on cast care at home. The nurse determines that the client needs further instruction if the client makes which statement? a) "I should avoid walking on wet, slippery floors." b) "I'm not supposed to scratch the skin underneath the cast." c) "It's okay to wipe dirt off the top of the cast with a damp cloth." d) "If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting."

d) "If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting." Rationale: Client instructions should include avoiding walking on wet slippery floors to prevent falls. The client should never scratch under a cast because of the risk of skin breakdown and ulcer formation. Surface soil on a cast can be removed with a damp cloth. If the cast gets wet, it can be dried with a hair dryer set to a cool setting to prevent skin breakdown. If the skin under the cast itches, cool air from a hair dryer may be used to relieve it.

The nurse is preparing to administer an intramuscular injection of pain medication to a new postoperative client. When the nurse walks into the client's room, the client asks why he is receiving an intramuscular form of the medication instead of the oral form. What is the nurse's best response with regard to the absorption of the medication? a) "Your health care provider wants you to have it this way." b) "Are you saying that you are not going to take this medication?" c) "Medications given this way have fewer side effects than those given orally." d) "Medications given this way are absorbed more quickly than by other routes."

d) "Medications given this way are absorbed more quickly than by other routes." Rationale: Medications given parenterally are absorbed more quickly than by other routes. The IM route provides faster medication absorption than the subcutaneous route because of the greater vascularity of the muscle. The remaining options do not answer the client's question and may be belittling or incorrect.

The nurse is completing medication reconciliation with a client just before his or her discharge to home. The client asks, "Why are you going over this list? They did that when I was admitted!" Which statement by the nurse is the best response? a) "Medication reconciliation is required before you can go home." b) "Your insurance company requires a list of medications that you will be taking." c) "We are checking to see what medications can be discontinued before you go home." d) "We do this to make sure you will be receiving the correct medications once you are at home."

d) "We do this to make sure you will be receiving the correct medications once you are at home." Rationale: Although medication reconciliation is a required procedure by The Joint Commission, the purpose is to reduce the risk of medication error and to ensure that the client receives the correct medication at home. Explanation of the purpose is a better answer than simply explaining that it is a required procedure.

A client has a prescription to receive purified protein derivative (PPD), 0.1 mL, intradermally. The nurse should administer the medication by using a tuberculin syringe according to which guidelines? a) 20-gauge, 1-inch needle inserted at a 30-degree angle, with the bevel side down b) 26-gauge, 5/8-inch needle inserted at a 45-degree angle, with the bevel side down c) 20-gauge, 1-inch needle inserted almost parallel to the skin, with the bevel side up d) 26-gauge, 5/8-inch needle inserted almost parallel to the skin, with the bevel side up

d) 26-gauge, 5/8-inch needle inserted almost parallel to the skin, with the bevel side up Rationale: A tuberculin skin test is administered by giving 0.1 mL of PPD intradermally. Administration involves drawing the medication into a tuberculin syringe with a 25- to 27-gauge, 5/8-inch needle. The injection is given by inserting the needle as close as possible to a parallel position with the skin and with the needle bevel facing up. This results in formation of a wheal when the PPD is administered correctly.

A nurse is assigned to care for a client who is experiencing episodes of postural hypotension. Which action should the nurse take to ensure safety while transferring the client from the bed to the chair? a) Arrange for a transfer board to be used. b) Perform the transfer using a hydraulic lift only. c) Put the client's shoes on so that the client will not slip on the floor during the transfer. d) Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.

d) Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair.

The nurse is caring for a client with a nasogastric (NG) tube connected to continuous suction. During assessment the nurse observes that the client is mouth-breathing, has dry mucous membranes, and has a foul breath odor. In planning care, which intervention would be most appropriate to maintain the integrity of this client's oral mucosa? a) Offer small sips of water frequently. b) Encourage the client to suck on sour, hard candy. c) Use lemon glycerin swabs to provide oral hygiene. d) Brush the teeth frequently; use mouthwash and water.

d) Brush the teeth frequently; use mouthwash and water. Rationale: After an NG tube is in place, mouth care is extremely important. With one naris occluded, the client tends to mouth-breathe, drying the mucous membranes. Small sips of water are contraindicated when the client is on gastric suction. Hard candy would increase the salivation, but would not be useful in cleaning the oral cavity. Lemon glycerin swabs have a drying and irritating effect on the mucous membranes.

The nurse is administering enteral feedings via a nasogastric (NG) tube. The nurse should take which action when caring for this client to maintain client safety? a) Maintain the client in a supine position. b) Change the NG tube with every other feeding. c) Increase the rate of the feeding if the infusion falls behind schedule. d) Check for tube placement and residual amount at least every 4 hours.

d) Check for tube placement and residual amount at least every 4 hours.

The nurse is preparing to administer an intradermal medication. Which action should the nurse take before administering the medication? a) Cleanse the site of injection with an alcohol swab and fan the alcohol dry. b) Cleanse the site of injection with an alcohol swab and pat it dry with tissue. c) Cleanse the site of injection with an alcohol swab and blow the alcohol dry. d) Cleanse the site of injection with an alcohol swab and wait for the alcohol to dry.

d) Cleanse the site of injection with an alcohol swab and wait for the alcohol to dry. Rationale: Before administering an intradermal medication, the site of injection is cleaned with an alcohol swab and patted dry with tissue. Alcohol needs to dry to appropriately. The actions in the remaining options are incorrect because they contaminate the site before the administration of the medication.

A nurse is providing instructions to a client regarding the use of ice packs to treat an eye injury. What should the nurse instruct the client to do? a) Avoid the use of commercially prepared ice bags. b) Keep the ice pack on the eye continuously for 24 hours. c) Place the ice pack directly on the eye and cover with gauze. d) Cover the ice pack with a pillowcase and place it on the eye.

d) Cover the ice pack with a pillowcase and place it on the eye. Rationale: If an ice pack is placed directly against the skin or left in place for an extended period, it carries a risk of tissue damage similar to that of a hot water bottle. To prevent tissue damage from excessive cold exposure, the ice pack should be removed in most cases after 30 minutes and may be reapplied after a short time. An ice pack should never be placed directly against the skin but should be covered with a pillowcase or towel. Commercially prepared ice bags are appropriate for use as an ice pack.

A client is receiving outpatient radiation treatments for carcinoma of the oropharynx and is experiencing dysphagia. The nurse should include which intervention in the plan of care? a) Encourage the client to drink only thin liquids. b) Teach the client to examine his oral mucosa monthly. c) Teach the client to speak slowly and enunciate clearly. d) Encourage the client to use artificial saliva to manage dryness.

d) Encourage the client to use artificial saliva to manage dryness. Rationale: Epithelial cells are destroyed by radiation involving the head and neck. Inflammation and ulceration occur because of the rapid cell destruction and impair normal saliva excretion and distribution. Artificial saliva aids in preventing further damage by lubricating the affected area. A client with difficulty swallowing should avoid drinking thin liquids because of the increased risk of aspiration resulting from epiglottis dysfunction related to radiation therapy. Examining the oral mucosa is a preventive maintenance intervention to alert the client to changes in the mucosa, but this should be done daily, not monthly. The client with dysphagia has difficulty swallowing, not difficulty speaking; therefore teaching the client to speak slowly and enunciate clearly would provide no health benefit for the impairment in swallowing.

The nurse is inserting a nasogastric (NG) tube into an adult client. During the procedure, the client begins to cough and have difficulty breathing. The nurse should take which priority action? a) Remove the tube, and notify the health care provider. b) Instruct the client to hold their breath and insert the NG tube. c) Remove the tube, and reinsert when the client fully recovers. d) Pull back on the tube, and wait until the client is breathing easily.

d) Pull back on the tube, and wait until the client is breathing easily.

A nurse has called a client's primary health care provider to clarify a medication prescription. The health care provider gives a telephone prescription to the nurse for a new medication. What action by the nurse would best promote accuracy at this time? a) Ensure that the prescription is written neatly. b) Double-check the prescription with another registered nurse. c) Call the pharmacy to verify the accuracy of the prescribed medication. d) Read the prescription back to the health care provider after writing it on the prescription sheet.

d) Read the prescription back to the health care provider after writing it on the prescription sheet. Rationale: The Joint Commission (TJC) requires a verification process, such as reading back the prescription to the prescriber, when a nurse takes either telephone or verbal prescriptions. This verification acts to promote accuracy and reduce errors. Although options 1, 2, and 3 may be a part of the correct procedure, option 4 describes the best action.

A nurse has a written prescription to discontinue an intravenous (IV) line. The nurse obtains which item from the unit supply area for use in applying pressure to the site after removing the IV catheter? a) Band-Aid b) Alcohol swab c) Betadine swab d) Sterile 2 × 2 gauze

d) Sterile 2 × 2 gauze Rationale: A dry sterile dressing, such as sterile 2 × 2 gauze, is used to apply pressure to the discontinued IV site. This material is absorbent, sterile, and nonirritating. A Betadine swab or alcohol swab would irritate the opened puncture site and would not stop the blood flow. A Band-Aid may be used to cover the site after hemostasis has occurred.

The nurse is teaching a client who had a stroke how to use a walker for ambulation. Which level of prevention is the nurse implementing? a) Basic level b) Primary level c) Secondary level d) Tertiary level

d) Tertiary level Rationale: The tertiary level is focused on rehabilitation skills. Therefore teaching a client who had a stroke how to use a walker is a tertiary level of prevention. The primary level is focused on prevention. The secondary level is a screening level that entails such procedures as vision screening, mammography, or similar screening tests. There is no basic level of prevention.

The registered nurse is observing a newly hired nurse perform a dressing change on a client with a leg ulcer. Sutilains is being used to treat the ulcer. Which observation, if made by the registered nurse, would indicate a need for further teaching with the newly hired nurse? a) The nurse cleans the wound with a sterile solution. b) The nurse places the sutilains in the refrigerator after use. c) The nurse moistens the wound with sterile normal saline and then applies the sutilains. d) The nurse washes and dries the wound and covers the sutilains application with a dry sterile dressing.

d) The nurse washes and dries the wound and covers the sutilains application with a dry sterile dressing. Rationale: The wound should be cleansed with a sterile solution before treatment. The nurse then thoroughly moistens the wound with normal saline or sterile water, applies a thin film of sutilains extending ¼ to ½ inch beyond the area to be débrided, and then applies a loose, thin dressing. The ointment should be refrigerated.

The community health nurse is performing a safety assessment in the home of a mother with two children, ages 1 and 3 years. Which, if noted during the assessment, presents the greatest hazard to the children? a) Small dog as a house pet b) Hot water heater set above 120° F c) Gate placed at the stairs of the second floor d) Toys with small loose parts in the playroom

d) Toys with small loose parts in the playroom Rationale: Toys with small loose parts would be the priority concern. Children at this age are likely to place the small toy parts in their mouths, which could lead to aspiration and choking. A small dog as a house pet is not necessarily a hazard. The water temperature of the hot water heater is a concern but is not the greatest hazard. The mother should be aware of and taught safety measures related to safe water temperatures for bathing the children. A gate placed at the stairs of the second floor is a safety measure.

The nurse prepares to administer an intramuscular injection to a 4-month-old infant. The nurse selects which best site to administer the injection? a) Ventrogluteal b) Dorsal gluteal c) Rectus femoris d) Vastus lateralis

d) Vastus lateralis Rationale: Intramuscular injection sites are selected on the basis of the child's age and muscle development of the child. The vastus lateralis is the only safe muscle group to use for intramuscular injection in a 4-month-old infant. The sites identified in options 1, 2, and 3 are unsafe.

A home care nurse performs a home safety assessment and discovers that a client is using a space heater in the apartment. Which instruction should the nurse provide to the client regarding the use of the space heater? a) A space heater should not be used in an apartment. b) The space heater should be placed in the hallway at night. c) The space heater should be kept at a low setting at all times. d) The space heater needs to be placed at least 3 feet from anything that can burn.

d) The space heater needs to be placed at least 3 feet from anything that can burn. Rationale: Space heaters need to be used appropriately because they present a great risk of fire. A space heater needs to be placed at least 3 feet from anything that can burn. A space heater can be used in an apartment if there is ample space and safety precautions are followed. Placing a heater in a hallway does not guarantee that it will be 3 feet from anything that can burn. A low setting does not reduce the risk of fire.

When caring for a client with an internal radiation implant, the nurse should observe which principles? Select all that apply. 1. Limiting the time with the client to 1 hour per shift. 2. Keeping pregnant women out of the client's room. 3. Placing the client in a private room with a private bath. 4. Wearing a lead shield when providing direct client care. 5 .Removing the dosimeter film badge when entering the client's room. 6. Allowing individuals younger than 16 years old in the room as long as they are 6 feet away from the client.

2. Keeping pregnant women out of the client's room. 3. Placing the client in a private room with a private bath. 4. Wearing a lead shield when providing direct client care. Rationale: The time that the nurse spends in a room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The client must be placed in a private room with a private bath. The nurse should wear a lead shield to reduce the transmission of radiation. The dosimeter film badge must be worn when in the client's room. Children younger than 16 years of age and pregnant women are not allowed in the client's room.

The nurse is preparing to instill medication into a client's nasogastric tube. Which actions should the nurse take before instilling the medication? Select all that apply. 1. Check the residual volume. 2. Aspirate the stomach contents. 3. Turn off the suction to the nasogastric tube. 4. Remove the tube and place it in the other nostril. 5. Check the stomach contents for a pH of less than 3.5.

1. Check the residual volume. 2. Aspirate the stomach contents. 3. Turn off the suction to the nasogastric tube. 5. Check the stomach contents for a pH of less than 3.5. Rationale: By aspirating stomach contents the residual volume can be determined and the pH checked. A pH less than 3.5 verifies gastric placement. The suction should be turned off before the tubing is disconnected to check for residual volume; in addition, suction should remain off for 30 to 60 minutes following medication administration to allow for medication absorption. There is no need to remove the tube and place it in the other nostril in order to administer a feeding; in fact, this is an invasive procedure and is unnecessary.

A nurse has been assigned to the care of four adult clients who are receiving continuous intravenous (IV) infusions. How often should the nurse plan to check the IV infusions and IV sites of these clients? a) Every 1 hour b) Every 2 hours c) Every 3 hours d) Every 4 hours

a) Every 1 hour Rationale: Safe nursing practice includes monitoring an IV infusion at least once per hour in an adult client. The IV site may be checked even more frequently, depending on agency policy and whether medication also is being infused.

A nurse is developing a plan of care for a client with late-stage Alzheimer's disease. The nurse identifies which client problem as having the highest priority? a) Risk for injury b) Social isolation behaviors c) Role performance alterations d) Inability to communicate verbally

a) Risk for injury Rationale: Clients who have Alzheimer's disease have significant cognitive impairment and are therefore at risk for injury. It is critical for the nurse to maintain a safe environment, particularly as the client's judgment becomes increasingly impaired. Options 2, 3, and 4 may be appropriate, but the highest priority is directed toward safety.

A client is being discharged to home after application of a plaster leg cast. Which statement indicates to the nurse that the teaching has been effective? a) "I will avoid getting the cast wet." b) "I will use my fingertips to lift and move the leg." c) "I can use a padded coat hanger end to scratch under the cast." d) "I need to cover the casted leg with warm blankets for the next few days."

a) "I will avoid getting the cast wet." Rationale :A plaster cast must remain dry to keep its strength. The cast should be handled using the palms of the hands, not the fingertips, until fully dry. The client should never scratch under the cast. A hair dryer set at a cool setting may be used to relieve an itch. Air should circulate freely around the cast to help it dry. Also, the cast gives off heat as it dries.

The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents and checks the gastric pH. The nurse verifies correct tube placement if which pH value is noted? a) 3.5 b) 7.0 c) 7.35 d) 7.5

a) 3.5

The nurse purchases a cup of coffee, a bottle of water, and a bagel in the hospital cafeteria and then returns to the nursing unit to take a morning break in the staff lounge. On entering the lounge, the nurse notes that the cushion of a chair is on fire. What should the nurse's first action be? a) Activate the fire alarm. b) Quickly pour the coffee on the fire. c) Open the bottle of water and throw it on the fire. d) Grab a fire extinguisher and attempt to put out the fire.

a) Activate the fire alarm. RACE

The nurse is developing a plan of care for a client receiving a nasogastric (NG) tube feeding. When formulating the plan of care, what should the nurse consider? a) Aspiration is a concern with an NG tube feeding. b) The client needs to be maintained in a supine position. c) The NG tube needs to be changed with every other feeding. d) The rate of the feeding needs to be increased if the infusion rate falls behind schedule.

a) Aspiration is a concern with an NG tube feeding. Rationale: NG tube feedings are beneficial for some clients but present several significant possible complications such as diarrhea, lactose intolerance, dumping syndrome, or excess fluid volume. Another serious complication is aspiration pneumonia, which is caused by regurgitation of formula contents from the stomach into the respiratory tract. Keeping the head of the bed elevated to 30 degrees at all times assists in the prevention of this complication. NG tubes may be left in place from weeks to months depending on the type of tube inserted. The rate of the feedings should not be increased unless prescribed. A rate that is too rapid also may cause diarrhea, fluid overload, or aspiration.

A nurse is caring for a client who is scheduled for abdominal surgery and administers the preoperative medications as prescribed. The nurse then raises the side rails on the stretcher, places the safety strap across the client, places the call bell near the client, and instructs the client to call for assistance as needed. Shortly thereafter the client calls the nurse and reports the need to urinate. Which action should the nurse take to meet this client's need? a) Assist the client onto a bedpan. b) Assist the client to the bathroom. c) Contact the health care provider and request a prescription for a Foley catheter. d) Tell the client that preoperative medications cause the urge to void, and check the bladder for distention.

a) Assist the client onto a bedpan. Rationale: Because preoperative medications cause sedation, the client should not be allowed to leave the bed or stretcher after the medications are administered. To ensure safety, the nurse should assist the client in using a bedpan. There is no need for a Foley catheter; in addition, a Foley catheter places the client at risk for infection. Option 4 is inappropriate; if the client verbalizes a need to void, the nurse should assist in meeting this need.

A client is in extreme pain from scrotal swelling that is caused by epididymitis. The nurse administers an intramuscular opioid analgesic in the left arm to relieve the pain. The nurse should plan to take which action next? a) Ensure client safety. b) Dim the lights in the room. c) Check the name bracelet of the client. d) Perform range-of-motion exercises to the left arm to promote medication absorption.

a) Ensure client safety. Rationale: The nurse should ensure client safety after he receives an opioid analgesic to prevent injury once the medication has taken effect. Dimming the light in the room is the next most helpful action. The name bracelet should have been checked before administering the medication. It is unnecessary to do range-of-motion exercises to the affected arm.

An adolescent is admitted to the hospital after an accidental gunshot wound to the foot. The nurse should plan to take which action as a first step for the prevention of future injury? a) Explore the client's knowledge of gun safety. b) Assess the client for a history of risk-taking behaviors. c) Refer the client to a firearm safety class sponsored by the hospital. d) Have the client watch a video on the tragedies of improper firearm use.

a) Explore the client's knowledge of gun safety. Rationale: A leading cause of accidental death in the adolescent population is improper use of firearms. Before implementing firearm safety goals, the nurse needs to obtain baseline data through a firearm safety history, which is described in the correct option. Option 2 may be indicated because of the relationships among accidents, impulsivity, and risk-taking behaviors, but assessing past risk-taking behaviors would not be the first step directed at prevention. Option 3 may be effective, but referral to a firearm safety course would not come before assessing the client's knowledge of gun safety. Option 4 may or may not be effective, at some point, for this client.

The nurse checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take? a) Hold the feeding. b) Reinstill the amount and continue with administering the feeding. c) Elevate the client's head at least 45 degrees and administer the feeding. d) Discard the residual amount and proceed with administering the feeding

a) Hold the feeding. Rationale: Unless specifically indicated, residual amounts more than 100 mL require holding the feeding. In addition, the feeding is not discarded unless its contents are abnormal in color or characteristics.

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position? a) Left Sims position b) Right Sims position c) On the left side of the body, with the head of the bed elevated 45 degrees d) On the right side of the body, with the head of the bed elevated 45 degrees

a) Left Sims position Rationale: For administering an enema, the client is placed in a left Sims position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the Sims position.

The nurse is preparing a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which nursing intervention should the nurse implement in preparation for arrival of the client? a) Prepare a private room at the end of the hallway. b) Assign one primary nurse to care for the client during the hospital stay. c) Place a sign on the door that indicates that visitors are limited to 60-minute visits. d) Place a linen bag outside of the client's room for discarding linens after morning care.

a) Prepare a private room at the end of the hallway. Rationale: The client with an internal cervical radiation implant should be placed in a private room at the end of the hall because this location provides less chance of radiation exposure to others. Nurses assigned to this client should be rotated so that one nurse is not consistently caring for the client and being exposed to excess amounts of radiation. The client's room should be marked with appropriate signs (per agency policy) that indicate the presence of radiation. Visitors should be limited to 30-minute visits. All linens should be kept in the client's room until the implant is removed, in case the implant has dislodged and needs to be located.

The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next? a) Reassess the client. b) Conduct a staff meeting to describe the fall. c) Document in the nurse's notes that an incident report was completed. d) Contact the nursing supervisor to update information regarding the fall.

a) Reassess the client. Rationale: After a client's fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall. The client's fall should be treated as private information and shared on a "need to know" basis. Communication regarding the event should involve only the individuals participating in the client's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is necessary.

The community health nurse has instructed a group of parents of preschoolers about home safety measures for children. Which statement by one of the parents should the nurse identify as something that requires the need for reinforcement of the instructions? a) Refers to medication as "candy for when you are sick" b) Says he or she will store medications in child-proof containers c) Keeps the Poison Control Center telephone number readily available d) States the intention to label all toxic substances and place them in a locked area

a) Refers to medication as "candy for when you are sick" Rationale: Medicine should not be referred to as candy. Home safety measures are simple but important. Medications should be stored in child-proof containers. The number of tablets in a container should be limited. The Poison Control Center telephone number should be visible near all telephones. Toxic substances should be labeled with poison stickers and placed in a locked area out of reach of children.

The nurse provides instructions to the parents of an infant regarding car travel and safety seats. Which is the most appropriate information related to the safety of the infant? a) Restrain in a car seat in the back seat in a semireclined, rear-facing position b) Restrain in a car seat in the front seat in a semireclined, rear-facing position c) Restrain in a car seat in the back seat in a semireclined, forward-facing position d) Restrain in a car seat in the front seat in a semireclined, forward-facing position

a) Restrain in a car seat in the back seat in a semireclined, rear-facing position Rationale: Infants should be restrained in a car seat (convertible seat) or infant-only seat in a semireclined, rear-facing position in the back seat of the car. The infant is not placed in the front seat or in the forward-facing position; therefore options 2, 3, and 4 are incorrect. Additionally, parents should be instructed to always follow the guidelines from the manufacturer of the safety seat.

A health care provider has written a prescription for wrist restraints to be applied on a client from 10:00 PM to 7:00 AM because the client becomes disoriented during the night and is at risk for pulling out the nasogastric tube and the intravenous catheter. At 11:00 PM, the charge nurse makes rounds on all of the clients in the unit. When assessing the client with the restraints, which observation by the charge nurse indicates that the nurse who applied the restraints performed an unsafe action? a) The restraints were applied tightly. b) A safety knot was used to secure the restraints. c) The call light was placed within reach of the client. d) The client's record indicates that the restraints will be released every 2 hours.

a) The restraints were applied tightly. Rationale: Restraints should never be applied tightly because that could impair circulation. The restraint should be applied securely (not tightly) to prevent the client from slipping through the restraint and endangering himself or herself. A safety knot should be used because it can be released easily in an emergency. The call light must always be within the client's reach in case the client needs assistance. Restraints, especially limb restraints, must be released every 2 hours (or per agency policy) to inspect the skin for abnormalities.

The home care nurse is performing an environmental assessment in the home of an older client. Which observation by the nurse requires intervention? a) Unsecured scatter rugs b) Clear exit passageways c) An operable smoke detector d) A prefilled medication cassette

a) Unsecured scatter rugs Rationale: Trauma to the older client in the home may be caused by a variety of factors. These include an unsteady gait, the presence of unsecured scatter rugs, cluttered passageways, inoperable smoke detectors, and a history of previous falls. Any assessment findings that could lead to injury or trauma in the home should be addressed immediately.

A client has a cerebellar lesion. The nurse should plan to obtain which item for use by the client? a) Walker b) Slider board c) Raised toilet seat d) Adaptive eating utensils

a) Walker Rationale: The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. A slider board would be used in transferring a client with weak or paralyzed legs from a bed to a stretcher or wheelchair. A raised toilet seat would be useful if the client did not have sufficient mobility or ability to flex the hips. Adaptive eating utensils would be beneficial if the client had partial paralysis of the hand.

The mother of a 2½-year-old child arrives at the hospital emergency department and reports to the nurse that the child has been complaining of a "tummy ache." The mother also reports that the child has been irritable and that it has been difficult to awaken the child. On further assessment, the nurse suspects lead poisoning. Which assessment question would elicit specific data related to this condition? a) "Does your child chew on pencils or crayons?" b) "Do you live in a house that is more than 25 years old?" c) "Have you noticed a sweet and fruity odor on the child's breath?" d) "Has your child been breathing very fast or sweating profusely?"

b) "Do you live in a house that is more than 25 years old?" Rationale: Homes that are older than 25 years may have lead paint and will most likely have lead pipes, which can contribute to lead poisoning. Pencil lead is made of graphite, so it does not present a hazard to the child. Crayons are not toxic. A sweet and fruity odor to the breath is a symptom of ketoacidosis. Breathing rapidly and diaphoresis are signs of salicylate poisoning.

The nurse is preparing to initiate an intravenous line containing a high dose of potassium chloride and plans to use an intravenous infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action? a) Initiate the intravenous line without the use of a pump. b) Contact the electrical maintenance department for assistance. c) Plug in the pump cord in the available plug above the room sink. d) Use an extension cord from the nurses' lounge for the pump plug.

b) Contact the electrical maintenance department for assistance. Rationale: Electrical equipment must be maintained in good working order and should be grounded; otherwise it presents a physical hazard. An intravenous line that contains a dose of potassium chloride should be administered by an infusion pump. The nurse needs to use hospital resources for assistance. A regular extension cord should not be used because it poses a risk for fire. Use of electrical appliances near a sink also presents a hazard.

A client is being weaned from parenteral nutrition (PN), also known as total parenteral nutrition, and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription? a) Discontinue the PN. b) Decrease PN rate to 50 mL/hour. c) Start 0.9% normal saline at 25 mL/hour. d) Continue current infusion rate prescriptions for PN.

b) Decrease PN rate to 50 mL/hour. Rationale: When a client begins eating a regular diet after a period of receiving PN, the PN is decreased gradually. PN that is discontinued abruptly can cause hypoglycemia. Clients often have anorexia after being without food for some time, and the digestive tract also is not used to producing the digestive enzymes that will be needed. Gradually decreasing the infusion rate allows the client to remain adequately nourished during the transition to a normal diet and prevents the occurrence of hypoglycemia. Even before clients are started on a solid diet, they are given clear liquids followed by full liquids to further ease the transition. A solution of normal saline does not provide the glucose needed during the transition of discontinuing the PN and could cause the client to experience hypoglycemia.

The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first? a) Check for medication interactions. b) Determine whether there are medication duplications. c) Call the prescribing health care provider (HCP) and report polypharmacy. d) Determine whether a family member supervises medication administration.

b) Determine whether there are medication duplications. Rationale: Polypharmacy is a concern in the older client. Duplication of medications needs to be identified before medication interactions can be determined because the nurse needs to know what the client is taking. Asking about medication administration supervision may be part of the assessment but is not a first action. The phone call to the HCP is the intervention after all other information has been collected.

A client is to undergo weekly intravesical chemotherapy for bladder cancer for the next 8 weeks. What instruction should the nurse provide to the client regarding management of the urine as a biohazard? a) Void into a bedpan and then empty the urine into the toilet. b) Disinfect the toilet with bleach after voiding for 6 hours after a treatment. c) Purchase extra bottles of scented disinfectant for daily bathroom cleansing. d) Have one bathroom strictly set aside for the client's use for the next 2 months.

b) Disinfect the toilet with bleach after voiding for 6 hours after a treatment. Rationale: After intravesical chemotherapy, the client treats the urine as a biohazard. This involves disinfecting the urine and the toilet with household bleach for 6 hours after the treatment. Using a bedpan for voiding is of no value in this situation. Scented disinfectants are of no particular use. The client does not need to have a separate bathroom for personal use.

The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse develops a postoperative plan of care for the client and should include which intervention in the plan? a) Maintain the client in a prone position. b) Elevate and immobilize the grafted extremity. c) Maintain the grafted extremity in a flat position. d) Keep the grafted extremity covered with a blanket

b) Elevate and immobilize the grafted extremity. Rationale: Autografts placed over joints or on lower extremities are elevated and immobilized following surgery for 3 to 7 days, depending on the surgeon's preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the client in a prone position and covering the extremity with a blanket can disrupt the graft site.

The nurse is instructing a client who had a stroke and has weakness on one side how to ambulate with the use of a cane. Which instruction should the nurse provide to the client? a) Hold the cane on the affected (weak) side. b) Hold the cane on the unaffected (strong) side. c) Move the cane forward first along with the unaffected (strong) leg. d) Move the cane and the unaffected (strong) leg down first when going down stairs.

b) Hold the cane on the unaffected (strong) side. Rationale: The cane is kept on the strong side of the body. It would be hard to hold the cane on the weak side. The cane is assisting the weakened leg, so the weakened leg moves with the cane, or right after it, in ambulating or in going down stairs.

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. What action should the nurse take next? a) Immediately inflate the balloon. b) Insert the catheter 2.5 cm to 5 cm and inflate the balloon. c) Withdraw the catheter about 1 inch and inflate the balloon. d) Insert the catheter until resistance is met and inflate the balloon.

b) Insert the catheter 2.5 cm to 5 cm and inflate the balloon. Rationale: The balloon of the urinary catheter is behind the opening at the insertion tip. The catheter is inserted 2.5 cm to 5 cm after urine begins to flow to provide sufficient space to inflate the balloon. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra. Inflating the balloon in the urethra could produce trauma.

The nurse is planning to instruct a client with chronic vertigo about safety measures to prevent exacerbation of symptoms or injury. Which instruction should the nurse plan to include in the client's teaching plan? a) Turn the head slowly when spoken to. b) Remove throw rugs and clutter in the home. c) Go to the bedroom and lie down when vertigo is experienced. d) Drive only when feelings of dizziness have not been experienced for several hours.

b) Remove throw rugs and clutter in the home. Rationale: The client with chronic vertigo should maintain the home without throw rugs and in a state that is free of clutter because the effort of trying to regain balance after slipping could trigger the onset of vertigo. To further prevent vertigo attacks, the client should change positions slowly and should turn the entire body, not just the head, when spoken to. If vertigo does occur, the client should immediately sit down or grasp the nearest piece of furniture. The client should avoid driving and using public transportation. The sudden movements involved in each could precipitate an attack.

The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation by the nurse indicates unsafe application of the safety device by the UAP? a) Placing a safety knot in the safety device straps b) Safely securing the safety device straps to the side rails c) Applying safety device straps that do not tighten when force is applied against them d) Securing so that two fingers can slide easily between the safety device and the client's skin

b) Safely securing the safety device straps to the side rails Rationale: The safety device straps are secured to the bed frame and never to the side rail to avoid accidental injury in the event that the side rail is released. A half-bow or safety knot should be used for applying a safety device because it does not tighten when force is applied against it and it allows quick and easy removal of the safety device in case of an emergency. The safety device should be secure, and one or two fingers should slide easily between the safety device and the client's skin.

The nurse is preparing to administer an oral medication to an infant. Which position should the nurse place the infant? a) Prone b) Semi-Fowler's c) Trendelenburg's d) Dorsal recumbent

b) Semi-Fowler's Rationale: The nurse should administer oral medications with the infant sitting in an upright position to prevent aspiration if the infant cries or resists. Semi-Fowler's is an upright position. Trendelenburg's position is on the back with the head lowered, and prone is on the abdomen. Oral medications could not be administered to an infant in either of these positions. Dorsal recumbent means on the back and flat, so there would be a risk of aspiration with this position.

The nurse is caring for an 18-month-old child who has been vomiting. Which is the most appropriate position for this child while sleeping? a) Supine b) Side-lying position c) Prone with the head elevated d) Prone with the face turned to the side

b) Side-lying position Rationale: The vomiting child should be placed in an upright or side-lying position to prevent aspiration. Placing the child supine or prone will place the child at risk for aspiration if vomiting occurs.

The nurse has observed that an older client has episodes of extreme agitation. Which measure is most appropriate for the nurse to implement to avoid episodes of agitation? a) Wait until the client's agitation has subsided before approaching the client. b) Speak and move slowly toward the client while assessing the client's needs. c) Speak to the client at the entrance of the room to avoid any episodes of agitation. d) Walk up behind the client and gently put a hand on the client's shoulder while speaking.

b) Speak and move slowly toward the client while assessing the client's needs. Rationale: Speaking and moving slowly toward the client will prevent the client from becoming further agitated. Any sudden moves or speaking too quickly may cause the client to become agitated and could trigger a violent episode. Remaining at the entrance of the room may make the client feel alienated. If the client's agitation is not addressed, it will only increase. Therefore, waiting for the agitation to subside is not an appropriate option. Walking up behind the client may cause the client to become startled and react violently.

The health care provider (HCP) prescribes fat emulsion (Intralipids), given intravenously, for a client. The nurse should consult with the HCP before administering the fat emulsion solution if which is noted in the client's record? a) The client has an allergy to iodine. b) The client has an allergy to egg yolks. c) The client has a blood glucose level of 120 mg/dL. d) The client is receiving total parenteral nutrition (TPN)

b) The client has an allergy to egg yolks. Rationale: Before administering any medication, the nurse must assess for allergy or hypersensitivity to substances used in producing the medication. Fat emulsions such as Intralipids may contain an emulsifying agent obtained from egg yolks. Clients sensitive to eggs are at risk for developing hypersensitivity reactions.

The home health nurse performs an assessment on a client who had cardiac surgery 10 days ago. The client states, "I get dizzy in the shower." On the basis of the client's statement, which option should the nurse assess first? a) The bathroom environment in the home b) The temperature of the water of the client's shower c) The client's insurance plan for reimbursement of medical equipment d) The client's insurance plan regarding coverage for home health assistive personnel care

b) The temperature of the water of the client's shower Rationale: The client may be taking hot showers, which can cause vasodilation with a consequent decrease in venous return to the heart. Decreased venous return decreases cerebral blood flow, leading to symptoms of dizziness. By assessing the temperature of the shower first, the nurse may identify the problem and instruct the client to decrease the water temperature or defer hot showers or baths until the healing process has occurred. The client's complaint is dizziness. Factors that increase dizziness would be the first assessment. Options 1, 3, and 4 do not directly relate to the client's complaint.

The nurse develops a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? a) Out-of-bed activities as desired b) Bed rest with the affected extremity kept flat c) Bed rest with elevation of the affected extremity d) Bed rest with the affected extremity in a dependent position

c) Bed rest with elevation of the affected extremity Rationale: For the client with deep vein thrombosis, elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. Bed rest is indicated to prevent emboli and to prevent pressure fluctuations in the venous system that occur with walking.

The nurse is caring for an older client who had a hip pinned after being fractured. Which should the nurse do to prevent further injury? a) Respond to the call light within 10 minutes. b) Use a night light in the hospital room and the bathroom. c) Medicate the client with a sleeping pill to encourage him or her to sleep through the night. d) Keep all four side rails in the up position, preventing the client from getting out of bed.

b) Use a night light in the hospital room and the bathroom. Rationale: Use of a night light may help with orientation as well as fall prevention. Option 1 is not appropriate because 10 minutes is a long time for someone to have to wait after pressing the call light. Responding promptly to the client's use of the call light minimizes the chance that the client will try to get up alone, which could result in a fall. A sleeping pill may increase the fall risk of a client who tries to get up during the night. Having full side rails (or four side rails) could increase the level of injury when a client tries to get out of bed in spite of the side rails. In addition, agency policy is always followed with regard to the use of side rails.

The nurse is providing medication instructions to a parent. Which statement by the parent indicates a need for further instruction? a) "I should cuddle my child after giving the medication." b) "I can give my child a frozen juice bar after he swallows the medication." c) "I should mix the medication in the baby food and give it when I feed my child." d) "If my child does not like the taste of the medicine, I should encourage him to pinch his nose and drink the medication through a straw."

c) "I should mix the medication in the baby food and give it when I feed my child." Rationale: The nurse would teach the parent to avoid putting medications in foods because it may give an unpleasant taste to the food, and the child may refuse to accept the same food in the future. In addition, the child may not consume the entire serving and would not receive the required medication dosage. The mother should provide comfort measures immediately after medication administration, such as touching, holding, cuddling, and providing a favorite toy. The mother should offer juice, a soft drink, or a frozen juice bar to the child after the child swallows the medication. If the taste of the medication is unpleasant, the child should pinch the nose and drink the medication through a straw.

The home care nurse visits a client who has been started on oxygen therapy. The nurse provides instructions to the client regarding safety measures for the use of oxygen in the home. Which statement, if made by the client, indicates a need for further instruction? a) "I need to be sure that no one smokes in my home." b) "I need to be sure that I stay at least 10 feet away from any burning candles." c) "It is all right to use an electric razor for shaving only if I leave it plugged in for a short time." d) "I need to be sure that there is space between the oxygen concentrator and the wall in the room."

c) "It is all right to use an electric razor for shaving only if I leave it plugged in for a short time." Rationale: The use of small electric items, tools, or other equipment could emit sparks and should be avoided while oxygen is in use. The use of this equipment could result in fire and injury to the client. The client also should be instructed not to allow smoking in the home and to stay at least 10 feet away from any type of flame. The oxygen concentrator is kept away from walls and corners to permit adequate airflow.

The nurse provides home care instructions to a client with sickle cell anemia. Which statement by the client indicates a need for further instruction? a) "I'm going to take a painting class." b) "I've learned to knit and sew my own clothes." c) "When I'm feeling better, I'm returning to the soccer team." d) "I'm using a schedule to maintain my increased fluid intake."

c) "When I'm feeling better, I'm returning to the soccer team." Rationale: Clients with sickle cell anemia are advised to avoid strenuous activities. Quiet activities as tolerated are recommended when the client is feeling well. Increasing fluid intake is encouraged to assist in preventing sickle cell crisis.

The nurse is administering an acetaminophen (Tylenol) suppository to a child with a fever. The nurse inserts the suppository into the rectum a distance of no more than how many centimeters? a) 0.5 b) 1 c) 2 d) 2.5

c) 2 Rationale: The child's rectal vault is not as long as that of an adult, and the distance required to place medications is approximately 1 to 2 cm. After insertion, the buttocks should be held together until the urge to expel the suppository has passed.

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees identify which client as most typically a victim of abuse? a) A 75-year-old man who has moderate hypertension b) A 68-year-old man who has newly diagnosed cataracts c) A 90-year-old woman who has advanced Parkinson's disease d) A 70-year-old woman who has early diagnosed Lyme disease

c) A 90-year-old woman who has advanced Parkinson's disease Rationale: Elder abuse includes physical, sexual, or psychological abuse, misuse of property, and violation of rights. The typical abuse victim is a woman of advanced age with few social contacts and at least one physical or mental impairment that limits her ability to perform activities of daily living. In addition, the client usually lives alone or with the abuser and depends on the abuser for care.

The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted? a) A clotting time of 10 minutes b) An ammonia level of 20 mcg/dL c) A platelet count of 50,000 cells/mm3 d) A white blood cell count of 5000 cells/mm3

c) A platelet count of 50,000 cells/mm3 Rationale: Bleeding precautions need to be initiated when the platelet count decreases. The normal platelet count is 150,000 to 450,000 cells/mm3. When the platelet count decreases, the client is at risk for bleeding. The normal white blood cell count is 4500 to 11,000 cells/mm3. When the white blood cell count drops, neutropenic precautions need to be implemented. The normal clotting time is 8 to 15 minutes. The normal ammonia value is 10 to 80 mcg/dL.

The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action? a) Position the client supine to assist in medication absorption. b) Aspirate the nasogastric tube after medication administration to maintain patency. c) Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication. d) Change the suction setting to low intermittent suction for 30 minutes after medication administration.

c) Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication. Rationale: If a client has a nasogastric tube connected to suction, the nurse should wait 30 to 60 minutes before reconnecting the tube to the suction apparatus to allow adequate time for medication absorption. The client should not be placed in the supine position because of the risk for aspiration. Aspirating the nasogastric tube will remove the medication just administered. Low intermittent suction also will remove the medication just administered.

The nurse plans to administer a medication by intravenous (IV) bolus through the primary IV line. The nurse notes that the medication is incompatible with the primary IV solution. Which is the appropriate nursing action to safely administer the medication? a) Start a new IV line for the medication. b) Flush the tubing after the medication with sterile water. c) Flush the tubing before and after the medication with normal saline. d) Call the health care provider for a prescription to change the route of the medication.

c) Flush the tubing before and after the medication with normal saline. Rationale: When giving a medication by IV bolus, if the medication is incompatible with the IV solution, the tubing is flushed before and after the medication with infusions of normal saline. Option 1 is premature and not necessary. Sterile water is not used for an IV flush. Option 4 is inappropriate.

A nursing student is assigned to administer an intramuscular iron injection to a client. The coassigned nurse asks the student about the technique for administration of this medication. The student indicates understanding of the administration procedure by identifying what as the correct injection site and method? a) Anterolateral thigh using an air lock b) Deltoid muscle using a 1-inch needle c) Gluteal muscle using Z-track technique d) Subcutaneous tissue of the abdomen using a 1-inch needle

c) Gluteal muscle using Z-track technique Rationale: The correct technique for administering intramuscular iron is deep in the gluteal muscle using Z-track technique. This method minimizes the possibility that the injection will stain the skin a dark color. The medication is not given in the thighs, arms, or abdomen or by the subcutaneous route.

A nurse is preparing to infuse (piggyback) a 50-mL dose of a compatible medication through the primary intravenous (IV) line. How should the nurse correctly attach the medication bag? a) Hanging the medication bag level with the primary IV bag b) Hanging the medication bag lower than the primary IV bag c) Hanging the medication bag higher than the primary IV bag d) Disconnecting the primary IV solution and plugging in the medication

c) Hanging the medication bag higher than the primary IV bag Rationale: For an intermittent IV infusion that is piggybacked to the primary IV line, the bag for the intermittent infusion is placed higher than the primary solution bag. This allows gravity to assist in infusing the medication. Once the intermittent infusion is complete, the primary IV infusion will resume at the drip rate set for the intermittent infusion. For this reason, it also is important to remember to check the infusion frequently and reset the primary IV drip rate correctly once the intermittent infusion is complete.

The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion? a) Right side b) Low Fowler's c) High Fowler's d) Supine with the head flat

c) High Fowler's Rationale: During insertion of a nasogastric tube, the client is placed in a sitting or high Fowler's position to facilitate insertion of the tube and reduce the risk of pulmonary aspiration if the client should vomit. The right side, and low Fowler's and supine positions place the client at risk for aspiration; in addition, these positions do not facilitate insertion of the tube.

The nurse has instructed a client with a continuous passive motion (CPM) device applied to the leg about the device and its use. The nurse determines that the client has misunderstood one of the teaching points if the client asks which question? a) How to use the "stop-go" button b) About reporting discomfort in the knee to the nurse c) How to reset the degrees of flexion or extension according to comfort d) Whether the knee should stay aligned with the hinged joint on the machine

c) How to reset the degrees of flexion or extension according to comfort Rationale: The client should not adjust the flexion and extension settings. These settings are determined by the orthopedic surgeon and are maintained as prescribed. The client is instructed about how to stop and start the machine and to notify the nurse about knee discomfort. The client also should be aware of proper positioning so that the nurse can be notified if the leg slips. Other important actions by the nurse with use of this device are to assess the neurovascular status of the extremity and to ensure that the device is padded with manufactured disposable padding before the client's leg is placed in the device.

The nurse is preparing to administer medications to a client via a percutaneous endoscopic gastrostomy (PEG) tube. Which medication prescription should the nurse question? a) Furosemide (Lasix) 20 mg via PEG tube daily b) Digoxin (Lanoxin) 0.25 mg via PEG tube daily c) Isosorbide mononitrate (Imdur) 30 mg via PEG tube daily d) Acetaminophen (Tylenol) elixir 650 mg via PEG every 4 hours as needed for temperature >101° F

c) Isosorbide mononitrate (Imdur) 30 mg via PEG tube daily Rationale: The process for administration of medications via PEG tube includes checking for bowel sounds, residual, and placement prior to medication administration. Then, the nurse should crush the medications and mix with tap water to be administered one at a time followed by a flush in between each medication. Enteric coated tablets, sustained-release tablets, such as isosorbide mononitrate, and controlled release tablets and capsules should not be crushed because their mechanism of slow-release is interrupted.