ATI Fundamentals 3.0: Fundamentals

A nurse is caring for a client who has a prescription for acetaminophen 325 mg PO for an oral temperature above 38.4°C. Above what Fahrenheit (F) temperature should the nurse administer acetaminophen to the client? (Fill in the blank with the numeric value only. Round the answer to the nearest tenth. Use a leading zero if applicable but do not use a trailing zero.) Fill in the blank

Correct Answer: 101.1 Follow these steps for the conversion of degrees Celsius to Fahrenheit: Step 1: What is the unit of measurement the nurse should calculate? Fahrenheit Step 2: Set up an equation and solve for X. F = (C x 9/5) + 32 F = (38.4 x 9/5) + 32 F = 69.12 + 32 F = 101.12 Step 3: Round if necessary. 101.12 = 101.1 Step 4: Determine whether the conversion to Fahrenheit makes sense. If a Fahrenheit temperature is equal to the Celsius temperature multiplied by 9/5 plus 32, it makes sense that a Celsius temperature of 38.4° is equal to a Fahrenheit temperature of 101.1°. The nurse should administer acetaminophen if the client's temperature is above 101.1° Fahrenheit.

A nurse is caring for a client who is receiving dextrose 5% in water IV at 150 mL/hr and has ingested 4 oz of water and 1/2 pint of milk. What is the total 8-hour fluid intake in milliliters that the nurse should document for this client? (Fill in the blank with the numeric value only. Round the answer to the nearest whole number. Use a leading zero if applicable but do not use a trailing zero.)

Correct Answer: 1560 Follow these steps for the conversion of oz to mL: Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: Set up an equation and solve for X. 1 oz / 30 mL = 4 oz / X mL X = 120 Step 3: Round if necessary. Step 4: Determine whether the conversion to mL makes sense. If 1 oz = 30 mL, it makes sense that 4 oz = 120 mL. Follow these steps for the conversion of pints to mL: Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: Set up an equation and solve for X. 1 pint / 480 mL = 0.5 pint / X mL X = 240 Step 3: Round if necessary. Step 4: Determine whether the conversion to mL makes sense. If 1 pint = 480 mL, then 1/2 pint = 240 mL. For the total intake, calculate: 150 mL x 8 hr = 1200 mL + 120 mL + 240 mL = 1560 mL

A nurse is reinforcing teaching with a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective? A. "I should expect my heart rate to take longer to return to normal after exercise as I get older." B. "Urinary incontinence is something I will have to live with as I grow older." C. "I can expect to have less ear wax as I get older." D. "My stomach will empty more quickly after meals as I grow older."

Correct Answer: A. "I should expect my heart rate to take longer to return to normal after exercise as I get older." Older adults experience decreased cardiac output, which causes increased pulse rate during exercise. However, the pulse rate also takes longer to return to normal after exercise. Incorrect Answers: B. Although bladder capacity decreases in older adults, urinary incontinence is not a normal finding. Older adults should report incontinence so that it can be investigated and treated. C. Older adults have an increased buildup of cerumen in the ears, which can raise the expected incidence of problems with hearing loss. D. Decreased gastric emptying is an expected finding in older adults.

A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long-term goal of weight loss? A. Attempting to increase the clients' self-motivation B. Keeping detailed records of each client's progress C. Testing client learning after each teaching session D. Avoiding discussing topics that might cause client anxiety

Correct Answer: A. Attempting to increase the clients' self-motivation Motivation to learn is important for improving a client's commitment to achievement of a health goal, as well as for increasing the amount and speed of learning. Incorrect Answers: B. This will help track individual progress; however, it does not improve client commitment to long-term goals. C. Testing learning helps determine whether outcomes are reached; however, it does not affect a client's commitment to a goal. D. Anxiety can interfere with learning and should be addressed early in the teaching process.

After collecting data on a client's radial pulses, the nurse documents "radial pulses 4+ bilaterally." This finding indicates which of the following pulse qualities? A. Bounding B. Full C. Variable D. Weak

Correct Answer: A. Bounding A pulse of 4+ is bounding and does not disappear with moderate pressure. Pulse strength ranges from absent (0) to bounding (4+). Incorrect Answers: B. Full pulse strength is 3+. C. Variable typically describes the pulse's rate or rhythm, not its strength. D. A weak pulse is 1+.

Correct Answer: A. Bounding A pulse of 4+ is bounding and does not disappear with moderate pressure. Pulse strength ranges from absent (0) to bounding (4+). Incorrect Answers: B. Full pulse strength is 3+. C. Variable typically describes the pulse's rate or rhythm, not its strength. D. A weak pulse is 1+.

Correct Answer: A. Bounding A pulse of 4+ is bounding and does not disappear with moderate pressure. Pulse strength ranges from absent (0) to bounding (4+). Incorrect Answers: B. Full pulse strength is 3+. C. Variable typically describes the pulse's rate or rhythm, not its strength. D. A weak pulse is 1+.

A nurse is caring for a client who has a prescription for the collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse plan to take when obtaining the specimen? A. Collect the specimen once the client rises in the morning B. Force fluids during the day and collect the specimen in the evening C. Collect the specimen after antibiotics have been started D. Collect 2 mL of sputum before sending the specimen to the laboratory

Correct Answer: A. Collect the specimen once the client rises in the morning The nurse should plan to collect the sputum specimen when the client arises in the morning because the client is able to more easily cough up the secretions that have accumulated during the night. Generally, the deepest specimens are obtained in the early morning, and it is preferable to collect the specimen before breakfast. The nurse should instruct the client to rinse the mouth, take a deep breath, and cough prior to expectorating into the sterile container. Incorrect Answers: B. The nurse should encourage the client to force fluids, especially clear liquids, to help thin the secretions. However, evening hours are not the preferred time for obtaining a deep sputum specimen. C. The nurse should collect the sputum specimen ordered for culture and sensitivity before the client receives antibiotic therapy to avoid interference with the laboratory results. D. The nurse should collect 4 to 10 mL of sputum before sending the specimen to the laboratory to provide an adequate amount of sputum for culture and sensitivity.

A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein? A. Eggs B. Cereal C. Peanut butter D. Pasta

Correct Answer: A. Eggs Complete proteins contain all of the essential amino acids to support growth and homeostasis. Examples of complete proteins include eggs, meat, poultry, seafood, milk, yogurt, cheese, soybeans, and soybean products. Incorrect Answers: B. Incomplete proteins are missing 1 or more of the essential amino acids necessary to support growth and maintain homeostasis. Cereal is an example of an incomplete protein. However, it can be combined with skim milk to make a complete protein. C. Peanut butter is an example of an incomplete protein. However, it can be combined with whole wheat bread to make a complete protein. D. Pasta is an example of an incomplete protein. However, it can be combined with cheese to make a complete protein.

A nurse is contributing to the planning of an in-service session about nutrition. Which of the following nutrient functions should the nurse include in the teaching? A. Fats provide energy B. Carbohydrates repair body tissue C. Fats regulate fluid balance D. Carbohydrates prevent interstitial edema

Correct Answer: A. Fats provide energy Fat serves as a stored energy source for the body, providing 9 cal/g of energy. Incorrect Answers: B. Proteins play a role in tissue repair. C. Protein is primarily responsible for regulating fluid balance. D. The presence of protein prevents interstitial edema. The appropriate amount of albumin in blood keeps interstitial edema from occurring.

A nurse is reinforcing teaching with a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group? A. Independent moral development B. Acceptance of body changes C. Strengthening ties with the family of origin D. Developing concrete reasoning

Correct Answer: A. Independent moral development According to Kohlberg's theory of moral development, making individual decisions about moral issues is a function of the highest level of moral development, the post-conventional level. Young adults who have reached this level separate themselves from the rules and tenets of others and make decisions according to their own beliefs and principles. Incorrect Answers: B. Acceptance of body changes should take place during adolescence. C. Young adults need to develop intimacy outside of the family. D. Concrete thinking develops during middle childhood. Abstract reasoning develops during adolescence.

A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first? A. Inspect both breasts simultaneously B. Squeeze the nipples C. Palpate the breast and tail of Spence D. Palpate the axillary lymph nodes

Correct Answer: A. Inspect both breasts simultaneously According to evidence-based practice, the nurse should first inspect both breasts with the client's arms in several different positions to look for asymmetry, masses, retraction, lesions, inflammation, and dimpling. Incorrect Answers: B. The nurse should compress the nipples to identify the presence of any discharge. However, evidence-based practice indicates that the nurse should use a different technique before compression. C. The nurse should palpate the breast and tail of Spence to determine the consistency of breast tissue and the presence of masses. However, evidence-based practice indicates that the nurse should use a different technique before palpation of the breast because doing so can alter the accuracy or effectiveness of another phase of the examination. D. The nurse should palpate the axillary lymph nodes, which become involved when cancerous lesions metastasize. However, evidence-based practice indicates that the nurse should use a different technique before palpation of the axillary lymph nodes to avoid altering the accuracy or effectiveness of another phase of the examination.

A nurse is helping a client perform range-of-motion exercises of the neck. For evaluating neck flexion, which of the following motions should the nurse instruct the client to perform? A. Touching his chin to his chest B. Moving his head sideways C. Turning his head in a circle D. Moving his head to an erect position

Correct Answer: A. Touching his chin to his chest Flexion of the neck is moving the chin down so that it rests on the chest. Incorrect Answers: B. Lateral flexion of the neck is moving the head sideways toward the shoulder as far as possible. C. Rotation is turning the head as far as possible in a circular movement to each side. D. Extension of the neck is moving the head to an erect position after flexing or hyperextending it.

A nurse is caring for a client who has injuries from a motor-vehicle crash. Which of the following client statements should the nurse address first? A. "My fear is that this injury will cause me to lose my job." B. "I can't sleep well because whenever I move in my sleep, the pain wakes me up." C. "I don't know what I will do if my car isn't safe or even drivable after the crash." D. "I wonder how I am going to be able to take care of my family."

Correct Answer: B. "I can't sleep well because whenever I move in my sleep, the pain wakes me up." The priority action for the nurse when using Maslow's hierarchy of needs is to meet the client's physiological need for comfort. This is the highest priority among these options. The nurse should re-evaluate the client's pain management plan immediately. Incorrect Answers: A. The client's fear of job loss ties into the client's identity and economic survival. However, it is a self-esteem need, and there is another need that is the priority. C. The client's concern about the vehicle is a safety and security need; however, there is another need that is the priority. D. The client's need to care for family in the same way as before is a love and belonging need; however, there is another need that is the priority

A nurse is performing an otoscopic examination of a client's right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding? A. Obtain an audiology referral B. Document this as an expected finding C. Irrigate the ear with warm water D. Document mild inflammation

Correct Answer: B. Document this as an expected finding The light the otoscope reflects off the tympanic membrane is cone-shaped or triangular. In the right ear, it is visible in the right lower quadrant of the eardrum. In the left ear, it is visible in the left lower quadrant. Incorrect Answers: A. Difficulty hearing or understanding speech indicates the need for a referral to an audiologist for audiometry testing. C. Cerumen blocking visualization of the eardrum indicates the need for irrigation. D. A pink eardrum, not a visible triangle of light, indicates mild inflammation.

A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse take to reduce the client's risk for aspiration? A. Irrigate the tubing with 30 mL of sterile water for irrigation B. Elevate the head of the bed by 30° to 45° C. Suggest changing the feeding to lactose-free formula D. Warm the enteral formula to room temperature before feeding

Correct Answer: B. Elevate the head of the bed by 30° to 45° Elevating the head of the bed to at least 30° and preferably 45° helps prevent the gravitational reflux of gastric contents, thereby decreasing the risk of aspiration. Incorrect Answers: A. Irrigating the tubing will not reduce the client's risk of aspiration. Irrigation can help prevent or resolve clogging of the tube. C. Changing the feeding to lactose-free formula will not decrease the client's risk of aspiration. It will reduce gastrointestinal irritation or upset in clients who are sensitive to lactose. D. Warming the enteral formula before feeding will not decrease the client's risk of aspiration. It can help reduce abdominal cramping and discomfort from cold formula ingestion.

A nurse is communicating with a group of clients about what to expect during the postoperative phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as a sign of effective communication? Check Answer A. Motivation for communication is evident. B. Feedback is provided. C. A message is communicated to the group of clients. D. Multiple channels are used by the sender.

Correct Answer: B. Feedback is provided. The nurse should obtain feedback in verbal and/or nonverbal forms as evidence of successful communication. Feedback can indicate to the nurse whether the meaning of the message was understood by the recipient. Incorrect Answers: A. The element of "referent" motivates communication between people (e.g. a sound or perception). This will not assist in determining whether the communication is effective. C. The element of message is only the content of what the sender is trying to convey in the communication process. It can contain both verbal and nonverbal expression. Messages should be clear and concise. However, even though a message might be clearly delivered, the communication may not be effective. D. The element of "channels" includes conveying a message by visual, auditory, and facial expressions. However, this will not assist in determining whether the communication is effective.

A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing? A. Lateral thigh B. Lower abdomen C. Mid-abdominal region D. Medial thigh

Correct Answer: B. Lower abdomen After inserting an indwelling urinary catheter, the nurse should secure the catheter tubing to the client's upper thigh or lower abdomen, by using adhesive tape or catheter securement device. This location will decrease tension and trauma to the urethra. Incorrect Answers: A. Securing the indwelling urinary catheter tubing to the client's lateral or outside thigh can create tension on the client's urethra which can cause trauma and injury. C. Securing the indwelling urinary catheter tubing to the client's mid-abdominal region can create tension on the client's urethra and does not allow for the downward flow of urine via gravity into the drainage bag. D. Securing the indwelling urinary catheter tubing to the client's medial or mid-thigh area can create tension on the client's urethra which can cause trauma and injury.

A nurse is reinforcing teaching about nutrition with a middle adult client who has a sedentary job. Which of the following factors should the nurse consider? A. There is an increased risk of eating disorders at this age. B. The basal metabolic rate could decrease. C. Daily vitamins become necessary to meet nutritional needs. D. Limiting the intake of fish to once per week reduces cardiovascular risks.

Correct Answer: B. The basal metabolic rate could decrease. The basal metabolic rate decreases as adipose tissue replaces skeletal muscle mass. This places the client at risk for weight gain if he does not maintain a healthy diet. Incorrect Answers: A. Eating disorders such as anorexia more commonly develop during adolescence and young adulthood. C. Daily vitamins are not necessary if middle adults consume a healthful, balanced diet. D. To reduce the risk of hypertension and coronary artery disease, the client should consume fish at least twice per week.

A nurse is reinforcing teaching of postoperative deep breathing and coughing exercises with a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? A. The client asks the nurse to repeat the instructions before attempting the exercises. B. The client reports severe pain. C. The client asks the nurse how often deep breathing should be done after surgery. D. The client tells the nurse that this exercise will probably be painful after surgery.

Correct Answer: B. The client reports severe pain. A client who is experiencing severe pain is not able to concentrate and therefore is not ready to learn a new activity. Incorrect Answers: A. Asking the nurse to repeat the instructions demonstrates that, while the client might not totally understand the mechanics of performing the exercises, the client does have a readiness to learn the activity. C. Asking about the frequency of the activity indicates a readiness to learn. The client is motivated to perform the activity and wants to know how often to do it. D. The client's statement indicates a readiness to learn because the client is able to think about the possible effects of the exercise following surgery.

A nurse is teaching a client who has asthma about the proper use of an albuterol inhaler. Which of the following client statements indicates an understanding of the teaching? A. "I should rinse my mouth right before I use the inhaler." B. "After the first puff, I will wait 10 seconds before taking the second puff." C. "I will shake the inhaler well right before I use it." D. "I will tilt my head forward while inhaling the medication."

Correct Answer: C. "I will shake the inhaler well right before I use it." The nurse should instruct the client to shake the inhaler vigorously for 3 to 5 seconds, which will mix the medication within the inhaler evenly. Incorrect Answers: A. The nurse should instruct the client to rinse the mouth with water following the use of the inhaler to reduce irritation and infection, not before using the inhaler. B. The nurse should instruct the client to wait 20 to 30 seconds between inhalations of bronchodilator medications such as albuterol. D. The nurse should instruct the client to place the inhaler in the mouth and tightly close the lips around the mouthpiece to create a seal. The client should then depress the canister, take a deep breath, and hold it for at least 10 seconds.

A nurse in a clinic is caring for a client who has returned for a follow-up visit after treatment of a laceration on her upper arm. Which of the following actions should the nurse perform when removing the sutures that the client received at her last visit? A. Assure the client that the procedure will not cause any discomfort B. Clip the suture twice on each side of the knot C. Clip the suture as close to the skin as possible D. Wear clean gloves throughout the procedure

Correct Answer: C. Clip the suture as close to the skin as possible The nurse should clip the suture as close to the skin as possible, right next to an insertion or exit point. This action prevents pulling the exposed portion of the suture along with any surface bacteria through the underlying skin. Incorrect Answers: A. Although it should not be painful, suture removal can cause pulling and stinging sensations that can be uncomfortable for the client. B. The nurse should clip the suture only once to facilitate removal of the entire suture at once. D. The nurse should wear sterile gloves to prevent transferring any microorganisms onto the surface of the healing wound.

A nurse is reinforcing teaching for a client who has a new prescription for home oxygen therapy. Which of the following instructions should the nurse include? A. Do not use any electrical devices when receiving oxygen B. Keep the oxygen tank lying on the floor when there is any risk of knocking it over C. Do not use any materials containing oil or alcohol when using oxygen D. Use synthetic blankets and clothing when using oxygen

Correct Answer: C. Do not use any materials containing oil or alcohol when using oxygen Oxygen is a highly flammable gas. The client should not use any grease, oil, nail polish remover, alcohol, or any other volatile substances when using supplemental oxygen. Incorrect Answers: A. Electrical devices are acceptable for use near oxygen. However, the client should make sure any electrical equipment near the oxygen supply is functioning as it should so that it does not create any electrical sparks, which could cause a fire. B. The client should keep the oxygen tank upright and secure in its holder at all times. D. Woolen and synthetic materials can create sparks; therefore, the client should use a cotton blanket and wear cotton clothing when using supplemental oxygen.

A nurse is preparing to perform oral care for a client who is unresponsive. Which of the following actions should the nurse plan to take? Check Answer A. Place the client supine B. Keep both side rails up C. Raise the level of the bed D. Inspect the client's mouth using a finger sweep

Correct Answer: C. Raise the level of the bed The nurse should raise the bed to allow the use of proper body mechanics and reduce the risk of self-injury. Incorrect Answers: A. To prevent the risk of aspiration, the nurse should raise the client's head to 30° or place the client in a side-lying position. B. To prevent straining and reduce the risk of self-injury, the nurse should lower the near side rail. D. To reduce the risk of self-injury, the nurse should never insert fingers into the mouth of an unresponsive client.

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? A. Apply a fecal collection system B. Apply a barrier cream C. Cleanse and dry the area D. Check the client's perineum

Correct Answer: D. Check the client's perineum Caring for this client requires the application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data in the area of irritation will provide the nurse with the knowledge to make an appropriate decision. Incorrect Answers: A. The nurse should apply a fecal collection system to divert the feces away from the area of skin irritation; however, there is another action the nurse should take first. B. The nurse should apply a barrier cream to decrease skin breakdown in the perianal area from feces; however, there is another action the nurse should take first. C. The nurse should cleanse and dry the perianal area to decrease skin irritation; however, there is another action the nurse should take first.

While in the hospital, a client who has a terminal illness tells the nurse, "I can't believe I'm dying. There are a lot of bad people in the world who are healthy, and here I am dying!" Which of the following responses should the nurse offer? A. "Everyone dies sometimes, some sooner than others." B. "Who do you think deserves to die more than you?" C. "It does seem unfair, doesn't it?" D. "Tell me more about how you feel about dying."

Correct Answer: D. "Tell me more about how you feel about dying." This is a therapeutic response from the nurse that seeks more information to form an accurate assessment of what the client is feeling. Incorrect Answers: A. This is a nontherapeutic response that dismisses and minimizes the client's feelings. B. This is a nontherapeutic response that could be perceived as confrontational by the client. C. While this response acknowledges the client's feelings, it is a closed-ended statement that does not facilitate further exploration of the client's feelings.

A nurse is collecting data as part of a comprehensive physical examination of a client. The nurse should use inspection to evaluate which of the following? A. Liver size B. Pedal edema C. Skin texture D. Gait

Correct Answer: D. Gait Inspection is the technique of looking or observing. Gait inspection involves watching the client's walking movements and observing for any unusual findings. Incorrect Answers: A. Evaluating liver size requires palpation. B. Evaluating pedal edema requires palpation. C. Evaluating skin texture requires palpation.

A nurse is initiating the use of a sequential compression device for a client who is postoperative following knee surgery. Which of the following actions should the nurse take? A. Set the ankle pressure at 70 mmHg B. Have the client turn onto a side C. Place a sleeve on top of each leg with the opening at the knee D. Make sure 2 fingers can fit under the sleeves

Correct Answer: D. Make sure 2 fingers can fit under the sleeves If 2 fingers cannot fit between the sleeves and the legs, the device could impair the client's circulation when the nurse inflates the sleeves. Incorrect Answers: A. The nurse should set the ankle pressure between 35 and 55 mmHg to prevent skin breakdown and circulatory impairment. A pressure of 40 mmHg is average. B. The nurse should assist the client into a semi-Fowler's position to make it easier to apply the sleeves. C. The nurse should place the sleeve under each leg with the opening at the knee and then wrap the sleeve around the leg securely.

A nurse is collecting data from a client who has a fluid-volume deficit. Which of the following findings should the nurse expect? A. Crackles B. Hypertension C. Dependent edema D. Weak pulses

Correct Answer: D. Weak pulses Weak, thready pulses are a manifestation of fluid-volume deficit. Other manifestations include flat neck veins when the client is supine, postural hypotension, and sudden weight loss. Incorrect Answers: A. Crackles in the lungs are a manifestation of fluid-volume excess, not fluid-volume deficit. B. Hypertension is a manifestation of fluid-volume excess, not fluid-volume deficit. C. Dependent edema is a manifestation of fluid-volume excess, not fluid-volume deficit.

A nurse is evaluating the development of a group of clients. The nurse should understand that, according to Erikson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development? A. Middle adulthood B. Adolescence C. Childhood D. Young adulthood

Correct Answer: D. Young adulthood The developmental task of young adulthood is intimacy vs. isolation. Incorrect Answers: A. The developmental task of middle adulthood is generativity vs. self-absorption and stagnation. B. The developmental task of adolescence is identity vs. role confusion. C. The developmental task of school-aged children is industry vs. inferiority.

A nurse is collecting data from a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment? (Select all that apply.) Check Answer A. Exophthalmos B. Dry, brittle hair C. Edema D. Butterfly rash on the face E. Poor wound healing

Correct Answers: B. Dry, brittle hair C. Edema E. Poor wound healing Dry, brittle hair that falls out easily suggests inadequate protein intake and malnutrition. Edema can occur when albumin levels are lower than the expected reference range; this finding indicates the client might be experiencing protein-calorie malnutrition. Poor wound healing suggests the client might be experiencing proteincalorie malnutrition. Adequate wound healing depends on the ingestion of sufficient protein, calories, water, vitamins (especially C and A), iron, and zinc. Incorrect Answers: A. Exophthalmos is a manifestation of hyperthyroidism. D. A red facial rash, often termed a butterfly rash because of its shape across the nose and on the cheeks, is a manifestation of systemic lupus erythematosus.

A nurse is reinforcing teaching with the parent of a child who is to take 30 mL of a liquid medication. The parent has a hollow medication spoon that has marks to indicate teaspoons and tablespoons. How many tablespoons of medication should the nurse instruct the parent to give the child? (Fill in the blank with the numeric value only. Round the answer to the nearest whole number. Use a leading zero if applicable but do not use a trailing zero.) Fill in the blank

Correct Answer: 2 Follow these steps for the conversion of mL to tbsp: Step 1: What is the unit of measurement the nurse should calculate? tbsp Step 2: Set up an equation and solve for X. 15 mL/1 tbsp = 30 mL/X tbsp 15X = 30 X = 2 Step 3: Round if necessary. Step 4: Determine whether the conversion to tbsp makes sense. If 15 mL = 1 tbsp, then 30 mL = 2 tbsp.

A nurse is calculating a client's intake for a 12-hr shift. The client had dextrose 5% in 0.45% sodium chloride infusing at 125 mL/hr, gentamicin 150 mg in 100 mL at 1400, famotidine20 mg in 50 mL at 1000 and 1600, 250 mL of blood over 2 hr, and a nasogastric flush of 30 mL every 2 hr. What is the total intake in milliliters that the nurse should document for this client for this 12-hr period? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) Fill in the blank

Correct Answer: 2130 For the total intake, calculate the following: 125 mL x 12 hr = 1500 mL + 100 mL + (50 mL x 2 = 100 mL) + 250 mL + (30 mL x 6 = 180 mL) = 2130 mL.

A nurse is calculating the protein needs of a young adult client who weighs 132 lb. The RDA for protein for an adult who has no health medical conditions is 0.8 g/kg. How many grams of protein per day should the nurse recommend for this client? (Fill in the blank with the numeric value, rounding to 2 figures. Lead with a 0 if the answer is less than 1.)

Correct Answer: 48 132/2.2 = 60 kg 60 kg x 0.8 g = 48 g

A nurse is collecting data from a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect? A. Increased blood pressure B. Decreased blood sugar level C. Decreased oxygen use D. Increased gastrointestinal motility

Correct Answer: A. Increased blood pressure The nurse should expect a client who is experiencing stress and anxiety to manifest increased blood pressure and heart rate as a result of sympathetic stimulation. Incorrect Answers: B. The nurse should expect a client who is experiencing stress and anxiety to manifest an increase in blood sugar levels due to the release of glucocorticoids and gluconeogenesis. C. The nurse should expect a client who is experiencing stress and anxiety to manifest an increase in oxygen use due to the increased metabolic rate and oxygen demands of the body. D. The nurse should expect a client who is experiencing stress and anxiety to manifest decreased gastrointestinal motility, which can result in constipation and flatus.

A nurse is preparing to administer a unit of packed RBCs to a client when she discovers that the IV line is no longer patent. The IV team can send someone in 30 minutes to initiate a new line. Which of the following actions should the nurse take? Check Answer A. Return the blood to the laboratory B. Place the blood in the medication room C. Place the blood in the refrigerator D. Leave the blood at the client's bedside

Correct Answer: A. Return the blood to the laboratory Because the nurse knows that the delay will be more than a few minutes, she should return the unit of packed RBCs immediately to the laboratory, where the technician will maintain it at the appropriate temperature until the client is ready to receive it. Incorrect Answers: B. The unit of packed RBCs should not be at room temperature because the lack of temperature control could damage the blood. C. Blood products require specific temperature regulation, which is not consistently possible with a standard nursing-unit refrigerator. D. The nurse should never leave blood products or medications at the bedside due to the potential for loss, misuse, or contamination.

A nurse is collecting data from a 5-year old client during a routine examination. Which of the following activities should the nurse expect the child to perform? Check Answer A. Ride a bicycle with training wheels B. Climb a tree C. Throw and catch a ball D. Play a musical instrument

Correct Answer: A. Ride a bicycle with training wheels By the age of 5 years, preschoolers should be able to ride a bicycle with training wheels, skip and jump rope, and print letters and numbers. They should also be able to demonstrate creativity and imagination. Incorrect Answers: B. Climbing a tree is a motor developmental task that school-aged children, not preschoolers, should be able to perform; therefore, this client is ahead of developmental norms and does not require intervention. C. Throwing and catching a ball are motor developmental tasks that school-aged children, not preschoolers, should be able to perform; therefore, this client is ahead of developmental norms and does not require intervention. D. Playing a musical instrument or having another skill that requires fine-motor coordination is a motor developmental task that school-aged children, not preschoolers, should be able to perform; therefore, this client is ahead of developmental norms and does not require intervention.

A nurse is preparing to assist an older adult client with ambulation; the client has been on bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall? A. Use a gait belt during ambulation B. Ensure the client is wearing socks before ambulating C. Instruct the client to sit on the edge of the bed for 15 seconds before ambulating D. Walk 2 feet behind the client during ambulation

Correct Answer: A. Use a gait belt during ambulation The nurse should use a gait belt to keep the client's center of gravity at midline and to decrease the risk of a fall. Incorrect Answers: B. The nurse should ensure the client is wearing non-skid shoes or slippers when ambulating to decrease the risk of a fall from slipping. C. The nurse should encourage the client to dangle the legs on the edge of the bed for 60 seconds before attempting to ambulate to decrease the risk of a fall caused by orthostatic hypotension. D. The nurse should walk beside the client to provide physical support while ambulating and to decrease the risk of a fall.

A nurse is instructing a client about collecting a 24-hour urine specimen for creatinine clearance. Which of the following statements should the nurse identify as an indication that the client understands the procedure? Check Answer A. "The next time I urinate will be the first specimen of the collection." B. "I'll make sure to keep the collection bottle in the container of ice they gave me." C. "Once the container is half full, I no longer have to add any more urine." D. "It's okay if a piece of toilet paper gets in the bottle. They'll remove it when they do the test."

Correct Answer: B. "I'll make sure to keep the collection bottle in the container of ice they gave me." The urine collection must remain chilled to prevent any change in urine composition during the collection. Incorrect Answers: A. The collection begins after the next time the client urinates. C. The urine collection for creatinine clearance specifies the duration of collection, not a minimal volume of urine. D. The presence of toilet tissue, menstrual blood, and feces will contaminate the specimen.

A nurse is caring for a client who reports using several herbal supplements. Which of the following actions should the nurse take? A. Discourage use of unregulated medications and supplements B. Verify that the herbal supplements do not interact with medications the provider has prescribed C. Tell the client to take no more than 2 herbal supplements D. Review the dangers of taking plant-derived medications and supplements

Correct Answer: B. Verify that the herbal supplements do not interact with medications the provider has prescribed Many herbal products interact with other prescription and nonprescription medications. Valerian, for example, interacts with antihistamines as well as barbiturates and other sleep-promoting medications. The nurse should report any potential interactions to the provider. Incorrect Answers: A. Although herbal products are not subject to the regulation and scrutiny of the U.S. Food and Drug Administration, many of them are safe and potentially effective in treating a variety of health concerns. C. The nurse's responsibility is to obtain a list of all the medications and herbal products the client takes so that the provider can review them and make recommendations. There are no specific limits the nurse should set on how many herbal products the client can use. D. Pharmaceutical companies make many prescription medications from plants (e.g. digoxin, reserpine, aspirin, and morphine).

A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP indicates that further instruction is required? A. "I should not leave all 4 side rails up unless there is a prescription for restraints." B. "An alert client will be safest if I raise the 2 upper side rails at the head of the bed." C. "If the client seems confused, I'll raise all 4 side rails to prevent injury." D. "If a client is sedated, I should raise all 4 side rails to prevent a fall out of bed."

Correct Answer: C. "If the client seems confused, I'll raise all 4 side rails to prevent injury." Raising all 4 side rails can increase the client's risk of injury. The client might try to climb over the side rails, which could result in a fall or injury. Incorrect Answers: A. Side rails are a form of restraint when all 4 rails are up. This requires a prescription from the provider after less restrictive methods have been unsuccessful. B. Leaving the 2 upper side rails up improves the client's ability to turn and move around in bed. The client will also be able to use the rails when getting out of bed, which will help prevent falls. D. Raising all 4 side rails is not considered implementing a restraint if the client is sedated. This action reduces the client's risk of injury due to falling out of bed.

A nurse is reinforcing teaching about bladder retraining for a client who has urinary incontinence. Which of the following instructions should the nurse include? A. Wake up every 2 hours to urinate during the night B. Drink citrus juices throughout the day C. Try to block the urge to urinate until the next scheduled time D. Limit fluids to no more than 1 L (34 oz) during waking hours

Correct Answer: C. Try to block the urge to urinate until the next scheduled time When the client is following a schedule of voiding intervals and feels the urge to urinate before the next scheduled time, the client should try to practice slow, deep breathing to help reduce the urge. The client can also try 5 or 6 strong and quick pelvic muscle exercises. Incorrect Answers: A. The client should wake up every 4 hours to urinate during the night; for most clients, this will occur just once during sleeping hours. B. Citrus juices can irritate the bladder, increasing the likelihood of incontinence episodes. D. The client should reduce fluid intake for 4 hours before bedtime; however, the client should drink plenty of fluids during other waking hours and avoid drinking large amounts at once.

A nurse is reinforcing teaching with a client who is postoperative about the importance of turning, coughing, and breathing deeply. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "If I do this often, I won't experience muscle wasting." B. "If I do this often, I won't get pneumonia." C. "If I do this often, I won't get constipation." D. "If I do this often, I won't have a fast heartbeat."

Correct Answer: B. "If I do this often, I won't get pneumonia." Turning, coughing, and breathing deeply help prevent respiratory complications, such as pneumonia, by promoting lung expansion and secretion removal. Incorrect Answers: A. Exercising the muscles, actively or passively, helps prevent muscle wasting. C. Resuming a progressive diet with an adequate fluid intake and early ambulation will help prevent constipation. Fiber supplements and stool softeners can also be beneficial. D. A rapid heart rate is not usually a major postoperative concern. However, prevention includes avoiding stressors that might cause it, such as unrelieved pain or sudden exertion. Careful pain management and gradual resumption of activities can also help.

A nurse is assessing the pH of a client's gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect? A. 6 B. 2 C. 10 D. 8

Correct Answer: B. 2 A pH of 2 is within the expected reference range of 0 to 4 for gastric secretions. Incorrect Answers: A. A pH of 6 can indicate the tube is in the lung. The expected reference range for lung secretions is greater than 6. C. A pH of 10 can indicate a false reading because the value is alkaline, which is too high for intestinal or lung secretions. D. A pH of 8 can indicate the tube has migrated down into the intestines, where the expected reference range is between 7 and 8.

A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider? A. Calcium 9.5 mg/dL B. Sodium 150 mEq/L C. Potassium 4 mEq/L D. Magnesium 1.5 mEq/L

Correct Answer: B. Sodium 150 mEq/L A sodium level of 150 mEq/L is greater than the expected reference range of 135 to 145 mEq/L. This client is at risk for dehydration due to diarrhea. Hypernatremia is a manifestation of dehydration, and the nurse should report this finding to the provider. Incorrect Answers: A. A calcium level of 9.5 mg/dL is within the expected reference range of 9 to 10.5 mg/dL. C. A potassium level of 4 mEq/L is within the expected reference range of 3.5 to 5 mEq/L. However, this client is at risk for hypokalemia due to diarrhea, so the client's potassium level should be monitored. D. A magnesium level of 1.5 mEq/L is within the expected reference range of 1.3 to 2.1 mEq/L.

As part of a neurological examination, a nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique? A. Gustation B. Stereognosis C. Proprioception D. Kinesthesia

Correct Answer: B. Stereognosis Stereognosis is the ability to identify an object's size, shape, and texture via tactile sensation. Incorrect Answers: A. Gustation is the ability to taste. C. Proprioception is the awareness of the position of the body. D. Kinesthesia is the ability to sense the position and movement of body parts without visualizing them.

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique? Check Answer A. Applying sterile gloves to open catheter package B. Wiping the labia minora in an anteroposterior direction C. Spreading the labia with the dominant hand D. Using a cotton ball to wipe the right and left labia majora

Correct Answer: B. Wiping the labia minora in an anteroposterior direction The nurse should wipe anteroposterior both the right and left labia minora with separate cotton swabs to destroy any microorganisms in the area that would contaminate the catheter. Incorrect Answers: A. The nurse should apply sterile gloves after opening the catheter package because the outside of the package is not considered sterile. C. The nurse should use the nondominant hand to spread the labia and provide the optimal view of the urethral meatus. The nondominant hand is considered contaminated once the hand touches the client's skin. D. The nurse should use a separate cotton ball to wipe the right and left labia majora to destroy any microorganisms on the skin surface that would contaminate the catheter.

A nurse is collecting data from a client. Which of the following statements by the nurse reflects the communication technique of clarifying? A. "Now that we have talked about your medications, let's talk about your pain." B. "Are you having other symptoms?" C. "It sounds like your pain is intermittent." D. "It seems as though you have really had a rough time these past few weeks."

Correct Answer: C. "It sounds like your pain is intermittent." This response reflects the communication technique of clarifying. The nurse should use this technique to ensure an understanding of the client's message. Incorrect Answers: A. This is an example of the communication technique of focusing. The nurse can use this technique to keep the conversation moving in an organized direction. B. This is an example of the communication technique of asking a relevant question. These kinds of questions are open-ended, allowing the client to offer more information to the nurse. D. This communication technique is an example of sharing empathy. With this technique, the nurse is able to convey understanding and acceptance of what the client is or has been experiencing.

A client has 1 L of dextrose 5% in 0.45% sodium chloride infusing IV at 125 mL/hr. How many hours will it take for the liter to infuse? (Fill in the blank with the numeric value only. Round to the nearest whole number. Use a leading zero if applicable but do not use a trailing zero.) Fill in the blank

Correct Answer: 8 Follow these steps to calculate the duration of the infusion: Step 1: What is the unit of measurement the nurse should calculate? hr Step 2: What is the volume of the infusion? 1 L Step 3: What is the total infusion time? X hr Step 4: Should the nurse convert the units of measurement? Yes (L does not equal mL) 1 L = 1,000 mL Step 5: Set up the equation and solve for X. Volume (mL)/Time (hr) = X mL/hr 1,000 mL/X hr = 125 mL/hr X = 8 hr Step 6: Round if necessary. Step 7: Determine whether the duration of the infusion makes sense. If the client is receiving 1 L of fluid at 125 mL/hr, it will take 8 hours for the entire amount to infuse.

A nurse is reinforcing teaching with a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching? A. "I'll wear nonsterile gloves." B. "I'll use adhesive remover each time." C. "I'll take my pain pill after I change the dressing." D. "I'll fold the dressing with the soiled surface facing outward."

Correct Answer: A. "I'll wear nonsterile gloves." Wearing gloves prevents the spread of microorganisms outside of the dressings and onto the client's hands. The gloves the client uses can be clean and do not need to be sterile, unless the provider specifically prescribes sterile gloves for dressing changes. Incorrect Answers: B. The client should use adhesive remover only if he has significant problems with tape removal or residual adhesive on especially sensitive skin. C. If the client expects the dressing removal to hurt, he should take an analgesic long enough before the dressing change for the medication to take effect. D. The client should remove the dressing by folding the soiled surfaces inward to prevent the transfer of microorganisms to the client's hands and to other surfaces.

A nurse is instructing an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? A. "Sometimes, I should use soap and water rather than an alcoholbased hand rub to clean my hands." B. "I will use cold water when I wash my hands to protect my skin from becoming too dry." C. "I will apply friction for at least 10 sec while washing my hands." D. "After washing my hands, I will dry them from the elbows down."

Correct Answer: A. "Sometimes, I should use soap and water rather than an alcohol-based hand rub to clean my hands." While alcohol-based hand rubs are as effective as soap and water in providing proper hand hygiene, the Centers for Disease Control and Prevention recommend washing hands with soap and water at certain times (e.g. when the hands are visibly soiled with dirt or body fluids). Incorrect Answers: B. Hand hygiene should be performed with warm water, which preserves the protective oil of the skin better than hot water. C. Friction is required to loosen and remove dirt and pathogens from the hands. To be effective, friction should be applied for at least 15 to 20 seconds. D. Drying should be performed from the cleanest area (fingertips) to the least clean area (forearms) to prevent contamination of the newly cleaned hands.

A nurse is reinforcing teaching with a preschooler about how to use a metered-dose inhaler. Which of the following methods should the nurse use during this instructional session? A. A simple demonstration of inhaler use B. A discussion of health problems C. Collaboration in instruction D. Mutual goal-setting

Correct Answer: A. A simple demonstration of inhaler use For preschoolers, simple explanations and demonstrations are developmentally appropriate. The nurse should explain how the inhaler works and demonstrate its use (without the medication canister inside it). To make sure the client knows how to use the inhaler, the nurse should ask for a return demonstration. Incorrect Answers: B. Incorporating a discussion of health concerns and problems is a useful strategy for school-aged children, not for preschoolers. C. Preparing instructional sessions as a collaboration between the nurse and the client is a useful strategy for adolescents, not for preschoolers. D. Setting learning goals mutually is a useful strategy for young adults, not for preschoolers.

A new resident provider asks the nurse for an access code to review a client's online record. The resident is not scheduled to attend the facility's computer orientation class until next week. Which of the following actions should the nurse take? A. Explain that sharing access codes is against policy and refer the resident to the supervisor B. Access the client's online data and monitor the resident during usage C. Access the online client data system and allow the resident to locate the client's data D. Ask the client to give permission for the resident to access the medical records

Correct Answer: A. Explain that sharing access codes is against policy and refer the resident to the supervisor Staff should never share access codes and passwords or allow people who do not have their own access code to use the system. Sharing codes is a breach of federal guidelines for data security and client confidentiality. Incorrect Answers: B. C. Allowing an individual who does not have a personal access code to access the system is a breach of federal guidelines for data security and client confidentiality. D. The resident should not have access to the client's information before participating in the facility's training, which includes information about data security and client confidentiality. Even then, the resident should only have access to information needed to provide direct care to specific clients.

As a nurse is preparing to administer liquid medication from a bottle to a client. Which of the following actions should the nurse take? A. Hold the medication bottle with the label against the palm of the hand when pouring B. Place the cap with the inside facing down on a hard surface C. Fill the cup until the medication is even with the edge of the dosage scale D. Pour any excess liquid back into the bottle when measuring

Correct Answer: A. Hold the medication bottle with the label against the palm of the hand when pouring The nurse should hold the multidose bottle with the label against the palm of the hand when pouring to avoid contaminating the label with spilled medication, which could cause information on the label to fade or become illegible. Incorrect Answers: B. The nurse should remove the cap of the medication bottle and place it with the inside of the cap facing up on a hard surface to prevent contamination of the inside of the cap and to maintain cleanliness. C. The nurse should fill the cup until the medication is even with the surface or base of the meniscus of the dosage scale to ensure the client receives an accurate dose of the medication. D. The nurse should discard any excess liquid into the sink as wasted medication and should wipe clean the lip of the bottle after measuring.

A nurse is caring for a group of clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? A. Provide oral care to a client who cannot take oral fluids B. Check a client's IV insertion site for manifestations of infiltration C. Assess a client's ability to ambulate D. Demonstrate the use of a glucometer to a client who has diabetes mellitus

Correct Answer: A. Provide oral care to a client who cannot take oral fluids Providing oral care to a client who cannot take oral fluids is within the range of function for an AP. Therefore, the nurse can assign this task to the AP. Incorrect Answers: B. Checking a client's IV insertion site for manifestations of infiltration is not within the range of function for an AP. Therefore, the nurse should not assign this task to the AP. C. Assessing a client's ability to ambulate is not within the range of function for an AP. Therefore, the nurse should not assign this task to the AP. D. Demonstrating the use of a glucometer to a client who has diabetes mellitus is not within the range of function for an AP. Therefore, the nurse should not assign this task to the AP.

A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first? A. Remove the sleeve of the gown from the arm without the IV line B. Slow the infusion using the roller clamp C. Disconnect the IV line from the pump D. Bring the IV solution and tubing from the outside to the end of the sleeve of the gown

Correct Answer: A. Remove the sleeve of the gown from the arm without the IV line According to evidence-based practice, the nurse should first remove the gown from the client's arm without the IV line. Beginning the process in this way will enable the nurse to move the gown fully off the client and then stop the system to remove the gown from the line, resulting in minimal interruption of the IV flow. Incorrect Answers: B. The nurse should slow the infusion using the roller clamp to prevent a large volume infusion of IV solution while changing the gown. However, there is another action the nurse should take first. C. The nurse should disconnect the IV line from the pump while removing and reapplying the gown quickly to maintain the infusion rate prescribed with the pump. However, there is another action the nurse should take first. D. The nurse should bring the IV solution and tubing through the outside to the end of the sleeve of the gown to prevent tangling of the tubing and the gown. However, evidence-based practice indicates that the nurse should take a different action first.

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps relieve pain. Which of the following responses should the nurse make? A. "It provides a distraction from the pain." B. "It modulates the transmission of the pain impulse." C. "It promotes increased circulation to the painful area." D. "It elicits a relaxation response."

Correct Answer: B. "It modulates the transmission of the pain impulse." The nurse should inform the client that a TENS unit applies low-voltage electrical stimulation directly over a location of pain at an acupressure point. It modulates the transmission of the pain impulse and can also cause a release of endorphins to assist with pain relief. Incorrect Answers: A. The nurse should inform the client that distraction is a method that can draw the client's attention away from the pain and help decrease the perception of pain. Methods can include visual, auditory, tactile and intellectual distraction. However, this is not the way that a TENS unit helps to relieve pain. C and D. The nurse should inform the client that massage can be applied to facilitate relaxation, which decreases muscle tension. It can also decrease pain intensity by increasing superficial circulation to an area of the body experiencing pain. However, this is not the way that a TENS unit helps to relieve pain.

A nurse is collecting data from a client who has mixed aphasia. Which of the following strategies should the nurse use to help facilitate communication with this client? A. Speak loudly to the client B. Ask simple, short questions C. Reduce environmental noise D. Use a single form of communication at a time

Correct Answer: B. Ask simple, short questions Keeping language simple and brief can help the client understand its content. Facial and hand gestures can also help. Incorrect Answers: A. A client who has mixed aphasia has difficulty with understanding and expression, not hearing. C. Reducing environmental noise is a helpful strategy for clients who have a hearing loss, but it will not enhance communication for a client who has aphasia. D. The nurse should use several forms of communication that are helpful for clients who have aphasia such as images and communication boards, along with verbal and nonverbal communication.

A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source of this sound? A. Low battery power B. Excessive wax in the ear canal C. A volume setting that is too low D. A crack in the ear tube

Correct Answer: B. Excessive wax in the ear canal Factors that can make a hearing aid whistle include a poor seal with the ear mold, an ear infection, excessive wax in the ear canal, an improper fit, or a malfunction. Incorrect Answers: A. A hearing aid with low battery power will not work effectively, but it will not whistle. Removing the battery at night can help extend the life of the battery. C. A hearing aid might whistle if the volume is too high, not too low. D. A crack in the ear tube of an in-the-canal hearing aid can impair the hearing aid's amplification of sound; however, it would not cause whistling.

A nurse is collecting data from a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. The nurse should identify that this manifestation is consistent with which of the following eye disorders? Check Answer A. Retinopathy B. Glaucoma C. Cataracts D. Macular degeneration

Correct Answer: B. Glaucoma An obstruction of the flow of the vitreous humor of the eye is a manifestation of glaucoma. This obstruction leads to increased intraocular pressure, resulting in damage to the eye. Incorrect Answers: A. The nurse should identify that manifestations of retinopathy include changes in the blood vessels of the retina, which can lead to blindness. C. The nurse should identify that manifestations of cataracts include an increase in the opacity of the lens, blocking rays of light from entering the eye. D. The nurse should identify that manifestations of macular degeneration include changes in the sharp and central vision. These findings are often associated with aging.

A nurse is collecting data from a client who requires hygiene care. Which of the following pieces of information is the nurse's priority to determine before preparing to bathe the client? A. What type of soap and lotion the client uses at home B. How much the client can assist with bathing C. Whether the client usually bathes in the morning or in the evening D. How important daily bathing is to the client

Correct Answer: B. How much the client can assist with bathing The greatest risk to the client's safety is an injury resulting from an overestimation of the client's ability to help with hygiene care. Therefore, the nurse's priority is to collect data about the client's muscle strength, flexibility, vision, cognition, and sensation and to adjust hygiene procedures accordingly to ensure safety. Incorrect Answers: A. Although it is important for the client's comfort to consider the client's personal preferences for skin care products, there is a higher priority for the nurse to determine. C. Although it is important for the client's comfort to try to honor the daily routines followed at home, there is a higher priority for the nurse to determine. D. Although it is important for the nurse to determine priorities about how often the client usually bathes, there is a higher priority for the nurse to determine.

A nurse is collecting data from a client who reports nausea and vomiting for 2 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? A. Decreased urine specific gravity B. Increased heart rate C. Decreased hematocrit D. Increased skin turgor

Correct Answer: B. Increased heart rate An increased heart rate should indicate to the nurse that the client is experiencing fluid volume deficit. Other findings can include an increased BUN level, dry mucous membranes, and dark yellow urine. Incorrect Answers: A. An increase in urine specific gravity should indicate to the nurse that the client is experiencing fluid volume deficit. C. An increased hematocrit should indicate to the nurse that the client is experiencing fluid volume deficit. D. Poor skin turgor should indicate to the nurse that the client is experiencing fluid volume deficit.

A nurse is caring for a client who has a temperature of 38.7°C (101.7°F). Which of the following actions should the nurse take? A. Apply an alcohol-water solution to the client's skin B. Keep the client's bed linens dry C. Apply ice packs to the groin D. Limit the client's fluid intake to 1183 mL (40 oz) of fluid per day

Correct Answer: B. Keep the client's bed linens dry The nurse should maximize the client's heat loss by keeping the client's clothes and bed linens dry. The nurse should also reduce external coverings on the client's bed without causing shivering. Incorrect Answers: A. This therapy is no longer recommended as an intervention for a fever because it can lead to shivering, which is counterproductive and can cause an increase in energy expenditure. C. This therapy is no longer recommended as an intervention for fever because it can lead to shivering, which is counterproductive and can cause an increase in energy expenditure. D. The nurse should satisfy the client's increased metabolic needs by providing the client with at least 1893 mL (64 oz) of fluid per day.

A nurse is preparing to attend a care plan conference for a client who has severe burns. Which of the following criteria should the nurse identify as a part of an effective conference? A. The planning process for the conference is centered on the nursing staff. B. Other health care professionals are in attendance at the conference. C. Controversial opinions contributed to the plan of care are not tolerated during the conference. D. The conference focuses on a discussion of the client's heath care issues with minimal focus of resolving them.

Correct Answer: B. Other health care professionals are in attendance at the conference. An effective conference should consist of other health care professionals contributing to the plan of care for goalsetting and to establish positive client outcomes. The members of the conference consist of the nursing team, who should invite other health professionals such as physical therapists, dieticians, and occupational therapists to contribute to the plan of care. Incorrect Answers: A. The planning process for the conference is centered on determining the client's care plan goals and establishing positive client outcomes. C. During any client care plan conference, differences of opinion will occur. Therefore, it is important to encourage a climate of respect and a nonjudgmental attitude so that all attendees can work toward remaining open-minded about other attendees' contributions. This can lead to more productive sharing and the establishment positive client outcomes. D. The purpose of the conference is to develop resolutions for the numerous client care problems that require an interprofessional team to set goals and measurable positive outcomes.

A nurse is preparing to administer a bolus feeding to a client through an NG tube and observes that the exit mark on the tube has moved since the last feeding. Which of the following actions should the nurse plan to take? A. Auscultate over the client's stomach while injecting air B. Request an X-ray of the client's abdomen C. Place the head of the client's bed in a flat position D. Administer the feeding if the pH of the aspirated contents is greater than 6

Correct Answer: B. Request an X-ray of the client's abdomen The nurse should request an X-ray to verify the placement of the NG tube both after the initial insertion of the tube and if displacement of the tube is suspected. The nurse should verify NG tube placement prior to administering a bolus feeding. Incorrect Answers: A. The nurse should not verify the NG tube placement by auscultating over the stomach while injecting air because it is difficult to distinguish whether the sound is coming from the stomach, lung, or intestine. C. The nurse should verify the NG tube placement and elevate the head of the client's bed before administering a bolus tube feeding to reduce the risk of aspiration. D. The pH of gastric contents should be 5 or less. Aspirated contents that have a pH of 6 or greater indicates the NG tube is in the lungs or intestines. Therefore, the nurse should not administer the feeding.

A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make? A. "During this phase, feed your child anything that she will eat." B. "Increase the amount of calories and water your child consumes." C. "Keep a diary of the foods your child eats each day." D. "Provide a large variety of fruit juices for your child to choose from."

Correct Answer: C. "Keep a diary of the foods your child eats each day." The nurse should encourage the parent to keep a diary of the foods the child eats throughout the day for 1 week. This can help the parent realize that the child may be eating better than expected. Evidence suggests that children can self-regulate their caloric intake. When they eat less at a meal, they can compensate by eating more at another meal or by having a snack. Incorrect Answers: A. The nurse should inform the parent that children's dietary habits can change from day to day. It is important to feed the child healthy foods and focus on the quality of food rather than the quantity of food during this time. B. The nurse should inform the client that calorie and fluid requirements decrease slightly in a preschool-aged child. The nurse should not promote an increase of calories and water in the child's diet. D. The nurse should inform the parent that excessive consumption of sweetened beverages, including fruit juices, can be associated with adverse health effects such as dental caries, obesity, and metabolic syndrome.

A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care? A. "Social services can contact various community resources that will be helpful." B. "I will review the care plan to make any necessary changes." C. "Let's set up a meeting time with the doctor to discuss your options for home care." D. "I will make a list of things we need to do before discharge."

Correct Answer: C. "Let's set up a meeting time with the doctor to discuss your options for home care." With family-centered care, the nurse considers the health of the family as a unit; therefore, the client and family help determine outcomes and goals. Setting up a meeting to discuss this option with the provider will give the family a sense of autonomy and foster the family-centered nursing environment. Incorrect Answers: A. In family-centered care, the family and client are the focus; therefore, the family must decide, with input from the health care team, which community resources to contact. The nurse should, however, make suggestions and offer support. B. The nurse should offer suggestions and support but should not make decisions about changes to the care plan. D. The family must decide, with the nurse's input, what to do before the client goes home.

A nurse is reinforcing teaching with an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? A. "Drink a minimum of 1,000 milliliters of fluid daily." B. "Increase your intake of refined-fiber foods." C. "Sit on the toilet 30 minutes after eating a meal." D. "Take a laxative every day to maintain regularity."

Correct Answer: C. "Sit on the toilet 30 minutes after eating a meal." Increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 minutes after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation. Incorrect Answers: A. The nurse should instruct the client to consume a minimum of 1,500 mL of fluid to prevent constipation. B. The nurse should instruct the client to increase consumption of coarse fiber and whole grains rather than refined-fiber foods. D. The nurse should not recommend intake of daily laxatives, as consistent use hinders natural defecation habits and can cause constipation rather than cure it.

During a physical examination of a client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect additional data? A. Confrontation test B. Symmetry of palpebral fissures C. Corneal light reflex D. Accommodation test

Correct Answer: C. Corneal light reflex The corneal light reflex requires the nurse to shine a penlight at the client's eyes and visualize whether the light shines on the same spot bilaterally. This test will indicate the alignment of the client's eyes as well as any deviation inward or outward. With strabismus, the eyes will not align when the client focuses. Incorrect Answers: A. A confrontation test compares the visual fields of the client with that of the examiner. B. The palpebral fissure is the space between the eyelids; it is unequal in clients who have ptosis, which is drooping of a single eyelid or both eyelids. D. The test for accommodation determines whether the client's pupils constrict as they focus on an object the examiner brings closer to the eyes.

A nurse is caring for client who has terminal pancreatic cancer. When the client states, "It's devastating that I will not be here to see my child graduate," the nurse should identify that the client is in which of the following stages of grief as defined by Kubler-Ross? Check Answer A. Anger B. Bargaining C. Depression D. Acceptance

Correct Answer: C. Depression During the stage of depression, the client has realized the full impact of the loss or impending death and might express hopelessness and despair. Incorrect Answers: A. During the stage of anger, the client shows resistance or blames other people, a higher power, or the situation itself. B. During the stage of bargaining, the client stalls their awareness of the loss by negotiating to keep it from occurring. D. During the stage of acceptance, the client will integrate the loss into their life, for example, by making final arrangements.

A nurse is caring for a client with a BMI of 29 who expresses a desire to lose weight. Which of the following actions should the nurse take first? A. Refer the client to a nutritionist B. Discuss eating strategies with the client C. Determine the client's intention to change current eating habits D. Instruct the client to perform 30 min of vigorous exercise daily

Correct Answer: C. Determine the client's intention to change current eating habits When using the nursing process, the nurse should first assess the client's readiness to commit to a change in behaviors. Incorrect Answers: A. Effective weight management requires establishing and following healthy eating habits. The nurse should refer the client to a nutritionist for an evaluation of dietary needs and planning a diet to promote weight loss. However, this is not the first action the nurse should take. B. The nurse should discuss various eating strategies such as portion control and the reduction or elimination of sugar-sweetened beverages as a means of reducing weight. However, this is not the first action the nurse should take. D. Although the nurse should recommend increasing physical activity to promote overall health and weight loss, this is not the first action the nurse should take.

A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? A. Place an oxygen mask on the client B. Check the client's pulse C. Determine whether the client is able to breathe D. Wrap arms around the client from behind

Correct Answer: C. Determine whether the client is able to breathe Caring for this client requires application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. This client is demonstrating the universal choking gesture. If the client is unable to move air in our out, severe airway obstruction is present. The client will need emergency interventions to clear a partial obstruction, indicated by stridor or minimal airway passage. As long there is good air exchange and the client can cough and breathe spontaneously, the nurse should stay with the client and monitor her condition. Incorrect Answers: A. The nurse should place an oxygen mask on the client to provide supplemental oxygen. However, there is another action the nurse should take first. B. The nurse should check the client's pulse as part of cardiopulmonary resuscitation (CPR) if the client becomes unconscious. However, there is another action the nurse should take first. D. The nurse should wrap arms around the client from behind to perform an abdominal thrust if breathing is obstructed. However, there is another action the nurse should take first.

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? A. Auscultate for bowel sounds after each feeding B. Ensure the formula is cold before administering C. Elevate the client's head of bed 45° before the feeding D. Flush the tubing with 15 mL of water after the enteral feeding

Correct Answer: C. Elevate the client's head of bed 45° before the feeding The nurse should elevate the client's head of bed between 30° and 45° to prevent aspiration. Incorrect Answers: A. The nurse should auscultate for bowel sounds before each feeding to ensure the client has peristalsis bowel activity for the digestive system to digest or absorb the enteral nutrition. B. The nurse should ensure the formula is at room temperature before administering because cold formula might cause intestinal cramping and discomfort. D. The nurse should flush the tubing with at least 30 mL of water after the enteral feeding to maintain patency of the feeding tube.

A nurse is collecting data from a client who is having difficulty breathing. The nurse should assist the client into which of the following positions? A. Supine B. Lateral C. Fowler's D. Trendelenburg

Correct Answer: C. Fowler's Sitting upright promotes full expansion of both lungs and facilitates ventilation and perfusion. Incorrect Answers: A. Although many clients find lying on their back to be comfortable, this position does not facilitate lung expansion for a client who has dyspnea. B. A side-lying position facilitates expansion of a lung. However, a client who has dyspnea needs maximum expansion of both lungs. D. Lowering the head of the bed with the foot of the bed raised in a straight incline can promote venous circulation and facilitate postural drainage. However, it will not improve lung expansion for a client who has dyspnea.

A nurse is reinforcing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks both the client's native language and the nurse's, arrives to drive the client home. Which of the following actions should the nurse take? A. Ask the client's neighbor to call a family member to interpret B. Ask the client's neighbor to translate the information C. Obtain the services of an interpreter D. Document the inability to provide discharge instructions

Correct Answer: C. Obtain the services of an interpreter Federal mandates require a professional medical interpreter to translate the client's health care information into the client's native language. Incorrect Answers: A. Using a family member to interpret could breach the client's confidentiality. In addition, the family member might not be familiar enough with medical terminology to translate information accurately. B. Although the neighbor can speak both languages, this action could breach the client's confidentiality. In addition, the neighbor might not be familiar enough with medical terminology to translate information accurately. D. The nurse is responsible for providing discharge instructions the client can understand.

A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take? A. Raise the enema bag if the client experiences cramping B. Lubricate 2.54 cm (1 in) of the tip of the rectal tube prior to insertion C. Place the client in a left Sims' position D. Don sterile gloves prior to the procedure

Correct Answer: C. Place the client in a left Sims' position The nurse should place the client into a left Sims' position for the insertion of an enema. This left lateral position facilitates the flow of the enema solution into the sigmoid and descending colon. The anus is exposed by flexing the right leg. Incorrect Answers: A. The nurse should administer the fluids slowly and lower the container for a client who experiences fullness or pain during the administration of the enema. B. The nurse should lubricate 5.08 cm (2 in) of the tip rectal tube prior to insertion. D. The nurse should don clean gloves to perform an enema procedure for a client.

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? A. Stand toward the client's stronger side B. Instruct the client to lean backward from the hips C. Place the wheelchair at a 45° angle to the bed D. Assume a narrow stance with feet 15 cm (6 in) apart

Correct Answer: C. Place the wheelchair at a 45° angle to the bed Positioning the wheelchair at a 45° angle allows the client to pivot, lessening the amount of rotation required. Incorrect Answers: A. Safely transferring a client from a bed to a wheelchair requires the nurse to stand in front of the client toward the side that requires the most support. This technique will help maintain balance during the transfer. B. Safely transferring a client from a bed to a wheelchair requires the nurse to instruct the client to lean forward from the hips. This technique positions the client in the proper direction of the movement. D. Safely transferring a client from a bed to a wheelchair requires the nurse to assume a wide stance with a foot in front of the other. This technique protects the nurse from losing balance during the transfer.

A nurse in a long-term care facility is feeding a client. Which of the following observations should the nurse identify as an indication that the client requires an evaluation for dysphagia? Check Answer A. Speaking rapidly B. Hiccupping frequently C. Pocketing food D. Preferring clear liquids

Correct Answer: C. Pocketing food Incomplete oral clearance (pocketing food in the cheeks, under the tongue, or on the hard palate) is a common manifestation of dysphagia or difficulty swallowing. Pocketing results in collections of food in the mouth, causing an aspiration risk after the meal. Incorrect Answers: A. Clients who have dysphagia tend to speak slowly, with speech that lacks strength and coordination. B. Clients who have dysphagia tend to belch, cough, regurgitate, and lose food from the lips. D. Clients who have dysphagia might already have learned to choose foods and fluids that are easier for them to swallow. In general, thick liquids are easier for these clients to swallow than thin fluids.

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take? A. Remove the NG tube B. Advance the NG tube quickly C. Pull the NG tube back slightly D. Ask the client to tilt his head backward

Correct Answer: C. Pull the NG tube back slightly The nurse should slightly pull back the NG tube and instruct the client to breathe slowly. Once the client relaxes, the nurse should gently advance the tube as the client swallows. Incorrect Answers: A. The nurse should not remove the NG tube if the client begins to cough and gag because this can result in increased discomfort for the client. B. The nurse should not advance the NG tube while the client is coughing because this can result in inserting the tube into the client's trachea. D. The nurse should ask the client to tilt his head forward to assist with the insertion of the NG tube into the esophagus.

A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an assistive personnel (AP). The nurse later observes the AP emptying the bag without wearing gloves. Which of the following actions should the nurse take? A. Notify the charge nurse about the incident B. Insist that the AP attend an in-service training about standard precautions C. Talk with the AP about the technique used D. Observe the AP a second time and intervene if the technique remains the same

Correct Answer: C. Talk with the AP about the technique used The nurse who delegates a task is responsible for providing the right supervision and evaluation. The nurse is responsible for providing feedback to the AP and should reinforce the correct procedure for this task with the AP, which includes wearing gloves. Incorrect Answers: A. The nurse does not need to notify the charge nurse about the incident. The nurse who delegates a task transfers responsibility for the task but retains accountability for the task. The nurse should evaluate the AP's performance and provide feedback as needed. B. Although further training and education may be necessary, the nurse should discuss the situation with the AP and listen attentively to the reason for the AP's actions. If the cause of the error is a lack of understanding of the procedure, the nurse can conduct training for the AP and other staff who may need assistance. The nurse can also gain assistance from the education department. D. The nurse should not allow the AP an opportunity to make the same mistake twice. The nurse should discuss the situation with the AP to determine the cause of the incorrect procedure and intervene the first time it is observed.

A nurse is collecting data from a female client who reports abdominal pain. Further findings reveal a temperature of 39.2°C (102.6°F), a heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority? A. Heart rate of 105 B. Soft nontender abdomen C. Temperature D. Overdue menses

Correct Answer: C. Temperature Elevated temperature is an emergent physiological need that requires priority intervention by the nurse. The nurse should consider Maslow's hierarchy of needs, which includes 5 levels of priority. These levels are as follows: physiological needs, safety and security needs, love and belonging needs, personal achievement and self-esteem needs, and achieving full potential, the ability to problem-solve, and cope with life situations. When applying Maslow's hierarchy of needs, the nurse should review physiological needs before addressing the client's needs by following the remaining 4 hierarchal levels. However, it is important for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with lower levels, depending on the situation. Incorrect Answers: A. This is an important assessment finding because the client's heart rate is elevated. However, a fever and pain can contribute to tachycardia. This is not the priority. B. This is an important assessment finding because of the client's report of pain. However, a soft nontender abdomen is an expected finding and should not cause concern. This is not the priority. D. This is an important assessment finding because of the client's report of pain. However, an irregularity in the menstrual cycle is a common finding when a client is stressed. This is not the priority.

A nurse is inserting an indwelling urinary catheter into the penis of a client. Which of the following actions should the nurse take? A. Place the client supine with his knees flexed B. Put on clean gloves for the procedure C. Use the nondominant hand to grasp the penile shaft D. Cleanse the urinary meatus in a spiral motion from the shaft inward to the meatus

Correct Answer: C. Use the nondominant hand to grasp the penile shaft To position the penis for insertion of the catheter, the nurse should use the nondominant hand to grasp the shaft just below the glans and hold it at up at a right angle to the client's body. This helps straighten the urethra to facilitate insertion of the catheter. Incorrect Answers: A. The nurse should place the client supine with his legs extended and his thighs spread slightly outward. Supine with knee flexion is the position for inserting a urinary catheter for a female client, not a male client. B. The nurse must wear sterile gloves when inserting a urinary catheter to reduce the risk of a catheter-associated urinary tract infection. D. The nurse should cleanse the urinary meatus in a spiral motion beginning at the meatus and working outward around the glans.

A nurse is collecting data from a client who is postoperative following abdominal surgery. Which of the following findings is the nurse's priority to report to the surgeon immediately? A. Nausea with 1 episode of vomiting B. Incisional pain of 5 on a 0 to 10 scale C. Warm, tender area on the right calf D. Serosanguineous fluid from a surgical drain

Correct Answer: C. Warm, tender area on the right calf The greatest risk to this client is an injury from thrombus formation; therefore, this is the priority finding that the nurse should report to the surgeon immediately. This is a life-threatening postoperative complication because the thrombus could dislodge and become a pulmonary embolism. Incorrect Answers: A. The nurse should inform the surgeon of the client's gastrointestinal status to determine whether an antiemetic, a slower dietary progression, or an increase in IV fluids is necessary; however, another finding is the priority. B. The nurse should inform the surgeon of the severity of the client's incisional pain, especially if it is increasing or if pain medication does not relieve it; however, another finding is the priority. D. The nurse should track the amount of drainage from the surgical drain and keep the surgeon informed to confirm that the drainage is adequate and not excessive, bloody, or purulent; however, another finding is the priority.

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? A. Instruct the client to defecate into the toilet bowl B. Transfer the specimen to a sterile container C. Refrigerate the collected specimen D. Place the stool specimen collection container in a biohazard bag

Correct Answer: D. Place the stool specimen collection container in a biohazard bag The nurse should place the specimen collection container in a biohazard bag with the client label placed on the container and the bag for easy identification and to prevent contamination with microorganisms. Incorrect Answers: A. The nurse should have the client defecate into a bedpan or a container for stool collection. The toilet water can dilute and contaminate the liquid specimen. B. The nurse should place the stool specimen in a clean container using a tongue depressor. C. The nurse should send the collected stool specimen immediately to the laboratory after labeling the specimen properly to prevent contamination with microorganisms and to keep the specimen from getting cold or hot.

A nurse is contributing to the plan of care for a client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight? A. Calibrate the scales weekly B. Use a different scale for each weighing session C. Weigh the client on arising in the morning D. Weigh the client without clothing

Correct Answer: C. Weigh the client on arising in the morning The nurse should weigh the client on arising each day, after voiding and before breakfast. An accurate weight requires the client to be weighed wearing the same type of garments and on the same carefully calibrated scale (balanced to 0 before each use). Accurate daily weights provide the easiest measurement of volume status. An increase of 1 kg (2.2 lb) is equal to 1,000 mL (1 L) of retained fluid. Incorrect Answers: A. The nurse should calibrate the scales to 0 each day or before each use to provide accurate information. B.The n urse should weigh the client using the same scale each time because there generally is a slight difference between readings from each scale. D. The nurse should plan to have the client's weight taken wearing the same type of clothing each time to provide an accurate reading and to avoid embarrassment.

A nurse is reinforcing preoperative teaching with a client who is scheduled for arthroplasty in the next month and might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following suggestions should the nurse make? A. "Ask your provider to prescribe epoetin before the surgery." B. "You should take iron supplements prior to the surgery." C. "Ask a family member donate blood for you." D. "Donate autologous blood before the surgery."

Correct Answer: D. "Donate autologous blood before the surgery." Autologous blood transfusion is the collection and reinfusion of the client's own blood. With preoperative autologous blood donation, the blood is drawn from the client 3 to 5 weeks before an elective surgical procedure and stored for transfusion at the time of the surgery. Autologous blood is the safest form of blood transfusion; exclusive use of a client's own blood eliminates exposure to transfusion-transmitted infection. Incorrect Answers: A. Epoetin is a hematopoietic growth factor used for the treatment of anemia. While taking epoetin prior to surgery may boost the client's hematocrit levels, it is inappropriate if the client already has an adequate hematocrit level. Furthermore, this action may not eliminate the need for a blood transfusion and its related risks. B. While taking an iron supplement prior to surgery may boost the client's hemoglobin levels, it is inappropriate if the client already has an adequate hemoglobin level and intake of iron from dietary sources. Furthermore, this action may not eliminate the need for a blood transfusion and its related risks. C. A directed blood donation from a family member does not eliminate the risk of acquiring an infection.

A nurse is reinforcing teaching with a client who is using a patientcontrolled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I'll limit pushing the button so I don't get an overdose." B. "If I push the button and still have pain after 2 minutes, I'll push it again." C. "I'll ask my niece to push the button when I am sleeping." D. "I can still use my TENS unit even though I'm pushing the PCA button."

Correct Answer: D. "I can still use my TENS unit even though I'm pushing the PCA button." The nurse should encourage the client to use nonpharmacological methods of pain management such as transcutaneous electrical nerve stimulation (TENS) while using a PCA pump to help reduce the amount of opioid dosing the client needs. Incorrect Answers: A. PCA devices have a timing control or lockout mechanism that allows a preset minimum interval between medication doses and limits the total dose per hour. This safety feature prevents analgesic overdosing. B. PCA devices have a timing control or lockout mechanism that usually allows dosing every 6 to 8 minutes. If the client pushes the button after 2 minutes, the pump will not deliver any medication. C. Only the client should operate the PCA pump. When someone else operates it, it bypasses a safety feature that requires the client to be awake and decide whether more medication is needed.

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular-sized cuff for a client who is obese. Which of the following explanations should the nurse give the AP? A. "The reading will be inaudible if the cuff is too small for the client." B. "The width of the cuff bladder should be 75% of the circumference of the client's arm." C. "As long as the cuff will circle the arm, the reading will be accurate." D. "Using a cuff that is too small will result in an inaccurately high reading."

Correct Answer: D. "Using a cuff that is too small will result in an inaccurately high reading." Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. Blood pressure readings can be falsely high if the cuff is too small for the client. Incorrect Answers: A. Although the BP reading for a client who is obese may be difficult to hear with any cuff, a cuff that is too small for the client will not yield an inaudible reading. B. The width of the cuff bladder should be 40% of the circumference of the client's arm. C. A cuff that is an incorrect size for the client will not yield an accurate reading.

A nurse is collecting data about a client's spiritual wellbeing. Which of the following questions should the nurse ask? A. "When did you start to believe in your faith?" B. "How often do you perform religious rituals?" C. "Which church do you regularly attend?" D. "What is your source of strength and hope?"

Correct Answer: D. "What is your source of strength and hope?" This is a broad, open-ended question that encourages the client to express feelings without any assumptions on the nurse's part. It focuses on a global view of spirituality as a complex concept that encompasses the client's life experiences and beliefs about strength, love, and hope. Incorrect Answers: A. This is a nontherapeutic response that assumes the client has a religion-based belief system. A spiritual evaluation addresses spirituality, which can include religious beliefs but does not depend on their existence. B. C. This is a nontherapeutic response that assumes the client has a religion-based belief system.

A nurse is beginning her shift and reviewing the medication administration records (MARs) for her clients. She notes a medication dosage above the safe range and sees that another nurse administered that dosage during the previous shift. Which of the following actions should the nurse take? A. Call the nurse to verify that the client received that dosage B. Administer the medication in a safe dosage C. Give the dose the provider prescribed D. Call the provider to clarify the dosage

Correct Answer: D. Call the provider to clarify the dosage After collecting data from the client to check for adverse effects of the medication, the nurse should notify the provider of her observations to determine the next action. Incorrect Answers: A. The MAR indicates what dosage the nurse administered. B. It is not within the nurse's scope of practice to change the medication dosage. C. The nurse has identified a potential problem with the prescribed dosage; therefore, the nurse should not give that dosage.

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? A. Withdraw the specimen from the drainage bag B. Cleanse the collection port with soap and water C. Place the specimen in a clean specimen cup D. Clamp the tubing below the collection port

Correct Answer: D. Clamp the tubing below the collection port The nurse should clamp the tubing below the collection port to allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup. Incorrect Answers: A. The nurse should use a fresh urine specimen obtained near the indwelling urinary catheter to prevent contamination. B. The nurse should cleanse the collection port with an antimicrobial swab to prevent contamination. C. The nurse should place the specimen in a sterile specimen cup to prevent contamination.

A nurse is reviewing a client's 24-hour dietary recall. The client reports eating a slice of toasted white bread with butter, a banana, a glass of milk, and a cup of coffee for breakfast; grilled chicken, a baked potato, and a glass of milk for lunch; an apple and cheddar cheese for a snack; and 2 servings of chicken, 2 cups of steamed broccoli, and a glass of milk for dinner. The nurse should identify that this client's diet is deficient in which of the following food groups? A. Dairy B. Vegetables C. Fruits D. Grains

Correct Answer: D. Grains The nurse should identify that the client only consumed 1 serving of grains on the day of the 24-hour dietary recall. The recommendation is 3 or more ounce-equivalents of whole-grain products per day according to the United States Department of Agriculture (USDA) dietary guidelines. Additionally, the choice of white bread is low in fiber, which can lead to constipation and an increased risk of developing hyperlipidemia. The USDA guidelines recommend that at least half of the grains consumed be whole-grain. Incorrect Answers: A. The client consumed 3 servings of dairy throughout the day, which is the recommended daily amount according to the USDA dietary guidelines. B. The client consumed at least 2 1/2 cups of vegetables, which is the recommended daily amount according to the USDA dietary guidelines. C. The client consumed 2 servings of fruit, which is the recommended daily amount according to the USDA dietary guidelines.

A nurse is caring for a client who requires a chest X-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? A. Explain the X-ray procedure to the client B. Help the client into a wheelchair before the transporter arrives C. Ask if the client has any questions D. Identify the client using 2 identifiers

Correct Answer: D. Identify the client using 2 identifiers The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the risk posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Once the client's identity is determined, the nurse can then proceed with the other options. This action is the priority because it promotes the safety of the client. The nurse should be certain that each client receives only what has been prescribed and must ensure that the correct client is being transported for a chest X-ray. Incorrect Answers: A. The nurse should explain the X-ray procedure to the client. However, there is another action the nurse should take first. B. The nurse should have the client ready for the procedure. However, there is another action the nurse should take first. C. The nurse should inquire if the client has any questions about the procedure. However, there is another action the nurse should take first.

During the insertion of a urinary catheter for a client, the tip of the catheter brushes against the nurse's arm. Which of the following actions should the nurse take? A. Wipe the catheter with povidoneiodine and continue the catheter insertion B. Soak the catheter in chlorhexidine for 15 min and then reattempt insertion C. Continue with the catheter insertion D. Obtain a new catheter and reattempt insertion

Correct Answer: D. Obtain a new catheter and reattempt insertion Insertion of a urinary catheter is a sterile procedure. The only way to ensure sterility is to obtain a new sterile catheter and by following surgical asepsis throughout the insertion procedure. Incorrect Answers: A. B. Insertion of a urinary catheter is a sterile procedure. Antibacterial solutions do not guarantee sterility. These actions could increase the client's risk of a catheter-associated urinary tract infection. C. Once the tip of the catheter touches a nonsterile surface, it is contaminated and should not be inserted.

A nurse is collecting data from a client. Which of the following actions should the nurse take to determine the client's tissue perfusion? A. Perform a Romberg test B. Check nails for Beau's lines C. Palpate for respiratory excursion D. Perform a blanch test

Correct Answer: D. Perform a blanch test The blanch test is used to check capillary refill, which is an indicator of peripheral circulation and tissue perfusion. Incorrect Answers: A. The Romberg test is used to determine a client's balance and gross motor function. It is not used to determine tissue perfusion. B. Beau's lines are depressions in the nail from temporary disturbance of nail growth. Beau's lines are caused by systemic illness or injury and are not indicators of tissue perfusion. C. Respiratory excursion is palpated to determine thoracic expansion and depth of breathing. It is not used to determine tissue perfusion.

A nurse is auscultating the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse hears a high-pitched scratching sound with the diaphragm of the stethoscope placed at the third intercostal space of the left sternal border. Which of the following heart sounds should the nurse document? A. Audible click B. Murmur C. Third heart sound D. Pericardial friction rub

Correct Answer: D. Pericardial friction rub A pericardial friction rub has a scratching, grating, or squeaking leathery sound. It tends to be high frequency and best heard with the diaphragm of the stethoscope at the third intercostal space of the left sternal border. A pericardial friction rub is a manifestation of pericardial inflammation and can be heard with infective pericarditis, with myocardial infarction, following cardiac surgery or trauma, and with some autoimmune problems such as rheumatic fever. A client who develops pericarditis typically has chest pain that becomes worse with inspiration or coughing and may be relieved by sitting up and leaning forward. Incorrect Answers: A. An audible clicking sound occurs in clients who have prosthetic valve replacement surgery. B. A heart murmur has a swishing or a whistling sound. Heart murmurs are caused by turbulent blood flow through valves or ventricular outflow tracts. Low- and medium-frequency sounds are more easily heard with the bell of the stethoscope applied lightly to the skin; high-frequency sounds are more easily heard with a diaphragm. A murmur can be a manifestation of valvular disease. C. A third heart sound (S3) is a low-pitched sound after the second heart sound. An S3 is caused by rapid ventricular filling during diastole. It is best heard at the mitral area, with the client lying on the left side. An S3 is commonly heard in children and young adults. In older adults and clients who have heart disease, an S3 often indicates heart failure.

A nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. Which of the following actions should the nurse take? A. Change the tube feeding bag every 48 hours B. Chill the formula prior to administration C. Increase the infusion rate D. Request a prescription for an isotonic enteral nutrition formula

Correct Answer: D. Request a prescription for an isotonic enteral nutrition formula The nurse should assist a client who develops diarrhea while receiving NG tube feedings by consulting with the provider and the dietitian regarding changing the client's formula to an isotonic formula. This formulation can be easier for the client to digest and can decrease diarrhea. Incorrect Answers: A. The nurse should change the bag and tubing every 24 hours to decrease bacterial growth within the feeding tube system. The nurse should also employ aseptic technique. B. The nurse should ensure the formula is at room temperature prior to administration. Cold formula can result in abdominal cramping and discomfort. C. The nurse should decrease the infusion rate for a client who develops diarrhea while receiving feedings via NG tube. This can assist in reducing diarrhea as well as gastric intolerance to the formula.

A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring? A. Right task B. Right circumstance C. Right person D. Right communication

Correct Answer: D. Right communication The situation could have been avoided if the right communication was given by the nurse to the AP. The right communication entails providing clear, concise instructions regarding the task, including the objective, limits, and expectations. Incorrect Answers: A. The nurse delegated the right task. The nurse can delegate a task to an AP that is repetitive, requires minimal supervision, is relatively noninvasive, has predictable results, and has minimal potential for risk. Obtaining a client's temperature is within the range of function for an AP. B. The nurse correctly delegated the task in the right circumstance. This entails consideration of the appropriate client setting, the available resources, and other factors relevant to the situation. C. The nurse delegated the taking of a client's temperature to the right person. This entails delegating the right task to the right person to be performed on the right person. Obtaining a client's temperature is within the range of function for an AP and the client's temperature was recorded as collected.

A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes? A. Allows minimal treatment B. Benefits the client's family C. Offers hope of a cure D. Supports self-determination

Correct Answer: D. Supports self-determination The nurse must honor the client's autonomy and ability to make health care decisions. The client has the right to refuse treatment; as the client's advocate, the nurse must support that right. Incorrect Answers: A. The client has the right to refuse all treatment, and the nurse has the duty to honor that right. B. The nurse's priority is to provide care that benefits the client, not necessarily the family. C. Offering hope of a cure when lung cancer is advanced is a nontherapeutic response and provides false reassurance to the client.

A nurse is reinforcing teaching for a client about managing her tracheostomy care. Which of the following instructions should the nurse include? A. Wear sterile gloves when performing tracheostomy care at home B. Use sterile water to rinse the inner cannula C. Perform tracheostomy care three times a week D. Wear a tracheostomy cover when outdoors

Correct Answer: D. Wear a tracheostomy cover when outdoors A tracheostomy cover protects the client's airway from dust, chilly air, and any other airborne particles that could otherwise enter the airway. Incorrect Answers: A. Within the home environment, clean gloves are sufficient. B. Within the home environment, tap water is sufficient for rinsing the inner cannula. C. At home, the client should perform tracheostomy care daily.

A nurse is obtaining a capillary blood sample to determine a client's blood glucose level. The nurse prepares and punctures the client's finger for the procedure but does not obtain an adequate amount of blood. Which of the following actions should the nurse take? A. Smear the small amount of blood onto the testing strip B. Hold the finger above heart level C. Massage the client's fingertip D. Wrap the client's finger in a warm washcloth

Correct Answer: D. Wrap the client's finger in a warm washcloth Warmth helps increase the blood flow to the client's finger. Incorrect Answers: A. Smearing the blood on the reagent strip will cause an inaccurate result. B. To improve blood flow, the nurse should keep the client's hand in a dependent position. C. Massaging can hemolyze the specimen, causing an inaccurate result.