CMS Fundamentals

A nurse is reinforcing teaching with a client about how to use an albuterol metered-dose inhaler. After removing the cap from the inhaler and shaking the canister, the nurse should instruct the client to take the following steps in which order?

"Hold the mouthpiece 1 to 2 inches in front of your mouth." "Tilt your head back slightly and open your mouth wide." "Depress the canister while taking a slow, deep breath." "Hold your breath for 10 seconds."

A nurse is preparing to change a dressing on a client who is receiving negative-pressure wound therapy (NPWT). In what sequence should the nurse plan to take the following actions?

Turn off the vacuum on the NPWT device and administer the prescribed analgesic. Remove the soiled dressing and perform hand hygiene. Apply sterile or clean gloves and irrigate the wound. Apply skin protectant or a barrier film to the skin around the wound. Place prepared foam into the wound bed and cover with transparent dressing. Connect the tubing to transparent film and turn on the NPWT unit.

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

A. A simple demonstration of inhaler use

A nurse is caring for a client who has chronic kidney disease. The kidneys regulate body fluids and assist with which of the following functions? A. Regulation of acid-base balance B. Reabsorption of nutrients for cellular growth C. Regulation of body temperature D. Secretion of hormones needed for growth

A. Regulation of acid-base balance

A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching? A. "I will have the steps to my house painted a dark color." B. "I will put a night-light in the hallway." C. "I will put on socks when I get out of bed." D. "I will secure any wires in my home under rugs."

B. "I will put a night-light in the hallway."

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."

B. "It modulates the transmission of the pain impulse."

A nurse is reinforcing teaching about crutches for a client who has a fracture of the right foot. Which of the following instructions should the nurse give the client? A. "When you go up a flight of stairs, place your right foot on the first step." B. "Keep the rubber crutch tips securely in place." C. "When standing, keep the crutches 12 inches in front of you and 12 inches to the side." D. "Place your weight on the crutch pads at your armpits."

B. "Keep the rubber crutch tips securely in place."

A nurse is collecting data for the health history of a client who is postoperative and has paralytic ileus. Which of the following findings should the nurse expect? A. Frequent bowel sounds with flatus B. Absent bowel sounds with distention C. Hyperactive bowel sounds with diarrhea D. Normal bowel sounds with increased peristalsis

B. Absent bowel sounds with distention

A nurse on a medical unit is caring for a client who has difficulty sleeping. Which of the following actions should the nurse take to promote the client's ability to fall asleep? A. Encourage the client to ambulate in the hallway just before bedtime B. Allow the client to maintain the same bedtime routine as at home C. Keep the room temperature warm D. Offer the client a cup of hot chocolate before bedtime

B. Allow the client to maintain the same bedtime routine as at home

A nurse on a pediatric unit is caring for a child who is 4 years old. To help with communication and play activities for this client, the nurse should consider which of the following characteristics of Piaget's preoperational period? A. Seriation B. Animism C. Reversibility D. Self-consciousness

B. Animism

A nurse is collecting data from a client who has asthma and reports several food allergies. Which of the following actions should the nurse perform first? A. Document the client's food allergies in the medical record B. Ask the client to identify the specific food allergies C. Monitor the client for indications of anaphylaxis D. Have epinephrine available for administration

B. Ask the client to identify the specific food allergies

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions is the nurse's priority? A. Administer a bronchodilator B. Assist the client to an upright position C. Encourage the client to use pursed-lip breathing D. Turn the client from side to side.

B. Assist the client to an upright position

A nurse is collecting data about a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries? A. Palpation of both carotid arteries simultaneously B. Auscultation of the arteries for bruits with the bell of the stethoscope C. Palpation of the arteries for murmurs bilaterally D. Auscultation of the arteries for thrills with the diaphragm of the stethoscope

B. Auscultation of the arteries for bruits with the bell of the stethoscope

A nurse rates a client's biceps reflex as 2+. Which of the following characteristics should the nurse document about the client's reflexes? A. Diminished B. Average C. Brisk D. Hyperactive

B. Average

A nurse is assisting with the planning of an in-service training session about various dietary practices. Which of the following pieces of information should the nurse recommend including in the teaching? A. Ovo-vegetarian diets exclude eggs. B. Kosher diets involve restrictions regarding how food must be prepared. C. Macrobiotic diets are plant-based and exclude all animals and seafood. D. Flexitarian diets exclude the consumption of dairy products.

B. Kosher diets involve restrictions regarding how food must be prepared.

A nurse is assisting a provider with performing thoracentesis to remove pleural fluid. How should the nurse position the client? A. Sitting upright and facing forward in bed B. Leaning forward over a pillow C. Lying supine D. Side-lying with the head flexed

B. Leaning forward over a pillow

A nurse is collecting health history data from a client who is deaf and uses American Sign Language (ASL) to communicate. The nurse will be working with an ASL interpreter. Which of the following actions should the nurse perform when working with the interpreter? A. Face away from the client to avoid creating a distraction B. Pace speech to allow time for the interpreter to convey the words C. Make eye contact with the interpreter when explaining the procedure D. Stand in the background while the interpreter translates the message

B. Pace speech to allow time for the interpreter to convey the words

A nurse is caring for a client who, after multiple less restrictive interventions, continues to pick at and dislodge his nasogastric tube. The provider has prescribed wrist restraints. Which of the following actions should the nurse take? A. Tie the straps of the restraints to the bed's side rails B. Pad the client's wrists before applying the restraints C. Make sure three 3 fingers fit under each restraint after application D. Check the skin under the restraints every 3 to 4 hours

B. Pad the client's wrists before applying the restraints

A nurse employs a thorough, systematic method for obtaining objective data about a client. Which of the following methods should the nurse use to collect this information? A. Health history B. Physical examination C. Review of systems D. Interview

B. Physical examination

A nurse is monitoring a client's laboratory results. Which of the following results should the nurse report to the provider? A. Sodium 140 mEg/L B. Potassium 3.0 mEg/L c. Chloride 100 mEq/L D. Magnesium 2.0 mEq/L

B. Potassium 3.0 mEg/L

A nurse is assisting with planning a community presentation for parents. When suggesting a discussion of controlling impulses and cooperating with others, the nurse should plan to relate it to Erikson's developmental task for which of the following age groups? A. Toddlers B. Preschoolers C. School-aged children D. Adolescents

B. Preschoolers

A nurse is planning an instructional session about walking with a cane for a client who has a moderate sensorineural hearing loss. Which of the following actions should the nurse take? A. Approach the client from behind and gently tap her shoulder B. Sit at the same level as the client C. Speak at a high vocal volume D. Avoid visible gestures

B. Sit at the same level as the client

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 mEg/L C. Potassium 4 mEq/L D. Magnesium 1.5 mEq/L

B. Sodium 150 mEg/L

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.

B. The basal metabolic rate could decrease.

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.

B. The client reports severe pain.

A nurse is reviewing the laboratory results of a client who is preoperative. Which of the following results should the nurse report to the surgeon? A. Platelet count 210,000/mm^3 B. WBC count 18,000/mm^3 C. Sodium 140 mEq/L D. Fasting glucose 92 mg/dL

B. WBC count 18,000/mm^3

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? 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

B. Wiping the labia minora in an anteroposterior direction

A nurse is examining a client's thyroid gland. Which of the following instructions should the nurse give the client before inspecting and palpating this gland? A. "Tilt your head slightly forward." B. "Keep your head straight and look ahead of you." C. "Tilt your head back and swallow." D. "Turn your head to the side against my hand."

C. "Tilt your head back and swallow."

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? A. Anger B. Bargaining C. Depression D. Acceptance

C. Depression

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

C. Determine the client's intention to change current eating habits

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

C. Determine whether the client is able to breathe

A nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following? A. Retention B. Oliguria C. Diuresis D. Dysuria

C. Diuresis

A nurse is collecting data about a client's pulses of the lower extremities. The nurse should identify which of the following as the location of the most distal pulse? A. Popliteal B. Posterior tibial C. Dorsalis pedis D. Femoral

C. Dorsalis pedis

A nurse is collecting baseline data about a client's chest as part of a physical examination. Which of the following actions should the nurse take first? A. Auscultate the thorax B. Palpate the thorax C. Inspect the thorax D. Percuss the thorax

C. Inspect the thorax

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? A. Tie the restraints to the side rails B. Perform range-of-motion exercises to the wrists every 3 hr C. Remove the restraints individually D. Obtain a PRN prescription for the restraints

C. Remove the restraints individually

A home health nurse is visiting the home of a caregiver who says he is "exhausted" from working part-time in addition to caring for his mother, who is an older adult and has severe dementia. Which of the following options should the nurse suggest to the caregiver? A. Rehabilitation B. Assisted-living facility C. Respite care D. Adult day care facility

C. Respite care

A nurse is collecting baseline data about a client's respirations as part of a comprehensive physical examination. Which of the following types of breath sounds should the nurse report to the provider? A. Bronchial B. Vesicular C. Rhonchi D. Bronchovesicular

C. Rhonchi

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? A. Contact the family and ask them to stay with the client B. Offer to call the client's minister C. Sit and hold the client's hand D. Leave the room and allow the client to cry privately

C. Sit and hold the client's hand

A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in which of the following positions for evaluation? A. Sims' B. Supine C. Sitting D. Standing

C. Sitting

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

C. Use the nondominant hand to grasp the penile shaft

A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use? A. Deltoid B. Ventrogluteal C. Vastus lateralis D. Dorsogluteal

C. Vastus lateralis

A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take? A. Use a 10 mL syringe B. Attach a 22-gauge catheter to the syringe C. Warm the irrigating solution to 37°C (98.6°F) D. Administer an analgesic 10 minutes before the irrigation

C. Warm the irrigating solution to 37°C (98.6°F)

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

C. Warm, tender area on the right calf

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

C. Weigh the client on arising in the morning

A nurse is caring for a client who just received a diagnosis of cancer. The client states, "I just don't know what I'm going to do now." Which of the following responses should the nurse make? A. "In time you'll know the right thing to do." B. "I am sorry. Would you like me to call someone for you?" C. "There are multiple treatment options for you to consider." D. "Can you explain the concerns you're having right now?"

D. "Can you explain the concerns you're having right now?"

During completion of a health history, a client reports having chest pain intermittently for the past week. Which of the following questions is the nurse's priority? A. "Did you report the chest pain episodes to your physician?" B. "Is there a history of heart disease in your family?" C. "Have you had this pain before?" D. "Can you tell me what the pain felt like and show me exactly where it was?"

D. "Can you tell me what the pain felt like and show me exactly where it was?"

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."

D. "Donate autologous blood before the surgery."

A nurse is reinforcing teaching with a client who is using a patient-controlled analgesia (PA) 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? C A. "l'Il 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."

D. "I can still use my TENS unit even though I'm pushing the PCA button."

A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will empty the pouch when it is about 75% full." B. "I will replace the pouch every 10 days or so." C. "I will make the opening in the skin barrier about a half inch bigger than my stoma." D. "I will make sure to replace my pouch around 4 hours after I eat."

D. "I will make sure to replace my pouch around 4 hours after I eat."

By asking a client to explain the statement, "A bird in the hand is worth 2 in the bush," the nurse is evaluating the client's ability in which of the following intellectual functions? A. Judgment B. Short-term memory C. Attention span D. Abstract reasoning

D. Abstract reasoning

A nurse in a provider's office is collecting data from a 3-year-old client during a routine physical examination. Which of the following findings should the nurse report to the provider? A. Can skip B. Can identify 4 colors C. Cannot print their name D. Cannot walk-up stairs independently

D. Cannot walk-up stairs independently

A nurse is caring for a middle adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks? A. Managing a home B. Establishing a sense of self in the adult world C. Forming new friendships D. Ceasing to compare personal identity with those of others

D. Ceasing to compare personal identity with those of others

A nurse documents clubbing of the fingernails for a client who has emphysema. The nurse should identify that which of the following is the underlying cause of this finding? A. Trauma B. Severe infection C. Iron-deficiency anemia D. Chronic hypoxemia

D. Chronic hypoxemia

A nurse is preparing to assist with discharge planning for a client with a new colostomy who has low health literacy. When reinforcing teaching about changing the appliance, which of the following guidelines should the nurse follow? A. Prepare for a lengthy instructional session B. Use acronyms to make medical terms easier to remember C. Avoid unnecessary repetition of instructions D. Connect new instructions with what the client already knows

D. Connect new instructions with what the client already knows

A nurse is caring for a client who has terminal cancer. The client is proceeding with plans to build a new house. This behavior would typically indicate which of the following stages of grief? A. Acceptance B. Bargaining C. Anger D. Denial

D. Denial

A nurse on a medical-surgical unit is caring for a client who develops deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider? A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis

D. Metabolic acidosis

A nurse is collecting data from a term newborn who is 8 hours old. Which of the following reflexes should the nurse identify as a preliminary indication that during gestation, the newborn developed the ability to hear? A. Babinski B. Tonic neck C. Rooting D. Moro

D. Moro

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

D. Perform a blanch test

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

D. Pericardial friction rub

A home health nurse enters a client's home and finds a used insulin syringe, without a cap, on the table. Which of the following actions should the nurse take? A. Recap the needle on the syringe B. Schedule a nurse to administer future injections for this client C. Explain to the client that the syringe should be disposed of in the bathroom trash can D. Place the syringe in a puncture-proof disposal container

D. Place the syringe in a puncture-proof disposal container

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the temperature? A. Rectal B. Tympanic C. Oral D. Temporal

D. Temporal

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

D. Weak pulses

A nurse enters a client's room and finds smoke coming from under the bed. What sequence of actions should the nurse take in this situation?

Move the client out of the room Pull the unit fire alarm Shut all surrounding windows and doors Attempt to put out the smoke with a fire extinguisher

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

A. Bounding

A nurse is collecting data from a client whose potassium level is 2.8 mE/L. Which of the following findings should the nurse expect? A. Decreased bowel sounds B. Hyperactive deep-tendon reflexes C. Paresthesias D. Irritability

A. Decreased bowel sounds

A nurse is reinforcing teaching with a middle adult client about health promotion and disease prevention. The nurse should remind the client that which of the following changes could occur? A. Decreased estrogen and testosterone production B. Increased tone of the large intestines C. Increased percentage of the body's muscle mass D. Decreased incidence of chronic illnesses

A. Decreased estrogen and testosterone production

A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first? A. Gloves B. Gown C. Eyewear D. Mask

A. Gloves

A nurse in a provider's office is measuring an adult client and notes a decrease in height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders? A. Osteoporosis B. Scoliosis C. Kyphosis D. Lordosis

A. Osteoporosis

A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client? A. Test for the presence of the client's gag reflex B. Place the client in the supine position C. Use a firm toothbrush for tooth and gum care D. Use 2 gauze-wrapped fingers to hold the mouth open

A. Test for the presence of the client's gag reflex

A nurse is caring for a middle adult client. Which of the following statements indicates that the client has completed Erikson's developmental task for her age group? A. "I am comfortable with my decision to choose a lifelong partner." B. "I think I have done a good job with my children since they are all independent now." C. "As I look back over my life, I can see that I have achieved most of the goals I set for myself" D. "I love my work so much that I don't want to think about retirement."

B. "I think I have done a good job with my children since they are all independent now."

A nurse is supervising a newly licensed nurse who is administering a controlled substance. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A. Placing an unused portion of the medication in a sharps box B. Asking another nurse to observe disposal of an unused portion of the medication C. Counting the inventory of the available narcotic after administering the medication D. Making sure that a nurse signs the control inventory form after disposal of an unused portion of the medication

B. Asking another nurse to observe disposal of an unused portion of the medication

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

B. How much the client can assist with bathing

A nurse is assisting with the admission of a client to a facility. The client wears eyeglasses and has a hearing aid. Which of the following actions should the nurse take before beginning the interview process? A. Sit beside the client during the interview B. Make sure the device is functioning C. Make sure lighting in the room is soft D. Ensure a lengthy interview process to give the client adequate time to answer questions

B. Make sure the device is functioning

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."

C. "It sounds like your pain is intermittent."

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."

C. "Keep a diary of the foods your child eats each day."

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."

C. "Sit on the toilet 30 minutes after eating a meal."

A nurse is reviewing adult cardiopulmonary resuscitation (CPR) with a newly licensed nurse. Which of the following steps should the nurse identify as the first response when performing CPR? A. Call for assistance B. Begin chest compressions C. Confirm unresponsiveness D. Give rescue breaths

C. Confirm unresponsiveness

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

C. Fowler's

A nurse is instilling antibiotic ear drops for a client who has an ear infection. Which of the following actions should the nurse take? A. Make sure the drops are at room temperature B. Wear sterile gloves during the instillation C. Have the client lie on the side opposite the infected ear D. Pull the client's pinna downward to straighten the ear canal

C. Have the client lie on the side opposite the infected ear

A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take? A. Assign the client to a private room B. Keep 4 side rails up while the client is in bed C. Monitor the client at least once every hour D. Request a PRN prescription for restraints

C. Monitor the client at least once every hour

A nurse is caring for a client who has xerostomia with a lack of saliva. The nurse should identify that which of the following nutrients will be affected by the lack of salivary amylase? A. Fat B. Protein C. Starch D. Fiber

C. Starch

A nurse is measuring a client's vital signs. The client's heart rate is 105/min. The nurse should document this finding as which of the following alterations? A. Palpitation B. Bradycardia C. Tachycardia D. Dysrhythmia

C. Tachycardia

A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make? A. "You look just fine to me." B. "Nobody expects you to look beautiful in the hospital." C. "I understand how you feel. I would feel the same way." D. "Would you like to talk about how you feel?"

D. "Would you like to talk about how you feel?"

A nurse is collecting data from a client who is postoperative. Which of the following findings should the nurse identify as an indication that the client is experiencing pain? A. Diarrhea B. Pupillary constriction C. Flushing D. Grimacing

D. Grimacing

A nurse is collecting baseline data of a client's peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse? A. Below the medial malleolus B. In the popliteal fossa C. In the antecubital space D. On the dorsum of the foot

A. Below the medial malleolus

A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin assisting with discharge planning? A. 1 week prior to discharge B. Upon admission to the care facility C. Once the discharge date is identified D. When the client addresses the topic with the nurse

B. Upon admission to the care facility

A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement? (Select all that apply.) A. Auscultate injected air B. Verify initial X-ray examination C. Measure the length of the exposed tube D. Determine the pH of the aspirated fluid E. Check the aspirated fluid for glucose

B. Verify initial X-ray examination C. Measure the length of the exposed tube D. Determine the pH of the aspirated fluid

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

B. Verify that the herbal supplements do not interact with medications the provider has prescribed

A nurse discovers that a client received the wrong medication. Which of the following actions should the nurse take first? A. Complete a medication error report B. Notify the prescribing provider C. Collect data from the client D. Notify the charge nurse

C. Collect data from the client

A nurse is explaining Piaget's theory of cognitive development to a group of day care providers for employees' children at an acute-care facility. Which of the following activities should the nurse include as an example of concrete operational thinking? A. Playing in the sand B. Playing dress-up with old clothes C. Collecting and trading game cards D. Describing interpersonal relationships

C. Collecting and trading game cards

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

C. Corneal light reflex

A nurse is preparing to collect data about the function of a client's trigeminal nerve or cranial nerve (CN) V. Which of the following items should the nurse gather for the test? A. Sugar B. Coffee C. Cotton wisps D. Snellen chart

C. Cotton wisps

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? A. Provide the client with a glass of water B. Assist the client into a sitting position C. Explain the procedure to the client D. Measure the length of tubing to be inserted

C. Explain the procedure to the client

A nurse on a same-day procedure unit is caring for several clients undergoing different types of procedures. A client who has which of the following devices can safely undergo magnetic resonance imaging (MRI)? A. Coronary artery stents B. Aneurysm clip C. Hearing aids D. Automated internal defibrillator

C. Hearing aids

A nurse is reinforcing teaching with a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein? A. Eggs B. Soybeans C. Lentils D. Yogurt

C. Lentils

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."

C. Let's set up a meeting time with the doctor to discuss your options for home care."

A nurse is caring for a client who requires the insertion of a nasogastric tube. Which of the following actions should the nurse take when preparing to insert the tube? A. Wear sterile gloves for the insertion procedure B. Assist the client into a side-lying position C. Measure the distance from the nose to the earlobe to the xiphoid D. Lubricate the tip of the tube with petroleum jelly

C. Measure the distance from the nose to the earlobe to the xiphoid

A nurse is assisting with the initiation of seizure precautions for a client who has a seizure disorder. Which of the following equipment should the nurse recommend having readily available at the client's bedside? A. Vest restraint B. Tongue blade C. Oxygen equipment D. Neck brace

C. Oxygen equipment

A nurse is collecting data about a client's abdomen. Which of the following positions should the nurse tell the client to assume for this examination? A. Lithotomy B. Lateral C. Supine D. Sims'

C. Supine

A nurse is preparing to instill a vaginal medication in suppository form to a client. Which of the following actions should the nurse take during this procedure? A. Don sterile gloves B. Use the dominant hand to retract the labia C. Use the index finger to insert the suppository D. Ease the suppository along the anterior vaginal wall

C. Use the index finger to insert the suppository

A nurse is preparing to administer oral phenytoin to a client who has a seizure disorder. Before administering the medication, which of the following actions should the nurse take? A. Document the administration of the medication B. Count the available medication and sign for it C. Measure the client's respiratory rate D. Check the medication dose and the client's identification

D. Check the medication dose and the client's identification

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? A. Auscultate for the blood pressure at the dorsalis pedis artery B. Measure the blood pressure with the client sitting on the side of the bed C. Place the cuff 7.6 cm (3 in) above the popliteal artery D. Place the bladder of the cuff over the posterior aspect of the thigh

D. Place the bladder of the cuff over the posterior aspect of the thigh

A nurse is caring for a client who is dehydrated. An insensible fluid loss of approximately 500 to 600 mL occurs each day through which of the following organ? A. Kidneys B. Lungs C. Gastrointestinal tract D. Skin

D. Skin

A nurse is caring for a client who is receiving an IV infusion of 5% dextrose in lactated Ringer's. The nurse notices that the area around the catheter insertion site is edematous and cooler than the surrounding skin on the forearm Which of the following actions should the nurse take? A. Switch the fluid to 0.9% sodium chloride B. Place the arm in a dependent position C. Prepare to administer a diuretic D. Stop the infusion

D. Stop the infusion

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

D. Supports self-determination

A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment? A. The client places a crutch on each side when assuming a sitting position B. The client moves the unaffected leg onto a step first when descending stairs C. The client places weight on the axillae when walking D. The client has slightly flexed elbows when ambulating with the crutches

D. The client has slightly flexed elbows when ambulating with the crutches

After collecting data from a client, the nurse documents "1+ pedal edema bilaterally." This indicates the nurse observed an indentation of which of the following depths after applying pressure? A 2 mm B 4 mm C 6mm D 8 mm

A 2 mm

A nurse is reinforcing teaching about crutch use with a client who has had knee surgery. Which of the following instructions should the nurse include? A. "Hold both crutches with a hand when you sit down in a chair." B. "Stand with the crutches about 9 inches in front and 9 inches to the side of your feet." C. "Lean your weight on the crutch pads at your armpits." D. "Wear leather-soled shoes when you use your crutches."

A. "Hold both crutches with a hand when you sit down in a chair."

A nurse is reinforcing teaching about heat therapy with a client who has low back pain. Which of the following statements by the client indicates an understanding of the teaching? A. "I need to place a towel between the heating pad and my skin." B. "I'll need to turn up the temperature if I cannot feel the heat." C. "I'll sleep on top of the heating pad to increase the heat penetration" D. "Keeping the heat continuously on my back will help it heal."

A. "I need to place a towel between the heating pad and my skin."

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."

A. "I should expect my heart rate to take longer to return to normal after exercise as I get older."

A middle adult client is discussing future plans with the nurse. Which of the following statements should the nurse identify as an indication that the client is having difficulty achieving Erikson's developmental task of this age group? A. "We miss our daughter so much that we are going to move closer." B. "I think this is the year that I can plan on managing the funding at church." C. "I really wish that I could lose some of this weight." D. "I am spending more time at work now that my son is at college."

A. "We miss our daughter so much that we are going to move closer."

A nurse is reinforcing teaching for a client about performing range-of-motion exercises of the wrist. To have the client demonstrate adduction, which of the following instructions should the nurse give? A. "With your palm facing down, move your wrist sideways toward your thumb." B. "Move your palm toward the inner part of your forearm." C. "With your palm facing down, move your wrist sideways toward your little finger." D. "Bring the back of your hand as far back toward the wrist as you can."

A. "With your palm facing down, move your wrist sideways toward your thumb."

A nurse is caring for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A. A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask B. A client who has emphysema and is receiving humidified oxygen at 3 L/min via a transtracheal oxygen cannula C. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar D. A client who has COPD and is receiving oxygen at 2 L/min via nasal cannula

A. A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask

A nurse is caring for a client who is well-hydrated and has no visible evidence of nutritional deficiencies. A laboratory result within the expected reference range for which of the following substances is an indication that the client has adequate protein uptake and synthesis? A. Albumin B. Calcium C. Sodium D. Potassium

A. Albumin

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

A. Attempting to increase the clients' self-motivation

A nurse is collecting data from a client who is undergoing a physical examination. Following inspection, which of the following techniques should the nurse use next when evaluating the client's abdomen? A. Auscultation B. Light palpation C. Percussion D. Deep palpation

A. Auscultation

A nurse is caring for a client who reports not sleeping at night, which interferes with her ability to function during the day. Which of the following interventions should the nurse suggest to this client? A. Avoid beverages that contain caffeine B. Take a sleep medication regularly at bedtime C. Watch television for 30 minutes in bed to relax prior to falling asleep D. Advise the client to take several naps during the day

A. Avoid beverages that contain caffeine

A nurse is assisting with an admission interview for a client. Which of the following items of data should the nurse collect during the introduction phase of the interview? A. Client's comfort and ability to participate in the interview B. Previous illnesses and surgeries C. Events surrounding the recent illness D. Sociocultural history

A. Client's comfort and ability to participate in the interview

A nurse is collecting data from a client who has fluid-volume excess. Which of the following findings should the nurse expect? A. Crackles in the lung fields B. Flat neck veins C. Postural hypotension D. Dark yellow urine

A. Crackles in the lung fields

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

A. Eggs

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

A. Fats provide energy

A nurse is presenting an in-service session about nutrition. Which of the following simple sugars should the nurse identify as the carbohydrate found in milk? A. Lactose B. Sucrose C. Maltose O D. Fructose

A. Lactose

A nurse is assisting with the screening of a client who has an S-shaped spinal column with unequal shoulder heights. The nurse should identify these findings as manifestations of which of the following abnormalities? A. Scoliosis B. Lordosis C. Torticollis D. Kyphosis

A. Scoliosis

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

A. Touching his chin to his chest

A nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student indicates a potential problem with achieving Erikson's developmental task for this age group? A. "I am in no hurry to get married. I think I'll enjoy single life for a while." B. "I go home on the weekends to be with my family because I don't have any good friends here on campus." C. "I am interested in politics and might consider becoming an elected official." D. "I am looking forward to finishing school and going to work in my family's business."

B. "I go home on the weekends to be with my family because I don't have any good friends here on campus."

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."

B. "If I do this often, I won't get pneumonia."

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

B. 2

A nurse is caring for a group of clients in a long-term care facility. The nurse should understand that which of the following clients is eligible for hospice services at this time? A. A client who has multiple sclerosis and uses a wheelchair B. A client who has end-stage cirrhosis C. A client who has hemiplegia due to a stroke D. A client who has cancer and receives weekly radiation therapy

B. A client who has end-stage cirrhosis

A nurse is reinforcing teaching with a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups are responsible for movement at the knee joint? A. Antigravity B. Antagonistic C. Synergistic D. Skeletal

B. Antagonistic

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

B. Ask simple, short questions

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? 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.

B. Feedback is provided.

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

B. Glaucoma

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

B. Lower abdomen

A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the client's body? A. Heart B. Lungs C. Thyroid gland D. Skin

B. Lungs

A nurse is measuring a client's vital signs. The clients resting radial pulse rate is 55/min. Which of the following actions should the nurse take next? A. Document the finding B. Measure the client's apical pulse rate C. Talk with the client about factors that can affect the pulse rate D. Notify the provider about the radial pulse rate

B. Measure the client's apical pulse rate

A nurse is caring for a client in a long-term care facility. Which of the following findings should alert the nurse to the possibility that the client has developed delirium? A. Gradual memory loss B. Reduced level of consciousness C. Difficulty with abstract thought D. Verbalized feelings of hopelessness

B. Reduced level of consciousness

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

B. Request an X-ray of the client's abdomen

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? A. The lower medial quadrant of the buttock near the coccyx B. The side hip between the iliac crest and anterior iliac spine C. The tissue of the posterior upper arm D. The lower inner thigh, 2 finger widths above the patella

B. The side hip between the iliac crest and anterior iliac spine

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."

C. "I will shake the inhaler well right before I use it."

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." 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."

C. "If the client seems confused, I'll raise all 4 side rails to prevent injury."

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse implement? A. Place the client in a semi-private room B. Wear a mask when providing care C. Apply a gown when in the client's room D. Dispose of all bed linens used by the client

C. Apply a gown when in the client's room

A nurse is reviewing the laboratory results for a client who has a non-healing wound. Wound cultures have identified vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse initiate? A. Airborne B. Droplet C. Contact D. Protective

C. Contact

A nurse is measuring vital signs for a client and notices a pulse irregularity. Which of the following actions should the nurse take? A. Measure the pulse using a Doppler ultrasound stethoscope B. Check the client's pedal pulses C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart D. Take the pulse at each peripheral site and count the rate for 30 sec

C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart

A nurse is reinforcing teaching with a group of unit nurses about the experiences of clients who are having surgery. Which phase of care begins with transferring the client to the surgical suite table and ends with the transfer to PACU? A. Preoperative B. Postoperative C. Intraoperative D. Admission

C. Intraoperative

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."

D. "Tell me more about how you feel about dying."

A nurse is collecting data regarding a client's nutritional status during a community health screening. The nurse determines the client is consuming 500 calories per day more than his energy level requires. When will the client have gained 4.5 kg (10 Ib)? A. 10 months B. 5 months C. 5 weeks D. 10 weeks

D. 10 weeks

A nurse is taking a client's vital signs. Which of the following findings is outside the expected reference range? A. Pulse rate 90/min B. Rectal temperature 38°C (100.4°F) C. Pulse oximetry 95% D. BP 145/90 mmHg

D. BP 145/90 mmHg

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

D. Clamp the tubing below the collection port

A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take? A. Clean the incision from bottom to top B. Apply sterile gloves prior to opening the dressing packages C. Remove the tape by pulling away from the wound D. Clean the drain site from the center outward

D. Clean the drain site from the center outward

A nurse is caring for a client who has the head of his bed elevated to a 45° angle with his knees slightly flexed. Which of the following positions should the nurse document for the client? A. Sims' B. Prone C. Supine D. Fowler's

D. Fowler's

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? A. Tenderness when touched B. Pink, shiny tissue with a grainy appearance C. Serosanguineous drainage D. Halo of erythema on the surrounding skin

D. Halo of erythema on the surrounding skin

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

D. Identify the client using 2 identifiers

A nurse is reviewing the laboratory results of a client and notes a WBC count of 3,600/mm^3. The nurse should identify this result as an indication of which of the following conditions? A. Leukoplakia B. Leukemia C. Leukocytosis D. Leukopenia

D. Leukopenia

A nurse is performing a physical examination of a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques? A. Percussion B. Auscultation C. Inspection D. Palpation

D. Palpation

A nurse is witnessing a client signing an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? A. The client fully understands the provider's explanation of the procedure. B. The client has been informed about the risks and benefits of the procedure. C. The nurse witnessed the provider's explanation of the procedure. D. The signature on the preoperative consent form is the client's.

D. The signature on the preoperative consent form is the client's.

A nurse enters a client's room and notices smoke coming from a wastebasket in the adjacent bathroom. Which of the following actions should the nurse take first? A. Close the door to the client's room B. Attempt to extinguish the fire C. Activate the facility's fire alarm system D. Transport the client to an area away from the smoke

D. Transport the client to an area away from the smoke

A nurse is reinforcing discharge teaching with a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching? A. "A nurse will show me how to care for my wound." B. "A nurse will stay with me at home during the day." C. "I will call the nurse to change my bed linens." D. "I will call the nurse to help me bathe in the morning.

A. "A nurse will show me how to care for my wound."

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus? A. "Bear down." B. "Perform Kegel exercises." C. "Hold your breath." D. "Raise your head off of the pillow."

A. "Bear down."

A nurse is administering medication to a client who asks the nurse to leave the medication at the bedside so she can take it at a later time. Which of the following responses should the nurse provide? A. "Call me when you are ready, and I will return with the medication." B. "Since you were taking this medication at home, I will leave it for you to take." C. "I will come back in 30 minutes to make sure you took the medication so that I can chart the time." D. "If you refuse to take the medication now, I can't give it again until your next scheduled time."

A. "Call me when you are ready, and I will return with the medication."

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'Il 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."

A. "I'll wear nonsterile gloves."

A nurse is reinforcing teaching about body mechanics with assistive personnel. Which of the following instructions should the nurse include? (Select all that apply.) A. "Sit with your back supported." B. "Keep your knees at hip level." C. "Use an ergonomically designed computer keyboard." D. "Keep your elbows away from your body." E. "Adjust the monitor screen so that you have to tilt your head slightly to look at it."

A. "Sit with your back supported." B. "Keep your knees at hip level." C. "Use an ergonomically designed computer keyboard."

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 alcohol-based 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."

A. "Sometimes, I should use soap and water rather than an alcohol-based hand rub to clean my hands."

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection insulin methods. Which of the following statements should the nurse provide? A. "Tell me what I can do to help you overcome your fear of giving yourself injections." B. "I am sure your provider will not be pleased that you refuse to give yourself insulin injections." C. "It's okay. Your partner can learn how to give you the insulin injections." D. "You won't be able to go home unless you learn to give yourself insulin injections."

A. "Tell me what I can do to help you overcome your fear of giving yourself injections."

A nurse is evaluating a client for conductive hearing loss. Using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear? A. Air conduction is less than bone conduction in the left ear. B. Air conduction is greater than bone conduction in the left ear. C. Sound is lateralizing to the right ear. D. Sound is lateralizing to the left ear.

A. Air conduction is less than bone conduction in the left ear.

A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate? A. Airborne B. Droplet C. Contact D. Protective environment

A. Airborne

A nurse is caring for a client who has a terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first? A. Ask why the client is refusing the pain medication B. Administer a PRN antianxiety medication C. Assist the client in changing positions D. Offer the client a heat or cold pack to place on painful areas

A. Ask why the client is refusing the pain medication

A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states, "It's too late for me to quit." Which of the following actions should the nurse take? A. Assist the client in finding local smoking-cessation assistance programs B. Tell the client that she will be all right now that she is receiving medical care c. Inform the client that she must stop smoking or the provider will not be able to care for her D. Advocate for the client by supporting her statement about not quitting

A. Assist the client in finding local smoking-cessation assistance programs

A nurse is beginning a therapeutic relationship with a client. Which of the following actions should the nurse perform to convey empathy when using the therapeutic communication technique of active listening? A. Assume an open position B. Sit upright while leaning back into the chair C. Avoid direct eye contact until the client initiates it D. Sit next to the client

A. Assume an open position

A nurse is reinforcing teaching with a client who needs to reduce cholesterol levels. Which of the following foods should the nurse suggest that the client add to his diet? A. Carrot B. Porkchop C. Shrimp D. Egg yolks

A. Carrot

A nurse is caring for a client who is postoperative and has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hours. Which of the following actions should the nurse take first? A. Check to determine if the catheter tubing is kinked B. Palpate the bladder C. Obtain a prescription to irrigate the catheter with 0.9% sodium chloride D. Encourage the client to drink more fluids

A. Check to determine if the catheter tubing is kinked

A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? (Select all that apply.) A. Coat the tip of the tube with a water-soluble lubricant B. Ask the client to swallow water while the tube enters her throat C. Place the coiled tube in ice chips prior to insertion D. Tell the client to tilt her head backward as insertion begins E. Instruct the client to bear down during insertion

A. Coat the tip of the tube with a water-soluble lubricant B. Ask the client to swallow water while the tube enters her throat E. Instruct the client to bear down during insertion

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

A. Collect the specimen once the client rises in the morning

A nurse is collecting data during a neurological examination of a client. When asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing? A. Cranial nerve XII B. Cranial nerve X C.Cranial nerve VIll D. Cranial nerve V

A. Cranial nerve XII

A nurse on a medical-surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client's record first? A. Data collection for the client B. Plan of care for the client C. Nursing interventions performed for the client D. Evaluation of the client's progress

A. Data collection for the client

A nurse is measuring a client's blood pressure. The nurse notes that the systolic reading is typical for the client, but the diastolic reading is considerably higher than the client's usual baseline. Which of the following errors in blood- pressure measurement is a possible cause of a falsely elevated result? A. Deflating the cuff too slowly B. Using a bladder cuff that is too wide C. Inflating the cuff insufficiently D. Holding the stethoscope too tightly against the skin

A. Deflating the cuff too slowly

A nurse is replacing the surgical dressing on a client who had abdominal surgery. Which of the following actions should the nurse take? A. Don clean gloves to remove the old dressing B. Loosen the dressing by pulling the tape away from the wound C. Remove the entire old dressing at once D. Open sterile supplies after applying sterile gloves

A. Don clean gloves to remove the old dressing

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops? A. Drop the eye medication into the lower conjunctival sac. B. Apply gentle pressure in the outer opening of the eye for 2 minutes C. Hold the eyedropper 0.5 cm (0.2 in) from the cornea D. Instruct the client to close eyes tightly after administration

A. Drop the eye medication into the lower conjunctival sac.

A nurse is admitting a client who is experiencing an exacerbation of heart failure. At which of the following times should the nurse initiate discharge planning? A. During the admission process B. As soon as the client's condition is stable C. During the initial team conference D. On the day prior to discharge

A. During the admission process

A nurse is reinforcing teaching with a client about how to obtain a capillary finger-stick blood sample. Which of the following actions by the client requires the nurse to intervene? A. Elevates the finger above heart level B. Rubs the fingertip with an alcohol pad C. Punctures the side of the fingertip D. Wraps the finger in a warm cloth

A. Elevates the finger above heart level

A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief? A. Encourage the client to listen to soft music B. Instruct the client to practice tai chi C. Place a jasmine-scented air freshener in the client's room D. Offer the client ginger tea

A. Encourage the client to listen to soft music

A nurse is assisting with the admission of a client who will undergo a craniotomy. During the planning phase of the nursing process, to which of the following areas should the nurse contribute? A. Establishing client outcomes B. Collecting information about past health problems C. Determining whether the client has met goals D. Identifying the client's specific health problems

A. Establishing client outcomes

A nurse is collecting data for a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? A. Evaluate pedal pulses B. Obtain a medical history C. Measure vital signs D. Ask the client if he is experiencing any pain in the leg

A. Evaluate pedal pulses

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

A. Explain that sharing access codes is against policy and refer the resident to the supervisor

A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) items should the nurse don prior to providing client care? (Select all that apply.) A. Gown B. Gloves C. Mask D. Hair cover E. Goggles

A. Gown B. Gloves

A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. Which of the following actions should the nurse plan to take? A. Hold the dropper 1 cm (0.5 in) above the ear canal during administration B. Apply pressure to the nasolacrimal duct following administration C. Place a cotton ball into the inner ear canal for 30 minutes following administration D. Straighten the ear canal by pulling the auricle down and back prior to administration

A. Hold the dropper 1 cm (0.5 in) above the ear canal during administration

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

A. Hold the medication bottle with the label against the palm of the hand when pouring

A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside. Which of the following actions should the nurse take? A. Hold the sterile drape above the waist and away from the body B. Drop sterile objects toward the edges of the sterile field C. Hold packaged supplies 7.6 cm (3 in) above the sterile field D. Hold sterile objects over the field before setting them down on the field

A. Hold the sterile drape above the waist and away from the body

A nurse is caring for a client who has a stage Il pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer? A. Hydrocolloid B. Collagen C. Calcium alginate D. Proteolytic enzyme

A. Hydrocolloid

A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take? A. Hyper oxygenate the client before suctioning B. Insert the catheter during exhalation C. Apply suction during insertion of the catheter D. Apply suction for no more than 15 seconds

A. Hyper oxygenate the client before suctioning

A nurse is collecting data from a client whose calcium level is 7.1 mg/dL. Which of the following findings should the nurse expect? A. Hyperactive reflexes B. Anorexia C. Lethargy D. Facial edema

A. Hyperactive reflexes

A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur? A. Hyperglycemia B. Hypotension C. Heightened immune response D. Bleeding tendencies

A. Hyperglycemia

During a client care staff meeting, a charge nurse discusses potential problems with data security that affect confidential client information. Which of the following environments should the charge nurse identify as an acceptable area for discussing clients' information? A. In the unit medication room B. Outside the door of a client's room C. In the cafeteria during a break D. In the hallway near the nurses' station

A. In the unit medication room

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

A. Increased blood pressure

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

A. Independent moral development

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

A. Inspect both breasts simultaneously

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed? A. Lock the wheels on the bed and stretcher B. Instruct the client to raise his arms above his head C. Elevate the stretcher 2.5 cm (1 in) above the height of the bed D. Log roll the client

A. Lock the wheels on the bed and stretcher

A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from the bed to a wheelchair. Which of the following actions indicates that the AP understands how to perform this task? A. Locking the brakes on the bed and the wheelchair before moving the client B. Lowering the footplates of the wheelchair before the transfer C. Placing the wheelchair perpendicular to the bed D. Placing the wheelchair on the client's weaker side prior to the transfer

A. Locking the brakes on the bed and the wheelchair before moving the client

A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift in which the client received atenolol instead of allopurinol. Which of the following interventions is the nurse's priority? A. Measure the client's apical pulse B. Administer the allopurinol to the client C. Inform the nurse manager D. Complete an incident report

A. Measure the client's apical pulse

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

A. Provide oral care to a client who cannot take oral fluids

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? A. Pull back the suction catheter by 1 cm (0.5 in) if the client starts coughing B. Allow 30 seconds between suctioning passes C. Hyperventilate the client with 50% oxygen for 30 seconds D. Perform a maximum of 4 passes with the suction catheter

A. Pull back the suction catheter by 1 cm (0.5 in) if the client starts coughing

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

A. Remove the sleeve of the gown from the arm without the IV line

A nurse is contributing to the plan of care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? A. Renew the prescription for restraints within 24 hours B. Secure the restraint with the buckle side next to the client's skin C. Ensure 4 fingers can be inserted under the secured restraint D. Remove the restraint every 3 hours

A. Renew the prescription for restraints within 24 hours

A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaC02 32 mmHg, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances? A. Respiratory alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Metabolic alkalosis

A. Respiratory alkalosis

A nurse is preparing to administer a unit of packed RBs 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? 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

A. Return the blood to the laboratory

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? A. Ride a bicycle with training wheels B. Climb a tree C. Throw and catch a ball D. Play a musical instrument

A. Ride a bicycle with training wheels

A nurse is collecting data from a client as part of a neurological examination. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests? A. Romberg B. Kinesthetic sensation C. 2-point discrimination D. Weber

A. Romberg

A nurse is collecting data about a client's incision and observes the drainage to be blood-tinged. Which of the following terms should the nurse use to document this finding? A. Sanguineous B. Purulent C. Serous D. Hyperemia

A. Sanguineous

A nurse is collecting data about a client who is unconscious. Family members are present and answer the nurse's questions about the client's medical history. The nurse should document this information as which of the following types of data? A. Secondary source data B. Experiential data C. Primary source data D. Quantitative data

A. Secondary source data

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume? A. Sodium B. Calcium C. Potassium D. Magnesium

A. Sodium

A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion? A. Sodium 123 mEg/L B. Blood glucose 100 mg/dL C. Potassium 3.5 mEq/L D. Hemoglobin 13 g/dL

A. Sodium 123 mEg/L

A nurse on a medical unit is caring for a client who has been coughing intermittently during meals, attempting to clear her throat repeatedly, and eating only a small portion of her meals. The nurse should recommend a referral to which of the following members of the interprofessional team to evaluate the client for dysphagia? A. Speech-language pathologist B. Social worker C. Physical therapist D. Occupational therapist

A. Speech-language pathologist

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first? A. Start chest compressions B. Provide breaths with a manual resuscitation bag C. Administer oxygen D. Establish an airway

A. Start chest compressions

A nurse is preparing to administer a medication to a client. Which of the following administration schedules indicates that the nurse should administer the medication once and as soon as possible? A. Stat prescription B. PRN prescription C. Standing prescription D. Single prescription

A. Stat prescription

A nurse is reinforcing teaching with a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching? A. The client holds the cane on the unaffected side. B. The client walks by stepping with the unaffected leg before the affected leg. C. The client holds the cane directly next to the foot. D. The client holds the cane with a straight elbow.

A. The client holds the cane on the unaffected side.

A nurse is reinforcing teaching about range-of-motion exercises with a client who has osteoarthritis. Which of the following positions indicates the client's correct understanding of supination of the hand? A. The client holds the hand with the palm up. B. The client holds the hand with the palm down. C. The client points the fingers toward the floor. D. The client points the fingers toward the ceiling.

A. The client holds the hand with the palm up.

A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client's insomnia? A. The client watches television in bed during the day. B. The client drinks warm milk before bedtime. C. The client goes to bed at 2200 every night. D. The client gets up to use the bathroom once during the night.

A. The client watches television in bed during the day.

A nurse is reinforcing teaching with a client who has heart failure about reducing his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? A. The involvement of the client in planning the change B. The emphasis the provider places on the dietary changes C. The learning theory the nurse uses to teach the dietary changes D. The extent of the dietary changes planned for the client

A. The involvement of the client in planning the change

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

A. Use a gait belt during ambulation

A nurse is planning to administer pain medication to a client who has postoperative pain following abdominal surgery. Which of the following actions should the nurse take first? A. Use the pain scale to determine the client's pain level B. Discuss the adverse effects of pain medication with the client C. Obtain the client's vital signs D. Check the client's allergies

A. Use the pain scale to determine the client's pain level

A nurse is collecting data about a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields? A. Vesicular B. Bronchial C. Rhonchi D. Bronchovesicular

A. Vesicular

A nurse is contributing to the plan of care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and/or minerals should the nurse plan to increase in the client's diet? A. Vitamin C and zinc B. Vitamin D C. Vitamin K and iron D. Calcium

A. Vitamin C and zinc

A nurse is caring for a client who has a deficiency in vitamin D. Which of the following foods should the nurse recommend the client include in his diet? A. Whole milk B. Chicken C. Oranges D. Dried peas

A. Whole milk

A nurse in a provider's office is talking with an older adult client who reports having trouble sleeping. Which of the following statements should the nurse identify as a possible cause of the client's sleeping difficulties? A. "I take a warm shower when getting ready to go to bed." B. " often have a cup of coffee with my dessert before going to bed." C. "I usually read a chapter in a book before I go to bed." D. "I make sure I do my exercises in the morning."

B. " often have a cup of coffee with my dessert before going to bed."

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads as follows: "clear liquids; advance diet as tolerated." Which of the following responses should the nurse make? A. "Lunch trays should be here within the hour." B. "I am going to listen to your abdomen." C. "I'll get you some water to drink." D. "I would wait a bit to avoid feeling sick."

B. "I am going to listen to your abdomen."

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."

B. "I can't sleep well because whenever I move in my sleep, the pain wakes me up."

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? 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."

B. "I'll make sure to keep the collection bottle in the container of ice they gave me."

A nurse is assisting with preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements indicates that the client understands medical asepsis? A. "I'll wrap the old dressing in a paper bag and put it in the trash." B. "I'll wash my hands before I remove the old dressing and again before putting on the new one." C. "I'Il need to take a pain pill 30 min before I change the dressing. D. "I'll wear sterile gloves when I apply the new dressing."

B. "I'll wash my hands before I remove the old dressing and again before putting on the new one."

A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure? A. "Inhale forcefully during insertion." B. "Raise your index finger if you need to pause during the insertion." C. "Bear down during insertion." D. "Avoid making any swallowing motions during the insertion."

B. "Raise your index finger if you need to pause during the insertion."

A nurse is measuring the blood pressure of several clients. Which of the following results is within the expected reference range for blood pressure? A. 142/85 mmHg B. 116/70 mmHg C. 130/76 mmHg D. 124/82 mmHg

B. 116/70 mmHg

A nurse in a long-term care facility is attending to a group of clients. One of the clients is walking in the hallway, bumping into walls, and not responding to his name. Which of the following actions should the nurse perform first? A. Offer the client a nutritious snack B. Accompany the client back to his room C. Reorient the client to his surroundings D. Administer a PRN antianxiety medication

B. Accompany the client back to his room

A nurse is planning a community presentation for young adults. Which of the following behaviors should the nurse suggest incorporating into the presentation as part of Erikson's expected developmental task for this age group? A. Learning a socially productive skill B. Adjusting to living with a partner C. Establishing a sense of sexual identity D. Maintaining an economic standard of living

B. Adjusting to living with a partner

A nurse is assisting with the admission of a client who has tuberculosis. In addition to standard precautions, which of the following transmission-based precautions be added to the client's plan of care? A. Protective B. Airborne C. Droplet D. Contact

B. Airborne

A nurse is implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take? A. Apply a cold pack to an area that is edematous B. Check capillary refill before applying an ice pack to the affected area C. Fill an ice pack half full of crushed ice D. Apply an ice pack for 60 minutes intervals

B. Check capillary refill before applying an ice pack to the affected area

A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. The client states she slipped while getting out of bed. Which of the following actions should the nurse take first? A. Complete an incident report B. Check the client for injuries C. Make sure the client has skid-free footwear D. Remind the client to ask for help with getting out of bed

B. Check the client for injuries

A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. Which of the following actions should the nurse perform first after the transfer? A. Administer pain medication B. Check the client's vital signs C. Instruct the client to use the incentive spirometer every hour D. Provide ice chips per provider prescription

B. Check the client's vital signs

A nurse is reinforcing teaching with a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching? A. Change the colostomy bag following breakfast B. Cleanse the skin around the stoma with warm water C. Change the pouch every day D. Place an aspirin in the ostomy pouch to decrease odor

B. Cleanse the skin around the stoma with warm water

A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse take? A. Wear sterile gloves when collecting the specimen VI B. Cleanse the wound with 0.9% sodium chloride irrigation C. Allow the collection swab to absorb old exudate D. Rotate the collection swab over the edges of the wound

B. Cleanse the wound with 0.9% sodium chloride irrigation

A nurse is assisting with teaching a newly licensed nurse about pain management in clients age 65 and older. Which of the following pieces of information should the nurse include? A. Clients who are age 65 or older experience a decreased ability to perceive pain compared to young adult clients. B. Clients who are age 65 or older are reluctant to report pain. C. Clients who are age 65 or older should not receive opioid narcotics. D. Clients who are age 65 or older experience a shorter duration of action of medications than young adult clients.

B. Clients who are age 65 or older are reluctant to report pain.

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

B. Document this as an expected finding

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.) A. Exophthalmos B. Dry, brittle hair C. Edema D. Butterfly rash on the face E. Poor wound healing

B. Dry, brittle hair C. Edema E. Poor wound healing

A nurse is contributing to the plan of care for a client who had a stroke and is scheduled to receive feeding via a gastrostomy tube. Which of the following actions should the nurse recommend prior to initiating each feeding? A. Warm the feeding in a microwave oven B. Elevate the head of the bed C. Flush the tube with 0.9% sodium chloride for irrigation D. Verify the gastric pH is above 4

B. Elevate the head of the bed

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

B. Elevate the head of the bed by 30° to 45°

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? A. Change the topic because the client is trying to divert attention from the illness to the nurse B. Encourage the client to express his thoughts about death and dying C. Tell the client that religious beliefs are a personal matter D. Offer to contact the client's minister or the facility's chaplain

B. Encourage the client to express his thoughts about death and dying

A nurse on a medical-surgical unit observes smoke billowing from a client's room. Which of the following actions should the nurse take first? A. Close the door to the client's room B. Evacuate the client from the room C. Sound the fire alarm D. Activate the fire extinguisher

B. Evacuate the client from the room

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

B. Excessive wax in the ear canal

A nurse is collecting data on a client. The nurse should recognize that which of the following findings places the patient at risk for impaired skin integrity? A. 3+ Achilles reflex B. Faint pedal pulses C. Feet warm to the touch bilaterally D. Capillary refill less than 2 sec

B. Faint pedal pulses

A nurse is collecting data for a client who has had diarrhea and decreased urination for several days. Which of the following actions should the nurse take to determine if the client is dehydrated? A. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink B. Grasp a skinfold on the chest under the clavicle, release it, and note whether it springs back C. Press the skin in above the ankle for 5 sec, release it, and note the depth of the impression D. Measure the skin fold thickness at the upper arm using a pair of calibrated skinfold calipers

B. Grasp a skinfold on the chest under the clavicle, release it, and note whether it springs back

A nurse is reinforcing teaching about how to use an incentive spirometer with a client who is recovering from gallbladder surgery. Which of the following pieces of information should the nurse include in the teaching? A. Exhale slowly to reach goal volume B. Hold a breath for 5 seconds after goal volume is reached C. Continue to deep-breathe between each cycle D. Limit the repeat pattern of breathing to 5 breaths

B. Hold a breath for 5 seconds after goal volume is reached

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take? A. Place the soiled linens on a chair while making the bed B. Hold the linens away from the body and clothing C. Place the linens on the floor before placing them in a linen bag D. Shake the clean linens to unfold

B. Hold the linens away from the body and clothing

A nurse is caring for a toddler at a well-child visit when the mother cries out, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction? A. Flushing of the skin B. Inability of the toddler to cry or speak C. Presence of nausea and mild emesis D. Capillary refill time 1.5 second

B. Inability of the toddler to cry or speak

A nurse is in the facility's cafeteria when she notices a person grasping at the front of the neck in apparent distress. Which of the following behaviors should the nurse identify as an indication that the person requires an abdominal thrust intervention immediately? A. Uncontrollable cough B. Inability to speak C. Regurgitation D. Open mouth

B. Inability to speak

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

B. Increased heart rate

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

B. Keep the client's bed linens dry

A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique? A. Preventing the transfer of microorganisms to the nurse B. Keeping microorganisms from entering the wound C. Applying minimal pressure to the wound D. Keeping excess moisture from entering the wound

B. Keeping microorganisms from entering the wound

A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following actions should the nurse take? A. Maintain the client's head of the bed at 20° B. Monitor the client's blood glucose level C. Flush the enteral feeding tube with 10 mL of cool water after each medication D. Obtain an X-ray after beginning the feeding

B. Monitor the client's blood glucose level

A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? A. Abdominal binder B. Montgomery straps C. Hypoallergenic tape D. Plastic tape

B. Montgomery straps

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastrostomy tube for enteral feedings. Which pieces of information are critical to communicate to the next nurse caring for this client? (Select all that apply.) A. Room temperature B. New prescriptions C. Number of visitors D. Arterial blood gas results E. Tracheal secretion characteristics

B. New prescriptions D. Arterial blood gas results E. Tracheal secretion characteristics

A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse perform first when using the nursing process? A. Identify goals for client care B. Obtain client information C. Document nursing care needs D. Evaluate the effectiveness of care

B. Obtain client information

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? A. Obtaining hydrogen peroxide for the tracheostomy care B. Obtaining cotton balls for the tracheostomy care C. Obtaining sterile gloves for the tracheostomy care D. Obtaining a sterile brush for the tracheostomy care

B. Obtaining cotton balls for the tracheostomy care

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? A. Encourage the client to drink fluids before swallowing food B. Offer the client tart or sour foods first C. Tilt the client's head backward when swallowing D. Turn on the television

B. Offer the client tart or sour foods first

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.

B. Other health care professionals are in attendance at the conference.

A nurse is contributing to the planning of an in-service session about nutrition. Which of the following pieces of information should the nurse recommend for the teaching? A. Fat breaks down into amino acids. B. Protein serves as an energy source when other sources are inadequate. C. Glucose breaks down into ammonia. D. Carbohydrates provide 9 cal/g of energy.

B. Protein serves as an energy source when other sources are inadequate.

A nurse is assisting with planning a community campaign about seasonal influenza. Which of the following plans should be included as a secondary prevention strategy? A. Holding a community clinic to administer influenza immunizations B. Screening groups of older adults in nursing care facilities for early influenza manifestations C. Educating parents of young children about the dangers of influenza D. Finding rehabilitation programs for older adults who have complications from influenza

B. Screening groups of older adults in nursing care facilities for early influenza manifestations

A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff is which of the following? (Select all that apply.) A. Allowing the client to speak B. Stabilizing the position of the tube C. Preventing aspiration of secretions D. Preventing air leaks E. Preventing tracheal injury

B. Stabilizing the position of the tube C. Preventing aspiration of secretions D. Preventing air leaks

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

B. Stereognosis

A nurse on a medical unit is caring for a client who has a seizure disorder. Which of the following items is the nurse's priority to keep near the client at all times? A. Oxygen equipment B. Suction equipment C. Clean gloves D. Extra linens

B. Suction equipment

A nurse is reinforcing teaching with a group of clients about nutrition. Which of the following definitions of the recommended dietary allowance (DA) should the nurse include in the teaching? A. The DA is a comprehensive term that includes various dietary standards and scales. B. The DA defines the level of nutrient intake that meets the needs of healthy people in various groups. C. The RDA defines the levels of nutrients that should not be exceeded to prevent adverse health effects. D. The RDA is the daily percentage of energy intake values for fat, carbohydrate, and protein.

B. The DA defines the level of nutrient intake that meets the needs of healthy people in various groups.

A nurse is developing a plan of care for a client. Which of the following pieces of information should the nurse consider when planning care that is culturally congruent? A. Illness is not influenced by culture. B. The meaning of disease can vary widely across cultures. C. Assigning clients to specific cultural categories facilitates communication. D. Predetermined criteria should generate client care activities.

B. The meaning of disease can vary widely across cultures.

A nurse is collecting data from a client who is postoperative following knee surgery. The nurse observes a frayed electrical cord on the continuous passive motion (PM) machine. Which of the following actions should the nurse take? A. Consult the surgeon about discontinuing the client's PM therapy B. Unplug the CPM device and remove it from the client's room C. Wrap electrical tape around the frayed portion of the cord securely D. Perform passive range-of-motion exercises of the client's knee

B. Unplug the CPM device and remove it from the client's room

A nurse is caring for an adult client who communicates an unmet spiritual need. Which of the following client statements should indicate to the nurse that the client is experiencing spiritual distress? A. "Life has ups and downs." B. "I believe that I control my own destiny." C. "God is punishing me for something." D. "I like to keep my rosary beads in bed with me."

C. "God is punishing me for something."

A nurse in an oncology clinic is collecting data for a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? A. "My parents are retired, and they have come to help with our children." B. "I am going to ask my husband to go to counseling with me." C. "I keep having nightmares about my upcoming surgery." D. "My girlfriends bought me a nice wig."

C. "I keep having nightmares about my upcoming surgery."

A nurse is reinforcing teaching about nutritious diets to a group of adult women. Which of the following statements should the nurse include in the teaching? A. "Include at least 3 g of sodium in your daily diet." B. "Limit wine consumption to 230 mL daily." C. "Include 2.5 cups of vegetables in your daily diet." D. "Limit water intake to 1.5 L each day."

C. "Include 2.5 cups of vegetables in your daily diet."

A nurse is assisting with discharge teaching for a client who has type 2 diabetes mellitus. The client expresses concern about cooking an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse provide? A. "The home health dietitian will visit your house and help you learn to cook all over again." B. "The dietitian will give you a list of foods and dietary choices that will keep your diabetes under control." C. "The dietitian will help you choose foods that meet both your cultural and health requirements." D. "It may be difficult, but I know you can change your eating and cooking habits with some help from the dietitian."

C. "The dietitian will help you choose foods that meet both your cultural and health requirements."

A nurse is collecting data from a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? A. "Does the medication you're taking relieve the pain?" B. "Can you point to where the pain is the worst?" C. "What do you think caused the onset of your pain?" D. "Changing positions makes your pain worse, right?"

C. "What do you think caused the onset of your pain?"

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? A. Encourage the child to cough frequently to clear congestion from anesthesia B. Place a heating pad on the child's neck for comfort C. Administer analgesics to the child on a routine schedule throughout the day and night D. Provide the child with ice cream when oral intake is initiated

C. Administer analgesics to the child on a routine schedule throughout the day and night

A nurse is assisting a client who has dysphagia at mealtime. Which of the following actions should the nurse take? A. Assist the client into a semi-sitting position B. Have the client lean slightly backward C. Advise the client to tuck his chin downward D. Instruct the client to tilt his head slightly backward

C. Advise the client to tuck his chin downward

A nurse is preparing a presentation for a group of older adults at a senior community center about nutrition and exercise. Which of the following strategies should the nurse use in preparing learning activities for this group of clients? A. Print handout material on colorful paper B. Present the information at a ninth-grade reading level C. Allow rest periods during the presentation D. Schedule the presentation in the late afternoon

C. Allow rest periods during the presentation

A nurse is preparing to administer timolol eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take? A. Instruct the client to blink several times after instillation of the medication B. Ask the client to look straight ahead during instillation of the medication C. Apply pressure to the bridge of the nose after instillation of the medication D. Place each drop of the medication directly on to the client's cornea

C. Apply pressure to the bridge of the nose after instillation of the medication

A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions? A. Shaking soiled linen before putting it in a hamper B. Removing his face mask when standing 0.5 m (1.6 feet) from the client C. Assigning another client with the same infection to share the room with the client D. Allowing the client to visit a family member in the lobby of the facility

C. Assigning another client with the same infection to share the room with the client

A nurse is reinforcing teaching with a client who has hypertension and is starting medication therapy for treatment. The provider has recommended that, because of these new medications, the client should increase her intake of potassium. Which of the following foods should the nurse remind the client to include in her diet? A. Mozzarella cheese B. White rice C. Bananas D. Grape juice

C. Bananas

A nurse in a provider's office is reinforcing teaching with a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching? (Select all that apply.) A. Canned peaches B. White rice C. Black beans D. Whole-grain bread E. Tomato juice

C. Black beans D. Whole-grain bread

A nurse is assisting with the care of a client who requires ventilatory assistance with breathing following a motor vehicle crash. The nurse should suspect that the client has an injury to which of the following parts of the brain? A. Hypothalamus B. Cerebral cortex C. Brainstem D. Cerebellum

C. Brainstem

While drawing blood for laboratory testing from a client, a nurse observes a blood spill on her gloved hand. client has no documented bloodstream infection. Which of the following actions should the nurse take? A. wash the gloved hands and then throw the gloves away B. Prepare an incident report to document the event C. Carefully remove the gloves and follow with hand hygiene D. Ask the provider to order a blood culture to determine the risk of infection

C. Carefully remove the gloves and follow with hand hygiene

A nurse is caring for a client who has a stage Ill pressure ulcer on his heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? A. Obtain the prescribed irrigation solution B. Don personal protective equipment C. Check the client's pain level D. Place a waterproof pad under the client's extremity

C. Check the client's pain level

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

C. Clip the suture as close to the skin as possible

A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client's bedside and perform which of the following procedures? A. Check the client's name and medical record number on the MAR against the room and bed number B. Call the client by name and check the name on her identification band against the MAR C. Compare the medical record number and name on the MAR with the client's identification band D. Ask the client's visitor to identify the client by name and to state the client's birth date

C. Compare the medical record number and name on the MAR with the client's identification band

A nurse in a provider's clinic is taking a client's age, height, weight, and vital signs. The nurse should identify this action as part of which of the following components of the nursing process? A. Planning B. Evaluation C. Data collection D. Implementation

C. Data collection

A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk for which of the following health alterations? A. Increased intestinal motility B. Respiratory alkalosis C. Decreased cardiac output D. Hypocalcemia

C. Decreased cardiac output

A nurse is collecting data from a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect? A. Muscle tremors B. Positive Chvostek's sign C. Depressed deep-tendon reflexes D. Numbness around the mouth

C. Depressed deep-tendon reflexes

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

C. Do not use any materials containing oil or alcohol when using oxygen

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give the dietary assistant? A. Don a gown before entering the room and remove it before exiting B. Wear a mask while in the client's room C. Don gloves when entering the room and use hand sanitizer when exiting D. Take no special precautions unless engaging in direct contact with the client

C. Don gloves when entering the room and use hand sanitizer when exiting

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

C. Elevate the client's head of bed 45° before the feeding

A nurse is providing palliative care for a client who is at the end of life. The client is having difficulty breathing and has audible respiratory gurgling. Which of the following actions should the nurse take? A. Increase the amount of light in the room B. Reposition the client from side to side every 4 hours C. Elevate the head of the client's bed D. Apply an electric blanket

C. Elevate the head of the client's bed

A nurse is working with the facility's language interpreter to explain a wound-care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when explaining the procedure to the client? A. Make eye contact with the interpreter B. Break sentences into shorter segments to allow time for interpretation C. Ensure the interpreter and the client speak the same dialect D. Speak in a loud tone of voice

C. Ensure the interpreter and the client speak the same dialect

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? A. Hold the irrigator 1.25 cm (0.5 in) above the eye B. Direct the irrigation solution upward toward the upper eyelid C. Exert pressure on the bony prominences when holding the eyelids open D. Direct the irrigation from the outer canthus to the inner canthus of the eye

C. Exert pressure on the bony prominences when holding the eyelids open

A nurse is reinforcing teaching with a middle adult client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of routine health screening for women 50 to 64 years of age? A. Annual Papanicolaou (Pap) tests B. Mammogram every 2 years C. Eye examination every 2 years D. Annual colonoscopy

C. Eye examination every 2 years

A nurse is caring for a client who is dehydrated. Which of the following laboratory values should the nurse expect for this client? A. BUN 18 mg/dL B. Capillary refill 1.5 seconds C. Hct 55% D. Urine specific gravity 1.001

C. Hct 55%

At a well-child visit, a nurse is collecting data from a 6-month-old infant. Which of the following findings should the nurse report to the provider? A. Turning from her side to her back B. Laughing and babbling when content C. Head lagging when the parent pulls the infant up to sit D. Bringing objects from her hand to her mouth

C. Head lagging when the parent pulls the infant up to sit

A nurse is collecting data from a client who is experiencing stress over a near fall out of bed. Which of the following physiological responses should the nurse expect to observe due to the client's fight-or-flight response? A. Decreased respiratory rate B. Pinpoint pupils C. Increased blood pressure D. Bronchiolar construction

C. Increased blood pressure

A nurse in a provider's office is collecting data from an older adult client. Which of the following findings should the nurse expect? A. Low systolic blood pressure B. Increased muscle mass C. Increased cerumen D. Larger pupils

C. Increased cerumen

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? A. Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube B. Position the client on his right side C. Insert the tip of the tubing 8 cm (3.1 in) D. Hold the enema container 61 cm (24 in) above the rectum

C. Insert the tip of the tubing 8 cm (3.1 in)

A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client's HIV infection status. Which of the following actions should the nurse take? A. Inform the guard that the warden must request this information B. Ask the guard to sign a release of information form C. Instruct the guard to ask the inmate D. Complete an incident report

C. Instruct the guard to ask the inmate

A nurse is using the Braden scale to predict the pressure-ulcer risk for a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate? A. Incontinence B. Mental state C. Nutrition D. General physical condition

C. Nutrition

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

C. Obtain the services of an interpreter

A nurse is collecting data about a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings? A. Peripheral pulses equal bilaterally at a rate of 60/min B. Radial, brachial, and pedal pulses bilaterally weak C. Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities D. Brachial, radial, popliteal, and dorsalis pedis pulses regular, 58, and bilaterally palpable

C. Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? A. Maintain suction while removing the NG tube B. Instill 100 mL of air into the NG tube before removal C. Pinch the NG tube while removing the tube D. Instruct the client to breathe in and out during the removal of the NG tube

C. Pinch the NG tube while removing the tube

A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take? 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

C. Place the client in a left Sims' position

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

C. Place the wheelchair at a 45° angle to the bed

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? A. Speaking rapidly B. Hiccupping frequently C. Pocketing food D. Preferring clear liquids

C. Pocketing food

A nurse is removing a dressing over the surgical incision of a client who is postoperative following abdominal surgery. Today, the client reported that "something opened up." The nurse finds that the incision has separated and intestinal tissue is protruding. After calling for help, which of the following actions should the nurse take? A. Apply an abdominal binder B. Apply dry, sterile gauze over the incision C. Position the client supine with the knees in flexion D. Place gentle pressure with an abdominal pad over the evisceration

C. Position the client supine with the knees in flexion

A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take? A. Deliver the formula at a slower rate B. Request a lower-fat formula C. Provide more water with feedings D. Instill a lactose-free formula

C. Provide more water with feedings

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

C. Pull the NG tube back slightly

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? 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

C. Raise the level of the bed

A nurse is preparing to administer a partial dose of a prefilled opioid analgesic parenterally to a client. Which of the following actions should the nurse plan to take? A. Return the unused portion of the medication to the pharmacy B. Dispose of the wasted medication into a sharps container C. Record the amount of medication wasted on the controlled substance inventory record D. Ask an assistive personnel (AP) to witness the wasting of the controlled substance

C. Record the amount of medication wasted on the controlled substance inventory record

A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. The nurse notes that the part of the arm immediately surrounding the insertion site is red and feels warm. Which of the following actions should the nurse take? A. Change the infusion tubing B. Flush the IV catheter C. Remove the IV catheter D. Apply a cool compress to the site

C. Remove the IV catheter

A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for the client? A. Perform tracheostomy care using medical asepsis B. Allow enough slack under the tracheostomy ties to insert 3 fingers C. Soak the inner cannula of the tracheostomy tube in normal saline D. Cut a sterile gauze pad to place between the neck and tracheostomy tube

C. Soak the inner cannula of the tracheostomy tube in normal saline

A nurse is caring for a client who has breast cancer. The client has been receiving radiation therapy for several months and now refuses to undergo further treatment. Which of the following actions should the nurse take? A. Suggest the client talk with someone who has survived breast cancer B. Encourage the client not to give up C. Support the client's decision D. Refer the client to a counselor

C. Support the client's decision

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

C. Talk with the AP about the technique used

A nurse is checking the IV insertion site for infiltration for a client who is receiving fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? A. Redness at the IV catheter entry site B. Palpable cord that is felt along the vein used for the infusion C. Taut skin around the IV catheter site that is cool to the touch D. Bleeding at the IV insertion site

C. Taut skin around the IV catheter site that is cool to the touch

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

C. Temperature

A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors places the client at risk of developing complicated grief? A. The deceased was a close friend. B. The client lived far from the deceased. C. The death was sudden. D. The client has not visited the deceased in a long time.

C. The death was sudden.

A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical handwashing technique? A. The nurse washes each part of her hands with 5 strokes. B. The nurse washes from the elbows down to the hands. C. The nurse washes with her hands held higher than her elbows. D. The nurse uses minimal friction when washing her hands.

C. The nurse washes with her hands held higher than her elbows.

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

C. Try to block the urge to urinate until the next scheduled time

A charge nurse is providing teaching to a newly licensed nurse about removing sutures from a client's laceration. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A."I will use a staple remover and remove each suture individually." B. "Bandage scissors are used to cut the sutures." C. "Tweezers are necessary only for removal of retention sutures." D. "I will clip each suture close to the skin and pull it through from the other side."

D. "I will clip each suture close to the skin and pull it through from the other side."

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."

D. "Using a cuff that is too small will result in an inaccurately high 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?"

D. "What is your source of strength and hope?"

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse offer? A. "It's for your safety. Dentures can slip and block your airway during surgery." B. "You wouldn't want your teeth to be lost or broken during surgery, would you?" C. "The anesthesiologist requires everyone to remove their dentures." D. "What worries you about being without your teeth?"

D. "What worries you about being without your teeth?"

A nurse is supervising a newly licensed nurse who is suctioning a client's tracheostomy. The nurse should identify that which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A. Using clean technique to perform the procedure B. Applying suction while inserting the catheter C. Lubricating the suction catheter with an oil-based lubricating jelly D. Administering high-flow oxygen prior to the procedure

D. Administering high-flow oxygen prior to the procedure

A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. Which of the following actions should the nurse take? A. Tell the client the provider does not want her to remain in bed B. Allow the client to remain in bed until her pain subsides C. Instruct the family to perform ADLs for the client D. Advise the client to perform range-of-motion exercises while in bed

D. Advise the client to perform range-of-motion exercises while in bed

A nurse is using a portable ultrasound bladder scanner to measure a client's post-void residual. Which of the following actions should the nurse take? A. Have the client urinate 20 minutes before the scan B. Assist the client into a semi-Fowler's position C. Position the scanner head at the symphysis pubis D. Apply light pressure to the scanner head once it is in position

D. Apply light pressure to the scanner head once it is in position

A nurse is reinforcing teaching with a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes? A. Identify the risks of non-adherence C B. Schedule learning sessions to demonstrate the psychomotor skills the client will need C. Provide clearly written and easy-to-understand materials D. Assist the client to identify ways that these changes will result in positive personal outcomes

D. Assist the client to identify ways that these changes will result in positive personal outcomes

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse have the client perform just before inserting the catheter? A. Swallow water B. Prepare for a painful sensation C. Hold her breath D. Bear down gently

D. Bear down gently

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

D. Call the provider to clarify the dosage

A nurse is assisting with the care of a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect an injury to which of the following areas of the brain? A. Hypothalamus B. Cerebral cortex C. Pituitary D. Cerebellum

D. Cerebellum

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

D. Check the client's perineum

A nurse is preparing to administer a tuberculin skin test to a client. After performing hand hygiene, which of the following actions should the nurse take? A. Select a 23-gauge needle B. Insert the needle into the skin at a 25° angle C. Massage the injection area following removal of the needle D. Circle the area of the injection with a pen

D. Circle the area of the injection with a pen

A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? A. Irrigate the tubing with sterile normal water once each shift B. Cleanse the opening with soap and water after emptying C. Maintain the tubing above the level of the surgical incision D. Collapse air from the device after emptying

D. Collapse air from the device after emptying

A nurse finds a client sitting on the floor by the toilet in the bathroom adjacent to his room. He states that he is fine after slipping on the tile floor but is having difficulty getting up. Which of the following actions should the nurse take first? A. Remind the client to use the call light to summon help when he needs to use the bathroom B. Help the client to return to bed and rest C. Complete an incident report according to the facility's policy D. Collect data from the client about any health alterations before, during, or after the fall

D. Collect data from the client about any health alterations before, during, or after the fall

A nurse is caring for a client who is unstable and has vital signs measured every 15 min by an electronic blood pressure machine. The machine begins to measure the blood pressure at varied intervals, and the readings are inconsistent. Which of the following actions should the nurse take? A. Turn on the machine every 15 min to measure the client's blood pressure B. Record only blood pressure readings needed for the 15-min intervals C. Obtain manual and automatic readings and compare them D. Disconnect the machine and measure the blood pressure manually every 15 min

D. Disconnect the machine and measure the blood pressure manually every 15 min

A nurse is performing a mental-status examination for a client who has manifestations of dementia. Which of the following directions should the nurse give the client when evaluating the client's ability to think abstractly? A. Subtract 7 serially, starting at 100 B. Describe a previous illness C. Explain what to do if a fire started in his bedroom D. Discuss the meaning of a common proverb

D. Discuss the meaning of a common proverb

A nurse is assisting with the admission of a client to the medical unit and asks if he has advance directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able." The nurse should identify that the client is referring to which of the following documents? A. Informed consent form B. Living will document C. Do-not-resuscitate (DNR) directive D. Durable power of attorney document

D. Durable power of attorney document

A nurse is discussing fire safety with newly hired nurses. Which of the following actions is the priority if a fire occurs in the healthcare facility? A. Close the fire doors on the unit B. Spray a fire extinguisher on the fire C. Pull the nearest fire alarm D. Evacuate clients from the unit

D. Evacuate clients from the unit

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client? A. Speak directly toward the client's impaired ear B. Exaggerate lip movements C. Speak loudly D. Face the client when speaking

D. Face the client when speaking

A nurse is administering 3 liquid medications through a client's nasogastric tube. Which of the following actions should the nurse take? A. Position the head of the client's bed at 15 degrees® B. Mix the medications together in a medication cup C. Pour the medications into the enteral formula container D. Flush the tube with water before and after instilling each medication

D. Flush the tube with water before and after instilling each medication

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? C A. Liver size B. Pedal edema C. Skin texture D. Gait

D. Gait

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

D. Grains

A nurse is teaching a group of unit nurses about a client who has a surgical wound that is healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching? A. The wound edges are well-approximated. B. The wound is closed at a later date. C. A skin graft is placed over the wound bed. D. Granulation tissue fills the wound during healing.

D. Granulation tissue fills the wound during healing.

A nurse is administering a controlled substance to a client who is postoperative. The IM dosage requires the nurse to use only part of the amount of medication in the vial. Which of the following actions should the nurse take? A. Lock the vial in the controlled-substances cabinet for later use B. Crush the vial between 2two paper towels and place it in a sharp's container C. Return the opened vial to the pharmacy D. Have another nurse witness the disposal of the medication

D. Have another nurse witness the disposal of the medication

A nurse in an urgent-care center is caring for a 15-year-old client whose symptoms suggest a sexually transmitted infection (STI). The client's parent is unavailable, but the client's grandmother accompanied the client to the clinic. Which of the following actions should the nurse take? A. Explain that the treatment can wait until the parent is available B. Inform the grandmother that she may give consent for the treatment C. Invoke the principle of implied consent and prepare the client for treatment D. Have the adolescent sign the consent form

D. Have the adolescent sign the consent form

A nurse is preparing to measure a client's blood pressure with a sphygmomanometer and a stethoscope. Which of the following actions should the nurse take? A. Wrap the cuff loosely around the client's arm B. Use a cuff with a bladder that encircles 60% of the client's upper arm C. Place the cuff so its lower edge is 1.3 cm (0.5 in) above the antecubital space D. Have the client place both feet flat on the floor

D. Have the client place both feet flat on the floor

A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care-associated infections (HAls). Which of the following routes of infection should the manager identify as an iatrogenic HAl? A. Infection acquired from improper hand hygiene B. Infection acquired by drug resistance C. Infection acquired from inappropriate waste disposal D. Infection acquired from a diagnostic procedure

D. Infection acquired from a diagnostic procedure

A nurse in a provider's office is caring for a client who has blepharitis. Which of the following actions should the nurse take first? A. Reinforce teaching with the client about proper instillation of antibiotic eye drops B. Apply warm compresses to the affected eye C. Dim the lights in the client examination room D. Inspect the eyes for drainage or redness

D. Inspect the eyes for drainage or redness

A client who has glaucoma of the right eye self-administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following actions should the nurse take? A. Confirm that the client performed the procedure correctly B. Instruct the client to look at the floor while instilling the eye drop C. Remind the client to avoid using a facial tissue after instillation D. Instruct the client to apply pressure to the inside corner of the eye after instillation

D. Instruct the client to apply pressure to the inside corner of the eye after instillation

A nurse in an acute-care facility is assisting with planning care for a client who is alert but is temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse suggest to prevent a complication of immobility? A. Move the client from supine to a low-Fowler's position every 2 to 3 hours to help prevent orthostatic hypotension B. Limit fluid intake to 1 L (33.8 oz) in 24 hours to help prevent dependent edema C. Encourage the client to turn from side to side every 3 to 4 hours to help prevent respiratory complications D. Instruct the client to perform foot and leg exercises every 1 to 2 hours while awake to help prevent thrombophlebitis

D. Instruct the client to perform foot and leg exercises every 1 to 2 hours while awake to help prevent thrombophlebitis

A nurse is assisting with planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse suggest? A. Serve foods at warm or hot temperatures B. Offer the client low-density foods C. Make sure the client lies supine after meals D. Limit drinking liquids when eating food

D. Limit drinking liquids when eating food

A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first? A. Provide oxygen B. Turn the client onto his side C. Provide privacy D. Lower the client to the floor

D. Lower the client to the floor

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

D. Make sure 2 fingers can fit under the sleeves

A nurse is planning to reinforce teaching for a client who is learning to self-inject a medication subcutaneously. The nurse does not speak the client's language, so arrangements are made for a medical interpreter from the facility to assist. Which of the following actions should the nurse take when working with the interpreter and the client? A. Speak loudly to the interpreter B. Make eye contact with the interpreter when instructing the client about the procedure C. Use metaphors and colloquial expressions D. Make sure the client and the interpreter are culturally compatible

D. Make sure the client and the interpreter are culturally compatible

A nurse is caring for a client who requires a protective environment. Which of the following precautions should the nurse implement for this client? A. Place the client in a private room with negative--pressure airflow B. Wear an N95 respirator when giving the client direct care C. Make sure the client's room has at least 6six air exchanges per hour D. Make sure the client wears a mask when outside his room

D. Make sure the client wears a mask when outside his room

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room. The client states she no longer wants to have the surgery. Which of the following actions should the nurse take? A. Tell the client it is too late for her to change her mind because the surgery is already scheduled B. Telephone the operating room and cancel the surgery C. Inform the client's family of the situation D. Notify the provider about the client's decision

D. Notify the provider about the client's decision

A nurse in a long-term care facility is in the dining room while residents are eating lunch. One resident begins to choke and is coughing strongly. Which of the following actions should the nurse take? A. Assist the client to the floor B. Perform an abdominal thrust C. Open the airway with a head-chin tilt D. Observe the client closely

D. Observe the client closely

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 povidone-iodine 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

D. Obtain a new catheter and reattempt insertion

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? A. Open all sterile supplies and solutions B. Stabilize the tracheostomy tube C. Don sterile gloves D. Perform hand hygiene

D. Perform hand hygiene

A nurse is leading an education session about disposing of biohazardous materials. Which of the following instructions should the nurse include in the teaching? A. Use isopropyl alcohol to clean up blood spills B. Discard empty blood bags in a bedside trash can C. Break used needles before discarding D. Place soiled linen in a single linen bag

D. Place soiled linen in a single linen bag

A nurse is preparing a liquid medication from a multi-dose bottle prior to administering it to a client. Which of the following actions should the nurse take? A. Make sure the label on the bottle faces downward when pouring the medication B. Place the medication cup on a paper towel C. Check that the mark for the dosage matches the fluid level at the top of the meniscus D. Place the cap of the bottle upside down on a clean surface

D. Place the cap of the bottle upside down on a clean surface

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

D. Place the stool specimen collection container in a biohazard bag

A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs to which of the following functional classifications? A. Skeletal muscle relaxants B. Beta-adrenergic blockers C. Broad-spectrum anti-infectives D. Plasma volume expanders

D. Plasma volume expanders

A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage? A. Sanguineous exudate B. Serous exudate C. Serosanguineous exudate D. Purulent exudate

D. Purulent exudate

A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take? A. Tie a secure knot with the restraint straps B. Attach the restraints' straps to the bed's side rails C. Make sure 3 fingers fit beneath the restraints D. Remove the restraints at least every 2 hrs

D. Remove the restraints at least every 2 hrs

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

D. Request a prescription for an isotonic enteral nutrition 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

D. Right communication

A nurse at a screening clinic is collecting data for a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? A. Fifth intercostal space just medial to the midclavicular line B. Second intercostal space to the left of the sternum C. Fifth intercostal space to the left of the sternum D. Second intercostal space to the right of the sternum

D. Second intercostal space to the right of the sternum

A nurse is applying antiembolic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings? A. Roll the stocking partially down if it is too long B. Remove the stocking once per day C. Bunch and pull the stocking halfway up the calf D. Turn the stocking inside out to the heel before applying

D. Turn the stocking inside out to the heel before applying

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

D. Wear a tracheostomy cover when outdoors

A nurse is collecting data from a client at admission. The client reports a latex allergy. Which of the following precautions should the nurse take when caring for this client? A. Snap gloves on and off to reduce any lingering allergens B. Wear powdered hypoallergenic latex gloves C. Rinse non-disposable items with ethylene oxide D. Wrap IV tubing with tape

D. Wrap IV tubing with tape

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

D. Wrap the client's finger in a warm washcloth

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

D. Young adulthood

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.). a. 101.3 b. 100.9 c. 101.1 d. 102.1

c. 101.1