Comprehensive Needs Review Fundamentals

A nurse is preparing to administer sotalol to a client with a prescription for 320 mg/day divided equally every 12 hr. The medication is available in 80 mg tablets. How many tablets should the nurse administer per dose? (Fill in the blank with the numeric value only, round the answer to the nearest tenth, and use a leading zero if applicable. Do not use a trailing zero.)

Correct Answer: 2 Follow these steps for the ratio and proportion method of calculation: Step 1: What is the unit of measurement the nurse should calculate? tablet Step 2: What is the dose the nurse should administer? 320 mg/day Step 3: What is the dose available? 80 mg Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 1 tablet Step 6: Set up an equation and solve for X. Have/Quantity = Desired/X 80 mg/1 tablet = 320 mg/X tablet X = 4 Step 7: Round if necessary. Step 8: Determine whether the amount to administer makes sense. If there are 80 mg/tablet and the prescription reads 320 mg/day divided into 2 doses, the nurse should administer 2 tablets with each dose. Follow these steps for the "desired over have" method of calculation: Step 1: What is the unit of measurement the nurse should calculate? tablet Step 2: What is the dose the nurse should administer? 320 mg/day Step 3: What is the dose available? 80 mg Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 1 tablet Step 6: Set up an equation and solve for X. Desired x Quantity/Have = X 320 mg x 1 tablet/80 mg = X 4 = X Step 7: Round if necessary. Step 8: Determine whether the amount to administer makes sense. Follow these steps for the dimensional analysis method of calculation: Step 1: What is the unit of measurement the nurse should calculate? tablet Step 2: What is the quantity of the dose available? 1 tablet Step 3: What is the dose available? 8 mg Step 4: What is the dose the nurse should administer? 320 mg Step 5: Should the nurse convert the units of measurement? No Step 6: Set up an equation and solve for X. X = Quantity/Have x Conversion (Have)/Conversion (Desired) x Desired/ X = 1 tablet/80 mg x 320 mg/ X = 4 Step 7: Round if necessary. Step 8: Determine whether the amount to administer makes sense.

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 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, and use a leading zero if applicable. Do not use a trailing zero.)

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

A nurse is teaching the parent of a child who is to take 10 mL of a liquid medication. The parent has a hollow medication spoon with marks to indicate teaspoons and tablespoons. How many teaspoons should the nurse instruct the parent to give the child? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

Correct Answer: 2 Follow these steps for the conversion of mL to tsp: Step 1: What is the unit of measurement the nurse should calculate? tsp Step 2: Set up an equation and solve for X. 5 mL/1 tsp = 10 mL/X tsp 5X = 10 X = 2 Step 3: Round if necessary. Step 4: Determine whether the conversion to tsp makes sense. If 5 mL = 1 tsp, then 10 mL = 2 tsp.

A nurse is preparing to administer 40 mL of 0.9% sodium chloride IV to infuse over 20 min. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

Correct Answer: 30 To solve using ratio and proportion and "desired over have" methods: Step 1: What is the unit of measurement the nurse should calculate? gtt/min Step 2: What is the volume the nurse should infuse? 40 mL Step 3: What is the total infusion time? 20 min Step 4: Should the nurse convert the units of measurement? No Step 5: Set up the equation and solve for X. Volume (mL)/Time (min) x drop factor (gtt/mL) = X 40 mL/ 20 min x 15 gtt/mL = X gtt/min 30 = X Step 6: Round if necessary. Step 7: Determine whether the amount to administer makes sense. If the prescription is 200 mL 0.9% sodium chloride IV infused over 20 min, the nurse should set the manual IV infusion to deliver 0.9% sodium chloride IV at 30 gtt/min. To solve using dimensional analysis: Step 1: What is the unit of measurement the nurse should calculate? gtt/min Step 2: What is the quantity of the drop factor that is available? 15 gtt/min Step 3: What is the total infusion time? 20 min Step 4: What is the volume the nurse should infuse? 40 mL Step 5: Should the nurse convert the units of measurement? No Step 6: Set up the equation and solve for X. X = Quantity/1 mL x Conversion (hr)/Conversion (min) x Volume (mL)/Time X gtt/min = 15 gtt/1 mL x 40 mL/20 min X = 30 Step 7: Round if necessary. Step 8: Determine whether the amount to administer makes sense.

A nurse is monitoring a client's fluid intake. For breakfast, the client consumed 8 oz of milk, 10 oz of water, 4 oz of flavored gelatin, 1 scrambled egg, 1 crisp piece of bacon, and 2 biscuits with jelly. How many mL should the nurse record as the client's fluid intake? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

Correct Answer: 660 8 oz + 10 oz + 4oz = 22 oz Follow these steps to convert ounces to milliliters: Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: Set up an equation and solve for X. 1 oz / 30 mL = 22 oz / X mL X = 660 mL Step 3: Round if necessary. Step 4: Reassess to determine if the conversion to mL makes sense. If 1 oz = 30 mL, then 22 oz = 660 mL.

A nurse is caring for a client whose intake and output flow sheet for 0700 to 1500 indicates the following: voided x3: 350 mL, 200 mL, 150 mL; wound drainage 2 tsp; and emesis 2 oz. What total output in milliliters should the nurse document for this 8 hr period? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

Correct Answer: 770 Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: Set up an equation and solve for X. 1 tsp/5mL = 2 tsp/X mL X = 10 Step 3: Round if necessary. Step 4: Determine if the conversion to mL makes sense. If 1 tsp = 5 mL, then 2 tsp = 10 mL. Follow these steps for the conversions of oz to mL: Step 1: What unit of measurement should the nurse calculate? mL Step 2: Set up an equation and solve for X. 1 oz/30 mL = 2 oz/X mL X = 60 Step 3: Round if necessary. Step 4: Determine whether the conversion to mL makes sense. If 1 oz = 30 mL, then 2 oz = 60 mL. For the total intake, calculate: 350 mL + 200 mL + 150 mL + 10 mL + 60 mL = 770 mL

A client has 1 L of dextrose 5% in 0.45% sodium chloride infusing IV at 125 mL/hr. How many hours will it take for the liter to infuse? (Fill in the blank with the numeric value only and round to the nearest whole number.)

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

A nurse is teaching a client how to perform range-of-motion exercises of the wrist. To perform adduction, which of the following instructions should the nurse include? "With your palm facing down, move your wrist sideways toward your thumb." "Move your palm toward the inner part of your forearm." "With your palm facing down, move your wrist sideways toward your little finger." "Bring the back of your hand as far back toward the wrist as you can."

Correct Answer: A. "With your palm facing down, move your wrist sideways toward your thumb." This motion describes adducting the wrist. The client should be able to move her wrist 30º to 50º with this motion. Incorrect Answers:B. This motion is flexing the wrist. C. This motion is abducting the wrist. D. This motion is hyperextending the wrist.

After assessing a client, the nurse documents "1+ pedal edema bilaterally." This indicates that the nurse observed an indentation of which of the following depths after applying pressure? 2 mm 4 mm 6 mm 8 mm

Correct Answer: A. 2 mm The nurse should document a 2 mm indentation after applying and removing pressure as 1+ pedal edema. Incorrect Answers:B. The nurse should document a 4 mm indentation after applying and removing pressure as 2+ pedal edema. C. The nurse should document a 6 mm indentation after applying and removing pressure as 3+ pedal edema. D. The nurse should document an 8 mm indentation after applying and removing pressure as 4+ pedal edema.

A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing? Cranial nerve XII Cranial nerve X Cranial nerve VIII Cranial nerve V

Correct Answer: A. Cranial nerve XII The nurse is checking the function of cranial nerve XII (hypoglossal), which innervates the tongue, by observing a range of tongue movements. Incorrect Answers:B. The nurse checks the functioning of cranial nerve X (vagus) by asking the client to vocalize. C. The nurse checks the functioning of cranial nerve VIII (vestibulocochlear) through using the Rinne and Weber tests and asking the client if he can hear a whisper. D. The nurse checks the functioning of cranial nerve V (trigeminal) by asking the client to clench his teeth and palpating the masseter muscles for contraction.

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

Correct Answer: A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The nurse should frequently check the bag on a rebreather mask to ensure it inflates properly. If the bag is deflated, the client will rebreathe exhaled carbon dioxide instead of receiving the prescribed oxygen dose. Therefore, the nurse should first see the client who has heart failure and is receiving 100% oxygen via partial rebreather mask. Oxygen is a gas that can cause toxicity and is highly combustible, and higher concentrations of oxygen increase the risk of client injury. Incorrect Answers:B. Routine treatment for chronic lung conditions can include the use of a transtracheal oxygen cannula; therefore, there is another client the nurse should plan to see first. The client will learn to use this device alone, and the system can provide adequate oxygenation with a low flow rate of oxygen. Three liters per minute of oxygen is the equivalent of 32% oxygen delivery. C. Routine treatment for a client who has an old tracheostomy includes the administration of humidified oxygen or air via tracheostomy collar. Therefore, there is another client the nurse should plan to see first. The nurse should use humidification to promote loosening of respiratory secretions and prevent cannula obstruction. Forty percent oxygen is the equivalent of administering oxygen at 6L/min. D. Routine treatment for a client who has COPD involves the administration of low-dose therapy. Therefore, there is another client the nurse should plan to see first. Clients who have COPD depend on a low oxygen level to drive their respiratory rate. Two liters per minute of oxygen is the equivalent of 28% oxygen delivery.

A nurse is assessing a client for conductive hearing loss. When 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? Air conduction is less than bone conduction in the left ear. Air conduction is greater than bone conduction in the left ear. Sound is lateralizing to the right ear. Sound is lateralizing to the left ear.

Correct Answer: A. Air conduction is less than bone conduction in the left ear. This finding indicates conductive hearing loss of the left ear. Incorrect Answers:B. This finding does not indicate hearing loss of any type. C. D. These are possible results of the Weber test, not the Rinne test.

A nurse is using the I-SBAR communication tool to give a client's provider information about the client. The nurse should convey this client's pain status in which portion of the report? Assessment Background Situation Recommendation

Correct Answer: A. Assessment The nurse provides information about assessment findings in this portion of the report, including vital signs, pain assessment, and changes in assessment findings. Incorrect Answers: B. The nurse provides information about pertinent medical history, laboratory findings, allergies, and code status in this portion of the report. C. The nurse provides information about problems the client is experiencing in this portion of the report. D. The nurse makes recommendations about treatment and asks the provider about additional treatment in this portion of the report.

A nurse is performing a focused assessment of a client's peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse? Below the medial malleolus In the popliteal fossa In the antecubital space On the dorsum of the foot

Correct Answer: A. Below the medial malleolus The nurse should palpate the posterior tibial pulse by curving the fingers around the medial malleolus on the inner surface of the client's ankle. Incorrect Answers:B. The nurse should evaluate the client's popliteal pulse by palpating behind the knee in the area of the popliteal fossa. C. The nurse should evaluate the client's brachial pulse by palpating in the groove between the biceps and triceps muscles in the area of the antecubital fossa. D. The nurse should evaluate the client's dorsalis pedis pulse by palpating on the dorsum of the foot.

A nurse is reviewing the laboratory values of a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? Decreased calcium Decreased potassium Increased potassium Increased calcium

Correct Answer: A. Decreased calcium Calcium is necessary for nerve conduction and muscle contractions. When the client's total calcium level is <8.4 mg/dL, tetany and muscle spasms may occur. The nurse should tap the facial nerve in front of the client's ear. If facial muscle twitching follows this stimulus, it is a positive Chvostek's sign and an indication of hypocalcemia. Positive Trousseau's You would also see muscle tremors, tingling, and numbness. Incorrect Answers:B. Hypokalemia occurs when the client's potassium is <3.5 mEq/L. The nurse should assess the client for muscle weakness and other clinical manifestations of hypokalemia, not a positive Chvostek's sign. C. Hyperkalemia occurs when the client's potassium is >5.0 mEq/L. The nurse should assess the client for muscle weakness, cardiac dysthymias, and other clinical manifestations of hyperkalemia but not a positive Chvostek's sign. D. Hypercalcemia occurs when the client's total calcium level is <10.5 mg/dL. The nurse should assess the client for lethargy, weakness, depressed deep tendon reflexes, and other clinical manifestations of hypercalcemia but not a positive Chvostek's sign.

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? Encourage the client to listen to soft music Instruct the client to practice tai chi Place a jasmine-scented air freshener in the client's room Offer the client ginger tea

Correct Answer: A. Encourage the client to listen to soft music The nurse should encourage the client to use music therapy to reduce anxiety, provide a distraction, and relieve pain. Incorrect Answers:B. The nurse should instruct the client to practice tai chi to stimulate the immune system and to improve joint function and mobility. However, it is not effective for pain management. C. The nurse can use aromatherapy to promote the client's comfort and healing. However, jasmine is used to improve mood and is not effective for pain management. D. The nurse should offer the client ginger tea, if it is not contraindicated, to reduce nausea. However, it is not effective for pain management.

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? Hemolytic Febrile Circulatory overload Sepsis

Correct Answer: A. Hemolytic A hemolytic reaction occurs when the client's blood is incompatible with the donor's blood. Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion reaction. Incorrect Answers:B. A febrile reaction occurs when the client's blood is sensitive to the WBCs and platelets in the donor's blood. Fevers, chills, headaches, and flushing are indications of a febrile reaction. C. Circulatory overload occurs when blood is administered too quickly for the client's circulatory system to handle. Dyspnea, coughing, headaches, and hypertension are indications of circulatory overload. D. Sepsis occurs when the blood is contaminated with bacteria. High fevers, vomiting, and diarrhea are indications of sepsis.

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

Correct Answer: A. Hydrocolloid The nurse should apply a hydrocolloid dressing to a stage II pressure ulcer. This type of dressing is applied to absorb exudate and to produce a moist environment that will facilitate healing while preventing maceration of surrounding skin. Incorrect Answers:B. The nurse should apply collagen to a clean, moist wound to stop bleeding, bring cells into the wound, and stimulate their proliferation to facilitate healing. C. The nurse should apply calcium alginate to a stage IV pressure ulcer. This type of dressing is used for wounds with significant exudate and must be covered with a secondary dressing. D. The nurse should apply a proteolytic enzyme to an unstageable pressure ulcer. This type of dressing is applied to facilitate debridement and to soften eschar.

A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? Loss Trust Self-disclosure Risk-taking

Correct Answer: A. Loss At the close of a relationship, even when planned, loss is an expected feeling for both the client and the nurse. It is important for both the nurse and the client to terminate the relationship without feelings of guilt or anxiety. Incorrect Answers:B. The nurse should address the concept of trust during the introductory phase of the relationship. C. The nurse should address the concept of appropriate self-disclosure during the working phase of the relationship. D. The nurse should address the concept of risk-taking in the working phase of the relationship.

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

Correct Answer: A. Osteoporosis A loss of height is often an early indication of osteoporosis. This occurs due to loss of calcium in the vertebrae, which can cause them to fracture and collapse. Incorrect Answers:B. Scoliosis does not precipitate a decrease in the height of a client. It is an abnormal lateral curve of the spine. C. Kyphosis does not precipitate a decrease in the height of a client. It is an exaggerated posterior curvature of the thoracic spine (i.e. hunchback). D. Lordosis does not precipitate a decrease in the height of a client. It is an exaggerated lumbar curvature (i.e. swayback).

A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take? Repeat each joint motion 5 times during each session Move the joint to the point of considerable resistance Sit approximately 2 ft from the side of the bed closest to the joint being exercised Exercise the smaller joints first

Correct Answer: A. Repeat each joint motion 5 times during each session To maintain the client's joint mobility, the nurse should repeat each motion 3 to 5 times. Incorrect Answers:B. The nurse should move the joint to the point of slight resistance. C. The nurse should stand at the side of the bed closest to the joint being exercised. D. The nurse should exercise the large joints first.

***A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances? Respiratory alkalosis Metabolic acidosis Respiratory acidosis Metabolic alkalosis

Correct Answer: A. Respiratory alkalosis This client's pH is elevated above the expected reference range of 7.35 to 7.45, indicating alkalosis. Additionally, the client's PaCO2 is below the expected reference range of 35 to 45 mmHg, which indicates a respiratory origin. Hence, the nurse should conclude that the client's elevated pH and decreased PaCO2 indicate respiratory alkalosis. Incorrect Answers:B. ABGs are drawn to determine the acid-base balance in the arterial blood. Acidosis is determined by measuring a pH lower than the expected reference range of 7.35 to 7.45. This client has a pH of 7.5 and therefore does not have acidosis. C. This client's pH is elevated above the expected reference range of 7.35 to 7.45. Acidosis is presented by a lower pH, usually below 7.35. D. Metabolic origin is determined by examining the HCO3- levels. The client's bicarbonate is within the expected reference range of 22 to 26 mEq/L.

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? Sodium 123 mEq/L Blood glucose 100 mg/dL Potassium 3.5 mEq/L Hemoglobin 13 g/dL

Correct Answer: A. Sodium 123 mEq/L A sodium level of 123 mEq/L is below the expected reference range of 136 to 145 mEq/L. Low sodium levels can cause confusion and lead to seizures, coma, and death. Incorrect Answers:B. A blood glucose of 100 mg/dL is within the expected reference range of 70 to 110 mg/dL for fasting and less than 200 mg/dL for a casual blood draw. C. A potassium level of 3.5 mEq/L is within the expected reference range of 3.5 to 5 mEq/L. D. A hemoglobin level of 13 g/dL is within the expected reference range of 12 to 18 g/dL.

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

Correct Answer: A. The client holds the cane on the unaffected side. The nurse should instruct the client to hold the cane on the unaffected side to provide a wide base of support and stability. Incorrect Answers:B. The nurse should instruct the client to walk by stepping with the affected leg before the unaffected leg to maintain stability. C. The nurse should instruct the client to place the cane at about 15 cm (6 in) to the side of the foot to provide balance and support. D. The nurse should instruct the client to hold the cane with the elbow slightly flexed to provide support and stability.

A nurse is teaching range-of-motion exercises to a client who has osteoarthritis. Which of the following client positions demonstrates an understanding of supination of the hand? The client holds the hand with the palm up. The client holds the hand with the palm down. The client points the fingers toward the floor. The client points the fingers toward the ceiling.

Correct Answer: A. The client holds the hand with the palm up. The nurse should identify the client holding the hand with the palm up as a demonstration of supination of the hand. Incorrect Answers:B. Holding the hand with the palm down is a demonstration of pronation of the hand. C. Pointing the fingers toward the floor is a demonstration of flexion of the hand. D. Pointing the fingers toward the ceiling is a demonstration of extension of the hand.

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

Correct Answer: A., C., B, D. Auscultation, Percussion, Light palpation, Deep Palpation According to evidence-based practice, the nurse should listen for bowel sounds in all 4 quadrants before palpating the client's abdomen. Palpation and percussion can stimulate the bowel and increase the frequency of bowel sounds, leading to false results. palpate the client's abdomen to identify any areas of tenderness. percuss the abdomen to identify tympany or dullness Incorrect: If you are assessing anything other than the abdomen inspection, palpation, percussion, and auscultation.

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

Correct Answer: B. "Keep the rubber crutch tips securely in place." The client should never use crutches without the rubber crutch tips. The client should inspect the tips regularly, replace them when they show signs of wear, and remove and dry them thoroughly with paper towels if they become wet. Incorrect Answers:A. The client should put his weight on the crutches, place his left foot on the first step, transfer his weight to the left foot, move the crutches to the step, and then bring up his right foot. C. The basic crutch stance should have the crutches 15 cm (6 in) in front and 15 cm (6 in) to the side of the client's feet, forming a tripod or triangular position. D. The client should have his arms bear the weight of his body. Pressure on the axillae can damage the radial nerve and cause weakness and partial paralysis below his elbows.

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? 6 2 10 8

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

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following pieces of information should the nurse include? A 2-month-old infant can turn from his abdomen to his back. A 10-month-old infant can pull up to a standing position. A 4-month-old infant can sit up without support. A 6-month-old infant can crawl on his hands and knees.

Correct Answer: B. A 10-month-old infant can pull up to a standing position. An 8- to 10-month-old infant can pull up to a standing position. Incorrect Answers:A. An infant cannot turn from his abdomen to his back until 5 months of age. C. A 6- to 8-month-old infant can sit up without support. D. An 8- to 10-month-old infant can crawl on hands and knees.

A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative. Which of the following clients should the nurse see first? A client who is 1 day postoperative following a lobectomy for small-cell carcinoma and has a chest tube with 35 mL/hr of bright red, bloody drainage A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage A client who is 2 days postoperative following the excision of an abdominal mass and has a portable wound suction device with 20 mL/hr of serosanguinous drainage A client who is 1 day postoperative following the excision of a bladder wall tumor and prostate and has continuous bladder irrigation with 300 mL/hr reddish-pink urine

Correct Answer: B. A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage The nurse should apply the unstable vs stable priority-setting framework when caring for clients. Using this framework, unstable clients are prioritized due to needs that threaten survival. The nurse should first address problems involving the airway, breathing, or circulatory status that are life-threatening. Clients whose vital signs or laboratory values indicate a risk of becoming unstable are also a higher priority than clients who are stable. The nurse may need to use nursing knowledge to determine which option describes the most unstable client. An ostomy bag full of blood indicates that the client's bowel is hemorrhaging, and the nurse must report this finding to the surgeon immediately. The client may require fluid replacement, transfusion, and additional surgery to repair the bleeding vessel. This finding poses an immediate threat to the client's circulation. Incorrect Answers: A. Following a lobectomy, the client may need chest tubes for both pneumothorax and hemothorax (collapse of the lung with blood in the pleural space). Fully reinflating and removing the remaining blood can take several days or more, depending on the severity of the trauma. Chest tube drainage of 35 mL is within the expected parameters for an adult client, especially on the first postoperative day. A client who has a draining chest tube after a lobectomy is stable. C. A portable suction device drains a surgical wound by gentle, continuous self-suction. Over time, the drainage will change from sanguineous to serosanguinous to serous. Serosanguinous drainage of 20 mL/hr on the second postoperative day is within the expected reference range for an adult client. A client who has a draining wound after abdominal surgery is stable. D. Continuous bladder irrigation (CBI) prevents clots from forming in the bladder. To keep the client's urine free of clots and mucous plugs, the nurse should irrigate the bladder with 0.9% sodium chloride. During the first few postoperative days, reddish-pink urine at an hourly output slightly greater than the amount of solution the nurse instills is expected. Consequently, drainage of 300 mL/hr on the first postoperative day is within the expected reference range for this client.

A nurse is teaching 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 is responsible for movement at the knee joint? Antigravity Antagonistic Synergistic Skeletal

Correct Answer: B. Antagonistic The nurse should teach the client that the antagonistic muscle group is responsible for movement of the knee joint by contracting while other muscles relax. Incorrect Answers:A. The antigravity muscle group is responsible for stabilizing the knee joint. C. The synergistic muscle group is responsible for contracting in sync to cause the same movement. Therefore, 2 muscles contract as other muscles relax. However, this is not occurring within a joint. D. The skeletal muscle group is responsible for supporting posture and producing voluntary movement.

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

Correct Answer: B. Average Reflexes range on a scale of 0 to 4+. Active or expected reflexes are 2+. Incorrect Answers:A. Diminished reflexes are 1+ or less. C. Brisk reflexes are 3+ or more. D. Hyperactive reflexes are 4+.

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

Correct Answer: B. Hold the breath for 5 sec after goal volume is reached The nurse should instruct the client to hold the breath for 3 to 5 seconds after reaching maximal inspiratory volume. This decreases the collapse of alveoli, which helps prevent the risk of atelectasis and pneumonia. Incorrect Answers:A. The nurse should instruct the client to inhale slowly to reach the goal volume and to decrease the collapse of alveoli in the client's lungs. C. The nurse should instruct the client to breathe normally for short periods of time between each cycle of breaths to reduce hyperventilation and fatigue. D. The nurse should instruct the client to repeat the patterns for 10 to 20 breaths every hour while awake to prevent atelectasis and pneumonia.

***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? Calcium 9.5 mg/dL Sodium 150 mEq/L Potassium 4 mEq/L Magnesium 1.5 mEq/L

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

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

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

A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying? "Now that we have talked about your medications, let's talk about your pain." "Are you having other symptoms?" "It sounds like your pain is intermittent." "It seems as though you have really had a rough time these past few weeks."

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

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

Correct Answer: C. Apply pressure to the puncta after instilling the medication The nurse should instill the medication into the conjunctival sac and apply pressure to the puncta for 1 to 2 minutes afterward to prevent systemic absorption of the medication. Incorrect Answers:A. The nurse should instruct the client to close the eyes gently and to avoid blinking after instillation to prevent any loss of the medication out of the eye and promote absorption. B. The nurse should instruct the client to look upward toward the ceiling during instillation of the medication to allow proper placement of the medication and to suppress the client's blink reflex. D. The nurse should instill the medication into the client's conjunctival sac and should take measures to protect the client's cornea during administration.

A nurse is explaining Piaget's theory of cognitive development to a group of daycare 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? Playing in the sand Playing dress-up with old clothes Collecting and trading game cards Describing interpersonal relationships

Correct Answer: C. Collecting and trading game cards Collecting and trading game cards require seriation of the cards, involving what to collect, what to trade, and what has value. This is a characteristic of Piaget's concrete operational stage for ages 7 to 11 years. Incorrect Answers:A. Playing in the sand is an example of Piaget's sensorimotor stage, which characterizes children from birth to 2 years of age. B. Playing dress-up involves pretending, which reflects Piaget's preoperational thinking stage for ages 2 to 7 years. D. Describing interpersonal relationships requires abstract thought, which is part of Piaget's formal operational reasoning stage for ages 11 years and beyond.

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

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

A nurse is talking with a client whose provider recently informed him of terminal pancreatic cancer. When the client reports that he understands the full impact of this diagnosis, the nurse should identify that the client is in which of the following stages of dying? Anger Bargaining Depression Acceptance

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

A nurse is teaching a group of unit nurses about the experiences of clients who are having surgery. In which phase of care is the client transferred to the surgical suite table before being transferred to the PACU? Preoperative Postoperative Intraoperative Admission

Correct Answer: C. Intraoperative Intraoperative care begins when the client is transferred to the surgical suite table and ends when the client is admitted to the PACU. Incorrect Answers:A. Preoperative care begins when the client agrees to have surgery and ends when the client is transferred to the surgical suite table. B. Postoperative care begins when the client is admitted to the PACU and ends when healing is complete. D. The client's admission to the facility where the surgery is to take place is part of the preoperative phase and typically occurs outside of the surgical suite.

A nurse is caring for a client who has a fecal impaction. Before the digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? Carminative Hypertonic Oil retention Sodium polystyrene sulfate

Correct Answer: C. Oil retention The nurse should administer an oil retention enema prior to the removal of a fecal impaction to soften the stool. This makes the procedure less painful for the client. Incorrect Answers:A. The nurse should administer a carminative enema to assist a client to expel flatus. B. The nurse should administer a hypertonic fluid solution to cleanse the client's bowels (e.g. in preparation for surgery). D. The nurse should administer a sodium polystyrene sulfate enema to a client who has a high potassium level.

A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? People who practice the Islamic faith pray over the deceased for a period of 5 days before burial. People who practice the Hindu faith bury the deceased with their head facing north. People who practice Judaism stay with the body of the deceased until burial. People who are practicing the Buddhist faith have the female family members prepare the body following death.

Correct Answer: C. People who practice Judaism stay with the body of the deceased until burial. In the Jewish faith, a family member often stays with the body until burial occurs. Incorrect Answers:A. For those who practice the Islamic faith, the body of the deceased is washed and wrapped during a ritual and then buried as soon as possible following death. B. People who practice the Hindu faith may place the body with the head facing north following death. However, cremation rather than burial is practiced by those of the Hindu faith. D. Male family members prepare the body following death for individuals practicing the Buddhist faith.

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? The nurse washes each part of her hands with 5 strokes. The nurse washes from the elbows down to the hands. The nurse holds her hands higher than her elbows while washing. The nurse uses minimal friction when washing her hands.

Correct Answer: C. The nurse holds her hands higher than her elbows while washing. The nurse who is performing a surgical handwashing technique should wash while holding her hands higher than the elbows so that water and soapsuds can drain away from the clean area toward the dirty area. Incorrect Answers:A. Surgical scrubbing requires the nails be scrubbed with 15 strokes and each other part of the hand with 10 strokes. B. An important principle of surgical handwashing is to scrub the hands first and then work toward the elbows. D. Scrubbing is performed with a specially designed and premedicated brush when performing surgical handwashing. The use of mechanical friction is necessary to decontaminate the skin effectively.

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

Correct Answer: C. Vastus lateralis The nurse should use the vastus lateralis site over the anterior thigh for IM injections for infants and children. Incorrect Answers: A. The nurse can use the deltoid muscle for injecting small volumes of medication for children 18 months of age and older, but its proximity to several nerves and arteries make it a riskier choice. B. This is a safe site for IM injections for clients older than 7 months. D. This site is unsafe to use because of its proximity to the sciatic nerve and the superior gluteal nerve and artery.

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

Correct Answer: C. Warm the irrigating solution to 37°C (98.6°F) The nurse should prepare about 200 mL of irrigating solution and warm it to body temperature to minimize discomfort and vascular constriction. Incorrect Answers:A. The nurse should use a syringe that has at least a 30 mL capacity. B. The nurse should use an 18- or 19-gauge catheter. A smaller catheter will exert too much pressure on the wound. D. The nurse should administer an analgesic 20 to 30 minutes before the irrigation to give the medication enough time to provide pain management during the procedure.

A nurse is caring for a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect injury to which of the following areas of the brain? Hypothalamus Cerebral cortex Pituitary Cerebellum

Correct Answer: D. Cerebellum The nurse should suspect an injury to the cerebellum if the client is experiencing difficulty controlling balance and coordination. A client's movements can become uncoordinated, unsure, and clumsy following an injury to this area of the brain. Incorrect Answers:A. The nurse should suspect an injury to the hypothalamus if a client is experiencing difficulty with sleeping. This area of the brain serves as the sleep center in the body by secreting hypocretins that promote rapid eye movement (REM) sleep. B. The nurse should suspect an injury to the cerebral cortex if a client is experiencing difficulty with expression. This area of the brain contains the neural networks that facilitate complex behaviors like learning, memory, and language. C. The pituitary gland secretes several hormones such as adrenocorticotropic hormone that produce cortisol. These hormones are necessary for stress adaptation.

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

Correct Answer: D. Granulation tissue fills the wound during healing. A beefy, red tissue called granulation tissue fills the wound during healing. The wound is left open to drain and heal by secondary intention, which should occur within 5 to 21 days. Open wounds increase the risk of wound infection. Incorrect Answers:A. Primary intention involves the closing of the wound using sutures or staples at the time the incision is made; the suture line edges become well-approximated during healing. B. Tertiary intention includes using sutures to close an open wound at a later date after the wound drains and starts to heal. C. Tertiary intention can include the provider placing grafted skin over the client's wound bed after a wound is left open to drain and start healing. Skin grafting is required for deeper wounds such as full-thickness burns and is only rarely required for surgical wounds that do not heal.

nurse is assessing the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? Audible click Murmur Third heart sound Pericardial friction rub

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

A nurse is 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? Sanguineous exudate Serous exudate Serosanguineous exudate Purulent exudate

Correct Answer: D. Purulent exudate Purulent exudate on the client's dressings includes thick yellow, green, or brown drainage and usually indicates wound sloughing or infection. Incorrect Answers:A. Sanguineous exudate drainage on the client's dressings indicates an accumulation of RBCs from the plasma that appears bright red on the dressings. B. Serous exudate drainage on the client's dressings indicates plasma from the blood and appears watery and clear to light yellow in color. C. Serosanguineous exudate drainage on the client's dressings indicates plasma mixed with light bloody drainage, which is typically pale yellow to blood-tinged. Watery drainage may also be evident.

A nurse is preparing to change a dressing on a client who is receiving negative pressure wound therapy (NPWT). What sequence of actions should the nurse plan to take? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer: 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 a skin protectant or a barrier film to the skin around the wound. Place prepared foam into the wound bed and cover with a transparent dressing. Connect the tubing to transparent film and turn on the NPWT unit. Step 1: The nurse should turn off the vacuum on the NPWT device to loosen the dressing and administer the prescribed analgesic. Step 2: The nurse should gently remove the soiled dressing and perform hand hygiene. Step 3: The nurse should apply sterile or clean gloves and irrigate the wound to remove debris. Step 4: The nurse should apply a skin protectant or a barrier film to the surrounding skin to ensure an airtight seal and protect the skin. Step 5: The nurse should place foam in the wound bed and cover it with a transparent dressing to provide an airtight seal. Step 6: The nurse should attach the drainage tube to the transparent dressing and turn on the NPWT unit. Step 7: The nurse should check for air leaks and patch the dressing as needed with transparent film.

A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client? Vastus lateralis Dorsogluteal Deltoid Ventrogluteal

Correct Answer: D. Ventrogluteal According to evidence-based practice, the ventrogluteal site is the safest injection site for all adults because it contains thick gluteal muscles and does not contain major nerves or blood vessels. Incorrect Answers:A. The vastus lateralis is safe for adults because it is thick and away from major blood vessels and nerves. However, according to evidence-based practice, it is not the safest injection site. B. The dorsogluteal site is close to the sciatic nerve, as well as the superior gluteal nerve and artery. Therefore, according to evidence-based practice, it is not the safest injection site. C. The deltoid site is easy to access. However, according to evidence-based practice, it is not the safest site because the muscle is small and sometimes poorly developed. Additionally, it is close to numerous arteries and nerves.

A community health nurse is conducting a class about body mechanics for county office workers. Which of the following instructions should the nurse include? (Select all that apply.) "Sit with your back supported." "Keep your knees at hip level." "Use an ergonomically designed computer keyboard." "Keep your elbows away from your body." "Adjust the monitor screen so that you have to tilt your head slightly to look at it."

Correct Answers: A. "Sit with your back supported." B. "Keep your knees at hip level." C. "Use an ergonomically designed computer keyboard." Using lumbar support in a straight-back chair helps maintain good posture and prevent back pain. Keeping the knees at the level of the hip or higher helps reduce the risk of lordosis, which is an exaggeration of the curve of the lumbar spine. Using a keyboard that maintains ergonomic positioning of the wrists can help prevent carpal tunnel syndrome. Incorrect Answers:D. Keeping the upper arms and elbows close to the body limits straining of the shoulders and the upper back muscles. E. Tilting the screen and tilting the head to look at it can strain the cervical spine.

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) Set the suction machine at 120 mmHg Provide oral hygiene frequently Measure the amount of drainage from the NG tube every shift Secure the NG tube to the client's gown Apply petroleum jelly to the client's nares

Correct Answers: B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown Frequent oral hygiene provides comfort for the client since mucous membranes become dry and uncomfortable when a client cannot drink fluids. Measuring the drainage at least every shift helps the provider calculate fluid loss and prescribe appropriate replacement therapy. An unsecured NG tube can irritate the nares if the tube is pulled or caught on the bed or other equipment. The tube can also be dislodged if not secured appropriately. Incorrect Answers:A. Single-lumen NG tubes are used for intermittent suction, and the machine is set at 80 to 100 mmHg. Higher suction settings can traumatize the gastric lining. E. The client could aspirate an oil-based lubricant like petroleum jelly into the lungs, which could result in lipid pneumonia. A water-soluble lubricant should be applied to the nares to help prevent or relieve dry skin.

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 includes which of the following? (Select all that apply.) Allowing the client to speak Stabilizing the position of the tube Preventing aspiration of secretions Preventing air leaks Preventing tracheal injury

Correct Answers: B. Stabilizing the position of the tube C. Preventing aspiration of secretions D. Preventing air leaks An inflated cuff helps prevent movement of the endotracheal tube, reduces the risk of aspiration of oropharyngeal secretions, and keeps air from leaking around the outer portion of the endotracheal tube. Incorrect Answers:A. The client cannot speak when an endotracheal tube is in place. E. An inflated cuff does not prevent tracheal injury. If the cuff is overinflated and exerting a pressure that exceeds 25 mmHg, it can cause tracheal ischemia and necrosis.