Fundamentals Physiological Aspects/ Basics

A client who has reached the stage of acceptance in the grieving process appears peaceful, but demonstrates a lack of involvement with the environment. How should the nurse address this behavior? 1. Ignore the client's behavior when possible. 2. Accept the behavior the client is exhibiting. 3. Explore the reality of the situation with the client. 4. Encourage participation within the client's environment

2. Accept the behavior the client is exhibiting.

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls the expected sensory losses associated with aging. (Select all that apply.) 1. Difficulty in swallowing 2. Diminished sensation of pain 3. Heightened response to stimuli 4. Impaired hearing of high-frequency sounds 5. Increased ability to tolerate environmental heat

2. Diminished sensation of pain 4. Impaired hearing of high-frequency sounds

When being interviewed for a position as a licensed practical nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response? 1. Negligence 2. Malpractice 3. Breach of duty 4. False imprisonment

4. False imprisonment

A health care provider prescribes an antibiotic intravenous piggyback (IVPB) twice a day for a client with an infection. The health care provider prescribes peak and trough levels 48 and 72 hours after initiation of the therapy. The client asks the nurse why there is a need for so many blood tests. The nurse's best response is, "These tests will: 1. determine adequate dosage levels of the drug." 2. detect if you are having an allergic reaction to the drug." 3. permit blood culture specimens to be obtained when the drug is at its lowest level." 4. allow comparison of your fever to when the blood level of the antibiotic is at its highest."

1. determine adequate dosage levels of the drug."

A nurse is caring for a client for whom segmental postural drainage treatments are prescribed. The nurse should avoid scheduling the treatment at what time? 1. At bedtime 2. After a meal 3. One hour before a meal 4. One hour after awakening

2. After a meal

A client with cancer is informed that the chemotherapy is no longer working and that death is inevitable. Keeping in mind Kübler-Ross's stages of death and dying, place the following nursing interventions that are most appropriately associated with each stage in order from the stage of denial to acceptance. 1. Help the client identify realistic versus unrealistic goals. 2. Avoid confronting the client. 3. Redirect negative feelings constructively. 4. Help the client celebrate the simple pleasures in everyday life. 5. Provide maximal comfort measures.

2. Avoid confronting the client. 3. Redirect negative feelings constructively. 1. Help the client identify realistic versus unrealistic goals. 4. Help the client celebrate the simple pleasures in everyday life. 5. Provide maximal comfort measures.

A client with an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA) is scheduled for a computed tomography (CT) scan of the abdomen. To ensure client and visitor safety during transport, the nurse should implement which precaution? 1. No special precautions are required. 2. Cover the infected site with a dressing. 3. Drape the client with a covering labeled as biohazardous. 4. Place a surgical mask on the client.

2. Cover the infected site with a dressing.

A visitor in the waiting room of the emergency department has a syncopal episode and collapses on the floor. The event is witnessed by a nurse, who provides initial care. The nurse assessed the client, maintained safety of the environment, and gave a report to the emergency department nurse, who will provide ongoing care. What should the nurse who witnessed the event do next? 1. Contact the family 2. Document the incident 3. Report the incident to the nurse manager 4. Escort the client to the radiology department

2. Document the incident

The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin in the blood has what effect on oxygenation status? 1. Except with rare blood disorders, hemoglobin seldom affects oxygenation status. 2. There are many other factors that impact oxygenation status more than hemoglobin does. 3. A low hemoglobin level causes reduced oxygen-carrying capacity. 4. Hemoglobin reflects the body's clotting ability and may or may not impact oxygenation status.

3. A low hemoglobin level causes reduced oxygen-carrying capacity.

A client is admitted voluntarily to a psychiatric unit. Later, the client develops severe pain in the right lower quadrant and is diagnosed as having acute appendicitis. How should the nurse prepare the client for the appendectomy? 1. Have two nurses witness the client signing the operative consent form. 2. Ensure that the health care provider and the psychiatrist sign for the surgery because it is an emergency procedure. 3. Ask the client to sign the operative consent form after the client has been informed of the procedure and required care. 4. Inform the client's next of kin that it will be necessary for one of them to sign the consent form because the client is on a psychiatric unit.

3. Ask the client to sign the operative consent form after the client has been informed of the procedure and required care.

A nurse is taking care of a client who is extremely confused and experiencing bowel incontinence. What measures can the nurse take to prevent skin breakdown in this client? 1. Instruct the client to call for help with elimination needs; answer the client's call light immediately to avoid incontinence. 2. Place a waterproof pad under the client to prevent incontinence and soiling the linens. 3. Check the client's buttocks at least every two hours; clean the patient immediately after discovering incontinence. 4. Offer toileting to the client every two hours to prevent incontinence

3. Check the client's buttocks at least every two hours; clean the patient immediately after discovering incontinence.

A client reaches the point of acceptance during the stages of dying. What response should the nurse expect the client to exhibit? 1. Apathy 2. Euphoria 3. Detachment 4. Emotionalism

3. Detachment

A client comes to the medical clinic complaining of headaches. The nurse measures the blood pressure at 172/114. What should the nurse do first? 1. Page the on-call health care provider and continue to monitor the blood pressure. 2. Administer ibuprofen and have the client rest quietly for 20 minutes. 3. Elevate the head of the bed, provide reassurance, and reassess the blood pressure. 4. Place the client in the supine position, administer oxygen, and notify the health care provider.

3. Elevate the head of the bed, provide reassurance, and reassess the blood pressure.

A client is admitted with a diagnosis of premature labor. The nurse discovers that the client has been using heroin throughout her pregnancy. What is the most appropriate action for the nurse to take? 1. Notify the nurse manager of the unit. 2. Inform no one because all client information is confidential. 3. Inform the client's healthcare provider. 4. Alert the hospital security department because heroin is an illegal substance.

3. Inform the client's healthcare provider.

The nurse is caring for a client who is on a low carbohydrate diet. With this diet, there is decreased glucose available for energy, and fat is metabolized for energy resulting in an increased production of which substance in the urine? 1. Protein 2. Glucose 3. Ketones 4. Uric acid

3. Ketones

A client is hospitalized because of severe depression. The client refuses to eat, stays in bed most of the time, does not talk with family members, and will not leave the room. The nurse attempts to initiate a conversation by asking questions but receives no answers. The nurse is frustrated and tells the client that if there is no response, the nurse will leave and the client will remain alone. How should the nurse's behavior be interpreted? 1. A system of rewards and punishment is being used to motivate the client. 2. Leaving the client alone allows time for the nurse to think of other strategies. 3. This behavior indicates the client's desire for solitude that the nurse is respecting. 4. This threat is considered assault, and the nurse should not have reacted in this manner.

4. This threat is considered assault, and the nurse should not have reacted in this manner. **This response is a threat (assault) because the nurse is attempting to put pressure on the client to speak or be left alone. This is not a reward and punishment technique that is used in behavior modification therapy. Clients in emotional crisis should not be left alone.

The nurse is preparing to assess the four abdominal quadrants of a client who complains of stomach pain. When determining the order of the assessment, the nurse recognizes that it is important to assess the symptomatic quadrant: 1. first. 2. second. 3. third. 4. last.

4. last.

Four days after abdominal surgery a client has not passed flatus and there are no bowel sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely cause of the ileus? 1. Decreased blood supply 2. Impaired neural functioning 3. Perforation of the bowel wall 4. Obstruction of the bowel lumen

2. Impaired neural functioning

Immediately after receiving spinal anesthesia a client develops hypotension. To what physiological change does the nurse attribute the decreased blood pressure? 1. Dilation of blood vessels 2. Decreased response of chemoreceptors 3. Decreased strength of cardiac contractions 4. Disruption of cardiac accelerator pathways

1. Dilation of blood vessels

A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? 1. Evaluation 2. Data Collection 3. Nursing interventions 4. Proposed nursing care

1. Evaluation

What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? (Select all that apply.) 1 .Tetany 2 . Seizures 3 . Diarrhea 4 . Weakness 5 . Dysrhythmias

3 . Diarrhea 4 . Weakness 5 . Dysrhythmias

When caring for a client with varicella and disseminated herpes zoster, the nurse should implement which types of precautions? (Select all that apply.) 1 . Airborne 2. Contact 3. Droplet 4 . Hazardous Wastes 5 . Standard

5 . Standard 1 . Airborne 2. Contact

A client has a platelet count of 49,000/mL. The nurse should instruct the client to avoid which activity? 1. Ambulation 2. Blowing the nose 3. Visiting with children 4. The semi-Fowler's position

2. Blowing the nose

A client with rheumatoid arthritis does not want the prescribed cortisone and informs the nurse. Later, the nurse attempts to administer cortisone. When the client asks what the medication is, the nurse gives an evasive answer. The client takes the medication and later discovers that it was cortisone. The client states an intent to sue. What factors in this situation must be considered in a legal action? (Select all that apply.) 1 . Clients have a right to refuse treatment. 2. Nurses are required to answer clients truthfully. 3. The health care provider should have been notified. 4. The client had insufficient knowledge to make such a decision. 5. Legally prescribed medications are administered despite a client's objections.

1 . Clients have a right to refuse treatment. 2. Nurses are required to answer clients truthfully. 3. The health care provider should have been notified.

The nurse recognizes that which are important components of a neurovascular assessment? (Select all that apply.) 1. Orientation 2. Capillary refill 3. Pupillary response 4. Respiratory rate 5. Pulse and skin temperature 6. Movement and sensation

1. Orientation 4. Respiratory rate 5. Pulse and skin temperature

A nurse is reinforcing teaching to an adolescent about type 1 diabetes and self-care. Which questions from the client indicate a need for additional teaching in the cognitive domain? (Select all that apply.) 1. "What is diabetes?" 2 . "What will my friends think?" 3 . "How do I give myself an injection?" 4. "Can you tell me how the glucose monitor works?" 5 . "How do I get the insulin from the vial into the syringe?"

1. "What is diabetes?" 4. "Can you tell me how the glucose monitor works?"

A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? (Select all that apply.) 1. Pain history including location, intensity and quality of pain 2. Client's purposeful body movement in arranging the papers on the bedside table 3. Pain pattern including precipitating and alleviating factors 4. Vital signs such as increased blood pressure and heart rate 5. The client's family statement about increases in pain with ambulation

1. Pain history including location, intensity and quality of pain 3. Pain pattern including precipitating and alleviating factors

Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? (Select all that apply.) 1. Prayer 2. Hypnosis 3. Medication 4. Aromatherapy 5. Guided imagery

1. Prayer 2. Hypnosis 4. Aromatherapy 5. Guided imagery

A teenager begins to cry while talking with the nurse about the problem of not being able to make friends. What is the most therapeutic nursing intervention? 1. Sitting quietly with the client. 2. Telling the client that crying is not helpful. 3. Suggesting that the client play a board game. 4. Recommending how the client can change this situation.

1. Sitting quietly with the client.

Which nursing interventions require a nurse to wear gloves? (Select all that apply.) 1. Giving a back rub. 2. Cleaning a newborn immediately after delivery. 3. Emptying a portable wound drainage system. 4. Interviewing a client in the emergency department. 5. Obtaining the blood pressure of a client who is human immunodeficiency virus (HIV) positive

2. Cleaning a newborn immediately after delivery. 3. Emptying a portable wound drainage system.

What are the best ways for a nurse to be protected legally? (Select all that apply.) 1. Ensure that a therapeutic relationship with all clients has been established. 2. Provide care within the parameters of the state's nurse practice act. 3. Carry at least $100,000 worth of liability insurance. 4. Document consistently and objectively. 5. Clearly document a client's non-adherence to the medical regimen

2. Provide care within the parameters of the state's nurse practice act. 4. Document consistently and objectively. 5. Clearly document a client's non-adherence to the medical regimen

A home health nurse checks the client's vital signs and completes a follow- up visit. After completion of these tasks, the client asks the nurse to straighten the blankets on the bed. What is the nurse's most appropriate response? 1. "I would, but my back hurts today." 2. "Okay. It will be my good deed for the day." 3. "Of course. I want to do whatever I can for you." 4. "I would like to, but it is not in my job description."

3. "Of course. I want to do whatever I can for you."

A client is scheduled to receive phenytoin (Dilantin) 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication? 1. Sprinkle the powder from the capsule into a cup of water. 2. Insert a rectal suppository containing 100 mg of phenytoin. 3. Contact the prescriber to determine if a change to a suspension form would be possible. 4. Obtain a change in the administration route to allow an intramuscular (IM) injection

3. Contact the prescriber to determine if a change to a suspension form would be possible.

A nurse is evaluating the appropriateness of a family member's initial response to grief. What is the most important factor for the nurse to consider? 1. Personality traits 2. Educational level 3. Cultural background 4. Past experiences with death

3. Cultural background

When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as: 1. Evidence 2. Tort discovery 3. Proximate cause 4. Common cause

3. Proximate cause

A client becomes hostile when learning that amputation of a gangrenous toe is being considered. After the client's outburst, what is the best indication that the nurse-client interaction has been therapeutic? 1. Increased physical activity 2. Absence of further outbursts 3. Relaxation of tensed muscles 4. Denial of the need for further discussion

3. Relaxation of tensed muscles

A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past two days. The first thing the nurse should do when caring for this client is to: 1. Encourage fluids 2. Administer oxygen 3. Take the temperature 4. Collect a sputum specimen

3. Take the temperature

While caring for a client with a Hemovac portable wound drainage system, the nurse observes that the collection container is half full. The nurse empties the container. What is the next nursing intervention? 1. Encircle the drainage on the dressing. 2. Irrigate the suction tube with sterile saline. 3. Clean the drainage port with an alcohol wipe. 4. Compress the container before closing the port.

4. Compress the container before closing the port.

An older client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which interventions have specific gerontologic implications the nurse must consider? (Select all that apply.) 1. Assessment of skin turgor 2. Documentation of vital signs 3. Assessment of intake and output 4. Administration of antiemetic drugs 5 .Replacement of fluid and electrolytes

1. Assessment of skin turgor 4. Administration of antiemetic drugs 5 .Replacement of fluid and electrolytes

What nursing actions best promote communication when obtaining a nursing history? (Select all that apply.) 1. Establishing eye contact 2. Paraphrasing the client's message 3. Asking "why" and "how" questions 4. Using broad, open-ended statements 5. Reassuring the client that there is no cause for alarm 6. Asking questions that can be answered with a "yes" or "no"

1. Establishing eye contact 2. Paraphrasing the client's message 4. Using broad, open-ended statements

After several weeks of caring for clients who are in the terminal stage of illness, the nurse becomes aware of feeling depressed when coming to work. What should the nurse do? 1. Talk with other nurses on the unit. 2. Take several personal days off from work. 3. Limit emotional involvement with the clients. 4. Request a transfer to another area of the hospital.

1. Talk with other nurses on the unit.

The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? (Select all that apply.) 1. Whole grains 2. Cooked fruit and vegetables 3. Nuts and seeds 4. Lean red meats 5. Milk and eggs

1. Whole grains 2. Cooked fruit and vegetables 5. Milk and eggs

A client reports severe pain two days after surgery. After assessing the characteristics of the pain, which initial action should the nurse take next? 1. Encourage rest. 2. Obtain the vital signs. 3. Administer the prescribed analgesic. 4. Document the client's pain response

2. Obtain the vital signs.

The nurse should monitor for which involuntary physiological response in a client who is experiencing pain? 1Crying 2. Splinting 3. Perspiring 4. Grimacing

3. Perspiring

What clinical finding indicates to the nurse that a client may have hypokalemia? 1. Edema 2. Muscle spasms 3. Kussmaul breathing 4. Abdominal distention

4. Abdominal distention

A health care provider prescribes famotidine (Pepcid) and magnesium hydroxide/aluminum hydroxide (Maalox) for a client with a peptic ulcer. The nurse should teach the client to take the Maalox at what time? 1. Only at bedtime, when famotidine is not taken. 2. Only if famotidine is ineffective. 3. At the same time as famotidine, with a full glass or water 4. One hour before or two hours after famotidine

4. One hour before or two hours after famotidine

A client who weighs 176 pounds is receiving 8 mg/kg cyclosporine (Sandimmune) each day to prevent organ transplant rejection. How many milligrams should the nurse administer each day? Record your answer using a whole number. _________ mg First compute the client's weight in kilograms and then compute the dosage. Solve the problem using ratio and proportion.

Desired 176 pounds = x kg Have 2.2 pounds = 1 kg 2.2 x = 176 x = 176 ÷ 2.2 x = 80 kg Desired 80 kg X x mg Have 1 kg 8 mg 1x = 80 X 8 x = 640 mg

What physiological changes that occur with aging must be taken into consideration when the nurse provides care for the older adult? (Select all that apply.) 1 . Urinary urgency 2 . Loss of skin elasticity 3. Increased body warmth 4 . Swallowing difficulties 5 . Elevated blood pressure

1 . Urinary urgency 2 . Loss of skin elasticity 4 . Swallowing difficulties 5 . Elevated blood pressure

A nurse provides teaching for a client who is scheduled for a cholecystectomy. In the initial postoperative period, the nurse explains that the most important part of the treatment plan is: 1. Early ambulation 2. Coughing and deep breathing 3. Wearing anti-embolic elastic stockings 4. Maintenance of a nasogastric tube

2. Coughing and deep breathing

A 2-g sodium diet is prescribed for a client with stage 2 hypertension, and the nurse teaches the client the rationale for this diet. The client reports distaste for the food. The primary nurse hears the client request that the family "bring in a ham and cheese sandwich and fries." What is the most effective nursing intervention? 1. Discuss the diet with the client and family. 2. Tell the client why salty foods should not be eaten. 3. Explain the dietary restriction to the client's visitors. 4. Ask the dietitian to teach the client and family about sodium restrictions.

1. Discuss the diet with the client and family.

A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? (Select all that apply.) 1. Dry cerumen 2. Tears in the tympanic membrane 3. Difficulty hearing high-pitched voices 4. Decrease of hair in the auditory canal 5. Overgrowth of the epithelial auditory lining

1. Dry cerumen 3. Difficulty hearing high-pitched voices

To decrease abdominal distention following a client's surgery, what actions should the nurse take? (Select all that apply.) 1. Encourage ambulation 2. Give sips of ginger ale 3. Auscultate bowel sounds 4. Provide a straw for drinking 5. Offer an opioid analgesic

1. Encourage ambulation 3. Auscultate bowel sounds

Place each step of the nursing process in the order that it should be used. 1. Obtain client's nursing history. 2. State client's nursing needs. 3. Develop a plan of care. 4. Identify goals for care. 5. Implement nursing interventions.

1. Obtain client's nursing history. 2. State client's nursing needs. 4. Identify goals for care. 3. Develop a plan of care. 5. Implement nursing interventions.

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? (Select all that apply.) 1. Oral temperature 98.2° F 2. Apical pulse 88 beats per minute and regular 3. Respiratory rate of 30 per minute 4. Blood pressure 116/78 mm Hg while in a sitting position 5. Oxygen saturation of 92%

1. Oral temperature 98.2° F 2. Apical pulse 88 beats per minute and regular 4. Blood pressure 116/78 mm Hg while in a sitting position

A client has received instructions to take 650 mg aspirin (ASA) every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? (Select all that apply.) 1. Take the aspirin with meals or a snack. 2. Make an appointment with a dentist if bleeding gums develop. 3. Do not chew enteric-coated tablets. 4. Switch to Tylenol (acetaminophen) if tinnitus occurs. 5 . Report persistent abdominal pain.

1. Take the aspirin with meals or a snack. 3. Do not chew enteric-coated tablets. 5 . Report persistent abdominal pain.

Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibit formation of aqueous humor for a client with glaucoma? 1. Chlorothiazide (Diuril) 2. AcetaZOLAMIDE (Diamox) 3. Bendroflumethiazide (Naturetin) 4. Demecarium bromide (Humorsol)

2. AcetaZOLAMIDE (Diamox)

A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a hematoma is developing, edema is present and that the client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the applying of a/an: 1. Binder 2. Ice bag 3. Elastic bandage 4. Warm compress

2. Ice bag

A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client? 1. Arrangements will be made by the client and the client's family. 2. The plan is formulated and implemented early in the client's care. 3. The rehabilitation is minimal and short term because the client will return to former activities. 4. Arrangements will be made for long-term care because the client is no longer capable of self-care

2. The plan is formulated and implemented early in the client's care.

An adolescent that had an inguinal hernia repair is being prepared for discharge home. The nurse provides instructions about resumption of physical activities. Which statement by the adolescent indicates that the client understands the instructions? 1. "I can ride my bike in about a week." 2. "I don't have to go to gym class for 3 months." 3. "I can't perform any weightlifting for at least 3 weeks." 4. "I can never participate in football again."

3. "I can't perform any weightlifting for at least 3 weeks."

The nurse instructs a client that, in addition to building bones and teeth, calcium is also important for: 1. Bile production. 2. Blood production. 3. Blood clotting. 4. Digestion of fats.

3. Blood clotting.

A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive? 1. Hepatitis C (HepC) 2. Influenza type B (HIB) 3. Measles, mumps, rubella (MMR) 4. Diphtheria, tetanus, pertussis (DTaP)

3. Measles, mumps, rubella (MMR)

A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client: 1. Picks up the walker and carries it for short distances. 2. Uses the walker only when someone else is present. 3. Moves the walker no more than 12 inches in front of the client during use. 4. States that a walker will be purchased on the way home from the hospital.

3. Moves the walker no more than 12 inches in front of the client during use.

What factors are most important for the nurse to consider when delegating responsibilities? 1. Preferences of the clients and staff 2. Physical layout of the unit and client rooms 3. Staff member's level of education and expertise 4. Client's diagnosis and length of time in the hospital

3. Staff member's level of education and expertise

A nurse is caring for a client diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? 1. Droplet precautions 2. Reverse isolation 3. Surgical asepsis 4. Medical asepsis

3. Surgical asepsis

A recent immigrant from mainland China is critically ill and dying. What question should the nurse ask when collecting information to meet the emotional needs of this client? 1."Do you like living in this country?" 2. "When did you come to this country?" 3. "Is there a family member who can translate for you?" 4. "Which family member do you prefer to receive information?"

4. "Which family member do you prefer to receive information?"

The nurse is caring for a client that underwent a rhinoplasty surgical procedure 5 hours ago. After administering pain medication, the nurse notes the client is swallowing frequently. The nurse understands that the cause of frequent swallowing is most likely caused from: 1. A normal response to the analgesic 2. Oral dryness caused by nasal packing 3. An adverse reaction to anesthesia 4. Bleeding posterior to the nasal packing

4. Bleeding posterior to the nasal packing

A nurse preparing to apply restraints to a client should understand which of the following principles? 1. The law prohibits restraining clients until a written prescription is obtained. 2. Charges of felony may be leveled against nurses who use restraints improperly. 3. Nurses are not obligated to report institutions that use restraints unlawfully. 4. Charges of assault and battery may be leveled against nurses who use restraints improperly.

4. Charges of assault and battery may be leveled against nurses who use restraints improperly.

The nurse is caring for a client who is receiving therapy for vitamin B12 deficiency. Which finding indicates that the therapy is having the desired effect? 1.Normal serum electrolyte levels 2. Healthy skin integrity 3. Resolution of peripheral edema 4. Improved hemoglobin and hematocrit levels

4. Improved hemoglobin and hematocrit levels

A visitor from a room adjacent to a client asks the nurse what disease the client has. The nurse responds, "I cannot discuss any client's illness with you." What legal issue supports the nurse's response? 1. Libel 2. Slander 3. Negligence 4. Invasion of privacy

4. Invasion of privacy

A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. The nurse should assign the client to which type of room? 1. Private room 2. Semi-private room 3. Room with windows that can be opened 4. Negative airflow room

4. Negative airflow room

A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish normal bowel pattern? 1. Administer a mineral oil enema. 2. Offer one cup of fluid every hour. 3. Manually remove fecal impactions. 4. Offer a cup of prune juice

4. Offer a cup of prune juice

When providing preoperative teaching, the nurse should focus primarily on: 1. Helping the client and family decide if surgery is necessary. 2. Providing emotional support to the client and family. 3. Giving minute-by-minute details of the surgery to the client and family. 4. Providing general information to reduce client and family anxiety

4. Providing general information to reduce client and family anxiety

Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason? 1. To avoid strain on the incision 2. To promote drainage of the wound 3. To provide stimulation for the client 4. To reduce edema at the operative site

4. To reduce edema at the operative site

-A client is to receive 2000 mL of intravenous (IV) fluid in 12 hours. At what rate should the nurse set the electronic infusion control device? Record the answer using a whole number. ______ mL/hr

Electronic infusion control devices require a nurse to set the rate (mL/hr) and volume to be infused. Solve the problem by dividing the total milliliters to be infused by the number of hours of the infusion. 2000 ÷ 12 = 166.66. Most agencies will round this to a whole number (167), but some devices can be set to the nearest tenth (166.7), so the nurse should check agency policy.

The intake and output of a client over an eight-hour period is: 0800: Intravenous (IV) infusing; 900 mL left in bag; 0830: 150 mL voided; From 0900-1500 time period: 200 mL gastric tube formula + 50 mL water; Repeated x 2.; 1300: 220 mL voided; 1515: 235 mL voided; 1600: IV has 550 mL left in bag. What is the difference between the client's intake and output? Record the answer using a whole number. _________ mL

Intake includes 350 mL of IV fluid, 600 mL of nasogastric intubation (NGT) feeding, and 150 mL of water via NGT, for a total intake of 1100 mL; output includes voidings of 150, 220, and 235 mL, for a total output of 605 mL. Subtract 605 mL from 1100 mL for a difference of 495 mL.

Filgrastim (Neupogen) 5 mcg/kg/day by injection is prescribed for a client who weighs 132 lb. The vial label reads filgrastim 300 mcg/mL. How many milliliters should the nurse administer? Record the answer using a whole number. ______ mL

The health care provider prescribed 5 mcg/kg; therefore, 5 × 60 = 300 mcg. This desired amount is contained in 1 mL, as indicated on the vial label.

An intravenous (IV) solution of 1000 mL 5% dextrose in water is to be infused at 125 mL/hr to correct a client's fluid imbalance. The infusion set delivers 15 drops/mL. To ensure that the solution will infuse over an eight-hour period, at how many drops per minute should the nurse set the rate of flow? Record the answer using a whole number. ______ gtts/min

Use the following formula to solve the problem. Drops per minute = total volume in drops (total mL x drop factor)/Total time in minutes (hours x 60) Drops per minute = 1000 mL x 15/8 x 60 = 15,000/480 = 31.25 = 31 gtts/min