HESI Fundamentals V.2

A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A) Sexual activity patterns. B) Nutritional history. C) Leisure activities. D) Financial stressors.

B) Nutritional history. Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history (C) should be obtained first so that health teaching can be initiated if indicated. (A and C) can be used for stress management. Though (D) can be a source of anxiety, a nutritional history should be obtained first.

To assess the quality of an adult client's pain, what approach should the nurse use? A) Observe body language and movement. B) Provide a numeric pain scale. C) Ask the client to describe the pain. D) Identify effective pain relief measures.

C) Ask the client to describe the pain.

What self-care outcome is best for the nurse to use in evaluating a client's recovery form a stroke that resulted in left-sided hemiparesis? A) Promote independence by allowing client to perform all self-care activities. B) Participates in self-care to optimal level of capacity. C) Client verbalizes importance of hygienic practices in the recovery process. D) Self-care needs to be completed by the unlicensed assistive personnel.

C) Client verbalizes importance of hygienic practices in the recovery process.

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? A) Turning the client every 2 hours. B) Maintaining a cool room temperature. C) Encouraging increased fluid intake. D) Elevating the head of the bed 30 degrees.

C) Encouraging increased fluid intake.

What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency? A) Check capillary refill of toes on lower extremity with Unna's paste boot. B) Apply dressing to wound area before applying the Unna's paste boot. C) Wrap the leg from the knee down towards the foot. D) Remove the Unna's paste boot q8h to assess wound healing.

A) Check capillary refill of toes on lower extremity with Unna's paste boot.

The home health nurse is reviewing the personal care of an elderly client who lives alone. Which client assessment findings indicate the need to assign unlicensed assistive personnel (UAP) to provide routine foot care and file the client's toenails? Select all that apply. A) Syncope when bending. B) Hand tremors. C) Diminished visual acuity. D) Urinary incontinence. E) Shuffling gait.

A) Syncope when bending. B) Hand tremors. C) Diminished visual acuity.

On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? A) Assault. B) Battery. C) Malpractice. D) False imprisonment.

B) Battery Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching). Performing any procedure against the client's wishes can potentially poise a legal issue, such as battery (B), even if the procedure is of questionable benefit to the client. (A, C, and D) are not examples against the client's request.

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform? A) Tilt the pelvis forwards and backwards. B) Bend the arm by flexing the ulnar to the humerus. C) Turn the head to the right and left. D) Extend the arm at the side and rotate in circles.

B) Bend the arm by flexing the ulnar to the humerus.

The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3L/minute, and the client's oxygen saturation level is 92%. What intervention should the nurse implement? A) Decrease the flow rate to 1 L/minute. B) Discontinue the use of the nasal cannula. C) Apply lubricant to the cannula tubing. D) Place padding around the cannula tubing.

B) Discontinue the use of the nasal cannula.

The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? A) Empty the client's urinary drainage bag. B) Draw up the irrigating solution into the syringe. C) Secure the client's catheter to the drainage tubing. D) Use aseptic technique to instill the irrigating solution.

B) Draw up the irrigating solution into the syringe.

A client is discharged to a long-term care facility with an indwelling urinary catheter. Which nursing action should be included in the plan to reduce the client's risk for infection related to the catheter? A) Flush the catheter daily with sterile saline. B) Encourage increased intake of oral fluids. C) Administer a PRN antipyretic if a fever develops. D) Secure the drainage bag at bladder level during transport.

B) Encourage increased intake of oral fluids.

The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? A) Clamp the tube for 20 minutes. B) Flush the tube with water. C) Administer the medications as prescribed. D) Crush the tablets and dissolve in sterile water.

B) Flush the tube with water. The NGT should be flushed before, after, and in between each medication administered (B). Once all medications are administered, the NGT should be clamped for 20 minutes (A). (C and D) may be implemented only after the tubing has been flushed.

An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is A) Prone. B) Fowler's. C) Sims'. D) Supine.

B) Fowler's. The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration.

A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A) Administer the medication more rapidly using the same IV site. B) Initiate an alternate site for the IV infusion of the medication. C) Notify the healthcare provider before administering the next dose. D) Give the client a PRN dose of aspirin while the medication infuses.

B) Initiate an alternate site for the IV infusion of the medication. A cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated (B) before administering the next dose. Rapid administration (A) of intravenous cephalosporins can potentiate vessel irritation and increase the risk of thrombophlebitis. (C) is not necessary to initiate an alternative IV site. Although aspirin has anti-inflammatory actions, (D) is not indicated.

When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? A) Establish a new nursing diagnosis. B) Note which actions were not implemented. C) Add additional nursing orders to the plan. D) Collaborate with the healthcare provider to make changes.

B) Note which actions were not implemented. First, the nurse reviews which actions in the original plan were not implemented (B) in order to determine why the original plan did not produce the desired outcome. Appropriate revisions can then be made, which may include revising the expected outcome, or identifying a new nursing diagnosis (A). (C) may be needed if the nursing actions were unsuccessful, or were unable to be implemented. (D) other members of the healthcare team may be necessary to collaborate changes once the nurse determines why the original plan did not produce the desired outcome.

What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? A) Maintain in a lateral position using protective wrist and vest devices. B) Position prone with a small pillow below the diaphragm. C) Raise the head and knee gatch when lying in a supine position. D) Transfer into a wheelchair close to the nurse's station for observation.

B) Position prone with a small pillow below the diaphragm.

The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? A) Check for a blood return. B) Reposition the client's arm. C) Remove the IV site dressing. D) Flush the lock with saline.

B) Reposition the client's arm.

During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? A) Request another nurse to complete the physical assessment. B) Ask the client to stop crying and tell the nurse what is wrong. C) Acknowledge the client's distress and tell her it is all right to cry. D) Leave the room so that the client can be alone to cry in private.

C) Acknowledge the client's distress and tell her it is all right to cry. Acknowledging the client's distress and giving the client the opportunity to verbalize her distress (C) is a supportive response. (A, B, and D) are not supportive and do not facilitate the client's expression of feelings.

A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement? A) Document the client's circadian rhythms. B) Assess for flushed, warm skin regularly. C) Measure temperature at regular intervals. D) Vary sites for temperature measurement.

C) Measure temperature at regular intervals.

When measuring vital signs, the nurse observes that a client is using accessory neck muscles during respiration. What follow-up action should the nurses take first? A) Determine pulse pressure. B) Auscultate heart sounds. C) Measure oxygen saturation. D) Check for neck vein distention.

D) Check for neck vein distention.

Which client care requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? A) Removing the empty food tray from a client with a urinary catheter. B) Washing and combing the hair of a client with a fractured leg in traction. C) Administering oral medications to a cooperative client with a wound infection. D) Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

D) Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client w/ left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A) Place the chair at a right angle to the bed on the client's left side before moving. B) Assist the client to a standing position, then place the right hand on the armrest. C) Have the client place the left foot next to the chair and pivot to the left before sitting. D) Move the chair parallel to the right side of the bed, and stand the client on the right foot.

D) Move the chair parallel to the right side of the bed, and stand the client on the right foot.

The nurse assesses an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8 F, and his output is 100 ml of concentrated urine during the last hour. He has wet- sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is most important for the nurse to implement? A) Administer a PRN antihypertensive prescription. B) Provide the client with an additional blanket. C) Encourage additional fluid intake. D) Turn the client q2h.

A) Administer a PRN antihypertensive prescription.

Which action by the nurse demonstrates culturally sensitive care? A) Asks permission before touching a client. B) Avoids questions about male-female relationships. C) Explains the differences between Western medical care and cultural folk remedies. D) Applies knowledge of a cultural group unless a client embraces Western customs.

A) Asks permission before touching a client. Physical contact, such as touching the head, in some cultures, is a sign of respect, whereas, in others, it is strictly forbidden. So asking permission before touching a client demonstrates culturally sensitive care.

In assisting an older adult client prepare to take a tub bath, which nursing action is most important? A) Check the bath water temperature. B) Shut the bathroom door. C) Ensure that the client has voided. D) Provide extra towels.

A) Check the bath water temperature.

A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? A) Commend the client for selecting a high biologic value protein. B) Remind the client that protein in the diet should be avoided. C) Suggest that the client also select orange juice, to promote absorption. D) Encourage the client to attend classes on dietary management of CRF.

A) Commend the client for selecting a high biologic value protein. Foods such as eggs and milk (A) are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair. Although a low-protein diet is followed (B), some protein is essential. Orange juice is rich in potassium, and should not be encouraged (C). The client has made a good diet choice, so (D) is not necessary.

The nurse observes a newly admitted older adult female take short steps and walk very slowly while pushing a walker in front of her. What action should the nurse take in response to these observations? A) Complete a full fall risk assessment of the client. B) Teach the client to take longer steps at faster pace. C) Suggest that the the client use a wheelchair instead of a walker. D) Place client on bedrest until the healthcare provider is notified.

A) Complete a full fall risk assessment of the client.

A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best? A) Determine the client's usual bedtime routine and include these rituals in the plan. of care as safety allows. B) Instruct the UAP not to wake the client under any circumstances during the night. C) Place a "Do Not Disturb" sign on the door and change assessments from every 4 to every 8 hours. D) Encourage the client to avoid pain medication during the day, which might increase daytime napping.

A) Determine the client's usual bedtime routine and include these rituals in the plan.

After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A) Determine the etiology of the problem. B) Prioritize nursing care interventions. C) Plan appropriate interventions. D) Collaborate with the client to set goals.

A) Determine the etiology of the problem. Before planning care, the nurse should determine the etiology, or cause, of the problem (A), because this will help determine (B, C, and D).

While the nurse is administering a bolus feeding to a client via a nasogastric tube, the client begins to vomit. Which action should the nurse implement first? A) Discontinue the administration of the bolus feeding. B) Auscultate the client's breath sounds bilaterally. C) Elevate the head of the bed to a high Fowler's position. D) Administer a PRN dose of a prescribed antiemetic.

A) Discontinue the administration of the bolus feeding. When a client receiving a tube feeding begins to vomit, the nurse should first stop the feeding to prevent further vomiting.

On the first day after abdominal surgery, the nurse auscultates a client's abdomen for bowel sounds; there are none. The nurse should: A) Document assessment findings in the client's medical record. B) Notify the health care provider (HCP). C) Ask another nurse to validate the absence of bowel sounds. D) Encourage the client to take more ice chips.

A) Document assessment findings in the client's medical record. Bowel sounds are not present until the third or fourth postoperative day; the nurse should document the assessment findings. Too many ice chips may promote abdominal distention, especially if the client is not ambulating in the intermediate postoperative period.

While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement? A) Encourage the client to see the clinic's grief counselor. B) Determine if the client has a family history of suicide attempts. C) Inquire about whether the life partner was suffering from AIDS. D) Consult with the health care provider about the client's need for antidepressant medications.

A) Encourage the client to see the clinic's grief counselor.

A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? A) Give an around-the-clock schedule for administration of analgesics. B) Administer analgesic medication as needed when the pain is severe. C) Provide medication to keep the client sedated and unaware of stimuli. D) Offer a medication-free period so that the client can do daily activities.

A) Give an around-the-clock schedule for administration of analgesics. The most effective management of pain is achieved using an around-the-clock schedule that provides analgesic medications on a regular basis (A) and in a timely manner. Analgesics are less effective if pain persists until it is severe, so an analgesic medication should be administered before the client's pain peaks (B). Providing comfort is a priority for the client who is dying, but sedation that impairs the client's ability to interact and experience the time before life ends should be minimized (C). Offering a medication-free period allows the serum drug level to fall, which is not an effective method to manage chronic pain.

The nurse observes a UAP positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. Which action should the nurse implement? A) Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. B) Ensure that the UAP has placed pillows effectively to protect the client. C) Ask the UAP to use some pillows to prop the client in a side-lying position. D) Assume responsibility for placing the pillows while the UAP complete another task.

A) Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. In an ideal world, you would have seizure guard pads, but in the HESI world, you do not have it. SO! Pillows guarding the rails is dangerous and could suffocate your patient if they seizure and it falls and covers their face. Blankets secured to the side rails can be tied down to ensure they do not fall on the patient's face.

Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client? A) Maintain standard precautions. B) Initiate contact isolation measures. C) Insert an indwelling urinary catheter. D) Instruct client in the use of adult diapers.

A) Maintain standard precautions.

The nurse assesses an older adult for signs of dehydration. Which findings would be consistent with a diagnosis of dehydration? A) Orthostatic hypotension. B) Moist crackles. C) Bounding pulse. D) Shortness of breath.

A) Orthostatic hypotension. Orthostatic hypotension or persistent hypotension is present in dehydration, as are poor skin turgor, dry oral mucous membranes, and tachycardia. If the dehydration is severe, the client may also be restless, confused, and thirsty. Most instances of crackles is indicative of excess fluid volume, not dehydration. Shortness of breath or a bounding pulse may be indicative of excess fluid, not dehydration.

The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction? A) Perform range-of-motion exercises to prevent contractures. B) Decrease the client's fluid intake to prevent diarrhea. C) Massage the client's legs to reduce embolism occurrence. D) Turn the client from side to back every shift.

A) Perform range-of-motion exercises to prevent contractures.

Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply.) A) Place the client in a side-lying position. B) Pull the auricle upward and outward. C) Hold the dropper 6 cm above the ear canal. D) Place a cotton ball into the inner canal. E) Pull the auricle down and back.

A) Place the client in a side-lying position. B) Pull the auricle upward and outward. The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E).

The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period of burn management. Which finding indicates that adequate fluid replacement has been achieved in the client? A) Urine output greater than 35 mL/hour. B) Blood pressure of 90/60 mm Hg. C) Fluid intake less than urinary output. D) An increase in body weight.

A) Urine output greater than 35 mL/hour. A urine output of 30 to 50 mL/h indicates adequate fluid replacement in the client with burns. An increase in body weight may indicate fluid retention. A urine output greater than fluid intake does not represent a fluid balance. Depending on the client, blood pressure of 90/60 mm Hg could indicate the presence of a hypovolemic state; by itself, it does not indicate adequate fluid replacement.

To avoid nerve injury, what location should the nurse select to administer a 3 mL IM injection? A) Ventrogluteal. B) Outer upper quadrant of the buttock. C) Two inches below the acromion process. D) Vastus lateralis.

A) Ventrogluteal.

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A) It is more difficult to find a superficial vein in the feet and ankles. B) A decreased flow rate could result in the formation of a thrombosis. C) A cannulated extremity is more difficult to move when the leg or foot is used. D) Veins are located deep in the feet and ankles, resulting in a more painful procedure.

B) A decreased flow rate could result in the formation of a thrombosis. Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (D) is not a consideration.

A nurse is performing an admission assessment on a client newly admitted to the hospital and has documented the client as being a member of the Native American subculture. A subculture is best described as which of the following? A) A cultural group with fewer than 5 million members in the United States. B) A unique cultural group that exists within the larger culture. C) A cultural group with values that are incongruent with those of the dominant culture. D) A unique cultural group with unspecified geographic origins.

B) A unique cultural group that exists within the larger culture. Subcultures are unique cultural groups that coexist within the dominant culture of the United States. Subcultures are not defined according to the size of their membership or the lack of specific geographic origins. Subcultures may have some values that differ from those of the dominant culture, but this is not their defining characteristic.

A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. Which action should the nurse implement? A) Document the client's request in the medical record. B) Ask the client if this decision has been discussed with his healthcare provider. C) Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts. D) Advise the client to designate a person to make healthcare decisions when the client is unable to do so.

B) Ask the client if this decision has been discussed with his healthcare provider. Advance directives are written statements of a person's wishes regarding medical care, and verbal directives may be given to a healthcare provider with specific instructions in the presence of two witnesses. To obtain this prescription, the client should discuss his choice with the healthcare provider.

A client has a nursing problem of, "Spiritual distress related to a loss of hope, secondary to impending death." Which intervention is best for the nurse to implement when caring for this client? A) Help the client to accept the final stage of life. B) Assist and support the client in establishing short-term goals. C) Encourage the client to make future plans, even if they are unrealistic. D) Instruct the client's family to focus on positive aspects of the client's life.

B) Assist and support the client in establishing short-term goals. Hopefulness is necessary to sustain a meaningful existence, even close to death. The nurse should help the client set short-term goals, and recognize the achievement of immediate goals, such as seeing a family member or listening to music.

A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide? A) Take a vitamin supplement tablet once a day. B) Change positions in the chair at least every hour. C) Increase daily intake of water or other oral fluids. D) Purchase a newer model wheelchair.

B) Change positions in the chair at least every hour.

The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next? A) Apply a warm compress proximal to the site. B) Check for kinks in the tubing and raise the IV pole. C) Adjust the tape that stabilizes the needle. D) Flush with normal saline and recount the drop rate.

B) Check for kinks in the tubing and raise the IV pole.

The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug? A) "Fill your lungs with air through your mouth and then compress the inhaler." B) "Compress the inhaler while slowly breathing in through your mouth." C) "Compress the inhaler while inhaling quickly through your nose." D) "Exhale completely after compressing the inhaler and then inhale."

B) "Compress the inhaler while slowly breathing in through your mouth."

The daughter of an older woman who became depressed following the death of her husband asks, "My mother was always well-adjusted until my father died. Will she tend to be sick from now on?" Which response is best for the nurse to provide? A) "She is almost sure to be less able to adapt than before." B) "It's highly likely that she will recover and return to her pre-illness state." C) "If you can interest her in something besides religion, it will help her stay well." D) "Cultural strains contribute to each woman's tendencies for recurrences of depression."

B) "It's highly likely that she will recover and return to her pre-illness state." Analysis of behavior patterns using Erikson's framework can identify age-appropriate or arrested development of normal interpersonal skills. Erikson describes the successful resolution of a developmental crisis in the later years (older than 65 years) to include the achievement of a sense of integrity and fulfillment, wisdom, and a willingness to face one's own mortality and accept the death of others.

The nurse attaches a pulse oximeter to a client's fingers and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading? A) BP 142/88 mmHg. B) 2+ edema of fingers and hands. C) Radial pulse volume is +3. D) Capillary refill time is 2 seconds.

B) 2+ edema of fingers and hands. (A) blood pressure has nothing to do with the patient's O2 saturation. (C) This means the patient's pulse is strong and appropriate, but does nothing to the O2 stat. (D) The patient is having appropriate blood flow and this has nothing to do with O2 stats. (B) is correct because when a patient has too much fluid in their body, they will have 2+ edema of fingers and hands, which means this fluid could also be in their lungs or sitting on their chest. Thus, decreasing their O2 stats.

Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A) Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C) Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D) Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.

B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance (B) rather than simply naming the condition. (A) identifies vesicles -- fluid filled blisters -- an incorrect description given the symptoms listed. (C) identifies papules -- solid elevated lesions, again not correctly identifying the symptoms. (D) identifies petechiae -- pinpoint red to purple skin discolorations that do not itch, again an incorrect identification.

A client has a cast applied to the left leg after sustaining a femur fracture during a skiing accident. Which interventions would the nurse provide to avoid complications from the cast application? Select all that apply. A) Bivalving the cast on both sides. B) Maintain the leg elevated above the level of the heart. C) Monitor distal pulses of the affected extremity. D) Apply warm compresses to the casted leg. E) Administer anticoagulation per healthcare provider's order.

B) Maintain the leg elevated above the level of the heart. C) Monitor distal pulses of the affected extremity. E) Administer anticoagulation per healthcare provider's order. The nurse would monitor the tightness of the cast by assessing the distal pulses and tightness of the cast. Edema can cause the cast to become tight and lead to compartment syndrome. Unless contraindicated, the leg would be elevated above the heart in order to increase venous return and decrease edema. Prophylactic anticoagulation will decrease the risk of clot formation. The nurse would apply cool compresses not warm. It is not within the nurse's scope of practice to cut the cast or bivalve the cast.

The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify placement of the IV access? A) Left brachial vein. B) Right cephalic vein. C) Dorsal side of the right wrist. D) Right upper extremity.

B) Right cephalic vein. The cephalic vein is large and superficial and identifies the anatomic name of the vein that is accessed, which should be included in the documentation. The basilic vein of the arm is used for IV access, not the brachial vein, which is too deep to be accessed for IV infusion. Although veins on the dorsal side of the right wrist are visible, they are fragile and using them would be painful, so they are not recommended for IV access. (D) is not specific enough for documenting the location of the IV access.

After a needle stick occurs while removing the cap from a sterile needle, which action should the nurse implement? A) Complete an incident report. B) Select another sterile needle. C) Disinfect the needle with an alcohol swab. D) Notify the supervisor of the department immediately.

B) Select another sterile needle.

The nurse determines a client's IV solution is infusing at 250 mL/hr. The prescribed rate is 125 mL/hr. Which action should the nurse take first? A) Determine when the IV solution was started. B) Slow the IV infusion to keep vein open rate. C) Assess the IV insertion site for swelling. D) Report the finding to the healthcare provider.

B) Slow the IV infusion to keep vein open rate. The nurse should first slow the IV flow rate to keep vein open (KVO) rate to prevent further risk of fluid volume overload, then gather additional assessment data, such as when the IV solution was started and the appearance of the IV insertion site before contacting the healthcare provider for further instructions.

The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention? A) The cuff wraps around the girth of the leg. B) The UAP auscultates the popliteal pulse with the cuff on the lower leg. C) The client is placed in a prone position. D) The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.

B) The UAP auscultates the popliteal pulse with the cuff on the lower leg. When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. The nurse should intervene with the UAP who has applied the cuff on the lower leg. (A) ensures an accurate assessment, and (C) provides the best access to the artery. Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher than in the brachial artery.

The nurse identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection? A) Administration of plasma expanders. B) Use of careful handwashing technique. C) Application of a topical antibacterial cream. D) Limiting visitors to the client with burns.

B) Use of careful handwashing technique.

Which action should the nurse implement when adding sterile liquids to a sterile field? A) Use an outdated sterile liquid if the bottle is sealed and has not been opened. B) Consider the sterile field contaminated if it becomes wet during the procedure. C) Remove the container cap and lay it with the inside facing down on the sterile field. D) Hold the container high and pour the solution into a receptacle at the back of the sterile field.

B) Consider the sterile field contaminated if it becomes wet during the procedure. Wet or damp areas on a sterile field allow organisms to wick from the table surface and permeate into the sterile area, so the field is considered contaminated if it becomes wet. Outdated liquids may be contaminated and should be discarded. The container's cap should be removed, placed facing up, and off the sterile field. To prevent contamination of the sterile field, liquids should be held close (6 inches) to the receptacle when pouring to prevent splashing, and the receptacle should be placed near the front edge to avoid reaching over or across the sterile field.

An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A) Prone. B) Fowler's. C) Sims'. D) Supine.

B) Fowler's The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration.

When caring for an immobile client, what nursing problem has the highest priority? A) Risk for fluid volume deficit. B) Impaired gas exchange. C) Risk for impaired skin integrity. D) Altered tissue perfusion.

B) Impaired gas exchange. The ABCs of caring for clients are airway, breathing, and circulation. Impaired gas exchange implies that the client is having trouble breathing, which has the highest priority of the nursing problems listed.

A male client with venous incompetence stands up and his blood pressure subsequently drops. Which finding should the nurse identify as a compensatory response? A) Bradycardia. B) Increase in pulse rate. C) Peripheral vasodilation. D) Increase in cardiac output.

B) Increase in pulse rate. When postural hypotension occurs, the body attempts to restore arterial pressure by stimulating the baroreceptors to increase the heart rate, not decrease it. Peripheral vasoconstriction of the veins and arterioles occurs with venous incompetence through the baroreceptor reflex. A decrease in cardiac output occurs when orthostatic hypotension occurs.

When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take? A) Deflate the cuff completely and immediately reattempt the reading. B) Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading. C) Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. D) Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.

C) Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. Deflating the cuff for 30 to 60 seconds allows blood flow to return to the extremity so that an accurate reading can be obtained on that extremity a second time.

During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? A) Adequate venous blood flow to the lower extremities. B) Estimated amount of body fat by an underarm skinfold. C) Degree of flexion and extension of the client's knee joint. D) Change in the circumference of the joint in centimeters.

C) Degree of flexion and extension of the client's knee joint. The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor (C). A doppler is used to measure blood flow (A). Calipers are used to measure body fat (B). A tape measure is used to measure circumference of body parts (D).

A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight-hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement? A) Notify healthcare provider and request to change the IV infusion to hypertonic D10W. B) Decrease in the infusion rate of the current IV and report to the healthcare provider. C) Document in the medical record that these normal findings are expected outcomes. D) Obtain potassium chloride 20 mEq in anticipation of a prescription to add to present IV.

C) Document in the medical record that these normal findings are expected outcomes. The results are all within normal range.(C). No changes are needed (A, B, and D).

A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment, and states that she is ready to go home to die. What intervention should the nurse initiate? A) Review the client's medical record for an advance directive. B) Determine if a do- not- resuscitate prescription has been obtained. C) Document that the client is being discharged against medical advice. D) Evaluate the client's mental status for competence to refuse treatment.

C) Document that the client is being discharged against medical advice.

Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A) Aspirating gastric contents to assure a pH value of 4 or less. B) Hearing air pass in the stomach after injecting air into the tubing. C) Examining a chest x-ray obtained after the tubing was inserted. D) Checking the remaining length of tubing to ensure that the correct length was inserted.

C) Examining a chest x-ray obtained after the tubing was inserted. Both (A and B) are methods used to determine proper placement of the NG tubing. However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator of proper placement

The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? A) Thalamus. B) Hypothalamus. C) Frontal lobe. D) Parietal lobe.

C) Frontal lobe. The frontal lobe (C) of the cerebrum controls higher mental activities, such as memory, intellect, language, emotions, and personality. (A) is an afferent relay center in the brain that directs impulses to the cerebral cortex. (B) regulates body temperature, appetite, maintains a wakeful state, and links higher centers with the autonomic nervous and endocrine systems, such as pituitary. (D) is the location of sensory and motor functions.

A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? A) Healthcare provider notified of failure to collect specimens for prescribed blood studies. B) Blood specimens not collected because client no longer wants blood tests performed. C) Healthcare provider notified of client's refusal to have blood specimens collected for testing. D) Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified.

C) Healthcare provider notified of client's refusal to have blood specimens collected for testing. When a client refuses a treatment, the exact words of the client regarding the client's refusal of care should be documented in a narrative format (C). (A, B, and D) do not address the concepts of informatics and legal issues.

A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. Which information should the nurse offer the client about the general use of herbal supplements? A) Most herbs are toxic or carcinogenic and should be used only when proven effective. B) There is no evidence that herbs are safe or effective as compared to conventional supplements in maintaining health. C) Herbs should be obtained from manufacturers with a history of quality control of their supplements. D) Herbal therapies may mask the symptoms of serious diseases, so frequent medical evaluation is required during use.

C) Herbs should be obtained from manufacturers with a history of quality control of their supplements. The current availability of many herbal supplements lacks federal regulation, research, control, and standardization in the manufacture of their purity and dose. Manufacturers that provide evidence of quality control, such as labeling that contains scientific generic name, name and address of the manufacturer, batch or lot number, date of manufacture, and expiration date, is the best information to provide.

The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A) If I exercise at least two times weekly for one hour, I will lower my cholesterol. B) I need to avoid eating proteins, including red meat. C) I will limit my intake of beef to 4 ounces per week. D) My blood level of low density lipoproteins needs to increase.

C) I will limit my intake of beef to 4 ounces per week. Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need to be eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low density lipoproteins (D) need to decrease rather than increase.

The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A) Infuse normal saline at a keep vein open rate. B) Discontinue the IV and flush the port with heparin. C) Infuse 10 percent dextrose and water at 54 ml/hr. D) Obtain a stat blood glucose level and notify the healthcare provider.

C) Infuse 10 percent dextrose and water at 54 ml/hr. TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood glucose level (D) and the healthcare provider cannot do anything about this situation.

Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next? A) Clamp the catheter and recheck it in 60 minutes. B) Pull the catheter back 3 inches and redirect upward. C) Leave the catheter in place and reattempt with another catheter. D) Notify the health care provider of a possible obstruction.

C) Leave the catheter in place and reattempt with another catheter. It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in place will help locate the meatus when attempting the second catheterization.

The nurse removes the dressing on a client's heel that is covering a pressure injury one inch in diameter and finds that there is straw-colored drainage seeping from the wound. Which description of this finding should the nurse include in the client's record? A) Stage 1 pressure injury draining serosanguineous drainage. B) Pressure injury at bony prominence with exudate noted. C) One-inch pressure injury draining serous fluid. D) Pressure injury on the heel with a small amount of purulent drainage.

C) One-inch pressure injury draining serous fluid. Serous drainage is clear watery plasma and provides accurate documentation based on the information provided. Information to stage this pressure injury is not provided, and serosanguineous drainage is pale and watery with a combination of plasma and red cells and may be blood-streaked. Exudate is a fluid such as pus and serum. Purulent drainage is thick, yellow, green, or brown indicating the presence of dead or living organisms and white blood cells.

What should the nurse do to prevent pressure ulcers in an older adult? A) Clean the skin daily using mild soap and hot water. B) Encourage the client to sit in a chair as much as possible. C) Perform a systematic skin assessment at least once a day. D) Massage bony prominences gently every shift.

C) Perform a systematic skin assessment at least once a day. Daily skin inspection is essential in preventing pressure ulcers. Hot water is irritating to skin and should be avoided. Massaging bony prominences is contraindicated and may actually promote skin breakdown. Prolonged, uninterrupted chair sitting should be avoided; the client's position should be adjusted at least every hour.

How should the nurse handle linens that are soiled with incontinent feces? A) Put the soiled linens in an isolation bag, then place it in the dirty linen hamper. B) Place an isolation hamper in the client's room and discard the linens in it. C) Place the soiled linens in the designated fluid-resistant dirty linen bag and deposit them in the dirty linen hamper. D) Ask the housekeeping staff to pick up the soiled linen from the dirty utility room.

C) Place the soiled linens in the designated fluid-resistant dirty linen bag and deposit them in the dirty linen hamper. The nurse should be careful to keep the soiled linens from contaminating the fresh linens and should handle the soiled linens like any other dirty linens as outlined in the facility guidelines/protocols.

When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first? A) Apply the blood pressure cuff securely. B) Record the client's pulse rate and rhythm. C) Position the client supine for a few minutes. D) Assist the client to stand at bedside.

C) Position the client supine for a few minutes.

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A) Position the client on the right side of the bed in reverse Trendelenburg. B) Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C) Reposition in a Sim's position with the client's weight on the anterior ilium. D) Raise the side rails on both sides of the bed and elevate the bed to waist level.

C) Reposition in a Sim's position with the client's weight on the anterior ilium. The left sided Sims' position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sims' position, which distributes the client's weight to the anterior ilium (C). (A) is inaccurate. (B and D) should be implemented once the client is positioned.

A client is in contact isolation due to stage IV coccyx wound infected with methicillinresistant staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple reentries to the client's room. In which order should the nurse perform the interventions? A) Change coccyx dressing, perform tracheostomy care, restart the IV. B) Perform tracheostomy care, change coccyx dressing, restart the IV. C) Restart the IV, perform tracheotomy care, change coccyx dressing. D) Change coccyx dressing, restart the IV, perform tracheostomy care.

C) Restart the IV, perform tracheotomy care, change coccyx dressing.

The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A) Tossed salad, low-sodium dressing, bacon and tomato sandwich. B) New England clam chowder, no-salt crackers, fresh fruit salad. C) Skim milk, turkey salad, roll, and vanilla ice cream. D) Macaroni and cheese, diet Coke, a slice of cherry pie.

C) Skim milk, turkey salad, roll, and vanilla ice cream. Skim milk, turkey, bread, and ice cream (C), while containing some sodium, are considered low-sodium foods. Bacon (A), canned soups (B), especially those with seafood, hard cheeses, macaroni, and most diet drinks (D) are very high in sodium.

A nurse reports to the hospital occupational health nurse (OHN) that he/she was splashed with blood during the resuscitation of an HIV-positive client. The nurse asks the OHN when he/she will know whether he/she is positive or negative for HIV infection. Which of the following is the most appropriate response by the OHN? A) "The test results will vary during the first year of testing for the disease." B) "We will test you in 4 weeks, and then we will have a definitive answer." C) "Accurate results will be obtained by testing at 3 months and again at 6 months." D) "Most nurses who have been splashed do not test positive if they wash immediately."

C) "Accurate results will be obtained by testing at 3 months and again at 6 months." Ninety-five percent of exposed individuals will seroconvert within 3 months; 99% will convert by 6 months. The other options do not accurately reflect the timeline for seroconversion following exposure.

The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client? A) "Monitoring Your Blood Pressure at Home." B) "Smoking Cessation as a Lifelong Commitment." C) "Decreasing Cholesterol Levels Through Diet." D) "Stress Management for a Healthier You."

C) "Decreasing Cholesterol Levels Through Diet." A health promotion brochure about decreasing cholesterol is most important to provide this client, because the most significant risk factor contributing to development of arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. (A) does not address the underlying causes of arteriosclerosis. (B) and (D) are also important factors for reversing arteriosclerosis but are not as important as lowering cholesterol.

Using the Morse Fall Risk scale, the nurse should initiate highest fall risk precautions for which client? A) An 84-year-old client with diabetes admitted with new-onset confusion who reportedly fell at home last week, is currently on bed rest, and has normal saline infusing per saline lock. B) A 48-year-old alert and oriented client with quadriplegia admitted for wound care of a stage IV pressure ulcer, receiving IV antibiotics per a peripherally inserted central catheter. C) A 62-year-old client with a history of Parkinson's disease, admitted for pneumonia and receiving IV antibiotics, who has fallen at home but is able to ambulate with a cane and who during his hospitalization has gotten out of bed without calling for assistance. D) A 27-year-old client with acute pancreatitis receiving morphine sulfate IV every 2 hours as needed for pain; no significant medical history, smokes two packs of cigarettes.

C) A 62-year-old client with a history of Parkinson's disease, admitted for pneumonia and receiving IV antibiotics, who has fallen at home but is able to ambulate with a cane and who during his hospitalization has gotten out of bed without calling for assistance.

Which response by a client with a nursing diagnosis of Spiritual distress, indicates to the nurse that a desired outcome measure has been met? A) Expresses concern about the meaning and importance of life B) Remains angry at God for the continuation of the illness. C) Accepts that punishment from God is not related to illness. D) Refuses to participate in religious rituals that have no meaning.

C) Accepts that punishment from God is not related to illness. Acceptance that she is not being punished by God indicates a desired outcome (C) for some degree of resolution of spiritual distress. (A, B, and D) do not support the concept of grief, loss, and cultural/spiritual acceptance.

The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure? A) Dilute each of the medications with sterile water prior to administration. B) Mix the medications in one syringe before opening the feeding tube. C) Administer water between the doses of the two liquid medications. D) Withdraw any fluid from the tube before instilling each medication.

C) Administer water between the doses of the two liquid medications. Water should be instilled into the feeding tube between administering the two medications to maintain the patency of the feeding tube and ensure that the total dose of medication enters the stomach and does not remain in the tube. These liquid medications do not need to be diluted when administered via a feeding tube and should be administered separately, with water instilled between each medication

A signed consent form indicated a client should have an electromyogram, but a myelogram was performed instead. Though the myelogram revealed the cause of the client's back pain, which was subsequently treated, the client filed a lawsuit against the nurse and healthcare provider for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff because these events represent which infraction? A) A quasi-intentional tort because a similar mistake can happen to anyone. B) Failure to respect client autonomy to choose based on intentional tort law. C) Assault and battery with deliberate intent to deviate from the consent form. D) An unintentional tort because the client benefited from having the myelogram.

C) Assault and battery with deliberate intent to deviate from the consent form. The client was not properly informed of the procedure, and failure to obtain informed consent constitutes assault and battery.

A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first? A) Instruct the caregiver to offer a glass of warm prune juice at mealtimes. B) Notify the health care provider and request a prescription for a large-volume enema. C) Assess the client's medical record to determine the client's normal bowel pattern. D) Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.

C) Assess the client's medical record to determine the client's normal bowel pattern.

After the nurse tells an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all health care providers and nurses. How should the nurse respond? A) Ask the client to remain quiet so the procedure can be performed safely. B) Concentrate on completing the insertion as efficiently as possible. C) Calmly reassure the client that the discomfort will be temporary. D) Tell the client a joke as a means of distraction from the procedure.

C) Calmly reassure the client that the discomfort will be temporary.

A female nursing home resident and her family only speak Spanish. During a visit, the entire family begins to cry hysterically. When unable to determine why the family is upset, what intervention is most important for the nurse to implement? A) Ask a Spanish speaking staff member to talk with the family. B) Use a Spanish translation reference to interview the family. C) Close the door to client's room to provide family privacy. D) Sit quietly with the family to offer comfort and support.

C) Close the door to client's room to provide family privacy.

While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding? A) Reposition the pulse oximeter clip to obtain a new reading. B) Stop suctioning until the pulse oximeter reading is above 95%. C) Complete the intermittent suction of the nasopharynx. D) Apply an oxygen mask over the client's nose and mouth.

C) Complete the intermittent suction of the nasopharynx.

When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum "tents" when gently pinched. Which action should the nurse implement? A) Confirm the finding by further assessing the client for jugular vein distention. B) Offer the client high protein snacks between regularly scheduled mealtimes. C) Continue the planned nursing interventions to restore the client's fluid volume. D) Change the plan of care to include a nursing diagnosis of impaired skin integrity.

C) Continue the planned nursing interventions to restore the client's fluid volume.

The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A) Place the chair at a right angle to the bed on the client's left side before moving. B) Assist the client to a standing position, then place the right hand on the armrest. C) Have the client place the left foot next to the chair and pivot to the left before sitting. D) Move the chair parallel to the right side of the bed, and stand the client on the right foot.

D) Move the chair parallel to the right side of the bed, and stand the client on the right foot. (D) uses the client's stronger side, the right side, for weight-bearing during the transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of transfer and include the use of poor body mechanics by the caregiver.

Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized client with an indwelling urinary catheter? A) Ensure that the client's perineal area is cleansed twice a day. B) Maintain accurate documentation of the fluid intake and output. C) Encourage frequent ambulation if allowed or regular turning if on bedrest. D) Obtain a prescription for removal of the catheter as soon as possible.

D) Obtain a prescription for removal of the catheter as soon as possible. The best intervention to reduce the risk of urosepsis (the spread of an infectious agent from the urinary tract to systemic circulation) is the removal of the urinary catheter as quickly as possible.

An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day. What is the best action for the nurse to implement when assisting the client from the bed to the chair? A) Use a mechanical lift to transfer from the bed to a chair. B) Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair. C) Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three. D) Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed.

D) Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed.

An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? A) Generalized dry skin. B) Localized dry skin on lower extremities. C) Red flush over entire skin surface. D) Rashes in the axillary, groin, and skin fold regions.

D) Rashes in the axillary, groin, and skin fold regions. Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes (D), skin breakdown, and the development of pressure ulcers. (A, B, and C) do not address the concepts of inflammation and tissue integrity.

The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A) Encourage the client to cough to help loosen secretions. B) Advise the client to increase the intake of oral fluids. C) Rotate the suction catheter to obtain any remaining secretions. D) Re-oxygenate the client before attempting to suction again.

D) Re-oxygenate the client before attempting to suction again. Suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time (D). (A, B, and C) may be performed after the client is re-oxygenated and additional suctioning is performed.

A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which intervention is best for the nurse to implement? A) Encourage the client to use a nicotine patch. B) Reassure the client that it is almost time for another break. C) Have the client leave the unit with another staff member. D) Review the schedule of outdoor breaks with the client.

D) Review the schedule of outdoor breaks with the client.

Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? A) White blood cell count. B) Albumin. C) Calcium. D) Sodium.

D) Sodium. Monitoring serum sodium levels for hyponatremia is indicated during prolonged NG suctioning because of loss of fluids.

A client complains of abdominal discomfort and nausea while receiving tube feedings. Which intervention is most appropriate for this problem? A) Change the feeding container daily. B) Place the client in semi-Fowler's position while feeding. C) Give the feedings at room temperature. D) Stop the feedings and check for residual volume.

D) Stop the feedings and check for residual volume. Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings. Stopping the feeding and checking for residual volume helps assess the reason for the client's nausea and discomfort. If residual volume is greater than 100 ml, hold the feeding and notify the physician. Feedings are normally given at room temperature to minimize abdominal cramping; however, this action doesn't help assess why nausea and discomfort are occurring. Elevating the head of the client's bed to at least 30 degrees prevents aspiration during feeding. Also, feeding containers are changed daily to prevent bacterial growth.

The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first? A) Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client. B) Sit quietly in the client's room until the client leaves the bathroom. C) Allow the client to cry alone and leave the client in the bathroom. D) Talk to the client and attempt to find out why the client is crying.

D) Talk to the client and attempt to find out why the client is crying.

A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first? A) Accept and document the client's wish to refrain from bathing. B) Offer to give the client a bed bath, avoiding the perineal area. C) Obtain written brochures about menstruation to give to the client. D) Teach the importance of personal hygiene during menstruation with the client.

D) Teach the importance of personal hygiene during menstruation with the client.

A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse do first? A) Clamp the nasogastric tube. B) Confirm placement of the tube. C) Use a syringe to instill the medications. D) Turn off the intermittent suction device.

D) Turn off the intermittent suction device.

A male client has a nursing problem of "spiritual distress." Which intervention is best for the nurse to implement when caring for this client? A) Use distraction techniques during times of spiritual stress and crisis. B) Reassure the client that his faith will be regained with time and support. C) Consult with the staff chaplain and ask that the chaplain visits with the client. D) Use reflective listening techniques when the client expresses spiritual doubts.

D) Use reflective listening techniques when the client expresses spiritual doubts. The most beneficial nursing intervention is to use nonjudgmental reflective listening techniques, to allow the client to feel comfortable expressing his concerns.

When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which action may the nurse institute independently? A) Applying an antibiotic cream to the area three times per day. B) Massaging the area with an astringent every 2 hours. C) Using a povidone-iodine wash on the ulceration three times per day. D) Using normal saline solution to clean the ulcer and applying a protective dressing as necessary.

D) Using normal saline solution to clean the ulcer and applying a protective dressing as necessary. The nurse may wash the area with normal saline solution and apply a protective dressing. These interventions will protect the area and are within the nurse's scope of practice. A nurse must obtain a physician's order to use a povidone-iodine wash or an antibiotic cream. Massaging with an astringent can further damage the skin.

The nurse is teaching a client about the use of the syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions? A) Remove needle before discarding used syringes. B) Wear gloves to dispose of the needle and syringe. C) Don a face mask before administering the medication. D) Washes hands before handling the needle and syringe.

D) Washes hands before handling the needle and syringe. (A) is not correct because it is not safe and the client could poke him or herself. (B) is appropriate, but does not refer to standard precautions. IC) refers to droplet precautions. (D) is correct because it refers to standard precautions.

A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, "Will it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse to provide? A) "It may hurt a little because of the incision made in your throat." B) "It won't hurt because you're such a big boy." C) "It won't hurt because we put you to sleep." D) "It may hurt but we'll give you medicine to help you feel better."

D) "It may hurt but we'll give you medicine to help you feel better." Answering questions simply and directly provides comfort for the preschool-age child and builds confidence in the healthcare team.

The nurse has just received change-of-shift report for four clients. Based on this report, the nurse should assess which client first? A) A 52-year-old with pneumonia and chronic back pain who is requesting pain medication. B) A 38-year-old who is 2 days post-mastectomy due to breast cancer, having difficulty coping with the diagnosis. C) An 84-year-old with resolving left-sided weakness who is slightly confused and has been awake most of the night. D) A 35-year-old admitted after motor vehicle accident whose urine output has totaled 30 mL over the last 2 hours.

D) A 35-year-old admitted after motor vehicle accident whose urine output has totaled 30 mL over the last 2 hours. Urine output should be at least 500 mL in 24 hours (20 mL/h); this client's output has been just 15 mL/h for the past 2 hours requiring further assessment by the nurse. The nurse should first assess all clients and address physiological needs including pain control and safety measures; the nurse should then take time with the client having difficulty coping in order to listen and further determine her needs.

When caring for an immobile client, what nursing diagnosis has the highest priority? A) Risk for fluid volume deficit. B) Impaired gas exchange. C) Risk for impaired skin integrity. D) Altered tissue perfusion.

D) Altered tissue perfusion.

The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later the client reports that he is still unable to sleep, despite following the same routine every night. Which action should the nurse take first? A) Instruct the client to add regular exercise as a daily routine. B) Determine if the client has been keeping a sleep diary. C) Encourage the client to continue the routine until sleep is achieved. D) Ask the client to describe the routine he is currently following.

D) Ask the client to describe the routine he is currently following. The nurse should first evaluate whether the client has been adhering to the original instructions. A verbal report of the client's routine will provide more specific information than the client's written diary. The nurse can then determine which changes need to be made. The routine practiced by the client is clearly unsuccessful, so encouragement alone is insufficient.

During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse? A) Reassure the client that many obese people have concerns about sex. B) Remind the client that sexual relationships need not be affected by obesity. C) Determine the frequency of sexual intercourse. D) Ask the client to talk about specific concerns.

D) Ask the client to talk about specific concerns.

The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed. A) Administer nasal oxygen at a rate of 5 L/min. B) Help the client to lie back down in the bed. C) Quickly pivot the client to the chair and elevate the legs. D) Check the client's blood pressure and pulse deficit.

D) Check the client's blood pressure and pulse deficit. (A) is incorrect because it does not say that the patient has a decrease in O2 stats. (B) is incorrect because you assume the patient is already laying down and you have a task at hand. (C) MOVE SLOW after surgery! Never quickly move a patient. You could injury yourself and the client. (D) is correct; make sure they are physiologically stable first before moving them.

The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take? A) Consult with the pharmacist about the need to continue the medication. B) Administer the antihypertensive medication as prescribed preoperatively. C) Withhold the medication until the client is fully alert and vital signs are stable. D) Contact the health care provider to renew the prescription for the medication.

D) Contact the health care provider to renew the prescription for the medication.

The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next? A) Raise the bed to a comfortable working level. B) Bend the client's knee. C) Move the knee toward the chest as far as it will go. D) Cradle the client's heel.

D) Cradle the client's heel.

During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report? A) The occurrence of any episodes of sleep apnea. B) The child's blood pressure, pulse, and respirations. C) Length of rapid eye movement (REM) sleep that the child is experiencing. D) Description of the family's home environment.

D) Description of the family's home environment.

The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement? A) Encourage the client to increase ambulation in the room. B) Offer the client a high-carbohydrate snack for energy. C) Force fluids to thin the client's pulmonary secretions. D) Determine if pain is causing the client's tachypnea.

D) Determine if pain is causing the client's tachypnea.

An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What action should the nurse implement first? A) Establish a toileting schedule to decrease episodes of incontinence. B) Complete a functional assessment of the client's self-care abilities. C) Apply a barrier ointment to intact areas that may be exposed to moisture. D) Determine the size and depth of skin breakdown over the sacral area.

D) Determine the size and depth of skin breakdown over the sacral area.

When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled "opened" and dated 48 hours prior to the current date. Which is the best action for the nurse to take? A) Use the normal saline solution once more and then discard. B) Obtain a new sterile syringe to draw up the labeled saline solution. C) Use the saline solution and then relabel the bottle with the current date. D) Discard the saline solution and obtain a new unopened bottle.

D) Discard the saline solution and obtain a new unopened bottle. Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded.

A client with cancer-related pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia? A) Ask the client's spouse wife to hold the client's hands while the nurse puts the pill under the tongue. B) Emphasize the rationale for taking the medication now as ordered. C) Try to persuade the client to take the medication as ordered by the doctor. D) Document the client's choice and re-assess pain in 1 hour.

D) Document the client's choice and re-assess pain in 1 hour.

When making the bed of a client who needs a bed cradle, which action should the nurse include? A) Teach the client to call for help before getting out of bed. B) Keep both the upper and lower side rails in a raised position. C) Keep the bed in the lowest position while changing the sheets. D) Drape the top sheet and covers loosely over the bed cradle.

D) Drape the top sheet and covers loosely over the bed cradle. A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle. A client using a bed cradle may still be able to ambulate independently and does not require raised side rails.

During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A) Provide additional coffee on the client's breakfast tray. B) Exchange the client's grape juice for cranberry juice. C) Bring the client additional fruit at mid-morning. D) Encourage additional oral intake of juices and water.

D) Encourage additional oral intake of juices and water. Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit. Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract infection. The client needs to restore fluid volume more than solid foods (C).

A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A) Obtain the pre-transfusion hemoglobin level. B) Prime the tubing and prepare a blood pump set-up. C) Monitor vital signs q15 minutes for the first hour. D) Ensure the accuracy of the blood type match.

D) Ensure the accuracy of the blood type match. All interventions should be implemented prior to administering blood, but (D) has the highest priority. Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction.

Which would be most helpful when coaching a client to stop smoking? A) Review the negative effects of smoking on the body. B) Explain how smoking worsens high blood pressure. C) Discuss the effects of passive smoking on environmental pollution. D) Establish the client's daily smoking pattern.

D) Establish the client's daily smoking pattern. A plan to reduce or stop smoking begins with establishing the client's personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risks, but this knowledge has not been shown to help clients change their smoking behavior.

The home health nurse visits an older client who lives at home with her husband. The client is experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for which the client is at risk, has the greatest priority when planning the client's care? A) Disturbed sleep pattern. B) Caregiver role strain. C) Impaired skin integrity. D) Fluid volume imbalance.

D) Fluid volume imbalance. Diarrhea can lead to fluid volume loss, which is potentially life-threatening, so the highest priority is to prevent a fluid volume imbalance.

An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A) Massage any reddened areas for at least five minutes. B) Encourage active range of motion exercises on extremities. C) Position the client laterally, prone, and dorsally in sequence. D) Gently lift the client when moving into a desired position.

D) Gently lift the client when moving into a desired position. To avoid shearing forces when repositioning, the client should be lifted gently across a surface (D). Reddened areas should NOT be massaged (A) since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion (B) may be limited on the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip.

A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? A) Contact the healthcare provider and complete a medication variance form. B) Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C) Notify the charge nurse and complete an incident report to explain the missed dose. D) Give the missed dose at 1300 and change the schedule to administer daily at 1300.

D) Give the missed dose at 1300 and change the schedule to administer daily at 1300. To ensure that a therapeutic level of medication is maintained, the nurse should administer dose as soon as possible, and revise the administration schedule accordingly to prevent dangerously increasing the level of medication in the bloodstream (D). The nurse should document the reason for the late dose, but (A and C) are not warranted. (B) could result in increased blood levels of the drug.

Which indicates that performing passive range-of-motion (ROM) exercises on an unconscious client has been successful? A) Preservation of muscle mass. B) Prevention of bone demineralization. C) Increase in muscle tone. D) Maintenance of joint mobility.

D) Maintenance of joint mobility. The goal of performing passive ROM exercises is to maintain joint mobility. Active exercise is needed to preserve bone and muscle mass. Passive ROM movements do not prevent bone demineralization or have a positive effect on the client's muscle tone.

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A) Loosen the right wrist restraint. B) Apply a pulse oximeter to the right hand. C) Compare hand color bilaterally. D) Palpate the right radial pulse.

A) Loosen the right wrist restraint. The priority nursing action is to restore circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also important nursing interventions, but do not have the priority of (A). Pulse oximetry (B) measures saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression- the restraints.

A nurse is preparing to give medications through a nasogastric feeding tube. Which action should prevent complications during administration? A) Mix each medication individually. B) Use sterile gloves for the procedure. C) Monitor vital signs before giving medications. D) Mix all medications together to facilitate administration.

A) Mix each medication individually. Medications should be mixed separately (A) to prevent clumping.

A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A) 9 a.m., 1 p.m., and 5 p.m. B) 8 a.m., 4 p.m., and midnight. C) Before breakfast, before lunch and before dinner. D) With breakfast, with lunch, and with dinner.

B) 8 a.m., 4 p.m., and midnight. Theophylline should be administered on a regular around-the-clock schedule (B) to provide the best bronchodilating effect and reduce the potential for adverse effects. (A, C, and D) do not provide around-the-clock dosing. Food may alter absorption of the medication (D).

A male client with unstable angina needs a cardiac catheterization, so the healthcare provider explains the risks and benefits of the procedure, and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take? A) Answer the client's specific questions with a short understandable explanation. B) Postpone the procedure until the client understands the risks and benefits. C) Call the client's next of kin and ask them to provide verbal consent. D) Page the healthcare provider to return and provide additional explanation.

B) Postpone the procedure until the client understands the risks and benefits.

A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A) Record the coughing incident. No further action is required at this time. B) Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D) Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action (C). (A and B) are not indicated. The auscultating method (D) has been found to be unreliable for small-bore feeding tubes.

A client presents to the OB triage unit with no prenatal care and painless bright red vaginal bleeding. Which interventions are most indicated? A) Applying an external fetal monitor and completing a physical assessment. B) Obtaining a fundal height assessment on the client. C) Applying an external fetal monitor and performing a sterile vaginal examination. D) Obtaining fundal height and performing a sterile vaginal examination.

C) Applying an external fetal monitor and performing a sterile vaginal examination. Bright red vaginal bleeding without contractions could indicate a placenta previa. A sterile vaginal exam should never be done on a woman with a known or suspected placenta previa. Applying the external fetal monitor will allow the nurse to assess fetal status. A complete physical assessment of the client is indicated. A fundal height is used to monitor fetal growth during pregnancy but does not provide information related to vaginal bleeding.

The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant grandution. The wound has a gauze dressing covering the area. What action should the nurse implemented? A) Apply a hydro gel (Duaderm) dressing. B) Increase the frequency of the dressing changes. C) Replace the gauze with transparent dressing. D) Leave the dressing off until consulting with the healthcare provider.

C) Replace the gauze with transparent dressing.

A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the client's protein status for the longest length of time? A) Trasnferrin. B) Prealbumin. C) Serum albumin. D) Urine urea nitrogen.

C) Serum albumin.

During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem?

Close-ended questions. Lay descriptors of health problems can be vague and nonspecific. To efficiently obtain specific information, the nurse should use close-ended questions (C) that focus on common signs and symptoms about the client's health problem. (A, B, and D) are used when therapeutically interacting and should be used after specific information is obtained from the client.

An older woman with end stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take first? A) Discuss with the client her meaning of heroic measures. B) Obtain a "do not resuscitate" (DNR) prescription. C) Set up a family conference to discuss the client's. D) Consult the palliative care team about client's care.

A) Discuss with the client her meaning of heroic measures.

A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the nurse to implement when caring for this client? A) Use distraction techniques during times of spiritual stress and crisis. B) Reassure the client that his faith will be regained with time and support. C) Consult with the staff chaplain and ask that the chaplain visit with the client. D) Use reflective listening techniques when the client expresses spiritual doubts.

C) Consult with the staff chaplain and ask that the chaplain visit with the client.

A client diagnosed with primary open-angle glaucoma received a prescription for biotic eye drops, pilocarpine HCl (Pilocarpine). What instruction should the nurse plan to include in this client's teaching? A) "Do not allow the dropper bottle to touch the eye." B) "Administer the medication directly on the cornea." C) "Squeeze your eye closed after administering the drops." D) "Wash your hands after each administration of eye drops."

A) "Do not allow the dropper bottle to touch the eye."

A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What actions should the nurse take first? A) Assess for side effects of the medication. B) Document the client's responses. C) Complete a medication error report. D) Determine if the pain was relieved.

A) Assess for side effects of the medication.

What client statement indicates to the nurse that the client requires assistance with bathing? A) "I wasn't able to pack a bag before I left for the hospital." B) "I don't understand why I'm so weak and tired." C) "I only bathe ever other day." D) "I left my eyeglasses at home."

B) "I don't understand why I'm so weak and tired."

A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client? A) Use disposable plates and utensils. B) Stay in a room with the door closed. C) Dispose of soiled dressings in plastic bags that are securely closed. D) Others who are in the same room with the client should wear a mask.

C) Dispose of soiled dressings in plastic bags that are securely closed.

The nurse is providing wound care to a client with stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states "clean the wound and then apply collagenase." Collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the nurse cleanse the pressure ulcer? A) Lightly coat the wound with povidone-iodine solution. B) Irrigate the wound with sterile normal saline. C) Flush the wound with sterile hydrogen peroxide. D) Remove the eschar with a wet-to-dry dressing.

B) Irrigate the wound with sterile normal saline.

When evaluating a client's plan of care, the nurse determines that a desire outcome was not achieved. Which action should the nurse implement first? A) Establish a new nursing diagnosis. B) Note which actions were not implemented. C) Add additional nursing orders to the plan. D) Collaborate with the HCP to make changes.

B) Note which actions were not implemented. First, the nurse should review which actions in the original plan were not implemented (B) in order to determine why the original plan did not produce the desired outcome. Appropriate revisions can then be made, which may include revising the expected outcome, or identifying a new nursing diagnosis (A). (C) may be needed if the nursing actions were unsuccessful, or were unable to be implemented. (D) other members of the healthcare team may be necessary to collaborate changes once the nurse determines why the original plan did not produce the desired outcome.

During shift change report, the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the client's heart sounds?

B) Use the stethoscope bell over the valvular areas of the anterior chest.

Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia? A) Monitor daily urine output volume. B) Drink plenty of water whenever thirsty. C) Use salt tablets for sodium content. D) Review food labels for sodium content.

D) Review food labels for sodium content.

A student nurse requires additional teaching if which of the following factors is identified as contributing to a client's risk for infection? A) Proper nutrient intake. B) Impairment of primary body system defenses. C) Chronic disease. D) Inadequate secondary defenses.

A) Proper nutrient intake. Malnutrition, rather than proper nutrient intake, would put the client at risk for infection. Inadequate secondary defenses, impaired primary defenses, and chronic disease put the client at risk by lowering the body's ability to fight infection.

An elderly client fractured his hip as a result of a fall at home. Because of his extensive cardiac history and chronic obstructive pulmonary disease, surgery isn't an option. The client tells the nurse he doesn't know how he's going to get better. Which response is best? A) "You're doing fine." B) "What is your biggest concern right now?" C) "Give it some time and you'll be OK." D) "You don't believe you're doing well?"

B) "What is your biggest concern right now?" Open-ended questions allow a client to control what he wants to discuss and help a nurse determine care needs. Telling the client that he's fine or that he just needs more time doesn't encourage him to verbalize his concerns. Reiterating the client's concerns may not encourage him to verbalize his feelings.

At 0100 on a male client's second postoperative night, the client states he is unstable to sleep and plans to read until feeling sleepy. What action should the nurse implement? A) Leave the room and close the door to the client's room. B) Assess the appearance of the client's surgical dressing. C) Bring the client a prescribed PRN sedative-hypnotic. D) Discuss symptoms of sleep deprivation with the client.

C) Bring the client a prescribed PRN sedative-hypnotic.

When assessing a male client, the nurse finds that he is fatigue, and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client's laboratory values to validate the existence of which? A) Hyperphosphatemia. B) Hypocalcemia. C) Hypermagnesemia. D) Hypokalemia.

D) Hypokalemia.

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? A) Assist the ambulating client back to the bed. B) Encourage the client to ambulate to resolve pneumonia. C) Obtain a prescription for portable oxygen while ambulating. D) Move the oximetry probe from the finger to the earlobe.

A) Assist the ambulating client back to the bed. An oxygen saturation below 90% indicates inadequate oxygen. First, the client should be assisted to return to bed (A) to minimize oxygen demands. Ambulation increases aeration of the lungs to prevent pooling of respiratory secretions, but the client's activity at this time is depleting oxygen saturation of the blood, so (B) is contraindicated. Increased activity increases respiratory effort, and oxygen may be necessary to continue ambulation (C), but first the client should return to the bed to rest. Oxygen saturation levels at different sites should be evaluated AFTER the client returns to bed (D).

The nurse removes the dressing on a client's heel that is covering a pressure sore one- inch in diameter and finds that there is straw- colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record? A) Stage 1 pressure sore draining sero-sanguineous drainage. B) Pressure sore at bony prominence with exude noted. C) One-inch pressure sore draining serous fluid. D) Pressure sore on heel with a small amount of purulent drainage.

C) One-inch pressure sore draining serous fluid.

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A) Apply a condom catheter. B) Apply a skin protectant. C) Encourage increased fluid intake. D) Assess for bladder distention.

D) Assess for bladder distention. Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention (D). (A and B) are useful actions to protect the skin of a client with urinary incontinence. (C) may worsen the bladder distention.

A client has a wound with a drain. When performing wound cleansing around the drain, the nurse should cleanse in which direction? A) Laterally, from one side of the wound to the opposite side. B) Laterally, from the distal area to the center. C) From the superior portion of the wound to the inferior. D) In a widening circle around the drain, outward from the center.

D) In a widening circle around the drain, outward from the center.

When assessing a client who starts to wheeze related data should obtain? A) Presence of radiation. B) Heart sounds. C) Body temperature. D) Precipitating factors.

D) Precipitating factors.

Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? A) Height in inches or centimeters. B) Weight in kilograms or pounds. C) Triceps skin fold thickness. D) Upper arm circumference.

D) Upper arm circumference. Upper arm circumference (D) is an indirect measure of muscle mass. (A and B) do not distinguish between fat (adipose) and muscularity. (C) is a measure of body fat.

A client who has been diagnosed with terminal cancer tells the nurse, "The doctor told me I have cancer and do not have long to live." Which response is best for the nurse to provide? A) "That's correct, you do not have long to live." B) "Would you like me to call your minister?" C) "Don't give up, you still have chemotherapy to try." D) "Yes, your condition is serious."

D) "Yes, your condition is serious."

The nurse working in the emergency department is assessing four clients' ability to tolerate pain. Which client is likely to tolerate a higher level of pain? A) A 10- year- old who was burned by a camp fire earlier today. B) A 70- year- old who has a postoperative infection form a surgery one week ago. C) A 23- year- old woman who sprained her knee while bicycling. D) A 55- year- old woman who has had moderate low back pain for three months.

D) A 55- year- old woman who has had moderate low back pain for three months.

What is the most effective way to implement a teaching plan? A) Teach the information that the client wants to learn first. B) Streamline the teaching plan to include only essential information. C) Present to the client all the information necessary to meet the objectives. D) Provide the client with written material to review before teaching sessions.

A) Teach the information that the client wants to learn first.

The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. Which action(s) should the nurse implement prior to assisting the client to the chair? (Select all that apply.) A) Premedicate the client with an analgesic. B) Inform the client of the plan for moving to the chair. C) Obtain and place a portable commode by the bed. D) Ask the client to push the IV pole to the chair. E) Clamp the indwelling catheter. Assess the client's blood pressure.

A) Premedicate the client with an analgesic. B) Inform the client of the plan for moving to the chair. D) Ask the client to push the IV pole to the chair. E) Clamp the indwelling catheter. Assess the client's blood pressure. Premedicating the client with an analgesic reduces the client's pain during mobilization and maximizes compliance. To ensure the client's cooperation and promote independence, the nurse should inform the client about the plan for moving to the chair and encourage the client to participate by pushing the IV pole when walking to the chair. The nurse should assess the client's blood pressure prior to mobilization, which can cause orthostatic hypotension.

A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first? A) Pulse characteristics. B) Open airway. C) Entrance and exit wounds. D) Cervical spine injury.

A) Pulse characteristics. Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the pulse rate and regularity is a priority. Because the client is talking, he has an open airway, so that assessment is not necessary. Assessing for options C and D should occur after assessing for adequate circulation.

How should the nurses handle linens that are soiled with incontinent feces? A) Put the soiled linens in an isolation bag, then place it in the dirty linen hamper. B) Place an isolation hamper in the client's room and discard the linens in it. C) Place the soiled linens in a pillow case and deposit them in the dirty linen hamper. D) Ask the housekeeping staff to pick up the soiled linen from the dirty utility room.

A) Put the soiled linens in an isolation bag, then place it in the dirty linen hamper.

When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next? A) Record the amount on the client's fluid output record. B) Encourage the client to increase oral fluid intake. C) Notify the health care provider of the findings. D) Palpate the client's bladder for distention.

A) Record the amount on the client's fluid output record.

The nursing staff in the cardiovascular intensive care unit are creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy? A) Remove identifying information of the clients who participated. B) Recall that authored content may be legally discoverable. C) Share material from credible, peer reviewed sources only. D) Respect all copyright laws when adding website content.

A) Remove identifying information of the clients who participated.

Which client assessment data is most important for the nurse to consider before ambulating a postoperative client? A) Respiratory rate. B) Wound location. C) Pedal pulses. D) Pain rating.

A) Respiratory rate. Mobilization and ambulation increase oxygen use, so it is most important to assess the client's respiratory rate before ambulation to determine tolerance for activity.

A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? A) Sensory pattern, area, intensity, and nature of the pain. B) Trigger points identified by palpation and manual pressure of painful areas. C) Schedule and total dosages of drugs currently used for breakthrough pain. D) Sympathetic responses consistent with onset of acute pain.

A) Sensory pattern, area, intensity, and nature of the pain.

A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24-hour dietary recall? (Select all that apply.) A) Snack of potato chips and diet soda. B) Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee. C) Breakfast of eggs, bacon, toast, and coffee. D) Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea. E) Bedtime snack of crackers and milk.

A) Snack of potato chips and diet soda. B) Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee. C) Breakfast of eggs, bacon, toast, and coffee.

A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24-hour dietary recall? (Select all that apply.) A) Snack of potato chips, and diet soda. B) Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee. C) Breakfast of eggs, bacon, toast, and coffee. D) Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea. E) Bedtime snack of crackers and milk.

A) Snack of potato chips, and diet soda. B) Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee. E) Bedtime snack of crackers and milk.

While caring for a child and mother from an Asian culture, which action should the nurse implement to accommodate the clients' cultural needs? A) Speak initially with the oldest family member to show respect. B) Realize that Southeast Asians may not take Western medications. C) Ask the husband to step out during the mother's pelvic examination. D) Tell the family that planning health care is provided in private with the client.

A) Speak initially with the oldest family member to show respect. Members of the Asian culture have high respect for others, especially those in positions of authority. Extended family members need to be included in the nursing care plan. Southeast Asians do not necessarily refuse Western medications. Asians also believe that touching strangers is not acceptable, particularly health professionals whom they have not previously known.

A client's infusion of normal saline infiltrated earlier today, and approximately 500 mL of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding stronger pain medications. What initial action is most important for the nurse to take? A) Ask about any past history of drug abuse or addiction. B) Measure the pulse volume and capillary refill distal to the infiltration. C) Compress the infiltrated tissue to measure the degree of edema. D) Evaluate the extent of ecchymosis over the forearm area.

B) Measure the pulse volume and capillary refill distal to the infiltration. Pain and diminished pulse volume (B) are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast) or internal pressure (usually form subcutaneous infused fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the extremity. (A) should not be pursued until physical causes of the pain are ruled out. (C) is less of a priority than determining the effects of the edema on circulation and nerve function. Further assessment of the client's ecchymosis can be delayed until the signs of edema and compression that suggest compartment syndrome have been examined (D).

Which action should the nurse implement to mitigate the formation of a hip pressure injury for a client who is immobile? A) Maintain in a lateral position using protective wrist and vest devices. B) Partial side lying with hip elevated to 30 degrees (30-degree lateral position). C) Raise the head and knee gatch when lying in a supine position. D) Transfer into a wheelchair close to the nurse's station for observation.

B) Partial side lying with hip elevated to 30 degrees (30-degree lateral position). The partial side-lying position with hip elevation maintains alignment and provides the best pressure relief over the hip bony prominence. Raising the head and bed gatch may reduce shearing forces due to sliding down in bed, but it interferes with venous return from the legs and places pressure on the sacrum, predisposing to pressure injury formation. Sitting in a wheelchair places the body weight over the ischial tuberosities and predisposes it to a potential pressure point.

On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination? A) Remind the client to turn every two hours while lying in bed. B) Provide warm prune juice before the client goes to bed at night. C) Teach the client to splint the incision while walking to the bathroom. D) Administer an analgesic before the client attempts to defecate.

B) Provide warm prune juice before the client goes to bed at night. Prune juice is a natural laxative that stimulates peristalsis, and warming the prune juice facilitates peristalsis.

The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted? A) Temperature increases. B) Pulse rate decreases from 78 to 52 beats/min. C) Respiratory rate increases from 16 to 24 breaths/min. D) Blood pressure increases from 110/84 to 118/88 mm/Hg.

B) Pulse rate decreases from 78 to 52 beats/min. Parasympathetic reaction can occur as a result of digital stimulation of the anal sphincter, which should be stopped if the client experiences a vagal response, such as bradycardia.

The nurse is caring for a hospitalized client who was placed in restraints due to confusion. The family removes the restraints while they are with the client. When the family leaves, what action should the nurse take first? A) Apply the restraints to maintain the client's safety. B) Reassess the client to determine the need for continuing restraints. C) Document the time the family left and continue to monitor the client. D) Call the healthcare provider for a new prescription.

B) Reassess the client to determine the need for continuing restraints.

The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client's foot in a basin of warm water placed on the bed. What action should the nurse take? A) Remove the basin of water from the client's bed immediately. B) Remind the UAP to dry between the client's toes completely. C) Advise the UAP that this procedure is damaging to the skin. D) Add skin cream to the basin of water while the foot is soaking.

B) Remind the UAP to dry between the client's toes completely.

During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take? A) Assign an unlicensed assistive personnel to transport the client via a wheelchair. B) Remind the client to walk carefully down the stairs until reaching a lower floor. C) Ask the client to help by assisting a wheelchair-bound client to a nearby elevator. D) Open the closest fire doors so that ambulatory clients can evacuate more rapidly.

B) Remind the client to walk carefully down the stairs until reaching a lower floor.

A female client's significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client's estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement? A) Obtain a prescription from the healthcare provider regarding visitation privileges. B) Request a consultation with the ethics committee for resolution of the situation. C) Encourage the client to speak with her husband regarding his disruptive behavior. D) Communicate the client's wishes to all members of the multidisciplinary team.

B) Request a consultation with the ethics committee for resolution of the situation.

The nurse obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the nurse implement first? A) Use an electronic sphygmomanometer to take the BP every 30 minutes. B) Retake the blood pressure in the same arm, deflating the cuff slowly. C) Ask another nurse to recheck the blood pressure to compare results. D) Obtain another blood pressure cuff and retake the blood pressure.

B) Retake the blood pressure in the same arm, deflating the cuff slowly.