NURS321 PrepU Questions

The nurse is taking the apical pulse of a 6-month-old infant. Upon completion, the nurse tells the parent the infant's pulse is 140 beats per minute. The parent is concerned, stating, "That seems kind of high!" The nurse responds:

"I know it seems fast, but normal infant heart rates are 100-160 beats per minute."

What is the most appropriate nursing response when a client with a BMI of 29 expresses concerns of developing hypertension

"Since weight is one factor that can increase the risk of developing hypertension we will refer you to a nutritionist for weight management."

A nursing student is reviewing the progression of an infection. Place the following in the order in which each would occur during the communicable period. -exposure to the pathogen -nonspecific symptoms -positive laboratory tests -return of appetite

1. exposure to the pathogen 2. nonspecific symptoms 3. positive laboratory tests 4. return of appetite Explanation: During the communicable period, a person is exposed to the pathogen (incubation period), then develops nonspecific symptoms (prodromal period), then specific symptoms with positive laboratory test results (acute phase), and finally, a return to normal with appetite and energy returning (convalescent period).

When assessing an infant's axillary temperature, it will be:

1°F (0.5°C) lower than an oral temperature.

The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps in the order that the nurse should take when donning sterile gloves. Use all options. 1. Place the fingers of the gloved hands inside the cuff of the remaining glove and insert the fingers while stretching it over the hand 2. With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand 3. Carefully open the inner package taking care not to touch the inner surface of the package or the gloves 4. Adjust gloves on both hands if necessary, touching only sterile areas w/ other sterile areas

3, 2, 1, 4 Explanation: The correct order of putting on sterile gloves is as follows. First, the nurse should open the package, taking care not to touch the inner surface of the package or gloves. Then, the nurse should pick up the glove at the folded cuff with the thumb and forefinger and insert fingers while pulling the glove over the hand. Next, the nurse should place the finger of the gloved hand inside the cuff of the remaining glove, taking care not to touch outside of the folded cuff. Once both gloves are on, the nurse adjusts the gloves touching only sterile areas. If gloves are donned not following this order, there is an increased risk for contamination of the sterile gloves.

The nurse must assess a client's systolic blood pressure using a Doppler ultrasound. Place the following steps to this procedure in the correct order. Use all options. 1. place the doppler tip in the gel and move it around until hearing the pulse 2. note the point on the gauge where the pulse disappears 3. inflate the cuff while continuing to use the Doppler device on the artery 4. place a small amount of conducting gel over the artery 5. wrap the cuff around the limb smoothly and snugly, and fasten it 6. center the bladder of the cuff over the artery, lining the artery marker on the cuff of the artery

6, 5, 4, 1, 3, 2 pg 664

Which client would the nurse consider at risk for low blood pressure?

A client with low blood volume

The nurse is providing education to a senior circle group during an active flu season about the differences between viruses and bacteria. What statements made by the attendees indicates that the education has been effective? Select all that apply. A. "There are some Immunizations that are available for select viruses. B. "The virus enters the host cell's metabolism and replicates itself" C. "Viruses are not as harmful as bacteria." D. "There are some viruses that may be associated with cancers." E. "I can take an antibiotic to eradicate a viral infection ".

A, B Explanation: A virus invades a living cell many times its size, uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup. Viruses cause AIDS, chickenpox, colds, cold sores, encephalitis, hepatitis, herpes, HPV, influenza, measles, mononucleosis, mumps, polio, rabies, shingles, pneumonia, and many other diseases. They have been associated with some cancers and leukemias and with many autoimmune diseases. Viruses may be just as harmful as bacteria since there is not an effective treatment for a virus.

A nurse is conducting a home assessment of a 90-year-old client with a history of several minor strokes that have left the client with a hemiplegic gait. The nurse is particularly concerned about falls. Which activities would help to prevent falls for this client? Select all that apply. A. removing clutter from the floor B. moving the bedroom to the ground floor C. installing hardwood floors D. placing nightlights in the bathroom and hallways

A, B, C pp. 1152 Explanation: Removing clutter from the floor, placing nightlights in the bathroom and hallways, and moving the bedroom to the ground floor will reduce the risk of falling and encourage the client to increase his mobility. Installing hardwood floors may induce falls due to the smooth surface; wall-to-wall carpeting would provide traction.

A client has been diagnosed with peripheral vascular disease of the lower extremities. What will the nurse assess to accurately chart the circulation status in the client's legs? Select all that apply. A. skin temperature of feet B. pitting edema C. capillary refill time D. pedal pulses E. breath sounds

A, B, C, D pg 655

The nurse is caring for a newborn with bluish nails and lips, rapid respirations, sweating, and having difficulty feeding. Which considerations should the nurse use when assessing the blood pressure to screen for potential cardiac problems? Select all that apply. A. Assess blood pressure in upper extremities. B. Report small differences in left and right blood pressures. C. Assess blood pressure in lower extremities. D. If the diastolic blood pressure continues to "0," document as the systolic pressure over "P" for pulse E. Use the 5th Korotkoff sound as the systolic blood pressure.

A, B, D pg 685

The nurse is preparing discharge teaching for a client admitted for sepsis. The client asks what is included when the nurse checks vital signs. Which assessment(s) is included? Select all that apply. A. blood pressure B. pulse C. allergies D. respiratory rate E. temperature F. weight

A, B, D, E pg 669

The nurse is preparing discharge teaching for a client admitted for sepsis. The client asks what is included when the nurse checks vital signs. Which assessment(s) is included? Select all that apply. A. pulse B. respiratory rate C. weight D. blood pressure E. allergies F. temperature

A, B, D, F pg 669

A nurse is teaching a client about the importance of checking the skin for changes that might suggest skin cancer. After describing the typical lesions associated with melanoma, the nurse determines that the teaching was successful when the client identifies which characteristic? Select all that apply. A. Change in the mole B. Irregular edges C. Symmetrical shape D. Single color E. Larger than 1/4 inch in diameter

A, B, E Explanation: The lesions of melanoma are asymmetrical (that is, if a line is drawn through a mole, the two halves will not match) with uneven or irregular borders and a variety of colors or shades within the lesion. The size is larger in diameter than the size of the eraser on a pencil (1/4 inch or 6 mm), but they may sometimes be smaller when first detected. The lesions are evolving, which means that any change—in size, shape, color, elevation, or another trait, or any new symptom such as bleeding, itching, or crusting—points to danger.

The nurse is performing an initial admission assessment from a client. What subjective data gathered from the client will the nurse document? Select all that apply. A. Client informs the nurse there is a floater in the left eye B. Reports of abdominal pain of 4 on a 0 to 10 point scale C. Peripheral pulses +3 D. Skin warm and dry E. Hypoactive bowel sounds in all four quadrants F. The client states, "I feel nauseated."

A, B, F Explanation: Subjective data includes any reports or information that the client gives. These include: Reports of abdominal pain of 4 on a 0 to 10 point scale, The client states, "I feel nauseated", and the client informs the nurse there is a floater in the left eye. Objective data is assessment data that are gathered by the nurse and are inspected, palpated, percussed, or auscultated by the health care team.

A nurse is teaching a young female client about breast cancer prevention. The client, who has no family history or other elevated risk of breast cancer, asks at what age she needs to begin having mammograms. What is the nurse's best response? A. "According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that." B. "Why do you want to know? Do you have a history of breast or ovarian cancer in your family?" C. "Don't worry about that yet; you are still young. You will not need a mammogram until you are in your 40s." D. "Your physician will decide when it is best for you to begin having mammograms based on your family history."

A. "According to the American and Canadian Cancer Societies, your first mammogram should be done at age 40 and then yearly after that." Explanation: Often during a physical assessment, clients indicate a desire for more health information. To help establish a trusting relationship and provide accurate teaching, the nurse's best response is to educate the client on the American Cancer Society or Canadian Cancer Society guidelines, which state that the first mammogram should be done at age 40 and then yearly. After providing that information to the client, questions on family history of breast or ovarian cancer are appropriate.

The nurse is teaching an adult client how to monitor the pulse rate. Which statement by the client demonstrates understanding of a normal pulse rate? A. "If my pulse is higher than 100 beats/min at rest, that is considered abnormal." B. "The normal pulse rate is 12 to 20 beats/min." C. "I will call the health care provider if my pulse is below 80 beats/min." D. "It is normal for my pulse to be lower than 40 beats/min while sleeping."

A. "If my pulse is higher than 100 beats/min at rest, that is considered abnormal." pg 653

The UAP asks the nurse what hand rolls are used for when providing client care. What is the appropriate nursing response? A. "To preserve the client's functional ability to grasp and pick up objects." B. "To help client to turn independently." C. "To prevent foot drop." D. "To prevent the legs from rotating outward."

A. "To preserve the client's functional ability to grasp and pick up objects." pp. 1159 Explanation: Trochanter rolls prevent the legs from rotating outward. Hand rolls preserve the client's functional ability to grasp and pick up objects and help the client avoid contractures. Foot boards prevent foot drop. Side rails help a weak client turn independently and protect the client from falling out of bed.

A client has undergone foot surgery and will use crutches in the short term. Which teaching point should the nurse provide to the client? A. "Your elbows will be slightly bent when you are using your crutches." B. "If you feel tired while walking with your crutches, rest your weight on your armpits for a moment and then continue slowly." C. "We'll have the nursing assistant watch you while you walk around the unit the first time." D. "When your crutches fit right, most of your body weight will be supported by your armpits."

A. "Your elbows will be slightly bent when you are using your crutches." pp. 1169 Explanation: When using crutches, the elbow should be slightly bent at about 30 degrees and the hands, not the armpits, should support the client's weight. Supervision of the client learning to use crutches should not be performed by unlicensed assistive personnel (UAP). The client should stop ambulating and sit down, if fatigued.When using crutches, the elbow should be slightly bent at about 30 degrees and the hands, not the armpits, should support the client's weight. Supervision of the client learning to use crutches should not be performed by unlicensed assistive personnel (UAP). The client should stop ambulating and sit down, if fatigued.

When assessing an infant's axillary temperature, it will be: A. 1°F (0.5°C) lower than an oral temperature. B. the same as the tympanic temperature. C. 1°F (0.5°C) higher than an oral temperature. D. 1°F (0.5°C) higher than a rectal temperature.

A. 1°F (0.5°C) lower than an oral temperature. pg 651-652 *rectal temp may be 1ºF higher than oral temp and axillary temp may be 1ºF lower than oral temp*

A nurse suspects that a client has a respiratory infection. Which symptom would the nurse be least likely to assess? A. clear mucus B. abnormal breath sounds C. dyspnea D. productive cough

A. Clear mucus Explanation: Assessment findings associated with a respiratory infection include productive cough, dyspnea, and abnormal breath sounds. Sputum changes in color from clear to possibly yellow, brown, or green.

What nursing diagnosis would be most appropriate for a client admitted with heart failure? A. Ineffective tissue perfusion B. Impaired gas exchange C. Risk for denial D. Acute pain

A. Ineffective tissue perfusion Explanation: Heart failure can cause ineffective tissue perfusion which can lead to fatigue, pain and activity intolerance. Impaired gas exchange would be more appropriate for respiratory disorders

A client has been reporting persistent headaches. Which is an example of subjective data? A. Pain is 4 out of 10 on a pain scale. B. Temperature is 104.1°F (40.1°C) C. The client is oriented to person, place, and time. D. The client us slow to respond to questions

A. Pain is 4 out of 10 on a pain scale. Explanation: Communicating the client's pain level is only something the client can state and validate. Subjective data are those symptoms, feelings, perception, preferences, values, and information that only the client can describe. The rest of the options can be directly observed or measured and are known as objective data.

While performing an admission assessment, the nurse auscultates a high-pitched, scratching, and grating sound at the left lower sternal border. The nurse should use what term to document the sound? A. Pericardial friction rub B. Split sound C. Aortic ejection click D. Pericardial murmur

A. Pericardial Friction rub Explanation: The pericardial friction rub is the most important physical sign of acute pericarditis. It may have up to three components during the cardiac cycle and is high pitched, scratching, and grating. It can best be heard with the diaphragm of the stethoscope at the left lower sternal border. A murmur is a blowing or swooshing sound that occurs due to turbulent blood flow through the heart or great vessels. One normal variation in heart sounds is the split heart sound. When the valves close at the same time, one S2 is heard for both valves. If the valves close at slightly different times, however, two discernible components of the same sound are heard, a situation referred to as a split heart sound. Aortic ejection sounds are best heard at the apex.

A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure? A. Surgical asepsis technique B. Strict reverse isolation C. Droplet precautions D. Medical asepsis technique

A. Surgical asepsis technique Explanation: Surgical asepsis technique is the technique followed to insert an indwelling urinary catheter. Surgical asepsis techniques, used regularly in the operating room, labor and delivery areas, and certain diagnostic testing areas, are also used by the nurse at the client's bedside. Procedures that involve the insertion of a urinary catheter, sterile dressing changes, or preparing an injectable medication are examples of surgical asepsis techniques. An object is considered sterile when all microorganisms, including pathogens and spores, have been destroyed. Medical asepsis, or clean technique, involves procedures and practices that reduce the number and transfer of pathogens. Medical asepsis procedures include performing hand hygiene and wearing gloves. Strict reverse isolation is an isolation technique where the client is protected from the nurse, other health care providers, and visitors. A client that has immune system disorders, in which the client might not be able to fight off an organism, would be kept in an environment to minimize exposure to the organism. Droplet precaution is a technique where appropriate personal protective equipment (PPE) is worn so as not to carry the organism via droplet from exposed client to others.

Infection occurs when the host is exposed to pathogens. What type of pathogen uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup? A. Virus B. Fungi C. Parasites D. Bacteria

A. Virus Explanation: A virus invades a living cell many times its size, uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup.

The nurse is preparing to administer a medication that the client takes to treat a cardiac dysrhythmia. Which site should the nurse use to assess pulse in this client? A. apical B. brachial C. radial D. carotid

A. apical pg 657

When a client is obese or has a thick chest wall, what is difficult to palpate? A. Apical impulse B. Grade 4 murmur C. Sternal angle D. JVP

A. apical impulse Explanation: Obesity or a thick chest wall makes palpation of the apical impulse difficult.

A nurse is assessing the respirations of a 60-year-old female client and finds that the client's breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation? A. auscultate the lung sounds and count respirations B. administer oxygen C. perform a pain assessment D. notify the HCP

A. auscultate the lung sounds and count respirations pg 656-657

The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of? A. Bruits B. Gallops C. Murmurs D. Normal findings

A. bruits Explanation: Distinguishing a murmur from a bruit can be challenging. Murmurs originate in the heart or great vessels and are usually louder over the upper precordium and quieter near the neck. Bruits are higher pitched, more superficial, and heard only over the arteries. A gallop is a generic term for an additional heart sounds heard besides the normal S1 and S2 sound.

The nurse is assessing the client's blood pressure (BP) and heart rate (HR) for orthostatic hypotension. In which step should this nurse intervene because of potential danger? A. client stands at bedside, becomes pale, diaphoretic B. Client in supine position for 3 minutes and BP 120/70; HR 70; asymptomatic C. Client sitting at edge of bed, feet dangling for 3 minutes; asymptomatic D. After 3 minutes of sitting, BP 100/50; HR 90.

A. client stands at bedside, becomes pale, diaphoretic pg 662

A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what? A. Crepitus or crepitation B.Inflammation C. Arthritis D. Fremitus

A. crepitus **IGNORE QUESTION** Explanation: Problems with the temporomandibular joint include pain or a grating feeling called crepitus.

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin. The nurse can anticipate that the digoxin will: A. decrease the apical pulse. B. decrease the respiratory rate. C. decrease the blood glucose. D. decrease the blood volume.

A. decrease the apical pulse pg 656

The nurse is caring for a client who just informed her that he noticed some blood in the toilet after a bowel movement. The nurse assesses the client's anal area and notes a deep linear separation in the skin that extends into the dermis. The nurse recognizes that this skin lesion is characteristic of: A. fissure B. erosion C. ulcer D. crust

A. fissure **PROBS IGNORE** Explanation: A fissure is characterized as a deep linear separation in the skin that extends into the dermis. Erosion is a loss of superficial epidermis; it is moist and may bleed. An ulcer appears as a loss of epidermis and dermis and may bleed. Crusts are dried residue (serum, pus, or blood) on the skin.

The nurse is getting ready to change the client's wound dressing. Which step best supports infection control? A. handwashing B. sterile gauze C. clean environment D. sterile gloves

A. handwashing Explanation: A person's defenses may be compromised when exposed to the health care system, for a multitude of reasons. Healthcare-associated infections (HAIs) often result from poor hand hygiene and invasive procedures occurring within the health care system. HAIs occur frequently in skilled nursing facilities (SNF), jails, and other residential facilities where auxiliary staff have varied levels of training to care for high-risk individuals.

The nurse is preparing to perform an examination of the abdomen of a 23-year-old client admitted 3 days ago with gastroenteritis. What sequence of techniques will the nurse use to assess the abdomen of this client? A. inspection, auscultation, percussion, palpation B. auscultation, inspection, palpation, percussion C. percussion, auscultation, palpation, inspection D. inspection, palpation, auscultation, percussion

A. inspection, auscultation, percussion, palpation Explanation: The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation are done after auscultation because they stimulate bowel sounds. **normal order is: Inspection Palpation Percussion Auscultation**

The nurse is preparing to assess the peripheral pulse of an adult client. Which action is correct? A. lightly compress the client's radial artery using the first, second, and third fingers B. encircle the client's antecubital fossa with both hands and lightly compress the brachial artery with the first finger of both thumbs C. grasp the client's inner wrist with the non dominant thumb positioned over the radial artery D. compress the radial artery until no pulsation is felt, then gently remove the fingertips until the pulsation returns

A. lightly compress the client's radial artery using the first, second, and third fingers pg 678-680

In auscultating a client's heart sounds, a nurse hears a swooshing sound over the pre cordium. The nurse recognizes this sound as which of the following? A. murmur B. S1 C. S2 D. auscultatory gallop

A. murmur Explanation: Blood normally flows silently through the heart. There are conditions, however, that can create turbulent blood flow in which a swooshing or blowing sound may be auscultated over the pre cordium; this sound is known as a murmur. S1, the first heart sound, sounds like "lub," and S2, the second heart sound, sounds like "dubb." Ventricular gallop is a name for the third heart sound, S3, which is not a swooshing sound over the pre cordium.

A nurse needs to measure the blood pressure of a client with an electronic manometer. Which of the following advantages does an electronic manometer provide over an aneroid manometer or mercury manometer? A. no stethoscope is required B. need for readjustment is eliminated C. ability to read gauge from any direction D. inexpensive depending on quality

A. no stethoscope is required pg 663-664

A nurse is evaluating a client's orientation after he was brought into the ER following a car accident. What is indicated by "Oriented x3"? A. oriented to person, place, and time B. oriented to person, situation, and time C. oriented to hospital, person, and date D. oriented to person, place, and situation

A. oriented to person, place, and time Explanation: Oriented ×3 indicates that the client is oriented to person (one's own name, the names of significant others, or knowing the nurse), place (location, city, or state), and time (time of day, day of week, or date).

A 57-year-old client is admitted to the medical unit with a 3-day history of sharp, nonradiating epigastric pain and vomiting. The client denies seeing blood in the stool. When assessing this client's abdomen, what assessment technique would the nurse perform last? A. palpation B. inspection C. percussion D. auscultation

A. palpation Explanation: The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation are done after auscultation because they stimulate bowel sounds.

Which outcome best reflects achievement of the goal, "The client will demonstrate correct steps in taking his own pulse rate"? A. palpation of the radial pulse on the thumb side of the inner aspect of the wrist B. light palpation of the femoral pulse below the inguinal area C. firm palpation of bilateral carotid artery for one minute D. firm placement of thumb on the inner wrist of the opposite arm

A. palpation of the radial pulse on the thumb side of the inner aspect of the wrist pg 657

After taking vital signs of an older adult, the nurse writes down findings as T = 98.9/37.2 oral, P = 104, R = 18, BP = 120/82. Based on the collected data, which step would the nurse take next? A. take pulse again to assess for tachycardia B. wait 20 minutes and recheck oral temperature C. recheck BP lvl to ensure accuracy D. talk with client to allow them to relax before retaking vital signs

A. take pulse again to assess for tachycardia pg 653

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client? A. Take the restraints off, stay with her, and talk gently to her. B. Sedate her with sleeping pills and leave the restraints on. C. Leave the restraints on and talk with her, explaining that she must calm down. D. Talk with the client's family about taking her home because she is out of control.

A. take the restraints off, stay with her, and talk gently to her Explanation: Physical restraints increase the possibility of the occurrence of falls, skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration respiratory difficulties, and even death. The best action in this situation is for the nurse to remove the restraint, stay with the client and gently talk to her. Sedating her with sleeping pills is a chemical form of restraint. Leaving the restraints on the client to talk to her is going to cause further agitation and bruising of her wrists. The client's condition—not confusion and agitation—dictates when the client is discharged.

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure? A. the ability of the arteries to stretch B. the oxygen levels in the blood C. the volume of air entering the lungs D. the thickness of circulating blood

A. the ability of the arteries to stretch pg 659

The nurse hears a distinctive first heart sound while auscultating a client's heart rate. What does this heart sound represent? A. the beginning of systole B. opening of the mitral valve C. the ending of diastole D. closure of the aortic valve

A. the beginning of systole Explanation: Closure of the AV valves, mitral and tricuspid, produces the first heart sound, S1, which indicates the beginning of systole. The closure of the atrial valve begins a cycle of diastole. During systole, the left ventricle starts to contract and ventricular pressure rapidly exceeds left atrial pressure, shutting the mitral valve. Aortic valve closure produces the second heart sound, S2.

Which client's blood pressure best describes the condition called hypotension? A. the systolic reading is below 100 and diastolic reading is below 60 B. the systolic reading is below 110 and the diastolic reading is above 80 C. the systolic reading is below 120 and the diastolic reading is below 80 D. the systolic reading is above 102 and diastolic reading is above 60

A. the systolic reading is below 100 and diastolic reading is below 60 pg 661

Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound? A. wheezes B. pleural friction rub C. stertorous breathing D. fine crackles

A. wheezes **PROBS IGNORE** Explanation: Wheezes are continuous sounds originating in small air passages that are narrowed by secretions, swelling, or tumors; the wheezes may be inspiratory or expiratory. A pleural friction rub is a grating sound caused by an inflamed pleura rubbing against the chest wall. Crackles are fine-to-coarse crackling sounds made as air moves through wet secretions. Stertorous breathing describes noisy, strenuous respirations.

The nurse is attempting to assess a client's radial pulse. The pulse is weak, irregular and unable to be counted. What action would the nurse take next?

Assess the apical pulse

An older adult client admitted 4 days ago is being treated for chronic obstructive pulmonary disease (COPD) and now appears confused. What question will the nurse ask to determine the client's level of orientation? A. "How are you feeling?" B. "Can you tell me where you are right now?" C. "Do you know what day this is?" D. "Have you been more confused?"

B. "Can you tell me where you are right now?" Explanation: Asking the client to identify where he or she is represents an open-ended question and allows the nurse to assess the client's level of consciousness without ambiguity. Asking the client open-ended questions is a better way to assess level of consciousness than asking closed-ended questions that can be answered with a simple yes or no response. Asking the client how he or she feels will not assess orientation to person, place, or time.

The nurse begins auscultating a client's heart sounds at the 2nd intercostal space right sternal border. Which location should the nurse assess next? A. 4th left intercostal space B. 2nd intercostal space left sternal border C. 5th left intercostal space midclavicular line D. 3rd intercostal space left sternal border

B. 2nd intercostal space left sternal border Explanation: Since the nurse started at the base of the heart, the next location to assess would be the 2nd intercostal space left sternal border. The 3rd left intercostal space would be assessed next and followed by the 4th intercostal space. The 5th left intercostal space midclavicular line would be assessed last.

The postoperative client refuses to do deep breathing, and he refuses to turn while in bed. He informs the nurse that it hurts for him to do both of these things. Which intervention should the nurse perform first? A. Educate the client of the importance of infection prevention. B. Assess client's pain level and manage pain accordingly. C. Inform the physician of the client's noncompliance D. Inform the client that these exercises must be done at regular intervals.

B. Assess client's pain level and manage pain accordingly Explanation: Encouraging clients to cough, breathe deeply, blow the nose, and move the body promotes clearance of respiratory secretions, which may become infected if allowed to pool in the lower respiratory tract. Retained secretions prevent adequate gas exchange at the alveolar level and reduce oxygen available to the tissues to combat infection, heal injured tissues, and meet metabolic needs. Secondary infections are commonly associated with impaired respiratory tract function. Timing is an important consideration when administering analgesics. To time analgesics appropriately, know the average duration of action for the drug and time administration so that the peak analgesic effect occurs when the pain is expected to be most intense. For example, an analgesic would be offered before ambulating a client postoperatively.

How should a nurse assess a client for pulse rate deficit? A. Check for pulse inequality between right and left carotid arteries B. Assess for a difference between the apical and radial pulse C. Auscultate for split S1 at the base and apex D. Observe for a decrease in jugular venous pressure

B. Assess for a difference between the apical and radial pulse Explanation: The nurse should assess the pulse deficit by assessing the difference in the apical and radial pulse. Pulse deficit is the difference between the apical and peripheral/radial pulses. Differences in the amplitude or rate of the carotid pulse may indicate stenosis. A split S1 occurs when the left and right ventricles contract at different times (asynchronous contraction). Decrease in jugular venous pressure can occur with dehydration secondary to a decrease in total blood volume but does not cause a pulse deficit.

When preparing a sterile field, the nurse notes that the bottle of sterile saline was opened 48 hours ago and is half full. What action does the nurse take to ensure that the saline used is sterile? A. Pour the saline into a sterile container on the sterile field by holding it 6 in (15 cm) above the container. B. Discard the bottle and get a new one because the saline has expired. C. Since the bottle has been open, previously used, and unexpired, "lip" it by pouring a small amount into a waste container or waste cup. D. Use the saline for the procedure and discard the remaining amount because it has been 48 hours since opening.

B. Discard the bottle and get a new one because the saline has expired. Explanation: Once a bottle of sterile saline is open, the contents must be used within 24 hours of opening. Lipping the opening of the bottle and pouring the saline into a sterile container by holding it 6 in (15 cm) above the container would be appropriate, but contents in the bottle are expired. The nurse should discard the bottle and get a new one.

Which statement describes diastolic blood pressure? A. To assess diastolic pressure, the blood pressure measured during ventricular contraction. B. During ventricular relaxation, blood pressure is due to elastic recoil of the vessels. C. The pressure is highest when the ventricles of the heart eject blood into the aorta and pulmonary arteries. D. The flow of blood is produced by contractions of the heart and by the resistance to blood flow through the vessels.

B. During ventricular relaxation, blood pressure is due to elastic recoil of the vessels pg 684

Which mask should the nurse don when caring for a client with tuberculosis? A. No mask is needed B. Filtered respirator C. Low-efficiency particulate air (LEPA) D. Surgical mask

B. Filtered respirator Explanation: When caring for a client with tuberculosis, the nurse should don a filtered respirator mask to filter the inspired air. A surgical mask, also known as a procedure mask, is intended to be worn by health care professionals during surgery and during nursing to catch the bacteria shed in liquid droplets and aerosols from the wearer's mouth and nose. Low-efficiency particulate air (LEPA) masks are not used in health care.

A client who has been lying prone reports shortness of breath and a sensation of choking. Into which position will the nurse place the client? A. Sims' B. Fowler's C. prone D. supine

B. Fowlers Explanation: Fowler's position, a semi-sitting position, will assist the client with dyspnea because this position allows the abdominal organs to drop away from the diaphragm. The other position choices do not promote oxygenation.

What teaching will the community health nurse include for parents of toddlers? A. Peer pressure can contribute to risk-taking. B. Household cleaners must be kept out of reach. C. Purchase protective sporting equipment. D. Place the child securely on a changing table.

B. Household cleaners must be kept out of reach Explanation: Toddlers are naturally inquisitive and more mobile than infants and fail to understand dangers; therefore, it is appropriate to teach parents of toddlers to keep household cleaners out of reach. Teaching about changing table safety is more appropriate for infants. Teaching about protective sporting gear is appropriate for school-age children who are physically active. Teaching about peer pressure is more appropriate for adolescents.

The nurse is teaching an unlicensed assistive personnel (UAP) about fire safety. Which UAP statement demonstrates that teaching has been effective? A. "I know that nurses are the only ones who can extinguish a fire." B. "I will rescue clients from harm before doing anything else." C. "I will leave all doors open after rescuing clients." D. "I will sound the alarm before I start moving a client from a room."

B. I will rescue clients from harm before doing anything else Explanation: The RACE acronym should be used when managing a fire: Rescue, Alarm, Confine, and Extinguish. Teaching has been effective when the UAP knows to rescue clients first.

An 8-year-old boy fell off his bicycle. He was not wearing a helmet and has sustained a concussion. What information should the nurse teach the parents about concussions? A. "Try to keep him resting for a few days at home using the television and his video games." B. "It is important to monitor frequently for headache, vomiting, visual disturbances, and changes in alertness." C. "Wearing bicycle helmets will keep your child safe from head injuries." D. "Concussions happen often in children of this age group, and they always bounce back fine."

B. It is important to monitor frequently for headache, vomiting, visual disturbances, and changes in alertness Explanation: Frequent neurologic assessments are crucial after a traumatic brain injury to assess for subtle changes as they begin. Helmets are meant to protect the wearer, but head injury can still occur. "Passing off" an injury as something that kids get and "bounce back" from is wrong and potentially harmful. Watching TV and video games stimulates brain activity and may worsen the child's symptoms and the injury itself.

The nurse is assisting a client from the bed into a wheelchair. What is a recommended guideline for this procedure? A. Make sure the bed brakes are unlocked. B. Raise the head of the bed to a sitting position. C. Put the chair at the foot of the bed. D. Place the bed in the highest position.

B. Raise the head of the bed to a sitting position pp. 1190 Explanation: When assisting a client from the bed into a wheelchair, the nurse would place the bed in the lowest position and raise the head of the bed to a sitting position. The nurse would make sure the bed brakes are locked and put the wheelchair next to the bed, locking the brakes of the chair.

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client? A. Sedate her with sleeping pills and leave the restraints on. B. Take the restraints off, stay with her, and talk gently to her. C. Talk with the client's family about taking her home because she is out of control. D. Leave the restraints on and talk with her, explaining that she must calm down.

B. Take the restraints off, stay with her, and talk gently to her Explanation: Physical restraints increase the possibility of the occurrence of falls, skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration respiratory difficulties, and even death. The best action in this situation is for the nurse to remove the restraint, stay with the client and gently talk to her. Sedating her with sleeping pills is a chemical form of restraint. Leaving the restraints on the client to talk to her is going to cause further agitation and bruising of her wrists. The client's condition—not confusion and agitation—dictates when the client is discharged.

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse? A. A detailed description of the restraint application process B. The alternative measures attempted before applying the restraints C. The type of personal protective equipment used by the nurse during restraint application D. A verbal prescription for the restraints, renewed every 48 hours

B. The alternative measures attempted before applying the restraints Explanation: Reasonable measures to avoid the use of restraints must be attempted before implementation; these measures must be documented. Verbal restraint prescriptions must be renewed every 24 hours, not every 48 hours. Neither a detailed description of the restraint application process nor the type of personal protective equipment used by the nurse during restraint application are required to be documented.

Which client's blood pressure best describes the condition called hypotension? A. The systolic reading is above 102 and diastolic reading is above 60. B. The systolic reading is below 100 and diastolic reading is below 60. C. The systolic reading is below 120 and the diastolic reading is below 80. D. The systolic reading is above 110 and diastolic reading is above 80.

B. The systolic reading is below 100 and diastolic reading is below 60 pg 661

A client might have an aortic regurgitation murmur. Which is the best position to accentuate the murmur? A. Supine B. Upright, but leaning forward C. Upright D. Left lateral decubitus

B. Upright, but leaning forward Explanation: Leaning forward slightly in the upright position brings the aortic valve and the left ventricular outflow tract closer to the chest wall, so it will be easier to hear the soft diastolic decrescendo murmur of aortic insufficiency (regurgitation). The examiner can further hear this soft murmur by having the client hold his or her breath in exhalation.

A nurse plans to measure the temperature of a client with mild diarrhea, but the client has just had hot soup. Which action should the nurse perform to obtain the accurate temperature of the client? A. Ask the client to drink a glass of cold water before measuring the oral temperature B. Wait for 30 minutes before measuring the oral temperature C. Use the axillary site for an alternate measurement site D. Obtain the client's temperature rectally after lubricating the rectum

B. Wait for 30 minutes before measuring the oral temperature pg 652

Clients demonstrating apnea have what? A. decreased rate and depth of respirations B. a temporary cessation of breathing C. normal respiratory rate of 20 D. increased rate and depth of respirations

B. a temporary cessation of breathing pg 658

When assessing a client's radial pulse, the nurse notes an irregular rhythm with a rate of 62 beats per minute. What intervention should the nurse implement next? A. compare w/ previously documented findings B. auscultate the apical pulse for 60 sec C. obtain a bedside electrocardiogram D. report the findings to the HCP

B. auscultate the apical pulse for 60 sec pg 681

A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an): A. fungi. B. bacteria. C. virus. D. protozoa.

B. bacteria Explanation: A client suffers from bloody diarrhea after eating contaminated food at a local restaurant. The client has been infected with a(an):

The bicuspid, or mitral, valve is located A. at the beginning of the ascending aorta. B. between the left atrium and the left ventricle. C. at the exit of each ventricle near the great vessels. D. between the right atrium and the right ventricle.

B. between the left atrium and the left ventricle. Explanation: The bicuspid (mitral) valve is composed of two cusps and is located between the left atrium and the left ventricle.

Which piece of personal protective equipment (PPE) should be removed first? A. Gown B. Gloves C. Goggles D. Respirator

B. gloves Explanation: The order for removal of PPE is gloves, goggles, gown, and respirator. If removal of PPE is not in that order, contamination of the nurse can occur.

A client is admitted to the emergency department for multiple lacerations due to a vehicular accident. After wound care, the doctor writes an order for Tdap (Tetanus-diphtheria-pertussis) vaccination. The primary reason for this vaccine is: A. it induces humoral immunity in the client's blood. B. it is a vaccine given to booster antibodies towards the tetanus pathogen. C. It counteracts the effects of the inflammatory process. D. it is an antiviral vaccine used to eradicate wound infection.

B. it is a vaccine given to booster antibodies towards the tetanus pathogen. Explanation: Active immunity is produced when the immune system is stimulated, either naturally or artificially, to produce antibodies. Natural immunity occurs after an infection has run its course.

A public health nurse is providing community education to older adults regarding their risk of poisoning. Which information does the nurse include in the teaching? A. avoiding the use of alternative and complementary therapies B. keeping medications in clearly labeled containers C. reviewing hidden sources of lead in the household environment D. using alternatives to chemical-based cleaning supplies

B. keeping medications in clearly labeled containers Explanation: Medication overdoses are among the more common sources of poisoning in older adults, a phenomenon that can be reduced by ensuring that medications are in clearly labeled containers to avoid administration errors. Cleaning supplies and lead are more significant sources of poisoning in infants and children. Alternative and complementary therapies carry risks, but it would be unnecessary to recommend complete avoidance of all such therapies.

A nurse is preparing to turn a client who is unable to mobilize independently. Which action best ensures the safety of both the client and the nurse? A. using back muscles to gently and gradually pull the client to the side B. positioning a friction-reducing sheet under the client to facilitate movement C. placing the bed in its lowest position to reduce the client's risk for falls D. standing at the top of the bed and having a colleague stand at the bottom of the bed

B. positioning a friction-reducing sheet under the client to facilitate movement pp. 1181-1182 Explanation: After placing the bed in a comfortable working position (usually elbow height of the caregiver), position a nurse on either side of the bed, place a friction-reducing sheet under the client, and use the leg muscles to pull the client to the side

A nurse needs to assess the temperature of a client with high fever. Which site will most closely reflect core body temperature of the client? A. mouth B. rectum C. axilla D. ear

B. rectum pg 652

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure? A. the oxygen levels in the blood B. the ability of the arteries to stretch C. the volume of air entering the lungs D. the thickness of circulating blood

B. the ability of the arteries to stretch pg 659

When administering beta blocker medications, the physician adds an order to hold medication when the client is bradycardic. Which statement explains this order? A. the client's systolic blood pressure is less than 100 mm Hg B. the client's pulse rate is below 60 beats per minute C. the client is unable to stay upright when blood pressure is checked D. the client's respiratory rate is less than 18 breaths per minute

B. the client's pulse rate is below 60 beats per minute pg 653

The nurse is auscultating the heart sounds of an adult client. To auscultate Erb point, the nurse should place the stethoscope at the A. apex of the heart near the midclavicular line (MCL). B. third to fifth intercostal space at the left sternal border. C. second intercostal space at the right sternal border. D. fourth or fifth intercostal space at the left lower sternal border.

B. third to fifth intercostal space at the left sternal border Explanation: Erb's point: Third to fifth intercostal space at the left sternal border.

The nurse is providing teaching about cardiovascular disease in a community setting. What risk factors would the nurse identify to the group as those they can modify through lifestyle choices? Select all that apply. A. Blood pressure B. Age C. Cholesterol D. Smoking D. Family history

C, D, A Explanation: Smoking, cholesterol and blood pressure can be controlled through lifestyle choices. Age and family history are non-modifiable risk factors.

The registered nurse is caring for a client with a waist restraint. Which tasks should the nurse delegate safely to the unlicensed assistive personnel (UAP)? Select all that apply. A. Determine if the waist restraint is too tight. B. Chart the skin findings during the 2-hour check. C. Obtain, record, and report vital signs. D. Assess the client's need to continue the waist restraint. E. Provide a bedpan and pericare.

C, E Explanation: The registered nurse (RN) cannot delegate the nursing process, so the RN should assess the client's continued need for the waist restraint and perform the ongoing assessment, including the condition of the client's skin, circulation, and if the restraint is too tight. The nurse may safely delegate to UAP the following tasks: providing a bedpan; providing pericare; and obtaining, recording, and reporting vital signs to the RN.

The nurse is encouraging the client to use hand rolls to prevent contractures. Which statement by the client indicates that further teaching is necessary? A. "The hand rolls help keep my thumb positioned away from my hand." B. "I need to remove the hand roll often to exercise my hand muscles." C. "The hand rolls help me develop strength in my grip." D. "I can use a rolled-up washcloth if I don't have a hand roll."

C. "The hand rolls help me develop strength in my grip." pp. 1158 Explanation: Hand rolls prevent contractures (permanently shortened muscles that resist stretching) of the fingers. They keep the thumb positioned slightly away from the hand and at a moderate angle to the fingers. The fingers are kept in a slightly neutral position rather than a tight fist. A rolled-up washcloth or a ball can be used as an alternative to commercial hand rolls. Hand rolls are removed regularly to facilitate movement and exercise. Hand rolls are not used to strengthen the grip.

The nurse assesses the client's pulses to be normal. How would the nurse document this information? A. 0 B. 1+ C. 2+ D. 4+

C. +2 Explanation: On most scales, normal pulses are recorded as 2+. Absent pulses are 0, weak pulses are 1+, full or somewhat increased pulses are 3+, and a bounding pulse is a 4+.

The nurse has completed an assessment and notes that the client's blood pressure is 132/92 mmHg. What is this client's pulse pressure? A. 112 mm Hg B. 132 mm Hg C. 40 mm Hg D. 224 mm Hg

C. 40 mm Hg pg 659

A client is admitted to the hospital with tuberculosis. Which statement by the nurse explains how to reduce the risk of transmission to others? A. "No visitors are allowed in the room to decrease the spread of disease." B. "Everyone who enters the room must wear a gown and gloves." C. "All visitors who enter the room must wear N95/surgical masks." D. "Under no circumstances should you touch the client."

C. All visitors who enter the room must wear N95/surgical masks Explanation: Tuberculosis is an airborne respiratory disease, which requires a HEPA-style respirator or N95 mask when visitors or staff enter the room of a client with known or suspected disease. Gowning and gloving do not prevent airborne transmission. Visitors are permitted and there is no firm prohibition against touching the client.

The nurse is attempting to assess a client's radial pulse. The pulse is weak, irregular and unable to be counted. What action would the nurse take next? A. Get another nurse for validation. B. Document the findings. C. Assess the apical pulse. D. Assess the carotid pulse.

C. Assess the apical pulse pg 678-680

A nurse is assessing the respirations of a 60-year-old female client and finds that the client's breaths are so shallow that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation? A. Notify the health care provider. B. Perform a pain assessment. C. Auscultate the lung sounds and count respirations. D. Administer oxygen.

C. Auscultate the lung sounds and count respirations pg 656-657 *Clients should be taught when performing HBPM that they should call the health care provider if the averages of HBPM readings increase/decrease by 10, or if she has any concerns*

The nurse is caring for an 88-year-old male admitted 2 days ago for dehydration. The nurse brings the client his breakfast tray and notes that the client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate? A. Use facial expressions and sign language to communicate. B. Ask the client if he left his earplugs in his ears. C. Check the client's ear canals for cerumen. D. Speak to the older adult client in a high-frequency tone of voice.

C. Check the client's ear canals for cerumen. Explanation: Ear wax (cerumen) becomes drier in older adults and can block the ear canal and cause decreased hearing. Asking the client if he has earplugs in his ears is not appropriate. Using facial expressions and sign language is appropriate in communicating with the hard of hearing, but this client's hearing loss was acute and requires further assessment. When speaking to older adults who are hearing-impaired, one needs to use low tones to facilitate communication; high-frequency tones are problematic for older adults.

The nurse places the stethoscope on the 3rd intercostal space at the left sternal border. Which area is the nurse auscultating for heart sounds? A. Pulmonic B. Aortic C. Erb point D. Mitral

C. Erb point Explanation: Erb's point is auscultated at the 3rd intercostal space at the left sternal border. The aortic area is located at the second intercostal space at the right sternal border. The mitral area is located at the fifth intercostal space near the left mid-clavicular line. The pulmonic area is located at the 2nd or 3rd intercostal space at the left sternal border.

Upon review of a client's microbiology culture results, the nurse recognizes which organism as indicative of normal flora? A. Shigella in the urinary tract B. Escherichia coli in the urinary tract C. Escherichia coli in the intestinal tract D. Shigella in the intestinal tract

C. Escherichia coli in the intestinal tract Explanation: Escherichia coli resides in the intestinal tract, is normal flora, and does not cause harm or infection in the client. Shigellosis is an infectious disease caused by a group of bacteria called Shigella, closely related to E. coli. Most people who are infected with Shigella develop diarrhea, fever, and stomach cramps starting a day or two after they are exposed to the bacteria.

During the health history interview with a 40-year-old man, the nurse uses the genogram to specifically assess for major family risk for cardiovascular disease by asking about which of the following? A. Weight patterns within his family B. Diabetes mellitus in his extended family C. Heart attacks in his father and siblings D. Hypertension in his grandparents

C. Heart attacks in his father and siblings Explanation: Risk of developing heart disease is increased if one or more immediate family members (parents or siblings) have had an MI, hypertension, or high cholesterol.

A 25-year-old optical technician comes to the clinic for evaluation of fatigue. As part of the physical examination, the nurse listens to her heart and hears a murmur only at the cardiac apex. Which valve is most likely to be involved based on the location of the murmur? A. Aortic B. Tricuspid C. Mitral D. Pulmonic

C. Mitral Explanation: Mitral valve sounds are usually heard best at and around the cardiac apex.

What is the primary role of the nurse in the care of clients who experience domestic violence? A. Calling the police B. Serving as a witness in court C. Providing prompt recognition of the potential or actual threat to safety D. Identifying health education and counseling measures for the family

C. Providing prompt recognition of the potential or actual threat to safety Explanation: The nurse is often the initial health care provider in contact with an abused child or a battered woman or man. Prompt recognition of the potential or actual threat to safety is crucial, and the nursing assessment may play a vital role in identifying a harmful environment.

The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation? A. Remove the thermometer and assess the temperature via another method. B. Call for assistance and anticipate the need for CPR. C. Remove the thermometer and assess the blood pressure and heart rate. D. Leave the thermometer in and notify the physician.

C. Remove the thermometer and assess the blood pressure and heart rate pg 652

A nurse is preparing discharge education for a client with a newborn infant. What is the highest priority item that must be included in the education plan? A. Lock all cabinets that contain cleaning supplies. B. Give warm bottles of formula to the infant. C. Restrain the infant in a car seat. D. Keep all pots and pans in lower cabinets.

C. Restrain the infant in a car seat. Explanation: The client should restrain the infant in a car seat when driving. Infants are especially vulnerable to injuries resulting from falling off changing tables or being unrestrained in automobiles. Locking the cabinets, giving warm bottles of formula to the infant, and keeping all pots and pans in lower cabinets are secondary teachings.

A 62-year-old female client being treated for hypertension did not take her daily BP medication over the weekend because she was out of medication and the pharmacy was closed. Her average home blood pressure monitoring (HBPM) reading has been 130/82. Today her BP has been 138/90, 135/85, and 142/86. She calls the on-call nurse for her health care provider. What is the most appropriate thing for this nurse to advise this client? A. To take the medication that she missed and retake her BP B. Not to worry and to take double the dose of BP medication C. To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns. D. To call her health care provider

C. To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns pg 669-670

Infection occurs when the host is exposed to pathogens. What type of pathogen uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup? A. bacteria B. protozoa C. Virus

C. Virus Explanation: A virus invades a living cell many times its size, uses the cell's metabolism, and replicates itself while destroying the cell or changing the cell's genetic makeup.

Which type of mobility aid would be most appropriate for a client who has poor balance? A. a single-ended cane with a straight handle B. axillary crutches C. a cane with four prongs on the end (quad cane) D. a single-ended cane with a half-circle handle

C. a cane with four prongs on the end (quad cane) pp. 1169 Explanation: Canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support are recommended for clients with poor balance. Single-ended canes with half-circle handles are recommended for clients requiring minimal support and those who will be using stairs frequently. Single-ended canes with straight handles are recommended for clients with hand weakness because the handgrip is easier to hold but are not recommended for clients with poor balance. Axillary crutches are used to provide support for clients who have temporary restrictions on ambulation.

A staff development nurse is providing an in-service to a group of nurses on the use of restraints in health care facilities. What is an example of a chemical restraint? A. side rails B. a geriatric chair with a tray C. a dose of an antipsychotic D. a dose of an analgesic

C. a dose of antipsychotic Explanation: Drugs that are used to control behavior and are not included in the person's normal medical regimen can be considered a chemical restraint. Side rails and a geriatric chair with a tray are examples of physical restraints. Analgesics address pain and are not a restraint.

The nurse has palpated the client's radial artery and identified a heart rate of 88 beats per minute with an irregular rate. What is the nurse's most appropriate action? A. reassess the client's radial pulse in 15 min B. palpate the radial pulse on opposite wrist C. auscultate the client's apical heart rate D. page the client's primary care provider

C. auscultate the client's apical heart rate pg 657

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac medication. The nurse can anticipate that the digoxin will: A. decrease the respiratory rate. B. decrease the blood glucose. C. decrease the apical pulse. D. decrease the blood volume.

C. decrease the apical pulse pg 655-656

The nurse is caring for a 72-year-old client who has a history of asthma and hypertension and recently had some medication changes. Which action should the nurse prioritize after noting the client has a diminished appetite with reports of nausea as well as dizziness upon standing? A. institute precautions against falling B. monitor for weight changes C. evaluate new cardiovascular medications D. assess for an infection

C. evaluate new cardiovascular medications pg 653

When educating families on fire safety, it is important to: A. use extension cords to prevent shock. B. keep a fire extinguisher in a closet. C. have a meeting place outside the home. D. account for all members and then exit.

C. have a meeting place outside the home Explanation: The whole family should regularly practice crawling on the floor, using escape routes, and having a meeting place outside the home in case of fire. Attempting to account for all family members before exiting the burning structure is dangerous and may result in the loss of life. Shock is possible with extension cords. Having a fire extinguisher is important, but it should be kept in an area with access and not a closet.

A nurse needs to assess the temperature of a client with high fever. Which site will most closely reflect core body temperature of the client? A. mouth B. rectum C. axilla D. ear

C. rectum pg 652

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight? A. Rock the client back and forth to raise the client up in bed. B. Shift their weight back and forth from the legs to the back muscles. C. Shift their weight back and forth, from back leg to front leg. D. Turn the client from side to side while pushing upward.

C. shift their weight back and forth, from back leg to front leg pp. 1185 Explanation: The nurses would use a rocking motion to counteract the client's weight. The nurses would shift their weight back and forth, from back leg to front leg, count to three, and then move the client up toward the head of the bed. Rocking the client or turning the client from side to side is not used to move a client.

The nurse is assisting a client with limited mobility to turn in bed. After successfully turning the client to the side, where would the nurse place an additional pillow? A. under the client's feet B. in front of the client's abdomen C. supporting the client's back D. under the client's head

C. supporting the client's back pp. 1160 Explanation: The nurse would place the pillow under the client's back to provide support and help maintain the proper position. A pillow can also be placed between the knees. More than one pillow under the client's head is not necessary. Placing a pillow in front of the client's abdomen would be helpful for a client who has undergone abdominal surgery. Placing a pillow under the client's feet is not helpful for the side lying position.

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client? A. the 3-month-old child who is unable to raise the head when prone B. the 18-month-old child who is unable to stack blocks C. the 24-month-old child who is unable to walk unassisted D. the 6-month-old child who is unable to roll over

C. the 24-month-old child who is unable to walk unassisted Explanation: At 15 months of age, most toddlers can walk unassisted; there would be concern for a 24-month-old child who could not. At 3 months of age, an infant may be able to raise the head, but this is not expected at this age. Rolling over is usually accomplished between 6 and 9 months of age, so it would not be expected for all 6-month-old infants. Stacking blocks is accomplished by most 3-year-olds, but doing so at 18 months is considered early.

The nurse is providing health teaching for a client who flies often for business. Which risk factor associated with flying will the nurse emphasize? A. skeletal contractures B. pooling of secretions C. thrombus formation D. oliguria

C. thrombus formation pp 1144 Explanation: Prolonged sitting can increase a client's risk for thrombus formation. The nurse will emphasize this and teach stretching exercises. Skeletal contractures, pooling of secretions, and oliguria are not risk factors associated with flying (prolonged sitting).

The nurse is caring for a client who works in a warehouse and has been having low back pain. Which statement by the client indicates the need for more education regarding safe lifting? A. "I bend with my knees when I pick up boxes." B. "I stand with my feet apart so I have a better stance when I lift." C. "I try to rest between periods of lifting." D. "I hold the boxes away from my body so I do not drop them on my feet."

D. "I hold the boxes away from my body so I do not drop them on my feet." pp 1136 Explanation: Heavy objects should be held close to the body to distribute the weight evenly and prevent muscle strain. The other statements are correct lifting techniques.

The nurse is interviewing a client to obtain the health history. Which question would the nurse ask first? A. "Are you having any pain?" B. "What medications do you normally use?" C. "Do you have any allergies?" D. "What brings you in here today?"

D. "What brings you in here today?" Explanation: The first subject usually discussed in a client interview is the client's specific reason for seeking care, commonly called the "chief complaint" or "chief concern." Other questions (e.g., about pain, medications and allergies) would be used as the client interview continues.

The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that the client is able to move onto the stretcher without the nurse's help. What is the nurse's best response? A. "That is fine if you want to transfer without my help; ring your call bell after you have transferred and are ready to go." B. "I can only allow you to transfer without assistance with a physician's order, so I will help you now." C. "You may not transfer without my help, because you need a friction-reducing device to prevent harm to your skin." D. "You are free to move onto the stretcher without assistance, but I will supervise for your safety."

D. "You are free to move onto the stretcher without assistance, but I will supervise for your safety." pp. 1136 Explanation: If the client is fully able to assist in the transfer, the nurse should allow the client to complete the movement independently, with supervision for safety. A physician order is not necessary for a transfer from a stretcher to a bed. The client can move independently and therefore does not need a friction-reducing device. A nurse should remain at the bedside to monitor the transfer.

The community health nurse is talking with four clients. Who does the nurse identify that would most benefit from teaching about alcohol and drug use? A. 40-year-old female who is working two jobs B. 34-year-old male who does not use a seat belt C. 25-year-old female who just accepted her first job D. 19-year-old male college student majoring in physics

D. 19-year-old male college student majoring in physics Explanation: Young adults, particularly those who just became emancipated from parental supervision, are at the highest risk for alcohol and drug use. Other clients may have other safety risk factors, but are not at a proportionately higher risk for alcohol and drug use.

The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device? A. A client with a thoracic incision B. A client who has an abdominal incision C. A client who is confined to bed rest D. A client who has leg strength and can cooperate with the movement

D. A client who has leg strength and can cooperate with the movement Explanation: The gait belt is used to help the client stand and provides stabilization during pivoting. Gait belts also allow the nurse to assist in ambulating clients who have leg strength, can cooperate, and require minimal assistance. A gait belt is not used on clients who have either an abdominal or thoracic incision. A gait belt would not be used on a client who is confined to bed rest.

About which public health principle should the nurse educate clients to prevent the spread of West Nile virus? A. Self-quarantine yourself for 2 weeks if you feel ill B. Use a face mask when in crowds C. Use hand sanitizer after touching any public surface D. Avoid contact with mosquitoes

D. Avoid contact with mosquitos Explanation: Biologic vectors are living creatures that carry pathogens that transmit disease. West Nile virus is transmitted via mosquitoes, so the nurse should teach avoidance of mosquitoes to prevent the spread of West Nile virus. A hand sanitizer prevents the spread of a virus spread by contact with surfaces. Self-quarantine is not necessary to prevent the spread of West Nile virus; avoidance of mosquitos is the best way to accomplish this. Blood and body fluid precautions are used to prevent the spread of diseases spread through contact with these fluids. West Nile virus is not spread by airborne or droplet transmission so use of a face mask is not appropriate.

A nurse is applying the principles of Standard and Contact Precautions in the care of a hospital client. Which action violates these principles? A. The nurse applies non-medicated hand cream after performing hand hygiene. B. The nurse performs hand hygiene after touching the client's surroundings. C. The nurse performs hand hygiene before putting on gloves. D. The nurse removes her gown and then removes her gloves.

D. D. The nurse removes her gown and then removes her gloves. Explanation: Gloves should be removed prior to a gown. Hand hygiene is necessary before applying gloves and after touching a client's surroundings. The use of moisturizers is acceptable.

The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In counting the apical pulse, the nurse recognizes which characteristic about heart sounds? A. The lub-dub sounds occur within 2 seconds of each other. B. Each lub-dub is two beats. C. Heart sounds are caused by the opening of heart valves. D. Each lub-dub is one beat.

D. Each lub-dub is one beat. Explanation: Each lub (the first heart sound) represents the closure of the mitral and tricuspid valves during systole, and the dub (the second heart sound) represents the closure of the aortic and pulmonic valves during diastole. Together the lub-dub sounds are counted as one beat. The two sounds occur within 1 second or less of each other, depending on the heart rate.

The poison control nurse receives a call from the parent of a 2-year-old child. The parent states, "I just took a quick shower, and when I finished, I walked into the kitchen and found my child with an open bottle of household cleaner." What is the poison control nurse's appropriate response? A. "Did you leave the household chemical in reach of your child?" B. "You should not have left your child alone while you showered." C. "Induce vomiting and call 911 right away." D. "Is your child breathing at this time?"

D. Is your child breathing at this time? Explanation: Initial treatment for a victim of suspected poisoning involves maintaining breathing and cardiac function, so the nurse will ask about the child's respiratory status. Definitive treatment depends on the substance, the client's condition, and if the substance is still in the stomach; vomiting should not be induced until more information is gathered. Instructing the parent about leaving the child alone is not therapeutic at this time.

The nurse is teaching a client about good posture when lying down to go to sleep. Which teaching will the nurse include? A. "Sleep with your head tilted to one side to take pressure off your neck." B. "Your feet should be at 45-degree angles from the legs." C. "Keep knees and legs very straight." D. "Picture yourself with good posture standing; that is how good lying posture works."

D. Picture yourself with good posture standing; that is how good lying posture works pp. 1159 Explanation: The best posture lying down will be the same as standing posture, except the client is horizontal. Knees should be slightly flexed; feet should be at a right angle from the legs; the head and neck muscles should be in a neutral position, centered between the shoulders. It is not correct to say to keep the knees and legs very straight, to position feet at a 45-degree angle from the legs, or to sleep with the head tilted to one side.

A nurse is assessing the pulse volume of a client with influenza. The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse? A. Pulse is felt easily, and moderate pressure causes it to disappear. B. Pulse is strong, and light pressure causes it to disappear. C. Pulse is strong and remains strong despite moderate pressure. D. Pulse is felt with difficulty and disappears with slight pressure.

D. Pulse is felt with difficulty and disappears with slight pressure pg 652-653

The nurse is caring for a client who has been placed in strict isolation. Which nursing action is appropriate? A. No special precautions are required. B. Deliver flowers and balloons to the room. C. Allow many family members to visit at once. D. Remove fresh fruit from the room.

D. Remove fresh fruit from the room Explanation: Fresh fruit and flowers can carry pathogens and chemicals to which the client should not be exposed. The number of visitors should be controlled to prevent exposure to multiple infection opportunities.

What is an accurate guideline for the use of PPE? A. Substitute personal glasses for protective eyewear, if desired. B. When wearing gloves, work from "dirty" areas to "clean" ones. C. Put on PPE after entering the client's room. D. Replace gloves if they are visibly soiled.

D. Replace gloves if they are visibly soiled. Explanation: If gloves become torn or heavily soiled, they should be removed and replaced. PPE should be put on before entering the client's room and glasses should not be substituted for protective eyewear. Work should progress from "clean" areas to "dirty" areas.

When auscultating the heart, the nurse is most likely to hear a diastolic murmur after which heart sound? A. Preload B. Afterload C. S1 D. S2

D. S2 Explanation: Diastolic murmurs occur during filling, from the end of S2 to the beginning of the next S1, when the mitral and tricuspid valves are open and the aortic and pulmonic valves are closed. Preload is an indicator of how much blood will be forwarded to and ejected from the ventricles. The heart has to pump against the high blood pressures in the arteries and arterioles. This pressure in the great vessels is termed afterload. Preload and afterload are not heart sounds but volume and pressure indicators.

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report? A. The nurse should make a copy of the safety event report and place it in the client's medical record. B. The nurse should await results of the x-ray before filing the report. C. The nurse should include a note on the client's chart that mentions the report. D. The nurse should record the incident in the client's medical record and fill out a safety event report separately.

D. The nurse should record the incident in the client's medical record and fill out a safety event report separately. Explanation: The nurse completes the safety event report immediately after an unintentional injury and is responsible for recording the incident and its effect on the client in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation. The nurse should not wait until after the x-ray to complete the form.

A nurse is preparing to implement an order for the use of restraints to ensure a client's safety. Which statement accurately describes a guideline to follow? A. Respond to the past history of the client (including previous falls) to determine the need for restraints. B. Individualize the use of restraints and choose the most easily used device. C. Alert the health care provider and the client's family if restraints are ordered by the client's primary nurse. D. Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others.

D. Time-limit the use of restraints and release the client from the restraint as soon as he or she is no longer a risk to self or others. Explanation: The client should be released from the restraint as soon as he or she is no longer a risk to self or others. Decisions should be based on the client's present status, not on his or her history. Restraints must be ordered by a health care provider and the least restrictive device should be used.

The nurse has provided a family with education related to car seat safety for a 9-month-old infant. Which statement indicates an understanding of the teaching? A. "We place our infant in a rear-facing car seat in the front of the car so that we can see them in case of choking." B "We place our infant in a front-facing car seat in the front of the car so that they do not cry." C. "We place our infant in a front-facing car seat in the middle of the back seat of the car." D. "We place our infant in a rear-facing car seat in the back seat of the car."

D. We place our infant in a rear-facing car seat in the back seat of the car Explanation: Children from birth to 2 years of age should remain in a rear-facing infant seat in the back seat of the car until they reach the maximum height and weight for a rear-facing child car seat. A rear-facing car seat should not be placed in the front seat; front passenger air bags can injure or kill young children in a crash. When children outgrow their rear-facing car seats, they should be buckled in a forward-facing car seat with a harness in the back seat until they reach the maximum weight or height limit of forward-facing car seats.

The nurse should use the bell of the stethoscope during auscultation of: A. a client's apical heart rate. B. a client's bowel sounds. C. a client's breath sounds. D. a client's heart murmur.

D. a client's heart murmur Explanation: The bell of the stethoscope is used to listen to low-pitched sounds, such as heart murmurs. The diaphragm of the stethoscope is used to listen to high-pitched sounds such as normal heart sounds, breath sounds, and bowel sounds.

To assess subjective data related to a client's elimination pattern, the nurse: A. reviews the latest laboratory report of the urine. B. notes the frequency, amount, and time the client voids. C. palpates the abdomen for pain or distention. D. asks the client about changes in elimination patterns.

D. asks the client about changes in elimination patterns. Explanation: The nurse should focus the interview on the client's normal urinary and bowel patterns, noting any recent changes.

To obtain subjective data about a newly admitted client's sleep pattern, the nurse: A. inspects the client's eyes for redness. B. documents the client's affect and yawning. C. determines how frequently the client naps. D. asks the client what promotes sleep.

D. asks the client what promotes sleep. Explanation: The assessment of sleep and rest focuses on the client's normal sleep patterns, alterations from the normal pattern, and satisfaction with quality of rest and sleep.

The nurse has finished assessing a newly admitted 6-month-old Native American/First Nations client. Which clinical findings should be immediately reported to the health care provider? A. the abdomen appearing large in relation to the pelvis B. a blue-black macular area over the sacral area C. the anterior fontanel bulging when the client cries D. circumoral cyanosis when the client is at rest

D. circumoral cyanosis when the client is at rest Explanation: Circumoral cyanosis, a condition of bluish or grayish skin around the mouth, may indicate inadequate oxygenation, and thus should be reported immediately to the health care provider. Mongolian spot is a common variation of hyperpigmentation in newborns of African, Turkish, Asian, Native American/First Nations, and Hispanic heritage. It is a harmless blue-black to purple macular area of hyperpigmentation that is usually located at the sacrum or buttocks, but sometimes occurs on the abdomen, thighs, shoulders, or arms. The anterior fontanel bulging when the client cries and the abdomen appearing large in relation to the pelvis are normal findings.

The school nurse is preparing a presentation about safety promotion for middle school-aged students. Which topic will the nurse plan to include? A. identifying hazards associated with falls B. practicing moderation when consuming alcohol C. avoiding workplace injury D. consistently using seat belts

D. consistently using seat belts Explanation: Seat belt use is an important safety precaution for middle school-aged children due to their increased risk for motor vehicle accidents. Improper seat belt use (or lack of seat belt use) increases the risk for injury. It is not appropriate to teach middle school-aged children about moderation with alcohol, because they should be taught about abstaining from alcohol use in general. Workplace injuries and falls do not directly relate to the age group.

The nurse is assessing a newly admitted client. Auscultation of the client's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. How does the nurse document this finding? A. sonorous wheeze B. friction rub C. sibilant wheeze D. crackles

D. crackles **PROBS IGNORE** Explanation: Crackles are described as bubbling- or popping-type sounds that are usually audible during inspiration. Wheezes are typically musical in tone and continuous. Sibilant wheezes are high-pitched and shrill-sounding breath sounds that occur when the airway becomes narrowed. They often have a musical quality to them. These are the typical wheezes heard when listening to an asthmatic client. A sonorous wheeze is an added sound with a musical pitch occurring during inspiration or expiration, heard on auscultation of the chest and caused by air passing through bronchi that are narrowed by inflammation, spasm of smooth muscle, or presence of mucus in the lumen. A friction rub is a continuous, grating-type sound.

In order to palpate an apical pulse when performing a cardiac assessment, where should the nurse place the fingers? A. right of midclavicular line at the fifth intercostal space B. left midclavicular line at the third intercostal space C. right of the midclavicular line at the third intercostal space D. left midclavicular line at the fifth intercostal space

D. left midclavicular line at the fifth intercostal space Explanation: The apical pulse is the point of maximal impulse and is located in the fifth intercostal space at the left midclavicular line when the client is placed in a sitting position. The apical impulse is palpated in the mitral area and therefore cannot be palpated at the left midclavicular line at the third intercostal space, at right of the midclavicular line at the third intercostal space and at right of the midclavicular line at the fifth intercostal space.

The nurse adjusts a client's bed to a comfortable working height in order to turn the client. What would be the nurse's next action? A. pull the client to the edge of the bed to which the client will be turning B. push the client to the edge of the bed to which the client will be turning C. push the client to the opposite side of the bed D. move the client to edge of the bed opposite the side that client will be turning

D. move the client to edge of the bed opposite the side that client will be turning pp. 1181 Explanation: When turning a client in bed, the nurse would use a friction-reducing sheet to pull the client to the edge of the bed that is opposite the side the client will be turning. Pushing the client to the opposite side of the bed is not good for back safety. Consult a Safe Patient Handling algorithm to determine whether assistive devices or additional nurses are needed, depending on the individual client.

A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure? A. brachial artery B. over the lower arm C. radial artery D. over the client's thigh

D. over the client's thigh pg 667

The pediatric nurse is caring for a newborn infant. In which position will the nurse place the infant to sleep? A. lateral B. prone C. Sims' D. supine

D. supine pp 1137 Explanation: Supine position is recommended as a way to reduce the incidence of sudden infant death syndrome (SIDS) among newborns. The other positions are inappropriate for placing an infant to sleep.

The home care nurse is assessing a 37-year-old client's vital signs at rest. Which finding requires nursing intervention? A. respirations 18 breaths/min B. pulse rate 70 beats/min C. blood pressure 116/80 mm Hg D. temporal temperature 100.8º F (38.2º C)

D. temporal temperature 100.8º F (38.2º C) pg 646

The nurse is assessing the pulse of a young adult who is training for a triathlon competition. The pulse rate is 48 beats/min. What education should the nurse provide to the client? A. there's a conduction abnormality that is most likely congenital since the client is so young B. the client will have to be very careful when changing positions since the heart rate is low C. a medication regimen ti bring the heart rate up will be required D. the heart rate is within normal limits due to the exercise regimen the client is following

D. the heart rate is within normal limits due to the exercise regimen the client is following pg 653

A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record? A. there's a non-auscultatory gap B. there's an adult diastolic pressure C. there's a widening in the diameter of the artery D. there's an auscultatory gap

D. there's an auscultatory gap pg 665

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring? A. transfer boards B. mechanical lift C. roller sheet D. transfer belt

D. transfer belt pp. 1153 Explanation: A transfer belt is designed for clients who can bear weight and help with the transfer but are unsteady. The other options are inappropriate for this client.

A nurse needs to measure the blood pressure of a client with an electronic manometer. Which of the following advantages does an electronic manometer provide over an aneroid manometer or mercury manometer?

No stethoscope is required pp 663-664

Which term indicates a potentially serious client condition?

Pyrexia pp 647

After taking vital signs of an older adult, the nurse writes down findings as T = 98.9/37.2 oral, P = 104, R = 18, BP = 120/82. Based on the collected data, which step would the nurse take next?

Take the pulse again to assess for tachycardia

A nurse will assess the oral temperature of a postoperative client. Prior to performing this assessment, which should the nurse identify?

The client's most recent temperature pp 670-677

A nurse is assessing a client's blood pressure manually. The nurse should identify the client's systolic blood pressure (SBP) when which event occurs?

The first faint, but clear sound appears

A nurse needs to count a client's heart rate. For which reason would the nurse assess the client's apical pulse?

The radial pulse is difficult to obtain pg 657

When assessing a client's radial pulse, the nurse notes an irregular rhythm with a rate of 62 beats per minute. What intervention should the nurse implement next?

auscultate the apical pulse for 60 sec

An ultrasonic Doppler is used for:

auscultating a pulse that is difficult to palpate.

The nurse notes that the temperature of an ill client is 101°F (38.3°C). Which intervention would the nurse take to regulate the client's body temperature?

give the client a bath in tepid water Explanation: The body loses heat to the water through conduction during tepid baths. Applying a blanket would reduce radiant heat loss and would raise the client's temperature. Increasing the body's metabolic rate will result in an increase in temperature. Blowing warm air over the client will increase the temperature.

The temperature is 102°F (39°C) during a heat wave. The nurse can expect admissions to the emergency room to present with:

increased temperature

The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as:

orthopnea

The nurse needs to assess the carotid arteries of the client. Which assessment technique would be appropriate for the nurse to use?

palpate one artery at a time

The nurse has palpated the client's radial artery and identified a heart rate of 88 beats per minute with an irregular rate. What is the nurse's most appropriate action?

palpate the client's apical heart rate

The nurse is caring for a 77-year-old client who is recovering from surgery. After notifying the health care provider of the incident recorded in the client's chart (above), what will the nurse anticipate teaching the client?

postural hypotension

A pulse deficit is the difference between:

the apical pulse and the radial pulse rate Explanation: When a pulse deficit is present, the radial pulse is always lower than the apical pulse rate.