PrepU Basic Physical Care

A client rings a call bell to request pain medication. Upon performing the pain assessment, the nurse informs the client that she will return with the pain medication. The nurse's promise to return with the pain medication is an example of which principle of bioethics? A) Justice. B) Fidelity. C) Autonomy. D) Nonmaleficence.

B) Fidelity. Fidelity is keeping one's promises and never abandoning a client entrusted to care without first providing for the client's needs. Autonomy respects the rights of clients or their surrogates to make healthcare decisions. Nonmaleficence is avoiding causing harm. Justice involves giving each his or her due and acting fairly.

Which of the following is the recommended nursing assessment to confirm placement of the nasogastric (NG) tube into the stomach of a client? A) Measure to the second or third black marking on the NG tube. B) Obtain a chest X-ray and measure the pH of stomach contents. C) NG tube length is equal to the distance from the client's ear lobe to the nose, plus the distance from the nose to the tip of the xiphoid process; this will confirm correct placement. D) Apply the stethoscope to the xiphoid process and instill 50 mL of air into the tube and listen for a gurgling or popping sound.

B) Obtain a chest X-ray and measure the pH of stomach contents. A chest X-ray and pH that shows acidity are the only definitive diagnostic tools to confirm placement. The other choices are not best practice. Measuring the tube or using makings do not confirm placement, only approximate distance for insertion.

A nurse is performing a sterile dressing change. Which action contaminates the sterile field? A) Pouring solution onto a sterile field cloth B) Holding sterile objects above the waist C) Opening the outermost flap of a sterile package away from the body D) Leaving a 1″ (2.5-cm) edge around the sterile field

A) Pouring solution onto a sterile field cloth Pouring solution onto a sterile field cloth contaminates the sterile field because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. Holding sterile objects above the waist, leaving a 1″ edge around the sterile field, and opening the outermost flap of a sterile package away from the body maintain the sterile field.

A nurse is assigned to a client with a cardiac disorder. The nurse should question an order to monitor the client's body temperature by which route? A) Rectal B) Oral C) Axillary D) Tympanic

A) Rectal When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take temperature. Using this route could stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. The other options are appropriate routes for measuring the temperature of a client with a cardiac disorder.

Which client is at increased risk for developing a wound infection? A) A client with a body mass index (BMI) of 27. B) A client with an albumin level of 2.4 g/dl. C) A client with a hemoglobin of 11.4. D) A client that does not ambulate on first post-op day.

B) A client with an albumin level of 2.4 g/dl. Nutrition plays an important role in wound healing. Because vitamins and protein are essential for wound healing, a client with an albumin level less than 3.0 g/dl is considered malnourished and is at increased risk for developing a wound infection. Frequent pain medication allows the client to be more comfortable and does not increase risk of infection. A client not ambulating on post-op day 1 is at greater risk of deep vein thrombosis and pneumonia. A client who has a BMI of 27 is considered overweight and isn't at increased risk for developing a wound infection.

A nurse-manager is reviewing incidents that occurred recently. For which of the following events will the manager need to make a report to the board of nursing? A) A client develops a urinary tract infection after several days with an indwelling catheter. B) A nurse documents administering narcotics to a client while personally using the medication. C) A client falls from bed when the nurse did not raise the side rails after providing care. D) A home health nurse notifies a primary care provider of a decline in client health.

B) A nurse documents administering narcotics to a client while personally using the medication. Nurse practice/health profession acts regulate nursing licensure and practice. Each state, province, or territory has its own legislation. Violations of criminal law, such as possession of controlled substances, assault, battery, negligence, and rape, must be reported to the board of nursing as well as the police. Most cases of malpractice fall within the realm of civil law.

Immediately following pelvic surgery, a client has an indwelling urinary catheter. Which nursing action would be helpful to prevent a catheter-related urinary tract infection? A) Monitor the color, clarity, and amount of urine output. B) Advocate for limited use of a duration of indwelling urinary catheters. C) Provide catheter and perineal care twice daily. D) Palpate for lower abdominal distention once per shift.

B) Advocate for limited use of a duration of indwelling urinary catheters. Urinary catheters should be limited in use and duration only as needed for client care. The guideline also specifies that if used, the catheter should be inserted using aseptic technique, secured to provide unobstructed flow and drainage, and maintained in a way that protects sterility of the catheter and the drainage system.

In evaluating a client's response to nutrition therapy, which laboratory test would be of highest priority to examine? A) CBC differential B) Albumin level C) Serum potassium level D) Lymphocyte count

B) Albumin level Protein and vitamin C help build and repair injured tissue. Albumin is a major plasma protein; therefore, a client's albumin level helps gauge his nutritional status. Potassium levels indicate fluid and electrolyte status. Lymphocyte count and differential count help assess for infection.

A nurse is working within the managed care delivery model. Which of the following is true regarding managed care? A) All plans have the same values underlying the delivery of care. B) All systems reflect the values of efficiency and effectiveness. C) There are no conflicts between cost-effectiveness and respectful care. D) Their values are not reflected in the decision making.

B) All systems reflect the values of efficiency and effectiveness. All systems in the managed care delivery model reflect the values of efficiency and effectiveness. Different plans may have different values underlying the delivery of care. However, they all reflect the business plan values of efficiency and effectiveness. Their values are reflected in the decision making and the policy development of the organization. Value conflicts between cost-effectiveness and respectful care may be seen.

A nurse is caring for an elderly client who is being discharged to a skilled nursing facility. What should the nurse consider as a priority intervention in developing the discharge plan for this client? A) Send all of the client's belongings to the skilled nursing facility. B) Provide instructions that ensure continuity of care. C) Instruct the client's family to go to the facility during mealtime. D) Give the facility the client's therapy schedule.

B) Provide instructions that ensure continuity of care. The goal of discharge planning in all settings is continuity of care. This action aids the client's transition to a new setting and can shorten facility stays. Sending the client's belongings would be important; however this action does not ensure that the plan of care developed in the acute care setting will continue. Instructing the family to go to the facility at mealtime may be helpful for the client, but does not ensure the continuity of care.

A nurse who is preparing to boost a client up in bed instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner? A) Friction B) Shearing forces C) Impaired circulation D) Localized pressure

B) Shearing forces Friction, impaired circulation, localized pressure, and shearing forces are all risk factors of pressure ulcer development; trapeze use reduces shearing forces. Shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis) can occur as clients slide down in bed or are pulled up in bed. Subcutaneous skin layers adhere to the sheets while deeper layers, muscle, and bone slide in the direction of movement. To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move him up in bed, and keep the head of the bed no higher than 30 degrees.

The nurse understands that client position is important when treating dyspnea. What position would be contraindicated for a client who has dyspnea? A) Orthopneic B) Supine C) Contour D) Fowler's

B) Supine In the supine position, the abdominal contents press against the diaphragm, impeding expansion of the lungs. The other choices are correct to assist with ease of breathing.

A nurse-manager on an oncology unit has been informed that she must determine which nursing care delivery system (NCDS)/nursing care delivery model (NCDM) is best for efficient client care, client satisfaction, and cost reduction. Knowing that two or three registered nurses, four licensed practical nurses, and five nursing assistants are generally on duty on each shift and that the clients can easily be grouped by geographic location and client care needs, the nurse-manager and her staff appropriately decide to implement which NCDS/NCDM? A) Functional nursing B) Team nursing C) Case management D) Primary nursing

B) Team nursing Team nursing is efficient and less costly to implement than primary or case management systems. Because staff members know each other well, they can function effectively as a team. Although functional nursing is the most cost-effective, care is commonly fragmented and clients are less satisfied. Case management and primary nursing require more registered nurses than are available.

In addressing health promotion for a patient who is a member of another culture, the nurse should be guided by which of the following principles? A) The nurse should avoid performing health promotion education if this is not a priority in the patient's culture. B) The patient may have a very different understanding of health promotion. C) A culture's conceptualization of health promotion is a result of that culture's level of socioeconomic development. D) Health promotion is a concept that is largely exclusive to American culture.

B) The patient may have a very different understanding of health promotion. As a component of cultural assessment, the nurse should seek to understand the cultural lens through which the patient may understand health promotion. Health promotion is not a concept exclusive to Western cultures, though it may be considered differently among non-Western cultures. Even if health promotion is not a priority in a patient's culture, this does not necessarily mean that the nurse should not address issues related to health promotion in a respectful and relevant manner. Health promotion is not directly linked to socioeconomic development levels.

A nurse should question an order for a heating pad for a client who has: A) an edematous lower leg. B) active bleeding. C) a reddened abscess. D) purulent wound drainage.

B) active bleeding. Heat application increases blood flow and therefore is contraindicated in active bleeding. For the same reason, however, applying heat to a reddened abscess, an edematous lower leg, or a wound with purulent drainage promotes healing.

The night nurse has completed the change of shift report. As the day nurse makes rounds on a postpartum client receiving magnesium sulfate, it is noted the client developed significantly elevated blood pressure during the past shift. Further assessment reveals the magnesium sulfate rate is infusing well below the prescribed rate. In addition to adjusting the infusion rate and notifying the health care provider (HCP), what is the most important action by the nurse? A) Ask the charge nurse if an incident report is necessary. B) Discuss the matter with the night nurse the next time she works. C) Complete an incident report. D) Evaluate the client's BP for 4 hours before making decision.

C) Complete an incident report. Safety is the highest priority, and a nursing error has occurred. If the day nurse decides to tell the night nurse, the timing of the notification will be up to the nurse initiating the incident report. The nurse should confer with the charge nurse concerning the incident, but completion of the report is required. Waiting for several hours to initiate the report based on changes in client data and assessment is not an ethical or professional decision and should not be considered; again, safety is the highest priority.

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

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

The nurse recognizes that the goals established for a client's discharge are more likely to be accomplished when: A) The nurse develops the goals. B) The physician develops the goals. C) The multidisciplinary team develops the goals. D) The client assists in developing the goals.

D) The client assists in developing the goals. If the client is involved in establishing the goals, it is more likely that the expected outcomes of the discharge plan will be met. The client may fail to follow the plan if the goals are not mutually agreed on or are not based on a complete assessment of the client's needs.

The nurse is suctioning a client's tracheostomy. For what reason during the procedure does the nurse complete the above action? A) To lubricate the outside of the suction catheter B) To regulate the suction pressure C) To loosen the client's thick, tracheal secretions D) To clear secretions from the tubing

D) To clear secretions from the tubing The picture shows a nurse inserting the suction catheter in a container of water. The hole on the catheter is then occluded creating suction. The water is used to clear the catheter and tubing of secretions. The tubing does not need primed or lubricated. The catheter removes the secretions but does not loosen them.

After suctioning a client, a nurse should expect to find: A) a heart rate of 104 beats/minute. B) brisk capillary refill. C) a respiratory rate of 28 breaths/minute. D) clear breath sounds.

D) clear breath sounds. Clear breath sounds, which indicate that secretions have been removed, indicate effective suctioning. An above-normal respiratory rate, such as a rate of 28 breaths/minute, may indicate that the airway isn't clear of secretions and the client's respiratory rate has increased to compensate. A slightly increased heart rate, such as a rate of 104 beats/minute, may indicate health concerns unrelated to suctioning. Brisk capillary refill indicates adequate cardiovascular function and is unrelated to suctioning.

The health care provider prescribes furosemide 40 mg intravenous push daily. The medication comes in a vial of 50 mg/mL. How much medication should the nurse administer?

0.8 mL

A client has been using Chinese herbs and acupuncture to maintain health. What is the best response by the nurse when asked if this practice could be continued during recuperation from a long illness? A) "Once you have recovered from this illness, you can go back to your traditional ways." B) "Let's discuss your desire to integrate these practices with the physician and advocate on your behalf." C) "Have you spoken to the physician about using the Chinese herbs and acupuncture?" D) "What do you want to accomplish by using these methods rather than researched practices?"

B) "Let's discuss your desire to integrate these practices with the physician and advocate on your behalf." The client has a right to incorporate some of the traditional Chinese therapies. It is important to be respectful of cultural beliefs and to advocate for the client. Contacting the physician is important because there could be herbal-drug interactions. Each of the other choices does not respect cultural choices or explore the possibility of interactions. Openness with health care members is important because clients may choose to integrate these therapies without notifying the nurse or the physician.

The nurse teaches a client to perform deep breathing exercise after surgery. Which statement by the client best reflects that the teaching has been effective? A) "I will heal faster if I perform deep breathing." B) "These exercises will help prevent pneumonia." C) "I will require less pain medication if I do deep breathing." D) "If I do these exercises, I don't have to get out of bed."

B) "These exercises will help prevent pneumonia." Deep breathing maximizes gaseous exchange, ridding the body of excess carbon dioxide and thus preventing stasis and complications. All other answers are incorrect.

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

B) Encouraging increased fluid intake Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions and ensures adequate hydration. Turning the client every 2 hours would help prevent pressure ulcers but wouldn't help with the secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions.

A client in cardiac rehabilitation would like to eat the right foods to ensure adequate endurance on the treadmill. Which nutrient is most helpful for promoting endurance during sustained activity? A) protein B) carbohydrate C) water D) fat

B) carbohydrate The stored glucose of muscle glycogen is the major fuel during sustained activity. Glucose production slows as the body begins to depend on fat stores for glucose and fatty acids. Protein is not the body's preferred energy source. Fat is a secondary source of energy. Water is not an energy source, although sufficient water is required to engage in aerobic activity without causing dehydration.

The nurse is teaching an older adult how to prevent falls. The nurse should tell the client to: A) turn on bright lights in the room so the client can see items in the room. B) instruct the client to rise slowly from a supine position. C) encourage the client to not use assistive devices because they reduce independence. D) instruct the client not to exercise painful joints.

B) instruct the client to rise slowly from a supine position. Normal age-related changes can predispose older adults to falling and include vision, hearing, cardiovascular, musculoskeletal, and neurological changes. One of the most common problems facing older adults is the loss of tissue elasticity that affects the arteries. This loss of elasticity results in a decrease in tissue recoil and leads to changes in blood pressure with position changes. When they rise too quickly from a supine position, they feel light-headed and dizzy and can fall. The nurse should instruct clients to change positions slowly and to dangle the legs a few minutes when arising from a supine position. When aging, the lens of the eye becomes sensitive to very bright light which can causes a glare and visual disturbances that can lead to falls. Rooms should be well lit, but not with bright lights that cause a glare. Neurological changes are seen in impaired reflexes and thus postural instability. This loss of postural stability leads to falls. The need of assistive devices (hand rails, cane, walkers) helps reduce falls and promote independence. If joint pain develops and remains untreated, it can cause older adults to become sedentary or immobile. This disuse of muscles contributes to muscle weakness and falls. Nursing interventions should be directed at encouraging regular ambulation and joint movement (range of motion).

A nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's: A) lower thigh. B) lower foot. C) knee. D) ankle.

B) lower foot. An elastic bandage should be applied from the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client's foot. Beginning at the ankle, lower thigh, or knee will not promote venous return.

A nurse-manager appropriately behaves as an autocrat in which situation? A) Planning vacation time for staff B) Evaluating a new medication-administration process C) Directing staff activities if a client experiences a cardiac arrest D) Identifying the strengths and weaknesses of a client-education video

C) Directing staff activities if a client experiences a cardiac arrest In a crisis situation, the nurse-manager should take command for the benefit of the client. Planning vacation time and evaluating procedures and client resources require staff input and are actions characteristic of a democratic or participative manager.

Four clients in a critical care unit have been diagnosed with Psuedomonas aeruginosa. The Infection Prevention and Control Department has determined that this is probably a nosocomial infection. Select the most appropriate intervention by the nurse. The nurse should: A) initiate contact precautions. B) initiate transmission-based precautions. C) ensure that staff members do not have artificial fingernails. D) wear an N-95 mask when caring for the four clients.

C) ensure that staff members do not have artificial fingernails. It is well documented that the subungal areas of the hand harbor bacteria that can be transmitted to others despite aggressive hand-washing procedures, and therefore it is important that the staff on this unit do not have artificial fingernails that could be the source of the infection on this unit. The Joint Commission (TJC), in the 2011 National Patient Safety Goals (NPSG.07.01.01), includes using "the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World Health Organization" to prevent infection. There is no need to institute transmission-based or contact precautions. It is not necessary to wear a mask when caring for these clients.

A client suddenly loses consciousness. What should the nurse do first? A) Assess for responsiveness. B) Call for assistance. C) Assess for pupillary response. D) Palpate for a carotid pulse.

A) Assess for responsiveness. A nurse always should assess for responsiveness first to prevent injuries to a client who isn't in cardiac or respiratory arrest. After assessing the client, the nurse should call for assistance, open the client's airway, check for breathing, and palpate for a carotid pulse. Assessing for pupillary response would waste valuable time and is inappropriate.

The selection of a nursing care delivery system (NCDS) is critical to the success of client care in a nursing area. Which factor is essential to the evaluation of an NCDS? A) Identifying who will be responsible for making client care decisions B) Determining how planned absences, such as vacation time, will be scheduled so that all staff are treated fairly C) Deciding what type of dress code will be implemented D) Identifying salary ranges for various types of staff

A) Identifying who will be responsible for making client care decisions Determining who has responsibility for making decisions regarding client care is an essential element of all client care delivery systems. Dress code, salary, and scheduling planned staff absences are important to any organizations, but they are not actually determined by the NCDS.

The nurse is documenting the assessment of a wound on a client's foot. Which of the following assessments would be included as subjective data? A) Temperature is 100.4 degrees F (38 degrees C). B) Area around the wound is tender to touch. C) Drainage from the wound is yellow. D) Area around the wound is pink and swollen.

B) Area around the wound is tender to touch. Subjective data is that which is reported by the client. The other options represent objective data that is observed by the nurse.

A physician orders chest physiotherapy for a client with pulmonary congestion. When should the nurse plan to perform chest physiotherapy? A) When the nurse has time B) After meals C) Before meals D) When the client has time

C) Before meals To avoid tiring the client or inducing vomiting, chest physiotherapy is best performed before meals. Scheduling chest physiotherapy around client or nurse convenience is inappropriate.

Professional regulations and laws that govern nursing practice are in place for which of the following reasons? A) To limit the number of nurses in practice B) To protect the safety of the public C) To ensure that practicing nurses are of good moral standing D) To ensure that enough new nurses are always available

B) To protect the safety of the public Governing bodies, professional regulations, and laws are in place to protect the public by ensuring that nurses are accountable for safe, competent, and ethical nursing practice. The other options do not describe accurately the role and responsibility of the governing bodies and the regulations and laws of nursing.

Which action must a nurse perform when cleaning the area around a Jackson-Pratt wound drain? A) Wear sterile gloves and a mask. B) Remove the drain before cleaning the skin. C) Clean from the center outward in a circular motion. D) Clean briskly around the site with alcohol.

C) Clean from the center outward in a circular motion. The nurse should move from the center outward in ever-larger circles when cleaning around a wound drain because the skin near the drain site is more contaminated than the site itself. The nurse should never remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may irritate the skin and, because it evaporates, has no lasting effect on bacteria. The nurse should wear sterile gloves to prevent contamination, but need not wear a mask.

To reduce the possibility of catheter-related urinary tract infections (CAUTIs), the nurse should: A) clean the periurethral area with antiseptics. B) ensure that clients who are incontinent have indwelling urinary catheters. C) minimize urinary catheter use and duration of use in all clients. D) use sterile technique when providing catheter care.

C) minimize urinary catheter use and duration of use in all clients. Minimizing urinary catheter use and duration of use in all clients, particularly those at higher risk for CAUTI or mortality from catheterization such as women, the elderly, and clients with impaired immunity, will reduce the opportunity for infection. The nurse should avoid the use of urinary catheters for clients who are incontinent; a bladder training program and frequent use of the toilet are preferred; external catheters may be used if necessary in incontinent clients. The nurse should not clean the periurethral area with antiseptics; cleansing the meatal surface during daily bathing or showering is appropriate. Using sterile technique to help to reduce CAUTI is not necessary. Hand hygiene immediately before and after insertion or any manipulation of the catheter device or site is sufficient.

The nurse is assigning care to the unlicensed assistive personnel (UAP) for a client with a nasogastric tube with intermittent suction after gastric surgery. Which tasks cannot be delegated to the UAP? A) recording output B) securing the nasal tape C) repositioning the tube D) documenting the color of the drainage

C) repositioning the tube Repositioning the tube in a client who has undergone gastric surgery should be performed (per prescription of the surgeon) by the registered nurse. Recording output, securing the nasal tape, cleansing the nares, and documenting the color of the drainage could safely be delegated to the UAP.

A nurse medicates a client with another client's morning medicines. What is the best action by the nurse upon realizing the error? A) Have the nursing assistant complete a set of vital signs. B) Call the practitioner of the patient who received the wrong medications. C) Notify the charge nurse of the error. D) Assess the patient for the medications' effects.

D) Assess the patient for the medications' effects. The nurse should immediately assess the client who received the wrong medications. This assessment should include potential allergies to the medications and the side effects of the medications. The nurse should then notify the practitioner and the charge nurse. An incident report should be completed and submitted as directed by the facility's policy. The nurse should complete a set of vital signs with the assessment of the client.

The nurse is recording the intake and output for a client with the following: D5NSS 1,000 ml; urine 450 ml; emesis 125 ml; Jackson Pratt drain #1 35 ml; Jackson Pratt drain #2 32 ml; and Jackson Pratt drain #3 12 ml. How many milliliters would the nurse document as the client's output? Record your answer using a whole number.

654 mL

A nursing student and a preceptor nurse are discussing nursing liability. Which statement if made by the student would indicate to the nurse that the student understands the concept of liability? A) "A client can still file a lawsuit outside of the statute of limitations if the the discovery of the harm has been more recent." B) "There is a grace period of 1 year after a client is injured and when they can file a law suit." C) "A client has 5 years to sue if they feel they have been harmed." D) "A form of alternative dispute resolution is to have a client sign a waiver before treatment that indicates he or she cannot sue in case of error."

A) "A client can still file a lawsuit outside of the statute of limitations if the the discovery of the harm has been more recent." Statute of limitations is the time period during which the injured party must file a case. Discovery rule refers to the time when the client discovers the injury. The statute of limitations typically allows clients to file a lawsuit within 2 years of discovery; however, the time may vary from state to state. Grace period refers to the contractually specified time during which payment is permitted, without penalty, beyond the due date of the debt. Alternative dispute resolution refers to any means of settling disputes outside the courtroom setting.

A client who has had a laparoscopic cholecystectomy has adhesive strips over the puncture sites. When preparing the client for discharge, which client statements indicate that the teaching has been successful? Select all that apply. A) "I can resume my normal diet when I want." B) "I can take a shower 2 days later." C) "I need to avoid driving for about 4 weeks." D) "I should spend 2 to 3 days in bed before resuming activity." E) "I may experience some pain in my right shoulder."

A) "I can resume my normal diet when I want." B) "I can take a shower 2 days later." E) "I may experience some pain in my right shoulder." Following a laparoscopic cholecystectomy, the client can resume a normal diet as tolerated. The client may experience right shoulder pain from the gas that was used to inflate the abdomen during surgery. The client can take a shower 48 hours after the surgery. The adhesive strips will fall off in about 10 days. The client can resume driving within 3 to 4 days following surgery as long as the client is not taking pain medication. There is no need for the client to maintain bed rest in the days following surgery. Light exercise such as walking can be resumed immediately.

A nurse manager is auditing the nursing unit's adherence to infection control practices. Which of the following observations causes the nurse manager to be most concerned that the clients on the unit are at risk for infection? A) Hand hygiene is forgotten between clients by several nurses on the unit. B) A client receives a prophylactic antibiotic 20 minutes late. C) A nurse does not wear a mask when entering the room of a client on contact precautions. D) A nurse does not use sterile scissors to cut the tape for a wound dressing.

A) Hand hygiene is forgotten between clients by several nurses on the unit. Hand hygiene is the single most important infection prevention and control practice. A mask is not necessary for clients on contact precautions, and tape does not have to be cut with sterile scissors. Although administering the antibiotic late is cause for concern, it does not present as big a risk as failure to perform hand hygiene.

A nurse is required to irrigate a client's nasogastric tube, a procedure the nurse has not performed before. What is the most appropriate action by the nurse? A) Contact the nurse educator for an in-service and support in performing the skill. B) Ask another nurse to irrigate the nasogastric tube for him/her each time it is required. C) Refuse the assignment because he/she has never irrigated a nasogastric tube. D) Irrigate the nasogastric tube by following the steps outlined in the procedure manual.

A) Contact the nurse educator for an in-service and support in performing the skill. The nurse has a responsibility for recognizing his/her limitations and to seek assistance when necessary. Because the nurse has not performed this skill previously, the nurse educator is the appropriate person to provide inservice and support so the client receives safe and competent care. The other options are incorrect because they do not demonstrate expected behavior for a nurse who has identified a gap in his/her learning or expertise.

The nurse-manager of an outpatient facility isn't satisfied with discharge planning policies and procedures. Knowing other managers at similar facilities regarded as the "best" in the country, which steps should the nurse-manager take as part of a continuous quality-improvement process? A) Contact the nurse-managers at the best facilities and compare their discharge planning policies and procedures with those of her facility. B) Ask her staff nurses to investigate discharge policies and procedures at other outpatient facilities and recommend changes. C) Ask the nurse-managers at the best facilities for their policies and procedures so she can adopt them. D) Ask the staff nurses to form a task force to review and revise discharge policies and procedures.

A) Contact the nurse-managers at the best facilities and compare their discharge planning policies and procedures with those of her facility. Benchmarking is a good approach for the nurse-manager to take. Benchmarking is the process of comparing an organization's delivery of client care practices in one organization to those in the best health care organizations. Because the nurse-manager already has contacts at the best facilities, she's the most appropriate person to obtain the necessary information. The nurse-manager, however, shouldn't automatically change her policies and procedures to match those of the best facilities. Instead, she should evaluate the policies to determine which ones might be implemented at her facility. Then she and her staff should make appropriate recommendations for change. Asking her staff to form a task force is a good idea, but benchmarking saves time and effort and enables the nurse-manager to obtain information from excellent resources.

Two nurses are working the night shift on a medical unit. The first nurse completes an initial shift assessment on assigned clients. One hour later, the second nurse finds the first nurse asleep in the lounge. The first nurse remains asleep for the next 4 hours and then wakes up to do client rounds. What should the second nurse do in this situation? A) Discuss the situation with the first nurse, including the safety implications of sleeping on the job. B) Cover by assessing the first nurse's patients hourly. C) Ask the nurse on the day shift to report the situation to the nurse manager. D) Nothing; the first nurse's patients did not call for assistance.

A) Discuss the situation with the first nurse, including the safety implications of sleeping on the job. The second nurse is responsible for immediately discussing this behavior and its safety implications with the first nurse. The other options do not demonstrate behavior representative of advocating for safe and competent care.

While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. In which order of priority from first to last should the nurse take the actions? All options must be used. A) Document as required by the facility. B) Assess the client's current condition and vital signs. C) If no acute injury, get help, and carefully assist the client back to bed. D) Notify the client's health care provider (HCP) and family. B) Assess the client's current condition and vital signs. C) If no acute injury, get help, and carefully assist the client back to bed. D) Notify the client's health care provider (HCP) and family.

A) Document as required by the facility. The nurse should first assess the client and then, if there is no acute injury, help the client get back into bed. The nurse must notify the HCP and the family of the fall, and finally, document the event on the client's health record.

A nurse must irrigate a gaping abdominal incision with sterile normal saline, using a piston syringe. How should she proceed? A) Irrigate continuously until the solution becomes clear. B) After the irrigation, apply a wet-to-damp dressing to the wound. C) After the irrigation, moisten the area around the wound with normal saline. D) Rapidly instill a stream of irrigating solution into the wound.

A) Irrigate continuously until the solution becomes clear. To wash away tissue debris and drainage effectively, the nurse should irrigate the wound until the solution becomes clear. After irrigation, the nurse should dry the area around the wound; moistening this area promotes microorganism growth and skin irritation. When the area is dry, the nurse should apply a dry, sterile dressing rather than a wet-to-damp dressing. The nurse should always instill the irrigating solution gently. Rapid or forceful instillation can damage tissues.

An obese, malnourished client has undergone abdominal surgery. While ambulating on the fourth postoperative day, she complains to the nurse that her dressing is saturated with drainage. Before this activity, the dressing was dry and intact. Which is the best initial action for the nurse to take? A) Lift the dressing to assess the wound. B) Apply an abdominal binder. C) Reinforce the existing dressing with another dressing. D) Splint the abdomen with a pillow and call the surgeon.

A) Lift the dressing to assess the wound. The client probably has a wound evisceration or dehiscence. The first step is to assess the wound; then the nurse can implement appropriate measures. Splinting the abdomen, applying an abdominal binder, or reinforcing the existing dressing would delay treatment.

A client who is to receive general anesthesia has a serum potassium level of 5.8 mEq/L (5.8 mmol/L). What should be the nurse's first response? A) Notify the anesthesiologist. B) Call the operating room to cancel the surgery. C) Send the client to surgery. D) Make a note on the client's record.

A) Notify the anesthesiologist. The nurse should notify the anesthesiologist because a serum potassium level of 5.8 mEq/L (5.8 mmol/L) places the client at risk for arrhythmias when under general anesthesia. It is not the role of the nurse to cancel surgery. The nurse should not automatically send a client with abnormal laboratory findings to surgery because the procedure may be canceled. Once the client is inside the operating room and sterile supplies have been opened up for the procedure, the client is usually charged. The nurse should call ahead of time to communicate the abnormal laboratory result instead of noting the finding on the client's record. The information on the record should not be reviewed until after the client has been transported to the operating room and the supplies have been opened.

A healthcare provider obtains informed consent for a surgical procedure after the adult client had received sedation. Which is the nurse's best action? A) Notify the healthcare provider that the consent is not valid B) Reschedule the procedure for the next day C) Call the client's next of kin to sign the surgical permit D) Request the client sign a waiver if he or she wishes to have surgery

A) Notify the healthcare provider that the consent is not valid Valid consent must be freely given by the client who is at least 18 years of age, unless emancipated. The nurse must ensure that the consent has been obtained prior to premedication; consent is not valid if the client has received medications that may affect judgment or decision-making capacity.

A client in a long-term care facility has signed a form stating that he does not want to be resuscitated. He develops an upper respiratory infection that progresses to pneumonia. His health rapidly deteriorates, and he is no longer competent. During morning rounds, the nurse finds this client without vital signs. What should the nurse do next? A) Notify the physician that the client has no vital signs. B) Call the nurse supervisor for further directions. C) Begin cardiopulmonary resuscitation and call for an ambulance. D) Go to the desk and review the client's chart to determine resuscitation status.

A) Notify the physician that the client has no vital signs. The resident has signed a document indicating a wish not to be resuscitated. The nurse should be aware of the resident's "do not resuscitate" status and should not need to go to the desk to confirm this. The nurse should notify the physician so that he or she can pronounce the death and notify the family.

The nursing instructor is working with a student in a pre-operative unit. The student notices that the informed consent has not been signed. Which is the best action taken by the student nurse for obtaining informed consent? A) Notifying the physician involved with the procedure that the consent has not been signed B) Notifying the social worker C) Asking the primary nurse to get the informed consent D) Asking the nurse working with the physician to get the informed consent

A) Notifying the physician involved with the procedure that the consent has not been signed The physician involved with the procedure is responsible for obtaining the client's informed consent. The primary nurse or the nurse working with the physician may witness the client's signature. The social worker may not obtain informed consent.

A nurse is working with an unlicensed assistive personnel (UAP). Which clients should the nurse assign to the UAP? Select all that apply. A) Older adult client who had hip replacement surgery and needs to walk in the hall with a walker. B) Adult client who had abdominal surgery yesterday and requires a dressing change. C) Adult client who had a hysterectomy 3 days ago and requires vital sign checks every 4 hours. D) Adult client newly diagnosed with diabetes who is learning to administer insulin. E) Young adult client who requires tube feedings.

A) Older adult client who had hip replacement surgery and needs to walk in the hall with a walker. B) Adult client who had abdominal surgery yesterday and requires a dressing change. C) Adult client who had a hysterectomy 3 days ago and requires vital sign checks every 4 hours. The UAP can assist clients ambulate and take vital signs. It is within the RN scope of practice to teach the client to administer insulin, change dressings, and administer tube feedings.

Which assessment is most supportive of the nursing diagnosis, impaired skin integrity related to purulent inflammation of dermal layers as evidenced by purulent drainage and erythema? A) Oral temperature of 101° F (38.3° C) B) Wound healing by primary intention C) A heart rate of 88 beats/minute D) Dry and intact wound dressing

A) Oral temperature of 101° F (38.3° C) The nursing diagnosis indicates that the client's wound, which has purulent drainage, is infected. In response to the infection, the client's temperature would be elevated. A heart rate of 88 beats/minute, healing by primary intention, and a dry, intact dressing demonstrate normal assessment findings.

A nurse must apply a wet-to-damp dressing over an ulcer on a client's left ankle. How should the nurse proceed? A) Pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound. B) Cover the saturated fine-mesh gauze dressings with an elastic bandage. C) Apply an occlusive dressing over the saturated fine-mesh gauze dressings. D) Apply the saturated fine-mesh gauze dressings over the wound.

A) Pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound. The nurse should pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound because necrotic tissue is usually more prevalent in those areas. The nurse should wring out excess moisture from saturated fine-mesh gauze dressings because saturated dressings won't dry properly. The nurse shouldn't apply an occlusive dressing or elastic bandage because these products can prevent air circulation and hinder drying of the fine-mesh gauze.

Which task should a nurse choose to delegate to a nursing assistant? Select all that apply. A) Performing a blood glucose check B) Evaluating a client's response to a blood pressure medication C) Taking a client's vital signs D) Documenting a client's oral intake E) Assessing a client's pain

A) Performing a blood glucose check C) Taking a client's vital signs D) Documenting a client's oral intake Registered nurses are responsible for all phases of the nursing process. These responsibilities include assessing a client's pain and evaluating a client's response to treatment. A nurse may delegate tasks such as taking vital signs, documenting intake and output, and performing blood glucose checks if she follows the five rights of delegation. The five rights of delegation include: right task (the task is within the delegate's scope of practice), right person (the person is competent to perform the task), right communication (the nurse gives the right directions to complete the task), right feedback (the nurse works collaboratively with the delegate), and right follow-up (the nurse follows-up on the task after it has been completed).

Which statement is a guideline to help nurses protect themselves from liability? A) Practice within the scope of the nursing standards of practice.. B) Do what the client desires even though the nurse may disagree. C) Follow all physician's orders. D) Obtain malpractice insurance.

A) Practice within the scope of the nursing standards of practice.. State Boards of Nursing and the provincial or territorial nursing regulatory bodies set acceptable standards for nursing for a particular state or Canadian province or territory. Practicing within those guidelines will protect the nurse from liability. The nurse shouldn't follow all physician's orders because physicians may not be aware of guidelines for nurses and may delegate inappropriate treatment or practice for the nurse. The client doesn't know standards of care and isn't responsible for the nurse's actions. Insurance won't prevent a liability suit, it will only assist the nurse if a suit should be filed.

Performance improvement is an important component of continuous quality improvement. Which action should an effective nurse-manager take when conducting performance evaluations? A) Provide feedback on strengths as well as areas for improvement and clarify what she expects the staff member to accomplish before the next performance evaluation. B) Conduct performance evaluations in a group setting so input from peers and subordinates influences evaluation of a staff member's effectiveness. C) Whenever possible, delegate responsibility for conducting performance evaluations to primary nurses to help them achieve professional growth. D) Provide written documentation of areas for improvement. Areas of strength needn't be documented because these areas are complimentary and don't describe actions the staff member must take to improve.

A) Provide feedback on strengths as well as areas for improvement and clarify what she expects the staff member to accomplish before the next performance evaluation. An effective performance evaluation recognizes strengths, identifies areas for improvement, and clarifies performance expectations. The nurse-manager should conduct performance evaluations privately, not in front of others. She should document in writing all components of a performance evaluation. Although input from staff members can be useful in preparing performance evaluations, delegating all responsibility to others is inappropriate. The nurse-manager is responsible for the performance of the staff.

A nurse takes informed consent from a client scheduled for abdominal surgery. Which of the following is the most appropriate principle behind informed consent? A) Provides the client with in-depth knowledge about the treatment options available. B) Helps the client to make a living will regarding future health care required. C) Protects the client's right to self-determination in health care decision making. D) Helps the client refuse treatment that he or she does not wish to undergo.

A) Provides the client with in-depth knowledge about the treatment options available. Informed consent protects the client's right to self-determination in health care decision making. Informed consent helps the client to refuse a treatment that the client does not wish to undergo and helps the client to gain in-depth knowledge about the treatment options available, but the most important function is to encourage shared decision making. Informed consent does not help the client to make a living will.

A diabetic client with peripheral vascular disease is ordered to wear knee-high elastic compression stockings continuously until discharge. Which of the following would be the priority for this client after the stockings are applied? A) Remove elastic stockings once per day and observe lower extremities. B) Elevate the client's legs while out of bed. C) Teach the client isotonic leg exercises. D) Order a second pair of stockings to be rotated each day.

A) Remove elastic stockings once per day and observe lower extremities. Elastic stockings are used to promote venous return and prevent deep vein thrombosis. A client with peripheral vascular disease and diabetes is at risk for skin breakdown, and the nurse must therefore remove the stockings once per day to observe the condition of the skin. Elevating the client's legs while out of bed and teaching isometric leg exercises will promote venous return. However, after applying the stocking, the nurse's priority should be the client's skin integrity. Ordering a second pair of stockings would not be a priority.

Entering a client's room, a nurse on the maternity unit sees a mother slapping the face of a crying neonate. Which action should the nurse take in this situation? A) Return the neonate to the nursery, inform the physician so he can thoroughly examine the neonate for B) injuries, and notify social services for assistance. B) Return the neonate to the nursery and inform coworkers so they can monitor the mother's behavior. C) Confront the mother by asking her what she's doing and why. D) Leave the room immediately, without the neonate, and notify the nursing supervisor.

A) Return the neonate to the nursery, inform the physician so he can thoroughly examine the neonate for B) injuries, and notify social services for assistance. The neonate's safety and protection is the first priority. The nurse should immediately return the neonate to the nursery and inform the physician of the neonate's abuse. By being the neonate's advocate, the nurse allows the physician to examine the neonate for injuries resulting from the incident. Social services should be notified. The neonate shouldn't remain in the room with the mother unsupervised. The nurse should follow the facility's policy and procedure for reporting suspected and actual child abuse. Although the incident may be part of the mother and neonate's revised care plan, it requires immediate intervention, not simple notification of coworkers. Confronting the mother doesn't provide for the neonate's safety.

A nurse is giving a presentation to retirement home residents on fall prevention and injury reduction. Which of the following would be the most important priority? A) Teaching about adjusting to change of position by sitting for a few minutes before standing to lessen dizziness B) Discussion of instability and effective use of ambulatory aids to stabilize the base of support C) Explanation of the importance of a health professional evaluating gait and assessing for motor deficits D) Discussion about decreasing activity and favoring the use of wheelchairs, rather than mobility aids, to reduce the incidence of falls

A) Teaching about adjusting to change of position by sitting for a few minutes before standing to lessen dizziness Sitting for a few minutes is the most appropriate to discuss to help maintain safety and reduce falls. Reliance on wheelchairs rather than mobility aids will result in weakening of the muscles and less strength and stability. The remaining actions would be important factors but not the immediate priority.

An Asian-American client is scheduled for discharge after being diagnosed with type 1 diabetes mellitus. Before leaving the health care facility, the nurse demonstrates the technique of self-administration of insulin and explains the importance of the client's prescribed insulin regimen in controlling blood glucose levels. What may the nurse conclude if the client continues to stare blankly? A) The client disapproves of the insulin treatment. B) The client did not pay attention to the procedure. C) The client is surprised by the complexity of the procedure. D) The client has understood the procedure.

A) The client disapproves of the insulin treatment. The nurse should conclude that the client disapproves of the treatment. It may indicate that the client disapproves of the procedure but, due to cultural practices, does not openly verbalize disapproval. Asian Americans may not openly disagree with authority figures, such as physicians and nurses, because of their respect for harmony. Such reticence can conceal disagreement or potential non-compliance with a particular therapeutic regimen that is unacceptable from their perspective. The client, however, does not show any sign of understanding the procedure, nor does he openly make any comments on the procedure. He also does not give any indication of surprise with regard to the complexity of the procedure.

When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the appliance frequently. Which outcome indicates that the client is following instructions? A) The seal around the stoma is intact. B) There is no odor present. C) The urine is a deep yellow. D) The skin around the stoma is red.

A) The seal around the stoma is intact. If the appliance becomes too full, it is likely to pull away from the skin completely or to leak urine onto the skin; thus if the seal is intact, the client is emptying the appliance regularly. The skin around the seal should not be red or irritated, which could indicate a leak. There will likely be an odor from the urine. Deep yellow urine indicates that the client should be increasing fluid intake.

A child has a nasogastric (NG) tube inserted by the nurse to administer a continuous feeding. Which of the following actions should the nurse take before starting the NG feeding on the child? Select all that apply. A) Verify the physician's order. B) Assess for bowel sounds. C) Heat the formula in a microwave. D) Prepare a 24-hour supply of formula. E) Check placement of the NG tube.

A) Verify the physician's order. B) Assess for bowel sounds. E) Check placement of the NG tube. Verifying the order, checking the placement of the NG tube, and assessing bowel sounds are necessary before initiating an NG feeding. Formula should not be heated in the microwave, and no more than a 4-hour supply should be hung to prevent the growth of microorganisms.

A client is being transferred from the recovery room to the medical surgical nursing unit. The nurse from the recovery room should report which information to the nurse in the medical surgical unit? Select all that apply. A) amount of blood loss B) current vital signs C) type of surgery D) name of insurance provider E) fluids infusing including rate and type of fluid F) names of all surgeons participating in the surgery

A) amount of blood loss B) current vital signs C) type of surgery E) fluids infusing including rate and type of fluid Transfer reports must include information about the client's surgery, all current treatments and medications, vital signs, including pain level, fluid status including blood loss, and current IV infusions. It is not necessary to identify the surgeons who were present during the surgery or report the name of the insurance provider.

When planning care for a group of clients, the nurse notes that which client is most susceptible to infection? A) an 86-year-old with burns from using a heating pad B) a 42-year-old with a recent, uncomplicated appendectomy C) an 18-year-old with diabetes mellitus D) a 6-year-old with a simple fracture of the femur

A) an 86-year-old with burns from using a heating pad The very young and the elderly are more susceptible to infection. An elderly client with a break in skin integrity, such as the 86-year-old with a burn, is at an increased risk for infection. The 6-year-old does not have a compound fracture (protruding through the skin) and is not at high risk for infection. A client with an appendectomy is at risk for infection of the surgical site but not as high a risk as the client with burns. While a client with diabetes is at risk for infection, this adolescent is not at high risk at this time.

A nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to pull out necessary I.V. lines and an indwelling urinary catheter. The nurse should: A) assess the client for pain. B) order soft restraints from the storeroom. C) leave the client and get help. D) read the facility's policy on restraints.

A) assess the client for pain. The nurse should assess the client for possible causes of the behavior, such as pain. A client should never be left alone while the nurse summons assistance. All staff members must receive annual instruction on the use of restraints, and the nurse should be familiar with the facility's policy. In most settings, the nurse must have a physician's order before restraining a client.

The nurse explains to the client that the main reason a back rub is used as therapy to relieve pain is because the massage: A) blocks pain impulses from the spinal cord to the brain. B) blocks pain impulses from the brain to the spinal cord. C) distracts the client's focus on the source of the pain. D) stimulates the release of endorphins.

A) blocks pain impulses from the spinal cord to the brain. A back rub stimulates the large-diameter cutaneous fibers, which block transmission of pain impulses from the spinal cord to the brain. It does not block the transmission of pain impulses or stimulate the release of endorphins. A back rub may distract the client, but the physiologic process of fiber stimulation is the main reason a back rub is used as therapy for pain relief.

To help minimize calcium loss from a hospitalized client's bones, the nurse should: A) encourage the client to walk in the hall. B) provide the client dairy products at frequent intervals. C) reposition the client every 2 hours. D) provide supplemental feedings between meals.

A) encourage the client to walk in the hall. Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore, encouraging the client to increase physical activity, such as by walking in the hall, helps minimize calcium loss. Turning or repositioning the client every 2 hours wouldn't increase activity sufficiently to minimize bone loss. Providing dairy products and supplemental feedings wouldn't lessen calcium loss — even if the dairy products and feedings contained extra calcium — because the additional calcium doesn't increase bone stimulation or osteoblast activity.

The nurse instructs the client who has had a hemorrhoidectomy not to use sitz baths until at least 12 hours postoperatively to avoid inducing which complication? A) hemorrhage B) constipation C) urine retention D) rectal spasm

A) hemorrhage Applying heat during the immediate postoperative period may cause hemorrhage at the surgical site. Moist heat may relieve rectal spasms after bowel movements. Urine retention caused by reflex spasm may also be relieved by moist heat. Increasing fiber and fluid in the diet can help prevent constipation.

The nurse is making rounds and observes a client who is unconscious (see figure). The unlicensed assistive personnel (UAP) has just turned the client from lying on her back. Before raising the side rail, the nurse should: A) inspect the skin at pressure points from the back-lying position. B) elevate the head of the bed to 30 degrees. C) ask the UAP to add a pillow under the right arm. D) help the UAP move the client closer to the head of the bed.

A) inspect the skin at pressure points from the back-lying position. The client is positioned correctly in the side-lying position. The pillows support the client's joints and do not cause unnecessary pressure on the joints or skin. It is not necessary to add another pillow under the arm or to elevate the head of the bed. The nurse should assess the client's skin for signs of breakdown, particularly at the elbows, back, hips, and heels where there were pressure points from the position in which the client was previously lying.

A nurse who works on an obstetrical inpatient unit has been assigned to the client safety committee. What client safety goals are most applicable to this setting? Select all that apply. A) involving clients in education to cord infections B) car seat instruction allowing infants to ride facing backward in the front seat C) providing effective and timely "hand-off reports" between labor and birth staff and mother-baby staff D) ensuring that preprocedure verifications are completed by health care providers (HCP) for any invasive procedure E) identifying safety risks specific to the unit, such as infant abduction

A) involving clients in education to cord infections C) providing effective and timely "hand-off reports" between labor and birth staff and mother-baby staff D) ensuring that preprocedure verifications are completed by health care providers (HCP) for any invasive procedure E) identifying safety risks specific to the unit, such as infant abduction Specific safety concerns on an obstetrical unit include a very specific "hand-off report" after birth and recovery has been completed and the couplet is transitioned to mother-baby care. In any invasive procedure including tubal ligations and circumcisions, preprocedure verification is a standard procedure. Client education concerning the potential for infection in obstetrics is essential for any incision areas. Infant abduction is an ever-present concern for those working in a mother-baby unit. Car seat instructions for new parents involve the infant being in the back seat of a car facing backward—not in the front seat. Education for the family includes this important area.

A priority for nursing care for an older adult who has pruritus, is continuously scratching the affected areas, and demonstrates agitation and anxiety regarding the itching is: A) preventing infection. B) increasing fluid intake. C) instructing the client not to scratch. D) avoiding social isolation.

A) preventing infection. The client is at risk for infection because of the pruritus, and the nurse should institute measures to help the client control the scratching such as cutting fingernails, using protective gloves or mitts, and, if necessary, using antianxiety medications. More information is required regarding the knowledge level of the client, but learning cannot take place when an individual's attention is distracted with pruritus. Increasing fluid intake is not a priority at this time. There are no data to indicate the client is experiencing social isolation.

A child undergoes rehydration therapy after having diarrhea and dehydration. A nurse is teaching the child's parents about dietary management. The nurse understands that the teaching plan has been successful when the parents tell the nurse that they will follow which type of diet? A) regular B) full liquid C) clear liquid D) soft

A) regular Dietary management following rehydration for diarrhea and mild dehydration would include offering the child a regular diet. Following rehydration, there is no need for the child to be on a special diet, such as a clear liquid, full liquid, or soft diet.

The client arrives in the emergency department following a bicycle accident in which the client's forehead hit the pavement. The client is diagnosed as having a hyphema. The nurse should place the client in which position? A) semi-Folwer's B) side-lying on the affected side C) supine D) side-lying on the unaffected side

A) semi-Folwer's A hyphema is the presence of blood in the anterior chamber of the brain. Hyphema is produced when a force is sufficient to break the integrity of the blood vessels in the eye and can be caused by direct injury, such as penetrating injury from a small bullet or pellet, or indirectly, such as from striking the forehead on the pavement during an accident. The client is treated by bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea.

The nurse uses Montgomery straps primarily so the client is free from: A) skin breakdown. B) falls. C) bruises. D) wandering.

A) skin breakdown. The nurse uses Montgomery straps primarily to avoid the removal of long-term abdominal dressing tape and ultimate skin breakdown.

A nurse is planning staffing for a nursing unit in which the primary need of the clients is learning how to manage their health problems. Which combination is the ideal mix of staff for this unit? A) three registered nurses (RNs) B) one RN and two licensed practical/vocational nurses (LPNs/VNs) C) one LPN/VN and two unlicensed assistive personnel (UAPs) D) one RN, one LPN/VN, and one UAP

A) three registered nurses (RNs) The ideal staffing for a nursing unit focused on client teaching and learning is to have three registered nurses. It is within the scope of practice for the RN to assess, plan, implement, coordinate, and evaluate client learning. It is not within the scope of practice for LPNs/VNs and UAP to provide client teaching.

The mother of a client who has a radium implant asks why so many nurses are involved in her daughter's care. She states, "The doctor said I can be in the room for up to 2 hours each day, but the nurses say they are restricted to 30 minutes." The nurse explains that this variation is based on the fact that nurses: A) work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. B) are at greater risk from the radiation because they are younger than the mother. C) touch the client, which increases their exposure to radiation. D) work with many clients and could carry infection to a client receiving radiation therapy, if exposure is prolonged.

A) work with radiation on an ongoing basis, while visitors have infrequent exposure to radiation. The three factors related to radiation safety are time, distance, and shielding. Nurses on radiation oncology units work with radiation frequently and so must limit their contact. Nurses are physically closer to clients than are visitors, who are often asked to sit 6 feet (182.9 cm) away from the client. Touching the client does not increase the amount of radiation exposure. Aseptic technique and isolation prevent the spread of infection. Age is a risk factor for people in their reproductive years.

When developing a nutritional plan for a child who needs to increase protein intake, the nurse should suggest which foods? Select all that apply. A) yogurt B) whole wheat bread C) peanut butter D) cooked dry beans E) apple

A) yogurt C) peanut butter D) cooked dry beans Yogurt, dry beans, and peanut butter all contain protein in amounts that make them good sources of protein for the child. Whole wheat bread and apples are carbohydrates and do not provide a sufficient source of protein.

The nurse at an outpatient surgical clinic witnesses client signatures. When obtaining signatures, which clients are able to sign their own consent for a procedure/surgery? Select all that apply. A) A 7-year-old who needs an open reduction internal fixation (ORIF) of the right arm B) A 62-year-old with macular degeneration who is ordered a routine colonoscopy C) A 16-year-old who is obtaining an elective breast reduction for back pain relief D) A 72-year-old widow with dementia who needs a mastectomy for cancer removal E) A married 17-year-old who requires a cholecystectomy for relief of nausea and pain

B) A 62-year-old with macular degeneration who is ordered a routine colonoscopy E) A married 17-year-old who requires a cholecystectomy for relief of nausea and pain There are many factors for the nurse to consider when evaluating whether a client can consent to surgery. These include being: mentally ill or disabled, a minor, under the influence of alcohol, drugs, or medication, in labor, under great stress or in pain at the time of consent, in a semi-conscious state. The 7 and 16 year old are minors while the 17 year old is married and an emancipated minor and able to give consent. Having difficulty seeing due to macular degeneration does not preclude the ability to have the consent read and then provide consent. Depending upon the severity of the dementia, the client will need to be evaluated for competence before independently providing consent.

A nurse-manager has decided to delegate responsibility for the review and revision of the surgical unit's client-education materials. Which statement illustrates the best method of delegation? A) Tell the nursing staff they're responsible for the review and revision and welcome their recommendations for improving the materials. B) Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members. C) Tell the nursing staff that the client education materials need revision. Ask the staff to select people to review the materials and make suggestions for change. D) Ask the assistant manager to develop a plan for the review and revision of client-education materials.

B) Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members. Delegation must be clear and precise. The nurse-manager must assign responsibility, identify the task to be accomplished, explain the necessary outcomes, and define the time frame available to complete the work. The remaining options don't clearly define the work to be done, don't clearly assign responsibility or specify desired outcomes, or establish a time frame for completion of the task.

A client is being discharged after abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care? A) Asking an occupational therapist to evaluate the client at home B) Asking the physician to write an order for home skilled nursing assessments and interventions C) Advocating for the client by ordering Meals on Wheels 5 days a week D) Notifying the American Cancer Society (Canadian Cancer Society) of the client's diagnosis

B) Asking the physician to write an order for home skilled nursing assessments and interventions Many clients are discharged from acute care settings so quickly that they don't receive complete instructions. Therefore, the first priority is to arrange for home health care. The American Cancer Society (Canadian Cancer Society) often sponsors support groups, which are helpful when the person is ready. However, contacting this organization would break client confidentiality, and even with the client's consent does not take precedence over ensuring proper home health care. Advocating for Meals On Wheels and asking for an occupational therapy evaluation are important, but these actions can occur later in rehabilitation.

A client in a long-term care facility refuses to take his oral medications. The nurse threatens that she will apply restraints and inject the medication if he doesn't take it orally. The nurse's statement constitutes which legal tort? A) Battery B) Assault C) Negligence D) Right to refuse care

B) Assault Assault occurs when a person puts another person in fear of harmful or threatening contact. Battery is offensive contact with another's body. If the nurse actually carried out the threat, battery would also apply. Negligence involves actions that don't meet the standard of care. The client has the legal right to refuse care. In this situation, the nurse should try to calm the client, allow him time to talk, and then determine if he will take the medications. If the client still won't take the medications, the nurse should document his refusal, note the medications involved, and notify the physician and nursing supervisor. The nurse should follow the facility's policy related to clients refusing care.

The nurse is conducting walking rounds and observes the client (see figure). What should the nurse do? A) Raise the side rails to full upright position. B) Assess the client to determine why she wants to sit up. C) Elevate the head of the bed. D) Loosen the bed restraints so the client can sit up.

B) Assess the client to determine why she wants to sit up. The nurse should first determine why the client wants to sit up and then, if needed delegate someone to assist the client. Loosening the restraints will not keep the client safe in bed. Raising the side rails and elevating the head of the bed do not address the client's needs.

The nurse is caring for an elderly patient who needs help with ADLs. Which of the following is most important for the nurse to understand when implementing care in order to avoid injury? A) The center of gravity is located at the waist. B) Bending and twisting while providing care may cause injury. C) A client's level of consciousness and ability to cooperate are not important factors during transfer. D) Tightening the abdominal muscles and tucking the pelvis may strain the lower back.

B) Bending and twisting while providing care may cause injury. Bending and twisting during routine care, such as bathing, should be avoided because these actions may cause injury. The center of gravity is at the level of the pelvis, not the waist. The nurse should assess a client's level of consciousness and ability to cooperate because the client should help as much as possible during transfer. Tightening the abdominal muscles and tucking the pelvis actually help protect the back.

Prior to going to surgery, the client tells the nurse that she cannot hear without her hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response? A) Explain to the client that it is policy not to take personal items to surgery because they may be lost or broken. B) Call the surgery unit to explain the client's concern, and ask if she can wear her hearing aid to surgery. C) Explain to the client that she will have a premedication that will make her sleepy before she goes to surgery and she will not need to hear. D) Tell the client that she will bring the hearing aid to the postanesthesia care unit so that she can have it as soon as she wakes up.

B) Call the surgery unit to explain the client's concern, and ask if she can wear her hearing aid to surgery. The nurse serves as a client advocate when helping the client addressing a client's concern. nurse should call the operating room and inform the intraoperative nurse about the client's request. A special container with correct identification can be prepared so that when the client is anesthetized and her hearing aid is removed, it will not be lost or broken. It is usual policy not to send personal belongings to surgery because they are easily broken or lost in the transfer of an anesthetized client with higher priority needs, but special needs do exist. In some instances, the nurse does bring a client's personal belongings to the postanesthesia care unit, but in this case the item involves the client's ability to communicate. Because the trend is to use little premedication, clients are more alert and may want to talk with their surgical team before going to sleep. Decreasing the client's anxieties preoperatively affects the amount of medication used to induce the client and her overall psychological and physiologic status. Telling the client that she will not need to hear is insensitive.

Which of the following theories of ethics most highly prioritizes the nurse's relationship with clients and the nurse's character in the practice of ethical nursing? A) Principle-based ethics. B) Care-based ethics. C) Utilitarianism. D) Deontology.

B) Care-based ethics. Central to the care-based approach to ethics is the nurse's relationships with clients and the nurse's "being," or character and identity. Deontology, utilitarianism, and principle-based ethics each prioritize goals and principles that exist beyond the particularities of the nurse-client relationship.

What role will the nurse have when admitting a client to a hospital for outpatient surgery that will result in discharge the same day? A) Prepare for long-term care needs. B) Complete regular admission procedures. C) Provide detailed information on the procedure. D) Schedule the client for screening tests.

B) Complete regular admission procedures. Clients entering the hospital setting for outpatient surgery have regular admission procedures conducted by the nurse. Scheduling of screening tests and initial teaching is completed in the days prior to the surgery. Same-day surgery and discharge may require community-based follow-up, but it generally does not require long-term care. Detailed information on the procedure will be provided by the physician performing the procedure.

A staff nurse on a busy pediatric unit would like to function effectively in the role of a leader. Which of the following actions would the nurse employ to be a leader? A) Ask the nursing administration for the authority to make decisions that will affect the staff. B) Encourage the staff to participate in the unit's decision-making process, and help the staff to improve their clinical skills. C) Tell the staff on the unit how to do their job effectively based on current research and relevant experience. D) Follow unit and hospital policy in daily situations.

B) Encourage the staff to participate in the unit's decision-making process, and help the staff to improve their clinical skills. A leader does not have formal power and authority but influences the success of a unit by being an excellent role model and by guiding, encouraging, and facilitating professional growth and development. A manager's formal power and authority within the organization are detailed in her job description. An autocrat is not interested in guiding or encouraging staff or in being an effective role model. A manager derives her authority by virtue of her position within an organization.

Two days after a right total knee replacement, a client rates his right-knee pain as 9 on a 10-point pain scale. A physician orders hydrocodone/APAP 1 tablet by mouth every 4 to 6 hours as needed for pain. When a nurse notifies the physician of the client's pain, the physician states that one hydrocodone/APAP tablet should be sufficient and refuses to order anything stronger for pain. Which measure should the nurse select to act as an advocate for the client? A) Document that the physician was notified of the client's pain and continue to administer hydrocodone/APAP as ordered. B) Follow the chain of command to obtain adequate pain relief for the client. C) Give the client 2 hydrocodone/APAP tablets every 4 hours. D) Give the client 1 hydrocodone/APAP tablet every 3 hours.

B) Follow the chain of command to obtain adequate pain relief for the client. Clients must receive adequate pain relief. Allowing a client to experience a pain score of 9 out of 10 is unacceptable nursing practice. Acting as a client advocate requires a nurse to be assertive, even if this means confronting a physician. If the physician doesn't give an order for adequate pain relief, the nurse should follow the chain of command to report the physician's inaction and obtain adequate pain relief for the client. A nurse may not adjust medication frequency or dosage without a physician's order.

A scrub nurse in the operating room has which responsibility? A) Positioning the client B) Handing surgical instruments to the surgeon C) Applying surgical drapes D) Assisting with gowning and gloving

B) Handing surgical instruments to the surgeon The scrub nurse assists the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the client, assists with gowning and gloving, applies appropriate equipment and surgical drapes, and provides the surgeon and scrub nurse with supplies.

When completing the preoperative checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first? A) Note this new allergy prominently on the medical record. B) Inform the anesthesiologist. C) Contact the scrub nurse in the operating room. D) Administer the prescribed preanesthetic medication.

B) Inform the anesthesiologist. The anesthesiologist who administers the anesthetic agent and monitors the client's physical status throughout the surgery must have knowledge of all known allergies for client safety. The completed record (with the preoperative checklist) must be available to all members of the surgical team, and any unusual last-minute observations that may have a bearing on anesthesia or surgery are noted prominently at the front of the medical record. The preanesthetic medication can cause light-headedness or drowsiness. The nurse in the scrub role provides sterile instruments and supplies to the surgeon during the procedure.

What should the nurse instruct a client who has cerumen build-up in the ear to do? Select all that apply. A) Use cotton tip applicators to remove the wax from the ear canal. B) Instill cerumenolytic drops in the ear canal. C) Irrigate the ear with sterile water after softening the wax with a cerumenolytic solution. D) Use small forceps to extract the wax. E) Wash the external ear with a washcloth.

B) Instill cerumenolytic drops in the ear canal. C) Irrigate the ear with sterile water after softening the wax with a cerumenolytic solution. E) Wash the external ear with a washcloth. The nurse can advise the client with cerumen that is impacted in the ear to use a wash cloth to clean the exterior part of the ear. The client can also instill cerumenocyltic drops to soften the ear wax. The client can then irrigate the ear canal with sterile water using a small bulb syringe. The client should not use cotton tipped applicators as they often push the cerumen further into the ear canal. The client should never put forceps in the ear.

The nurse is transferring an immobilized client. What is the best way for the nurse to maintain safety? Select all that apply. A) Keep the body straight when lifting to reduce pressure on the abdomen. B) Place the feet apart to increase the stability of the body. C) Ask for assistance from another staff member. D) Bend at the waist to provide the power for lifting. E) Relax the abdominal muscles and use the extremities to prevent strain.

B) Place the feet apart to increase the stability of the body. C) Ask for assistance from another staff member. Placing the feet apart creates a wider base of support and brings the center of gravity closer to the ground. This improves stability. Asking for assistance will also reduce the risk of injury for the nurse. The other choices all place the nurse at risk for back injury.

A nurse has custody of a client's daily Kardex and care plan so she can give a change-of-shift report. After reporting to the next shift, what steps should the nurse implement to maintain client confidentiality? A) Place the documents in the client's chart. B) Shred the documents or place them in a container to protect confidentiality. C) Leave the documents at the nurses' station. D) Throw the documents in the trash can.

B) Shred the documents or place them in a container to protect confidentiality. C) Leave the documents at the nurses' station. Kardexes, care plans, and other client documents contain confidential client information. The nurse should shred them or place them in a special confidential container for proper disposal. Regular garbage isn't secure and isn't an appropriate place to dispose of documents containing a client's name and information. Leaving the documents at the nurses' station may allow others to view them. It isn't necessary to place the nursing Kardex and care plan in the client's chart when the nurse has finished using them.

A client has a tumor of the posterior pituitary gland. The nurse planning his care would include which interventions? Select all that apply. A) Restrict fluids. B) Take daily weight. C) Assess urine specific gravity. D) Encourage intake of coffee or tea. E) Monitor intake and output.

B) Take daily weight. C) Assess urine specific gravity. E) Monitor intake and output. Tumors of the pituitary gland can lead to diabetes insipidus because of a deficiency of antidiuretic hormone (ADH). Decreased ADH reduces the ability of the kidneys to concentrate urine, resulting in excessive urination, excessive thirst, and excessive fluid intake. To monitor fluid balance, the nurse would weigh the client daily, measure urine specific gravity, and monitor intake and output. The nurse would encourage fluids to keep intake equal to output and prevent dehydration. Coffee, tea, and other fluids that have a diuretic effect would be avoided.

During a teaching session, a nurse demonstrates to a client how to change a tracheostomy dressing. Then the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure? A) The client cleans around the incision site, using gauze squares and full-strength hydrogen peroxide. B) The client rinses around the clean incision site, using gauze squares moistened with normal saline. C) After cleaning around the incision site, the client applies cotton-filled gauze squares as the sterile dressing. D) The client rinses around the clean incision site, using gauze squares moistened with tap water.

B) The client rinses around the clean incision site, using gauze squares moistened with normal saline. To change a tracheostomy dressing effectively, the client should rinse around the clean incision site, using gauze squares moistened with normal saline. If crusts are difficult to remove, the client may use a solution of 50% hydrogen peroxide and 50% sterile saline — not full-strength hydrogen peroxide. The client shouldn't use tap water, which may contain chemicals and other harmful substances. To prevent lint or fiber aspiration and subsequent tracheal abscess, the client should use sterile dressings made of nonraveling material instead of cotton-filled gauze squares.

Nurse researchers have proposed a study to examine the efficacy of a new wound care product. Which of the following aspects of the methodology demonstrates that the nurses are attempting to maintain the ethical principle of nonmaleficence? A) The nurses have given multiple opportunities for potential participants to ask questions and have been following the informed consent process systematically. B) The nurses are taking every responsible measure to ensure that no participants experience impaired wound healing as a result of the study intervention. C) The nurses have completed a literature review that suggests the new treatment may result in decreased wound healing time. D) The nurses have organized the study in such a way that the foreseeable risks and benefits are distributed as fairly as possible.

B) The nurses are taking every responsible measure to ensure that no participants experience impaired wound healing as a result of the study intervention. The principle of nonmaleficence dictates that nurses avoid causing harm. In this study, this may appear in the form of taking measures to ensure that the intervention will not cause more harm than good. The principle of justice addresses the distribution of risks and benefits and the informed consent process demonstrates that autonomy is being protected. Preliminary indications of the therapeutic value of the intervention show a respect for the principle of beneficence.

A nurse is obtaining a sterile urine specimen from a client's indwelling urinary catheter. During the procedure, the nurse should: A) wear sterile gloves when collecting urine. B) aspirate urine from the tubing port, using a sterile syringe and needle. C) disconnect the catheter from the tubing and collect urine. D) open the drainage bag and pour out some urine.

B) aspirate urine from the tubing port, using a sterile syringe and needle. To collect urine properly, the nurse should aspirate it from a port, using a sterile syringe and needle after cleaning the port. Opening a closed urine-drainage system, which would occur if the nurse disconnected the catheter from the tubing or opened the drainage bag, would increase the risk of urinary tract infection. Although standard precautions specify wearing gloves during contact with body fluids, the nurse need not wear sterile gloves for this procedure.

Which finding requires immediate intervention when planning care for an adolescent with cystic fibrosis (CF)? A) large, foul-smelling, and bulky stools B) chest pain with dyspnea C) poor weight gain D) delayed puberty

B) chest pain with dyspnea Chest pain and dyspnea are signs of a pneumothorax and should be treated immediately. Delayed puberty is common in adolescents with CF and is caused by poor nutrition. Poor weight gain is common in children with CF because so little is absorbed in the small intestine. Large, foul-smelling stools indicate noncompliance with taking enzymes and should be addressed, but respiratory complications are the greatest concern.

The nurse is making rounds and observes the client receiving oxygen (see figure). The nurse should: A) loosen the elastic band on the client's face. B) confirm that the flow rate is set to deliver oxygen at 6 to 10 L/min. C) position the mask lower on the client's nose. D) verify that the reservoir bag remains deflated.

B) confirm that the flow rate is set to deliver oxygen at 6 to 10 L/min. The client is receiving oxygen using a partial rebreathing mask which is positioned correctly. The correct flow rate for this type of oxygen mask is 6 to 10 L of oxygen per minute. To be effective, the mask must cover the client's face. The elastic band must be tight enough to secure the mask. When used correctly, the reservoir bag should inflate during the inspiratory phase.

The nurse is developing a primary disease prevention program for older adults. Which topic is the most appropriate? A) blood glucose screening for diabetes B) immunizations for influenza C) range of motion exercises D) diet and exercise for people with heart disease

B) immunizations for influenza The three levels of prevention are primary, secondary, and tertiary. The most important topic to include in a program for older adults that is to emphasize primary prevention is the importance of receiving immunizations to prevent disease such as influenza, pneumonia, and shingles. The goal of primary prevention is to protect healthy people from developing a disease or injury. Immunization is an example of a primary prevention strategy. Secondary prevention involves taking action to slow or stop the progress of a disease. Monitoring blood glucose for clients with diabetes or initiating diet and exercise programs for people with heart disease are examples of secondary prevention. Tertiary preventions are treatments aimed to reduce the negative impact of established disease by restoring function and reducing disease-related complications. An example of tertiary prevention is performing passive and active range of motion exercises to prevent disability.

A hospitalized client is experiencing a "fight-versus-flight," a stress-mediated physiologic response. As a result, the nurse should assess the client for: A) decreased arterial blood pressure. B) increased blood glucose. C) increased urinary output. D) decreased mental acuity.

B) increased blood glucose. Responses to physiologic stress, such as hospitalization, surgery, or pain, are a result of catecholamine release, and specifically include increased heart rate and blood pressure, increased bronchiolar dilation, water retention and decreased urinary output, increased blood glucose, and increased mental acuity.

Several day-shift nurses complain that the night-shift nurses aren't performing the daily calibration of the capillary glucose monitoring apparatus, which is their responsibility. It would be most prudent for a nurse-manager to: A) arrange a meeting of the day-shift and night-shift nurses. B) review the capillary glucose monitoring calibration log book. C) immediately remind the night-shift nurses of the daily calibrations. D) counsel the night charge nurse about the discrepancy.

B) review the capillary glucose monitoring calibration log book. When dealing with complaints, a nurse-manager should always gather data before taking action. Therefore, the nurse-manager should review the calibration documentation, then address the findings. It would be inappropriate for the nurse-manager to remind the staff of a responsibility that they may be fulfilling, arrange a meeting that could become confrontational, or counsel the charge nurse before investigating and gathering data relative to the complaint.

Proper hand placement for chest compressions during cardiopulmonary resuscitation (CPR) is essential to reduce the risk of which complication? A) myocardial infarction B) rib fracture C) emesis D) gastrointestinal bleeding

B) rib fracture Proper hand placement during chest compressions is essential to reduce the risk of rib fractures, which may lead to pneumothorax and other internal injuries. Gastrointestinal bleeding and myocardial infarction are generally not considered complications of CPR. Although the victim may vomit during CPR, this is not associated with poor hand placement, but rather with distention of the stomach.

Which indicates that a client has achieved the goal of correctly demonstrating deep breathing for an upcoming splenectomy? The client: A) uses diaphragmatic breathing in the lying, sitting, and standing positions. B) takes a deep breath in through the nose, holds it for 5 seconds, and blows out through pursed lips. C) breathes in through the nose and out through the mouth. D) breathes in through the mouth and out through the nose.

B) takes a deep breath in through the nose, holds it for 5 seconds, and blows out through pursed lips. The correct technique for deep breathing postoperatively to avoid atelectasis and pneumonia is to take in a deep breath through the nose, hold it for 5 seconds, then blow it out through pursed lips. The goal is to fully expand and empty the lungs for pulmonary hygiene.

The nurse is preparing a client for nonemergency surgery. The nurse should: A) obtain informed consent from the client. B) verify the client understands the informed consent form. C) inform the client about the risks of the surgery to be performed. D) explain the surgical procedure.

B) verify the client understands the informed consent form. The surgeon is responsible for explaining the surgical procedure to be performed and the risks of the procedure, as well as for obtaining the informed consent from the client. A nurse may be responsible for obtaining and witnessing a client's signature on the consent form. The nurse is the client's advocate, verifying that a client (or family member) understands the consent form and its implications, and that consent for the surgery is truly voluntary.

A client with heart failure must be monitored closely after starting diuretic therapy. The best indicator for the nurse to monitor is: A) vital signs. B) weight. C) urine specific gravity. D) fluid intake and output.

B) weight. Heart failure typically causes fluid overload, resulting in weight gain. Therefore, weight is the best indicator of this client's status. One pound gained or lost is equivalent to 500 ml. Fluid intake and output and vital signs are less accurate indicators than weight. Urine specific gravity reflects urine concentration, indicating overhydration or dehydration. Numerous factors can influence urine specific gravity, so it isn't the most accurate indicator of the client's status.

When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching? A) "I will administer the enema while lying on my back with both knees flexed." B) "I will administer the enema while lying on my right side with my left knee flexed." C) "I will administer the enema while lying on my left side with my right knee flexed." D) "I will administer the enema while sitting on the toilet."

C) "I will administer the enema while lying on my left side with my right knee flexed." Lying on the left side allows the enema solution to flow downward by gravity into the rectum and sigmoid colon. The other options don't accomplish this goal and, therefore, are less effective in evacuating the lower bowel.

A client is being admitted with a nursing home-acquired pneumonia. The unit has four empty beds in semiprivate rooms. The room that would be most suitable for this client is the one with a: A) 24-year-old client with non-Hodgkin's lymphoma. B) 55-year-old client with alcoholic cirrhosis. C) 60-year-old client admmitted for investigation of transient ischemic atttacks. D) 45-year-old client with abdominal hysterectomy.

C) 60-year-old client admmitted for investigation of transient ischemic atttacks. The client with a possible transient ischemic attack is the only client who has not had surgery and is not immunocompromised. The client with a recent surgery and incision should not be exposed to a client with infection. Clients with cancer or alcoholic cirrhosis are very susceptible to infection, and it would not be safe to expose them to a client with a respiratory infection.

A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which action should the nurse take? A) Stop the feeding and remove the NG tube as specified in the client's living will. B) Make the client comfortable as specified in the client's living will. C) Clear the client's airway. D) Start cardiopulmonary resuscitation.

C) Clear the client's airway. A living will gives information about what the client wants if he is in a terminal or permanently unconscious state. A living will doesn't apply to nonterminal events such as choking on an enteral feeding device. In this situation, the nurse should clear the client's airway. Making the client comfortable ignores the life-threatening event. Cardiopulmonary resuscitation isn't indicated. Removing the NG tube would exacerbate the situation.

The student nurse is admitting an elderly patient admitted with congestive heart failure and sets up the room with standard precautions. Which of the following is noted by the nursing instructor as the best action? A) Placing a body substance isolation sign on the client's door. B) Wearing a gown if the client is in respiratory isolation. C) Considering all body substances potentially infectious. D) Wearing gloves for all client contact.

C) Considering all body substances potentially infectious. Standard precautions are based on the concept that all body substances are potentially infectious and that direct contact with them must be avoided. The nurse should wear gloves when contact with body substances — not unsoiled articles or intact skin — is anticipated. Because all body substances from all clients are considered potentially infectious, signs on doors are unnecessary. Gloves and gowns are inappropriate when caring for a client in respiratory isolation because they don't prevent transmission of airborne respiratory infections. The nurse should wear a mask as a barrier to such infections.

A partner of a man diagnosed with Karposi's Sarcoma has refused antiretroviral therapy. The partner confides in the nurse that, "He has just given up. I know if he just takes the medication he will get better and we can go back to the life we once had." The nurse identifies that the partner is experiencing which stage of grieving? A) Anger stage B) Depression stage C) Denial stage D) Bargaining stage

C) Denial stage Denial, the avoidance of death's inevitability, is the first step of the grieving process. Anger, the most intense grief reaction, arises when people realize that a family member will die or has died. Bargaining occurs when family members attempt to stall or manipulate the outcome or death. Depression is a response to loss expressed as profound sadness or deep suffering.

The client has been prescribed vaginal cream for a yeast infection to be administered via a vaginal applicator. In which position would the nurse instruct the client to take for appropriate administration? A) Sim's position B) Supine position C) Dorsal recumbent position D) Low Fowler's position

C) Dorsal recumbent position The dorsal recumbent position (supine with the hips and knees bent) allows easy access to the vaginal orifice and proper placement for the medication. The other positions do not allow access to the vaginal orifice as the legs are closed.

Which nursing action is most beneficial to prevent fungal infections in hospitalized clients? A) Bathe the client daily B) Ensure air movement with a fan C) Dry all skin folds thoroughly D) Keep the client's skin moisturized

C) Dry all skin folds thoroughly Fungus spreads in warm, moist environments. The nurse must keep all skin folds on the warm body dry. Moisturized is needed for dry skin but does not prevent fungal infections. Bathing is appropriate but drying is key. Environmental air movement is not necessarily helpful.

A nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which instruction should the nurse include? A) Limit salt intake to 2 g per day. B) Encourage foods high in vitamin B. C) Encourage a high-calorie, high-protein diet. D) Restrict fluids to 1,500 ml per day.

C) Encourage a high-calorie, high-protein diet. The child should be encouraged to eat a high-calorie, high-protein diet. In cystic fibrosis, the pancreatic enzymes (lipase, trypsin, and amylase) become so thick that they plug the ducts. In the absence of these enzymes, the duodenum can't digest fat, protein, and some sugars; therefore, the child can become malnourished. A child with cystic fibrosis needs to drink plenty of fluid and take salt supplements, especially on warm days or when exercising, to help maintain hydration and adequate sodium levels. Water-soluble forms of the fat-soluble vitamins (A, D, E, and K) are essential.

Following abdominal surgery, a client refuses to deep breathe and cough every 2 hours as prescribed. What should the nurse do first? A) Suggest that the client increase the daily fluid intake to at least 2,500 mL. B) Respect the client's wishes, and turn the client from side-to-side more frequently. C) Explain the risks of not expanding the lungs and why the exercise is important. D) Ask the client's spouse to insist that the client take the deep breaths every 2 hours.

C) Explain the risks of not expanding the lungs and why the exercise is important. Following surgery, clients are at risk for respiratory complications and should take the necessary actions to prevent these. The nurse should first be sure that the client understands how to do the exercises and the potential complications if they are not done. It is not the spouse's responsibility to make the client do the exercise, but she can help. Increasing fluid intake and frequent turning are appropriate, but not sufficient for aerating the lungs.

The nurse applies warm compresses to a client's leg. To determine effectiveness of the compresses, the nurse should determine if there is: A) Less scaling on the skin. B) Decreased bruising. C) Improved circulation to the area. D) Decreased swelling in the area.

C) Improved circulation to the area. Heat applications cause vasodilation, which promotes circulation to the area, and increase tissue metabolism and leukocyte mobility. Heat applications do not prevent swelling; applications of cold are used to prevent swelling by causing vasoconstriction. Moist heat applications do not reduce bruising or scaling on the skin.

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

C) In a widening circle around the drain, outward from the center When cleaning the area around the drain, the nurse should wipe in a circle around the drain, working from the center outward. The nurse wipes laterally, from the center to the opposite side, when cleaning a large horizontal wound and wipes from the superior portion of the wound to the inferior when cleaning a vertical incision. Cleaning the wound laterally from the distal area to the center increases the client's risk for infection.

In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that she has made. The nurse is most clearly demonstrating which of the following professional values? A) Human dignity. B) Altruism. C) Integrity. D) Social justice.

C) Integrity. The nurse is demonstrating integrity, which is defined as acting in accordance with an appropriate code of ethics and accepted standards of practice. Seeking to remedy errors made by self or others is an example of integrity. Altruism is a concern for the welfare and being of others. Social justice is upholding moral, legal, and humanistic principles. Human dignity is respect for the inherent worth and uniqueness of individuals and populations.

Eight farm workers are admitted to the emergency department after they were splashed with "a couple of chemicals" at work 30 minutes ago. They have watery/itchy eyes, slight cough, diaphoresis, constricted pupils, and are conscious and oriented. Their clothes are wet. What action should the nurse do first? A) Remove their clothing. B) Begin decontamination shower. C) Isolate the clients. D) Apply oxygen at 3 L per nasal cannula.

C) Isolate the clients. Safety of the staff and others is the first priority. Isolating reduces the chance of contaminating others (secondary contamination). Vital signs can be obtained when it is safe—after protecting staff, clients, and visitors from secondary contamination. Oxygen is not indicated for any of the listed symptoms. Removing clothing is important to prevent further exposure to the client, but must be done in a safe manner to prevent secondary contamination to others. The clients can remove their own clothes and place them in plastic bags. After the safety of the staff and others is addressed, and the facility is prepared and properly trained staff is ready, the clients can be given a decontamination shower. If the staff is not trained, 911 may be the most appropriate response. Finding out which chemicals were involved is important, but does not take priority over preventing secondary contamination.

While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply? A) Sterile petroleum gauze B) Dry sterile dressing C) Moist sterile saline gauze D) Povidone-iodine-soaked gauze

C) Moist sterile saline gauzeMoist sterile saline dressings support wound healing and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine is used as an antiseptic cleaning agent but because it can irritate epithelial cells, it shouldn't be left on an open wound.

A physician orders supplemental oxygen for a client with a respiratory problem. Which oxygen delivery device should the nurse use to provide the highest possible oxygen concentration? A) Simple mask B) Venturi mask C) Nonrebreather mask D) Nasal cannula

C) Nonrebreather mask A nonrebreather mask provides the highest possible oxygen concentration — up to 95%. A nasal cannula doesn't deliver concentrations above 40%. A Venturi mask delivers precise concentrations of 24% to 44%, regardless of the client's respiratory pattern, because the same amount of room air always enters the mask opening. A simple mask delivers 2 to 10 L/minute of oxygen in uncontrollable concentrations.

A client returned from surgery eight hours ago and has not voided. Which action should the nurse take first? A) Tell the client to bear down and try to void. B) Call the physician to report the client's condition. C) Palpate over the synthesis pubis for fullness. D) Catheterize the client with a straight catheter.

C) Palpate over the synthesis pubis for fullness. Before taking any action, the nurse must palpate over the client's synthesis pubis. If the client's is retaining urine there will be fullness over the bladder. Urine retention is a common adverse effect of anesthesia. After confirming retention, the nurse should call the physician and expect an order to catheterize the client. Telling the client to bear down and try to void is inappropriate.

Before assisting a client to ambulate after surgery, the nurse helps the client to dangle the feet over the side of the bed. Which action will best prepare the client to dangle the feet over the side of the bed? A) Have the client flex and extend the feet while in a recumbent position. B) Position the client on his or her side for 5 minutes. C) Place the client in a high Fowler's position. D) Administer a prescribed analgesic 10 minutes prior to getting out of bed.

C) Place the client in a high Fowler's position. Many clients feel faint and weak when helped to ambulate for the first time after surgery. The client's circulatory system needs time to adjust to an upright position before the client is helped to a standing position. This is best done by placing the client in high Fowler's position in bed for a few minutes. After becoming accustomed to a sitting position, the client can then be helped to dangle the feet at the edge of the bed before ambulating. Although analgesics can promote comfort for the postoperative client, some can sedate the client and should not be given at the time the client is assisted out of bed. Having the client lie on the side of the bed or do leg exercises will not prepare the client to dangle the legs.

A client is admitted to the healthcare facility with active tuberculosis (TB). The nurse should include which intervention in the care plan? A) Keeping the door to the client's room open to observe the client B) Instructing the client to wear a mask at all times C) Putting on an individually-fitted mask when entering the client's room D) Wearing a gown and gloves when providing direct care

C) Putting on an individually-fitted mask when entering the client's room Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a mask when entering the client's room. Occupational Safety and Health Administration (OSHA/Canadian Centre for Occupational Health and Safety) standards require an individually-fitted mask. Having the client wear a mask at all times would hinder sputum expectoration and respirations would make the mask moist. A nurse who does not anticipate contact with the client's blood or body fluids need not wear a gown or gloves when providing direct care. A client with TB should be in a room with laminar airflow, and the room's door should be shut at all times.

When removing protective covering, what action should this nurse (see figure) take to avoid spreading nosocomial infections? A) Place the face mask over the mouth and nose before removing the hair covering. B) Tie the dangling strings of the mask around the neck. C) Remove the face mask. D) Wash hands before tying the strings on the mask.

C) Remove the face mask. The nurse should remove the face mask. The face mask contains nasal and oral droplets, which are easily transmitted to the hands as the mask dangles when left hanging around the neck. When a face mask is not worn over the mouth and nose, it should be completely removed.

The nurse is caring for a client with a nasogastric tube who is receiving intermittent tube feedings by gravity every 4 hours. The nurse aspirates 75 mL of residual prior to the next feeding. What action should the nurse take next? A) Discard the residual, and subtract the residual amount from the feeding. B) Hold the feeding, and recheck the residual in 4 hours. C) Return the residual and begin the feeding. D) Administer an amount of water equivalent to the feeding.

C) Return the residual and begin the feeding. The amount of residual is within normal limits, and the client should have the feeding started. The residual should be returned to help prevent electrolyte imbalances. The other options do not ensure adequate nutritional management for the client.

After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. What is an expected outcome of these exercises? A) The rate of air flow to the remaining lobe is controlled so that it will not become hyperinflated. B) There is increased blood flow to the lungs to allow them to recover from the trauma of surgery. C) The alveoli expand and increase the lung surface available for ventilation. D) The elevated diaphragm enlarges the thorax and increases the lung surface available for gas exchange.

C) The alveoli expand and increase the lung surface available for ventilation. Deep breathing helps prevent microatelectasis and pneumonitis and also helps force air and fluid out of the pleural space into the chest tubes. More than half of the ventilatory process is accomplished by the rise and fall of the diaphragm. The diaphragm is the major muscle of respiration; deep breathing causes it to descend, not elevate, thereby increasing the ventilating surface. Deep breathing increases blood flow to the lungs; however, the primary reason for deep breathing is to expand alveoli and prevent atelectasis. The remaining lobe naturally hyperinflates to fill the space created by the resected lobe. This is an expected phenomenon.

A client is receiving a bowel preparation of magnesium citrate the evening before a scheduled colonoscopy. Which factor should the nurse consider when providing care for this client? A) Antidiarrheal medication should be given if the client has more than two loose stools. B) Eating large meals should be encouraged to prevent weight loss. C) The client may require fluid and electrolyte replacement. D) Side rails should be raised at all times.

C) The client may require fluid and electrolyte replacement. Bowel preparation, which usually involves laxatives and sometimes enemas, may cause severe fluid and electrolyte loss. The nurse should monitor the client for dehydration and electrolyte loss. Diarrhea is expected after bowel preparation and shouldn't be treated. Most clients eat a light meal the evening before the procedure or are ordered a clear liquid diet. Raising the side rails may increase the risk of fall for a client with frequent diarrhea.

A client in a long-term care facility has signed a form stating that he does not want to be resuscitated. He develops an upper respiratory infection that progresses to pneumonia. His health rapidly deteriorates, and he is no longer competent. The client's family states that they want everything possible done for the client. Which of the following should happen in this case? A) The wishes of his family should be followed. B) The client should be resuscitated if he experiences respiratory arrest. C) The client should be treated with antibiotics for pneumonia. D) Pharmacologic interventions should not be initiated.

C) The client should be treated with antibiotics for pneumonia. The client has signed a document indicating a wish not to be resuscitated. Treating the pneumonia with antibiotics is not a resuscitation measure. The other options do not respect the client's right to choice.

Following an education session on proper hand hygiene, the nurse educator observes a nurse washing her/his hands before entering a client's room. Which of the following observations would alert the nurse educator to the need for further education? A) The nurse keeps her hands lower than her elbows while washing. B) The nurse uses at least 3 to 5 mL of liquid soap. C) The nurse dries from her forearms up toward her fingers. D) The nurse dries from her finger tips down toward her elbows.

C) The nurse dries from her forearms up toward her fingers. Hand hygiene procedures involve drying from the fingers toward the forearm and discarding the paper towel. The other options should be included in hand hygiene practices.

A nurse is providing home care to a client with a foot ulcer related to diabetes. The client needs daily insulin injections. Family caregivers do not possess the technical skills to inject insulin. Which of the following should the nurse keep in mind? A) Family caregivers are always perceived to be supportive of good care. B) The current reimbursement system recognizes the family's nontechnical value priorities. C) The nurse needs to be creative in integrating the technical and relational aspects of care. D) Nurses should avoid asking the family caregivers to conduct the skilled task.

C) The nurse needs to be creative in integrating the technical and relational aspects of care. The nurse needs to be creative in integrating the technical and relational aspects of care. The current reimbursement system does not recognize the family's nontechnical value priorities. Nurses are expected to educate the family caregivers to conduct the skilled task where possible. In this case, the nurse can teach the family caregivers to inject insulin. Family caregivers can be perceived to be nonsupportive of good care if the families do not follow through.

The nurse-manager of a 20-bed coronary care unit is not on duty when a staff nurse makes a serious medication error that results in a client's overdose. The client nearly dies. Which statement accurately reflects the accountability of the nurse-manager? A) Because the nurse-manager is off duty and not accountable for incidents that occur in his/her absence, he/she need not be notified. B) The nurse-manager only needs to be informed of the incident when he/she reports to work on the next scheduled day. C) The nurse-manager would receive a call at home from the on-duty nursing supervisor, apprising him/her of the problem as soon as possible. D) Although the nurse-manager is off duty and not responsible for what happened, the nursing supervisor would call the nurse-manager only if time permits.

C) The nurse-manager would receive a call at home from the on-duty nursing supervisor, apprising him/her of the problem as soon as possible. The nurse-manager is accountable for what happens on the unit 24 hours per day, 7 days per week. If a serious problem occurs, the nurse-manager should be notified as soon as possible. None of the other choices accurately reflect the nurse--manager's accountability in this situation.

It is important for nurses to communicate with clients about their health care because: A) clients are more demanding that their rights be respected. B) consumers of health care cannot keep up with rapid advances in science. C) health care services are often specialized and fragmented. D) the media provides misleading information.

C) health care services are often specialized and fragmented. Managing clients' health involves many specialized areas, such as respiratory therapy, medicine, laboratory, social services, and technical monitoring. One of the significant roles of the nurse is to ensure clear communication with the client and among the health care team. Due to expanded media coverage of health care issues, clients may be more aware of health care issues, but may not be able to determine if the information is accurate or pertains to them. Because of increasing numbers of media sources, both digital and print, it is difficult for consumers to keep up with all of the advances in the science of health care. Clients are more aware of their rights because of media exposure and information disseminated by health care facilities. However, respect for the client's rights should be the nurse's concern as well, and communication should not be impacted by a client's knowledge or demand for those rights.

A client has a reddened area over a bony prominence. The nurse finds an unlicensed nursing personnel (UAP) massaging this area. The nurse should: A) inform the UAP that massage is even more effective when combined with the use of lotion. B) explain to the UAP that massage is effective because it improves blood flow to the area. C) instruct the UAP that massage is contraindicated because it decreases blood flow to the area. D) reinforce the UAP's use of this intervention over the bony prominence.

C) instruct the UAP that massage is contraindicated because it decreases blood flow to the area. Massaging an area that is reddened due to pressure is contraindicated because it further reduces blood flow to the area. In the past, massaging reddened areas was thought to improve blood flow to the area, and some nursing personnel may still believe that massaging the area is effective in preventing pressure ulcer formation.

A client who has had the jaws wired begins to vomit. The nurse should first: A) administer an antiemetic intravenously. B) insert a nasogastric (NG) tube and connect it to suction. C) suction the client's airway as needed. D) use wire cutters to cut the wire.

C) suction the client's airway as needed. The nurse's first action is to clear the client's airway as necessary. Inserting an NG tube or administering an antiemetic may prevent future vomiting episodes, but these procedures are not helpful when the client is actually vomiting. Cutting the wires is done only as a last resort or in case of respiratory or cardiac arrest.

A client is recovering from an abdominal-perineal resection. To promote wound healing after the perineal drains have been removed the nurse should encourage the client to: A) shower daily. B) use a heating pad on the area. C) take sitz baths. D) apply moist dressings to the area.

C) take sitz baths. Sitz baths are an effective way to clean the operative area after an abdominal-perineal resection. Sitz baths bring warmth to the area, improve circulation, and promote healing and cleanliness. Most clients find them comfortable and relaxing. Between sitz baths, the area should be kept clean and dry. A shower will not adequately clean the perineal area. Moist dressings may promote wound contamination and delay healing. A heating pad applied to the area for longer than 20 minutes may cause excessive vasodilation, leading to congestion and discomfort.

An elderly couple who have just relocated to a long-term care facility have been unable to obtain a shared room. A staff member at the facility states that this should not be a concern and implies that sexual activity between the couple likely ceased many years ago. How should the nurse best respond to this individual's assertion? A) "Research has shown the nature of sexual activity changes with age but that it actually becomes more frequent." B) "It's true that they've probably stopped having sexual activity, but it's important for them to have companionship." C) "That's true, but it's important for us to give them the teaching they need in order to resume this part of their relationship." D) "Actually it's not true that older people always stop having sexual activity when they get older."

D) "Actually it's not true that older people always stop having sexual activity when they get older." Sexual activity need not be hindered by age. There is no evidence, however, that it becomes increasingly frequent in late adulthood.

The nurse has completed discharge teaching with new parents who will be bottle-feeding their normal term newborn. Which statement by the parents reflects the need for more teaching? A) "The baby should burp during and after each feeding with no projective vomiting." B) "Our baby should have 1 to 3 soft, formed stools a day." C) "Our baby will require feedings through the night for several weeks or months after birth." D) "We should weigh our baby daily to make sure he is gaining weight."

D) "We should weigh our baby daily to make sure he is gaining weight." Healthy infants are weighed during their visits to their health care provider (HCP) , so it is not necessary to monitor weights at home. Infants may require 1 to 3 feedings during the night initially. By 3 months, 90% of babies sleep through the night. Projective vomiting may indicate pyloric stenosis and should not be seen in a normal newborn. Bottle-fed infants may stool 1 to 3 times daily.

A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include: A) ice cream. B) fresh orange slices. C) steamed broccoli. D) ground beef patties.

D) ground beef patties. Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, making it less helpful in tissue repair.

A client with severe chest pain is brought to the emergency department. The client tells the nurse, "I just have a little indigestion." How should the nurse respond? A) "How will having chest pain change your life?" B) "We tried an antacid and it did not work. It is not indigestion." C) "Are you confused? You are having a heart attack." D) "You seem concerned about your chest pain."

D) "You seem concerned about your chest pain." During a crisis, it's common for a client to use denial, a coping mechanism exhibited by minimizing symptoms or avoiding discussion. The nurse must respond therapeutically to the client. Confrontation about the client's statement and asking the client if he/she is confused are not therapeutic. Asking how having chest pain will change the client's life is not appropriate in this acute phase.

A client has a chest tube inserted for the treatment of a pneumothorax. While turning in the bed, the client dislodges the tube and it is found in the bed. As the registered nurse is directing the health care team, place the actions of the registered nurse in the correct order. All options must be used. A) Assess the client's respiratory status. B) Assess vital signs and await further medical orders C) Direct the licensed practical/vocational nurse (LPN/VN) to notify the health care provider. D) Apply an occlusive dressing over the puncture site E) Tape the dressing on three sides

D) Apply an occlusive dressing over the puncture site E) Tape the dressing on three sides C) Direct the licensed practical/vocational nurse (LPN/VN) to notify the health care provider. A) Assess the client's respiratory status. B) Assess vital signs and await further medical orders A chest tube is a flexible, hollow tube placed through the chest wall and in to the pleural space. The chest tube is able to relieve trapped air and fluid. If a chest tube is dislodged and comes out, the nurse would immediately apply an occlusive dressing such as Vaseline gauze (many times kept in the client's room). The dressing is taped on three sides. The first action always focuses on the client. The nurse would direct another licensed nurse to immediately notify the health care provider. The nurse would then assess the respiratory status. The nurse would obtain vital signs and await further orders.

Which outcome criterion would be most appropriate for a client with a nursing diagnosis of Ineffective airway clearance? A) Respiratory rate of 28 breaths/minute B) Continued use of oxygen when necessary C) Presence of congestion on X-ray D) Breath sounds clear on auscultation

D) Breath sounds clear on auscultation The expected outcome for a client with Ineffective airway clearance is for the lungs to be clear of secretions (or congestion) on auscultation. Congestion on X-ray, continued use of and need for oxygen, and a respiratory rate of 28 breaths/minute indicate that the client is still experiencing airway problems.

Prior to the client having a pleural effusion drained, and after verifying client identification, the nurse should take the actions in what priority from first to last? All options must be used. A) Gather drainage kit supplies. B) Assess the client's respiratory rate, status, breath sounds, and discomfort level. C) Perform hand hygiene. D) Check the primary health care provider's prescription.

D) Check the primary health care provider's prescription. A) Gather drainage kit supplies. C) Perform hand hygiene. B) Assess the client's respiratory rate, status, breath sounds, and discomfort level. The pleural catheter and drainage system are indicated for intermittent, long-term drainage of symptomatic, recurrent pleural effusions that do not respond to medical management of the underlying disease. The nurse should first check the health care provider's prescription for draining the pleural catheter and next gather drainage kit supplies. After performing hand hygiene, explaining the procedure to the client, and assessing the client's respiratory rate, status, breath sounds, and pain level, the nurse can then put on sterile gloves from the procedure pack.

A client with a terminal diagnosis is anxious and concerned about the fact that breathing is taking so much energy and eating is very difficult. Most of the client's time is spent in bed, and the family is very concerned about recuperation. What is the best action by the nurse? A) Provide support for the family and encourage the client to become more actively involved in the care. B) Reinforce the meaning of supportive care to the family and restrict their visits so the client has more rest time. C) Determine where the client is regarding the stages of dying and discuss the findings with the family. D) Explore other ways to control symptoms and address the family's concerns more effectively.

D) Explore other ways to control symptoms and address the family's concerns more effectively. Trying other nursing measures may more effectively relieve the client's distress. These need to be explored. It is important to examine other ways to alleviate the other symptoms by ensuring rest periods just prior to eating and better pain management. In addition, it is the nurse's role to advocate and to support the client while explaining what is happening to the family. The client would need to request restriction of visits, and the client is the person who needs the support, then the family. Right now is not the right time to discuss stages of dying; addressing breathing problems is the priority.

A client asks to be discharged from the health care facility against medical advice (AMA). What should the nurse do first? A)Have the client sign an AMA form. B) Call a security guard to help detain the client. C) Prevent the client from leaving. D) Notify the physician.

D) Notify the physician. If a client requests a discharge AMA, the nurse should notify the physician immediately. If the physician can't convince the client to stay, the physician will ask the client to sign an AMA form, which releases the facility from legal responsibility for any medical problems the client may experience after discharge. If the physician isn't available, the nurse should discuss the AMA form with the client and obtain the client's signature. A client who refuses to sign the form shouldn't be detained because this would violate the client's rights. After the client leaves, the nurse should document the incident thoroughly and notify the physician that the client has left.

A nursing instructor is instructing group of new nursing students. The instructor reviews that surgical asepsis will be used for which of the following procedures? A) Colostomy irrigation B) Nasogastric tube irrigation C) Instilling eye drops D) I.V. catheter insertion

D) I.V. catheter insertion Caregivers must use surgical asepsis when performing wound care or any procedure that involves entering a sterile body cavity or breaking skin integrity. To achieve surgical asepsis, objects must be sterilized or kept free of all pathogens. Because inserting an I.V. catheter disrupts skin integrity and involves entry into a sterile cavity (a vein), surgical asepsis is required. Medical asepsis is used when instilling eye drops. The GI tract isn't sterile; therefore, irrigating a nasogastric tube or a colostomy requires only clean technique.

In which way does a nurse play a key role in error prevention? A) Informing the client of the Patient's Bill of Rights B) Notifying the Occupational Safety and Health Administration (OSHA) of workplace violations C) Never questioning a physician's order because the physician is ultimately responsible for the client outcome D) Identifying incorrect dosages or potential interactions of ordered medications

D) Identifying incorrect dosages or potential interactions of ordered medications The nurse must be knowledgeable about drug dosages and possible interactions when administering medications; she must follow appropriate policies to correct dosage errors or prevent potential interactions. The nurse is responsible for questioning unclear or ambiguous physician's orders and should never carry out an order with which she's uncomfortable. OSHA establishes comprehensive safety and health standards, inspects workplaces, and requires employers to eliminate safety hazards but notifying OSHA of medication errors doesn't resolve the problem. The client should be aware of his rights as a client, but that awareness doesn't play a key role in error prevention.

The nurse finds an unlicensed assistive personnel (UAP) massaging the reddened bony prominences of a client on bed rest. The nurse should: A) Explain that massage is effective because it improves blood flow to the area. B) Inform the UAP that massage is even more effective when combined with lotion during the massage. C) Reinforce the UAP's use of this intervention over the bony prominences. D) Instruct the UAP that massage is contraindicated because it decreases blood flow to the are

D) Instruct the UAP that massage is contraindicated because it decreases blood flow to the are Massaging areas that are reddened due to pressure is contraindicated because it further reduces blood flow to the area. The UAP should not massage the bony prominences or use lotion on the area. Massage does improve circulation and blood flow to muscle areas; however, because the area is reddened, the client is at risk for further skin breakdown.

A nurse is caring for an elderly client with a pressure ulcer on the sacrum. When teaching the client about dietary intake, which foods should the nurse emphasize? A) Legumes and cheese B) Whole grain products C) Fruits and vegetables D) Lean meats and low-fat milk

D) Lean meats and low-fat milk Although the client should eat a balanced diet, including foods from all food groups, the diet should emphasize foods that supply complete protein, such as lean meats and low-fat milk. Protein helps build and repair body tissue, which promotes healing. Legumes provide incomplete protein. Cheese contains complete protein, but it also includes fat, which should be limited to 30% or less of caloric intake. Whole grain products supply incomplete proteins and carbohydrates. Fruits and vegetables provide mainly carbohydrates.

The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. When coaching the client about the diet, the nurse should first: A) determine the client's knowledge level about cholesterol. B) ask the client to name foods that are high in fat, cholesterol, and salt. C) explain the importance of complying with the diet. D) assess the client's and family's typical food preferences.

D) assess the client's and family's typical food preferences. Before beginning dietary instructions and interventions, the nurse must first assess the client's and family's food preferences, such as pattern of food intake, lifestyle, food preferences, and ethnic, cultural, and financial influences. Once this information is obtained, the nurse can begin teaching based on the client's current knowledge level and then building on this knowledge base.

A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan? A) Assessing the client's temperature every 8 hours B) Wearing gloves during all client contact C) Monitoring the client's fluid intake and output D) Placing the client in respiratory isolation

D) Placing the client in respiratory isolation Because the client's signs and symptoms suggest a respiratory infection (possibly tuberculosis), respiratory isolation is indicated. Every 8 hours isn't frequent enough to assess the temperature of a client with a fever. Monitoring fluid intake and output may be required, but the client should first be placed in isolation. The nurse should wear gloves only for contact with mucous membranes, broken skin, blood, and other body fluids and substances.

A nurse-manager works for a nonprofit health care corporation whose revenues have significantly exceeded annual expenses. The nurse-manager has been told to anticipate which action? A) Identifying revenue as profit B) Reducing operating expenses to help the organization pay taxes on the revenue C) Dividing revenue among stockholders as dividends D) Receiving a portion of the revenue to improve client services on the unit

D) Receiving a portion of the revenue to improve client services on the unit In a nonprofit organization, revenue exceeding expenses is tax-exempt and is usually reinvested in the organization and used to improve services. A for-profit organization calls revenue in excess of expenses a profit and divides it as a dividend among stockholders or reinvests it in the organization.

A nurse manager observes bruises in the shape of finger marks around the elbows of an elderly, immobile client. The nurse should next: A) Report this finding to the nurse who is taking care of the client. B) Report this finding to the physician. C) Document the bruising and continue to assess the area over the next 72 hours. D) Report this finding to the Adult Protective Services (APS).

D) Report this finding to the Adult Protective Services (APS). Elderly clients are vulnerable to abuse. Bruising that is not located in areas typical for falls or bumps should be reported to the APS. The location and shape of this bruise are suggestive of abuse. The nurse taking care of this client and the physician should be alerted to the bruises after the APS is notified. The nurse should continue to assess the areas involved after notifying the APS.

A community health nurse is working disaster relief immediately after a flood. Which of the following would be priority interventions following this crisis? A) Providing vaccinations for childhood diseases. B) Finding safe housing for the survivors. C) Screening for waterborne diseases. D) Securing physical care. E) Organizing counseling for the survivors. B) Finding safe housing for the survivors. C) Screening for waterborne diseases.

D) Securing physical care. The nurse would prioritize care according to Maslow's hierarchy of needs the nurse. Physical needs, safe housing, and prevention of disease would be the priority. Counseling would come after the physical needs were met. Vaccinations for childhood diseases would not be appropriate. The clients would need vaccinated for tetanus if not up to date.

A nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin: A) enhances oxygen transport to tissues. B) reduces edema. C) restores the inflammatory response. D) enhances protein synthesis.

D) enhances protein synthesis. The client should be encouraged to consume foods high in vitamin C because vitamin C is essential for protein synthesis, an important part of wound healing. Hemostasis is responsible for the inflammatory response and reducing edema. Hemoglobin is responsible for oxygen transport.

Which of the following is the most important consideration when performing tracheotomy suctioning? A) Oxygen should be provided after each suctioning episode if desaturation occurs. B) Fluid intake should be limited to reduce the amount of secretions produced. C) Suctioning should be done routinely and frequently to prevent accumulation of secretions. D) The client should be hyperoxygenated, then suctioned for the duration of 10 to 15 seconds.

D) The client should be hyperoxygenated, then suctioned for the duration of 10 to 15 seconds. The most important aspect is to ensure the client is hyperoxygenated to increase oxygen saturation levels. Then suctioning should be limited to 10-15 seconds. This helps to prevent desaturation so that breathing is not compromised. It is not enough to apply oxygen if desaturation occurs. Suctioning should be done when necessary, not as a routine. Fluid intake is increased to help liquefy the secretions.

A client is scheduled for an appendectomy. What is the nurse's highest priority when planning preoperative teaching for this client? A) The client's skin should be assessed hourly. B) The client should be encouraged to take food and fluids to prevent dehydration and malnutrition. C) Surgical wound infection is most likely to occur during the first postoperative day. D) The client should begin coughing and deep-breathing exercises as soon as he's able to follow instructions.

D) The client should begin coughing and deep-breathing exercises as soon as he's able to follow instructions. The nurse should encourage the client to cough and breathe deeply as soon as possible after surgery to help prevent atelectasis and pneumonia. She shouldn't encourage the client to take food or fluids until bowel sounds are present (usually 24 hours postoperatively). Wound infection is a concern, but usually not during the first postoperative day. The nurse should assess the client's skin every 2 hours when he is made to either change position or get out of bed.

The nurse evaluates the effectiveness of the client's postoperative plan of care. Which outcome is expected for a client with an ileal conduit? A) The client verbalizes the understanding that physical activity must be curtailed. B) The client demonstrates how to catheterize the stoma. C) The client will place an aspirin in the drainage pouch to help control odor. D) The client will empty the drainage pouch frequently throughout the day.

D) The client will empty the drainage pouch frequently throughout the day. It is important that the client empty the drainage pouch throughout the day to decrease the risk of leakage. The client does not normally need to curtail physical activity. Aspirin should never be placed in a pouch because aspirin can irritate or ulcerate the stoma. The client does not catheterize an ileal conduit stoma.

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status? A) Checking the client's lungs for crackles during every shift B) Measuring and recording fluid intake and output C) Assessing the client's vital signs every 4 hours D) Weighing the client daily at the same time each day

D) Weighing the client daily at the same time each day Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs.

A client is being discharged with nasal packing in place. The nurse should instruct the client to: A) use normal saline nose drops daily. B) sneeze and cough with mouth closed. C) gargle every 4 hours with salt water. D) perform frequent mouth care.

D) perform frequent mouth care. Frequent mouth care is important to provide comfort and encourage eating. Mouth care promotes moist mucous membranes. Nose drops cannot be used with nasal packing in place. When sneezing and coughing, the client should do so with the mouth open to decrease the chance of dislodging the packing. Gargling should not be attempted with packing in place.

The nurse notices that a nurse colleague is wearing a lower lip ring. The nurse should: A) page the nurse supervisor to speak with the nurse. B) report the nurse to the unit manager. C) direct the nurse to go to the Office of Infection Control. D) request that the nurse remove the ring.

D) request that the nurse remove the ring. Professionalism in nursing is demonstrated by a nurse's appearance and ownership of actions; appearance is one means of contributing to a positive experience in a health care setting. The nurse should discuss the situation with the colleague first. To go to the manager's office or to direct the colleague to go to the Office of Infection Control will not promptly correct the professional dress code violation. Paging the nursing supervisor does not follow the line of command for reporting problems. Nurses must support professionalism; dress is an aspect of professionalism.

A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should: A) massage the abdomen once a shift. B) elevate the lower extremities. C) institute range-of-motion (ROM) exercise every 4 hours. D) use an alternating air pressure mattress.

D) use an alternating air pressure mattress. Edematous tissue is easily traumatized and must receive meticulous care. An alternating air pressure mattress will help decrease pressure on the edematous tissue. ROM exercises are important to maintain joint function, but they do not necessarily prevent skin breakdown. When abdominal skin is stretched taut due to ascites, it must be cleaned very carefully. The abdomen should not be massaged. Elevation of the lower extremities promotes venous return and decreases swelling.

Which situation violates the a client's privacy? A) A nurse gives a client's family members details of his condition from his medical records B) A nurse gives a client his chart and stays with him while he reads the new orders. C) When planning a client's discharge care, medical students discuss his home situation. D) A nurse allows a nursing student to review a client's chart the day before the student will be working on the unit.

A) A nurse gives a client's family members details of his condition from his medical records A nurse may not give information about a client to anyone without that client's consent. Nursing students and medical students may review client charts for the purpose of instruction and learning. The client has the right to see his chart. By remaining with the client while he reviews his chart, the nurse can explain notations that are confusing or unclear.

A nurse revises the care plan for a client who has difficulty dealing with a crying neonate. Which strategy should the new care plan implement early in this mother's hospital stay? A) Assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems B) Referring the client for anger-management therapy upon discharge C) When the infant is crying, always offer the bottle or breast first D) Proper methods for dealing with stressful situations, such as crying infants

A) Assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems Assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems is an important aspect in the implementation process. Assessment will also help the nurse identify situations that the mother perceives as stressors. Educating the client about alternative ways of expressing feelings and about crisis hotlines and community support systems should also be part of the care plan. The nurse hasn't established that the mother is angry, so anger-management therapy may not be necessary. The infant may not be crying due to hunger; assessing the mother's coping will help provide the basis for teaching the essential skills.

The client is to receive antibiotic intravenous (IV) therapy in the home. The nurse should develop a teaching plan to ensure that the client and family can manage the IV fluid and infusion correctly and avoid complications. What should the nurse instruct the client to do? Select all that apply. A) Call the health care provider (HCP) for a temperature above 100° F (37.8° C). B) Report signs of redness or inflammation at the site. C) Wear sterile gloves to change the fluids. Place the IV bag on a table level with the client's arm. D) Cleanse the port with alcohol wipes. E) Place the IV bag on a table level with the client's arm.

A) Call the health care provider (HCP) for a temperature above 100° F (37.8° C). B) Report signs of redness or inflammation at the site. D) Cleanse the port with alcohol wipes. When intravenous (IV) therapy must be administered in the home setting, teaching is essential. Written instructions, as well as demonstration and return demonstration help reinforce key points. The client and/or caregiver is responsible for adhering to the established plan of care that includes the treatment plan, monitoring plan, potential for complications, expected outcome/s, potential adverse effects, and plan for communicating with the HCP. Periodic laboratory testing may be necessary to assess the effects of IV therapy and the client's progress. The client should report signs of redness or inflammation that could indicate infection, and also report an elevated temperature. Prior to changing the fluids, the caregiver should cleanse the port with alcohol wipes. It is not necessary to use sterile gloves; the IV bag should be elevated to promote gravity flow.

A client with a nasogastric (NG) tube who is 2 days postoperative bowel resection is reporting increased abdominal pain and nausea. Which assessments or actions by the nurse would be most appropriate? A) Check the patency and amount of drainage from the NG tube. B) Explain that nausea is common because the NG tube irritates the gag reflex. C) Irrigate the NG tube with water and give an analgesic as ordered. D) Administer an analgesic and antiemetic as ordered.

A) Check the patency and amount of drainage from the NG tube. The client is experiencing abdominal pain and nausea. This subjective assessment data indicate that the NG tube may not be functioning, so assessment of its patency and the amount of drainage would be the first step. Then appropriate action can be taken if the tube is not patent. Giving an analgesic and antiemetic would alleviate the symptoms of pain and nausea, but would not correct the problem if the NG tube is not draining properly. Irrigations are done after assessment of patency. The gag reflex is triggered during insertion, but once in position does not cause nausea.

Which action associated with restraint use on a confused client can be delegated to an unlicensed healthcare worker/nursing assistant? A) Completion of range of motion on limbs restrained B) Evaluation of client response to restraint type C) Release of restraints as client symptoms improve D) Assessment of client restraint location in relation to mental status

A) Completion of range of motion on limbs restrained Any client assessment and subsequent decision making/judgment is in the scope of practice of the nurse. The unlicensed healthcare worker (UHW)/nursing assistant (NA) is able to complete the task of range of motion.

While hospitalized, a child develops a Clostridium difficile infection. The nurse can anticipate adding which of the following types of precautions for this client? A) Contact precautions B) Airborne precautions C) Droplet precautions D) Standard precautions

A) Contact precautions Contact precautions are used for serious illnesses that are easily transmitted by direct client contact or by contact with items in the client's environment. Clostridium difficile infection is an example of an infection that is spread in this manner. Droplet precautions are used for serious illnesses transmitted by large particle droplets. Standard precautions are used for all clients. Airborne precautions are used for suspected illnesses transmitted by airborne nuclei.

The family members of a client who is near death from colon cancer ask the nurse what to expect if the client becomes dehydrated. What should the nurse should tell them? A) Dehydration is expected during the dying process. B) The health care provider (HCP) will make the decision regarding hydration therapy. C) Dehydration may prolong the dying process. D) Hydration is used only in extreme situations of dehydration.

A) Dehydration is expected during the dying process. Dehydration is an expected event within the dying process. Hydration may be used in any situation of dehydration as long as it is within the client and family's wishes. Rehydrating the client may actually prolong the dying process. Decisions about treatment are made with the family.

What would be an appropriate action for the nurse prior to performing deep tracheal suctioning due to increased secretions? A) Hyperoxygenate the client before suctioning. B) Instill acetylcysteine into the tracheotomy before suctioning. C) Apply negative pressure as the catheter is being inserted. D) Deflate the cuff of the tracheotomy during suctioning.

A) Hyperoxygenate the client before suctioning. Preoxygenation and deep breathing assist in reducing suction-induced hypoxemia because it decreases the risk of atelectasis caused by negative pressure of suctioning. Deflating the cuff is not necessary and there is no reason to instill acetylcysteine into the tracheotomy before suctioning. Pressure is applied only with the removal of the catheter.

A nurse cares for a terminally ill client. Family members have requested that at the time of the client's death, the client's arms not be crossed and that any clothing or bandages with the client's blood be prepared for burial with the person. The nurse recognizes that this family follows the rituals of which religion? A) Judaism B) Buddhism C) Hinduism D) Islam

A) Judaism In Judaism, the Psalms and the last prayer of confession are said at the dying person's bedside. At death, the person's arms are not crossed; any clothing or bandages with the client's blood would be prepared for burial with the person. It is important that the whole person be buried together. Hinduism, Buddhism, and Islam do not follow these rituals.

When the nurse performs oral hygiene for an unconscious client, which nursing intervention is the priority? A) Keep a suction machine available. B) Place the client in a prone position. C) Wear sterile gloves while brushing the client's teeth. D) Use gauze wrapped around the fingers to clean the client's gums.

A) Keep a suction machine available. Maintaining a patent airway is the priority. Therefore, the nurse should keep suction equipment available to remove secretions. The client should be placed in a side-lying, not prone, position. Performing oral hygiene is a clean procedure; therefore, the nurse wears clean gloves, not sterile gloves. The nurse should never place any fingers in an unconscious client's mouth; the client may bite down. Padded tongue blades, swabs, or a toothbrush should be used instead; but maintaining the airway is the priority.

An adult client who is alert and oriented requires surgery. The client cannot read. Which of the following nursing interventions is the best? A) Read the consent form to the client and have the client verbalize understanding B) Ensure that the healthcare provider signs the consent form for the client C) Have a family member that can read sign the consent form D) Tell the client in the nurse's own words what the surgical procedure involves

A) Read the consent form to the client and have the client verbalize understanding The client is alert and able to make an informed consent. The consent should be read to the client and two nurses should witness verbal understanding. It is not appropriate for a healthcare provider or a family member to sign consent for an alert and oriented client.

A nurse, assigned to a client with emphysema, is providing shift report. Which nursing interventions would be appropriate to include? Select all that apply. A) Teach the use of postural drainage and chest physiotherapy. B) Encourage alternating client activity with rest periods. C) Teach diaphragmatic, pursed-lip breathing. D) Administer low-flow oxygen as needed. E) Maintain the client in a supine position as much as possible. F) Reduce fluid intake to less than 850 ml per shift.

A) Teach the use of postural drainage and chest physiotherapy. B) Encourage alternating client activity with rest periods. C) Teach diaphragmatic, pursed-lip breathing. D) Administer low-flow oxygen as needed. Diaphragmatic, pursed-lip breathing strengthens respiratory muscles and enhances oxygenation in clients with emphysema. Low-flow oxygen should be administered because a client with emphysema has chronic hypercapnia and a hypoxic respiratory drive. Alternating activity with rest allows clients to perform activities without distress. If the client has difficulty mobilizing copious secretions, the nurse would teach the client and family members how to perform postural drainage and chest physiotherapy. Fluid intake would be increased to 3,000 ml/day, if not contraindicated, to liquefy secretions and facilitate their removal. The client would be placed in high Fowler's position to improve ventilation.

A nurse observes an LPN measuring a client's urine output from an indwelling catheter drainage bag. Which observation by the nurse ensures that the client's urine has been measured accurately? A) The LPN pours the urine into a graduated measuring container. B) The LPN pours the urine into a paper cup that holds approximately 250 mL. C) The LPN holds the Foley drainage bag up to eye level. D) The LPN uses the measuring markings on the Foley drainage bag.

A) The LPN pours the urine into a graduated measuring container. The only means to measure urine output accurately is to use a container that has specific markings for measuring liquid. The other options would not provide an accurate measure of urine output.

A nurse gives a client the wrong medication. After assessing the client, the nurse completes an incident report. Which statement describes what will happen next? A) The incident report will provide a basis for promoting quality care and risk management. B) The nurse will be suspended and, possibly, terminated from employment at the facility. C) The facility will report the incident to the state board of nursing for disciplinary action. D) The incident will be documented in the nurse's personnel file.

A) The incident report will provide a basis for promoting quality care and risk management. Incident reports document unusual occurrences and deviations from care. Facilities use the internal documents to evaluate care, determine potential risks, or discover system problems that might have contributed to the error. This type of error won't result in a report to the state board of nursing or in the nurse's suspension. Some facilities do track the number of errors a nurse or a particular unit makes; the purpose of tracking errors is to provide appropriate education and to improve the nursing process.

A nurse prepares to transfer a client from a bed to a chair. Which principle demonstrates safe body mechanics? A) The nurse uses a rocking motion while helping the client to stand. B) The nurse stands an arm's length away from the client. C) The nurse keeps her feet as close together as possible. D) The nurse keeps her knees straight and stiff and bends at the waist.

A) The nurse uses a rocking motion while helping the client to stand. Rocking provides extra force when pushing or pulling. The nurse should keep any weight as close to her body as possible when lifting — not at arm's length. The nurse should keep her knees slightly bent and her feet spread apart to provide a wide base of support. Keeping the knees straight and stiff and bending at the waist and keeping the feet close together aren't examples of safe body mechanics. These positions could result in injury to the nurse or to the client.

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

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

A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for pneumothorax resolution, the nurse can anticipate that the client will require: A) a chest X-ray. B) monitoring of arterial oxygen saturation (SaO2). C) chest auscultation. D) arterial blood gas (ABG) studies.

A) a chest X-ray. Chest X-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia, possibly with respiratory acidosis and hypercapnia but these are not necessarily related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest has reexpanded sufficiently.

A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. The best action for the nurse to take is to: A) clean the area with normal saline solution and cover it with a protective dressing. B) remove the raised skin because the blister has already broken. C) apply a weakened alcohol solution to clean the area. D) wash the area with soap and water to disinfect it.

A) clean the area with normal saline solution and cover it with a protective dressing. The nurse should clean the area with a mild solution such as normal saline, and then cover it with a protective dressing. Soap and water and alcohol are too harsh. The body's first line of defense broke when the blisters opened; removing the skin exposes a larger area to the risk of infection.

Which nursing intervention is most important in preventing postoperative complications? A) early ambulation B) bowel and elimination monitoring C) pain management D) progressive diet planning

A) early ambulation Early ambulation is the most significant general nursing measure to prevent postoperative complications and has been advocated for more than 40 years. Walking the client increases vital capacity and maintains normal respiratory functioning, stimulates circulation, prevents venous stasis, improves gastrointestinal and genitourinary function, increases muscle tone, and increases wound healing. The client should maintain a healthy diet, manage pain, and have regular bowel movements. However, early ambulation is the most important intervention.

A client with cervical cancer is undergoing internal radium implant therapy. A lead-lined container and a pair of long forceps are kept in the client's hospital room for: A) handling of the dislodged radiation source. B) disposal of the client's eating utensils. C) storage of the radiation dose. D) disposal of emesis or other bodily secretions.

A) handling of the dislodged radiation source. Dislodged radioactive materials should not be touched with bare or gloved hands. Forceps are used to place the material in the lead-lined container, which shields the radiation. Exposure to radiation can occur only by direct exposure to the encased radioactive substance; it cannot result from contact with emesis or urine or from touching the client. Disposal of eating utensils cannot lead to radiation exposure. Radioactive dose materials are kept only in the radiation department.

When preparing to administer a tap water enema, in which position should the nurse place the client? A) left Sims' B) right lateral C) supine D) semi-Fowler's

A) left Sims' When administering an enema, the nurse should position the client in a left Sims position. Placing the client in this position facilitates the flow of fluid into the rectum and colon. It also allows the client to flex the right leg forward, adequately exposing the rectal area.

Which precautions should the health care team observe when caring for clients with hepatitis A? A) wearing gloves when giving direct care B) wearing a mask when providing care C) gowning when entering a client's room D) assigning the client to a private room

A) wearing gloves when giving direct care Contact precautions are recommended for clients with hepatitis A. This includes wearing gloves for direct care. A gown is not required unless substantial contact with the client is anticipated. It is not necessary to wear a mask. The client does not need a private room unless incontinent of stool.

Which intervention can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) working on a medical-surgical unit? A) Administer morphine 4 mg IV bolus B) Administer zolpidem 5 mg as needed for sleep C) Teach a client with newly diagnosed diabetes how to perform blood glucose testing D) Transfuse 1 unit packed red blood cells (RBCs)

B) Administer zolpidem 5 mg as needed for sleep The nurse practice act regulates nursing licensure and practice. When delegating activities, the nurse should assess the experience of LPN/LVNs and be familiar with both the nurse practice acts and hospital policies. LPN/LVN can administer oral medications, but cannot administer IV medications, transfuse blood, or perform client teaching. In addition, registered nurses should provide most of the care for unstable clients so client acuity needs to be a consideration.

A nurse is giving nutritional counseling to the mother of a child with celiac disease. Which statement by the mother indicates understanding? A) "My son can safely eat frozen and packaged foods." B) "My son can't eat wheat, rye, oats, or barley." C) "My son needs a gluten-rich diet." D) "My son must avoid potatoes, rice, and cornstarch."

B) "My son can't eat wheat, rye, oats, or barley." A child with celiac disease must follow a gluten-free diet. If the child eats foods containing gluten, changes in the intestinal mucosa will prevent the absorption of fats and other foods. Therefore, all foods containing wheat, rye, oats, and barley must be eliminated from the diet. Such foods as potatoes, rice, and cornstarch may be included in a gluten-free diet. Frozen and packaged foods, which may contain gluten fillers, should be avoided.

A physician orders a bland, full-liquid diet for a client. Which response, if made by the client, would indicate to the nurse that the client has understood the nurse's dietary teaching? A) "I will have orange juice, farina, and coffee." B) "Today I can have apple juice, chicken broth, and vanilla ice cream." C) "I can have oatmeal, custard, and tea." D) "For breakfast I will choose pineapple juice, a bran muffin, and milk."

B) "Today I can have apple juice, chicken broth, and vanilla ice cream." A bland, full-liquid diet may include some fruit juices and foods from all of the food groups. On this diet, the client should avoid gastric irritants, such as orange juice, coffee, tea, colas, cocoa, breads, bran (fiber), and highly seasoned foods.

The client has sore nares while a nasogastric (NG) tube is in place. Which nursing measure would be most appropriate to help alleviate the client's discomfort? A) Irrigate the tube with a cool solution. B) Apply a water-soluble lubricant to the nares. C) Have the client change position more frequently. D) Reposition the tube in the nares.

B) Apply a water-soluble lubricant to the nares. Applying a water-soluble lubricant to the nares helps alleviate sore nares when an NG tube is in place. Repositioning the tube does not eliminate the possibility of irritating the nares. Irrigating the tube with a cool solution or changing positions will not relieve the local irritation from the NG tube.

A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client? A) By placing the call button under the client's pillow B) By supplying a magic slate or similar device C) By suctioning the client frequently D) By providing a tracheostomy plug to use for verbal communication

B) By supplying a magic slate or similar device The nurse should use a nonverbal communication method, such as a magic slate, note pad and pencil, and picture boards (if the client can't write or speak English). The physician orders a tracheostomy plug when a client is being weaned off a tracheostomy; it doesn't enable the client to communicate. The call button, which should be within reach at all times for all clients, can summon attention but doesn't communicate additional information. Suctioning clears the airway but doesn't enable the client to communicate.

The children of an elderly male client who has suffered an ischemic stroke have informed the nurse that an herbalist will be coming to their father's bedside tomorrow to make recommendations for his care. Which of the following considerations should the nurse prioritize in light of the practitioner's planned visit? A) Taking measures to prevent cultural conflict when the practitioner comers to the hospital. B) Ensuring any complementary therapies are safe when combined with his prescribed therapy. C) Ensuring that the care team does not impose their beliefs on the family or the complementary practitioner. D) Identifying whether the family would prefer to pursue alternative or conventional treatment for their father.

B) Ensuring any complementary therapies are safe when combined with his prescribed therapy. While it is important for the nurse and the other members of the care team to ensure that stereotypes or cultural imposition do not exist, the priority in all aspects of care is safety. Consequently, potential interactions between the complementary therapies and conventional hospital treatments are a priority. The family should not be required to forgo conventional treatment to pursue some aspects of culturally based, complementary care.

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

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

When providing oral hygiene for an unconscious client, the nurse must perform which action? A) Place the client in semi-Fowler's position. B) Place the client in a side-lying position. C) Clean the client's tongue with gloved fingers. D) Swab the client's lips, teeth, and gums with lemon glycerin.

B) Place the client in a side-lying position. An unconscious client is at risk for aspiration. To decrease this risk, the nurse should place the client in a side-lying position when performing oral hygiene. Swabbing the client's lips, teeth, and gums with lemon glycerin would promote tooth decay. Cleaning an unconscious client's tongue with gloved fingers wouldn't be effective in removing oral secretions or debris. Placing the client in semi-Fowler's position would increase the risk of aspiration.

Which of the following must the nurse consider when positioning a client for tracheal suctioning? A) Maintain the head in a hyperextended position. B) Position in a semi-Fowler's position. C) Ensure that the client's neck is flexed. D) Position in low-Fowler's position.

B) Position in a semi-Fowler's position. The semi-Fowler's position is the correct position for suctioning a client. The other answers are incorrect based on incorrect positioning of client for suctioning. The neck should be in neutral position.

Which is the correct technique when the nurse is applying an elastic bandage to a leg? A) Increase tension with each successive turn of the bandage. B) Start at the distal end of the extremity and move toward the trunk. C) Secure the bandage with clips over the area of the inner thigh. D) Overlap each layer twice when wrapping.

B) Start at the distal end of the extremity and move toward the trunk. When applying an elastic bandage to a leg, start at the distal end and move toward the trunk in order to support venous return. Tension should be kept even and not increased with each turn to prevent circulatory impairment. Overlapping each layer twice when wrapping can also impair circulation. The clips securing the bandage should be placed on the outer aspect of the leg to avoid creating a pressure point on the other leg.

A client with metastatic bone cancer has signed a Do Not Resuscitate (DNR) order specifying comfort care only. Which would be included in the client's plan of care? Select all that apply. A) Intubating the client to facilitate mechanical ventilation B) Suctioning thick secretions to relieve dyspnea C) Administering antibiotic therapy to treat a respiratory infection D) Administering oral pain medication every hour E) Placing a feeding tube to ensure adequate caloric intake

B) Suctioning thick secretions to relieve dyspnea D) Administering oral pain medication every hour Because the client has signed a DNR order, only comfort measures should be taken. Insertion of a feeding tube would be inappropriate because it would sustain life. Oral pain medications would be necessary to promote comfort by relieving pain. In most cases, antibiotic therapy and intubation would not be performed if the sole goal of treatment is to maintain comfort and not to cure disease.

A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps? A) Because none of the clients suffered any serious damage, the nurse-manager can safely ignore their complaints. B) Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed. C) Review and revise the way client education is conducted in the surgeons' office. D) Inform the nurses who work in the facility that client education should be implemented as soon as the client is admitted to either the hospital or the outpatient surgical center.

B) Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed. Every nurse who provides client care should provide client education. Nurses must work together to establish the best methods of educating clients. The most appropriate response is to contact the facility's nurse-manager, not the nursing staff. Evaluating client education in only the surgeon's office doesn't consider the entire client education process and all of the staff providing it. Client education is an important nursing responsibility and every complaint deserves attention.

A client has an open cholecystectomy with bile duct exploration. Following surgery, the client has a t-tube. To evaluate the effectiveness of the t-tube, the nurse should: A) monitor the multiple incision sites for bile drainage. B) assess the color and amount of drainage every shift. C) irrigate the tube with 20 mL of normal saline every 4 hours. D) unclamp the t-tube and empty the contents every day.

B) assess the color and amount of drainage every shift. A t-tube is inserted in the common bile duct to maintain patency when there is a likelihood of edema. The tube remains in place until edema from the duct exploration subsides. The bile color should be gold to dark green, and the amount of drainage should be closely monitored to ensure tube patency. Irrigation is not routinely done, unless prescribed using a smaller volume of fluid. The t-tube is not clamped in the early postop period to allow for continuous drainage. An open cholecystectomy has one right subcostal incision, whereas a laparoscopic cholecystectomy has multiple small incisions.

When planning pain control for a client with terminal gastric cancer, a nurse should consider that: A) a client who can fall asleep isn't in pain. B) clients with terminal cancer may develop tolerance to opioids. C) only low doses of opioids are safe; higher doses may cause respiratory depression. D) pain medication should be given only when a client requests it.

B) clients with terminal cancer may develop tolerance to opioids. Clients with cancer may develop a tolerance to opioids, causing them to need higher doses to provide adequate pain relief. Although a nurse should always remain alert for adverse effects of opioids, clients may develop a tolerance for these effects. Therefore, it isn't likely that higher doses would cause respiratory depression. Administering pain medication around the clock maintains steady blood levels of opioids. Sleeping doesn't necessarily indicate pain relief, especially in a client who has chronic pain.

A client is recovering from abdominal surgery and has a nasogastric (NG) tube inserted. The expected outcome of using the NG tube is gastrointestinal tract: A) compression. B) decompression. C) lavage. D) gavage.

B) decompression. After abdominal surgery, the reason for inserting a NG tube is to decompress the gastrointestinal tract until peristaltic action returns. Compression may be used to control bleeding esophageal varices. Lavage is used to remove substances from the stomach or control bleeding. Gavage is used to provide enteral feedings.

A client undergoing chemotherapy tells the nurse, "I do not want to get out of bed in the morning, because I am so tired." The nursing plan of care should include: A) education on the use of filgrastim. B) individually tailored exercise program. C) bed rest until chemotherapy is completed. D) weight lifting when not experiencing fatigue.

B) individually tailored exercise program. An individualized exercise program will increase stamina and endurance. Weight lifting may be too vigorous. Filgrastim is used to increase white blood cells and is not applicable in this situation. Decreased hemoglobin and hematocrit predisposes the client to fatigue due to decreased oxygen availability. Bed rest causes muscle atrophy, adding to fatigue, and can contribute to deep vein thrombosis (DVT).

Which indicates that performing passive range-of-motion (ROM) exercises on an unconscious client has been successful? A) prevention of bone demineralization B) maintenance of joint mobility C) preservation of muscle mass D) increase in muscle tone

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

The nurse should instruct a client with heart disease to avoid which foods that contribute to increases in serum cholesterol? A) monounsaturated fat B) saturated fat C) polyunsaturated fat D) phospholipids

B) saturated fat Saturated fats raise blood cholesterol. Polyunsaturated fats maintain blood cholesterol. Monounsaturated fats may help to maintain or lower blood cholesterol. Phospholipids do not have an effect on cholesterol but act as emulsifiers, keeping fats dispersed in water.

The nurse is caring for a client who had an open cholecystectomy 24 hours ago. The client's vital signs have been stable over the last 24 hours, with most recent temperature 98.6° F (37° C), blood pressure (BP) 118/76 mm Hg, respiratory rate (RR) 16/min, and heart rate (HR) 78 bpm, but are now changing. Which set of vital signs indicates that the nurse should contact the health care provider (HCP)? A) temperature 99.5° F (37.5° C), BP 126/80 mm Hg, HR 58 bpm, RR 16/min B) temperature 101.8° F (38.8° C), BP 140/86 mm Hg, HR 94 bpm, RR 24/min C) temperature 100.7° F (38.2° C), BP 118/68 mm Hg, HR 84 bpm, RR 20/min D) temperature 97.5° F (36.4° C), BP 98/64 mm Hg, HR 98 bpm, RR 18/min

B) temperature 101.8° F (38.8° C), BP 140/86 mm Hg, HR 94 bpm, RR 24/min This client is exhibiting three of four signs of systemic inflammatory response syndrome (SIRS): temperature greater than 100.4° F (38° C) (or less than 96.8° F [36°C]), heart rate greater than 90 bpm, respiratory rate greater than 20 breaths/min. The fourth indicator is an abnormal white blood cell count (greater than 12,000 [12 × 109/L], less than 4000 [4 × 109/L] or greater than 10% [0.1 × 109/L] bands). At least two of these variables are required to define SIRS.

The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse makes which observation? A) use of protective goggles during a cesarean birth B) wearing of sterile gloves to bathe a neonate at 2 hours of age C) disposal of used scalpel blades in a puncture-resistant container D) placement of bloody sheets in a container designated for contaminated linens

B) wearing of sterile gloves to bathe a neonate at 2 hours of age One of the staff members needs further instructions when the nurse observes the staff member wearing sterile gloves to bathe a neonate at 2 hours of age. Clean gloves should be worn, not sterile gloves. Sterile gloves are more expensive than clean gloves and are not necessary when bathing a neonate. Wearing protective goggles during a cesarean birth is a standard blood precaution. Bloody sheets should be placed in a designated container. Scalpel blades, needles, syringes, and other equipment used during birthing should be disposed of safely in appropriate, labeled containers.

The nurse provides teaching on postoperative wound care to a client being discharged from a surgical unit. Which of the following statements documented by the nurse indicates that the client understood the teaching? A) "Client told to come back to the hospital if wound is warm, red, and draining." B) "Client advised to call the surgeon if pain increases beyond a level of 4 out of 10." C) "Client verbalized to the nurse the steps to follow if wound becomes red and warm." D) "Client given written instructions regarding wound care and management."

C) "Client verbalized to the nurse the steps to follow if wound becomes red and warm." By having the client repeat the instructions back to the nurse, the nurse can better assess the client's understanding of the health teaching provided. Documenting the statement as written substantiates the nurse's claim not only to provide health information but also to verify that the client understands the instructions. The other options may be included as part of the health teaching, but they do not demonstrate the client's understanding of the instruction.

When assessing pain in a client from Mexico, the nurse should understand the implications of which statement from the client about the pain experience? A) "This pain is killing me." B) "I cannot go on in pain like this any longer." C) "Enduring pain is a part of God's will." D) "I have got to see a health care provider right away."

C) "Enduring pain is a part of God's will." Although individuals differ, the most likely attitude of a Mexican-American client is to bear pain stoically, to endure pain as a part of God's will, and to delay seeking treatment.

A client asks the nurse how frequently she should have a mammogram. The nurse assesses that there is no family history of breast cancer and no risk factors with this particular client. Which statement, if made by the client, shows an understanding of the nurse's teaching regarding the frequency of mammograms? A) "I should have a mammogram only if I find a lump after self-breast examination." B) "I should have a mammogram once a year at age 40, then annually." C) "I should have a mammogram every year beginning at age 40." D) "I should have a mammogram twice yearly until age 50, then only yearly."

C) "I should have a mammogram every year beginning at age 40." Yearly mammograms should begin at age 40 and continue for as long as the woman is in good health. If health risks exist, such as family history, genetic tendency, or past breast cancer, more frequent examinations may be necessary.

The nurse is teaching a client how to manage a nosebleed. What instruction should the nurse give the client? A) "Lie down flat, and place an ice compress over the bridge of the nose." B) "Blow your nose gently with your neck flexed." C) "Sit down, lean forward, and pinch the soft portion of your nose." D) "Tilt your head backward, and pinch your nose."

C) "Sit down, lean forward, and pinch the soft portion of your nose." The client should assume a sitting position and lean forward. Firm pressure should be applied to the soft portion of the nose for approximately 10 minutes. Tilting the head backward can cause the client to swallow blood, which can obscure the amount of bleeding and also can lead to nausea. Ice compresses may be applied, but the client should not lie flat. Blowing the nose is to be avoided because it can increase bleeding.

Which of the following questions should the nurse ask a 47-year-old client to assist in establishing a nursing diagnosis of deficient knowledge? A) "When was your last prostate examination?" B) "When was your last colonoscopy?" C) "When was your last mammogram?" D) "When was your last smallpox vaccination?"

C) "When was your last mammogram?" The American Cancer Society (Canadian Cancer Society) guidelines state that women age 40 and older should have an annual mammogram. Routine screening colonoscopies and prostate examinations are performed beginning at age 50. Smallpox revaccination is not recommended.

A nurse-manager of an intensive care unit (ICU) can't be held legally responsible in a court of law for which action performed by the unit's staff? A) A nursing assistant attempts to initiate I.V. therapy. B) A staff nurse fills a client prescription at the hospital pharmacy because the pharmacist on duty is busy. C) A staff nurse refuses to follow a physician's order to administer medication because administering the dosage ordered could seriously harm the client. D) A nursing assistant administers medications to a client in ICU.

C) A staff nurse refuses to follow a physician's order to administer medication because administering the dosage ordered could seriously harm the client. The nurse-manager is legally responsible for actions that fall within the scope of practice of the staff members who perform them. A nurse may not knowingly administer or perform tasks that will harm a client. It's within a nurse's scope of practice to refuse to carry out such orders. A nurse-manager can't be held legally responsible for the nurse's refusal in this situation. Administering medications and initiating I.V. therapy aren't within the scope of practice for nursing assistants, and a staff nurse isn't licensed to fill prescriptions.The nurse-manager can be held legally responsible for these actions.

A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad? A) Client's nutritional status B) Client's risk for falls C) Client's level of consciousness D) Client's vital signs and breath sounds

C) Client's level of consciousness A client who has impaired consciousness or altered mental status is at increased risk for injury from a heating pad. When administering a heat treatment, a nurse should always check the temperature of the heating unit and examine the client's skin for redness or irritation. Risk for falls, vital signs, and nutrition level are also important assessment areas, but they aren't the priority assessment for a client using a heating pad.

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These assessments indicate which nursing diagnosis? A) Impaired urinary elimination B) Excess fluid volume C) Deficient fluid volume D) Imbalanced nutrition: Less than body requirements

C) Deficient fluid volume Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to deficient fluid volume, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema.

The nurse is caring for a client who has been admitted from a situation involving domestic abuse. Which of the following is a correct component in the nursing plan of care? A) Counseling the person committing the abuse B) Counseling the victim C) Documenting the situation and providing support for the victim D) Protecting the client's safety by completing an incident or occurrence report

C) Documenting the situation and providing support for the victim The nurse must carefully and adequately document her assessment of the abused victim in the chart (not an incident or occurrence report). The documentation must include statements from the victim, physical and psychological assessment findings, and observations relative to the abuse situation. The nurse should give the victim information about community resources, social agencies, and legal services to prevent recurrence of physical abuse. A professional nurse is not qualified to counsel the abuser or the victim. She should refer the abuser and the victim to a professional counselor trained in dealing with domestic violence.

Which would be the most appropriate measure for preventing the development of a paralytic ileus in a client who has undergone renal surgery? A) Continue IV fluid therapy. B) Offer 3 to 4 oz (90 to 120 mL) of a carbonated beverage periodically. C) Encourage the client to ambulate every 2 to 4 hours. D) Encourage use of a stool softener.

C) Encourage the client to ambulate every 2 to 4 hours. Ambulation stimulates peristalsis. A client with paralytic ileus is kept on nothing-by-mouth status until peristalsis returns. Carbonated beverages will increase gas and distention but will not stimulate peristalsis. A stool softener will not stimulate peristalsis. IV fluid infusion is a routine postoperative prescription that does not have any effect on preventing paralytic ileus.

The nurse is caring for a client with a Jackson-Pratt drain. Which of the following would be the most appropriate action by the nurse? A) Attach the tube to straight drainage to monitor the output. B) Irrigate the drain with normal saline to ensure patency. C) Ensure that the drainage receptacles are kept compressed to maintain suction. D) Leave the drain open to the air to ensure maximum drainage.

C) Ensure that the drainage receptacles are kept compressed to maintain suction. Portable wound drainage systems are self-contained and can be emptied and compressed to reestablish negative pressure, which promotes drainage. The other choices are incorrect because a Jackson-Pratt drain needs negative pressure in the bulb to promote drainage.

A severe winter storm has prevented most staff members from getting to work on a busy medical-surgical unit. One registered nurse, two licensed practical nurses, and three nursing assistants have been able to get to work. A nurse-manager must decide which nursing care delivery system (model) (NCDS) should be implemented for the best possible client care during this staffing crisis. The nurse-manager directs the staff to implement which NCDS (NCDM)? A) Primary nursing B) Team nursing C) Functional nursing D) Case management

C) Functional nursing Functional nursing best uses the skills of all staff in a timely manner during this crisis. This delivery system (model) requires the fewest staff and delegates tasks to those who can best perform them. Team nursing doesn't allow for the best use of a limited number of staff who must care for a large number of clients. Primary nursing and case management require more registered nurses than are currently available.

Which strategy can help make the nurse a more effective teacher? A) Using technical terms B) Using loosely structured teaching sessions C) Including the client in the discussion D) Providing detailed explanations

C) Including the client in the discussion An effective teacher always involves the client in the discussion. Using technical terms and providing detailed explanations usually confuse the client and act as barriers to learning. Using loosely structured teaching sessions permits distractions and deviations from teaching goals.

A primary unit nurse tells the nurse-manager that a newly hired registered nurse needs an additional week of orientation in order to function effectively on the staff. Which action is most appropriate for the nurse-manager to take? A) Schedule a staff meeting to find out if there are deficiencies or flaws in the orientation process. B) Fire the new nurse because the unit is short-staffed and needs nurses who can complete the orientation process in the normal length of time. C) Meet with the new nurse and the primary nurse and help set up an additional week of orientation. D) Tell the primary nurse that the new nurse must finish orientation within 6 weeks because of a staffing shortage.

C) Meet with the new nurse and the primary nurse and help set up an additional week of orientation. The nurse-manager is responsible for adequate orientation of new staff. A need for additional orientation doesn't mean that a nurse isn't competent. However, the new nurse should know what's expected of her and how soon she must fulfill those expectations. Firing the new nurse isn't the answer because she's apparently close to completing orientation and the primary nurse says she has good skills. Periodically reviewing and revising the orientation process is a good idea. However, in this case, the most appropriate course of action is to help the new nurse complete her orientation as efficiently as possible.

A nurse is caring for a child with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy? A) Monitor vital signs every 4 hours. B) Measure intake and output. C) Monitor the appearance, size, and number of stools. D) Measure blood urea nitrogen and serum creatinine levels.

C) Monitor the appearance, size, and number of stools. A gluten-free diet should eliminate fat, bulky, foul-smelling stools in a child with celiac disease. This finding indicates that the disease is controlled and the child is using nutrients effectively. Taking vital signs, measuring blood urea nitrogen and serum creatinine levels, and measuring intake and output don't indicate the effectiveness of nutritional therapy.

When assessing if a procedural risk to a client is justified, the ethical principle underlying the dilemma is known as which of the following? A) Pro-choice B) Self-determination C) Nonmaleficence D) Informed consent

C) Nonmaleficence Nonmaleficence is the principle of creating no harm. It refers to preventing or minimizing harm to an individual. The other options do not represent the situation presented in the question.

Which intervention should the nurse include in the plan of care to ensure adequate nutrition for a very active, talkative, and easily distractible client who is unable to sit through meals? A) Direct the client to the room to eat. B) Ask the client about food preferences. C) Offer the client nutritious finger foods. D) Ask the client's family to bring the client's favorite foods from home.

C) Offer the client nutritious finger foods. For the client who is unable to sit through meals to maintain adequate nutrition, the nurse should offer the client nutritious finger foods and fluids that he can consume while "on the run." Foods high in protein and carbohydrates, such as half of a peanut butter sandwich, will help to maintain nutritional needs. Adequate fluid intake is necessary, especially if the client has been started on lithium therapy. Directing the client to his room to eat is not helpful because the client will not stay in his room long enough to eat. Asking the client's family to bring his favorite foods or asking the client about his food preferences is not helpful in ensuring adequate nutrition for the hyperactive client who is unable to sit and eat.

Bacterial conjunctivitis has affected several children at a local day care center. A nurse should advise which measure to minimize the risk of infection? A) Close the day care center for 1 week to control the outbreak. B) Set up a conference with the parents of each child to explain the situation carefully. C) Perform thorough hand washing before and after touching any child in the day care center. D) Restrict the infected children from returning for 48 hours after treatment.

C) Perform thorough hand washing before and after touching any child in the day care center. Bacterial conjunctivitis is very contagious. Attention should be paid to thorough hand washing, a major means of stopping the transmission of the disease. Closing the day care center for 1 week is not necessary because thorough hand washing will stop the spread of the infection. Keeping the children out for 48 hours is not necessary. A child may return to day care after being treated for 24 hours. Although the parents of each child should be told about the outbreak, doing so will not help to curtail or prevent the spread of the infection.

To reduce the risk of pressure ulcer formation, which activity should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury? A) Move from the bed to the wheelchair every 2 hours. B) Bathe daily. C) Shift your weight every 15 minutes. D) Eat a high-carbohydrate diet.

C) Shift your weight every 15 minutes. The client who is wheelchair-bound with a spinal cord injury should be taught to make small weight shifts, lifting off the sacral area every 15 minutes. This decreases the risk of pressure ulcer formation. Bathing daily promotes skin cleanliness, but by itself will not prevent pressure ulcer formation. Eating a well-balanced diet that includes proteins and carbohydrates promotes good skin integrity. Moving from the bed to the wheelchair every 2 hours is not desirable because the client should not spend excessive amounts of time in bed. Pressure sores can develop in less than 2 hours.

A client has a nursing diagnosis of Ineffective airway clearance related to retained secretions. When planning this client's care, the nurse should include which intervention? A) Suctioning the client every 2 hours B) Improving airway clearance C) Teaching the client how to deep-breathe and cough D) Increasing fluids to 1500 ml/day

C) Teaching the client how to deep-breathe and cough Interventions should address the etiology of the client's problem — poor coughing. Teaching deep breathing and coughing addresses this etiology. Increasing fluids may improve the client's condition, but this intervention does not address poor coughing. Improving airway clearance is too vague to be considered an appropriate intervention. Suctioning is not indicated unless other measures fail to clear the airway.

For healing by secondary intention, a client's wound has been packed with medicated dressings. The nurse assesses the wound. Which finding indicates wound healing? A) The wound drainage is serous. B) The skin around the wound is edematous. C) The granulation tissue is at the wound edges. D) The tissue surrounding the wound is red and hot.

C) The granulation tissue is at the wound edges. Connective tissue develops and fills in (or approximates) the wound edges from granulation tissue. Thus, evidence of granulation tissue indicates wound healing. Edematous surrounding tissue and serous drainage are insufficient evidence that the wound is healing. Surrounding tissue which is red and hot is more indicative of infection.

A nurse is providing wound care to a client 1 day following an appendectomy. A drain was inserted into the incisional site during surgery. When providing wound care, the nurse should: A) gently irrigate the drain to remove exudate. B) remove the drain if wound drainage is minimal. C) clean the area around the drain moving away from the drain. D) remove the dressing and leave the incision open to air.

C) clean the area around the drain moving away from the drain. The nurse should gently clean the area around the drain by moving in a circular motion away from the drain. Doing so prevents the introduction of microorganisms to the wound and drain site. The incision cannot be left open to air as long as the drain is intact. The nurse should note the amount and character of wound drainage, but the surgeon will determine when the drain should be removed. Surgical wound drains are not irrigated.

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

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

The student nurse is caring for a client with a suspected respiratory infection. Which of the following statements by the nursing student indicates to the instructor that the student will facilitate the best time to collect this specimen? A) "I will collect the specimen early in the evening when secretions settle in the lungs." B) "I will collect the specimen before bedtime." C) "I will have the client give the specimen any time during the day." D) "I will instruct the client to give the specimen in the morning, as soon as the client awakens."

D) "I will instruct the client to give the specimen in the morning, as soon as the client awakens." Because sputum accumulates in the lungs during sleep, the nurse should collect a sputum specimen in the morning, as soon as the client awakens. This specimen will be concentrated, increasing the likelihood of an accurate culture. Sputum specimens collected at other times during the day are not concentrated and may not provide an accurate culture.

A nurse completes preoperative teaching for a client scheduled for a cholecystectomy. The client states, "If I lie still and avoid turning, I will avoid pain. Do you think this is a good idea?" What is the nurse's best response? A) "It is always a good idea to rest quietly after surgery, which will help minimize further pain." B) "The physician will probably order you to lie flat for 24 hours." C) "Why don't you decide about activity after you return from recovery?" D) "Turn from side to side every 2 hours, and the nurse will administer pain medication to assist in movement."

D) "Turn from side to side every 2 hours, and the nurse will administer pain medication to assist in movement." To prevent venous stasis and improve muscle tone, circulation, and respiratory function, the client should be encouraged to move around after surgery. Pain medication will be administered to permit movement. Early ambulation with associated pain management reduces postoperative risk, and all other answers do not reflect this.

In which circumstance may the nurse legally and ethically disclose confidential information about a client? A) A diagnosis of pancreatic cancer to a client's significant other B) The fact that a woman is 32 weeks pregnant with twins to the husband from whom she is legally separated C) A single male client's human immunodeficiency virus (HIV) status to his family members D) A taxi driver's diagnosis of an uncontrolled seizure disorder to a state agency

D) A taxi driver's diagnosis of an uncontrolled seizure disorder to a state agency A nurse may lawfully disclose confidential information about a client when the welfare of a person or group of people is at stake. A health care provider must inform the Department of Motor Vehicles that the taxi driver has an uncontrolled seizure disorder; disclosing the condition is in the best interest of public safety and the client's well-being. Confidentiality of HIV testing is required, but the client, who's HIV positive, should be encouraged to share the information with his family. Many state legislatures require maintaining confidentiality of HIV testing. The nurse may not disclose a diagnosis of pancreatic cancer or a pregnancy because these situations don't affect the welfare of a group of people.

A charge nurse tells a new nurse, "You really need to get your skills up to speed." The statement hurts and embarrasses the new nurse. How can she best handle the situation? A) Tell the charge nurse she needs to be more specific about what she means. B) Tell the charge nurse she feels hurt by her statement. C) Discuss her feelings with a coworker in order to vent. D) Ask for a private meeting to explore the charge nurse's concerns in detail.

D) Ask for a private meeting to explore the charge nurse's concerns in detail. The charge nurse's statement is vague; the priority issue is to gather information about what she meant. Meeting privately with the charge nurse is one way to diffuse tension in a nonthreatening manner and gather information that might have professional value for the nurse. Stating that the nurse felt hurt immediately focuses on subjective issues rather than objective concerns. Professional respect dictates inquiring about what the charge nurse meant, rather than telling her to be more specific. Discussing the situation with a coworker may make the nurse feel better but doesn't address the issue at hand.

When preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing? A) In the middle of the wound B) Over the total wound C) At the top of the wound D) At the base of the wound

D) At the base of the wound When a client is ambulating, gravity causes the drainage to flow downward. Covering the base of the wound with extra dressing will contain the drainage. Applying the thickest portion of the dressing at the top, in the middle, or over the total wound won't contain the drainage.

Which of the following assessment factors would indicate a need for oropharyngeal suctioning? A) Thin sputum, weak cough, and enlargement of the tonsils B) Auscultation of crackles in the lower lobes of the lungs C) Oxygen saturation levels of 95% and diaphragmatic breathing patterns D) Breathing rate of 36 breaths/min and noisy, gurgling respirations

D) Breathing rate of 36 breaths/min and noisy, gurgling respirations An increase in the breathing rate indicates hypoxia in the body. The signs of noisy, gurgling respirations indicate airway interference and the need for suctioning. Clients should be able to cough up thin sputum, and tonsil enlargement should not interfere. Crackles in lower lobes signify lung congestion, not airway impairment. Oxygen saturation levels of 95% are normal.

A client who recently immigrated from Korea to the U.S. or Canada is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after the client's admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action is most appropriate at this time? A) Documenting that the client is resting quietly and denies pain B) Calling a family member to obtain information about the client C) Giving the client the ordered as-needed pain medication D) Checking vital signs and assessing for nonverbal indications of pain

D) Checking vital signs and assessing for nonverbal indications of pain The nurse should consider the possibility that the client didn't understand the question or has been conditioned culturally not to complain openly of pain. Checking vital signs and assessing for nonverbal indications of pain help the nurse determine whether the client is in pain. Accepting the client's response without question or further assessment may result in inadequate intervention. Calling the family or giving pain medication isn't warranted at this time because the client denies pain and the nurse needs to obtain more information.

A physician orders hourly urine output measurement for a postoperative client with an indwelling catheter. The nurse records the following amounts of output for 2 consecutive hours: 8 a.m. (0800): 50 ml; 9 a.m. (0900): 60 ml. Based on these amounts, which action should the nurse take? A) Irrigate the indwelling urinary catheter. B) Increase the I.V. fluid infusion rate. C) Notify the physician. D) Continue to monitor and record hourly urine output.

D) Continue to monitor and record hourly urine output. Normal urine output for an adult with an indwelling catheter is at least 30 ml/hour. Therefore, this client's output is normal. Beyond continued evaluation, no nursing action is warranted.

A nurse is faxing client information to a nursing home. Which action should the nurse take to maintain client confidentiality? A) Obtaining a written order from the client's primary physician to fax the information B) Making sure the client's name and date of birth are displayed on the fax cover sheet C) Reading all information to the client before faxing D) Determining that the client has authorized release of the information

D) Determining that the client has authorized release of the information A nurse must obtain client authorization before sending any confidential information to a nursing home or other facility. A client's name and other protected information should never appear on a fax cover sheet. It isn't necessary to read the information to the client before sending it. A physician's order doesn't give a nurse the right to send confidential information without the client's permission.

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

D) Document the client's choice and re-assess pain in 1 hour. A client has the right to choose whether to take medication. The nurse should assess the client's pain regularly and educate the client that taking the medication before the pain gets out of control will be a better pain management plan. The other options do not reflect an understanding of the client's right to choice including the refusal of pain medication.

A nurse is reluctant to provide care at an accident scene. Which of the following legal definitions is true regarding the provision of nursing care? A) Negligence is intentional failure to act responsibly or deliberate omission of a professional act. B) Malpractice is failure to perform professional duties that result in client injury. C) Scope of practice involves general guidelines that define nursing. D) Good Samaritan laws are designed to protect the caregiver in emergency situations.

D) Good Samaritan laws are designed to protect the caregiver in emergency situations. Good Samaritan laws are designed to protect the caregiver in emergency situations. If the nurse stopped to provide care, legally there is protection. Failure to stop would constitute an issue. Malpractice involves the failure to perform professional duties; it may involve omissions of important care measures or performing care measures that are not appropriate in the situation. Negligence is failure to act professionally. Scope of practice includes specific guidelines of professional conduct.

A nurse implements a health care facility's disaster plan. Which action should she perform first? A) Provide treatment for incoming clients according to time of admission. B) Instruct all essential off-duty personnel to report to the facility within 24 hours. C) Turn off all cellular phones and pagers. D) Identify a command center at which activities are coordinated.

D) Identify a command center at which activities are coordinated. During a disaster, having a command center to provide direction and coordinate activities is crucial. Cellular phones and pagers may be essential communication tools during a disaster. Essential off-duty personnel should respond to a disaster as quickly as possible. Admitted clients should be triaged and treated in accordance with the facility's triage policy.

Which nursing intervention is appropriate for a client with an arm restraint? A) Applying the restraint loosely to prevent pressure on the skin B) Positioning the restrained arm in full extension C) Tying the restraint to the side rail D) Monitoring circulatory status every 2 hours

D) Monitoring circulatory status every 2 hours A nurse must assess the circulatory status of a restrained extremity every 2 hours to prevent circulatory impairment. To make sure the restraint is secure without compromising the circulation, the nurse should leave approximately one fingerbreadth between the restraint and the extremity. Tying a restraint to the side rail or an immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. The restrained arm or leg should be flexed slightly to allow joint movement without reducing the effectiveness of the restraint.

Which guidelines define and regulate what the nurse may and may not do as a professional? A) Standards of care B) State legislature C) Facility policies and procedures D) Nurse practice act

D) Nurse practice act Each state legislature has enacted a nurse practice act. These statutes outline the legal scope of nursing practice within a particular state. State boards of nursing oversee the statutory law. State legislatures create boards of nursing within each state; the state legislature itself doesn't regulate the scope of nursing. Facility policies govern the practice within a particular facility. Nurse practice acts set educational requirements for the nurse, distinguish between nursing practice and medical practice, and define the scope of nursing practice in that state. Standards of care, criteria that serve as a basis for evaluating the quality of nursing practice, are established by federal organizations, accreditation organizations, state organizations, and professional organizations.

Over the past few weeks, a client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which of the following measures does not comply with a least restraint policy? A) Placing the client in a bed with a bed alarm B) Raising one bed rail to offer stabilization when standing C) Providing a bed that is low to the floor D) Raising all side rails while the client is in bed

D) Raising all side rails while the client is in bed Raising all side rails on the bed would be a restraint and may increase the client's risk of a falling if he or she climbs out of bed. All the other options would comply with a least restraint policy.

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important? A) History of increased aspirin use B) An active daily walking program C) A history of diabetes mellitus D) Recent pelvic surgery

D) Recent pelvic surgery The client shows signs of deep vein thrombosis (DVT). The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes mellitus is a contributing factor associated with peripheral vascular disease.

A nurse is instructing a client who had abdominal surgery that day to do deep-breathing exercises. In which order from first to last should the nurse teach the client to perform diaphragmatic breathing and coughing? All options must be used. A) Cough deeply from the lungs. B) Exhale through pursed lips. C) Inhale through the nose. D) Splint the incisional site.

D) Splint the incisional site. C) Inhale through the nose. B) Exhale through pursed lips. A) Cough deeply from the lungs. The client must first splint the incision to avoid increased intolerable pain or he or she may not cooperate with the pulmonary ventilation. The next step is to inhale oxygen to expand the alveoli for a few seconds and then exhale carbon dioxide in successive steps 5 to 10 times. The client should try to cough on the end of the exhalation to remove retained secretions from the larger airways.

Which example may illustrate a breach of confidentiality and security of client information? A) The nurse provides information to a professional caregiver involved in the care of the client. B) The nurse informs a colleague that she should not be discussing client information in the hospital cafeteria. C) The nurse accesses client information on the computer at the nurse's station then logs off before answering a client's call bell. D) The nurse provides information over the phone to the client's family member who lives in a neighboring state.

D) The nurse provides information over the phone to the client's family member who lives in a neighboring state. Providing information over the phone to a family member without knowing whether the client wants the family member to know the information is a breach of confidentiality and security of client information. Providing information to a caregiver involved in the care of a client is not a breach in confidentiality, while providing information to a professional not involved in the care of the client is a breach in confidentiality. Client information should not be discussed in public areas, such as elevators or the cafeteria. Logging off a computer that displays client data is an appropriate method of protecting client confidentiality and information.

A client who's scheduled for open-heart surgery in 2 days has been having circulation problems in the feet and legs. The physician orders antiembolism stockings. The nurse is teaching the client about this treatment. What is the purpose of antiembolism stockings? A) To maintain warmth in the legs B) To decrease venous blood circulation from the legs and feet C) To decrease arterial blood circulation to the legs and feet D) To reduce or prevent edema of the legs and feet

D) To reduce or prevent edema of the legs and feet Made of elastic material, antiembolism stockings are designed to reduce or prevent edema of the legs or feet by promoting venous return. They do this by increasing — not decreasing — arterial and venous blood circulation to the legs and feet. They don't maintain warmth in the legs. Blankets can be used for this purpose.

A day-shift nurse gives a client an injection of pain medication. The nurse forgets to document the injection on the medication administration record (MAR). The day-shift nurse tells the evening-shift nurse that she gave the client 4 mg of morphine at 2 p.m. for postoperative pain but didn't document the injection. The evening-shift nurse puts the day-shift nurse's initials and the date and time the dose was administered in the appropriate area of the MAR. The evening-shift nurse's action is considered to be which type of documentation error? A) Improper correction B) Omission C) Late entry D) Unauthorized entry

D) Unauthorized entry This action is an unauthorized entry. A nurse shouldn't document for another nurse, except for an authorized entry in an emergency. Omission is a documentation error in which information is missing from the medical record. In this scenario, the day-shift nurse omitted documenting her administration of pain medication. A late entry refers to an entry made later than it should have been. The nurse should identify a necessary late entry as a "late entry" and document the reference date and time. An improper correction is an entry corrected in an improper manner, such as by erasing, using correction fluid, or obliterating the error with a marking pen. The nurse should always follow her facility's documentation guidelines.

Which nursing intervention for catheter care should have the highest priority? A) clamping the catheter periodically to maintain muscle tone B) changing the location where the catheter is taped to the client's leg C) irrigating the catheter with several milliliters of normal saline solution D) cleaning the area around the urethral meatus

D) cleaning the area around the urethral meatus Good catheter care, including meticulous cleaning of the area around the urethral meatus, is the highest priority for the client with an indwelling catheter. Clamping an indwelling catheter is not a part of nursing care and would require a prescription. Irrigation of the catheter, which requires breaking the closed system, is not a part of nursing care for this client. Manipulation of the catheter taped to the client's leg causes trauma to the urethral meatus, which can predispose the client to an infection and is also not recommended.

The nurse is preparing a 45-year-old female for a vaginal examination. The nurse should place the client in which postion? A) genupectoral position B) dorsal recumbent position C) Sims position D) lithotomy position

D) lithotomy position Although other positions may be used, the preferred position for a vaginal examination is the lithotomy position. This position offers the best visualization. If the client is elderly and frail, staff members may need to support the client's flexed legs while the examiner conducts the examination and obtains the Papanicolaou smear. Positioning the client in the other positions will make visualization more difficult and may not be as comfortable for the client.

Which nursing intervention is most important in preventing septic shock? A) obtaining vital signs every 4 hours for all clients B) administering IV fluid replacement therapy as ordered C) monitoring red blood cell counts for elevation D) maintaining asepsis of indwelling urinary catheters

D) maintaining asepsis of indwelling urinary catheters Maintaining asepsis of indwelling urinary catheters is essential to prevent infection. Preventing septic shock is a major focus of nursing care because the mortality rate for septic shock is as high as 90% in some populations. Very young and elderly clients (those younger than age 2 or older than age 65) are at increased risk for septic shock. Administering IV fluid replacement therapy, obtaining vital signs every 4 hours on all clients, and monitoring red blood cell counts for elevation do not pertain to septic shock prevention.

The nurse is planning care for a client on complete bed rest. The plan of care should include all except: A) use of thromboembolic disease support (TED) hose. B) turning every 2 hours. C) passive and active range-of-motion exercises. D) maintaining the client in the supine position.

D) maintaining the client in the supine position. Three factors contribute to the formation of venous thrombus and thrombophlebitis: damage to the inner lining of the vein (prolonged pressure), hypercoagulability of the blood, and venous stasis. Bed rest and immobilization are associated with decreased blood flow and venous pooling in the lower extremities. Keeping the client in the supine position would not be appropriate. Turning the client every 1 to 2 hours, passive and active range-of-motion exercises, and use of TED hose help prevent venous stasis in the lower extremities.

To ensure safety for a hospitalized blind client, the nurse should: A) require that the client has a sitter for each shift. B) require that the client stays in bed until the nurse can assist. C) keep the side rails up when the client is alone. D) orient the client to the room environment.

D) orient the client to the room environment. The priority goal of care for a client who is blind is safety and preventing injury. The initial action is to orient the client to a new environment. Taking time to identify the objects and where they are located in the room can achieve this goal. It is unrealistic to have someone stay with the client at all times or for the client to stay in bed until the nurse can assist. Using side rails creates unnecessary barriers and may be a safety hazard.

Which is appropriate for the nurse to include in a plan for the prevention of pressure ulcers? A) gentle massage of bony prominences every shift B) encouraging the client to sit up as much as possible C) daily skin cleaning with soap and hot water D) systematic skin assessment at least once per shift

D) systematic skin assessment at least once per shift The best treatment for a pressure ulcer is prevention. If a client has been determined to be at risk for developing a pressure ulcer, a systematic skin assessment should be conducted at least once per shift. Other preventive measures include daily gentle cleaning of the skin and avoiding harsh soaps and hot water, which are damaging to the skin. Massage of bony prominences is not done because it can increase damage to the underlying tissue. The client should be encouraged to change position at least every 2 hours to avoid pressure on any one area for a prolonged period.

When assessing a client's pain, which is the most reliable indicator of the existence and intensity of acute pain? A) the severity of the condition causing the pain B) the nurse's assessment C) the client's vital signs D) the client's self-report

D) the client's self-report The client's self-report of pain is the single most reliable indicator of the amount of pain the client is experiencing. Pain tolerance and the expression of pain can vary a great deal among clients. The nurse cannot determine the intensity of pain by measuring the client's blood pressure, pulse, or respiratory rate. It is essential that the nurse listen to the client. The nurse cannot rely on the nurse's own assessment to determine the extent of the pain. The severity of the client's condition does not determine the client's pain response.