ATI Final Exam ~ Review Questions

A nurse educator is teaching a module on safe medication administration to newly hired nurses. Which of the following statements by a newly hired nurse indicate understanding of the nurse' s responsibility when implementing medication therapy? (Select all that apply.) - "I will observe for medication side effects." - "I will monitor for therapeutic effects." - "I will prescribe the appropriate dose." - "I will change the dose if adverse effects occur." - "I will refuse to give a medication if I believe it is unsafe."

- "I will observe for medication side effects." - "I will monitor for therapeutic effects." - "I will refuse to give a medication if I believe it is unsafe."

A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse including in her counseling? (Select all that apply.) - Most food poisoning is caused by a virus. - Immunocompromised individuals are at risk for complications from food poisoning - Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products. - Healthy individuals usually recover from the illness in a few weeks. - Handling raw and fresh food separately to avoid cross contamination may prevent food poisoning.

- Immunocompromised individuals are at risk for complications from food poisoning - Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products. - Handling raw and fresh food separately to avoid cross contamination may prevent food poisoning.

A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? (Select all that apply.) - Restlessness - Tachypnea - Bradycardia - Confusion - Pallor

- Restlessness - Tachypnea - Pallor

A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include in the teaching? 1. "Flush the tube before and after each medication." 2. "Administer your medications with your enteral feeding." 3. "Administer tablets through the tube slowly." 4. "Mix all the crushed medications prior to dissolving in water."

1. "Flush the tube before and after each medication."

A nurse is caring for a client who is at risk for hypokalemia. Which of the following foods should be included in the client's diet? 1. Avocados 2. Corn 3. Asparagus 4. Cucumbers

1. Avocados

The nurse is observing a newly licensed nurse who is preparing a sterile field for a dressing change. Which of the following actions by the newly licensed nurse should cause the nurse to intervene? 1. The newly licensed nurse places the cap of the sterile saline bottle on the sterile field. 2. The newly licensed nurse places sterile objects 1 inch from the border of the field. 3. The newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring. 4. The table is positioned at the level of the newly licensed nurse's waist.

1. The newly licensed nurse places the cap of the sterile saline bottle on the sterile field.

A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number.) _____________ mL/hr

107 mL/hr

A nurse is caring for a client who decides not to have surgery despite significant blockages in his coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? 1. Fidelity 2. Autonomy 3. Justice 4. Nonmaleficence

2. Autonomy

A nurse is reviewing laboratory data for a client who has contusions to the chest wall following a motor vehicle crash. Which of the following values should the nurse report? 1. Hct 40% 2. SaO2 86% 3. WBC 9,000 mm³ 4. Serum potassium 4.1 mEq/L

2. SaO2 86% **low oxygen (<90%); may indicate hypoxia**

A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy the next day. Which of the following client statements indicates that the client is ready to learn? 1. "I don't want my spouse to see my incision." 2. "Will you be able to give me pain medicine after the surgery?" 3. "Can you tell me about how long the surgery will take?" 4. "My roommate listens to everything I say."

3. "Can you tell me about how long the surgery will take?"

A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? 1. Fidelity 2. Autonomy 3. Justice 4. Beneficence

4. Beneficence

A nurse is preparing to perform nasopharyngeal suctioning for a client who is unable to cough up excessive secretions. Which of the following actions is appropriate? 1. Use the clean technique throughout the procedure. 2. Insert the catheter as the client exhales. 3. Apply suction for up the 20 seconds. 4. Perform suctioning while removing the catheter.

4. Perform suctioning while removing the catheter.

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? 1. BUN 15 mg/dL 2. Creatinine 0.8 mg/dL 3. Sodium 143 mEq/L 4. Potassium 5.4 mEq/L

4. Potassium 5.4 mEq/L **Electrolytes (ranges):** Sodium ~ 135-145 mEq/L Chloride ~ 95-105 mEq/L Potassium ~ 3.5-5.0 mEq/L Bicarbonate ~ 22-28 mEq/L Magnesium ~ 1.5-2.0 mEq/L

A nurse is monitoring an older adult client who is receiving IV fluid therapy. Which of the following assessment findings should the nurse recognize as an adverse effect of excess fluid therapy? (select all that apply.) - Edema - Crackles in lungs - Oliguria - Elevated blood pressure - Jugular venous distention

- Edema - Crackles in lungs - Elevated blood pressure - Jugular venous distention

A nurse is caring for a client who has been sitting in a chair for 3 hr. Which of the following problems is the client at risk for developing? 1. Stasis of secretions 2. Muscle atrophy 3. Pressure ulcer 4. Fecal impaction

3. Pressure ulcer

A nurse is teaching a client about taking multiple oral medications at home to include time-release capsules, liquid medications, enteric-coated pills, and narcotics. Which of the following statements by the client indicates an understanding of the teaching? 1. "I can open the capsule with the beads in it and sprinkle them on my oatmeal." 2. "If I am having difficulty swallowing, I will add the liquid medication to a batch of pudding." 3. "The pills with the coating on them can be crushed." 4. "I will eat two crackers with the pain pills."

4. "I will eat two crackers with the pain pills."

To promote the safe use of a cane for a client who is recovering from a minor musculoskeletal injury of the left lower extremity, which of the following instructions should the nurse provide? (Select all that apply.) - Hold the cane on the right side. - Keep two points of support on the floor. - Place the cane 15 inches in front of the feet before advancing. - After advancing the cane, move the weaker leg forward. - Advance the stronger leg so that it aligns evenly with the cane.

- Hold the cane on the right side. - Keep two points of support on the floor. - After advancing the cane, move the weaker leg forward.

A nurse is caring for a 5‑year‑old client whose parents report that she fears painful procedures, such as injections. Which of the following strategies should the nurse use to try to help ease the child's fear? (Select all that apply.) - Invite the child to assist with mealtime activities. - Cluster invasive procedures whenever possible. - Assign caregivers with whom the child is familiar. - Have the parents bring in a favorite toy from home. - Engage the child in pretend play with a toy medical kit.

- Invite the child to assist with mealtime activities. - Have the parents bring in a favorite toy from home. - Engage the child in pretend play with a toy medical kit.

A nurse is caring for a client who cannot bear weight on his fractured ankle. Which of the following client statements indicates a need for further teaching regarding three-point gait crutch walking? 1. "When I get out of a chair, I'll hold both crutches on the side next to my weak leg." 2. "When I sit down, I'll transfer my weight to my crutches and my strong leg." 3. "When I go up stairs, I'll alternate putting weight on my crutches and my strong leg." 4. "When I go down stairs, I'll start by moving both my crutches to the step below."

1. "When I get out of a chair, I'll hold both crutches on the side next to my weak leg."

A client who has an indwelling catheter reports a need to urinate. Which of the following interventions should the nurse perform? 1. Check to see whether the catheter is patent. 2. Reassure the client that it is not possible for her to urinate. 3. Recatheterize the bladder with a larger-gauge catheter. 4. Collect a urine specimen for analysis.

1. Check to see whether the catheter is patent.

A nurse is caring for a client who is receiving medication intramuscularly. The nurse should recognize that this route 1. increases infection rates. 2. is the safest option. 3. has the slowest absorption rate. 4. decreases the client's risk for reactions.

1. increases infection rates. **breaking skin integrity increases risk for infection**

A nurse educator is conducting a parenting class for new parents. Which of the following statements made by a participant indicates a need for further clarification and instruction? 1. "I will begin swimming lessons as soon as my baby can close her mouth under water." 2. "Once my baby can sit up, he should be safe in the bathtub." 3. "I will test the temperature of the water before placing my baby in the bath." 4. "Once my infant starts to push up, I will remove the mobile from over the bed."

2. "Once my baby can sit up, he should be safe in the bathtub."

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? 1. Increase the oxygen flow. 2. Assist the client to Fowler's position. 3. Promote removal of pulmonary secretions. 4. Obtain a specimen for arterial blood gases.

2. Assist the client to Fowler's position.

A nurse is preparing to care for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in the lungs. In addition to a gown and gloves, the nurse will need which of the following equipment in order to provide care? 1. Face shield 2. High-filtration mask 3. Shoe covers 4. Surgical cap

1. Face shield **MRSA = blood; mouth, nose, eye protection**

A nurse is caring for four clients. Which of the following actions should the nurse take to prevent the spread of infection? 1. Carry a client's soiled linens out of the room in a mesh linen bag. 2. Place a client who has tuberculosis in a room with negative-pressure airflow. 3. Provide disposable plates and utensils to a client who has HIV. 4. Dispose of a client's blood-saturated dressing in a garbage bag placed inside a second garbage bag.

2. Place a client who has tuberculosis in a room with negative-pressure airflow. **negative = air in positive = air out**

A nurse contacts the facility's interpreter to explain a therapeutic procedure for a client who does not speak English. Which of the following guidelines should the nurse follow when working with the interpreter? 1. Speak slowly to allow the interpreter to interpret each word. 2. Explain the purpose of the communication to the interpreter. 3. Address the interpreter when explaining the procedure information. 4. Supplement words with gestures and nonverbal reinforcement.

2. Explain the purpose of the communication to the interpreter.

A charge nurse is leading a staff education session about caring for a client who has hypocalcemia. Which of the following statements by a staff nurse indicates the need for further teaching? 1. "I should monitor for hand spasms during blood pressure cuff inflation." 2. "Clients who have a vitamin D deficiency are at risk for hypocalcemia." 3. "Clients who have hypocalcemia are at risk for pathologic fractures." 4. "I should implement seizure precautions for a client who has hypocalcemia."

3. "Clients who have hypocalcemia are at risk for pathologic fractures."

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter should be irrigated? 1. Urine has an unusual odor. 2. Urine specific gravity is 1.035. 3. Bladder scan reveals 525 mL of urine. 4. Urine is positive for ketones.

3. Bladder scan reveals 525 mL of urine. **Indwelling catheter = continuous flow; accumulation (urine) = blockage**

A nurse is preparing to administer a medication to a client. The medication was scheduled for administration at 0900. Which of the following are acceptable administration times for this medication? (Select all that apply.) - 0905 - 0825 - 1000 - 0840 - 0935

- 0905 - 0840 *within 30 min**

A client who is nonambulatory notifies the nurse to tell her that his trash can is on fire. After confirming the fire, which of the following actions should the nurse take next? 1. Call emergency fire code. 2. Extinguish the fire. 3. Confine the fire. 4. Evacuate the client.

4. Evacuate the client. **rescue client first**

A nurse is teaching a client who just found out she has type 1 diabetes mellitus how to check her blood glucose levels. Which of the following instructions should the nurse give the client for transferring her blood onto the reagent portion of the test strip? 1. Smear the blood onto the strip. 2. Squeeze the blood onto the strip. 3. Touch the puncture to stimulate bleeding. 4. Hold the test strip next to the blood on the fingertip.

4. Hold the test strip next to the blood on the fingertip.

A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? 1. Fidelity 2. Autonomy 3. Justice 4. Nonmaleficence

4. Nonmaleficence

A client is scheduled for surgery. The intraoperative nurse finds a necklace on the client after anesthesia has been administered. Which of the following interventions should be initiated? 1. Leave the necklace on the client. 2. Give the necklace to a family member. 3. Place the necklace in the client's chart. 4. Notify security for placement of the necklace.

4. Notify security for placement of the necklace.

A nurse is caring for a client who is postoperative. Which of the following nursing interventions reduce the risk of thrombus development? (Select all that apply.) - Instruct the client not to use the Valsalva maneuver. - Apply elastic stockings. - Review laboratory values for total protein level. - Place pillows under the client's knees and lower extremities. - Assist the client to change position often.

- Apply elastic stockings. - Assist the client to change position often.

A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? (Select all that apply.) - Apply suction while withdrawing the catheter. - Perform suctioning on a routine basis, every 2 to 3 hr. - Maintain medical asepsis during suctioning. - Use a new catheter for each suctioning attempt. - Limit suctioning to two to three attempts.

- Apply suction while withdrawing the catheter. - Use a new catheter for each suctioning attempt. - Limit suctioning to two to three attempts.

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? (Select all that apply.) - Apply the oxygen source loosely if the SpO2 decreases during the procedure. - Use surgical asepsis to remove and clean the inner cannula. - Clean the outer surfaces in a circular motion from the stoma site outward. - Replace the tracheostomy ties with new ties. - Cut a slit in gauze squares to place beneath the tube holder.

- Apply the oxygen source loosely if the SpO2 decreases during the procedure. - Use surgical asepsis to remove and clean the inner cannula. - Clean the outer surfaces in a circular motion from the stoma site outward.

A nurse is using an interpreter to communicate with a client. Which of the following are appropriate when communicating with a client and his family? (Select all that apply.) - Talk to the interpreter about the family while the family is in the room. - Ask the family one question at a time. - Look at the interpreter when asking the family questions. - Use lay terms if possible. - Do not interrupt the interpreter and the family as they talk.

- Ask the family one question at a time. - Use lay terms if possible. - Do not interrupt the interpreter and the family as they talk.

A nurse is planning diversionary activities for children on an inpatient pediatric unit. Which of the following should the nurse incorporate as appropriate play activities for preschoolers? (Select all that apply.) - Assembling puzzles - Pulling wheeled toys - Using musical toys - Using finger paints - Coloring with crayons

- Assembling puzzles - Using musical toys - Coloring with crayons

A nurse is planning care for a client who has had a stroke resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an AP? (Select all that apply.) - Assist the client with a partial bed bath. - Measure the client's BP after the nurse administers an antihypertensive medication. - Test the client's swallowing ability by providing thickened liquids. - Use a communication board to ask what the client wants for lunch. - Irrigate the client's indwelling urinary catheter.

- Assist the client with a partial bed bath. - Measure the client's BP after the nurse administers an antihypertensive medication. - Use a communication board to ask what the client wants for lunch.

A nursing instructor is acquainting a group of nursing students with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When she gives examples of the types of tasks certified nursing assistants (CNAs) may perform, which of the following client activities should she include? (Select all that apply.) - Bathing - Ambulating - Toileting - Determining pain level - Measuring vital signs

- Bathing - Ambulating - Toileting - Measuring vital signs

A provider is discharging a client with a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.) - Apply petroleum jelly around and inside the nares. - Remove the nasal cannula during mealtimes. - Check the position of the cannula frequently. - Report any nasal stuffiness, nausea, or fatigue. - Post "no smoking" signs in a prominent location.

- Check the position of the cannula frequently. - Report any nasal stuffiness, nausea, or fatigue. - Post "no smoking" signs in a prominent location.

A nurse in a provider's office is assessing a client who reports losing control of urine whenever she coughs, laughs, or sneezes. The client relates a history of three vaginal births, but no serious accidents or illnesses. Which of the following interventions are appropriate for helping to control or eliminate the client's incontinence? (Select all that apply.) - Limit total daily fluid intake. - Decrease or avoid caffeine. - Increase the intake of calcium supplements. - Avoid the intake of alcohol. - Use Credé maneuver.

- Decrease or avoid caffeine. - Avoid the intake of alcohol.

A client has an admission blood glucose reading of 260 mg/dL and no documented history of diabetes mellitus. While the nurse reviews the client's medication history, which of the following types of medications should alert the nurse to the possibility that the client has developed an adverse effect of pharmacologic therapy? (Select all that apply.) - Diuretics - Corticosteroids - Oral anticoagulants - Opioid analgesics - Antipsychotics

- Diuretics - Corticosteroids - Antipsychotics

A nurse is assessing a client's ability to learn self-monitoring of blood glucose using a glucometer. Which of the following abilities should the nurse confirm that the client has before proceeding with teaching? (Select all that apply.) - Finger dexterity - Visual acuity - Color vision - Basic literacy - Demonstration ability

- Finger dexterity - Visual acuity - Demonstration ability

A nurse is preparing to initiate a bladder training program for a client who has a voiding disorder. Which of the following actions should the nurse take? (Select all that apply.) - Establish a schedule of voiding prior to meal times. - Have the client record voiding times. - Gradually increase the voiding intervals. - Remind client to hold urine until next scheduled voiding time. - Provide a sterile container for voiding.

- Have the client record voiding times. - Gradually increase the voiding intervals. - Remind client to hold urine until next scheduled voiding time.

A nurse educator on a medical unit is reviewing factors that increase the risk of urinary tract infections (UTIs) with a group of assistive personnel. Which of the following should be included in the review? (Select all that apply.) - Having sexual intercourse on a frequent basis - Lowering of testosterone levels - Wiping from front to back - The location of the vagina in relation to the anus - Undergoing frequent catheterization

- Having sexual intercourse on a frequent basis - Undergoing frequent catheterization

A nurse is reviewing the laboratory test results for a client who is receiving treatment for septicemia with a prolonged fever. Which of the following indicates the client is developing dehydration? (Select all that apply.) - Hct 55% - Serum osmolarity 260 mOsm/kg - Serum sodium 150 mEq/L - Urine specific gravity 1.035 - Serum creatinine 0.6 mg/dL

- Hct 55% - Serum sodium 150 mEq/L - Urine specific gravity 1.035

A nurse is teaching self-monitoring of blood glucose (SMBG) to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply.) - Perform SMBG once daily at bedtime. - Wipe his hand with an alcohol swab. - Hold his hand in a dependent position prior to the puncture. - Place the puncturing device perpendicular to the site. - Prick the outer edge of his fingertip for the blood sample.

- Hold his hand in a dependent position prior to the puncture. - Place the puncturing device perpendicular to the site. - Prick the outer edge of his fingertip for the blood sample.

A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? (Select all that apply.) - Family members who smoke must be at least 10 ft from the client when oxygen is in use. - Nail polish should not be used near a client who is receiving oxygen. - A "No Smoking" sign should be placed on the front door. - Cotton bedding and clothing should be replaced with items made from wool. - A fire extinguisher should be readily available in the home.

- Nail polish should not be used near a client who is receiving oxygen. - A "No Smoking" sign should be placed on the front door. - A fire extinguisher should be readily available in the home.

A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the interprofessional care team may assist the client in understanding the medication's effects? (Select all that apply.) - Provider - Certified nursing assistant - Pharmacist - Registered nurse - Respiratory therapist

- Provider - Pharmacist - Registered nurse

A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. Which of the following is an expected finding? (Select all that apply.) - Hot, dry skin - Hypertension - Tachycardia - Syncope - Decreased skin turgor

- Tachycardia - Syncope - Decreased skin turgor

A nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) immunization recommendations with the parents of two preschoolers. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) - Haemophilus influenzae type b - Varicella - Polio - Hepatitis A - Seasonal influenza

- Varicella - Polio - Seasonal influenza

A nurse is providing instructions for an older adult client who has a prescription for an electric heating pad to his lumbosacral area. Which of the following client statements indicates a correct understanding of the teaching? 1. "I will remove the heating pad in 30 minutes." 2. "I will need to turn up the heating pad after it has been in place for 10 minutes." 3. I'll sleep on top of the pad to get better heat penetration." 4. "I can pin the heating pad to my gown to keep it in place."

1. "I will remove the heating pad in 30 minutes." **client should apply periodically and no more than 30-45 min (longer can result in tissue damage)**

A nurse is working with an Orthodox Jewish client who has just given birth to a stillborn infant. Which of the following interventions is appropriate? 1. Ask the family if there are any special rituals that they would like to follow at this time. 2. Inform the parents of the importance of conforming to hospital policy regarding the death of a fetus. 3. Remain in the room, giving the parents the opportunity to initiate a discussion about cultural rituals. 4. Take the fetus out of the room, and allow the parents time to grieve together.

1. Ask the family if there are any special rituals that they would like to follow at this time.

A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next? 1. Clean sutures along with the incision site. 2. Grasp the sutures at the know with a pair of forceps. 3. Cut the sutures close to the skin on one side. 4. Pull out the sutures with forceps in one piece.

1. Clean sutures along with the incision site. **greatest risk to this client is infection; clean to minimize risk**

A provider prescribes a 24-hr urine collection for a client. Which of the following actions should the nurse take? 1. Discard the first voiding. 2. Keep all voidings in a container at room temperature. 3. Ask the client to urinate and pour the urine into a specimen container. 4. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container.

1. Discard the first voiding.

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? 1. During the admission process 2. As soon as the client's condition is stable 3. During the initial team conference 4. After consulting with the client's family

1. During the admission process **discharge planning starts at admission (patient needs for during and after hospital)**

A nurse is caring for a young child who is prescribed a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take? 1. Examine personal values about the issue. 2. Tell the parents that this is a necessary procedure. 3. Inform the parents that their consent is not required. 4. Contact the chaplain to explain the importance of the procedure.

1. Examine personal values about the issue. **provide unbiased care**

A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? 1. Hypotension 2. Bradycardia 3. Clammy skin 4. Bradypnea

1. Hypotension

A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse anticipate including in the plan of care? 1. Infuse hypotonic IV fluids. 2. Implement a fluid restriction. 3. Increase sodium intake. 4. Administer sodium polystyrene sulfonate (Kayexalate).

1. Infuse hypotonic IV fluids.

Which of the following is the responsibility of a nurse who is caring for a client receiving PCA? 1. Instruct the family to refrain from pushing the button for the client while she is asleep. 2. Inform the client that because she is on PCA, vital signs will be taken every 8 hr. 3. Teach the client to avoid pushing the button unless pain is above a 7 on a scale of 0 to 10. 4. Increase the basal rate and shorten the lock-out interval time if the client's pain level is too high.

1. Instruct the family to refrain from pushing the button for the client while she is asleep.

A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients is at risk for hypervolemia? 1. A client who has a new diagnosis of adrenal insufficiency 2. A client who has heart failure 3. A client who is receiving treatment for diabetic ketoacidosis 4. A client who has abdominal ascites

2. A client who has heart failure

A nurse prepares an injection of morphine (Duramorph) to administer to a client who reports pain. Prior to administering the medication, the nurse is called to another room to assist another client onto a bedpan. She asks a second nurse to give the injection. Which of the following actions should the second nurse take? 1. Offer to assist the client needing the bedpan. 2. Administer the injection prepared by the other nurse. 3. Prepare another syringe and administer the injection. 4. Tell the client needing the bedpan she will have to wait for her nurse.

1. Offer to assist the client needing the bedpan.

A nurse in a clinic is providing teaching to an older adult client about nutritional considerations associated with aging. Which of the following should the nurse include in the teaching? 1. Protein intake is often inadequate in older adults 2. Vitamin and mineral requirements decline in older adults 3. Thirst sensation increases in older adults 4. Lack of adequate fat in the diet is often seen in older adults

1. Protein intake is often inadequate in older adults

A nurse is caring for a client who is postoperative following colostomy placement. Which of the following findings should the nurse report to the provider? 1. Stoma appears purple in color. 2. Protrusion of stoma from the abdomen. 3. Mucosa of the stoma bleeds slightly when touched. 4. Red peristomal skin under the adhesive.

1. Stoma appears purple in color. **notify provider if stoma appears dark in color (impaired circulation)**

A nurse is teaching a client about self-administering NPH insulin. Which of the following actions by the client indicates a need for further teaching? 1. The client inserts the needle at a 30°-angle. 2. The client rolls the vial between both hands. 3. The client holds the syringe in place for 5 seconds following injection. 4. The client uses her anterior thigh as the injection site.

1. The client inserts the needle at a 30°-angle. **Insert needle at 45° to 90° (depending on adipose/fat tissue)**

A nurse is caring for a client and performing blood glucose monitoring. Which of the following is an appropriate nursing intervention? 1. Wipe away the first drop of blood from the client's finger. 2. Gently massage the client's finger in a distal to proximal direction. 3. Puncture the tip of the client's finger. 4. Hold the client's finger in an elevated position prior to testing.

1. Wipe away the first drop of blood from the client's finger. **first drop is more serous; contains fewer RBCs**

A nurse is performing a spiritual assessment on a client newly admitted to the unit. The nurse recognizes that the purpose of performing a spiritual assessment is to 1. identify the client's religious and spiritual beliefs, affiliations, and practices. 2. apply commonly accepted concepts of spirituality to the nurse's interactions with the client. 3. allow the nurse to make educated assumptions about the client's spiritual needs related to health care. 4. encourage the client to focus on beliefs that are consistent with health care interventions.

1. identify the client's religious and spiritual beliefs, affiliations, and practices.

A nurse is planning care for a client who is a devout Muslim and is 3 days postoperative following a hip arthroplasty. The client is scheduled for two physical therapy sessions today. Which of the following statements by the nurse indicates culturally appropriate care to the Muslim client? 1. "I will make sure the menu includes kosher options." 2. "I will discuss the daily schedule with the client to make sure the client will have time for prayer." 3. "I will make sure to use direct eye contact when speaking with this client." 4. "I will make sure daily communion is available for this client."

2. "I will discuss the daily schedule with the client to make sure the client will have time for prayer."

A nurse is teaching an adult client how to administer ear drops. Which of the following statements by the client indicates understanding of the proper technique? 1. "I will straighten my ear canal by pulling my ear down and back." 2. "I will gently apply pressure with my finger to the tragus of my ear after putting in the drops." 3. "I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in." 4. "After the drops are in, I will place a cotton ball all the way into my ear canal."

2. "I will gently apply pressure with my finger to the tragus of my ear after putting in the drops."

A nurse is talking with parents of a preschooler who describe several issues that concern them. Which of the following problems the parents verbalized should the nurse identify as the priority for further assessment and intervention? 1. "Our son will only eat a few things, like burgers and bananas, and pretty much refuses everything else." 2. "Our son has these temper tantrums every time we tell him to do something he doesn't want to do." 3. "We think our son truly believes that his toys have personalities and talk to him, especially at night." 4. "We feel bad when we see our son trying so hard to button his shirt. We just tell him this is something he'll just have to learn to do."

2. "Our son has these temper tantrums every time we tell him to do something he doesn't want to do."

A nurse educator is teaching a module on pharmacokinetics to a group of newly licensed nurses. Which of the following statements by a newly licensed nurse indicates an understanding of the first-pass effect? 1. "Some medications block normal receptor activity regulated by endogenous compounds or receptor activity caused by other medications." 2. "Some medications may have to be administered by a nonenteral route to avoid inactivation as they travel through the liver." 3. "Some medications leave the body more slowly and therefore have a greater risk for medication accumulation and toxicity." 4. "Some medications have a wide safety margin, so there is no need for routine serum medication level monitoring."

2. "Some medications may have to be administered by a nonenteral route to avoid inactivation as they travel through the liver."

A nurse is instructing a client who is postoperative about the sequential compression device the provider has prescribed. Which of the following client statements should indicate to the nurse that the client understands the teaching? 1. "This device will keep me from getting sores on my skin." 2. "This thing will keep the blood pumping through my leg." 3. "With this thing on, my leg muscles won't get weak." 4. "This device is going to keep my joints in good shape."

2. "This thing will keep the blood pumping through my leg."

A nurse is checking blood pressures at a community health screening. Which of the following clients is at high risk for primary hypertension? 1. A client who is pregnant 2. A client who has an elevated LDL 3. A client who takes oral contraceptives 4. A client who has kidney disease

2. A client who has an elevated LDL

A nurse in a provider's office is collecting data from the mother of a 1-year-old child. The client states that her child is old enough for toilet training. Following an educational session by the nurse, the client now states that her earlier ideas have changed. She is now willing to postpone toilet training until the child is older. Learning has occurred in which of the following domains? 1. Cognitive 2. Affective 3. Psychomotor 4. Kinesthetic

2. Affective

A nurse has just inserted an NG tube for a client. Which of the following assessment findings indicates that the tube is properly positioned? 1. The tube aspirate has a pH of 7. 2. An x-ray shows the end of the tube above the pylorus. 3. Bowel sounds are present on auscultation. 4. The client reports relief of nausea.

2. An x-ray shows the end of the tube above the pylorus. **X-ray to confirm gastric placement**

A nurse is evaluating how well a client learned the information presented in an instructional session about following a heart-healthy diet. The client states that she understands what to do now. Which of the following actions by the nurse should assist the nurse in evaluating the client's learning? 1. Encourage the client to ask questions. 2. Ask the client to explain how to select or prepare meals. 3. Encourage the client to fill out an evaluation form. 4. Ask the client if she has resources for further instruction on this topic.

2. Ask the client to explain how to select or prepare meals.

A nurse is caring for a preschooler who has heart disease. The provider prescribes digoxin at the maximum adult dose. Which of the following actions should the nurse take? 1. Give the medication as prescribed using the Six Rights of Medication Administration. 2. Call the provider to discuss concerns regarding the dosage for the child. 3. Assess the client's heart rate and rhythm before deciding whether or not to give the medication. 4. Administer the pediatric dose recommended in a medication-reference book.

2. Call the provider to discuss concerns regarding the dosage for the child.

A nurse is working with a newly hired nurse who is administering medications to clients. Which of the following actions by the newly hired nurse indicates an understanding of medication error prevention? 1. Taking all medications out of the unit-dose wrappers before entering the client's room 2. Checking with the provider when a single dose requires administration of multiple tablets 3. Administering a medication, then looking up the usual dosage range 4. Relying on another nurse to clarify a medication prescription

2. Checking with the provider when a single dose requires administration of multiple tablets

A nurse is planning teaching for a client who has a new diagnosis of type 1 diabetes mellitus about insulin self-administration. Which of the following actions should the nurse take first? 1. Encourage the client to include a family member in the teaching. 2. Determine the client's learning style. 3. Provide written directions for the client to use. 4. Schedule a series of teaching sessions.

2. Determine the client's learning style. **1st rule: assess (in this case: clients learning style)**

Following administration of levothyroxine 125 mcg at 0800, the nurse discovers the medication was given to a client for whom it was not prescribed. Which of the following is the correct way to document this error in the medical record of the client who received the medication? 1. Levothyroxine 125 mcg given at 0800 in error. Client is in no distress. 2. Levothyroxine 125 mcg given at 0800. Provider notified. 3. Levothyroxine 125 mcg given at 0800. Incident report filed. 4. Levothyroxine 125 mcg given at 0800 in error. Client informed of error.

2. Levothyroxine 125 mcg given at 0800. Provider notified.

A nurse is planning to insert a peripheral IV catheter in an older adult client. Which of the following actions should the nurse plan to take? 1. Insert the catheter at a 45° angle 2. Position the client's arm in the dependent position 3. Shave excess hair from the insertion site 4. Initiate IV therapy in the veins of the hand

2. Position the client's arm in the dependent position **veins distend due to gravity**

A nurse is caring for a client who is combative in the emergency department. The provider orders wrist restraints after the client attempts to assault the admitting nurse. Which of the following actions is appropriate for the nurse to take? 1. Tie restraints to the lower edge of the side rail. 2. Remove each restraint one at a time every 2 hr. 3. Ensure 3 finger-widths of space between the restraint and the client's wrist. 4. Use a square knot to securely tie the restraints to the bed.

2. Remove each restraint one at a time every 2 hr. **To perform ROM exercises and neurovascular checks**

A nurse is caring for a client who had a fasting blood sugar drawn at 0600. The client tells the nurse, "All I have had since midnight is water and some juice." Which of the following nursing actions is appropriate? 1. Document the caloric intake. 2. Reschedule this lab test for the next morning. 3. Notify the lab to obtain another specimen. 4. Obtain a prescription for a glucose tolerance test.

2. Reschedule this lab test for the next morning. **should fast for 8 to 12 hr before sample is drawn**

When a nurse is observing a client drawing up and mixing insulin injections, which of the following best demonstrates that psychomotor learning has taken place? 1. The client is able to discuss the appropriate technique. 2. The client is able to demonstrate the appropriate technique. 3. The client states that he understands. 4. The client is able to write the steps on a piece of paper.

2. The client is able to demonstrate the appropriate technique.

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions is appropriate for the client and family? 1. Remove the outer cannula cautiously for routine cleaning. 2. Use tracheostomy covers when outdoors. 3. Use sterile technique when performing tracheostomy care at home. 4. Cleanse irritated skin with full-strength hydrogen peroxide.

2. Use tracheostomy covers when outdoors.

A nurse is developing a plan of care for an African-American child who is preschool-age and experiencing pain. Which of the following is the best way for the nurse to assess the child's pain? 1. Ask the parents of the child to describe the pain. 2. Measure the child's vital signs. 3. Show the child the Oucher Pain Scale. 4. Observe the child's facial expression.

3. Show the child the Oucher Pain Scale.

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following is an appropriate response by the nurse? 1. "It allows the court to overrule an adult client's refusal of medical treatment." 2. "It permits a client to withhold medical information from health care personnel." 3. "It indicates the form of treatment a client is willing to accept in the event of a serious illness." 4. "It allows health care personnel in the emergency department to stabilize a client's condition."

3. "It indicates the form of treatment a client is willing to accept in the event of a serious illness."

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. The nurse understands that the preoperative teaching regarding pain control has been effective when the client states which of the following? 1. "I think I should take my pain medication more often, since it is not controlling my pain." 2. "Breathing faster will help me keep my mind off of the pain." 3. "It may help me to listen to music while I'm lying in bed." 4. "I don't want to walk today, because I'm experiencing some pain."

3. "It may help me to listen to music while I'm lying in bed." **nonpharmacological intervention to pain**

A client demonstrates anger when the nurse does not respond within 5 min of ringing for the nurse. Which of the following is an appropriate response by the nurse? 1. "I'm sorry, but another client needed my attention." 2. "I arrived as soon as I could. What can I do for you?" 3. "It must be frustrating. I have a few minutes now." 4. "We had an emergency on the unit, but now I'm here."

3. "It must be frustrating. I have a few minutes now." **therapeutic by acknowledging client's feelings**

A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma? 1. A nurse on a medical-surgical unit demonstrates signs of chemical impairment. 2. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints. 3. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. 4. A client who is terminally ill hesitates to name her spouse on her durable power of attorney form.

3. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill.

A nurse is talking with the father of a 4‑year‑old child who states that his daughter goes to bed at 8:30 p.m. and wakes up at about 7:30 a.m., but she often lies in bed talking to herself or gets up a few times before falling asleep 40 min later. At her preschool, the children take a 2‑hr afternoon nap. Which of the following recommendations should the nurse make to help improve the child's sleep behavior? 1. Offer the child a snack of her favorite treat right before bedtime. 2. Allow the child to watch an extra 30 min of TV in the evening. 3. Change the child's bedtime to 9 p.m. on days she napped. 4. Request that the preschool staff limit her nap time to 1 hr.

3. Change the child's bedtime to 9 p.m. on days she napped.

A nurse finds a client on the floor upon entering the client's room. The roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following is correct documentation of this incident? 1. Incident report completed. 2. Client climbed over the bedrails. 3. Client found lying on floor. 4. Client was trying to get out of bed.

3. Client found lying on floor. **remember, be Objective in documentation**

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? 1, Verify the client's name on his identification bracelet with the MAR. 2. Call the pharmacy to determine if the client's medications are available. 3. Compare the client's home medications with the provider's prescriptions. 4. Place the client's home medication bottles in a secure location.

3. Compare the client's home medications with the provider's prescriptions. **as defined as medication reconciliation**

A client is reporting pain at the insertion site of his IV catheter. The nurse observes a red line extending outward from the insertion site. Which of the following actions should the nurse take first? 1. Place a warm compress over the site 2. Restart the IV line at a different site. 3. Discontinue the infusion. 4. Document the findings.

3. Discontinue the infusion. **greatest risk = further injury to the vein; first action is to discontinue**

A nurse is preparing to administer morphine 4 mg IV bolus to a client. Available is morphine 5mg/mL. Which of the following is an appropriate nursing intervention? 1. Return the unused medication to the automatic dispensing system. 2. Keep the remaining medication at the client's bedside for later use. 3. Have a second nurse witness the disposal of remaining medication. 4. Lock remaining medication in secure cabinet.

3. Have a second nurse witness the disposal of remaining medication.

A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which of the following ethical principles? 1. Fidelity 2. Autonomy 3. Justice 4. Nonmaleficence

3. Justice

A nurse is caring for a client who is 1 day postoperative following a total knee arthroplasty. The client states his pain level is 10 on a scale of 0 to 10. After reviewing the client's medication administration record, which of the following medications should the nurse administer? 1. Meperidine (Demerol) 75 mg IM 2. Fentanyl 50 mcg/hr transdermal patch 3. Morphine 2 mg IV 4. Oxycodone 10 mg PO

3. Morphine 2 mg IV

A nurse is preparing to administer oral medications to a client who has dysphagia. Which of the following is an appropriate action by the nurse? 1. Have the client drink water from a straw after taking the medication. 2. Instruct the client to lift his chin upward when swallowing medications. 3. Offer each medication one at a time. 4. Place the medication in the client's mouth.

3. Offer each medication one at a time.

A nurse is caring for a client who is crying while reading from his devotional book. Which of the following interventions is appropriate for the nurse to take? 1. Contact the hospital's spiritual services. 2. Ask him what is making him cry. 3. Provide quiet times for these moments. 4. Turn on the television for a distraction.

3. Provide quiet times for these moments.

A nurse attempts to collect a capillary blood specimen via finger stick to test the glucose level of a client who has diabetes mellitus. The nurse is unable to obtain an adequate drop of blood for the reagent strip. Which of the following actions should the nurse take? 1. Puncture another finger to obtain a capillary specimen. 2. Test the client's urine with a urine reagent strip. 3. Wrap the client's hand in a warm, moist cloth. 4. Perform a venipuncture to obtain a venous sample.

3. Wrap the client's hand in a warm, moist cloth.

A nurse is caring for a client who shares the same religious background. The nurse should recognize that 1. members of the same religion share similar feelings about their religion. 2. a shared religious background generates mutual regard for one another 3. the same religious beliefs may influence individuals differently 4. they should discuss the differences and commonalities in their beliefs.

3. the same religious beliefs may influence individuals differently

A nurse is caring for a client with a diagnosis of terminal cancer. The nurse understands that the client is ready to hear information regarding palliative care when the client states which of the following? 1. "I am ready to learn about chemotherapy to help cure my cancer." 2. "I just want you to give me something to get this over with soon." 3. "I know that many people have recovered fully from cancer, and so will I." 4. "I want you to tell me about measures available to keep me comfortable."

4. "I want you to tell me about measures available to keep me comfortable." **palliative care = comfort and symptom control**

A nurse is caring for a client who has recently started using a hearing aid worn behind the ear. Which of the following client statements indicates to the nurse that he understands the use of this assistive device? 1. "This type of hearing aid does not allow for fine tuning of volume." 2. "I shouldn't have trouble keeping the hearing aid in place during exercise." 3. "I expect to hear a whistling sound when I first insert the hearing aid." 4. "I will be sure to remove my hearing aid before taking a shower."

4. "I will be sure to remove my hearing aid before taking a shower."

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following statements by the client indicates a need for further instruction by the nurse? 1. "I will tape electrical cords to the baseboards in each room." 2. "I will hire someone to trim the tree that overhangs the front porch stairs." 3. "I will remove the table from the hall." 4. "I will replace the old throw rug in the kitchen with a new one."

4. "I will replace the old throw rug in the kitchen with a new one." **use of throw rugs increase risk for falls**

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? 1. "Is your pain constant or intermittent?" 2. "What would you rate your pain on a scale of 0 to 10?" 3. "Does the pain radiate?" 4. "Is your pain sharp or dull?"

4. "Is your pain sharp or dull?" **Pain assess: severity = pain scale quality = sharp or dull chronicity = constant or intermittent**

A nurse is caring for a client who is a Jehovah's Witness and is scheduled for surgery as a result of a motor vehicle crash. The surgeon tells the client that a blood transfusion is essential. The client tells the nurse that based on his religious values and mandates, he cannot receive a blood transfusion. Which of the following responses by the nurse is appropriate? 1. "I believe in this case you should really make an exception and accept the blood transfusion." 2. "I know your family would approve of your decision to have a blood transfusion." 3. "Why does your religion mandate that you cannot receive any blood transfusions?" 4. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution."

4. "Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution."

A nurse is preparing to administer digoxin (Lanoxin) to a client who states, "I don't want to take that medication. I do not want one more pill." Which of the following responses by the nurse is appropriate in this situation? 1. "Your physician prescribed it for you, so you really should take it." 2. "Well, let's just get it over quickly then." 3. "Okay, I'll just give you your other medications." 4. "Tell me your concerns with taking this medication."

4. "Tell me your concerns with taking this medication."

A nurse manager is overseeing the care of a unit. Which of the following should the nurse manager identify as a violation of HIPPA guidelines? 1. The assigned nurse reviews the medical chart with a nursing student. 2. A nursing student discusses a client's status with the assigned nurse at the bedside. 3. The assigned nurse returns a call to a client's Power of Attorney to discuss the client's care. 4. A nursing student consults a former classmate to assist with her documentation.

4. A nursing student consults a former classmate to assist with her documentation. **only those in direct care**

A nurse is giving an end-of-shift report about a client admitted earlier that day with pneumonia. Which of the following pieces of information is most essential to provide? 1. Admitting diagnosis 2. Diagnostic test results 3. Body temperature 4. Breath sounds

4. Breath sounds **ABCs**

A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? 1. Carbon monoxide has a distinct odor. 2. Water heaters should be inspected every 5 years. 3. The lungs are damaged from carbon monoxide inhalation. 4. Carbon monoxide binds with hemoglobin in the body.

4. Carbon monoxide binds with hemoglobin in the body.

A nurse receives report on a client who is receiving 0.9% sodium chloride at 125 mL/hr. When the nurse performs the initial assessment she notes that the client has received 80 mL for the last 2 hr. Which of the following actions should the nurse take first? 1. Reposition the client. 2. Document the client's IV intake in the medical record. 3. Request a new IV fluid prescription. 4. Check the IV tubing for obstruction.

4. Check the IV tubing for obstruction.

A nurse is preparing an instructional session about managing stress incontinence for an older adult. Which of the following actions should the nurse take first when meeting with the client? 1. Encourage the client to participate actively in learning. 2. Select instructional materials appropriate for the older adult. 3. Identify goals the nurse and the client agree are reasonable. 4. Determine what the client knows about stress incontinence.

4. Determine what the client knows about stress incontinence.

A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to take the client's vital signs every 15 min and call him back in 1 hr. From a legal perspective, which of the following actions should the nurse take next? 1. Document the provider's statement in the medical record. 2. Complete an incident report. 3. Consult the facility's risk manager. 4. Notify the nursing manager.

4. Notify the nursing manager. **status is deteriorating; use chain-of-command to ensure care**

A nurse is checking a client's blood pressure to assess for orthostatic hypotension. Which of the following actions should the nurse take? 1. Obtain blood pressure 30 min after each meal. 2. Obtain blood pressure immediately after the client ambulates. 3. Obtain blood pressure in each arm and leg. 4. Obtain blood pressure 2 min after assisting the client to a sitting position.

4. Obtain blood pressure 2 min after assisting the client to a sitting position. **orthostatic hypotension = drop in BP when get up; take BP in supine, sitting, standing (1-3min intervals)**

A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? 1. Social worker 2. Certified nursing assistant 3. Registered dietitian 4. Occupational therapist

4. Occupational therapist

A nurse is caring for a client who is on bed rest. Which of the following interventions should the nurse implement to maintain the patency of the client's airway? 1. Encourage isometric exercises. 2. Suction every 8 hr. 3. Give low-dose heparin. 4. Promote incentive spirometer use.

4. Promote incentive spirometer use.

A nurse is caring for an older adult client who lives alone and is to be discharged in 3 days. He states that it is difficult to prepare adequate nutritious meals at home for just one person. To which of the following members of the health care team should the nurse refer him? 1. Registered dietitian 2. Occupational therapist 3. Physical therapist 4. Social worker

4. Social worker

A client who has had a cerebrovascular accident has persistent problems with dysphagia (difficulty swallowing). The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? 1. Social worker 2. Certified nursing assistant 3. Occupational therapist 4. Speech-language pathologist

4. Speech-language pathologist

A nurse is planning care to promote improved self-feeding for a client who has visual impairment. Which of the following interventions should nurse include in the plan of care? 1. Direct the client in what order to consume the food. 2. Provide small-handled utensils for the client. 3. Thicken liquids on the client's tray. 4. Use a clock pattern to describe food on the plate to the client.

4. Use a clock pattern to describe food on the plate to the client.

A nurse is planning to teach a preschool child how to properly use a metered dose inhaler. Which of the following methods is appropriate for this child? 1. Hold the child in the lap while giving explanations. 2. Help the child identify her feelings about using an inhaler. 3. Encourage independent learning. 4. Use role play and imitation when explaining.

4. Use role play and imitation when explaining.

To prevent foot drop in a client who has decreased mobility, the nurse should 1. place a pillow under the client's knees. 2. position a trochanter roll under the client's feet. 3. advise the client to wear rubber-soled slippers. 4. place the client's feet against a foot board perpendicular to the mattress.

4. place the client's feet against a foot board perpendicular to the mattress. **keep foot in dorsiflex, keep from foot drop**