ATI Funds Practice

A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse prioritize when using the nursing process? Identify goals for client care Obtain client information Document nursing care needs Evaluate the effectiveness of care

Obtain client information

A nurse is providing discharge teaching to a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching? "A nurse will show me how to care for my wound" "A nurse will stay with me at home during the day." "I will call the nurse to change my bed linens." "I will call the nurse to help me bathe in the morning"

"A nurse will show me how to care for my wound"

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states, "All this equipment is making me nervous". Which of the following responses should the nurse offer? "You wont need the equipment for very long" "All this equipment can be frightening" "Why does the equipment bother you?" "Let me tell you about what each machine does"

"All this equipment can be frightening"

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse provide? "Its for your safety. Dentures can slip and block your airway during surgery" "You wouldn't want your teeth to be lost or broken during surgery, would you?" "The anesthesiologist requires all clients to remove their dentures" "What worries you about being without your teeth?"

"What worries you about being without your teeth?"

A nurse is performing a spiritual assessment of a client. Which of the following questions should the nurse ask? "When did you start to believe in your faith?" "How often do you perform religious rituals?" "Which church do you regularly attend?" "What is your source of strength and hope?"

"What is your source of strength and hope?"

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? Daily weight Blood pressure Specific gravity Intake and output

Daily weight

A nurse is reviewing the laboratory values of a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? Decreased calcium Decreased potassium Increased potassium Increased calcium

Decreased calcium INCORRECT: all Hyperkalemia

A nurse is performing an otoscopic examination of a client's right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse in take in response to this finding? Obtain an audiology referral Document this as an expected finding Irrigate the ear with warm water Document mild inflammation

Document this as an expected finding (the light reflects off the tympanic membrane--> right ear= right lower quadrant of the eardrum left ear= left lower quadrant of the eardrum

A nurse is caring for a client who is having difficult breathing. The nurse should assist the client into which of the following positions? Supine Lateral Fowler's Trendelenburg

Fowler's INCORRECT: Trendelenburg= lowering the head of the bed with the foot of the bed raised into a straight incline can promote venous circulation

A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the following abdominal assessments should the nurse expect? Frequent bowel sounds with flatus Absent bowel sounds with distention Hyperactive bowel sounds with diarrhea Normal bowel sounds with increased peristalsis

Frequent bowel sounds with flatus (Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent, the abdomen is distended, and there is no flatus or stool.) CORRECT ANSWER Absent bowel sounds with distention (Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent and the abdomen is distended.) Hyperactive bowel sounds with diarrhea (Paralytic ileus is an immobile bowel. With this disorder, bowel sounds are absent, the abdomen is distended, and there is no flatus or stool.) Normal bowel sounds with increased peristalsis (Paralytic ileus is an immobile bowel with decreased peristalsis. With this disorder, bowel sounds are absent, the abdomen is distended, and there is no flatus or stool.)

A nurse is caring for a client who is postoperative following vascular surgery on the left femoral artery. The nurse should identify that the surgical wound should be cleansed in which of the following directions? From the middle of the thigh toward the wound From the left lower abdominal quadrant toward the wound From the left hip toward the wound From the wound toward the surrounding skin

From the wound toward the surrounding skin

A nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to assess which of the following? Liver size Pedel edema Skin texture Gait

Gait

A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching? Cream of rice Cottage cheese Gelatin Ice cream

Gelatin

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. This manifestation is consistent with which of the following disorders? Retinopathy Glaucoma Cataracts Macular degeneration

Glaucoma

A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first? Gloves Gown Eyewear Mask

Gloves ORDER: gloves goggles/face shield gown mask

A nurse is preparing to change the bed linens of a client who has AIDs and is incontinent of stool. Which of the following personal protective equipment items should the nurse don prior to providing client care? Select all that apply? Gown Gloves Mask Hair cover Goggles

Gown Gloves

A nurse is reviewing a client's 24 hour dietary recall. The client reports eating a slice of toasted white bread with butter, a banana, a glass of milk, and a cup of coffee for breakfast; grilled chicken, a baked potato, and a glass of milk for lunch; an apple and cheddar cheese for a snack; and 2 servings of chicken, 2 cups of steamed broccoli , and a glass of milk for dinner. This client's diet is deficit in which of the following food groups? Dairy Vegetables Fruits Grains

Grains

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching? The wound edges are well-approximated The wound is closed at a later date A skin graft is placed over the wound bed Granulation tissue fills the wound during healing

Granulation tissue fills the wound during healing (the wound is left open to drain and heal by secondary intention for 5-21 days) INCORRECT: The wound edges are well-approximated= PRIMARY INTENTION The wound is closed at a later date A skin graft is placed over the wound bed =both are TERTIARY INTENTION

A nurse is caring for a client who has a stage II pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer? Hydrocolloid Collagen Calcium alginate Proteolytic enzyme

Hydrocolloid INCORRECT: Calcium alginate--> stage IV Proteolytic enzyme-->unstageable pressure ulcer

A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur? Hyperglycemia Hypotension Heightened immune response Bleeding tendencies

Hyperglycemia (increased cortisol--> can lead to hypertension or hyperglycemia)

A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first? Inspect both breasts simultaneously Squeeze the nipples Palpate the breast and tail of Spence Palpate the axillary lymph

Inspect both breasts simultaneously

A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first? Inspection Auscultation Percussion Palpation

Inspection

A client who has glaucoma of the right eye self-administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following actions should the nurse take? Confirm that the client performed the procedure correctly Instruct the client to look at the floor while instilling the eye drop Remind the client to avoid using a facial tissue after instillation Instruct the client apply pressure to the inside corner of the eye after instillation

Instruct the client apply pressure to the inside corner of the eye after instillation (apply pressure over the nasolacrimal duct to prevent medication from flowing into the nasal passages)

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? Instruct the client to defecate into the toilet bowl. Transfer the specimen to a sterile container. Refrigerate the collected specimen. Place the stool specimen collection container in a biohazard bag.

Instruct the client to defecate into the toilet bowl. (The nurse should have the client defecate into a bedpan or a container for stool collection. The toilet water can dilute and contaminate the liquid specimen.) Transfer the specimen to a sterile container. (The nurse should place the stool specimen a clean container using a tongue depressor.) Refrigerate the collected specimen. (The nurse should send the collected stool specimen immediately to the laboratory after labeling the specimen properly to prevent contamination with microorganisms and prevent the specimen from getting cold.) CORRECT ANSWER Place the stool specimen collection container in a biohazard bag. (The nurse should place the specimen collection container in a biohazard bag with the client label placed on the container and the bag for easy identification, and to prevent contamination with microorganisms.)

A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take? Use a 10mL syringe Attach a 22-gauge catheter to the syringe Warm the irrigating solution to 37 C (98.6 F) Administer an analgesic 10 min before the irrigation

Warm the irrigating solution to 37 C (98.6 F) (prepare 200mL of solution and warm it to minimize discomfort) INCORRECT: Use a 10mL syringe--> should be 30 mL Attach a 22-gauge catheter to the syringe --> should be 18-19 Administer an analgesic 10 min before the irrigation--> administer 20-30 mins before

A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? Sweeping the floor Shoveling snow Cleaning windows Washing dishes

Washing dishes

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse implement? Place the client in a semi-private room Wear a mask when providing care Wear a gown when in the client's room Dispose of all bed linens used by the client

Wear a gown when in the client's room (contact isolation=gloves and gown)

A nurse is assessing a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields? Vesticular Bronchial Rhonchi Bronchovesicular

Vesticular (soft and low-pitched) INCORRECT: Bronchial (trachea) Rhonchi (trachea) Bronchovesicular (sternal border)

A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication of an infection? WBC 15,000 mm^3 Erythrocyte sedimentation rate (ESR) 15 mm/hr Urine pH 7.2 Urine specific gravity 1.0063

WBC 15,000 mm^3

A nurse is teaching a client who has low back pain about heat therapy. Which of the following statements by the client indicates an understanding of the teaching? "I need to place a towel between the heating pad and my skin" "Ill need to turn up the temperature if I can't feel the heat" "Ill sleep on top of the heating pad to increase the heat penetration" ""Keeping the heat continuously on my back will help it heal"

"I need to place a towel between the heating pad and my skin"

A nurse is teaching a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group? Independent moral development Acceptance of body changes Strengthening ties with the family of origin Development of concrete reasoning

CORRECT: Independent moral development (Kolhberg's theory of moral development--> post conventional level)

A nurse is providing teaching to a client who has a new colostomy about proper care. Which of the following information should the nurse include in the teaching? Change the colostomy bag following breakfast. Cleanse the skin around the stoma with warm water. Change the pouch every day. Place an aspirin in the ostomy pouch to decrease odor.

Change the colostomy bag following breakfast. (The nurse should instruct the client to change the colostomy bag before a meal because drainage from the ostomy is least likely to occur.) CORRECT ANSWER Cleanse the skin around the stoma with warm water. (The nurse should instruct the client to cleanse the skin around the stoma with warm water, because using soap can leave a residue on the skin and cause poor adherence of the pouch adhesive.) Change the pouch every day. (The nurse should instruct the client to change the pouch every 3 to 7 days to avoid skin breakdown around the stoma.) Place an aspirin in the ostomy pouch to decrease odor. (The nurse should instruct the client not to place an aspirin in the ostomy pouch to decrease odor, because it can cause stoma bleeding.)

A nurse is caring for a client who has a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? Irrigate the tubing with sterile normal water once during each shift Cleanse the opening with soap and water after emptying Maintain the tubing above the level of the surgical incision Collapse the device to remove air after emptying

Collapse the device to remove air after emptying (this creates enough suction to pull fluid exudate into the collection area of the device) INCORRECT: Irrigate the tubing with sterile normal water once during each shift (drainage system is NOT made for irrigating) Cleanse the opening with soap and water after emptying (cleanse with an alcohol wipe) Maintain the tubing above the level of the surgical incision (keep at below the level of the incision to promote drainage)

A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? Call for assistance Begin chest compressions Confirm unresponsiveness Give rescue breathes

Confirm unresponsiveness

A nurse is performing a mental-status examination on a client who has manifestations of dementia. Which of the following directions should the nurse give the client when evaluating the client's ability to think abstractly? Subtract by 7 starting at 100 Describe a previous illness Explain what to do if a fire were to happen in his bedroom Discuss the meaning of a common proverb

Discuss the meaning of a common proverb INCORRECT: Subtract by 7 starting at 100 (attention span) Describe a previous illness (remote memory) Explain what to do if a fire were to happen in his bedroom (client's judgement)

A nurse is assessing a client. Which is the following findings should the nurse identify as an indiction of protein-calorie malnourishment? (Select all that apply) Gingivitis Dry, brittle hair Edema Spoon-shaped nails Poor wound healing

Dry, brittle hair Edema--> when albumin levels are low Poor wound healing

A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the client's risk of aspiration? Irrigate the tubing with 30 mL of sterile water Elevate the head of the bed to 30 or 45 degrees Suggest changing the feeding to lactose-free formula Warm the enteral formula to room temp before feeding

Elevate the head of the bed to 30 or 45 degrees (helps prevent risk for aspiration)

A nurse is teaching a middle-aged female client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of the client's routine health screening? Annual Papanicolaou (Pap) testing Mammogram every 2 years Eye exam every 2 years Annual colonoscopy

Eye exam every 2 years (monitoring vision and checking for glaucoma--> age 65 and older) INCORRECT: Pap test--> ages 30-65 Mammo--> ages 45 Colonoscopy--> every 10 years

A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process? Identify goals for client care. Obtain client information. Document nursing care needs. Evaluate the effectiveness of care.

Identify goals for client care. (The nursing process is based on the scientific process. While identifying goals is an appropriate step in the nursing process, it is not the first step.) CORRECT ANSWER Obtain client information. (The nursing process is based on the scientific process. The first step in the scientific process is the collection of data. Therefore, the first step in the nursing process is assessing and obtaining information about the client.) Document nursing care needs. (The nursing process is based on the scientific process. While documenting the client's care needs is an appropriate step in the nursing process, it is not the first step.) Evaluate the effectiveness of care. (The nursing process is based on the scientific process. While evaluating the effectiveness of the client's care is an appropriate step in the nursing process, it is not the first step.)

A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft contender abdomen, and census overdue by 2 days. Which of the following findings should be the nurse's priority? Heart rate 105/min Soft, nontender abdomen Temperature Overdue menses

Heart rate 105/min (This is an important assessment finding because the client's heart rate is elevated. However, fever and pain can contribute to tachycardia. This is not the priority finding.) Soft, nontender abdomen (This is an important assessment finding because of the client's report of pain. However, a soft nontender abdomen is an expected finding and should not cause concern. This is not the priority finding.) CORRECT ANSWER Temperature (Elevated temperature is an emergent physiological need, which requires priority intervention by the nurse. The nurse should consider Maslow's Hierarchy of Needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's Hierarchy of Needs, the nurse should review physiological needs first. The nurse should then address the client's needs by following the remaining four hierarchal levels. However, it is important for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the situation.) Overdue menses (This is an important assessment finding because of the client's report of pain. However, an irregularity in the menstrual cycle is a common finding when a client is stressed. This is not the priority finding.)

A nurse is caring for a client who had a mastectomy and has a self-suctioning drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? Irrigate the tubing with sterile normal water once each shift. Cleanse the opening with soap and water after emptying. Maintain the tubing above the level of the surgical incision. Collapse the device of air after emptying.

Irrigate the tubing with sterile normal water once each shift. (The nurse should keep the diaphragm of the device compressed to maintain suction and prevent clotting of sanguineous drainage. This drainage system is not made for irrigating.) Cleanse the opening with soap and water after emptying. (The nurse should cleanse the drain opening with an alcohol wipe after opening it to decrease entry of microorganisms.) Maintain the tubing above the level of the surgical incision. (The nurse should maintain the drainage tubing below the level of the incision to enhance drainage.) CORRECT ANSWER Collapse the device of air after emptying. (The nurse should collapse the device of air after emptying the contents periodically to create enough suction to pull fluid exudate into the collection area of the device.)

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? Obtaining hydrogen peroxide for the tracheostomy care Obtaining cotton balls for the tracheostomy care Obtaining sterile gloves for the tracheostomy care Obtaining a sterile brush for the tracheostomy care

Obtaining hydrogen peroxide for the tracheostomy care (Half-strength peroxide solution is used to clean the inner cannula.) CORRECT ANSWER Obtaining cotton balls for the tracheostomy care (Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess. The charge nurse should intervene for this action.) Obtaining sterile gloves for the tracheostomy care (Tracheostomy care is a sterile procedure requiring the use of sterile gloves.) Obtaining a sterile brush for the tracheostomy care (Pipe cleaners, or a small sterile brush, can be used to remove thick or crusty secretions from the inner cannula.)

A nurse is initiating seizure precautions for a client who has a seizure disorder. Which of the following pieces of equipment should the nurse have readily available at the client's bedside? Vest restraint Tongue blade Oxygen equipment Neck brace

Oxygen equipment (to apply oxygen via mask or nasal cannula for patients who experience seizures)

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use? Stand toward the client's stronger side. Instruct the client to lean backward from the hips. Place the wheelchair at a 45° angle to the bed. Assume a narrow stance with feet 15 cm (6 in) apart.

Stand toward the client's stronger side. (Safely transferring a client from a bed to a wheelchair requires the nurse to stand in front of the client toward the side that requires the most support. This technique will help maintain balance during the transfer.) Instruct the client to lean backward from the hips. (Safely transferring a client from a bed to a wheelchair requires the nurse to instruct the client to lean forward from the hips. This technique positions the client in the proper direction of the movement.) CORRECT ANSWER Place the wheelchair at a 45° angle to the bed. (Positioning the wheelchair at a 45° allows the client to pivot, lessening the amount of rotation required.) Assume a narrow stance with feet 15 cm (6 in) apart. (Safely transferring a client from a bed to a wheelchair requires the nurse to assume a wide stance with one foot in front of the other. This technique protects the nurse from losing balance during the transfer)

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? Tie the restraints to the side rails. Perform range-of-motion exercises to the wrists every 3 hr. Remove the restraints one at a time. Obtain a PRN prescription for the restaints.

Tie the restraints to the side rails. (The nurse should not tie the restraints to the side rails because this can injure the client if the rails are lowered.) Perform range-of-motion exercises to the wrists every 3 hr. (The nurse should ensure that the restraints are removed and range-of-motion exercises are performed every 2 hr.) CORRECT ANSWER Remove the restraints one at a time. (The nurse should remove one restraint at a time for a client who is violent or noncompliant.) Obtain a PRN prescription for the restaints. (Restraint prescriptions can only be written for a 24-hr period and cannot be a PRN prescription.)

A nurse is reviewing measures to prevent back injuries with AP. Which of the following instructions should the nurse include? Stand 3 feet from the client when assisting with lifting Lock your knees when standing for long periods Lift up to 22.6 kg (50lb) without the use of assistive devices When lifting an object, spread your feet apart to provide a wide base of support

When lifting an object, spread your feet apart to provide a wide base of support

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? Withdraw the specimen from the drainage bag. Cleanse the collection port with soap and water. Place the specimen in a clean specimen cup. Clamp the tubing below the collection port.

Withdraw the specimen from the drainage bag. (The nurse should use a fresh urine specimen obtained near the indwelling urinary catheter to prevent contamination.) Cleanse the collection port with soap and water. (The nurse should cleanse the collection port with an antimicrobial swab to prevent contamination.) Place the specimen in a clean specimen cup. (The nurse should place the specimen in a sterile specimen cup to prevent contamination.) CORRECT ANSWER Clamp the tubing below the collection port. (The nurse should clamp the tubing below the collection port to allow fresh uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup.)

During a client care staff meeting, a nurse manager discusses potential problems with data security that affect confidential client information. Which if the following environments should the nurse manager identify as an acceptable place for discussing client's information? Areas with no public access Outside the door of a client's room In the cafeteria during break In the hallway near the nurses' station

Areas with no public access

A nurse is changing the dressings for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? Abdominal binder Montgomery straps Hypoallergenic tape Plastic tape

Abdominal binder (An abdominal binder can hold the dressings in place and decrease skin irritation while the client rests in bed, however, when the client ambulates, the dressings tend to slide out. Securing the dressings first is the preferred method when applying a binder. Therefore, the nurse should use a less restrictive intervention first.) CORRECT ANSWER Montgomery straps (The nurse should apply the least restrictive priority-setting framework. This framework assigns priority to nursing interventions that are least restrictive to the client, as long as those interventions do not jeopardize client safety. Least restrictive interventions promote client safety without using restraints. The nurse should only use physical or chemical restraints when the safety of the client, staff, or others is at risk. The nurse should plan to use Montgomery straps to minimize irritation to the skin near the incisional area. Montgomery straps are adhesive strips applied to the skin on either side of the surgical wound. The adhesive strips have holes for using gauze to tie the dressing securely. When the dressing is changed, the ties are released, the dressing replaced, and the ties secured again without removing the adhesive strips.) Hypoallergenic tape (Hypoallergenic tape is used when a client is sensitive to adhesive material; however, hypoallergenic tape can cause skin sensitivity when frequently removed and reapplied. The nurse should use a less restrictive intervention first.) Plastic tape (Plastic tape adheres well to skin and can cause skin sensitivity when frequently removed and reapplied. However, the nurse should use a less restrictive intervention first.)

A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. the nurse auscultates a high-pitched scratching sound during both systole and diastole with diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? Audible click Murmur Third heart sound Pericardial friction rub

Audible click (An audible clicking sound occurs in clients who have prosthetic valve replacement surgery.) Murmur (A heart murmur has a swishing or a whistling sound. Heart murmurs are caused by turbulent blood flow through valves or ventricular outflow tracts. Low- and medium-frequency sounds are more easily heard with the bell of the stethoscope applied lightly to the skin; high-frequency sounds are more easily heard with a diaphragm. A murmur can be a manifestation of valvular disease.) Third heart sound (A third heart sound is a low-pitched sound after the second heart sound. An S3 is caused by rapid ventricular filling during diastole. It is best heard at the mitral area, with the client lying on the left side. An S3 is commonly heard in children and young adults. In older adults and clients who have heart disease, an S3 often indicates heart failure.) CORRECT ANSWER Pericardial friction rub (A pericardial friction rub has a high-pitched scratching, grating, or squeaking leathery sound heard best with the diaphragm of the stethoscope at the left sternal border. A pericardial friction rub is a manifestation of pericardial inflammation and can be heard with infective pericarditis with myocardial infarction, following cardiac surgery or trauma, and with some autoimmune problems, such as rheumatic fever. The client who develops pericarditis typically has chest pain which becomes worse with inspiration or coughing and which may be relieved by sitting up and leaning forward.)

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? Auscultate for bowel sounds after each feeding. Ensure the formula is cold before administering. Elevate the client's head of bed 45° before the feeding. Flush the tubing with 15 mL of water after the enteral feeding.

Auscultate for bowel sounds after each feeding. (The nurse should auscultate for bowel sounds before each feeding to ensure the client has peristalsis bowel activity for the digestive system to digest or absorb the enteral nutrition.) Ensure the formula is cold before administering. (The nurse should ensure the formula is at room temperature before administering because cold formula might cause the client to have intestinal cramping and discomfort.) CORRECT ANSWER Elevate the client's head of bed 45° before the feeding. (The nurse should elevate the client's head of bed between 30° to 45° to prevent aspiration.) Flush the tubing with 15 mL of water after the enteral feeding. (The nurse should flush the tubing with at least 30 mL of water after the enteral feeding to maintain patency of the feeding tube.)

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? Encourage the child to cough frequently to clear congestion from anesthesia Place a heating pad on the child's neck for comfort Administer analgesics to the child on a routine schedule throughout the day and night Provide the child with ice cream when oral intake is initiated

CORRECT Administer analgesics to the child on a routine schedule throughout the day and night (to soothe their throat the nurse should administer pain meds routinely) INCORRECT Encourage the child to cough frequently to clear congestion from anesthesia (child should be discourage from coughing or clearing their throat) Place a heating pad on the child's neck for comfort (they should be offered an ice collar instead) Provide the child with ice cream when oral intake is initiated (milk products should be avoided as this coats the mouth and promotes coughing and clearing of the throat)

A nurse is caring for a client who has transferred to the surgical unit by stretcher from the PACU. Which of the following actions should the nurse perform immediately following the transfer? Administer pain medication Check the client's vital signs Instruct the client to use the incentive spirometer every 1 hr Provide ice chips as per provider prescription

Check the client's vital signs

A nurse is caring for a client who is in terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? Contact the family and ask them to stay with the client. Offer to call the client's minister. Sit and hold the client's hand. Leave the room and allow the client to cry privately.

Contact the family and ask them to stay with the client. (With this action, the nurse does not respond to the client's immediate needs and shifts the responsibility of helping the client to others.) Offer to call the client's minister. (This response by the nurse uses the nontherapeutic communication block of putting the client's needs on hold and shifts the responsibility of helping the client to someone else.) CORRECT ANSWER Sit and hold the client's hand. (With this action, the nurse uses the therapeutic communication techniques of silence, touch, and offering of self to the client.) Leave the room and allow the client to cry privately. (This is not an appropriate nursing action because it fails to acknowledge the client's distress.)

A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse that the AP understands how to perform this task? Locking the brakes on the bed and the wheelchair before moving the client Lowering the footplates of the wheelchair before the transfer Placing the wheelchair perpendicular to the bed Placing the wheelchair on the client's weaker side prior to the transfer

Locking the brakes on the bed and the wheelchair before moving the client

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature? Rectal Tympanic Oral Temporal

Rectal (The rectal route is very accurate for obtaining body temperature in young children; however, it should not be used for clients who have diarrhea.) Tympanic (The tympanic route can be used in young children, but should be avoided in a child who has an active ear infection or who has tympanostomy tubes in place.) Oral (The oral route is not appropriate for use with children under the age of 3.) CORRECT ANSWER Temporal (The temporal artery route, while not as accurate as the rectal route for obtaining a precise body temperature, is noninvasive and can be used to obtain a temperature in a toddler who might have an ear infection and who is having diarrhea. The nurse should place the probe behind the ear if the client is diaphoretic, but should avoid placing it over an area covered with hair.)

A nurse is caring for a client who has a prescription for acetaminophen 325 mg PO for an oral temperature above 38.4 C. Above what F temper should the nurse administer acetaminophen to the client?

101.1 F= (C x 9/5) + 32 F= (38.4 x 9/5) + 32 F= 101.12

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client? "Ask your provider to prescribe epoetin before the surgery." "You should ask your provider about taking iron supplements prior to the surgery." "Request a family member to donate blood for you." "Donate autologous blood before the surgery."

"Ask your provider to prescribe epoetin before the surgery." (Epoetin is a hematopoietic growth factor used for the treatment of anemia. While taking epoetin prior to surgery can boost the client's hematocrit levels, it is inappropriate if the client already has an adequate hematocrit level. Furthermore, this action might not eliminate the need for a blood transfusion and its related risks.) "You should ask your provider about taking iron supplements prior to the surgery." (While taking an iron supplement prior to surgery can boost the client's hemoglobin levels, it is inappropriate if the client already has an adequate hemoglobin level and intake of iron from dietary sources. Furthermore, this action might not eliminate the need for a blood transfusion and its related risks.) "Request a family member to donate blood for you." (A blood donation from a family member does not eliminate the risk of acquiring an infection.) CORRECT ANSWER "Donate autologous blood before the surgery." (Autologous blood transfusion is the collection and reinfusion of the client's blood. With preoperative autologous blood donation, the blood is drawn from the client 3 to 5 weeks before an elective surgical procedure and stored for transfusion at the time of the surgery. Autologous blood is the safest form of blood transfusion because exclusive use of a client's own blood eliminates exposure to transfusion-transmitted infection.)

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus? "Bear down" "Perform Kegel exercises" "Hold your breath" "Raise your head off the pillow"

"Bear down"

A nurse is teaching a client with lower extremity weakness how to use a 4-point crutch gait. Which of the following instructions should the nurse include in the teaching? "Support the majority of your weight on the axillae" "Keep your elbows extended" "Bear weight on both on both of your legs" "Move both crutches forward at the same time"

"Bear weight on both on both of your legs" (client should keep 3 points on the ground at all times--> must be able to bear weight on both legs)

A nurse is caring for a client who just received a diagnosis of cancer. The client states, 'I just dont know what i am going to do now". Which of the following responses should the nurse make? "In time you will now the right thing to do" "I am sorry. Would you like me to call someone for you?" "There are multiple treatment options for you to consider" "Can you explain the concerns you're having right now?"

"Can you explain the concerns you're having right now?"

During the completion of a health history with a nurse, a client reports intermittent chest pain for the past week. Which of the following questions is the nurse's priority? "Did you report the chest pain episodes to your physician?" "Is there a history of heart disease in your family?" "Have you had this pain before?" "Can you tell me what the pain felt like and show me exactly where it was?"

"Can you tell me what the pain felt like and show me exactly where it was?"

A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussions with the client? "Does the medication you're taking relieve the pain?" "Can you point to where the pain is the worst?" "What do you think caused the onset of your pain?" "Changing positions makes your pain worse, right?"

"Does the medication you're taking relieve the pain?" (The nurse is using a close-ended statement that generally elicits a one or two word response and is restrictive when seeking more information. Closed-ended questions are used to obtain information quickly in an emergency situation.) "Can you point to where the pain is the worst?" (The nurse is using a close-ended statement that generally elicits a one or two word response and is restrictive when seeking more information. The nurse should use the pain scale or have the client describe the pain to elicit an open-ended conversation.) CORRECT ANSWER "What do you think caused the onset of your pain?" (The nurse is using an open-ended question that allows the client to respond with a wide range of information by using more than one or two words.) "Changing positions makes your pain worse, right?" (The nurse is using a close-ended statement that generally elicits a one or two word response and is restrictive when seeking more information. Closed-ended questions are used to obtain information quickly in an emergency situation. The nurse should ask the client to describe which position facilitates the greatest relief of the pain to elicit an open-ended conversation.)

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month and may require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse share with the client? "Ask you provider to prescribe epoetin before the surgery" "You should ask your provider about taking iron supplements prior to the surgery" "Ask a family member to donate blood for you" "Donate autologous blood before the surgery"

"Donate autologous blood before the surgery" (the collection and reinfusion of the client's blood for the time of surgery)

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? "Drink a minimum of 1,000 milliliters of fluid daily." "Increase your intake of refined-fiber foods." "Sit on the toilet 30 minutes after eating a meal." "Take a laxative every day to maintain regularity."

"Drink a minimum of 1,000 milliliters of fluid daily." (The nurse should instruct the client to consume a minimum of 1,500 mL of fluid to prevent constipation.) "Increase your intake of refined-fiber foods." (The nurse should instruct the client to increase consumption of coarse-fiber and whole grains, rather than refined-fiber foods.) CORRECT ANSWER "Sit on the toilet 30 minutes after eating a meal." (Increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 min after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation.) "Take a laxative every day to maintain regularity." (The nurse should not recommend intake of daily laxatives because consistent use hinders natural defecation habits and can cause constipation, rather than cure it.)

A nurse is planning an in-service training session about nutrition. Which of the following statements should the nurse include in the teachings? "Fats provide energy" "Carbohydrates repair body tissue" "Fats regulate fluid balance" "Carbohydrates prevent interstitial edema"

"Fats provide energy" (9cal/g of energy) INCORRECT: "Carbohydrates repair body tissue"--> PROTEIN "Fats regulate fluid balance"--> PROTEIN "Carbohydrates prevent interstitial edema"--> ALBUMIN aka protein

A nurse is caring for an adult client who communicates an unmet spiritual need. Which of the following client statements should indicate to the nurse that the client is experiencing spiritual distress? "Life has its ups and downs" "I believe that I control my own destiny" "God is punishing me for something" "I like to keep my rosary beads in bed with me"

"God is punishing me for something"

A nurse is teaching a client how to use an albuterol metered-dose inhaler. After removing the cap from the inhaler and shaking the canister, what sequence of instructions should the nurse give the client? Place in order "Depress the canister while taking a slow, deep breath" "Hold the mouthpiece 1-2 inches in front of your mouth" "Tilt your head back and slightly open your mouth wide" "Hold your breath for 10 mins"

"Hold the mouthpiece 1-2 inches in front of your mouth" "Tilt your head back and slightly open your mouth wide" "Depress the canister while taking a slow, deep breath" "Hold your breath for 10 mins"

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription states, "clear liquids; advance diet as tolerated". Which of the following responses should the nurse make? "Lunch trays should be here within the hour" "I am going to listen to your abdomen" "Ill get you some water to drink" "Let's wait a bit so you don't feel sick"

"I am going to listen to your abdomen" (to determine the presence of bowel signs before clear liquids can be administered)

A nurse is planning to insert a nasogastric tube for a client after explaining the procedure the client states, "You are not putting that hose down my throat" Which of the following statements should the nurse make? "Lets get the process over with bc you won't get better without this tube" "You should talk to your provider about your fears" "Why don't you want this tube inserted" "I can see that this is upsetting you"

"I can see that this is upsetting you"

A nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? "Ill limit pushing the button so I don't get an overdose" "If I push the button and still have pain after 2 mins, Ill push it again" "Ill ask my niece to push the button when I am sleeping" "I can still use my transcutaneous electrical nerve stimulation unit while Im pushing the PCA button"

"I can still use my transcutaneous electrical nerve stimulation unit while Im pushing the PCA button" (nurse should encourage the use of non-pharmacological methods to reduce the amount of opioid dosing)

A nurse is caring for a client who has injuries resulting from a motor-vehicle crash. Which of the following client statements should the nurse address first? "I'm afraid this injury will cause my to lose my job" "I can't sleep well because whenever I move in my sleep the pain wakes me up" "I don't know what I will do if my car isn't safe or even drivable after the crash" "I wonder how I am going to be able to take care of my family"

"I can't sleep well because whenever I move in my sleep the pain wakes me up"

A nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student should the nurse identify as a potential problem with achieving Erikson's developmental task for this age group? "I am in no hurry to get married. I think ill enjoy being single for a while" "I go on the weekends to be with my family because I do not have any good friends here on campus" "I am interested in politics and may consider becoming an elected official" "I am looking forward to finishing school and going to work for my family's business"

"I go on the weekends to be with my family because I do not have any good friends here on campus"

A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? "My parents are retired, and they have come to help with our children" "I am going to ask my husband to go to counseling with me" "I keep having nightmares about my upcoming surgery" "My girlfriends bought me a nice wig"

"I keep having nightmares about my upcoming surgery"

A nurse in a provider's office is talking with an older adult client who reports having trouble sleeping. Which of the following statements should the nurse identify as a possible cause of the client's sleeping difficulties? "I take a warm shower when getting ready for bed" "I often have a cup of coffee with my dessert before going to bed" "I usually read a chapter in a book before I go to bed" "I make sure I do my exercises in the morning"

"I often have a cup of coffee with my dessert before going to bed"

A nurse is teaching a group of older-adults about expected age-related changes. Which of the following statements by a group member indicates that the teaching has been effective? "I should expect my heart rate to take longer to return to normal after exercise as I get older." "Urinary incontinence is something I will have to live with as I grow older" "I can expect to have less ear wax as I get older" "My stomach will empty more quickly after meals as I grow older"

"I should expect my heart rate to take longer to return to normal after exercise as I get older."

A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin. Which of the following questions should the nurse ask the encourage discussion with the client? "Does the medication you're taking relieve the pain?" "Can you point to where the pain is the worse?" "What do you think caused the onset of your pain?" "Changing positions makes your pain worse, right?"

"What do you think caused the onset of your pain?"

A nurse is caring for a middle-aged adult client. The nurse should identify which of the following statements as an indication that the client has completed Erikson's developmental task for her age group? "I am comfortable with my decision to choose a lifelong partner" "I think I have done a good job with my children since they are all independent now" "As I look back over my life, I can see that I have achieved most of the goals I set for myself" "I love my work so much that it is difficult to think about retirement"

"I think I have done a good job with my children since they are all independent now" (middle adults--> generativity vs. stagnation)

A charge nurse is providing teaching to a newly licensed nurse about removing sutures from a client's laceration. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? "I will use a staple remover and remove each suture individually" "Bandage scissors are used to cut the sutures" "Tweezers are necessary only for removing retention sutures" "I will clip each suture close to the skin and pull it through from the other side"

"I will clip each suture close to the skin and pull it through from the other side" (does not disrupt wound healing" INCORRECT: "I will use a staple remover and remove each suture individually" =removes staples not sutures "Bandage scissors are used to cut the sutures"= too blunt and tip is loo large "Tweezers are necessary only for removing retention sutures"= not retention sutures

A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching? "I will have the steps to my house painted a dark color" "I will put a night-light in the hallway" "I will put on socks when I get out of bed" "I will secure any wires in my home under rugs"

"I will put a night-light in the hallway"

A nurse is teaching client who is postoperative about the importance of turning, coughing, and breathing deeply. Which of the following statements should the nurse identify as an indication that the client understands the instructions? "If I do this often, I wont experience muscle wasting" "If I do this often, I wont get pneumonia" "If I do this often, I wont get constipation" "If I do this often, I wont have a fast heartbeat"

"If I do this often, I wont get pneumonia" (to prevent respiratory complications)

A nurse is reviewing the use of side rails with an assistive personnel. Which of the following statements by the AP indicates that further teaching is required? "I should not leave all 4 side rails up unless there is a prescription for restraints" "An alert client will be safest if I raise the 2 upper side rails at the head of the bed" "If a client seems confused, Ill raise 4 side rails so that he doesn't hurt himself" "If a client is sedated, I should raise all 4 side rails to prevent a fall out of bed"

"If a client seems confused, Ill raise 4 side rails so that he doesn't hurt himself" (this would put them at greater risk for injury)

A nurse is instructing a client about collecting a 24 hour urine specimen for creatine clearance. Which of the following statements should the nurse identify as an indication that the client understands the procedure? "The next time I urinate will be the first specimen of the collection" "Ill make sure to keep the collection bottle in the container of ice they gave me" "Once the container is half full, I no longer have to add any more urine" "Its ok if a piece of toilet paper gets in the bottle. The lab people will remove it when they do the test"

"Ill make sure to keep the collection bottle in the container of ice they gave me" (must be remained chilled to prevent change in the composition)

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home which of the following statements should the nurse identify as an indication that the client understands medical asepsis? "Ill wrap the old dressing in a paper bag and put it in the trash" "Ill wash my hands before I remove the old dressing and again before putting on the new one" "Ill need to take a pain pill 30 mins before I change the dressing" "Ill wear sterile gloves when I apply the new dressing"

"Ill wash my hands before I remove the old dressing and again before putting on the new one"

A nurse is teaching a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching "Ill wear nonsterile gloves" "Ill use adhesive remover each time" "Ill take my pain pill after I change the dressing" 'Ill fold the dressing with the soiled surface facing outward"

"Ill wear nonsterile gloves"

A nurse is providing teaching about nutritious diets to a group of adult women. Which of the following statements should the nurse include? "Include at least 3 g of sodium in your daily diet" "Limit wine consumption to 230mL daily" "Include 2.5 cups of vegetables in your daily diet" "Limit water intake to 1.5 L each day"

"Include 2.5 cups of vegetables in your daily diet"

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps relieve pain. Which of the following responses should the nurse make? "It provides a distraction from the pain" "It modulates the transmission of the pain impulse" "It promotes increased circulation to the painful area" "It elicits a relaxation response"

"It modulates the transmission of the pain impulse"

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps to relieve pain. Which of the following responses should the nurse make? "It provides a distraction from the pain" "It modulates the transmission of the pain impulse" "It promotes increased circulation to the painful area" "It elicits a relaxation response"

"It modulates the transmission of the pain impulse" (applies low-voltage electrical stimulation directly over a location of pain at an acupressure point; it modulates the transmission of the pain impulse and can also cause a release of endorphins to assist with pain relief) INCORRECT: Distraction methods= visual, auditory, tactile, and intellectual distraction Massage= relaxation but wont relieve pain like a TENS unit

A nurse is measuring the blood pressure of several clients. Which of the following results is within the expected reference range for blood pressure? 142/85 mmHg 116/70 mmHg 130/76 mmHg 124/82 mmHg

116/70 mmHg

A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? "A lot of clients who are cared for at home have the same problem" "Dont worry about it. He will get a bath and that will take care of the odor" "It must be difficult to care for someone who is confined to a bed" "When was the last time that he had a bath?

"It must be difficult to care for someone who is confined to a bed"

A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying? "Now that we have talked about your medications, lets talk about your pain" "Are you having any other symptoms?" "It sounds like your pain is intermittent." "It seems as though you have really had a rough time these past few weeks."

"It sounds like your pain is intermittent."

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make? "It's for your safety. Dentures can slip and block your airway during surgery." "You wouldn't want your teeth to be lost or broken during surgery, would you?" "The anesthesiologist requires everyone to remove their dentures." "What worries you about being without your teeth?"

"It's for your safety. Dentures can slip and block your airway during surgery." (This represents the nontherapeutic communication technique of ignoring or dismissing the client's feelings. It does not address the client's agitation.) "You wouldn't want your teeth to be lost or broken during surgery, would you?" (This represents the nontherapeutic communication technique of disagreeing with the client and offering unsolicited advice. It does not address the client's agitation.) "The anesthesiologist requires everyone to remove their dentures." (This represents the nontherapeutic communication technique of focusing on inappropriate issues or individuals (the anesthesiologist). It does not address the client's agitation.) CORRECT ANSWER "What worries you about being without your teeth?" (This response by the nurse is therapeutic because it validates the client's feelings of agitation and seeks a reason for it.)

A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods". Which of the following statements should the nurse make? "During this phase, feed your child anything that she will eat" "Increase the amount of calories and water your child consumes" "Keep a diary of the foods your child eats each day" "Provide a large variety of fruit juices for your child to choose from"

"Keep a diary of the foods your child eats each day"

A nurse is providing teaching about crutches to a client who has a fracture of the right foot. Which of the following instructions should the nurse include? "When you go up a flight of stairs, place your right foot on the first step" "Keep the rubber crutch tips securely in place" "When standing, keep the crutches 12in in front of you and 12in to the side" "Place your weight on the crutch pads at your armpits"

"Keep the rubber crutch tips securely in place"

A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care? "Social services can contact various community resources that will be helpful" "I will review the care plan the make the necessary changes "Lets set up a meeting time with the doctor to discuss your options for home care" "I will make a list of things we need to do before discharge"

"Lets set up a meeting time with the doctor to discuss your options for home care"

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make? "Lunch trays should be here within the hour." "I am going to listen to your abdomen." "I'll get you some water to drink." "I would wait a bit, or you could feel sick."

"Lunch trays should be here within the hour." (This response is the nontherapeutic because it indicates that the client's immediate needs are not important.) CORRECT ANSWER "I am going to listen to your abdomen." (A common reason clients experience nausea and vomiting after surgery is delayed gastric emptying time or decreased peristalsis. The nurse should auscultate the client's abdomen to determine the presence of bowel sounds before clear liquids can be administered.) "I'll get you some water to drink." (When a client is ready to resume a postsurgical diet, it is preferable to offer a choice of clear liquids, rather than water. Water provides hydration, but no other nutrients.) "I would wait a bit, or you could feel sick." (This response reflects the nontherapeutic communication response of offering unsolicited advice to the client.)

A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? "My parents are retired, and they have come to help out with our children." "I am going to ask my husband to go to counseling with me." "I keep having nightmares about my upcoming surgery." "My girlfriends bought me a nice wig."

"My parents are retired, and they have come to help out with our children." (Clients who have social and emotional support systems tend to experience less psychological distress.) "I am going to ask my husband to go to counseling with me." (Open communication is an important method to improve relationships that might be strained. Seeking counseling is a positive strategy.) CORRECT ANSWER "I keep having nightmares about my upcoming surgery." (Nightmares and sleep disturbances are manifestations of anxiety and post-traumatic stress disorder. These indicate that the client is at risk for experiencing psychological distress.) "My girlfriends bought me a nice wig." (Clients who have social and emotional support systems tend to experience less psychological distress.)

A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure? "Inhale forcefully during the insertion" "Raise your index finger if you need to pause during the insertion" "Bear down during the insertion" "Avoid making any swallowing motions during the insertion"

"Raise your index finger if you need to pause during the insertion" (tell them it is uncomfortable and the gag reflex will be activated during the procedure so establishing a communication technique is vital)

A nurse is providing teaching to an older adult client who has constipation. Which of the following statement should the nurse include in the teaching? "Drink a minimum of 1,000 mL of fluid daily" "Increase your intake of refined-fiber foods "Sit on the toilet 30 mins after eating a meal" "Take a laxative every day to maintain regularity"

"Sit on the toilet 30 mins after eating a meal" INCORRECT: Should be 1,500mL

A community health nurse is conducting a class about body mechanics for county office workers. Which of the following instructions should the nurse include? Select all that apply "Sit with your back supported" "Keep your knees at hip level" "Use an ergonomically designed computer key board" "Keep your elbows away from your body" "Adjust the monitor screen so that you have to tilt your head slightly to look at it"

"Sit with your back supported" "Keep your knees at hip level" "Use an ergonomically designed computer key board"

An adolescent client in an outpatient mental health facility tells the nurse that he struggles to follow his treatment plan because his friends discourage him. Which of the following statements should the nurse make? "Dont worry; teenagers often have friends who give bad advice" "I think you should stop seeing those friends since they discourage you from following your treatment plan" "Tell me more about how your friends discourage you" "Where did you meet these friends?"

"Tell me more about how your friends discourage you"

A nurse is providing discharge teaching for a client who has type 2 diabetes mellitus and will be caring for herself at home. The client expresses concerns about preparing an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse offer? "The home health dietician will visit and help you learn to cook all over again" "The dietitian will give you a list of foods and dietary choices to keep your diabetes under control" "The dietitian will help you choose foods you are used to that also meet your health needs" "It may be difficult, but I know you can change your eating and cooking habits with help from the dietitian"

"The dietitian will help you choose foods you are used to that also meet your health needs"

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP "The reading will be inaudible if the cuff is too small for the client." "The width of the cuff bladder should be 75% of the circumference of the client's arm." "As long as the cuff will circle the arm the reading will be accurate." "Using a cuff that is too small will result in an inaccurately high reading."

"The reading will be inaudible if the cuff is too small for the client." (Although the blood pressure reading for a client who is obese may be difficult to hear with any cuff, a cuff that is too small for the client will not yield an inaudible reading.) "The width of the cuff bladder should be 75% of the circumference of the client's arm." (The width of the cuff bladder should be 40% of the circumference of the client's arm.) "As long as the cuff will circle the arm the reading will be accurate." (A cuff that is an incorrect size for the client will not yield an accurate reading.) CORRECT ANSWER "Using a cuff that is too small will result in an inaccurately high reading." (Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. Blood pressure readings can be falsely high if the cuff is too small for the client.)

A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? "There are times I should use soap and water rather than alcohol based hand rub to clean my hands." "I will use cold water when. i wash my hands to protect my skin from becoming too dry" "I will apply friction for at least 10 secs while washing my hands" "After washing my hands, I will dry them from the elbows down"

"There are times I should use soap and water rather than alcohol based hand rub to clean my hands."

A nurse is teaching a client who has urinary incontinence about bladder retraining. Which of the following instructions should the nurse include? "Wake up every 2 hr to urinate during the night" "Drink citrus juices throughout the day" "Try to block the urge to urinate until the next scheduled time" "Limit fluids to no more than 1 L (34oz) during waking hours"

"Try to block the urge to urinate until the next scheduled time" (they are following a schedule so they should try slow, deep breathing to help reduce the urge OR 5-6 strong and quick pelvic muscles exercises)

A nurse observes an AP preparing to obtain blood pressure with a regular-sized cuff for a patient who is obese. Which of the following explanations should the nurse give the AP? "The reading will be inaudible if the cuff is too small for the client" "The width of the cuff bladder should be 75% of the circumference of the client's arm" "As long as the cuff will circle the arm, the reading will be accurate" "Using a cuff that is too small will result in an inaccurately high reading"

"Using a cuff that is too small will result in an inaccurately high reading"

A middle-aged client is discussing future plans with the nurse. Which of the following statements should the nurse identify as an indication that the client is having difficulty achieving Erikson's developmental task for this age group? "We miss out daughter so much that we are going to move closer to her" "I think this year I can plan on managing the funding at the church" "I really wish I could lose some of this weight" "I find I am spending more time at work now that my son is at college"

"We miss out daughter so much that we are going to move closer to her"

A nurse is teaching a client how to perform ROM exercises of the wrist. To perform adduction, which of the following instructions should the nurse include? "With your palm facing down, move your wrist sideways toward your thumb" "Move your palm toward the inner part of your forearm" "With your palm facing down, move your wrist sideways toward your little finger" "Bring the back of your hand as far back toward the wrist as you can"

"With your palm facing down, move your wrist sideways toward your thumb" INCORRECT: "Move your palm toward the inner part of your forearm"= flexing "With your palm facing down, move your wrist sideways toward your little finger" =abducting "Bring the back of your hand as far back toward the wrist as you can"= hyperextending

A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make? "You look just fine to me" "Nobody expects you to look beautiful in the hospital" "I understand how you feel. I would feel the same way" "Would you like to talk about how you feel?"

"Would you like to talk about how you feel?"

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning how to self-inject insulin. Which of the following statements should the nurse make? "tell me what I can do to help you overcome your fear of giving yourself injections" "your provider will not be pleased that you refuse to give the insulin injection to yourself" "its ok, im sure your partner will be able to learn how to give the insulin injections" "You wont be able to go home unless you learn to give yourself insulin injections"

"tell me what I can do to help you overcome your fear of giving yourself injections"

A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? Wash the gloved hands and then throw the gloves away. Prepare an incident report to document the event. Carefully remove the gloves and follow with hand hygiene. Ask the provider to order a blood culture to determine the risk of infection

(Wash the gloved hands and then throw the gloves away. (Washing the hands while still gloved is not a recommended action.) Prepare an incident report to document the event. (Unless there is a break in the nurse's skin, there is no need for an incident report or further investigation.) CORRECT ANSWER Carefully remove the gloves and follow with hand hygiene. (Standard precautions require the use of gloves and hand hygiene in the care of all clients.) Ask the provider to order a blood culture to determine the risk of infection. (Unless there is a break in the nurse's skin, there is no need for further investigation.)

A nurse is preparing to change a dressing on a client who is receiving negative pressure wound therapy (NPWT). What sequence of actions should the nurse plan to take? Place them in order Apply a skin protectant or a barrier film to the skin around the wound Turn off the vacuum on the NPWT device and administer the prescribed analgesic Connect the tubing to the transparent film and turn on the NPWT unit Place prepared foam into the wound bed and cover with a transparent dressing Apply sterile or clean gloves and irrigate the wound Remove the soiled dressing and perform hand hygiene

1) Turn off the vacuum on the NPWT device and administer the prescribed analgesic 2)Remove the soiled dressing and perform hand hygiene 3)Apply sterile or clean gloves and irrigate the wound 4)Apply a skin protectant or a barrier film to the skin around the wound 5)Place prepared foam into the wound bed and cover with a transparent dressing 6)Connect the tubing to the transparent film and turn on the NPWT unit

A nurse is assessing a client's nutritional status. The nurse determines the client is consuming 500 calories more per day than his energy levels require. If his dietary habits do not change, how long will it take the client to gain 4.5 kg (10lb)? 10 months 5 months 5 weeks 10 weeks

10 weeks: 1 lb of body fat= 3,500 calories

A nurse is caring for a client who is receiving dextrose 5% in water IV at 150 mL/hr and has ingested 4 oz of water and 1/2 pint of milk. What is the total 8-hr fluid intake in millimeters that the nurse should document for this client?

1560 1oz/30ml= 4oz/Xml x=120 1pint/480mL= 0.5 pint/XmL x=240 150ml x 8 hr= 1200 ml+ 120 ml+ 240 ml= 1560 mL

A nurse is preparing to administer sotalol to a client with a prescription for 320 mg/day divided equally every 12 hour. The medication is available in 80 mg tablets. How many tablets should the nurse administer per dose?

2 Have/ Quantity= Desired/X 80mg/1 tablet= 320 mg/X tablet X=4???

A nurse is assessing the pH of a client's gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect? 6 2 10 8

2 (0-4 for gastric secretion) ACIDIC INCORRECT: 6= lungs 10=false reading 8=intestines

A nurse is teaching that parent of a child who is to take 30mL of liquid medication. The parent has a hollow medication spoon that has marks to indicate teaspoons and tablespoons. How many tablespoons of medication should the nurse instruct the parent to give the child?

2 tbsp 15mL/1 tbsp = 30 ml/X tbsp 15X=30 X=2

A nurse is teaching the parent of a child who is to take 10 mL of a liquid medication. The parent has a hollow medication spoon with marks to indicate teaspoons and tablespoons. How many teaspoons should the nurse instruct the parent to give the child?

2 tsp 5mL/1 tsp= 10 mL/Xtsp 5X=10 X=2

A nurse is calculating a client's intake for a 12 hour shift. The client had dextrose 5% in 0.45% sodium chloride infusing at 125 mL/hr, gentamicin 150 mg in 100 mL at 1400, ranitidine 50 mg in 50 mL at 1000 and 1600, 250 mL every 2 hours. What is the total intake in millimeters the nurse should document for this 12 hour period.

2130 125ml x 12hr= 1500+100+(50 x 2=100)+250+ (30 x 6= 180)= 2130

A nurse is preparing to administer 700mL of 0.9% sodium chloride IV to a child to infuse over 24 hours. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min (round to nearest whole number)?

29 RATIONALE: 1,440 mins= 24 hours 700mL/1440min x 60 gtt/mL= 29

After assessing a client, the nurse documents "1+ pedal edema bilaterally". This indicates that the nurse observed an indentation of which of the following depths after applying pressure? 2mm 4mm 6mm 8mm

2mm INCORRECT: 4mm=2+ 6mm=3+ 8mm=4+

A nurse at a screening clinical is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? 5th intercostal space just medial to the midclavicular line 2nd intercostal space to the left of the sternum 5th intercostal space to the left of the sternum 2nd intercostal space to the right of the sternum

2nd intercostal space to the right of the sternum

The nurse is preparing to administer 40 mL of 0.9% sodium chloride IV to infuse over 20 min. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

30 Volume (ml)/Time (min) x drop factor (gtt/mL)= X 40 mL/20 min x 15 gtt/mL = X gtt/min X=30

A nurse is calculating the protein needs of a young adult client who weighs 132 lbs. The RDA for protein for an adult who has no medical conditions is 0.8 g/kg. How many grams of protein per day should the nurse recommend for this client? Fill in the blank

48 g 132/2.2=60 kg 60 kg x 0.8 g= 48 g

A nurse is monitoring a client's fluid intake. For breakfast, the client consumed 8oz of milk, 10oz of water, 4 oz of flavored gelatin, 1 scrambled egg, 1 crisp piece of bacon, and 2 biscuits with jelly. How many mL should the nurse record as the client's fluid intake?

660mL

A nurse is caring for a client whose intake and output flow sheet for 0700 to 1500 indicates the following: voided x3: 350 mL, 200 mL, 150 mL; wound drainage 2 tsp; and emesis 2 oz. What total output in millimeters should the nurse document for this 8 hr period?

770

A client has 1 L of dextrose 5% in 0.45% sodium chloride infusing IV at 125 mL/hr. How many hours will it take for the liter to infuse?

8 1L=1000mL volume(ml)/time(hr)= X 1000ml/X hr= 125ml/hr x=8hr

A nurse is caring for a client who requires fluid restriction and may drink only 1 oz of water with each oral medication. How many millimeters of water should the nurse document as intake for the 3 separate medications the client receives during 12 hr shift?

90 1oz/30ml= 3oz/X ml x=90

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following pieces of information should the nurse include? A 2 month old infant can turn from his abdomen to his back A 10 month old infant can pull up to a standing position A 4 month old infant can sit up without support A 6 month old infant can crawl on his hands and knees

A 10 month old infant can pull up to a standing position

A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? A client who has a prescription for a transfusion of packed red blood cells A client who is being transported for a radiograph of the kidneys, ureters, and bladder A client who has a prescription for a tuberculin skin test A client who has distended bladder and need urinary catheterization

A client who has a prescription for a transfusion of packed red blood cells (procedure carries risks)

A nurse is caring for a group of clients in a long-term care facility. The nurse should understand that which of the following clients is eligible for hospice services at this time? A client who has multiple sclerosis and uses a wheelchair A client who has end-stage cirrhosis A client who has hemiplegia due to a stroke A client who has cancer and receives weekly radiation therapy

A client who has end-stage cirrhosis (life expectancy <6 months)

A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A client who has heart failure and is receiving 100% oxygen via partial rebreather mask A client who has emphysema and is receiving oxygen at 3L/min via transtracheal oxygen cannula A client who has an old trachestomy and is receiving 40% humidified oxygen via tracheostomy collar A client who has COPD and is receiving oxygen at 2L/min via nasal cannula

A client who has heart failure and is receiving 100% oxygen via partial rebreather mask

A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative. Which of the following clients should the nurse see first? A client who is 1 day postoperative following a lobectomy for small-cell carcinoma and has a chest tube with 35 mL/hr of bright red, bloody drainage A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage A client who is 2 days postoperative following the excision of an abdominal mass and has a portable wound suction device with 20 mL/hr of serosanguinous drainage A client who is 1 day postoperative following the excision of a bladder wall tumor and prostate and has continuous bladder irrigation with 300 mL/hr reddish-pink urine

A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage (ostomy bag full of blood means the clients bowel is hemorrhaging and to report it ASAP)

A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect? Frequent bowel sounds with flatus Absent bowel sounds with distention Hyperactive bowel sounds with diarrhea Normal bowel sounds with increased peristalsis

Absent bowel sounds with distention (paralytic ileus=immobile bowel)

A nurse asks a client to explain the statement, "A bird in the hand is worth two in the bush". Through this question, the nurse is evaluating the client's ability in which of the following intellectual functions? Judgement Short-term memory Attention span Abstract reasoning

Abstract reasoning

A nurse is caring for a group of clients in a long-term care facility. One of the client is walking along the hallway and bumping into walls and does not respond to his name. Which of the following actions should the nurse take first? Offer the client a nutritious snack Accompany the client back to his room Reorient the client to his surroundings Administer a PRN anti anxiety med

Accompany the client back to his room

A nurse is supervising a newly licensed nurse who is suctioning a client's tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? Using clean technique to perform the procedure Apply suction while inserting the catheter Lubricating the suction catheter with an oil-based lubricating jelly Administering high-flow oxygen prior to the procedure

Administering high-flow oxygen prior to the procedure (3-4 breaths of 100% oxygen via a resuscitation bag before suctioning to reduce the risk of hypoxia) INCORRECT: Using clean technique to perform the procedure= STERILE Apply suction while inserting the catheter= insert GENTLY Lubricating the suction catheter with an oil-based lubricating jelly = STERILE SALINE

A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. Which of the following actions should the nurse take? Tell the client the provider does not want her to remain in bed Allow the client to remain in bed until her pain subsides Instruct the family to perform ADLs for the client Advise the client to perform ROM exercises while in bed

Advise the client to perform ROM exercises while in bed

A nurse is assisting a client who has dysphagia at meal times. Which of the following actions should the nurse take? Assist the client into a semi-sitting position Have the client lean slightly backward Advise the client to tuck his chin downward Instruct the client to tilt his head slightly backward

Advise the client to tuck his chin downward

A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear? Air conduction is less than bone conduction in the left ear Air conduction is greater than bone conduction in the left ear Sound is lateralizing to the right ear Sound is lateralizing to the left ear

Air conduction is less than bone conduction in the left ear (indicates hearing loss in the LEFT ear) INCORRECT: C,D results of the Weber test

A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate? Airborne Droplet Contact Protective environment

Airborne

A nurse is admitting a client who has TB. In addition to standard precautions, which of the following transmission-based precautions should the nurse add to the client's plan of care? Protective Airborne Droplet Contact

Airborne (ex. measles/varicella)

A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first? Pain level Hydration status Airway Urinary output

Airway

A nurse is caring for a client who is well-hydrated and has no visible evidence of nutritional deficiencies. A laboratory result within the expected reference range for which of the following substances indicates adequate protein uptake and synthesis? Albumin Calcium Sodium Potassium

Albumin

A nurse on a medical unit is caring for a client who has difficulty sleeping. Which of the following actions should the nurse take to promote the client's ability to fall asleep? Encourage the client to ambulate in the hallway just before bedtime Allow the client to maintain the same bedtime routine as at home Keep the room temperature warm Offer the client a cup of hot chocolate

Allow the client to maintain the same bedtime routine as at home

A nurse is teaching a client who is postoperative following a knee arthroplasty about the muscle he will need to strengthen in physical therapy. Which of the following muscle groups is responsible for movement at the knee joint? Antigravity Antagonistic Synergistic Skeletal

Antagonistic INCORRECT: Antigravity=stabilizing the knee joint Synergistic=contracting in sync Skeletal=support and posture

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile techniques? Applies sterile gloves to open catheter package Wipes the labia minora in an anteroposterior direction Spreads the labia with the dominant hand Uses one cotton ball to wipe the right and left labia majora

Applies sterile gloves to open catheter package (The nurse should apply sterile gloves after opening the catheter package to maintain aseptic technique, because the outside of the package is not considered sterile.) CORRECT ANSWER Wipes the labia minora in an anteroposterior direction (The nurse should wipe anteroposterior both the right and left labia minora with separate cotton swabs to destroy any microorganisms in the area that would contaminate the catheter.) Spreads the labia with the dominant hand (The nurse should use the nondominant hand to spread the labia and provide the optimal view of the urethral meatus. The nondominant hand is considered contaminated once the hand touches the client's skin.) Uses one cotton ball to wipe the right and left labia majora (The nurse should use a separate cotton ball to wipe the right and left labia majora to destroy any microorganisms on the skin surface that would contaminate the catheter.)

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? Apply a fecal collection system. Apply a barrier cream. Cleanse and dry the area. Check the client's perineum.

Apply a fecal collection system. (The nurse should apply a fecal collection system to divert the feces away from the area of skin irritation; however, there is another action the nurse should take first.) Apply a barrier cream. (The nurse should apply a barrier cream to decrease skin breakdown in the perianal area from the feces; however, there is another action the nurse should take first.) Cleanse and dry the area. (The nurse should cleanse and dry the perianal area to decrease further skin irritation; however, there is another action the nurse should take first.) CORRECT ANSWER Check the client's perineum. (Caring for this client requires application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. The priority nursing action is for the nurse to collect more data by assessing the area of irritation.)

A nurse is using a portable ultrasound bladder scanner to measure a client's post-void residual volume. Which of the following actions should the nurse take? Have a client urinate 20 min before the scan Assist the client into a semi-Fowler's position Position the scanner head at the symphysis pubis Apply light pressure to the scanner head once it is in position

Apply light pressure to the scanner head once it is in position (hold it steady while pointing it slightly down toward the client's bladder) INCORRECT: Have a client urinate 20 min before the scan--> should be 10 MIN before Assist the client into a semi-Fowler's position--> SUPINE position Position the scanner head at the symphysis pubis--> ABOVE the symphysis pubis

A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take? Instruct the client to blink several times after instilling the medication Ask the client to look straight ahead during instillation of the medication Apply pressure to the puncta after instilling the medication Place the eye drop of the medication directly onto the client's cornea

Apply pressure to the puncta after instilling the medication (1-2 min)

A nurse in an urgent-care center is caring for a 15 year-old client whose symptoms suggest a sexually transmitted infection (STI). The client's parent is unavailable, but the client's grandmother accompanied the client to the clinic. Which of the following actions should the nurse take? Explain that the treatment can wait until the parent is available Inform the grandmother that she may give consent for the treatment Invoke the principle of implied consent and prepare the client for treatment Ask the adolescent to sign the consent form

Ask the adolescent to sign the consent form

A nurse in an emergency department is caring for a client who reports developing severe eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first? Instill proparacaine hydrochloride eye drops Perform ocular irrigation of the right eye Place the client in a supine position with the head turned toward the affected side Ask the client about first aid performed at the scene

Ask the client about first aid performed at the scene (must collect adequate data from the client like if eye irrigation was performed in order to proceed)

A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first? Document the client's food allergies in the medical record Ask the client to identify the specific food allergies Monitor the client for indications of anaphylaxis Have epinephrine available for administration

Ask the client to identify the specific food allergies

A nurse is caring for a client who has a terminal illness. The client is restless and reports sever pain but refused the prescribed opioid pain medication. Which of the following actions should the nurse take first? Ask why the client is refusing the pain medication Administer a PRN anti-anxiety medication Help the client change positions Offer the client a heat or cold pack to place on the painful area

Ask why the client is refusing the pain medication (assess the reason for refusal of meds)

A nurse is supervising a newly licensed nurse who is administering a controlled substance. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? Placing an unused portion of the medication in a sharp box Asking another nurse to observe the disposal of an unused portion of the medication Counting the inventory of the available narcotic after administering the medication Ensuring that another nurse signs the control inventory form disposal of an unused portion of medication

Asking another nurse to observe the disposal of an unused portion of the medication (they should witness to maintain safe control of the narcotic) INCORRECT: Placing an unused portion of the medication in a sharp box--> NO Counting the inventory of the available narcotic after administering the medication--> count before Ensuring that another nurse signs the control inventory form disposal of an unused portion of medication--> 2 nurses should sign

A nurse discovers that a client received the wrong medication. Which of the following actions should the nurse take first? Complete a medication error report Notify the prescribing provider Assess the client Notify the charge nurse

Assess the client

A nurse in a provider's clinic is taking a client's age, height, weight, and vital signs. The nurse should identify this action as part of which of the following components of the nursing process? Planning Evaluation Assessment Implementation

Assessment

A nurse on a medical-surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client's record first? Assessment Plan of care Nursing interventions performed Evaluation of progress

Assessment

A nurse is using the I-SBAR communication tool to give a client's provider information about the client. The nurse should convey this client's pain status in which portion of the report? Assessment Background Situation Recommendation

Assessment INCORRECT: Background (medical history) Situation (probs they are experiencing) Recommendation (for treatment)

A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis an is on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions? Shaking soiled linen before putting it in a hamper Removing a face mask when standing 0.5m (1.6ft) from the client Assigning another client with the same infection to share the room with the client Allowing the client to visit a family member in the lobby of the facility

Assigning another client with the same infection to share the room with the client INCORRECT: Removing a face mask when standing 0.5m (1.6ft) from the client--> 3.3 FEET

A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states "It's too late for me to quit". Which of the following actions should the nurse take? Assist the client in finding local smoke-cessation assistance programs Tell the client that she will be all right after receiving medical care Inform the client that she must stop smoking or the provider will not be able to care for you Advocate for the client by supporting her statement about not quitting

Assist the client in finding local smoke-cessation assistance programs

A nurse is beginning a therapeutic relationship with a client. Which of the following actions should the nurse take to convey empathy when using the therapeutic communication technique of active listening? Assume an open position Sit upright and lean back into the chair Avoid direct eye contact until the client makes it Sit next to the client

Assume an open position (sit with arms and legs uncrossed)

A nurse is planning weight-loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? Attempt to increase the client's self-motivation Keep detailed records of each client's progress Test client learning after each teaching session Avoid discussing topics that might increase client's anxiety

Attempt to increase the client's self-motivation

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? Auscultate for the blood pressure at the dorsalis pedis artery. Measure the blood pressure with the client sitting on the side of the bed. Place the cuff 7.6 cm (3 in) above the popliteal artery. Place the bladder of the cuff over the posterior aspect of the thigh.

Auscultate for the blood pressure at the dorsalis pedis artery. (The nurse should auscultate for the blood pressure at the popliteal artery.) Measure the blood pressure with the client sitting on the side of the bed. (The nurse should measure the blood pressure with the client prone if possible. Otherwise, the client should lie supine with the knee flexed.) Place the cuff 7.6 cm (3 in) above the popliteal artery. (The nurse should position the cuff 2.5 cm (1 in) above the popliteal artery.) CORRECT ANSWER Place the bladder of the cuff over the posterior aspect of the thigh. (This is the correct position for the nurse to place the bladder of the cuff when measuring a lower extremity blood pressure.)

A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse use next when assessing the client's abdomen? Auscultation Light palpation Percussion Deep palpation

Auscultation (palpate/percuss after in order to not stimulate bowel sounds and create a false result)

A nurse is assessing a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries? Palpation of both carotid arteries simultaneously Auscultation of the arteries for bruits with the bell of the stethoscope Palpation of the arteries for murmurs bilaterally Auscultation of the arteries for thrills with the diaphragm of the stethoscope

Auscultation of the arteries for bruits with the bell of the stethoscope (the bell is more effective than the diaphragm in transmitting blowing or swishing sounds)

A nurse rates a client's biceps reflex as 2+. Which of the following characteristics should the nurse document about the client's reflexes? Diminished Average Brisk Hyperactive

Average (0-4+ is the range) INCORRECT: Diminished= 1+ Brisk= 3+ Hyperactive= 4+

A nurse is taking a client's vital signs. Which of the following findings should the nurse identify as outside the expected reference range? Pulse rate 90/min Rectal temp 38C (100.4F) Pulse ox 95% BP 145/90 mmHG

BP 145/90 mmHG

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse have the client perform just before inserting the catheter? Swallow water Prepare for a painful sensation Hold her breath Bear down gently

Bear down gently

A nurse is performing a focused assessment of a client's peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse? Below the medial malleolus In the popliteal fossa In the antecubital space On the dorsum of the foot

Below the medial malleolus (curve the fingers around the medial malleolus on the inner surface of the client's ankle)

A nurse in a provider's office is teaching a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching? Select all that apply Canned peaches White rice Black beans Whole-grain bread Tomato juice

Black beans Whole-grain bread

After assessing the client's radial pulses, the nurse document "radial pulses 4+ bilaterally". The nurse should document this finding when a client's pulses have which of the following qualities? Bounding Full Variable Weak

Bounding INCORRECT: Full= 3+ Variable not for pulses Weak= 1+

A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings is another clinical manifestation of fluid volume excess? Sunken eyeballs Hypotension Poor skin turgor Bounding pulse

Bounding pulse

A nurse is caring for a client who requires ventilatory assistance with breathing following a motor vehicle crash. The nurse should suspect an injury to which of the following parts of the brain? Hypothalamus Cerebral cortex Brainstem Cerebellum

Brainstem (difficulty breathing= injury to the medulla and pons of the brainstem) INCORRECT: Hypothalamus= sleeping Cerebral cortex= expression Cerebellum= balance

A nurse is caring for a client who reports not sleeping at night, which interferes with her ability to function during the day. Which of the following interventions should the nurse suggest to this client? Avoid beverages that contain caffeine Take a sleep medication regularly at bedtime Watch TV for 30 min in bed to relax prior to falling asleep Advise the client to take several naps during the day

CORRECT Avoid beverages that contain caffeine INCORRECT Take a sleep medication regularly at bedtime (this is a last resort)

A nurse is implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take? Apply a cold pack to the edematous area Check capillary refill before applying an ice pack to the affect area Half-fill an ice pack with crush ice Apply an ice pack for 60 min intervals

CORRECT Check capillary refill before applying an ice pack to the affect area (check for adequate circulation as a cold pack could further decrease blood supply to the area) INCORRECT Apply a cold pack to the edematous area (avoid applying cold pack to edema as it can further decrease adequate circ and prevent absorption of the edema) Half-fill an ice pack with crush ice (should be filled 2/3) Apply an ice pack for 60 min intervals (30 min intervals)

A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of impaired skin integrity? 3+ Achilles reflex Faint pedal pulses Feet warm to the touch bilaterally Capillary refill of <2 sec

CORRECT Faint pedal pulses: this can indicate poor circulation and tissue perfusion INCORRECT 3+ Achilles reflex: more active reflex than expected

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? Pull suction catheter back 1cm (0.5 in) if the client starts coughing Allow 30 sec between suctioning passes Hyperventilate the client with 50% oxygen for 30 sec Perform a maximum of 4 passes with the suction catheter

CORRECT Pull suction catheter back 1cm (0.5 in) if the client starts coughing (this will remove the catheter from the mucosal wall of the trachea prior to suctioning) INCORRECT Allow 30 sec between suctioning passes (allow at last 1 minute to prevent hypoxia and to hyperventilate them) Hyperventilate the client with 50% oxygen for 30 sec (should be 100% oxygen for 2 mins) Perform a maximum of 4 passes with the suction catheter (max of 3 passes)

A nurse is performing a neurological assessment of a client. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following test? Romberg Kinesthetic sensation 2-point discrimination Weber

CORRECT Romberg: evaluates standing balance, first with the client's eyes open and then with them closed. INCORRECT Kinesthetic sensation: tests the clients ability to identify the position in which the examiner is holding the client's middle finger or great toe 2-point discrimination: the nurse touches various areas on a client's body with 1 and 2 pointed objects to see if they can discriminate between 1 and 2 objects Weber: hearing screening that uses a tuning fork

A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? Sit at the bedside while feeding the client Order pureed foods Make sure feedings are provided at room temperature Offer the client a drink of fluid after every bite

CORRECT Sit at the bedside while feeding the client (avoid appearing to be in a hurry) INCORRECT Order pureed foods (no mouth or throat injuries--> variety of textures) Make sure feedings are provided at room temperature (client pref) Offer the client a drink of fluid after every bite (only if the client is unable to communicate)

A nurse is performing an abdominal assessment of a client. Which of the following positions should the nurse tell the client to assume for this examination? Lithotomy Lateral Supine Sims'

CORRECT Supine INCORRECT Lithotomy--> gyn exams Lateral--> useful for auscultating the heart to detect murmurs Sims'--> rectal or vaginal exams

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? Vitamin C and zinc Vitamin D Vitamin K and iron Calcium

CORRECT Vitamin C and zinc (in addition vitamin E promotes wound healing) INCORRECT: Vitamin D (prevent osteoporosis) Vitamin K and iron (Vit K--> blood clots and iron--> rebuild RBC)

A nurse is teaching a group of unit nurses about the experiences of clients who are having surgery. In which phrase of care is the client transferred to the surgical suite table before being transferred to the PACU? Preoperative Postoperative Intraoperative Admission

CORRECT Intraoperative (this begins when the client is transferred to the surgical suite table and ends when they admitted to the PACU) INCORRECT Preop (when the client agrees to have the surgery-->them being transferred to the surgical suite table) Postop (when the client is admitted to the PACU-->when healing is complete) Admission (part of preop occurs outside the surgical suite)

A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective? "I should expect my heart rate to take longer to return to normal after exercise as I get older." "Urinary incontinence is something I will have to live with as I grow older." "I can expect to have less ear wax as I get older." "My stomach will empty more quickly after meals as I grow older."

CORRECT ANSWER "I should expect my heart rate to take longer to return to normal after exercise as I get older." (Older adults experience decreased cardiac output, which causes increased pulse rate during exercise. The pulse rate also takes longer to return to normal after exercise.) "Urinary incontinence is something I will have to live with as I grow older." (Although bladder capacity decreases in older adults, urinary incontinence is not an expected finding and older adults should report incontinence so that it can be investigated and treated.) "I can expect to have less ear wax as I get older." (Older adults have an increased buildup of cerumen in the ears, which may increase expected incidence problems with hearing loss.) "My stomach will empty more quickly after meals as I grow older." (Decreased gastric emptying is an expected finding in older adults.)

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make? "Tell me what I can do to help you overcome your fear of giving yourself injections." "I am sure your provider will not be pleased that you refuse to give yourself insulin injections." "It's okay. I'm sure your partner will be able to learn how to give you the insulin injections." "You won't be able to go home unless you learn to give yourself insulin injections."

CORRECT ANSWER "Tell me what I can do to help you overcome your fear of giving yourself injections." (This response illustrates the therapeutic communication technique of clarifying and offering of self. It is important for the nurse to allow the client to express feelings and fears and to support the client in learning how to give the injections.) "I am sure your provider will not be pleased that you refuse to give yourself insulin injections." (This response illustrates the nontherapeutic communication technique of challenging the client and ignores the client's concern.) "It's okay. I'm sure your partner will be able to learn how to give you the insulin injections." (This response illustrates the nontherapeutic communication technique of unwarranted reassurance and does not address the client's fears.) "You won't be able to go home unless you learn to give yourself insulin injections." (This response illustrates the nontherapeutic communication technique of threatening the client. This response will not help the client overcome his fears.)

A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? "There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands." "I will use cold water when I wash my hands to protect my skin from becoming too dry." "I will apply friction for at least 10 seconds while washing my hands." "After washing my hands I will dry them from the elbows down."

CORRECT ANSWER "There are times I should use soap and water rather than an alcohol-based hand rub to clean my hands." (While alcohol-based hand rubs are as effective as soap and water in providing proper hand hygiene, the Center for Disease Control and Prevention recommends washing hands with soap and water at certain times, such as when the hands are visibly soiled with dirt or body fluids.) "I will use cold water when I wash my hands to protect my skin from becoming too dry." (Hand hygiene should be performed with warm water. Warm water preserves the protective oil of the skin better than hot water.) "I will apply friction for at least 10 seconds while washing my hands." (Friction is required to loosen and remove dirt and pathogens from the hands. To be effective, friction should be applied for at least 15 to 20 seconds.) "After washing my hands I will dry them from the elbows down." (Drying should be performed from the cleanest area (fingertips) to the least clean area (forearms) to prevent contamination of the newly cleaned hands.)

A nurse is planning care for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask A client who has emphysema and is receiving oxygen at 3L/min via a transtracheal oxygen cannula A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar A client who has COPD and is receiving oxygen at 2 L/min via nasal cannula.

CORRECT ANSWER A client who has heart failure and is receiving 100% oxygen via a partial rebreather mask (The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The nurse should frequently check the bag on a rebreather mask to ensure it inflates properly. If the bag is deflated, the client will rebreathe his own exhaled carbon dioxide instead of receiving the prescribed oxygen dose. Therefore, the nurse should first see the client who has heart failure and is receiving 100% oxygen via a partial rebreather mask. Oxygen is a gas which can cause toxicity and is highly combustible, and higher concentrations of oxygen increase the risk of client injury.) A client who has emphysema and is receiving oxygen at 3L/min via a transtracheal oxygen cannula (Routine treatment for chronic lung conditions can include use of a transtracheal oxygen cannula; therefore, there is another client the nurse should plan to see first. The client will learn to use this device on his own, and the system can provide adequate oxygenation with a low flow rate of oxygen. Three liters per minute of oxygen is the equivalent of 32% oxygen delivery.) A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar (Routine treatment for a client who has an old tracheostomy includes administration of humidified oxygen or air via tracheostomy collar. Therefore, there is another client the nurse should plan to see first. The nurse should use humidification to promote loosening of respiratory secretions and prevent cannula obstruction. Forty percent oxygen is the equivalent of administering oxygen at 6L/min.) A client who has COPD and is receiving oxygen at 2 L/min via nasal cannula. (Routine treatment for a client who has COPD is to administer low dose therapy. Therefore, there is another client the nurse should plan to see first. Clients who have COPD depend on a low oxygen level to drive their respiratory rate. Two liters per minute of oxygen is the equivalent of 28% oxygen delivery.)

A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first? Assessment Plan of care Nursing interventions performed Evaluation of progress

CORRECT ANSWER Assessment (When caring for this client, the nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, he must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision.) Plan of care (The nurse should document the plan of care for the client. However, there is another action the nurse should document first.) Nursing interventions performed (The nurse should document interventions performed for the client. However, there is another action the nurse should document first.) Evaluation of progress (The nurse should document the evaluation of the client's progress. However, there is another action the nurse should document first.)

A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? Attempt to increase the clients' self-motivation. Keep detailed records of each client's progress. Test client learning after each teaching session. Avoid discussing areas that might cause client anxiety.

CORRECT ANSWER Attempt to increase the clients' self-motivation. (Motivation to learn is important in improving a client's committment to achievement of a health goal, as well as increasing the amount and speed of learning.) Keep detailed records of each client's progress. (This will help each client to track individual progress, but does not improve client progress toward individual goals.) Test client learning after each teaching session. (Testing learning helps to determine whether outcomes are reached but does not affect client's commitment to the goal.) Avoid discussing areas that might cause client anxiety. (Anxiety can interfere with learning and should be addressed early in the teaching process.)

A nurse is caring for a client who postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first? Check to determine if the catheter tubing is kinked. Palpate the bladder. Obtain a prescription to irrigate the catheter with 0.9% sodium chloride. Encourage the client to drink more fluids.

CORRECT ANSWER Check to determine if the catheter tubing is kinked. (The nurse should apply the least invasive priority-setting framework when caring for this client. This framework assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of facility-acquired infections. The first action the nurse should take is to inspect the tubing carefully, straightening out any kinks, and make certain that there are no dependent loops. A common reason a tube is not draining is that there is a kink in the tubing or that the client is lying on it.) Palpate the bladder. (The nurse should palpate the bladder or perform a bladder scan to determine if the bladder contains urine and the amount of urine. However, there is another action the nurse should take first.) Obtain a prescription to irrigate the catheter with 0.9% sodium chloride. (The nurse should obtain a prescription to irrigate the catheter to determine if the absent urine output is due to an obstruction from blood clots or sloughing of bladder tissue. However, there is another action the nurse should take first.) Encourage the client to drink more fluids. (The nurse can encourage the client to drink more fluids or obtain a prescription to increase the IV fluid rate if fluid overload is not a problem for the client to help increase kidney profusion and filtration of urine. However, there is another action the nurse should take first.)

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen? Collect the specimen upon arising in the morning. Force fluids during the day and collect the specimen in the evening. Collect the specimen after antibiotics have been started. Collect 2 mL of sputum before sending the specimen to the laboratory.

CORRECT ANSWER Collect the specimen upon arising in the morning. (The nurse should plan to collect the sputum specimen when the client arises in the morning because the client is able to more easily cough up the secretions that have accumulated during the night. Generally, the deepest specimens are obtained in the early morning, and it is preferable to collect the specimen before breakfast. The nurse should instruct the client to rinse the mouth, take a deep breath, and cough prior to expectorating into the sterile container.) Force fluids during the day and collect the specimen in the evening. (The nurse should encourage the client to force fluids, especially clear liquids, to help to thin respiratory secretions. However, evening hours are not the preferred time for obtaining a deep sputum specimen.) Collect the specimen after antibiotics have been started. (The nurse should collect the sputum specimen ordered for culture and sensitivity before the client receives antibiotic therapy to prevent interference with the laboratory results.) Collect 2 mL of sputum before sending the specimen to the laboratory. (The nurse should collect 4 to 10 mL of sputum before sending the specimen to the laboratory to provide an adequate amount of sputum to test for culture and sensitivity.)

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take? Don clean gloves to remove the old dressing. Loosen the dressing by pulling the tape away from the wound. Remove the entire old dressing at once. Open sterile supplies after applying sterile gloves.

CORRECT ANSWER Don clean gloves to remove the old dressing. (The nurse should use standard precautions by applying clean gloves whenever there is a possibility of coming into contact with secretions. Removing a soiled dressing is a procedure that requires wearing clean, not sterile, gloves. Sterile gloves are not necessary until the nurse applies the new sterile dressing.) Loosen the dressing by pulling the tape away from the wound. (The nurse should remove the tape by loosening and pulling toward the wound or dressing to decrease tension or stress on the healing wound edges.) Remove the entire old dressing at once. (The nurse should remove the old dressing one layer at a time to prevent the removal of drains and allow the nurse to assess the drainage.) Open sterile supplies after applying sterile gloves. (The nurse should open the sterile supplies after the removal of the old dressings, after washing her hands, and before applying sterile gloves to apply the sterile dressing to prevent microorganisms from contaminating the sterile field.)

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops? Drop the eye medication into the lower conjunctival sac. Apply gentle pressure in the outer opening of the eye for 2 min. Hold the eye dropper 0.5 cm (0.2 in) from the cornea. Instruct the client to close eyes tightly after administration.

CORRECT ANSWER Drop the eye medication into the lower conjunctival sac. (The nurse should drop the eye medication in the lower conjunctival sac to avoid placing the drops on the cornea and causing damage.) Apply gentle pressure in the outer opening of the eye for 2 min. (The nurse should apply gentle pressure to the nasolacrimal duct after instilling the eye medication for 30 to 60 seconds to keep the medication from running down the duct or out of the eye.) Hold the eye dropper 0.5 cm (0.2 in) from the cornea. (The nurse should hold the eye dropper 1 to 2 cm (0.4 to 0.8 in) from the lower conjunctival sac to protect the cornea of the eye from injury by preventing the tip of the dropper touching the eye.) Instruct the client to close eyes tightly after administration. (The nurse should instruct the client to close eyes gently when applying ointment or liquid to distribute the medication and to avoid expelling the medication or injuring the eye.)

While in the hospital, a client who has a terminal illness tells the nurse, "I can't believe I'm dying. A lot of bad people in the world are healthy, and here I am dying!" Which of the following responses should the nurse provide? "Everyone dies sometimes; some die sooner than others" "Who do you think deserves to die more than you?" "It does seem unfair doesn't it?" "Tell me more about how you feel about dying."

CORRECT: "Tell me more about how you feel about dying." INCORRECT: "It does seem unfair doesn't it?" (close-ended and does not facilitate further exploration of the client's feelings)

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? Evaluate pedal pulses. Obtain a medical history. Measure vital signs. Assess for leg pain.

CORRECT ANSWER Evaluate pedal pulses. (For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client.) Obtain a medical history. (The nurse should obtain the client's medical history. However, there is another action the nurse should take first.) Measure vital signs. (The nurse should obtain baseline vital signs. However, there is another action the nurse should take first.) Assess for leg pain. (The nurse should assess the client for pain. However, there is another action the nurse should take first.)

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from stretcher to the bed? Lock the wheels on the bed and stretcher. Instruct the client to raise his arms above his head. Elevate the stretcher 2.5 cm (1 in) above the height of the bed. Log roll the client.

CORRECT ANSWER Lock the wheels on the bed and stretcher. (Locking the wheels prevents the client from falling to the floor by not allowing the cart or bed to move apart or away from the client.) Instruct the client to raise his arms above his head. (The nurse should ask the client to cross his arms across his chest to prevent injuring the arms during the transfer.) Elevate the stretcher 2.5 cm (1 in) above the height of the bed. (The stretcher should be no more than 1.3 cm (0.5 in) above the height of the bed.) Log roll the client. (Logrolling is a technique used to prevent injury when moving a client who requires immobilization of the neck, back, or spine. It is not indicated for a client following abdominal surgery.)

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? Pull suction catheter back 1 cm (0.5 in) if the client starts coughing. Allow 30 seconds between suctioning passes. Hyperventilate the client with 50% oxygen for 30 seconds. Perform a maximum of 4 passes with the suction catheter.

CORRECT ANSWER Pull suction catheter back 1 cm (0.5 in) if the client starts coughing. (The nurse should pull the suction catheter back 1 cm (0.5 in) when the client starts to cough, or resistance is met. This will remove the catheter from the mucosal wall of the trachea prior to suctioning.) Allow 30 seconds between suctioning passes. (The nurse should allow at least 1 min between suctioning passes to prevent hypoxia and to hyperventilate the client.) Hyperventilate the client with 50% oxygen for 30 seconds. (The nurse should hyperventilate the client with 100 % oxygen for at least 2 min before suctioning to decrease hypoxia.) Perform a maximum of 4 passes with the suction catheter. (The nurse should perform a maximum of 3 passes with the suction catheter because suctioning can cause hypoxia and induce dysrhythmia.)

A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first? Remove the sleeve of the gown from the arm without the IV line. Slow the infusion using the roller clamp. Disconnect the IV line from the pump. Bring the IV solution and tubing from the outside to the end side of the sleeve of the gown.

CORRECT ANSWER Remove the sleeve of the gown from the arm without the IV line. (According to evidence-based practice, the nurse should first remove the gown from the client's arm without the IV line. Beginning this process will enable the nurse to move the gown fully off the client and last stop the system to remove the gown off the line, resulting in minimal interruption of the IV flow.) Slow the infusion using the roller clamp. (The nurse should slow the infusion using the roller clamp to prevent large volume infusion of IV solution while changing the gown. However, evidence-based practice indicates that the nurse should take a different action first.) Disconnect the IV line from the pump. (The nurse should disconnect the IV line from the pump while removing and reapplying the gown quickly to maintain the infusion rate prescribed with the pump. However, evidence-based practice indicates that the nurse should take a different action first.) Bring the IV solution and tubing from the outside to the end side of the sleeve of the gown. (The nurse should bring the IV solution and tubing through the outside to the end side of the sleeve of the gown to prevent tangling of the tubing and the gown. However, evidence-based practice indicates that the nurse should take a different action first.)

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? Renew the prescription for the use of restrains within 24 hr. Secure the restraint with the buckle side next to the client's skin. Ensure 4 fingers can be inserted under the secured restraint. Remove the restraint every 3 hr.

CORRECT ANSWER Renew the prescription for the use of restrains within 24 hr. (The nurse should plan to renew the prescription for the restraints within 24 hr, and only after the provider has evaluated the client.) Secure the restraint with the buckle side next to the client's skin. (The nurse should secure the client's restraints with the softer side next to the client's skin, with the buckle or velco closure on the outside.) Ensure 4 fingers can be inserted under the secured restraint. (The nurse should ensure 2 fingers can be inserted under the restraints to prevent the restraint from being too loose. If the nurse is unable to insert 2 fingers under the restraint, it could cause impaired circulation to the extremities.) Remove the restraint every 3 hr. (The nurse should remove the restraint at least every 2 hr and at that time check the client's skin, change the client position, toilet, or exercise the client.)

A nurse is teaching a client who has asthma about the proper use of an albuterol inhaler. Which of the following client statements indicates an understanding of the teaching? "I should rinse my mouth out right before I use my inhaler" "After the first puff, I will wait 10 seconds before taking the second puff" "I will shake the inhaler well right before I use it" "I will tilt my head forward while inhaling the medication"

CORRECT: "I will shake the inhaler well right before I use it" (3-5 seconds) INCORRECT: "I should rinse my mouth out right before I use my inhaler" (rinse after) "After the first puff, I will wait 10 seconds before taking the second puff" (wait 20-30 seconds) "I will tilt my head forward while inhaling the medication" (client should place inhaler in the mouth and tightly close the lips around the mouthpiece to create a seal. Then depress the canister, take a deep breath, and hold for at least 10 seconds"

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first? Start chest compressions. Provide breaths with a manual resuscitation bag. Administer oxygen. Establish an airway.

CORRECT ANSWER Start chest compressions. (The nurse should apply the safety and risk reduction priority-setting framework when caring for this client. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The nurse should perform cardiopulmonary resuscitation, which starts with chest compression, then opening the airway, and breathing for adults and pediatric clients because evidence indicates there is a great survival rate when chest compressions are started before a breath is initiated.) Provide breaths with a manual resuscitation bag. (The nurse should provide breaths with a manual resusciation bag to oxygenate a client during cardiopulmonary resuscitation; however, there is another action the nurse should take first.) Administer oxygen. (The nurse should administer oxygen to a client to ensure adequate oxygen is circulating during cardiopulmonary resuscitation; however, there is another action the nurse should take first.) Establish an airway. (The nurse should establish an airway to perform ventilations and oxygenate the client during cardiopulmonary resuscitation; however, there is another action the nurse should take first.)

A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? The involvement of the client in planning the change The emphasis the provider places on the dietary changes The learning theory the nurse uses to teach the dietary changes The extent of the dietary changes planned for the client

CORRECT ANSWER The involvement of the client in planning the change (According to evidence-based practice, client involvement in planning dietary changes is the most important factor in the client's ability to learn new habits.) The emphasis the provider places on the dietary changes (The emphasis the provider places on the dietary changes can influence the client's ability to learn new dietary habits; however, it is not the most important factor.) The learning theory the nurse uses to teach the dietary changes (The learning theory the nurse uses to teach dietary changes can influence the client's ability to learn new dietary habits; however, it is not the most important factor.) The extent of the dietary changes planned for the client (The extent of the changes planned can influence the client's ability to learn new dietary habits; however, it is not the most important factor.)

A nurse is preparing to assist with ambulation of an older adult client who was on bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall? Use a gait belt during ambulation. Ensure the client is wearing socks before ambulating. Instruct the client to sit on the edge of the bed for 15 seconds before ambulating. Walk 2 feet behind the client during ambulation.

CORRECT ANSWER Use a gait belt during ambulation. (The nurse should use a gait belt to keep the client's center of gravity midline and decrease the risk of a fall.) Ensure the client is wearing socks before ambulating. (The nurse should ensure the client is wearing nonskid shoes or slippers when ambulating to decrease the risk of a fall from slipping.) Instruct the client to sit on the edge of the bed for 15 seconds before ambulating. (The nurse should encourage the client to dangle her legs on the edge of the bed for 60 seconds before attempting to ambulate to decrease the risk of a fall caused from orthostatic hypotension.) Walk 2 feet behind the client during ambulation. (The nurse should walk beside the client to provide physical support ambulating and decrease the risk of a fall.)

A nurse is planning to administer pain medication to a client who has pain following abdominal surgery. Which of the following actions should the nurse take first? Use the pain scale to determine the client's pain level. Discuss the adverse effects of pain medication with the client. Obtain the client's vital signs. Check the client's allergies.

CORRECT ANSWER Use the pain scale to determine the client's pain level. (The nurse should consider Maslow's hierarchy of needs, which includes five levels of priority when caring for this client. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's hierarchy of needs priority-setting framework, the nurse should review physiological needs first. The nurse should then address the client's needs by following the remaining four hierarchal levels. It is important, however, for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. The fourth level of Maslow's hierarchy of needs includes usefulness, self-worth, and self-confidence in fulfilling self-esteem needs. Therefore, to meet the client's physiological needs, the first action the nurse should take is to begin pain management by asking the client to describe her pain.) Discuss the adverse effects of pain medication with the client. (The nurse should discuss the adverse effects of the pain medication with the client and instruct the client to report any problems with the intervention chosen. However, there is another action the nurse should take first.) Obtain the client's vital signs. (The nurse should obtain the client's vital signs before choosing an intervention to relieve the client's pain. Obtaining vital signs provides a baseline for the nurse to compare to when monitoring the client after treating the client's pain. Respiratory depression and decreased of blood pressure are adverse effects of opioid pain medications. However, there is another action the nurse should take first.) Check the client's allergies. (The nurse should check the client's allergies if the intervention is to administer a pain medication to relieve the client's pain. However, there is another action the nurse should take first.)

A nurse is planning care for a client who has a would infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? Vitamin C and zinc Vitamin D Vitamin K and iron Calcium

CORRECT ANSWER Vitamin C and zinc (The client's body needs both vitamin C and zinc to help fight a wound infection. The client should receive a multivitamin, and a mineral supplement of both. In addition, vitamin E supplements also are needed to aid in skin and wound healing.) Vitamin D (Vitamin D is important when used with calcium to prevent osteoporosis; however, it does not assist in the client's wound healing. The main function of vitamin D is to maintain normal calcium and phosphorus levels in the blood and it may protect against cancer.) Vitamin K and iron (Vitamin K is important for normal clotting of blood and for impaired intestinal synthesis caused from antibiotics. Iron is needed to rebuild RBCs for a client; however, neither is needed directly in the client's wound healing.) Calcium (Calcium is administered to prevent osteoporosis when used with vitamin D; however, it does not assist in the client's wound healing.)

A nurse is assessing a client's thyroid gland. Which of the following instructions should the nurse give the client before inspecting and palpating this gland? "tilt your head slightly forward" "keep your head straight and look ahead of you" "tilt your head back and swallow" "turn your head to the side against my hand"

CORRECT: "tilt your head back and swallow" (this allows an enlargement of the gland)

A nurse is explaining Piaget's theory of cognitive development to a group of daycare providers for employees' children at an acute care facility. Which of the following activities should the nurse include as an example of concrete operational thinking? Playing in the sand Playing dress-up with old clothes Collecting and trading game cards Describing interpersonal relationships

CORRECT: Collecting and trading game cards (this requires seriation of the cards, involving what to collect, what to trade and what has value--> Piaget's Concrete Operational stage for ages 7-11 years) INCORRECT: Playing in the sand (Piaget's Sensorimotor stage birth-2 years old) Playing dress-up with old clothes (involves pretending--> Piaget's Preoperational stage ages 2-7) Describing interpersonal relationships (formal operation stage --> ages 11 and beyond)

A nurse is planning care for a young adult client who has a terminal illness. Which of the following concepts of death should the nurse consider for this client? Death is unacceptable under any circumstance Magical thinking helps avoid thought of death Death is viewed as an interruption of what might have been Death is a natural consequence of a deteriorating body

CORRECT: Death is viewed as an interruption of what might have been (young adults do not typically welcome death at this age; they tend to see w whole life ahead of them so death is interrupting that) INCORRECT: Death is unacceptable under any circumstance (this is more for adolescents who tend to reject the end of life; especially their own) Magical thinking helps avoid thought of death (this is for preschoolers) Death is a natural consequence of a deteriorating body (this would be for older adults who would see death as a relief from chronic/terminal illness)

A nurse in an acute care facility is planning care for a client who is alert but temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse plan to take to prevent a complication of immobility? Move the client from supine to low Fowler's position every 2-3 hr to help prevent orthostatic hypotension Limit fluid intake to 1 L (33.8 oz) in 24 hr to help prevent dependent edema Encourage the client to turn from side to side every 3-4 hr to help prevent respiratory complications Instruct the client to perform foot and leg exercises every 1-2 hr while awake to help prevent thrombophlebitis

CORRECT: Instruct the client to perform foot and leg exercises every 1-2 hr while awake to help prevent thrombophlebitis (antiembolic exercises like flexion of the knees and rolls and pumps of the feet) INCORRECT Move the client from supine to low Fowler's position every 2-3 hr to help prevent orthostatic hypotension (this helps minimize the effects of orthostatic hypotension) Limit fluid intake to 1 L (33.8 oz) in 24 hr to help prevent dependent edema (patients who are immobile should ingest 1.1-1.4 L per 24 hr to prevent bladder complications; limiting fluid does not prevent dependent edema) Encourage the client to turn from side to side every 3-4 hr to help prevent respiratory complications (client should cough and breathe deeply ever 1-2 hours)

A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis

CORRECT: Metabolic acidosis (pH of 7.25 indicated acidosis and expected range of PaCO2) INCORRECT: Respiratory alkalosis (pH is elevated) Metabolic alkalosis (pH is elevated) Respiratory acidosis (PaCO2 is elevated)

A nurse is helping a client change his hospital gown. The client has an IV infusion via an infusion pump. Which of the following actions should the nurse take first? Remove the sleeve of the gown from the arm without the IV first Slow the infusion using the roller clamp Disconnect the IV line from the pump Bring the IV solution and tubing from the outside to the inside of the sleeve of the gown

CORRECT: Remove the sleeve of the gown from the arm without the IV first (beginning with the process will enable the nurse to move the gown fully off the client before stopping the system to reduce interruption) INCORRECT: Yes to all but NOT first

A nurse is assessing a client who is unconscious. Family members are present and answer the nurse's questions about the client's medical history. The nurse should document the information as which type of data? Secondary-source data Experiential data Primary-source data Quantitative data

CORRECT: Secondary-source data INCORRECT: Experiential data--> info the nurse collects

A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in which of the following positions for evaluation? Sims' Supine Sitting Standing

CORRECT: Sitting (costovertebral angle--> the spine and the 12th rib intersect and sitting promotes relaxation)

A nurse on a medical unit is caring for a client who has been coughing intermittently during meals, attempting to clear her throat repeatedly, and eating only a small portion of each meal. The nurse should recommend a referral to which of the following members of the interprofessional team to evaluate the client for dysphagia? Speech-language pathologist Social worker Physical Therapist Occupational therapist

CORRECT: Speech-language pathologist (they can perform a thorough eval of the client for dysphagia and help them learn to eat safely)

A nurse is preparing to instill a vaginal medication in suppository form to a client. Which of the following actions should the nurse take during this procedure? Don sterile gloves Use the dominant hand to retract the labia Use the index finger to insert the suppository Ease the suppository along the anterior vaginal wall

CORRECT: Use the index finger to insert the suppository INCORRECT: Don sterile gloves (clean NOT sterile) Ease the suppository along the anterior vaginal wall (posterior)

A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use? Deltoid Ventrogluteal Vastus Lateralis Dorsogluteal

CORRECT: Vastus Lateralis (over the anterior thigh--> for infants and children) INCORRECT Deltiod (18 months and older) Ventrogluteal (7 months and older) Dorsogluteal (unsafe bc its proximity to the sciatic nerve)

A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. Which of the following actions should the nurse take first? Complete an incident report Check the client for injuries Make sure the client has skid-free footwear Remind the client to ask for help when getting out of bed

Check the client for injuries

A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight? Calibrate the scales weekly. Use a different scale each time. Weigh the client on arising. Weigh the client without clothing.

Calibrate the scales weekly. (The nurse should calibrate the scales to 0 each day or before each use to provide accurate information.) Use a different scale each time. (The nurse should weigh the client using the same scale each time because there generally is a slight difference between readings from each scale.) CORRECT ANSWER Weigh the client on arising. (The nurse should weigh the client on arising each day, after voiding, and before breakfast. An accurate weight requires the client to be weighed wearing the same garments, and on the same carefully calibrated scale (balanced to zero before each use). Accurate daily weights provide the easiest measurement of volume status. An increase of 1 kg (2.2 lb) is equal to 1,000 mL (1 L) of retained fluid.) Weigh the client without clothing. (The nurse should plan to have the client's weight taken wearing the same type of clothing each to provide an accurate reading and to avoid embarrassment.)

charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? Call for assistance. Begin chest compressions. Confirm unresponsiveness. Give rescue breaths.

Call for assistance. (The nurse should call for assistance by activating the emergency response team. However, there is another action the nurse should take first.) Begin chest compressions. (The nurse should begin chest compressions. However, there is another action the nurse should take first.) CORRECT ANSWER Confirm unresponsiveness. (The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Establishing unresponsiveness is required before beginning CPR. If a client is unresponsive, the nurse should activate the emergency response team.) Give rescue breaths. (The nurse should give rescue breaths. However, there is another action the nurse should take first.)

A nurse is beginning her shift and reviewing the medication administration record (MARs) for the clients. She notes a dosage of a medication above the safe range and sees that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take? Call the nurse to verify the client received that dosage Give the medication in a safe dosage Give the dose the provider prescribed Call the provider to clarify the dosage

Call the provider to clarify the dosage

A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? Wash the gloved hand and then throw the gloves away Prepare an incident report to document the event Carefully remove the gloves and proceed with hand hygiene Ask the provider to order a blood culture to determine the risk of infection

Carefully remove the gloves and proceed with hand hygiene

A nurse is caring for a middle-aged adult client. The nurse should elevate the client for progress toward which of the following developmental tasks? Managing a home Establishing a sense of self in the adult world Forming new friendships Ceasing to compare personal identity with others

Ceasing to compare personal identity with others

A nurse is caring for a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect injury to which of the following areas of the brain? Hypothalamus Cerebral cortex Pituitary Cerebellum

Cerebellum (balance and coordination) INCORRECT: Hypothalamus (sleeping) Cerebral cortex (expression) Pituitary (stress and hormones)

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? Change the topic because the client is trying to divert attention from the illness to the nurse. Encourage the client to express his thoughts about death and dying. Tell the client that religious beliefs are a personal matter. Offer to contact the client's minister or the facility's chaplain.

Change the topic because the client is trying to divert attention from the illness to the nurse. (Changing the subject is a nontherapeutic communication technique that will block development of open communication between the nurse and client.) CORRECT ANSWER Encourage the client to express his thoughts about death and dying. (The nurse should recognize the client's need to talk about impending death, and encourage the client to discuss his thoughts on the subject. This is the therapeutic technique of reflecting. Depending on the situation, the nurse can also share some thoughts on this topic. Self-disclosure is a communication skill that can help open lines of communication when appropriate. If the nurse does not want to share personal beliefs, the communication skills of offering self and listening to the client's thoughts are appropriate.) Tell the client that religious beliefs are a personal matter. (This closed-ended response is a nontherapeutic communication technique that will block the communication with this client.) Offer to contact the client's minister or the facility's chaplain. (This response places the client's issue on hold and could cause barriers to communication between the nurse and the client.)

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take? Administer 0.9% sodium chloride until TPN is available from the pharmacy Check the client's capillary blood glucose level every 4 hours Obtain the client's weight each week Change the IV tubing every 3 days

Check the client's capillary blood glucose level every 4 hours (due to risk of hyperglycemia bc of the dextrose concentration) INCORRECT: Administer 0.9% sodium chloride until TPN is available from the pharmacy--> 10%-20% OF DEXTROSE in water Obtain the client's weight each week --> DAILY Change the IV tubing every 3 days--> EVERY 24 HOURS

A nurse is caring for a client who has stage III pressure ulcer on his heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? Obtain the prescribed irrigation solution Don personal protective equipment Check the client's pain level Place a waterproof pad under the client's extremity

Check the client's pain level

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? Apply a fecal collection system Apply a barrier cream Cleanse and dry the area Check the client's perineum

Check the client's perineum

A nurse is preparing to administer oral phenytoin to a client who has a seizure disorder. Before administering the medication, which of the following actions should the nurse take? Document the administration of the medication Count the amount of available medication on hand and sign for it Measure the client's respiratory rate Check the medication dose and the client's identification

Check the medication dose and the client's identification

A nurse is caring for a client who requires a peripheral IV insertion. When choosing a site, which of the following sites should the nurse select? Select a vein in the client's dominant arm Choose the most proximal vein in that extremity Choose a vein that is soft on palpation Select a site distal to previous venipuncture attempts

Choose a vein that is soft on palpation (bouncy feeling)

A nurse documents the presence of clubbing of the fingernails for a client who has emphysema. Which of the following is the underlying cause of this finding? Trauma Severe infection Iron-deficiency anemia Chronic hypoxemia

Chronic hypoxemia (low oxygen supply)

A nurse is preparing to administer a tuberculin skin test to a client. After performing hand hygiene, which of the following actions should the nurse take? Select a 23-gauge needle Insert the needle into the skin at a 25 degree angle Massage the area of injection following removal of the needle Circle the injection area with a pen

Circle the injection area with a pen (ensures the nurse will examine the correct site when reading the test 48-72 hours later)

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? Withdraw the specimen from the drainage bag Cleanse the collection port with soap and water Place the specimen in a clean specimen cup Clamp the tubing below the collection port

Clamp the tubing below the collection port (to allow FRESH, uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile cup)

A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take? Clean the incision from bottom to top Apply sterile gloves prior to opening dressing packages Remove the tape by pulling away from the wound Clean the drain site from the center outward

Clean the drain site from the center outward (to avoid introducing microorganisms from the periphery of the wound into the center of the wound)

A nurse is providing teaching about proper care to a client who has a new colostomy. Which of the following pieces of information should the nurse include in the teaching? Change the colostomy bag following breakfast Cleanse the skin around the stoma with warm water Change the pouch every day Place an aspirin in the ostomy pouch to decrease odor

Cleanse the skin around the stoma with warm water (no soap) INCORRECT: Change the colostomy bag following breakfast --> change BEFORE a meal Change the pouch every day--> change every 3-7 days

A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse perform? Wear sterile gloves when collecting the specimen Cleanse the wound with 0.9% sodium chloride irrigation Allow the collection swab to absorb old exudate Rotate the collection swab over the edges of the wound

Cleanse the wound with 0.9% sodium chloride irrigation (to remove any surface debris or old exudate) INCORRECT: Wear sterile gloves when collecting the specimen (CLEAN gloves) Rotate the collection swab over the edges of the wound (areas in the base of the wound)

A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview? Client's level of comfort and ability to participate in the interview Previous illnesses and surgeries Events surrounding the client's recent illness Sociocultural history

Client's level of comfort and ability to participate in the interview INCORRECT: WORKING PHASE for all

A nurse is teaching a newly licensed nurse about pain management in clients age 65 and older. Which of the following pieces of information should the nurse include in the teaching? Client who are age 65 or older experience a decreased ability to perceive pain compared to young adult clients Clients who are 65 or older are reluctant to report pain Clients who are 65 or older should not receive opioid narcotics Clients who are 65 or older experience a shorter duration

Clients who are 65 or older are reluctant to report pain

A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? Select all that apply Coat the tip of the tube with a water-soluble lubricant Ask the client to swallow water while the tube enters her throat Place the coiled tube in ice chips prior to insertion Tell the client to tilt her head backwards as insertion begins Instruct the client to bear down during insertion

Coat the tip of the tube with a water-soluble lubricant Ask the client to swallow water while the tube enters her throat Tell the client to tilt her head backwards as insertion begins

A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent? Urinary retention Cold extremities Hypertension Tachycardia

Cold extremities

A nurse is planning care for a client who has a prescription for collection of sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen? Collect the specimen when the client rises in the morning Force fluids during the day and collect the specimen in the evening Collect the specimen after antibiotics have been started Collect 2ml of sputum before sending the specimen to the lab

Collect the specimen when the client rises in the morning

A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client's bedside and perform which of the following verification procedures? Check the client's name and medical record number on the MAR against the room and bed number Call the client by name and check the name on her identification band against the MAR Compare the medical record number and name on the MAR with the client's identification band Ask the client's visitor to identify the client by name and to state the client's birth date

Compare the medical record number and name on the MAR with the client's identification band

A newly licensed nurse is preparing to administer medication to a client. The nurse notes that the provider has prescribed medication that is unfamiliar to him. Which of the following actions should the nurse take? Consult the medication reference book available on the unit Ask a more experienced nurse for information about the medication Call the client's provider and verify the prescription Ask the client if she takes this medication at home

Consult the medication reference book available on the unit

During a physical examination of a client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect additional data? Confrontation test Symmetry of palpebral fissures Corneal light reflex Accommodation test

Corneal light reflex (the eyes will not align when the client focuses)

A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test? Sugar Coffee Cotton wisps Snellen chart

Cotton wisps (sensory and motor function) INCORRECT: Sugar= facial nerve VII Coffee= olfactory nerve 1 Snellen chart= optic nerve II

A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? Blow into the spirometer to elevate the balls in the device Cough deeply after each use Clean the mouthpiece with an alcohol swab after each use Use the spirometer every 8 hours

Cough deeply after each use (proper use of the device loosens secretions in the client's lungs--> client should cough out that excess)

A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take? Measure the pulse using a Doppler ultrasound stethoscope Check the client's pedal pulses Count the apical pulse rate for 1 full minute and describe the rhythm in the chart Take the pulse at each peripheral site and count the rate for 30 sec

Count the apical pulse rate for 1 full minute and describe the rhythm in the chart

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the the following actions should the nurse perform first after discovering that the client's wound has eviscerated? Cover the incision with a moist sterile dressing Have the client lie on his back with his knees flexed Call the client's surgeon Reassure the client

Cover the incision with a moist sterile dressing

A nurse is assessing a client who has fluid-volume excess. Which of the following findings should the nurse expect? Crackles in the lung fields Flat neck veins Postural hypotension Dark yellow urine

Crackles in the lung fields (manifestations of the fluid-volume excess include--> crackles in the lungs, dependent edema, full neck veins when the client is upright, elevated blood pressure, and sudden weight gain)

A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing? Cranial nerve XII Cranial nerve X Cranial nerve VIII Cranial nerve V

Cranial nerve XII (hypoglossal--> range of tongue movements) INCORRECT: Cranial nerve X=vocalize Cranial nerve VIII=can hear a whisper Cranial nerve V=clench his teeth

A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations? Increased intestinal motility Respiratory alkalosis Decreased cardiac output Hypocalcemia

Decreased cardiac output (During immobility, the client's heart rate increases to compensate for increased venous pooling. The reduction in circulating volume increases the workload of the heart, resulting in orthostatic hypotension and decreased cardiac output)

A nurse is teaching a middle-aged adult about health promotion and disease prevention. The nurse should inform the client that which of the following changes could occur? Decreased estrogen and testosterone production Increased tone of the large intestines Increased percentage of the body's muscle mass Decreased incidence of chronic illness

Decreased estrogen and testosterone production

A nurse is caring for a client who has terminal cancer. The client is proceeding with plans to build a new home. The nurse should identify that this behavior typically indicates which of the following stages of grief? Acceptance Bargaining Anger Denial

Denial

A nurse is assessing a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect? Muscle tremors Positive Chvostek's sign Depressed deep-tendon reflexes Numbness around the mouth

Depressed deep-tendon reflexes (calcium level is above the expected range--> manifestations of hypercalcemia include depressed deep-tendon reflexes, vomiting, bone pain, lethargy, and weakness) INCORRECT: Muscle tremors, positive Chvostek's sign, and numbness around the mouth = hypocalcemia

A nurse is talking with a client whose provider recently informed him of terminal pancreatic cancer. When the client reports that he understands the full impact of this diagnosis, the nurse should identify that the client is in which of the following stages of dying? Anger Bargaining Depression Acceptance

Depression (they have realized the full impact of the loss and might express hopelessness and despair) INCORRECT: Anger--> resistance, blaming other or a higher power Bargaining-->stall awareness of the loss by trying to keep it from occuring Acceptance--> integrate the loss by making arrangements

A nurse is caring for a client who has a BMI of 29 and expresses a desire to lose weight. Which of the following actions should the nurse take first? Refer to client to a nutritionist Discuss eating strategies with the client Determine the client's intention to change current eating habits Instruct the client to perform 30 mins of vigorous exercise daily

Determine the client's intention to change current eating habits FIRST

A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? Place an oxygen mask on the client Check the client's pulse Determine whether the client is able to breathe Wrap arms around the client from behind

Determine whether the client is able to breathe

A nurse is caring for a client who is unstable and has vital signs measured every 15 mins by an electronic blood pressure machine. The nurse notices the machine begins to measure the BP at varied intervals, and the readings are inconsistent. Which of the following actions should the nurse take? Turn on the machine every 15 min to measure the client's BP Record only the blood pressure readings needed for 15 min intervals Obtain manual and automatic readings and compare them Disconnect the machine and measure the BP manually every 15 mins

Disconnect the machine and measure the BP manually every 15 mins

A nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following? Retention Oliguria Diuresis Dysuria

Diuresis (aka polyuria excretion of high volume of urine) INCORRECT: Oliguria= diminishing urine output despite an acceptable fluid intake Dysuria= painful/difficult urination: result of a UTI

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take? Don clean gloves to remove the old dressing Loosen the dressing by pulling the tape away from the wound Remove the entire old dressing at once Open sterile supplies after applying sterile gloves

Don clean gloves to remove the old dressing (sterile gloves are not necessary) INCORRECT: Loosen the dressing by pulling the tape away from the wound (pull TOWARDS the wound to decrease tension or stress on the wound edges) Remove the entire old dressing at once (remove layer by layer to prevent removal of drains and allow assessment of the drainage) Open sterile supplies after applying sterile gloves (open sterile supplies AFTER removing the old dressings and washing the hands and before donning sterile gloves to apply the dressing)

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give to the dietary assistant? Don a gown before entering the room and remove it before exiting Wear a mask while in the client's room Don gloves when entering the room and use hand sanitizer when exiting Take no special precautions unless engaging in direct contact with the client

Don gloved when entering the room and use hand sanitizer when exiting (no direct contact with client)

A nurse is assessing a client's pulses of the lower extremities. The nurse should identify which of the following as the location of the most distal pulse? Popliteal Posterior tibial Dorsalis pedis Femoral

Dorsalis pedis

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops? Drop the eye medication into the lower conjunctival sac Apply gently pressure to the out opening of the eye for 2 min Hold the eyedropper 0.5 cm (0.2 in) from the cornea Instruct the client to close the eyes tightly after administration

Drop the eye medication into the lower conjunctival sac (to avoid placing the drops on the cornea causing damage)

While admitting a client to the medical unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able" The nurse should identify that the client is referring to which of the following documents? Informed consent form Living will document Do-not-resuscitate (DNR) directive Durable power of attorney document

Durable power of attorney document (health care proxy)

A nurse is admitting a client who is experiencing an exacerbation of heart failure. At which of the following times should the nurse initiate discharge planning? During the admission process As soon as the client's condition is stable During the initial team conference On the day prior to discharge

During the admission process

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? Redness at the infusion site Edema at the infusion site Warmth at the infusion site Oozing of blood at the infusion site

Edema at the infusion site (due to fluid entering subcutaneous tissue) INCORRECT: Redness= phlebitis or infection Warmth= phlebitis or infection Oozing of blood= IV system is not intact

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of primary prevention? Teaching clients to perform self-exams of breasts and testicles Educating clients about the recommended immunization schedule for adults Teaching clients who have type 1 diabetes mellitus about care of feet Recommending that clients over the age of 50 have a fecal occult blood test annually

Educating clients about the recommended immunization schedule for adults INCORRECT: Teaching clients to perform self-exams of breasts and testicles and Recommending that clients over the age of 50 have a fecal occult blood test annually= secondary Teaching clients who have type 1 diabetes mellitus about care of feet= tertiary

A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein? Eggs Cereal Peanut butter Pasta

Eggs

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? Auscultate bowel sounds after each feeding Ensure the formula is cold before administering Elevate the head of the bed to 45 before the feeding Flush the tubing with 15 mL of water after the enteral feeding

Elevate the head of the bed to 45 before the feeding (30-45) INCORRECT: Auscultate bowel sounds after each feeding--> BEFORE Ensure the formula is cold before administering --> ROOM TEMP Flush the tubing with 15 mL of water after the enteral feeding--> 30ML

A nurse is preparing to administer a feeding via a gastrostomy tube to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding? Warm the feeding tube in a microwave oven Elevate the head of the client's bed Flush the tube with 0.9% sodium chloride for irrigation Verify that the client's gastric pH is above 4

Elevate the head of the client's bed INCORRECT: Warm the feeding tube in a microwave oven--> ROOM TEMP Flush the tube with 0.9% sodium chloride for irrigation--> FLUSH WITH WATER PRIOR Verify that the client's gastric pH is above 4--> should be BELOW 4

A nurse is teaching an AP how to obtain a capillary-finger stick blood sample. Which of the following actions by the AP requires the nurse to intervene? Elevating the finger about heart level Rubbing the fingertip with an alcohol pad Puncturing the side of the fingertip Wrap the finger in a warm cloth

Elevating the finger about heart level

A nurse is teaching an assistive personnel how to obtain a capillary finger-stick blood sample. Which of the following actions by the AP requires the nurse to intervene? Elevating the finger above heart level Rubbing the fingertip with an alcohol pad Puncturing the side of the fingertip Wrapping the finger in a warm cloth

Elevating the finger above heart level (should be below heart level in a dependent position to help increase blood flow)

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? Encourage the child to cough frequently to clear congestion from anesthesia. Place a heating pad at the child's neck for comfort. Administer analgesics to the child on a routine schedule throughout the day and night. Provide the child with ice cream when oral intake is initiated.

Encourage the child to cough frequently to clear congestion from anesthesia. (The child should be discouraged from coughing or clearing the throat following a tonsillectomy because these actions can contribute to bleeding.) Place a heating pad at the child's neck for comfort. (The nurse should offer an ice collar, not a heating pad, to ease the child's pain.) CORRECT ANSWER Administer analgesics to the child on a routine schedule throughout the day and night. (To soothe the client's throat following a tonsillectomy, the nurse should administer pain medication routinely around the clock. The nurse can provide the medication rectally or intravenously to avoid the oral route.) Provide the child with ice cream when oral intake is initiated. (Milk products, such as ice cream and pudding, are usually avoided because they coat the mouth and throat, causing the child to clear the throat. Clearing the throat can lead to bleeding. Ice chips and ice pops are usually the first items offered following a tonsillectomy.)

A nurse is auscultating a client's lungs and identifies rhonchi over the trachea and bronchi. Which of the following actions should the nurse take? Limit the client's fluid intake Assist the client into a supine position Administer oxygen at 2 L/min Encourage the client to cough

Encourage the client to cough

A nurse is caring for a client who has terminal illness the client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? Change the topic because the client is trying to divert attention from the illness Encourage the client to express thoughts about death and dying Tell the client that religious beliefs are a personal matter Offer to contact the client's minister or the facility's chaplain

Encourage the client to express thoughts about death and dying

A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief? Encourage the client to listen to soft music Instruct the client to practice tai chi Place a jasmine-scented air freshener in the client's room Offer the client ginger tea

Encourage the client to listen to soft music (music therapy)

A nurse is working with the facility's language interpreter to explain a wound-care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when describing the procedure? Make eye contact with the interpreter Break sentences into shorter segment to allow time for interpretation Ensure the interpreter and the client speak the same dialect Speak in a loud tone of voice

Ensure the interpreter and the client speak the same dialect

A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nurse process, which of the following actions should the nurse take? Establish client outcomes Collect information about past health problems Determine whether the client has met specific goals Identify the client's specific health problems

Establish client outcomes

A nurse is discussing fire safety with newly hired nurses. Which of the following actions is the priority if a fire occurs in the health care facility? Close the fire doors on the unit Use a fire extinguisher on the fire Pull the nearest fire alarm Evacuate clients from the unit

Evacuate clients from the unit (apply the safety and risk-reduction-priority setting framework)

A nurse on a medical-surgical unit observes smoke billowing from a client's room. Which of the following actions should the nurse take first? Close the door to the client's room Evacuate the client from the room Sound the fire alarm Activate the fire extinguisher

Evacuate the client from the room

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? Evaluate pedel pulses Obtain a medical history Measure vital signs Assess for leg pain

Evaluate pedel pulses

A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making whistling sounds. The nurse should identify which of the following factors as the source for this sound? Low battery power Excessive wax in the ear canal A volume setting that is too low A crack in the ear tube

Excessive wax in the ear canal

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? Hold the irrigator 1.25 cm (0.5 in) above the eye Direct the irrigation solution up toward the upper eyelid Exert pressure on the bony prominences when holding the eyelids open Direct the irrigation from the outer canthus to the inner canthus of the eye

Exert pressure on the bony prominences when holding the eyelids open (upper lid=against eyebrows lower lid= against cheekbone) INCORRECT: Hold the irrigator 1.25 cm (0.5 in) above the eye--> should be 2.5 in

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following information should the nurse include in the teaching? Exhale slowly to reach goal volume. Hold breath for 5 seconds after goal volume is reached Continue to deep breathe between each cycle. Limit repeat pattern of breathing to 5 breaths.

Exhale slowly to reach goal volume. (The nurse should instruct the client to inhale slowly to reach goal volume and to decrease collapse of alveoli in the client's lungs.) CORRECT ANSWER Hold breath for 5 seconds after goal volume is reached. (The nurse should instruct the client to hold her breath for 3 to 5 seconds after reaching maximal inspiratory volume. This decreases the collapse of alveoli, which helps to prevent the risk of atelectasis and pneumonia.) Continue to deep breathe between each cycle. (The nurse should instruct the client to breathe normally for short periods of time between each cycle of breaths, to reduce hyperventilation and fatigue.) Limit repeat pattern of breathing to 5 breaths. (The nurse should instruct the client to repeat the patterns for 10 to 20 breaths every hour while awake, which helps to prevent the risks of atelectasis and pneumonia.)

A new resident provider asks the charge nurse for an access code to review client's online records. The resident is not scheduled to attend the facility's orientation computer class until next week. Which of the following actions should the nurse take? Explain that it is against policy to share access codes and refer the resident to the supervisor Access the client's online data and monitor the resident as he reads them Access the online system and allow the resident to locate the client's data Ask each client to give permission for the resident to access medical records

Explain that it is against policy to share access codes and refer the resident to the supervisor

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? Give the client a glass of water Assist the client in a sitting position Explain the procedure to the client Measure the length of tubing to be inserted

Explain the procedure to the client

A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction? Flushing of the skin Inability of the toddler to cry or speak Presence of nausea and mild emesis Capillary refill time 1.5 sec

Flushing of the skin (The nurse should identify cyanosis as a finding associated with poor oxygenation, which could indicate an airway obstruction. The nurse should check the skin, nail beds, and mucous membranes to identify the presence of cyanosis.) CORRECT ANSWER Inability of the toddler to cry or speak (When the client has no sound passing through the vocal cords, the nurse should identify a complete airway obstruction is evident. The nurse should use the Heimlich maneuver to dislodge whatever is obstructing the trachea.) Presence of nausea and mild emesis (The presence of mild emesis does not indicate an airway obstruction. The nurse should monitor the client to ensure the client clears emesis from the oral cavity in order to prevent the airway from becoming obstructed.) Capillary refill time 1.5 sec (The expected finding for capillary refill time or blanch testing of the nail bed is less than 2 seconds; therefore, the nurse should not identify this finding as an indication of airway obstruction. Delayed capillary refill time can indicate circulatory impairment.)

A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? Explain the x-ray procedure to the client. Help the client into a wheelchair before the transporter arrives. Ask if the client has any questions. Identify the client using two identifiers.

Explain the x-ray procedure to the client. (The nurse should explain the x-ray procedure to the client. However, there is another action the nurse should take first.) Help the client into a wheelchair before the transporter arrives. (The nurse should have the client ready for the procedure. However, there is another action the nurse should take first.) Ask if the client has any questions. (The nurse should inquire if the client has any questions about the procedure. However, there is another action the nurse should take first.) CORRECT ANSWER Identify the client using two identifiers. (The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Once the client's identity is determined, the nurse can then proceed with the other options. This action is the priority action because it provides for the safety of the client. It is a nursing responsibility to be certain that each client receives only what has been prescribed. The nurse must assure that the correct client is being transported for a chest x-ray.)

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client? Speak directly into the client's impaired ear Exaggerate lip movements Speak loudly Face the client when speaking

Face the client when speaking

A nurse is communicating with a group of clients about what to expect during the postoperative phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as an evaluation of effective communication? The motivation for communication is evident Feedback is provided A message is communication to the group of clients Multiple channels are used by the sender

Feedback is provided

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. Which of the following ethical principles is the nurse demonstrating? Autonomy Fidelity Nonmaleficence Justice

Fidelity (keeping a promise) INCORRECT: Autonomy= ensuring they have the right to make personal decisions Nonmaleficence= doing no harm Justice= treating everyone fairly

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? Fifth intercostal space just medial to the midclavicular line Second intercostal space to the left of the sternum Fifth intercostal space to the left of the sternum Second intercostal space to the right of the sternum

Fifth intercostal space just medial to the midclavicular line (The mitral valve is located in the fifth intercostal space just medial to the midclavicular line.) Second intercostal space to the left of the sternum (The pulmonic valve is located in the second intercostal space to the left of the sternum.) Fifth intercostal space to the left of the sternum (The tricuspid valve is located in the fifth intercostal space to the left of the sternum.) CORRECT ANSWER Second intercostal space to the right of the sternum (The aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a midsystolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward.)

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? Leave the bag in place for 45 mins Fill the bag 2/3 full with ice Place the bag of ice uncovered on the client's ankle Tell the client that numbness is expected when the ice bag is in place

Fill the bag 2/3 full with ice

A nurse is caring for a client who has the head of his bed elevated to a 45 degree angle with his knees slightly flexed. Which of the following positions should the nurse document for the client? Sims' Prone Supine Fowler's

Fowler's

A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink Grasp a skin fold on the chest under the clavicle, release it and note whether it springs back Press the skin above the ankle for 5 seconds, release it, and note the depth of the impression Measure the skinfold thickness on the upper arm using a pair of calibrated skinfold calipers

Grasp a skin fold on the chest under the clavicle, release it and note whether it springs back

A nurse is assessing a client who is postoperative. Which of the following findings should the nurse identify as an indication that the client is experiencing pain? Diarrhea Pupillary constriction Flushing Grimacing

Grimacing

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? Tenderness when touched Pink, shiny tissue with a granular appearance Seosanguineous drainage Halo of erythema on the surrounding skin

Halo of erythema on the surrounding skin (should report to the provider when there is a ring of erythema (redness) on the surround skin)

A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning? Ask the client if he wants to self-administer his insulin Have the client list the steps of the procedure Have the client demonstrate the procedure Ask the client if he understands the purpose of the insulin

Have the client demonstrate the procedure

A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for this client? BUN 18 mg/dL Capillary refill 1.5 sec Hct 55% Urine specific gravity 1.001

Hct 55% (elevated hematocrit) INCORRECT: BUN 18 mg/dL= expected Capillary refill 1.5 sec= expected Urine specific gravity 1.001= (Low) HYPERVOLEMIA

A nurse in a same-day procedure unit is caring for several clients who are undergoing different types of procedures. The nurse should anticipate that the client who has which of the following devices can safely undergo an magnetic resonance imaging (MRI)? Coronary artery stents Aneurysm clip Hearing aids Automated internal defibrillator

Hearing aids (they can be removed!!!!)

A nurse is teaching a client about the lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes? Identify the risks of nonadherence Schedule learning sessions to demonstrate the psychomotor skills the client will read Provide clearly written and easy-to-understand materials Help the client identify ways that these changes will result in positive personal outcomes

Help the client identify ways that these changes will result in positive personal outcomes

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? Hemolytic Febrile Circulatory overload Sepsis

Hemolytic (occurs when the client's blood is incompatible with the donor's blood)

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of information should the nurse include in the teaching? Exhale slowly to reach the goal volume Hold the breath for 5 sec after the goal volume is reached Continue to breathe deeply between each cycle Limit the repeat pattern of breathing to 5 breaths

Hold the breath for 5 sec after the goal volume is reached (hold for 3-5 secs to decrease the collapse of alveoli)

A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. Which of the following actions should the nurse plan to take? Hold the dropper 1cm (0.5 in) above the ear canal Apply pressure to the nasolacrimal duct following administration Place a cotton ball into the inner ear canal for 30 mins following administration Straighten the ear canal by pulling the auricle down and back prior to administration

Hold the dropper 1cm (0.5 in) above the ear canal INCORRECT: Apply pressure to the nasolacrimal duct following administration--> eye drops Place a cotton ball into the inner ear canal for 30 mins following administration--> in the outermost for 15 mins Straighten the ear canal by pulling the auricle down and back prior to administration--> for a child 3 or younger

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? Hold the irrigator 1.25 cm (0.5 in) above the eye. Direct the irrigation solution upward toward the upper eyelid. Exert pressure on the bony prominences when holding the eyelids open. Direct the irrigation from the outer canthus to the inner canthus of the eye.

Hold the irrigator 1.25 cm (0.5 in) above the eye. (The nurse should hold the irrigator 2.5 cm (1 in) above the eye to prevent the irrigator from touching the eye and to prevent the solution from damaging the eye tissue.) Direct the irrigation solution upward toward the upper eyelid. (The nurse should direct the irrigation solution onto the lower conjunctiva sac to prevent injuring the cornea and having contaminated fluid flow down the nasolacrimal duct.) CORRECT ANSWER Exert pressure on the bony prominences when holding the eyelids open. (The nurse should hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating the eye.) Direct the irrigation from the outer canthus to the inner canthus of the eye. (The nurse should direct the irrigation solution from the inner canthus to the outer canthus of the eye to prevent injuring the cornea and having contaminated fluid flow down the nasolacrimal duct.)

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse perform? Place the soiled linens on the chair while making the bed Hold the linens away from the body and clothing Place the linens on the floor until a linen bag is available Shake the clean linens to unfold

Hold the linens away from the body and clothing

As a nurse is preparing to administer liquid medication from a bottle to a client, which of the following actions should the nurse take? Hold the medication bottle with the label against the palm of the hand when pouring Place the cap with the inside facing down on a hard surface Fill the cup until the medication is even with the edge of the dosage scale Pour any excess liquid back into the bottle after measuring

Hold the medication bottle with the label against the palm of the hand when pouring (to prevent contaminating the label with spilled medication that could cause information on the label to fade or become illegible)

A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside. Which of the following actions should the nurse take? Hold the sterile drape above the waist and away from the body Drop the sterile objects toward the edges of the sterile field Hold packaged supplies 7.6 cm (3in) above the sterile field Hold sterile objects over the field before setting them down on the field

Hold the sterile drape above the waist and away from the body (Contamination occurs when a nurse holds anything below the waist or touches anything other than a sterile object)

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention? Holding a community clinic to administer influenza immunizations. Screening groups of older adults in nursing care facilities for early influenza manifestations. Educating parents of young children about dangers of influenza. Finding rehabilitation programs for older adults who have complications from influenza.

Holding a community clinic to administer influenza immunizations. (Administering influenza immunizations is an example of primary prevention for people who are healthy but in danger of becoming ill.) CORRECT ANSWER Screening groups of older adults in nursing care facilities for early influenza manifestations. (Screening older adults who have some manifestations of illness to determine if they have influenza is an example of secondary prevention. Secondary prevention is focused on preventing complications of an illness or providing care to prevent illness from becoming severe.) Educating parents of young children about dangers of influenza. (Educating clients about the dangers of influenza is an example of primary prevention for people who are healthy but in danger of becoming ill.) Finding rehabilitation programs for older adults who have complications from influenza. (This is an example of tertiary prevention, which tries to prevent complications and help people recover from an existing illness.)

A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take? Hyperoxygenate the client before suctioning Insert the catheter during exhalation Apply suction during insertion of the catheter Apply suction for no more than 15 sec

Hyperoxygenate the client before suctioning (use a manual resuscitation bag to hyperoxygenate the client for several mins before suctioning)

A nurse is administering medication to a client who asks the nurse to leave the medication at the bedside to be taken at a later time. Which of the following responses should the nurse make? "Call me when you are ready, and I will return with the medication" "Since you were taking this medication at home, I will leave it for you to take" "I will come back in 30 mins to check that you took the medication so I can chart the time" "if you refuse to that the medication now, I cant give it to you until your next scheduled time"

I will return with the medication"

A nurse is caring for a client who requires a chest xray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? Explain the xray procedure to the client Help the client into a wheelchair before the transporter arrives Ask if the client has any questions Identify the client using 2 identifiers

Identify the client using 2 identifiers

A nurse is caring for a client who is 48 hour postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication? Blood loss NPO status after surgery Nasogastric tube suctioning Impaired peristalsis of intestines

Impaired peristalsis of intestines (normal bowel function is delayed for up to several days following a bowel resection)

A nurse is caring for a toddler at a well-child visit when the mother calls, "Help! My baby is choking on his food". Which of the following findings indicates the toddler has an airway obstruction? Flushing of the skin Inability to cry or speak Presence of nausea and mild emesis Capillary refill time of 1.5 sec

Inability to cry or speak

A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect? Increased blood pressure Decreased blood glucose level Decreased oxygen use Increased gastrointestinal motility

Increased blood pressure

A nurse is assessing a client who is experiencing stress following a near fall out of bed. Which of the following physiological responses should the nurse expect due to the fight-or-flight response? Decreased respiratory rate Pinpoint pupils Increased blood pressure Bronchiolar construction

Increased blood pressure

A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? Decreased urine specific gravity Increased heart rate Decreased hematocrit Increased skin turgor

Increased heart rate (fluid volume deficit)

A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care-associated infections (HAIs). Which of the following routes of infection should the manager identify as an iatrogenic HAI? Infection acquired from improper hand hygiene Infection acquired by drug resistance Infection acquired by inappropriate waste disposal Infection acquired from a diagnostic procedure

Infection acquired from a diagnostic procedure (result from diagnostic or therapeutic procedures)

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? Lubricate up to 3.2 cm(1.25 in) of the tip of the rectal tube Position the client on the right side Insert the tip of the tubing 8cm (3.1in) Hold the enema container 61cm (24in) above the rectum

Insert the tip of the tubing 8cm (3.1in) (7-10 cm or 3-4 in)

A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client's HIV infection status. Which of the following actions should the nurse take? Inform the guard that the warden must request this information Ask the guard to sign a release of information form Instruct the guard to ask the inmate Complete an incident report

Instruct the guard to ask the inmate (the client must offer the information freely--> therefore the guard must ask the client)

A nurse is caring for a client who has a temperature of 38.7 C (101.7 F). Which of the following actions should the nurse take? Apply an alcohol-water solution to the client's skin Keep the client's bed linens dry Apply ice packs to the groin Limit the client's fluid intake to 1183 mL (40 oz) of fluid per day

Keep the client's bed linens dry (maximize the client's heat loss and reduce external coverings on the bed without causing shivering)

A nurse is caring for a client who has a temperature of 38.7 C (101.7 F). Which of the following actions should the nurse take? Apply an alcohol-water solution to the client's skin Keep the client's bed linens dry Apply ice packs to the groin Limit the client's fluid intake to 1183 mL (40oz) pf fluid per day

Keep the client's bed linens dry (maximize the client's heat loss by keeping linens and clothes dry)

A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique? Preventing the transfer of the microorganisms to the nurse Keeping microorganisms from entering the wound Applying minimal pressure to the wound Keeping excess moisture from entering the wound

Keeping microorganisms from entering the wound

A nurse is planning an in-service training session about various dietary practices. Which of the following pieces of information should the nurse include in the teaching? Ovo-vegetarian diets exclude eggs Kosher diets have restriction regarding how the food must be prepared Macrobiotic diets are plant-based and exclude all animals and seafood Flexitarian diets exclude the consumption of dairy products

Kosher diets have restriction regarding how the food must be prepared INCORRECT: Macrobiotic--> include fish and seafood

A nurse is presenting an in-service training session about nutrition. Which of the following simple sugars should the nurse identify as the carbohydrate found in milk? Lactose Sucrose Maltose Fructose

Lactose

A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter? Lateral thigh Lower abdomen Mid-abdominal region Medial thigh

Lateral thigh (Securing the indwelling urinary catheter tubing to the client's lateral or outside thigh can create tension on the client's urethra which can cause trauma and injury.) CORRECT ANSWER Lower abdomen (After inserting an indwelling urinary catheter, the nurse should secure the catheter tubing to the client's upper thigh or lower abdomen, by using adhesive tape or catheter securement device. This location will decrease tension and trauma to the urethra.) Mid-abdominal region (Securing the indwelling urinary catheter tubing to the client's mid-abdominal region can create tension on the client's urethra and does not allow for the downward flow of urine via gravity into the drainage bag.) Medial thigh (Securing the indwelling urinary catheter tubing to the client's medial or mid-thigh area can create tension on the client's urethra which can cause trauma and injury.)

A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein? Eggs Soybeans Lentils Yogurt

Lentils (missing 1 or more of the essential amino acids= lentils, veggies, grains, nuts, seeds)

A nurse is reviewing a client's laboratory results and notes a WBC count of 3,600/mm^3. The nurse should identify this result as which of the following? Leukoplakia Leukemia Leukocytosis Leukopenia

Leukopenia (occurs when there is a DECREASE in WBCs-->makes the client at risk of infection) INCORRECT: Leukoplakia= involves thick white patches in the mucosa of the mouth Leukemia= uncontrolled production of blast cells or immature WBC in the bone marrow Leukocytosis= increase in WBC

A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse include? Serve foods at warm or hot temps Offer the client low-density foods Make sure the client lies supine after meals Limit drinking liquids with food

Limit drinking liquids with food (leads to early satiety and bloating, which results in the client consuming fewer calories) INCORRECT: Serve foods at warm or hot temps--> should be COLD or room temp food Offer the client low-density foods--> high protein, high caloric, nutrient dense foods Make sure the client lies supine after meals--> to reduce nausea client should sit upright for 1 hour after meals

A nurse in a provider's office is collecting information from an older adult client who reports taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects? Constipation Gastric ulcers Respiratory depression Liver damage

Liver damage (3-4 grams per day) INCORRECT: Constipation= opioid analgesics Gastric ulcers= aspirin Respiratory depression= opioid analgesics

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse perform to transfer the client from the stretcher to the bed? Lock the wheels on the bed and stretcher Instruct the client to raise his arms above his head Elevate the stretcher 2.5cm (1in) above the height of the bed Log-roll the client

Lock the wheels on the bed and stretcher

A nurse on a mental health unit is preparing to terminate the nurse-client relationship with. client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? Loss Trust Self-disclosure Risk-taking

Loss

A nurse is preparing to anchor the catheter tube with tape for a male client who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter? Lateral thigh Lower abdomen Mid-abdominal region Medial thigh

Lower abdomen (or upper thigh)

A nurse is caring for a client who starts to experience a seizure while sitting in a chair. Which of the following actions should the nurse take? Place a padded tongue blade in the client's mouth Lower the client to the floor and place a pad under the client's head Seek the help of a coworkers and lift the client back into bed Use an oropharyngeal airway to keep the upper airway passages open

Lower the client to the floor and place a pad under the client's head INCORRECT Use an oropharyngeal airway to keep the upper airway passages open (this can cause injury)

A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first? Provide oxygen Place the client in a side-lying position Provide privacy Lower the patient to the floor

Lower the patient to the floor

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube. Position the client on his right side. Insert the tip of the tubing 8 cm (3.1 in). Hold the enema container 61 cm (24 in) above the rectum.

Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube. (The nurse should lubricate 5 to 8 cm (2 to 3 in) of the tip of the rectal tube before inserting to decrease the risk of irritation or injury to the mucosa.) Position the client on his right side. (The nurse should position the client on the left side in the Sims' position to allow the solution to flow downward into the sigmoid colon and rectum and promote retention of the enema.) CORRECT ANSWER Insert the tip of the tubing 8 cm (3.1 in). (The nurse should insert the tip of the tubing 7 to 10 cm (3 to 4 in) along the rectal wall to prevent dislodging of the tube during the procedure and injury to the rectal mucosa.) Hold the enema container 61 cm (24 in) above the rectum. (The nurse should hold the enema container a maximum of 45 cm (18 in) above the rectum to prevent painful distention of the colon.)

A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the client's body? Heart Lungs Thyroid gland Skin

Lungs (creates a vibration that helps determine the density of the underlying tissue--> lungs are hollow organs)

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? Maintain suction while removing the NG tube. Instill 100 mL of air into the NG tube before removal. Pinch the NG tube while removing the tube. Instruct the client to breathe in and out during the removal of the NG tube.

Maintain suction while removing the NG tube. (The nurse should disconnect the NG tube from the suction apparatus before removal to decrease injury to the gastrointestinal mucosa.) Instill 100 mL of air into the NG tube before removal. (The nurse should instill 50 mL of air into the tube to clear the contents of gastric drainage and decrease the risk of aspiration on removal of the tube.) CORRECT ANSWER Pinch the NG tube while removing the tube. (The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents.) Instruct the client to breathe in and out during the removal of the NG tube. (The nurse should instruct the client to take a deep breath and to hold it during the removal of the NG tube to close off the glottis and decrease the risk of aspiration of any gastric contents.)

A nurse is admitting a client who has a hearing aid. Which of the following actions should the nurse take before beginning the interview process? Sit beside the client during the interview Make sure the device is functioning Make sure lighting in the room is soft Provide a lengthy interview process to allow adequate time to answer questions

Make sure the device is functioning

A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift in which the client received atenolol instead of allopurinol. Which of the following interventions in the nurse's priority? Measure the client's apical pulse Administer the allopurinol to the client Inform the nurse manager Complete an accident report

Measure the client's apical pulse (Atenolol is a beta blocker and can decrease the client's heart rate)

A nurse is measuring a client's vital signs. The client's resting radial pulse rate is 55/min. Which of the following actions should the nurse take next? Document the finding Measure the client's apical pulse rate Talk with the client about factors that can affect pulse rate Notify the provider about the client's radial pulse rate

Measure the client's apical pulse rate (to determine if there is a pulse deficit)

A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? Measure the pulse using a Doppler ultrasound stethoscope. Check the client's pedal pulses.

Measure the pulse using a Doppler ultrasound stethoscope. (The nurse should use a Doppler ultrasound stethoscope for a pulse that is nonpalpable or very difficult to palpate.) Check the client's pedal pulses. (The nurse should assess pedal pulses to determine circulation in the client's lower extremities.) CORRECT ANSWER Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. (If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 60 seconds to obtain an accurate rate. The nurse should document the irregularity in the client's medical record.) Take the pulse at each peripheral site and count the rate for 30 seconds. (The nurse should assess all peripheral pulses to determine the equality of blood perfusion to the extremities.)

A nurse is caring for a client who had a stroke and is at risk for of fallings. Which of the following actions should the nurse take? Assign the client to a private room Keep 4 side rails up while the client is in bed Monitor the client at least once every hour Request a PRN prescription for restraints

Monitor the client at least once every hour

A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take? Assign the client to a private room Keep 4 side rails up while the client in in bed Monitor the client at least once every hour Request a PRN prescription for restraints

Monitor the client at least once every hour

A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? Abdominal binder Montgomery straps Hypoallergenic tape Plastic tape

Montgomery straps (least restrictive; have holes for using gauze to tie the dressing securely)

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has gastrostomy tube for enteral feedings. Which pieces of information are critical to communicate to the next nurse who will be caring for this client? Select all that apply Room temp New prescriptions Number of visitors Arterial blood gas results Tracheal secretion characteristics

New prescriptions Arterial blood gas results Tracheal secretion characteristics

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room. The client states she no longer wants to have the surgery. Which of the following actions should the nurse take? Tell the client it is too late for her to change her mind because the surgery is already scheduled Telephone the operating room and cancel the surgery Inform the client's family about the situation Notify the provider of the client's decision

Notify the provider of the client's decision

A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate? Incontinence Mental state Nutrition General physical condition

Nutrition (Braden scale= nutrition, sensory perception, moisture, activity, mobility, and friction) INCORRECT: Incontinence, mental state, and General physical condition = Norton scale

A nurse in a long=term care facility is in the dining room while residents are eating lunch. One resident begins to choke and is coughing strongly. Which of the following actions should the nurse take? Assist the client to the floor Perform an abdominal thrust Open the airway with a head-chin tilt Observe the client closely

Observe the client closely (as long as they are able to cough strongly the nurse should not intervene)

A client who reports shortness of breath requests the nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? Encourage the client to take deep breaths Observe the rate, depth, and character of the client's respirations Prepare to administer oxygen Give the client a back rub to promote relaxation

Observe the rate, depth, and character of the client's respirations (nurse must collect data)

During the insertion of a urinary catheter for a client, the tip of the catheter brushes against the nurse's arm. Which of the following actions should the nurse take? Wipe the catheter with povidone-iodine and continue the catheter insertion Soak the catheter in chlorhexidine for 15 min and then reattempt insertion Continue with catheter insertion Obtain a new catheter and reattempt insertion

Obtain a new catheter and reattempt insertion

A nurse is caring for a client who has dysrhythmia. Which of the following techniques should the nurse use to assess for a pulse deficit? Obtain the apical and radial rates simultaneously Check the blood pressure in the left and right arms Compare the pulse strength in the upper extremities Palpate the pulses in the lower extremities

Obtain the apical and radial rates simultaneously (then subtract the difference)

A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks both the client's native language and the nurse's, arrive to drive the client home. Which of the following actions should the nurse take? Ask the client's neighbor to call a family member to interpret Ask the client's neighbor to translate the information Obtain the services of an interpreter Document the inability to provide discharge instructions

Obtain the services of an interpreter

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which fo the following actions by the newly licensed nurse requires intervention? Obtaining hydrogen peroxide for tracheostomy care Obtaining cotton balls for tracheosotmy care Obtaining sterile brush for tracheostomy care Obtaining sterile gloves for tracheosotmy care

Obtaining cotton balls for tracheosotmy care

A nurse is caring for an older adult who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? Encourage the client to drink fluids before swallowing food Offer the client tart or sour foods first Tilt the client's head backward when swallowing Turn on the television

Offer the client tart or sour foods first (to stimulate saliva)

A nurse is caring for a client who has a fecal impaction. Before the digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? Carminative Hypertonic Oil retention Sodium polystyrene sulfate

Oil retention INCORRECT: Carminative--> helps expel flatus Hypertonic--> cleanse the bowels Sodium polystyrene sulfate--> client with high potassium level

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? Open all sterile supplies and solutions. Stabilize the tracheostomy tube. Don sterile gloves. Perform hand hygiene.

Open all sterile supplies and solutions. (The nurse should open all sterile supplies and solutions prior to providing tracheostomy care. However, there is another action the nurse should take first.) Stabilize the tracheostomy tube. (The nurse should stabilize the tracheostomy tube to prevent accidental extubation while providing tracheostomy care. However, there is another action the nurse should take first.) Don sterile gloves. (The nurse should don sterile gloves prior to providing tracheostomy care to reduce the transmission of organisms. However, there is another action the nurse should take first.) CORRECT ANSWER Perform hand hygiene. (According to evidence-based practice, the nurse should first perform hand hygiene before touching the client or performing any skills, such as tracheostomy care. This is vital because contamination of the nurse's hands is a primary source of infection.)

A nurse in a provider's office is measuring a client and notes a loss height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders? Osteoporosis Scoliosis Kyphosis Lordosis

Osteoporosis

A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? BT for bedtime SC for subcutaneously PC for after meals HS for half-strength

PC for after meals

A nurse is collecting health history data from a client who is deaf and uses ALS to communicate. The nurse will be working with an ASL interpreter. Which of the following actions should the nurse take when working with the interpreter? Face away from the client to avoid distraction Pace speech to allow time for the interpreter to convey the words Make eye contact with the interpreter when explaining the procedure Stand in the background while the interpreter translates the message

Pace speech to allow time for the interpreter to convey the words

A nurse is performing a physical exam for a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques? Percussion Auscultation Inspection Palpation

Palpation

A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse which of the following statements by the newly licensed nurse indicates an understanding of the teaching? People who practice the Islamic faith pray over the deceased for a period of 5 days before burial People who practice the Hindu faith bury the deceased with their head facing north People who practice Judaism stay with the body of the deceased until burial People who practice the Buddhist faith have the female family members prepare the body following death

People who practice Judaism stay with the body of the deceased until burial

A nurse is performing a physical assessment of a client. Which of the following actions should the nurse take to assess the client's tissue perfusion? Perform a Romberg test Check nails for Beau's lines Palpate for respiratory excursion Perform a blanch test

Perform a blanch test (cap refill) INCORRECT: Romberg test= balance/gross motor function

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse perform first? Open all sterile supplies and solutions Stabilize the tracheostomy tube Put on sterile gloves Perform hand hygiene

Perform hand hygiene

A nurse is assessing the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? Audible click Murmur Third heart sound Pericardial friction rub

Pericardial friction rub (high-pitched scratching)

A nurse is assessing a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings Peripheral pulses equal bilaterally at a rate of 60/min Radial, brachial, and pedal pulses bilaterally weak Peripheral pulses bilaterally symmetric, equal, and strong, in all 4 extremities Brachial, radial, popiteal, and dorsalis pedis pulses regular, 58, and bilaterally palpable

Peripheral pulses bilaterally symmetric, equal, and strong, in all 4 extremities (peripheral pulses = radial, brachial, ulnar, femoral, popiteal, tibial, and dorsalis pedal pulses)

A nurse is employing a through, systematic method while obtaining objective data about a client. Through which of the following methods should the nurse collect this information? Health history Physical exam Review of systems Interview

Physical exam (physical findings are objective and the nurse should collect this info in a systematic way)

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? Maintain suction while removing the NG tube Instill 100mL of air into the NG tube before removal Pinch the NG tube while removing the tube Instruct the client to breathe in and out during the removal of the NG tube

Pinch the NG tube while removing the tube (to decrease the rick of aspiration of any gastric contents) INCORRECT: Maintain suction while removing the NG tube (the nurse should disconnect the NG tube from the suction apparatus before removal) Instill 100mL of air into the NG tube before removal (50 ml) Instruct the client to breathe in and out during the removal of the NG tube (hold their breathe during removal)

A nurse is assisting a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? Place an oxygen mask on the client. Check the client's pulse. Determine whether the client is able to breathe. Wrap arms around the client from behind.

Place an oxygen mask on the client. (The nurse should place an oxygen mask on the client to provide supplemental oxygen. However, there is another action the nurse should take first.) Check the client's pulse. (The nurse should begin rescue breathing as part of cardiopulmonary resuscitation (CPR) if the client becomes unconscious. However, there is another action the nurse should take first.) CORRECT ANSWER Determine whether the client is able to breathe. (Caring for this client requires application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. The client is demonstrating the universal choking gesture. If the client is unable to move air in or out, severe airway obstruction is present. The client would need emergency interventions to clear a partial obstruction, indicated by stridor or minimal airway passage. As long there is good air exchange and she can cough and breathe spontaneously, the nurse should stay with the client and monitor her condition.) Wrap arms around the client from behind. (The nurse should wrap arms around the client from behind to perform an abdominal thrust if breathing is obstructed. However, there is another action the nurse should take first.)

A nurse is leading an education session about disposing of biohazardous materials. Which of the following instructions should the nurse include in the teaching? Use isopropyl alcohol to clean blood spills Discard empty blood bags in a bedside trash can Break used needles before discarding them Place soiled linen in a single linen bag

Place soiled linen in a single linen bag INCORRECT: Use isopropyl alcohol to clean blood spills--> use chlorine bleach

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? Auscultate the blood pressure at the dorsalis pedis artery Measure the blood pressure with the client sitting on the side of the bed Place the cuff 7.6 cm (3in) above the popliteal artery Place the bladder of the cuff over the posterior aspect of the thigh

Place the bladder of the cuff over the posterior aspect of the thigh (lower extremity blood pressure)

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? Place the client in Trendelenburg position Perform percussions directly over the client's bare skin Use a flattened hand to perform percussions Remind the client that chest percussions can cause mild pain

Place the client in Trendelenburg position (right sided to promote drainage to the client's left side)

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? Place the client in a lateral position with the head turned to the side before beginning the procedure Use the thumb and index finger to keep the client's mouth open Rinse the client's mouth with an alcohol-based mouthwash following the procedure Cleanse the client's mucous membranes with lemon-glycerin sponges

Place the client in a lateral position with the head turned to the side before beginning the procedure

A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take? Raise the enema bag if the client experiences cramping Lubricate 2.54cm (1in) of the tip of the rectal tube prior to insertion Place the client in a left Sim's position Don sterile gloves prior to the procedure

Place the client in a left Sim's position INCORRECT: Raise the enema bag if the client experiences cramping-->administer SLOWLY Lubricate 2.54cm (1in) of the tip of the rectal tube prior to insertion--> 2 IN Don sterile gloves prior to the procedure--> CLEAN not sterile

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurses take? Select all that apply Carefully reinsert the intestine through the opening in the wound Place the client in a supine position with the hips and knees flexed Leave the room to call the surgeon Cover the wound and intestine with a sterile, moistened dressing Monitor the client for manifestations of shock

Place the client in a supine position with the hips and knees flexed (this helps prevent further tearing) Cover the wound and intestine with a sterile, moistened dressing Monitor the client for manifestations of shock

A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? Place the client supine. Keep both side rails up. Raise the level of the bed. Inspect the client's mouth using a finger sweep.

Place the client supine. (To prevent the risk of aspiration, the nurse should raise the client's head to 30° or turn the client to a side-lying position.) Keep both side rails up. (To prevent straining and the risk of self-injury, the nurse should lower the near side rail before performing mouth care.) CORRECT ANSWER Raise the level of the bed. (The nurse should raise the bed to allow for the use of proper body mechanics and reduce the risk of self-injury.) Inspect the client's mouth using a finger sweep. (To prevent the risk of care-giver injury, the nurse should never insert fingers into the mouth of an unresponsive client.)

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take? Place the soiled linens on the chair while making the bed. Hold the linens away from the body and clothing. Place the linens on the floor until able to place it in a linen bag. Shake the clean linens to unfold.

Place the soiled linens on the chair while making the bed. (The nurse should place the soiled linens in a linen bag immediately after removing the linen from the bed to prevent the spread of microorganisms on surfaces within the client's room and exposure to personnel.) CORRECT ANSWER Hold the linens away from the body and clothing. (The nurse should hold the linens away from the body and clothing to prevent soiling or the transfer of microorganisms. The microorganisms present on the nurse's clothing can expose other clients to microorganisms.) Place the linens on the floor until able to place it in a linen bag. (Soiled linen is contaminated with microorganisms and will further contaminate the floor and attract any microorganisms present on the floor, which places the nurse and the client at risk for infection.) Shake the clean linens to unfold. (Opening linens by shaking them causes movement of air. Air currents can carry dust and spread microorganisms throughout the room, which places the client and the nurse at risk for infection.)

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? Instruct the client to defecate into the toilet bowl Transfer the specimen to a sterile container Refrigerate the collected specimen Place the stool specimen collection container in a biohazard bag

Place the stool specimen collection container in a biohazard bag (with the client label ) INCORRECT: Instruct the client to defecate into the toilet bowl--> into a bed pan Transfer the specimen to a sterile container--> CLEAN container Refrigerate the collected specimen--> take it directly to the lab

A home health nurse enters a client's home and finds a used insulin syringe without a cap on the table. Which of the following actions should the nurse take? Recap the needle on the syringe Schedule a nurse to administer future injections for this client Explain to the client that the syringe should be disposed of in the bathroom trash can Place the syringe in a puncture-proof disposal container

Place the syringe in a puncture-proof disposal container

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? Stand toward the client's stronger side Instruct the client to lean backward from the hips Place the wheelchair at a 45 degree angle to the bed Assume a narrow stance with the feet 15 cm (6in) apart

Place the wheelchair at a 45 degree angle to the bed (allows the client to pivot, lessening the amount of rotation required)

A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the following functional classifications? Skeletal muscle relaxants Beta-adrenergic blockers Broad-spectrum anti-infective agents Plasma volume expanders

Plasma volume expanders (dextran and albumin help correct hypovolemia in emergency situations such as hemorrhage or burns) INCORRECT: Skeletal muscle relaxants=cyclobenzaprine and metaxalone Beta-adrenergic blockers= propranolol and carvedilol Broad-spectrum anti-infective agents = ampicillin and ceftixime

A nurse is preparing to perform postural drainage for a client. Which of the following actions should the nurse take? Give the client a bronchodilator immediately after the procedure Position the client for drainage of secretions by gravity Schedule postural drainage following meals Instruct the client regrading the importance of fluid restrictions

Position the client for drainage of secretions by gravity

A nurse is preparing to administer a cleaning enema to a patient. Which of the following actions should the nurse plan to take? Insert the rectal tuber 15.2 cm (6in) Wear sterile gloves to insert the tubing Position the client on his left side Hold the solution bag 91 cm (36in) above the client's rectum

Position the client on his left side INCORRECT: --> insert 7-10cm (3-4in) Clean gloves Hold the bag 30cm (12 in) above

A nurse is monitoring a client's laboratory results. Which of the following results should the nurse report to the provider Sodium 140 mEq/L Potassium 3.0 mEq/L Chloride 100 mEq/L Magnesium 2.0 mEq/L

Potassium 3.0 mEq/L

A nurse is planning an in-service training session about nutrition. Which of the following pieces of information should the nurse include? Fat breaks down into amino acids Protein serves as an energy source when other sources are inadequate Glucose breaks down into ammonia Carbohydrates provide 9cal/g of energy

Protein serves as an energy source when other sources are inadequate INCORRECT: Fat breaks down into amino acids-->PROTEIN does Glucose breaks down into ammonia --> PROTEIN does Carbohydrates provide 9cal/g of energy --> carbs= 4 cal/g of energy fat= 9 cal/g of energy

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? Limit the total caloric intake to 25 kcal/kg of body weight Provide an intake of 500 mg/day of vitamin E Limit fluid intake to 20 mL/kg of body weight per day Provide a protein intake of 1.5 g/kg of body weight per day

Provide a protein intake of 1.5 g/kg of body weight per day (necessary to maintain a positive nitrogen balance--> this promotes wound healing)

A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the clients urine is 1.035. Which of the following actions should the nurse take? Deliver the formula at a slower rate Request a lower-fat formula Provide more water with feedings Instill a lactose-free formula

Provide more water with feedings

A nurse is caring for a group of clients. Which of the following tasks should the nurse assign to an assistive personnel (AP) Provide oral care to a client who cannot take oral fluids Check a client's IV insertion site for manifestations of infiltration Assess a client's ability to ambulate Demonstrate the use of a glucometer to a client who has diabetes mellitus

Provide oral care to a client who cannot take oral fluids (within the range of function)

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply) Set the suction machine at 120 mmHg Provide oral hygiene frequently Measure the amount of drainage from the NG tube every shift Secure the NG tube to the client's gown Apply petroleum jelly to the client's nares

Provide oral hygiene frequently Measure the amount of drainage from the NG tube every shift Secure the NG tube to the client's gown INCORRECT: 80-100mmHg Water-soluable lubricant

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? Provide the client with a glass of water. Assist the client to a sitting position. Explain the procedure to the client. Measure the length of tubing to be inserted.

Provide the client with a glass of water. (The nurse should provide a glass of water to facilitate swallowing during tube insertion of the NG tube. However, there is another action the nurse should take first.) Assist the client to a sitting position. (The nurse should assist the client to a sitting position to more easily insert the NG tube and allow gravity to help facilitate the passage of the tube. However, there is another action the nurse should take first.) CORRECT ANSWER Explain the procedure to the client. (The nurse should apply the least invasive priority-setting framework when caring for this client. This framework assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of facility-acquired infections. Informing the client about the procedure reduces fear and assists in gaining the client's cooperation, which is important for NG tube insertion and is the priority nursing intervention.) Measure the length of tubing to be inserted. (The nurse should measure the length of the tubing to be inserted to ensure proper tube placement. However, there is another action the nurse should take first.)

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take? Remove the NG tube Advance the NG quickly Pull the NG tube back slightly Ask the client to tilt his head backward

Pull the NG tube back slightly

A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following type of drainage? Sanguineous exudate Serous exudate Serosanguineous exudate Purulent exudate

Purulent exudate (thick yellow, green, or brown drainage= sloughing or infection) INCORRECT: Sanguineous exudate (accumulation of RBCs from the plasma that appears bright red on the dressings) Serous exudate (plasma= appears watery and clear to light yellow) Serosanguineous exudate (pale yellow to blood tinged)

A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. Press the skin in above the ankle for 5 seconds, release it, and note the depth of the impression. Measure the skin fold thickness at the upper arm using a pair of calibrated skinfold calipers.

Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink. (The nurse uses this technique for assessing capillary refill.) CORRECT ANSWER Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. (The nurse should use this technique for assessing skin turgor. If the client has good turgor and is properly hydrated, the skin will immediately return to normal; with dehydration, the skin will remain tented. The nurse can also assess turgor by grasping a skin fold on the back of the forearm.) Press the skin in above the ankle for 5 seconds, release it, and note the depth of the impression. (The nurse uses this technique for determining how much pitting edema a client has.) Measure the skin fold thickness at the upper arm using a pair of calibrated skinfold calipers. (The nurse uses this technique for determining a client's body fat percentage.)

A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? Place the client supine Keep both side rails up Raise the level of the bed Inspect the client's mouth using a finger sweep

Raise the level of the bed

A nurse is preparing to administer a partial dose of a prefilled opioid analgesic parenterally to a client. Which of the following actions should the nurse plan to take? Return the unused portion of the medication to the pharmacy Dispose of the wasted medication into a sharps container Record the amount of medication wasted on the controlled substance inventory record Ask an assistive personnel (AP) to witness the wasting of the controlled substance

Record the amount of medication wasted on the controlled substance inventory record (2 nurses should sign the inventory record)

A nurse is planning to perform passive ROM exercises for a client. Which of the following actions should the nurse take? Repeat each joint motion 5x during each session Move the joint to the point of considerable resistance Sit approx. 2 ft from the side of the bed closet to the joint being exercised Exercise the smaller joints first

Repeat each joint motion 5x during each session

A nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. Which of the following actions should the nurse take? Change the tube feeding bag every 48 hrs Chill the formula prior to administration Increase the infusion rate Request a prescription for an isotonic enteral nutrition formula

Request a prescription for an isotonic enteral nutrition formula (easier to digest) INCORRECT: Change the tube feeding bag every 48 hrs= EVERY 24 HOURS

A nurse is caring for a client who is receiving an IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site. Redness at the IV catheter entry site A palpable cord is felt along the vein used for the infusion Taut skin around the IV catheter site that is cool to the touch Bleeding at the IV insertion site

Redness at the IV catheter entry site (The client who has redness at the IV catheter entry site might have a local infection. The nurse should remove the IV, clean the site with alcohol, and start a new IV line in another location.) A palpable cord is felt along the vein used for the infusion (The client who has a palpable cord felt along the vein might have phlebitis, which is inflammation of the inner layer of a vein. The nurse should discontinue the infusion and start a new IV line in another location.) CORRECT ANSWER Taut skin around the IV catheter site that is cool to the touch (The client who has taut skin around the IV catheter site that is cool to touch might have an infiltrated IV site. The nurse should stop the IV infusion, elevate the extremity, and apply a warm moist compress, or a cold compress according to the type of infiltration.) Bleeding at the IV insertion site (Bleeding at the IV insertion site might indicate the IV system is not intact. The nurse should check to determine if the IV system is intact and if the catheter is within the client's vein. The nurse might need to start a new IV line in another location if the bleeding does not stop after interventions.)

A nurse is caring for a client in a long-term care facility. Which of the following findings should alert the nurse to the possibility that the client developed delirium? Gradual memory loss Reduced level of consciousness Difficulty with abstract thought Verbalized feelings of hopelessness

Reduced level of consciousness

A nurse is caring for a client who has chronic kidney disease. The kidneys regulate body fluids as well as assisting which of the following functions? Regulation of acid-base balance Reabsorption of nutrients for cellular growth Regulation of body temp Secretion of hormones needed for growth

Regulation of acid-base balance (by retaining biocarbondate as they excrete hydrogen ions) INCORRECT: Small intestine--> absorbs nutrients for cellular growth Integumentary system--> regulates body temp Anterior pituitary gland--> secretes hormones

A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. The nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. Which of the following actions should the nurse take? Change the infusion tubing Flush the IV catheter Remove the IV catheter Apply a cool compress to the site

Remove the IV catheter

A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take? Tie a secure knot with the restraint straps Attach the restraints' straps to the bedside rails Make sure 3 fingers fit beneath the restraints Remove the restraint every 2 hour

Remove the restraint every 2 hour

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? Tie the restraint to the side of the bed rail Perform ROM exercises to the wrists every 3 hours Remove the restraints one at a time Obtain a PRN prescription for the restraints

Remove the restraints one at a time

A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? Aim the hose at the base of the fire Squeeze the handle of the extinguisher Remove the safety pin from the extinguisher Sweep the hose from side to side to dispense material

Remove the safety pin from the extinguisher

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? Renew the prescription for the use of restraints within 24 hours Secure the restraint with the buckle side next to the client's skin Ensure 4 fingers can be inserted under the secured restraint Remove the restraint every 3 hours

Renew the prescription for the use of restraints within 24 hours

A nurse is preparing to administer a bolus feeding to a client through an NG tube and observes that the exit mark on the tube has moved since the last feeding. Which of the following actions should the nurse plan to take? Auscultate over the stomach while injecting air Request an xray of the client's abdomen Place the head of the client's bed in a flat position Administer the feeding if the pH of the aspirated contents is >6

Request an xray of the client's abdomen (to determine the placement)

A nurse is reviewing a client's laboratory report. The client's ABG levels are pH7.5, PaCO2 32 mmHg, and HCO3- 24 mEq/L. The should determine that the client has which of the following acid-base imbalances? Respiratory alkalosis Metabolic acidosis Respiratory acidosis Metabolic alkalosis

Respiratory alkalosis ***pH level above the expected rage of 7.35-7.45--> elevated ***PaCO2 is below the expected range of 35-45 mmHg--> indicates a respiratory origin INCORRECT: Acidosis= pH level lower than expected Metabolic origin= HCO3- levels

A home health nurse is visiting an older adult client with severe dementia. The client's son, who serves as her primary caregiver, reports "exhausted" from working part-time and caring for his mother at home. Which of the following options should the nurse suggest to the caregiver? Rehabilitation Assisted living facility Respite care Adult day care facility

Respite care (service for caregivers who need time to rest from multiple responsibilities related to the care of a family member who needs assistance) INCORRECT: Adult day care facility--> for clients who need minimal assistance

A nurse is preparing to administer a unit of packed RBCs to a client when she discovers that the IV line is no longer patent. The IV team informs her that someone can come to initiate a new like in 30 min. Which of the following actions should the nurse take? Return the blood to the laboratory Place the blood in the medication room Place the blood in the refrigerator Leave the blood at the client's bedside

Return the blood to the laboratory

A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temp; however, the nurse wanted an oral temp. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring? Right task Right circumstance Right person Right communication

Right communication

A nurse is applying antiembolitic stockings for a client who has a history of DVT. Which of the following actions should the nurse take when applying the stockings? Roll the stocking partially down if too long. Remove the stocking once per day. Bunch and pull the stocking half way up the calf. Turn the stocking inside out up to the heel before applying.

Roll the stocking partially down if too long. (The nurse should apply another size stocking if the stocking is too long. Rolling the stocking partially down can decrease venous return and cause skin irritation.) Remove the stocking once per day. (The nurse should remove the stockings once every shift to inspect the skin and check circulation.) Bunch and pull the stocking half way up the calf. (The nurse should slide the top of the stocking up over the client's calf all at once to lessen constrictive wrinkles that can decrease venous return.) CORRECT ANSWER Turn the stocking inside out up to the heel before applying. (The nurse should turn the stocking inside out up to the client's heel to make the application of the stocking easier and cause less constrictive wrinkles.)

A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? 2-pont discrimination test Glasgow coma scale Babinski reflex Romberg test

Romberg test (stand with feet together and arms at the sides, first with eyes open and then with them closed to test balance)

A nurse is assessing a client's incision and observes the drainage to be blood-tinged. Which of the following terms should the nurse use to document this finding? Sanguineous Purulent Serous Hyperemia

Sanguineous (contains large amounts of red blood cells indicating that damaged capillaries are escaping from the plasma) INCORRECT: Purulent= thicker than other drainages (pus) Serous= serum; clear portion of the blood Hyperemia= not drainage

A nurse is caring for a client who is dehydrated. The nurse should expect that insensible fluid loss of approximately 500-600 mL occurs each day through which of the following organs? Kidneys Lungs Gastrointestinal tract Skin

Skin INCORRECT: Kidneys--> 1200-1500 Lungs-->400 GI tract-->100-200

A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage? Sanguineous exudate Serous exudate Serosanguineous exudate Purulent exudate

Sanguineous exudate (Sanguineous exudate drainage on the client's dressings indicates an accumulation of RBCs from the plasma that appears bright red on the dressings.) Serous exudate (Serous exudate drainage on the client's dressings indicates plasma from the blood and appears clear to light yellow, and is watery.) Serosanguineous exudate (Serosanguineous exudate drainage on the client's dressings indicates plasma mixed with light bloody drainage, which is typically pale yellow to blood-tinged and watery drainage.) CORRECT ANSWER Purulent exudate (Purulent exudate drainage on the client's dressings is thick yellow, green and brown drainage and usually indicates wound sloughing or infection.)

A nurse is screening a client who has an S-shaped spinal column with unequal shoulder heights. The nurse should identify these findings as manifestations of which of the following abnormalities? Scoliosis Lordosis Torticollis Kyphosis

Scoliosis

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a form of secondary prevention? Holding a community clinic to administer influenza immunizations Screening groups of older adults in nursing care facilities for early influenza manifestations Educating parents of young children about the dangers of influenza Finding rehabilitation programs for older adults who have complications related to influenza

Screening groups of older adults in nursing care facilities for early influenza manifestations

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? Lower medial quadrant of the buttock near the coccyx Side hip between the iliac crest and anterior iliac spine Tissue of the posterior upper arm Lower inner though 4 finger widths about the patella

Side hip between the iliac crest and anterior iliac spine

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observed the client crying? Contact the family and ask someone to stay with the client Offer to call the client's minister Sit and hold the client's hand Leave the room and allow the client to cry privately

Sit and hold the client's hand

A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse taken when performing tracheostomy care for the client? Perform tracheostomy care using medical asepsis Allow enough slack under the tracheostomy ties to insert 3 fingers Soak the inner cannula of the tracheostomy tube in normal saline Cut a sterile gauze pad to place between the neck and tracheostomy tube

Soak the inner cannula of the tracheostomy tube in normal saline (or a mixture of normal saline and hydrogen peroxide to loosen secretions) INCORRECT: Perform tracheostomy care using medical asepsis--> SURGICAL SEPSIS (STERILE) Allow enough slack under the tracheostomy ties to insert 3 fingers--> 2 fingers Cut a sterile gauze pad to place between the neck and tracheostomy tube--> NO client could aspirate on loose threads

A nurse is caring for a client who has perisperhal edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume? Sodium Calcium Potassium Magnesium

Sodium INCORRECT: Calcium= bone and tooth formation Potassium= smooth muscle contraction Magnesium= cardiac and skeletal muscles

A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion? Sodium 123 mEq/L Blood glucose 100 mg/dL Potassium 3.5 mEq/L Hemoglobin 13 g/dL

Sodium 123 mEq/L (ref range= 136-145 this can lead to seizures, coma, death) INCORRECT: Blood glucose ref range= 70-110 Potassium =3.5-5 Hemoglobin= 12-18

A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider? Calcium 9.5 m/dL Sodium 150 mEq/L Potassium 4mEq/L Magnesium 1.5 mEq/L

Sodium 150 mEq/L (135-145) INCORRECT: magnesium= 1.3-2.1 potassium= 3.5-5

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client? Speak directly into the client's impaired ear. Exaggerate lip movements. Speak loudly. Face the client when speaking.

Speak directly into the client's impaired ear. (The nurse should speak toward the client's best or normal ear. Moving closer to the better ear facilitates communication.) Exaggerate lip movements. (The nurse should accentuate the words, especially the consonants, so the information does not sound like mumbling. The client's ability to read lips is inhibited when using exaggerated lip movements.) Speak loudly. (The nurse who speaks loudly or shouts can cause distortion of the sounds because loud sounds are at a higher pitch.) CORRECT ANSWER Face the client when speaking. (The nurse should always directly face the client who has a hearing impairment and stand or sit at the same level to maximize communication. Many clients who are hearing impaired combine lip reading with their residual hearing when communicating.)

A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following? Select all that apply Allowing the client to speak Stabilizing the position of the tube Preventing aspirations of secretions Preventing air leaks Preventing tracheal injury

Stabilizing the position of the tube Preventing aspirations of secretions Preventing air leaks

A nurse is caring for a client who has xerostomia with a lack of saliva. Which of the following nutrients will be affected by the lack of salivary amylase? Fat Protein Starch Fiber

Starch (Salivary amylase begins digests the initial breakdown of starches--> the majority of starch breakdown occurs in the small intestine with pancreatic amylase INCORRECT: Lipase breaks down fats Pepsin breaks down proteins Fiber is not digestible

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first? Start chest compressions Provide breaths with a manual resuscitation bag Administer oxygen Establish an airway

Start chest compressions

A nurse is preparing to administer a medication to a client. Which of the following administration schedules should the nurse identify as a prescription to administer the medication once and as soon as possible? Stat prescription PRN prescription Standing prescription Single prescription

Stat prescription

As part of a neurological examination, a nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique? Gustation Stereognosis Proprioception Kinesthesia

Stereognosis (ability to identify objects via tactile sensation) INCORRECT: Gustation= ability to taste Proprioception= awareness of the position of the body Kinesthesia= ability to sense the position w/o visualizing them

A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in that day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take? Continue the teaching, but check afterward with the surgeon about the informed consent Stop the teaching and check with the surgeon about the informed consent Stop the teaching and ask the client to sign the informed consent Continue the teaching and check the client's medical record afterward for. signed consent form

Stop the teaching and check with the surgeon about the informed consent

A nurse on. a med-surg unit is caring for a client who is a risk of experiencing seizures. Which of the following pieces of equipment must be available at the client's bedside at all times?\ Suction equipment Clean gloves Blankets Oxygen

Suction equipment (to reduce the risk of aspiration)

A nurse is caring for a client who has breast cancer. The client has been receiving radiation therapy for several months and now refuses to undergo further treatment. Which of the following actions should the nurse take? Suggest the client talk with someone who has survived breast cancer Encourage the client to not give up Support the client's decision Refer the client to a counselor

Support the client's decision

A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes? Allow minimal treatment Benefits the client's family Offers hope for a cure Supports self-determination

Supports self-determination (honor client autonomy)

A nurse is measuring a client's vital signs. The client's heart rate is 105/min. The nurse should document his findings as which of the following alterations? Palpitation Bradycardia Tachycardia Dysrhythmia

Tachycardia

A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? Warm, dry skin Increased urinary output Tachycardia Bradypnea

Tachycardia (due to decreased circulating blood volume that occurs with internal bleeding, the oxygen-carrying capacity of the blood is reduced--> the body attempts to relieve the hypoxia by increasing the respiratory rate)

A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an an assistive personnel. The nurse later observes the AP emptying the bag without wearing gloves. Which of the following actions should the nurse take? Notify the charge nurse about the incident Insist that the AP attend an in-service training about standards precautions Talk with the AP about the technique used Observe the AP a second time and intervene if the technique remains the same

Talk with the AP about the technique used

A nurse is caring for a client who is receiving IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? Redness at the IV catheter entry site Palpable cord along the vein used for the infusion Taut skin around the IV catheter site that is cool to the touch Bleeding at the IV insertion site

Taut skin around the IV catheter site that is cool to the touch (the nurse should stop the IV infusion, elevate the extremity, and apply a warm moist compress or cold compress) INCORRECT: Redness at the IV catheter entry site= local infection Palpable cord along the vein used for the infusion= phlebitis Bleeding at the IV insertion site= IV in not intact

A nurse is preparing a client who is scheduled for hysterectomy for transport to the operating room when the client states she no longer wants to have surgery. Which of the following actions should the nurse take? Tell the client it is too late for her to change her mind because the surgery is already scheduled. Telephone the operating room and cancel the surgery. Inform the client's family about the situation. Notify the provider about the client's decision.

Tell the client it is too late for her to change her mind because the surgery is already scheduled. (The client has the right to refuse a procedure after giving consent.) Telephone the operating room and cancel the surgery. (This is not the responsibility of the nurse, but a decision the surgeon and the client must make.) Inform the client's family about the situation. (To respect the client's confidentiality, the family can be notified only after the client requests that the nurse do so.) CORRECT ANSWER Notify the provider about the client's decision. (Acting as the client advocate, the nurse should support the client in her decision and notify the provider.)

A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temp of 39.2C (102.6F), a heart rate of 105/min, a soft nontender abdomen, menses overdue by 2 days. Which of the following findings should be the nurse's priority? Heart rate of 105/min Soft nontender abdomen Temperature Overdue menses

Temperature (Maslow's Hierarchy of Needs)

A nurse is planning to obtain the vital signs of a 2 year old child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the child's temperature Rectal Tympanic Oral Temporal

Temporal

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? Tenderness when touched Pink, shiny tissue with a granular appearance Serosanguineous drainage A halo of erythema on the surrounding skin

Tenderness when touched (Tenderness when touched is an expected finding in a postoperative wound healing by secondary intention. Severe pain might indicate infection or underlying tissue destruction and should be reported.) Pink, shiny tissue with a granular appearance (Pink, shiny tissue with a grainy appearance is granulation tissue and indicates the proliferative stage of wound healing. This is an expected finding in a postoperative wound healing by secondary intention.) Serosanguineous drainage (Serosanguineous drainage, made up of RBCs and plasma, is an expected finding in a postoperative wound healing by secondary intention. Purulent drainage suggests an infection and should be reported.) CORRECT ANSWER A halo of erythema on the surrounding skin (The nurse should report to the provider when the client has a ring of erythema (redness) on the surrounding skin, which might indicate underlying infection. This and any other manifestation of infection, such as purulent drainage, swelling, warmth, or a strong odor, should be reported to the provider.)

A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client? Test for the presence of client's gag reflex Place the client in the supine position Use a firm toothbrush for tooth and gum care Use 2 gauze-wrapped fingers to hold mouth open

Test for the presence of client's gag reflex (should do this prior to oral care to determine the risk of aspiration)

An assistive personnel is helping a nurse care for a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? The AP uses soap and water to clean the perineal area The AP tapes the catheter to the inner thigh The AP hangs the collection bag at the level of the bladder The AP ensures there are no kinks in the drainage bag

The AP hangs the collection bag at the level of the bladder INCORRECT The AP uses soap and water to clean the perineal area (clean 3x daily)

A nurse is providing nutritional teaching to a group of clients. Which of the following definitions for the recommended dietary allowance (RDA) should the nurse include in the teaching? The RDA is a comprehensive term that includes various dietary standards and scales The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups The RDA defines the levels of nutrients that should not be exceeded to prevent adverse health effects The RDA is the daily percentage of energy intake values for fat, carbohydrate, and protein

The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups

A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment.

The appropriate sequence for the nurse to perform the abdominal assessment is to: inspect, auscultate, percuss, and then palpate. (This sequence prevents altering the bowel sounds and causing false results. The appropriate sequence for any other assessment for an adult client is inspection, palpation, percussion, and auscultation.)******

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? The client asks the nurse to repeat the instructions before attempting the exercises. The client reports severe pain. The client asks the nurse how often deep breathing should be done after surgery. The client tells the nurse that this exercise will probably be painful after surgery.

The client asks the nurse to repeat the instructions before attempting the exercises. (Asking the nurse to repeat the instructions demonstrates that, while the client might not totally understand the mechanics of performing the exercises, he does have a readiness to learn the activity.) CORRECT ANSWER The client reports severe pain. (A client who is experiencing severe pain is not able to concentrate and therefore, is not ready to learn a new activity.) The client asks the nurse how often deep breathing should be done after surgery. (Asking about the frequency of the activity indicates a readiness to learn. The client is motivated to perform the activity and wants to know how often to do it.) The client tells the nurse that this exercise will probably be painful after surgery. (The client's statement indicates to the nurse that the client has a readiness to learn because he is able to think about the possible effects of the exercise following surgery.)

A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? The client fully understands the provider's explanation of the procedure. The client has been informed about the risks and benefits of the procedure. The nurse witnessed the provider's explanation of the procedure. The signature on the preoperative consent form is the client's.

The client fully understands the provider's explanation of the procedure. (It is the responsibility of the provider who will perform the procedure to ensure that the client understands the explanation of the procedure.) The client has been informed about the risks and benefits of the procedure. (It is the responsibility of the provider who will perform the procedure to inform the client about the risks and benefits and to obtain consent.) The nurse witnessed the provider's explanation of the procedure. (It is not necessary for the nurse to witness the provider's explanation of the procedure.) CORRECT ANSWER The signature on the preoperative consent form is the client's. (The nurse acts as a witness to attest that it is the client's signature on the preoperative consent form. It is the responsibility of the provider who will perform the procedure to obtain consent by explaining the procedure along with the associated risks and benefits.)

A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment? The client places a crutch on each side when assuming a sitting position The client moves the unaffected leg onto a step first when descending stairs The client places weight on the axillae when walking The client has slightly fixed elbows when ambulating with the crutches

The client has slightly fixed elbows when ambulating with the crutches (this allows them to bear weight on the hands and NOT the axillae) INCORRECT: The client moves the unaffected leg onto a step first when descending stairs--> move the crutches first then the unaffected leg

A nurse is teaching a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching? The client holds the cane on the unaffected side The client walks by stepping with the unaffected leg before the affected leg The client holds the cane directly next to the foot The client holds the cane with a straight elbow

The client holds the cane on the unaffected side

A nurse is teaching ROM exercises to a client who has osteoarthritis. Which of the following client positions demonstrates an understanding of supination of the hand? The client holds the hand with the palm up The client holds the hand with the palm down The client points the fingers toward the floor The client points the fingers toward the ceiling

The client holds the hand with the palm up

A nurse is assisting a client who has a right-sided weakness while ambulating using a cane. Which of the following client actions should indicate to the nurse that the client understands the procedure of cane walking? The client hold the cane on the affected side The client advances the unaffected leg followed by the cane The client supports his this weight on the unaffected leg when moving the cane forward The client keeps 2 points of support on the ground

The client keeps 2 points of support on the ground

A nurse is demonstrating postoperative deep breathing and coughing exercises surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? The client asks the nurse to repeat the instructions before attempting the exercises The client reports severe pain The client asks the nurse how often deep breathing should be done before surgery The client tells the nurse that this exercise will probably be painful after surgery

The client reports severe pain

A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following entries should the nurse enter into the client's medical record? The client refused to take medication today The client stated, "I will not take this pill" The client seemed angry and hostile The client threw the medication on the floor

The client threw the medication on the floor

A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client's insomnia? The client watches TV in her bed during the day The client drinks warm milk before bedtime The client goes to bed at 2200 every night The client gets up to use the bathroom once during the night

The client watches TV in her bed during the day

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? The client who has impaired pharyngeal swallowing is at risk for choking when liquids (especially thin liquids) are offered while eating solid foods. Offer the client tart or sour foods first. Tilt the client's head backward when swallowing. Turn on the television.

The client who has impaired pharyngeal swallowing is at risk for choking when liquids (especially thin liquids) are offered while eating solid foods. (It is preferable to suggest "dry swallows" to clear the mouth between bites of food.) CORRECT ANSWER Offer the client tart or sour foods first. (The client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which helps with chewing and swallowing.) Tilt the client's head backward when swallowing. (The client who has impaired pharyngeal swallowing should tilt the head forward to promote swallowing.) Turn on the television. (The client who has impaired pharyngeal swallowing should minimize distractions at mealtimes to concentrate on chewing thoroughly and swallowing.)

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following pieces of information must the nurse verify with another nurse prior to the administration? Select all that apply The client's ID number The client's room number The client's name ABO compatibility Rh compatibility

The client's ID number The client's name ABO compatibility Rh compatibility ( to prevent transfusion reactions due to human error)

A nurse is providing nutrition counseling to a middle-aged adult client who has a sedentary job. Which of the following factors should the nurse consider? The risk of eating disorders increases at this age The client's basal metabolic rate could decrease Daily vitamins will become necessary to meet nutritional needs Limiting the intake of fish to once per week reduces cardiovascular risks

The client's basal metabolic rate could decrease (adipose tissue replaces skeletal muscle mass)

A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors increases the client's risk of developing complicated grief? The deceased was a close friend The client lived far from the deceased The death was sudden The client has not visited the deceased in a long time

The death was sudden

A nurse is providing teaching to a client with heart failure about reducing his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? The involvement of the client in planning the change The emphasis the provider places on the dietary changes The learning theory the nurse uses to teach dietary changes The extent of the dietary changes planned for the client

The involvement of the client in planning the change

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? The lower, medial quadrant of the buttock near the coccyx The side hip between the iliac crest and anterior iliac spine The tissue of the posterior upper arm The lower, inner thigh 4 finger widths above the patella

The lower, medial quadrant of the buttock near the coccyx (To administer intramuscular medication using the dorsogluteal site, the nurse should select the upper, lateral quadrant of the buttock. However, the nurse should recognize this site can increase risk of injury to the client because the medication is more likely to be injected into subcutaneous tissue, and there is increased risk of piercing the sciatic nerve.) CORRECT ANSWER The side hip between the iliac crest and anterior iliac spine (The side hip between the iliac crest and anterior iliac spine forms the boundaries for ventrogluteal injection; therefore, this is an appropriate site for the nurse to select. This site is the preferred site for intramuscular injections for an adult client. The nurse should prepare for injection by placing a hand on the client's greater trochanter (right hand on left hip, for example) with the first two fingers touching the iliac crest and anterior superior iliac spine, forming a "V" shape.) The tissue of the posterior upper arm (The nurse should select the outer, posterior tissue of the upper arm when preparing to administer a subcutaneous injection. For intramuscular injections of less than 1 mL, the nurse may select the deltoid muscle by placing four fingers on the deltoid muscle with the top finger on the acromion process. The injection site then is three finger widths below the acromion process, or about 5 cm (2 in).) The lower, inner thigh 4 finger widths above the patella (To administer intramuscular medication using the vastus lateralis site, the nurse should select the middle portion of the muscle from the midline of the thigh to the midline of the outer side of the thigh. The nurse can place one hand below the greater trochanter and the other hand just above the knee to locate middle portion of the muscle for the injection site.)

A nurse is developing a plan of care for a client. Which of the following pieces of information should the nurse consider when planning care that is culturally congruent? Illness is not influenced by culture The meaning of disease can vary widely across cultures Assigning clients to specific cultural categories facilities communication Predetermined criteria should generate client care activities

The meaning of disease can vary widely across cultures

A nurse on a med-surg unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand washing technique? The nurse washes each part of her hands with 5 stroked The nurse washes from the elbows down to the hands The nurse holds her hands higher than her elbows while washing The nurse uses minimal friction when washing her hands

The nurse holds her hands higher than her elbows while washing

A nurse on a medical-surgical unit is washing her hands prior to assisting with surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique? The nurse washes each part of her hands with 5 strokes. The nurse washes from the elbows down to the hands. The nurse washes with her hands held higher than her elbows. The nurse uses minimal friction when washing her hands.

The nurse washes each part of her hands with 5 strokes. (Surgical scrubbing requires the nails be scrubbed with 15 strokes and each other part of the hand with 10 strokes.) The nurse washes from the elbows down to the hands. (An important principle of surgical handwashing is to scrub the hands first, then work toward the elbows.) CORRECT ANSWER The nurse washes with her hands held higher than her elbows. (The nurse who is performing a surgical hand-washing technique should wash with her hands held higher than the elbows so that water and soapsuds can drain away from the clean area toward the dirty area.) The nurse uses minimal friction when washing her hands. (Scrubbing is performed with a specially designed and premedicated brush when performing surgical hand-washing. The use of mechanical friction is necessary to decontaminate the skin effectively.)

A nurse is witnessing a client sign an informed consent form for surgery. What is the nurse affirming by this action? The client fully understands the provider's explanation of the procedure The client has been informed about the risks and benefits of the procedure The nurse witness the provider's explanation of the procedure The signature on the preoperative consent form is the client's

The signature on the preoperative consent form is the client's (It is the responsibility of the provider who will perform the surgery to inform the client about the risk and benefits)

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching? The wound edges are well-approximated. The wound is closed at a later date. A skin graft is placed over the wound bed. Granulation tissue fills the wound during healing.

The wound edges are well-approximated. (Primary intention occurs when the closing of the wound using sutures or staples occurs at the time the incision is made and the suture line edges become well-approximated during healing.) The wound is closed at a later date. (Tertiary intention includes using sutures to close an open wound at a later date after the wound drains and starts to heal.) A skin graft is placed over the wound bed. (Tertiary intention can include the provider placing grafted skin over the client's wound bed after a wound is left open to drain and start healing. Skin grafting is required for deeper wounds, such as full-thickness burns, and is only rarely required for surgical wounds that do not heal.) CORRECT ANSWER Granulation tissue fills the wound during healing. (The nurse should include in the teaching that a beefy, red tissue called granulation tissue fills the wound during healing. The wound is left open to drain and heal by secondary intention that should occur within 5 to 21 days. Open wounds place the client at an increased risk for wound infection.)

A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? Fasten the ties on the restraint to the side rails of the bed Tie the restraint with a quick-release knot Allow a fingerbreadth between the restraint and the client's chest Place the restraint under the client's clothing

Tie the restraint with a quick-release knot

A nurse is caring for a semiconscious client who had a small bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct placement? Select all that apply Auscultate injected air Verify the initial xray examination Measure the length of the exposed tube Determine the pH of the aspirated fluid Check the aspirated fluid for glucose

Verify the initial xray examination Measure the length of the exposed tube Determine the pH of the aspirated fluid

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? Turn on the machine every 15 min to measure the client's blood pressure. Record only blood pressure readings needed for the 15-min intervals. Obtain manual and automatic readings and compare them. Disconnect the machine, and measure the blood pressure manually every 15 min.

Turn on the machine every 15 min to measure the client's blood pressure. (Because the measurements and the operation of the machine appear questionable, operating the equipment differently cannot ensure the accuracy of the readings. The nurse should tag the machine and take it out of use.) Record only blood pressure readings needed for the 15-min intervals. (Although the equipment is obtaining blood pressure readings, the increased measurements and dissimilar results suggest that the machine is malfunctioning. Thus, all the readings are possibly inaccurate. The nurse should tag the machine and take it out of use.) Obtain manual and automatic readings and compare them. (Although this option appears to provide a means of checking the machine, the fact that it is not operating correctly already suggests that the accuracy of the readings is questionable. The nurse should tag the machine and take it out of use.) CORRECT ANSWER Disconnect the machine, and measure the blood pressure manually every 15 min. (If the nurse questions the reliability of the monitoring equipment, a manual process should be used. Also, malfunctioning equipment can pose a safety risk for the client, so it must be tagged and removed.)

A nurse is applying antiembolitic stocking for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse taken when applying the stockings? Roll them partially down if too long Remove the once once per day Bunch and pull the stocking halfway up the calf Turn the stocking inside out up to the heel before applying

Turn the stocking inside out up to the heel before applying INCORRECT: **change every shift

A nurse is caring for a client who is admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin discharge planning? One week prior to the client's discharge Upon the client's admission to the care facility Once the discharge date is identified When the client addresses the topic with the nurse

Upon the client's admission to the care facility

A nurse is preparing to assist an older adult client with ambulation following bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall? Use a gait belt during ambulation Ensure the client is wearing socks before ambulating Instruct the client to sit on the edge of the bed for 15 sec before ambulating Walk 2ft behind the client during ambulation

Use a gait belt during ambulation

A nurse is planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first? Use the pain scale to determine the client's pain level Discuss the adverse effects of pain medication with the client Obtain the client's vital signs Check the client's allergies

Use the pain scale to determine the client's pain level

A nurse is preparing to administer an intramuscular injection to a young client which of the following injection sites is the safest for this client? Vastus lateralis Dorsogluteal Deltoid Ventrogluteal

Ventrogluteal (safest for all adults)

A nurse is caring for a client who reports using several herbal medicines. Which of the following actions should the nurse take? Discourage the use of unregulated medications and supplements Verify the herbal supplements do not interact with medications the provider has prescribed Tell the client to limit the number of herbal supplements to no more than 2 Describe the dangers of taking plant-derived medications and supplements

Verify the herbal supplements do not interact with medications the provider has prescribed

A client is being discharged home with oxygen therapy delivered through a nasal cannula. Which of the following instructions should the nurse provide to the client and family members? Use battery-operated equipment for personal care Apply mineral oil to protect the facial skin from irritation Remove the television set from the client's bedroom Wear cotton clothing to avoid static electricity

Wear cotton clothing to avoid static electricity

A nurse is caring for a client who has Clostridium difficile infection and is in contact isolation. Which of the following actions should the nurse take? Wear gloves when changing the client's gown Use alcohol-based hand sanitizer to cleanse the hands Wear a mask when assisting the client with his meal tray Place the client on complete bed rest

Wear gloves when changing the client's gown

A nurse is planning care for an adult client who has fluid volume excess. Which fo the following interventions should the nurse plan to include to monitor the client's weight? Calibrate the scales weekly Use a different scale each time Weigh the client on arising Weigh the client without clothing

Weigh the client on arising

A nurse is caring for a client who has a deficiency of vitamin D. Which of the following foods should the nurse recommend the client include in his diet? Whole milk Chicken Oranges Dried peas

Whole milk

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique? Applying the sterile gloves to open catheter package Wiping the labia minora in an anteroposterior direction Spreading of the labia with the dominant hand Using a cotton ball to wipe the right and left labia majora

Wiping the labia minora in an anteroposterior direction

A nurse is obtaining a capillary blood sample to determine a client's blood glucose level. The nurse prepares and punctures the client's finger for the procedure but does not obtain an adequate amount of blood. Which of the following actions should the nurse take next? Smear the small amount of blood onto the testing strip Hold the finger above heart level Massage the client's fingertip Wrap the client's finger in a warm washcloth

Wrap the client's finger in a warm washcloth

A nurse is evaluating the development of a group of clients. According to Erikson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development? Middle adulthood Adolescence Childhood Young adulthood

Young adulthood INCORRECT: Middle adulthood= generativity vs. self absorption and stagnation Adolescence= identity vs role confusion Childhood= industry vs inferiority