ATI IMP for CNF

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. first level= physiological needs; second level= safety and security needs; the third level= 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.

....

A nurse is monitoring a client who is receiving spinal anesthesia. The nurse should identify which of the following findings as a complication of the infusion? Maternal hypotension Fetal tachycardia Increased fetal heart rate variability Maternal hypothermia

ANSWER: A. Maternal hypotension is a common adverse effect of a spinal block. To prevent supine hypotension, the client should lie on a side or lie supine with a wedge under a hip to displace the uterus. Incorrect Answers: B. Spinal anesthesia is more likely to cause fetal bradycardia than fetal tachycardia. C. Spinal anesthesia is more likely to cause minimal or a lack of fetal heart rate variability than increased fetal heart rate variability. D. Spinal anesthesia is more likely to cause a fever than hypothermia.

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 1 cm (0.5 in) above the ear canal during administration Apply pressure to the nasolacrimal duct following administration Place a cotton ball into the inner ear canal for 30 minutes following administration Straighten the ear canal by pulling the auricle down and back prior to administration

ANSWER: A. The nurse should administer the otic medication by holding the dropper 1 cm (0.5 in) above the ear canal. Incorrect Answers:B. The nurse should apply pressure to the nasolacrimal duct following the administration of eye drops, not for an otic antibiotic. C. If necessary, the nurse can apply a cotton ball into the outermost part of the ear canal and remove it after 15 minutes. D. The nurse should straighten the ear canal by pulling the auricle down and back prior to administering otic medication for a child who is younger than 3 years of age.

A nurse is teaching assistive personnel (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 above heart level Rubbing the fingertip with an alcohol pad Puncturing the side of the fingertip Wrapping the finger in a warm cloth

ANSWER: A. The nurse should intervene if the client elevates the finger above the level of the heart. Holding the finger below the level of the heart in a dependent position will help increase blood flow to the area and ensure an adequate specimen for collection. Incorrect Answers:B. The client should clean the finger with an antiseptic swab or with soap and water. The client should allow the fingertip to dry completely. C. The client should puncture the side of the finger, avoiding sites beside bone. D. The client should wrap the finger in a warm cloth to increase blood flow to the area.

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."

ANSWER: B. TENS unit applies low-voltage electrical stimulation directly over a location of pain at acupressure point. It modulates transmission of pain impulse and can also cause release of endorphins to assist with pain relief. Incorrect Answers: A. The nurse should inform the client that distraction is a method that can draw the client's attention away from the pain and help decrease the perception of pain. Methods can include visual, auditory, tactile and intellectual distraction. However, this is not the way that a TENS unit helps to relieve pain. C. D. The nurse should inform the client that massage can be applied to facilitate relaxation, which decreases muscle tension. It can also decrease pain intensity by increasing superficial circulation to an area of the body experiencing pain. However, this is not the way that a TENS unit helps to relieve pain.

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 facilitates communication. Predetermined criteria should generate client care activities.

ANSWER: B. A client may define and react to disease based on his or her unique cultural perspective. The nurse should seek to understand a client's culture and life experiences in order to provide care that is effective, evidence-based, and culturally congruent. Incorrect Answers: A. A client's culture affects the social determinants of health and contributes to how an individual defines illness. Culture and life experiences play an important role in a client's view about health, illness, and health care. C. The nurse cannot make the assumption that all clients within a specific culture have the same beliefs. The nurse should consider each client as an individual and respect individual life patterns, values, and definitions of illness in order to provide culturally congruent care. D. nurse should consider that patterns of daily life n meaning are generated by the client, not predetermined criteria. To provide culturally congruent care, nurse should adjust client care activities such as medication administration or bath time to the client's daily patterns

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."

ANSWER: B. The nurse should inform the client that a TENS unit 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 Answers: A. The nurse should inform the client that distraction is a method that can draw the client's attention away from the pain and help decrease the perception of pain. Methods can include visual, auditory, tactile and intellectual distraction. However, this is not the way that a TENS unit helps to relieve pain. C. D. The nurse should inform the client that massage can be applied to facilitate relaxation, which decreases muscle tension. It can also decrease pain intensity by increasing superficial circulation to an area of the body experiencing pain. However, this is not the way that a TENS unit helps to relieve pain.

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

ANSWER: B. increased heart rate should indicate to the nurse that the client is experiencing fluid volume deficit. Other findings can include an increased BUN level, dry mucous membranes, dark yellow urine. Incorrect Answers: A. An increase in urine specific gravity should indicate to the nurse that the client is experiencing fluid volume deficit. C. An increased hematocrit should indicate to the nurse that the client is experiencing fluid volume deficit. D. Poor skin turgor should indicate to the nurse that the client is experiencing fluid volume deficit.

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

ANSWER: C. The nurse is not able to supply this information to the guard. In order for the guard to obtain this information, the client must offer the information freely. Therefore, the nurse should instruct the guard to ask the client for this information. Incorrect Answers: A. The nurse cannot discuss the client's HIV status with the guard or the warden without the client's consent. The client can share personal medical information if desired. B. The client can sign a release of information form to obtain medical records. Asking the guard to sign this form does not give the nurse permission to share the client's HIV status. D. The nurse would have no cause to complete an incident report in this situation. Incident reports are completed to record an event that is not consistent with standard procedures. An incident report would need to be completed if the nurse were to share the client's HIV status with the guard.

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 the 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."

ANSWER: C. The nurse should instruct the client to shake the inhaler vigorously for 3 to 5 seconds, which will mix the medication within the inhaler evenly. Incorrect Answers: A. The nurse should instruct the client to rinse the mouth with water following the use of the inhaler to reduce irritation and infection, not before using the inhaler. B. The nurse should instruct the client to wait 20 to 30 seconds between inhalations of bronchodilator medications such as albuterol. D. The nurse should instruct the client to place the inhaler in the mouth and tightly close the lips around the mouthpiece to create a seal. The client should then depress the canister, take a deep breath, and hold it for at least 10 seconds.

A nurse is caring for a client who requires a peripheral IV insertion. When choosing the 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 the extremity Choose a vein that is soft on palpation Select a site distal to previous venipuncture attempts

ANSWER: C. The nurse should select a vein that is soft and has a "bouncy" feeling when pressure is released upon palpation. Incorrect Answers: A. The nurse should place a peripheral IV into a client's non-dominant arm unless contraindicated for reasons such as a mastectomy or a dialysis fistula. B. The nurse should select a vein that is distal to areas where the tip of the catheter will not be at a point of flexion. D. The nurse should avoid a site that is distal to a previous venipuncture attempt or site. These areas often cause infiltration around a newly placed IV site.

A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an assistive personnel (AP). 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 standard precautions Talk with the AP about the technique used Observe the AP a second time and intervene if the technique remains the same

ANSWER: C. The nurse who delegates a task is responsible for providing the right supervision and evaluation. The nurse is responsible for providing feedback to the AP and should reinforce the correct procedure for this task with the AP, which includes wearing gloves. Incorrect Answers:A. The nurse does not need to notify the charge nurse about the incident. The nurse who delegates a task transfers responsibility for the task but retains accountability for the task. The nurse should evaluate the AP's performance and provide feedback as needed. B. Although further training and education may be necessary, the nurse should discuss the situation with the AP and listen attentively to the reason for the AP's actions. If the cause of the error is a lack of understanding of the procedure, the nurse can conduct training for the AP and other staff who may need assistance. The nurse can also gain assistance from the education department. D. The nurse should not allow the AP an opportunity to make the same mistake twice. The nurse should discuss the situation with the AP to determine the cause of the incorrect procedure and intervene the first time it is observed.

A nurse is teaching a client who has asthma about the proper use of albuterol inhaler. Which of the following client statements indicates understanding of the teaching? "I should rinse my mouth out right before I use the 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."

ANSWER: C. instruct to shake vigorously for 3 to 5 seconds, which will mix the medication within the inhaler evenly. Incorrect Answers: A. instruct the client to rinse the mouth with water following the use of the inhaler to reduce irritation and infection, not before using the inhaler. B. The nurse should instruct the client to wait 20 to 30 seconds between inhalations of bronchodilator medications such as albuterol. D. The nurse should instruct the client to place the inhaler in the mouth and tightly close the lips around the mouthpiece to create a seal. The client should then depress the canister, take a deep breath, and hold it for at least 10 seconds.

A nurse is assisting a client who has 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 holds the cane on the affected side The client advances the unaffected leg followed by the cane The client supports this weight on the unaffected leg when moving the cane forward The client keeps 2 points of support on the ground

ANSWER: D When ambulating with a cane, the client should keep 2 points of support on the ground at all times, which can be either both feet or a foot and the cane. Incorrect Answers: A. When ambulating with a cane, the client should hold the cane on the unaffected or stronger side of the body. B. When ambulating with a cane, the client should advance the cane and then follow it with the unaffected or stronger leg. C. When ambulating with a cane, the client should support weight on both legs when moving the cane forward.

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 flexed elbows when ambulating with the crutches.

ANSWER: D. The client should have slightly flexed elbows when ambulating with crutches. This allows the client to bear weight on the hands and not on the axillae. Incorrect Answers:A. The client should place the crutches together in a hand and use the other hand to grasp the arm of the chair. B. The client should move the crutches onto a step first when descending stairs, followed by the affected leg. C. The client should avoid placing weight on the axillae when walking. Continual pressure on the axillae can cause damage to the radial nerve, which can lead to crutch palsy or weakness of the muscles of the forearm, wrist, and hand.

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

ANSWER: D. The nurse should cleanse a surgical wound from the least contaminated location (the inside of the wound) toward the most contaminated (the surrounding skin).

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.

ANSWER: D. document exactly what took place to provide accurate, factual account of the events. Thus, the nurse should document the client's actions in the medical record. Incorrect Answers: A. The nurse should be specific when documenting information in the client's medical record. The nurse should document the name of the medication, the dose, and the time the client refused to take the medication. B. The nurse should only document information that is factual. The nurse should not quote a client as having stated something that the client did not say. Even though the client implied a refusal of the medication, the nurse should document the occurrence accurately in the medical record. C. The nurse should avoid the use of vague terminology when documenting an occurrence in the client's medical record because this can indicate the nurse is stating an opinion.

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

ANSWER: D. nurse should assist a client who develops diarrhea while receiving NG tube feedings by consulting with the provider and the dietitian regarding changing the client's formula to isotonic formula. This formulation can be easier for client to digest and can decrease diarrhea. Incorrect Answers: A. The nurse should change the bag and tubing every 24 hours to decrease bacterial growth within the feeding tube system. The nurse should also employ aseptic technique. B. The nurse should ensure the formula is at room temperature prior to administration. Cold formula can result in abdominal cramping and discomfort. C. The nurse should decrease the infusion rate for a client who develops diarrhea while receiving feedings via NG tube. This can assist in reducing diarrhea as well as gastric intolerance to the formula.

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."

Answer: C The nurse should encourage the parent to keep a diary of the foods the child eats throughout the day for 1 week. This can help the parent realize that the child may be eating better than expected. Evidence suggests that children can self-regulate their caloric intake. When they eat less at a meal, they can compensate by eating more at another meal or by having a snack. Incorrect Answers: A. The nurse should inform the parent that children's dietary habits can change from day to day. It is important to feed the child healthy foods and focus on the quality of food rather than the quantity of food during this time. B. The nurse should inform the client that calorie and fluid requirements decrease slightly in a preschool-aged child. The nurse should not promote an increase of calories and water in the child's diet. D. The nurse should inform the parent that excessive consumption of sweetened beverages, including fruit juices, can be associated with adverse health effects such as dental caries, obesity, and metabolic syndrome.

A nurse is caring for a middle-aged adult client. The nurse should evaluate 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 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? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) "Tilt your head back slightly and open your mouth wide." "Hold the mouthpiece 1 to 2 inches in front of your mouth." "Depress the canister while taking a slow, deep breath." "Hold your breath for 10 seconds.

Correct Answer: "Hold the mouthpiece 1 to 2 inches in front of your mouth." "Tilt your head back slightly and open your mouth wide." "Depress the canister while taking a slow, deep breath." "Hold your breath for 10 seconds." Step 1: The client should hold the mouthpiece 2 to 4 cm (1 to 2 in) from the mouth Step 2: The client should tilt the head back slightly, and then open the mouth. Step 3: The client should depress the medication canister while taking a deep breath to facilitate the delivery of the medication through the airway. Step 4: After holding this breath for 10 seconds, the client should resume a usual breathing pattern.

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? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Apply a skin protectant or a barrier film to the skin around the wound. Place prepared foam into the wound bed and cover with a transparent dressing. Connect the tubing to transparent film and turn on the NPWT unit. Apply sterile or clean gloves and irrigate the wound. Remove the soiled dressing and perform hand hygiene. Turn off the vacuum on the NPWT device and administer the prescribed analgesic.

Correct Answer: Turn off the vacuum on the NPWT device and administer the prescribed analgesic. Remove the soiled dressing and perform hand hygiene. Apply sterile or clean gloves and irrigate the wound. Apply a skin protectant or a barrier film to the skin around the wound. Place prepared foam into the wound bed and cover with a transparent dressing. Connect the tubing to transparent film and turn on the NPWT unit. Step 1: The nurse should turn off the vacuum on the NPWT device to loosen the dressing and administer the prescribed analgesic. Step 2: The nurse should gently remove the soiled dressing and perform hand hygiene. Step 3: The nurse should apply sterile or clean gloves and irrigate the wound to remove debris. Step 4: The nurse should apply a skin protectant or a barrier film to the surrounding skin to ensure an airtight seal and protect the skin. Step 5: The nurse should place foam in the wound bed and cover it with a transparent dressing to provide an airtight seal. Step 6: The nurse should attach the drainage tube to the transparent dressing and turn on the NPWT unit. Step 7: The nurse should check for air leaks and patch the dressing as needed with transparent film.

A nurse on the medical-surgical floor is stopped by the spouse of a client who is not assigned to the nurse and has been newly admitted from the emergency department. The spouse tells the nurse that the client would like to have some iced tea. Which of the following is the most appropriate response by the nurse? Delegate the task to the unlicensed assistive personnel (UAP) Suggest water since the client's admission assessment has not yet been completed Suggest that the spouse bring tea from the vending machine for the client Review the prescriptions of the healthcare provider first

Correct Answer:D. Review the prescriptions of the healthcare provider first The prescriptions of the healthcare provider should first be verified by a nurse who is unfamiliar with the client. Many clients who have been admitted from the emergency department are designated NPO, pending evaluation and diagnosis. Since some of these clients may require a surgical procedure and will remain NPO. Tea, coffee, and some soft drinks also contain caffeine, which can interfere with some studies, including nuclear cardiac scans, and may be contraindicated in some clients. Incorrect Answers: A. After the prescriptions have been verified, the nurse can assign the task to the UAP. B. The nurse must first verify if the client is NPO or can have fluids. Water is a good alternative if oral fluids are permissible. The nurse should verify whether the client's condition and prescriptions permit caffeine. C. If the client is permitted oral fluids and caffeine, the nurse can suggest the spouse bring tea from the cafeteria or vending machine if it is not readily available on the unit. Practice Connection: Before providing any care to a newly admitted client, including food and drink, the nurse should verify the healthcare provider's prescriptions. The client may have dietary restrictions or may be NPO.

A nurse is providing teaching to a client who has a new prescription for alprazolam. Which of the following items is a priority for teaching? A. "This medication can affect your ability to drive or handle mechanical equipment." B. "You should avoid drinking beverages that contain caffeine with this medication." C. "You should avoid taking antacids within 2 hours of this medication." D. "This medication should be taken with or shortly after meals." Flag question for later

Correct answer: (A) "This medication can affect your ability to drive or handle mechanical equipment." apply the safety and risk-reduction priority-setting framework, which 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, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Handling mechanical equipment or driving creates a safety risk for the client who takes alprazolam. Incorrect Answers: B. While consumption of caffeine can decrease the desired action of the medication, it is not the priority for this teaching. C. While antacids can delay absorption, this is not the priority for this teaching. D. While taking this medication with or shortly after meals can reduce gastrointestinal discomfort, it is not the priority for this teaching.

A nurse on a medical-surgical unit is caring for a client who is at 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

Correct answer: (A) Suction equipment. The greatest risk to a client who is having a seizure is an injury from aspirating secretions or emesis; therefore, must have suction equipment available for clearing the mouth of secretions or emesis to reduce this risk. Incorrect Answers: B. have clean gloves available to check the client's mouth for injuries to the mucous membranes or teeth; however, other equipment is the nurse's priority. C. The nurse should have blankets and linens available to pad the side rails if a seizure begins while the client is in bed to help prevent injury; however, other equipment is the nurse's priority. D. During and after a seizure, some clients require supplemental oxygen to maintain oxygen saturation; therefore, the nurse should have oxygen ready to administer. However, other equipment is the nurse's priority.

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? A. Use a gait belt during ambulation B. Ensure the client is wearing socks before ambulating C. Instruct the client to sit on the edge of the bed for 15 sec before ambulating D. Walk 2 ft behind the client during ambulation

Correct answer: (A) Use a gait belt during ambulation. use a gait belt to keep the client's center of gravity midline and decrease the risk of a fall. Incorrect Answers: B. ensure client is wearing non-skid shoes or slippers when ambulating to decrease risk of fall from slipping C. encourage client to dangle legs on edge of bed for 60 seconds before attempting to ambulate to decrease the risk of a fall due to orthostatic hypotension. D. walk beside the client to provide physical support while ambulating and decrease the risk of a fall.

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

Correct answer: (B) Cleanse the wound with 0.9% sodium chloride irrigation. cleanse the wound with sterile water or 0.9% sodium chloride irrigation to remove any surface debris or old exudate. Incorrect Answers: A. wear clean gloves to collect a wound culture specimen. The nurse's hands will not touch the wound or the culture swab. C. Pooled drainage can collect microorganisms that are not the pathogens causing the wound infection. D. The nurse should rotate the swab back and forth over clean areas in the base of the wound to collect the pathogens causing the wound infection. The edges of the wound can harbor superficial microorganisms from the skin that are not infecting the wound.

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

Correct answer: (B) Potassium 3.0 mEq/L. potassium level is below the expected reference range, indicating hypokalemia. The nurse should report this finding to the provider for instructions about preventing muscle weakness that could affect respiration.

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 thigh 4 finger-widths above the patella

Correct answer: (B) Side hip between the iliac crest and anterior iliac spine. side hip between iliac crest and anterior iliac spine forms the boundaries for a ventrogluteal injection; therefore, this is appropriate site. This site is preferred for intramuscular injections for an adult client. The nurse should prepare for injection by placing a hand on the client's greater trochanter (e.g. right hand on left hip) with the first 2 fingers touching the iliac crest and anterior superior iliac spine, forming a "V" shape. Incorrect Answers: A. To administer an intramuscular medication using the dorsogluteal site, the nurse should select the upper lateral quadrant of the buttock. However, this site can increase the risk of injury to the client because the medication is more likely to be injected into subcutaneous tissue, and there is an increased risk of piercing the sciatic nerve. C. select the outer posterior tissue of the upper arm for subcutaneous injection. For intramuscular injections that are <1 mL, select deltoid muscle by placing 4 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). D. To administer intramuscular medication using the vastus lateralis site, 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 a hand below the greater trochanter and the other hand just above the knee to locate the middle portion of the muscle for the injection site.

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 circumstances. Magical thinking helps avoid thoughts of death. Death is viewed as an interruption of what might have been. Death is a natural consequence of a deteriorating body.

Correct answer: (C) Death is viewed as an interruption of what might have been. Young adults tend to see a whole life ahead of them, so death is often seen as interrupting that life. Young adults do not typically welcome death at this time. Incorrect Answers:A. Adolescents tend to reject the end of life, especially their own. B. Preschoolers tend to avoid thoughts of death by employing magical thinking. D. Accepting the deterioration of the body is more likely among older adults, some of whom might consider death a relief from chronic or terminal illness.

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

Correct answer: (C) Depressed deep-tendon reflexes. total calcium level of 12.7 mg/dL is above the expected reference range. Manifestations of hypercalcemia include depressed deep-tendon reflexes, nausea, vomiting, bone pain, lethargy, weakness. Incorrect Answers: A. Muscle tremors, Positive Chvostek's and Trousseau's signs, Numbness and tingling around the mouth and in the extremities are manifestations of hypocalcemia, not hypercalcemia.

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.

Correct answer: (C) Don gloves when entering the room and use hand sanitizer when exiting. Clients who have MRSA infection require contact precautions. In addition to the use of standard precautions n meticulous hand hygiene, contact precautions require any staff member who will have contact with the client's environment to don gloves prior to entering room. Additional precautions, such as a gown, are required for contact with the client; a mask and goggles are needed if secretions from the infected area could spray into the worker's face. Delivering the tray will require contact with the client's environment; therefore, the dietary assistant must wear gloves. Incorrect Answers: A. Anyone who will have actual contact with this client must wear a gown. If the dietary assistant is just placing the lunch tray on the client's table, donning a gown is not necessary. B. MRSA does not spread via droplet or aerosol transmission; therefore, the dietary assistant does not need to wear a mask. D. Infections with multidrug-resistant organisms, such as MRSA, require special precautions to prevent transmission of the pathogen through contact with the client and the client's environment.

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

Correct answer: (C) Nutrition. Nutrition, sensory perception, moisture, activity, mobility, friction and shear are the parameters on Braden scale for determining a client's risk of developing pressure ulcers. Incorrect Answers: Incontinence, Mental state, General physical condition r parameter on the Norton scale, not on the Braden scale.

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

Correct answer: (C) Oil retention. administer oil retention enema prior to the removal of a fecal impaction to soften the stool. This makes the procedure less painful for the client. Incorrect Answers: A. carminative enema to expel flatus. B. hypertonic fluid solution to cleanse the client's bowels (e.g. in preparation for surgery). D. sodium polystyrene sulfate enema to a client who has a high potassium level.

A nurse is teaching a client about 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 need Provide clearly written and easy-to-understand materials Help the client identify ways that these changes will result in positive personal outcomes

Correct answer: (D) Help the client identify ways that these changes will result in positive personal outcomes. According to evidence-based practice, the motivation to change must precede taking steps to make the change. Therefore, helping clients identify ways that the changes will promote positive outcomes should precede other educational strategies for making the changes. The client should first see how the changes directly affect his/her life, thus enhancing the motivation to make the changes. Incorrect Answers:A. It is important for the client to understand all aspects of the illness as well as the consequences of nonadherence to recommended lifestyle changes. However, when the nurse is trying to motivate the client to make lifestyle changes, the client might perceive warnings about the dangers of nonadherence as a threat. Instead, the nurse should present this information after the client commits to making the recommended changes. B. Scheduling meetings about psychomotor skills is important for showing the client how to practice self-care. However, this is unlikely to encourage the client to make an initial commitment. This strategy will likely strengthen the client's adherence to the recommended life changes after the client has made an initial commitment to them. C. It is important for the client to understand all aspects of the illness, and clearly written and easy-to-understand instructional materials can be helpful. However, the nurse should present this information after the client is committed to change.

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

Correct answer: (D) Infection acquired from a diagnostic procedure. Iatrogenic HAIs directly result from diagnostic or therapeutic procedures. Incorrect Answers: A. Breaks in infection-control protocols, such as improper hand hygiene, are not considered a source of iatrogenic HAIs because they are not due to a diagnostic or therapeutic procedure. B. Drug resistance is not considered a source of iatrogenic HAIs because it is not the result of a diagnostic or therapeutic procedure. C. Inappropriate waste disposal is not considered a source of iatrogenic HAIs because it is not the result of a diagnostic or therapeutic procedure.

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

Correct answer: (D) Skin. The skin can excrete approximately 500 to 600 mL of insensible fluid loss. This type of fluid loss is continuous and can increase if the client is experiencing a fever or has had a recent burn to the skin. Incorrect Answers: A. kidneys excrete approximately 1,200 to 1,500 mL of urine daily. However, urine is not considered insensible fluid loss. This can increase depending on the client's intake of water. B. The lungs excrete approximately 400 mL of insensible fluid loss each day. C. The GI tract loses approximately 100 to 200 mL of fluid each day through feces. However, this is not considered insensible fluid loss.

A nurse is teaching a client how to perform range-of-motion 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."

Correct answer: (A) "With your palm facing down, move your wrist sideways toward your thumb." This motion describes adducting the wrist. The client should be able to move her wrist 30º to 50º with this motion. Incorrect Answers: B. This motion is flexing the wrist. C. This motion is abducting the wrist. D. This motion is hyperextending the wrist.

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 backward as insertion begins Instruct the client to bear down during insertion

Correct answer: (A) (B) (D) Lubricating the tube eases its passage. A water-based gel because will dissolve if the tube slips into the client's airway while using petroleum jelly could cause respiratory problems. Swallowing water reduces the risk of gagging and aspiration and helps propel the tube down the esophagus. Hyperextending the neck reduces the curvature of the nasopharynx, which facilitates the insertion of the NG tube. Incorrect Answers:C. Ice makes NG tubes rigid, increasing the risk of trauma to mucous membranes. E. Bearing down is helpful during the insertion of a urinary catheter, not an NG tube.

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 indication that the client has conductive hearing loss of 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.

Correct answer: (A) Air conduction is less than bone conduction in the left ear. This finding indicates conductive hearing loss of the left ear. Incorrect Answers: B. This finding does not indicate hearing loss of any type. C. D. These are possible results of the Weber test, not the Rinne test.

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 smoking-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 her Advocate for the client by supporting her statement about not quitting

Correct answer: (A) Assist the client in finding local smoking-cessation assistance programs. Smoking cessation slows the progression of chronic obstructive pulmonary disease (COPD). It is not "too late" for this client to stop smoking, and the nurse should encourage the client to do so. Incorrect Answers: B. This is an example of the nontherapeutic communication technique of giving false reassurance. Without smoking cessation, the client's condition will likely deteriorate further. C. Threatening the client with potential harm due to lack of care is unethical and abusive. This action by the nurse will not help the client stop smoking. Also, in this context, the nurse's action violates the ethical principle of beneficence. D. Advocacy aims to improve a client's health and safety. Rather than advocating for the client, the nurse is simply agreeing with the client, which is a nontherapeutic communication technique.

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

Correct answer: (A) Below the medial malleolus. The nurse should palpate the posterior tibial pulse by curving the fingers around the medial malleolus on the inner surface of the client's ankle. Incorrect Answers:B. The nurse should evaluate the client's popliteal pulse by palpating behind the knee in the area of the popliteal fossa. C. The nurse should evaluate the client's brachial pulse by palpating in the groove between the biceps and triceps muscles in the area of the antecubital fossa. D. The nurse should evaluate the client's dorsalis pedis pulse by palpating on the dorsum of the foot.

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

Correct answer: (A) Client's level of comfort and ability to participate in the interview. The nurse should assess the client's level of comfort and establish a rapport during the introductory or orientation phase. The nurse should engage in active listening and present a relaxed attitude to place the client at ease and encourage client participation. This will assist the nurse in gaining the necessary data to formulate appropriate nursing diagnoses and outcomes. Incorrect Answers: B. The nurse should assess the client's health history, including previous illnesses and surgeries, during the working phase of the interview. C, The nurse should assess the client's health history, including events surrounding the recent or current illness, during the working phase of the interview. D. The nurse should assess the client's sociocultural history during the working phase of the interview.

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

Correct answer: (A) Cranial nerve XII. The nurse is checking the function of cranial nerve XII (hypoglossal), which innervates the tongue, by observing a range of tongue movements. Incorrect Answers: B. The nurse checks the functioning of cranial nerve X (vagus) by asking the client to vocalize. C. The nurse checks the functioning of cranial nerve VIII (vestibulocochlear) through using the Rinne and Weber tests and asking the client if he can hear a whisper. D. The nurse checks the functioning of cranial nerve V (trigeminal) by asking the client to clench his teeth and palpating the masseter muscles for contraction.

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? A. Drop the eye medication into the lower conjunctival sac B. Apply gentle pressure to the outer opening of the eye for 2 min C. Hold the eyedropper 0.5 cm (0.2 in) from the cornea D. Instruct the client to close the eyes tightly after administration

Correct answer: (A) Drop the eye medication into the lower conjunctival sac The nurse should drop eye medication in lower conjunctival sac to avoid placing drops on cornea n causing damage. Incorrect Answers: B. 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. C. should hold eyedropper 1 to 2 cm (0.4 to 0.8 in) from the lower conjunctival sac to protect the cornea of eye from injury by preventing tip of dropper touching eye. D. instruct the client to close the eyes gently when applying ointment or liquid to distribute medication and to avoid expelling the medication or injuring the eye.

A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing 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.

Correct answer: (A) Establish client outcomes. The planning phase of the nursing process includes developing goals and outcomes that help the nurse create the client's plan of care. Incorrect Answers: B. The nurse should collect information about the client's past health problems during the assessment phase of the nursing process. C. The nurse should determine whether the client has met goals during the evaluation phase of the nursing process. D. The nurse should identify the client's specific health problems during the analysis phase of the nursing process.

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

Correct answer: (A) Hold the medication bottle with the label against the palm of the hand when pouring. hold a multidose 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. Incorrect Answers: B. The nurse should remove the cap of the medication bottle and place it with the inside facing up on a hard surface to prevent contamination of the inside of the cap and to maintain cleanliness. C. The nurse should fill the cup until the medication is even with the surface or meniscus base of the dosage scale to ensure the client receives an accurate dose. D. The nurse should discard any excess liquid medication into the sink as wasted medication and wipe the lip of the bottle clean after measuring.

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

Correct answer: (A) Hyperglycemia. Stress causes an increased secretion of cortisol, which can lead to hypertension and hyperglycemia. Incorrect Answers: B. Prolonged stress can lead to essential hypertension. C. Prolonged stress weakens the immune response, placing the client at risk of various infections and worsening the severity of those infections. D. Prolonged stress can lead to platelet aggregation and can increase the client's risk of myocardial infarction and stroke.

A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a 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

Correct answer: (A) Loss. At the close of a relationship, even when planned, loss is an expected feeling for both the client and the nurse. It is important for both the nurse and the client to terminate the relationship without feelings of guilt or anxiety. Incorrect Answers: B. The nurse should address the concept of trust during the introductory phase of the relationship. C. The nurse should address the concept of appropriate self-disclosure during the working phase of the relationship. D. The nurse should address the concept of risk-taking in the working phase of the relationship.

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

Correct answer: (A) Place the client in a lateral position with the head turned to the side before beginning the procedure. The nurse should place the client in a lateral position with the head turned to the side to reduce the risk of aspiration of fluids and secretions. Incorrect Answers: B. The nurse should use a padded tongue blade, not a thumb or an index finger, to keep the client's mouth open. If the client suddenly bites down, the nurse's fingers could be injured. C. The nurse should use either water or alcohol-free mouthwash to rinse the client's mouth. D. The nurse should use a foam swab because lemon-glycerin swabs dry and irritate the mouth and can damage the teeth.

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 the 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

Correct answer: (A) Place the client in the Trendelenburg position. The nurse should place the client in a right-sided Trendelenburg position to promote drainage from the client's left lower lobe. Incorrect Answers: B. The nurse should perform percussions over a single layer of clothing. C. The nurse should use a cupped hand to provide percussions. D. Chest percussions should not cause pain when the procedure is performed correctly. Place the client in the 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

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

Correct answer: (A) Repeat each joint motion 5 times during each session. To maintain the client's joint mobility, the nurse should repeat each motion 3 to 5 times. Incorrect Answers: B. The nurse should move the joint to the point of slight resistance. C. The nurse should stand at the side of the bed closest to the joint being exercised. D. The nurse should exercise the large joints first.

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 answer: (A) Sit at the bedside while feeding the client. The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client with the nurse's full attention during the feeding. Incorrect Answers: B. Without any mouth or throat injuries that make chewing or swallowing difficult, the client should be served foods of an appropriate variety of textures. Pureed foods are for clients who cannot chew, have difficulty swallowing, or do not have teeth. C. The nurse should ask the client if the food is the correct temperature. D. If the client is unable to communicate, the nurse should offer the client fluids after every 3 or 4 mouthfuls. However, there is no indication that this client is unable to communicate. Therefore, the client should tell the nurse when she would like a drink.

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 television 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.

Correct answer: (A) The client watches television in her bed during the day. To promote sleep, the client should avoid watching television in bed. She should use the bed only for sleep or sexual activities. Incorrect Answers: B. Warm milk provides L-tryptophan, an amino acid that promotes sleep. C. General sleep strategies include establishing a regular sleep schedule. A nightly bedtime of 2200 could be part of a bedtime routine to promote sleep. D. Although this can cause nighttime disruptions, waking once or twice to use the bathroom at night is common. Adults who do not have insomnia issues fall back to sleep readily.

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 2 ft behind the client during ambulation

Correct answer: (A) 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. Incorrect Answers: B. The nurse should ensure the client is wearing non-skid shoes or slippers when ambulating to decrease the risk of a fall from slipping. C. The nurse should encourage the client to dangle the legs on the edge of the bed for 60 seconds before attempting to ambulate to decrease the risk of a fall due to orthostatic hypotension. D. The nurse should walk beside the client to provide physical support while ambulating and decrease the risk of a fall.

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? Vesicular Bronchial Rhonchi Bronchovesicular Flag question for later

Correct answer: (A) Vesicular. The nurse will hear vesicular sounds over the periphery of the major lung fields. These sounds are soft and low-pitched. Incorrect Answers: B. The nurse will hear bronchial sounds over the trachea. These sounds are high-pitched, hollow, and loud. C. The nurse will hear rhonchi or gurgling sounds over the trachea and the bronchi if the airways are narrow due to secretions or swelling. D. The nurse will hear bronchovesicular sounds on either side of the sternal border anteriorly and between the scapulae posteriorly. These sounds are moderately loud with a medium pitch.

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 answer: (A) Vitamin C and zinc. The client's body needs both vitamin C and zinc to fight a wound infection. The client should receive a multivitamin and a mineral supplement of both these substances. In addition, vitamin E supplements also are needed to promote skin and wound healing. Incorrect Answers: B. Vitamin D is used with calcium to prevent osteoporosis; however, it does not assist with 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. C. Vitamin K is important for normal blood clotting and for impaired intestinal synthesis caused by antibiotics. Iron is needed to rebuild RBCs; however, neither is needed directly for wound healing. D. Calcium is administered to prevent osteoporosis when used with vitamin D; however, it does not aid wound healing.

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

Correct answer: (A) Whole milk. The fat-soluble vitamins (A, D, E, and K) require fatty substances or tissues to be dissolved and also require the presence of bile in the small intestine for absorption. Whole milk contains vitamins A and K and is often fortified with vitamin D. Incorrect Answers: B. The water-soluble vitamins (B complex and C) readily dissolve in water and are absorbed into the bloodstream from the small intestine. Chicken contains many of the B complex vitamins, including B2, B3, B6, B12, and pantothenic acid. C. The water-soluble vitamins (B complex and C) readily dissolve in water and are absorbed into the bloodstream from the small intestine. Oranges are a good source of vitamin C. D. The water-soluble vitamins (B complex and C) readily dissolve in water and are absorbed into the bloodstream from the small intestine. Dried peas are a good source of many of the B complex vitamins, including B1, folate, and pantothenic acid.

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." "I'll get you some water to drink." "Let's wait a bit so you don't feel sick."

Correct answer: (B) "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. Incorrect Answers: A. This response is the nontherapeutic and indicates that the client's immediate needs are not important. C. When a client is ready to resume a postsurgical diet, the nurse should offer clear liquids rather than water. Water provides hydration but no other nutrients. D. This response provides nontherapeutic communication by offering unsolicited advice to the client.

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."

Correct answer: (B) "I think I have done a good job with my children since they are all independent now." According to Erikson, the developmental task for middle adults is generativity vs. stagnation. Middle adults help shape future generations through community involvement, parenting, mentoring, and teaching. This statement about helping her children achieve independence indicates that the client has accomplished this developmental task. Incorrect Answers: A. This statement relates to Erikson's developmental task for young adults, which is intimacy vs. isolation. C. D. This statement relates to Erikson's developmental task for older adults, which is integrity vs. despair.

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? "I'll wrap the old dressing in a paper bag and put it in the trash." "I'll wash my hands before I remove the old dressing and again before putting on the new one." "I'll need to take a pain pill 30 minutes before I change the dressing." "I'll wear sterile gloves when I apply the new dressing."

Correct answer: (B) "I'll wash my hands before I remove the old dressing and again before putting on the new one." It is essential that the client understands the importance of hand hygiene before, during, and after any handling of the wound or its dressings. Incorrect Answers: A. Local regulations for disposal of contaminated items vary. In general, placing the old dressing in a plastic bag and sealing it is an acceptable means of disposal in household trash. C. This might be a good practice if the dressing changes are painful; however, this statement does not address medical asepsis, only pain management. D. Clean gloves and dressings are standard for clients at home. If sterile dressings are necessary, a home health care nurse should perform the dressing changes.

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

Correct answer: (B) (C) (D) Frequent oral hygiene provides comfort for the client since mucous membranes become dry and uncomfortable when a client cannot drink fluids. Measuring the drainage at least every shift helps the provider calculate fluid loss and prescribe appropriate replacement therapy. An unsecured NG tube can irritate the nares if the tube is pulled or caught on the bed or other equipment. The tube can also be dislodged if not secured appropriately. Incorrect Answers: A. Single-lumen NG tubes are used for intermittent suction, and the machine is set at 80 to 100 mmHg. Higher suction settings can traumatize the gastric lining. E. The client could aspirate an oil-based lubricant like petroleum jelly into the lungs, which could result in lipid pneumonia. A water-soluble lubricant should be applied to the nares to help prevent or relieve dry skin.

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 tube placement? (Select all that apply.) Auscultate injected air Verify the initial X-ray examination Measure the length of the exposed tube Determine the pH of aspirated fluid Check the aspirated fluid for glucose

Correct answer: (B) (C) (D) The nurse should confirm the NG tube placement by checking the X-ray results following the insertion of the NG tube. In addition, the nurse should check the length of the NG tube that is exposed by comparing the markings on the tube to the client's nose to verify tube placement. Finally, the nurse should check the pH of aspirated fluid to verify the tube placement. Incorrect Answers:A. Auscultating air injected into an NG tube is not a reliable method of determining correct NG tube placement. E. Checking for glucose in the aspirated fluid is not a reliable method of determining correct NG tube placement.

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 aspiration of secretions Preventing air leaks Preventing tracheal injury

Correct answer: (B) (C) (D) inflated cuff helps prevent movement of the endotracheal tube, reduces the risk of aspiration of oropharyngeal secretions, keeps air from leaking around the outer portion of the endotracheal tube. Incorrect Answers: A. The client cannot speak when an endotracheal tube is in place. E. inflated cuff does not prevent tracheal injury. If the cuff is overinflated and exerting a pressure that exceeds 25 mmHg, it can cause tracheal ischemia and necrosis.

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

Correct answer: (B) (C) (E) Dry, brittle hair that falls out easily suggests inadequate protein intake and malnutrition. Edema can occur when albumin levels are lower than the expected reference range and indicates protein-calorie malnutrition. Adequate wound healing depends on the ingestion of sufficient protein, calories, water, vitamins (especially C and A), iron, and zinc. Incorrect Answers: A. Gingivitis is a manifestation of vitamin C deficiency. D. Spoon-shaped nails are a manifestation of iron deficiency.

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

Correct answer: (B) 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. The nurse should apply the unstable vs stable priority-setting framework when caring for clients. Using this framework, unstable clients are prioritized due to needs that threaten survival. The nurse should first address problems involving the airway, breathing, or circulatory status that are life-threatening. Clients whose vital signs or laboratory values indicate a risk of becoming unstable are also a higher priority than clients who are stable. The nurse may need to use nursing knowledge to determine which option describes the most unstable client. An ostomy bag full of blood indicates that the client's bowel is hemorrhaging, and the nurse must report this finding to the surgeon immediately. The client may require fluid replacement, transfusion, and additional surgery to repair the bleeding vessel. This finding poses an immediate threat to the client's circulation. Incorrect Answers: A. Following a lobectomy, the client may need chest tubes for both pneumothorax and hemothorax (collapse of the lung with blood in the pleural space). Fully reinflating and removing the remaining blood can take several days or more, depending on the severity of the trauma. Chest tube drainage of 35 mL is within the expected parameters for an adult client, especially on the first postoperative day. A client who has a draining chest tube after a lobectomy is stable. C. A portable suction device drains a surgical wound by gentle, continuous self-suction. Over time, the drainage will change from sanguineous to serosanguinous to serous. Serosanguinous drainage of 20 mL/hr on the second postoperative day is within the expected reference range for an adult client. A client who has a draining wound after abdominal surgery is stable. D. Continuous bladder irrigation (CBI) prevents clots from forming in the bladder. To keep the client's urine free of clots and mucous plugs, the nurse should irrigate the bladder with 0.9% sodium chloride. During the first few postoperative days, reddish-pink urine at an hourly output slightly greater than the amount of solution the nurse instills is expected. Consequently, drainage of 300 mL/hr on the first postoperative day is within the expected reference range for this client.

A nurse is caring for a group of clients in a long-term care facility. One of the clients 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 antianxiety medication

Correct answer: (B) Accompany the client back to his room. apply the safety and risk-reduction priority-setting framework, which 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, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, nurse should first escort the client back to his room to protect him from injury due to wandering. Incorrect Answers:A. The client is at risk of inadequate nutrition because of the fluid and calorie expenditure from wandering; however, there is another action that the nurse should take first. C. D. The client is at risk of anxiety because of possible disorientation; however, there is another action that the nurse should take first.

A nurse is teaching a client who is postoperative following a knee arthroplasty about the muscles 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

Correct answer: (B) Antagonistic. The nurse should teach the client that the antagonistic muscle group is responsible for movement of the knee joint by contracting while other muscles relax. Incorrect Answers: A. The antigravity muscle group is responsible for stabilizing the knee joint. C. The synergistic muscle group is responsible for contracting in sync to cause the same movement. Therefore, 2 muscles contract as other muscles relax. However, this is not occurring within a joint. D. The skeletal muscle group is responsible for supporting posture and producing voluntary movement.

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

Correct answer: (B) Ask the client to identify the specific food allergies. The nurse should apply the nursing process priority-setting framework in order to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should first assess the client's allergies and identify the specific allergens to ensure the specific foods are not offered to the client during meals. Incorrect Answers:A. The nurse should document the client's food allergies in the medical record to communicate this information to other members of the health care team; however, there is another action that the nurse should perform first. C. The nurse should monitor the client for indications of anaphylaxis due to allergen exposure; however, there is another action that the nurse should perform first. D. The nurse should have epinephrine available for administration to treat the manifestations of an allergic reaction; however, there is another action that the nurse should perform first.

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

Correct answer: (B) Cleanse the wound with 0.9% sodium chloride irrigation. The nurse should cleanse the wound with sterile water or 0.9% sodium chloride irrigation to remove any surface debris or old exudate. Incorrect Answers: A. The nurse should wear clean gloves to collect a wound culture specimen. The nurse's hands will not touch the wound or the culture swab. C. Pooled drainage can collect microorganisms that are not the pathogens causing the wound infection. D. The nurse should rotate the swab back and forth over clean areas in the base of the wound to collect the pathogens causing the wound infection. The edges of the wound can harbor superficial microorganisms from the skin that are not infecting the wound.

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? A. Clients who are age 65 or older experience a decreased ability to perceive pain compared to young adult clients. B. Clients who are age 65 or older are reluctant to report pain. C. Clients who are age 65 or older should not receive opioid narcotics. D. Clients who are age 65 or older experience a shorter duration of action with medications than young adult clients.

Correct answer: (B) Clients who are age 65 or older are reluctant to report pain. instruct the newly licensed nurse that clients age 65 and older frequently can be reluctant to report pain because they might not want to bother or anger caregivers and might believe that pain is expected. Incorrect Answers: A. Clients age 65 and older do not experience a decrease in pain perception. C. Clients age 65 and older can receive opioid narcotics for pain relief. However, these clients metabolize medications slowly n might require lower doses than younger adults. D. Renal and liver function declines with age. Therefore, medications have a longer duration of action in clients who are age 65 and older. frequently monitor these clients for adverse effects n may need to administer a lower dosage of the medication at longer intervals compared to young adult clients.

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 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

Correct answer: (B) Elevate the head of the client's bed. Clients who have a brain injury are typically unable to swallow effectively and thus cannot protect their airway from aspiration. Even though this route bypasses the nasopharynx, it is still possible for the client to cough or vomit enteral formula into the oral cavity. Consequently, the nurse should strive to prevent aspiration by elevating the head of the bed prior to initiating the feeding. Incorrect Answers: A. Although cold enteral formula could cause cramping, it is not necessary to warm the feeding prior to administration. The formula should be at room temperature to improve the client's tolerance of gastrostomy feedings. Also, warming the formula in a microwave oven can cause uneven heat distribution and excessive heat; therefore, it is not a safe way to warm enteral feedings. C. The nurse should flush the tube with water prior to initiating the feeding to ensure the patency of the tube. D. Due to the acidity of gastric secretions, the pH of gastric contents should be below 4 to indicate proper placement of the gastrostomy tube. A pH above 4 suggests that the end of the tube is not in the stomach.

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 a whistling sound. 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

Correct answer: (B) Excessive wax in the ear canal. Factors that can make a hearing aid whistle include a poor seal with the ear mold, an ear infection, excessive wax in the ear canal, an improper fit, or a malfunction. Incorrect Answers: A. A hearing aid with low battery power will not work effectively, but it will not whistle. Removing the battery at night can help extend the life of the battery. C. A hearing aid might whistle if the volume is too high, not too low. D. A crack in the ear tube of an in-the-canal hearing aid can impair the hearing aid's amplification of sound; however, it would not cause whistling.

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 eye disorders? Retinopathy Glaucoma Cataracts Macular degeneration

Correct answer: (B) Glaucoma. The nurse should identify that obstruction of the flow of the vitreous humor of the eye is a manifestation of glaucoma. This obstruction leads to an increase in intraocular pressure, resulting in damage to the eye. Incorrect Answers: A. Manifestations of retinopathy include changes in the blood vessels of the retina that can lead to blindness. C. Manifestations of cataracts include an increase in the opacity of the lens, blocking rays of light from entering the eye. D. Manifestations of macular degeneration include changes in sharp and central vision and are often associated with aging.

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

Correct answer: (B) Lower abdomen. secure indwelling urinary catheter with tape to the lower abdomen or upper aspect of thigh to eliminate the penoscrotal angle and prevent tissue injury. Incorrect Answers: A. Taping the indwelling urinary catheter to the client's lateral or outside thigh can cause discomfort and tissue injury due to pressure on the urethra at the penoscrotal junction. C. Taping the indwelling urinary catheter to the client's mid-abdominal region can cause discomfort and does not allow the downward flow of urine via gravity into the drainage bag. D. Taping the indwelling urinary catheter to the client's medial or mid-thigh area can cause discomfort due to pressure on the urethra at the penoscrotal junction and can lead to tissue injury.

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

Correct answer: (B) Lungs. Percussion creates a vibration that helps the examiner determine the density of the underlying tissue. The lungs are hollow organs that can produce sounds such as resonance (a hollow sound over alveoli) or dullness (a dull sound over consolidated areas of the lungs or diaphragm). The nurse also uses auscultation and palpation when evaluating the lungs. Incorrect Answers: A. The nurse uses inspection, palpation, and auscultation to evaluate the heart. C. The nurse uses inspection and palpation to evaluate the thyroid gland. D. The nurse uses inspection and palpation to evaluate the skin.

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

Correct answer: (B) Montgomery straps. The nurse should apply the least-restrictive priority-setting framework, which assigns priority to nursing interventions that are the 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 members, or others is at risk. The nurse should plan to use Montgomery straps to minimize irritation of 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 is replaced, and the ties are secured again without removing the adhesive strips. Incorrect Answers: A. 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. C. 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. D. 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 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 mg/dL Sodium 150 mEq/L Potassium 4 mEq/L Magnesium 1.5 mEq/L

Correct answer: (B) Sodium 150 mEq/L. A sodium level of 150 mEq/L is greater than the expected reference range of 135 to 145 mEq/L. This client is at risk for dehydration due to diarrhea. Hypernatremia is a manifestation of dehydration, and the nurse should report this finding to the provider. Incorrect Answers:A. A calcium level of 9.5 mg/dL is within the expected reference range of 9 to 10.5 mg/dL. C. A potassium level of 4 mEq/L is within the expected reference range of 3.5 to 5 mEq/L. However, this client is at risk for hypokalemia due to diarrhea, so the client's potassium level should be monitored. D. A magnesium level of 1.5 mEq/L is within the expected reference range of 1.3 to 2.1 mEq/L.

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

Correct answer: (B) Stereognosis. Stereognosis is the ability to identify an object's size, shape, and texture via tactile sensation. Incorrect Answers: A. Gustation is the ability to taste. C. Proprioception is the awareness of the position of the body. D. Kinesthesia is the ability to sense the position and movement of body parts without visualizing them.

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.

Correct answer: (B) The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups. The RDA represents daily requirements considered adequate for healthy people. RDAs are based on estimated amounts for each nutrient, including additional amounts for individuals such as women or infants. Incorrect Answers: A. Dietary reference intakes (DRIs) include 4 nutrition-based standards that are used to plan dietary intake and evaluate a client's nutritional status. These dietary standards include RDAs, estimated average requirements (EARs), adequate intake (AI), and tolerable upper intake levels (ULs). C. Tolerable upper intake levels (ULs), not RDAs, are the levels of nutrients that should not be exceeded to prevent adverse effects. D. Acceptable macronutrient distribution ranges (AMDRs) are the daily percentage of energy intake values for fat, carbohydrate, and protein.

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

Correct answer: (B) Tie the restraint with a quick-release knot. The nurse should use a quick-release knot that can be untied easily in case the client's well-being requires quickly removing the restraints. Incorrect Answers: A. should not fasten the ties on the restraint to the side rails. If the side rails are lowered, client could be injured. C. allow two fingerbreadths between restraint n the client's chest. D. apply the restraint over the client's clothing.

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.

Correct answer: (B) Tie the restraint with a quick-release knot. The nurse should use a quick-release knot that can be untied easily in case the client's well-being requires quickly removing the restraints. Incorrect Answers: A. The nurse should not fasten the ties on the restraint to the side rails. If the side rails are lowered, the client could be injured. C. The nurse should allow two fingerbreadths between the restraint and the client's chest. D. The nurse should apply the restraint over the client's clothing.

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." "Don't 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 bed." "When was the last time that he had a bath?"

Correct answer: (C) "It must be difficult to care for someone who is confined to bed." This response addresses the feelings of partner by reflecting her feelings, which facilitates therapeutic communication because it is nonjudgmental and encourages the partner to express her feelings. Incorrect Answers: A. This automatic response implies that caregivers in the home are not able to keep clients odor-free. It is a judgmental statement that is not therapeutic. B. Telling partner not to worry blocks communication by devaluing her feelings and her concern about the odor. D. This response implies that the odor of urine has developed because she has not bathed her husband for some time, which is judgmental and nontherapeutic.

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, let's talk about your pain." "Are you having other symptoms?" "It sounds like your pain is intermittent." "It seems as though you have really had a rough time these past few weeks."

Correct answer: (C) "It sounds like your pain is intermittent." nurse should use this technique to ensure understanding of the client's message. Incorrect Answers: A. This is an example of the communication technique of focusing. The nurse can use this technique to keep the conversation moving in an organized direction. B. This is an example of the communication technique of asking a relevant question. These kinds of questions are open-ended and allow the client to offer more information to the nurse. D. This is an example of the communication technique of sharing empathy. With this technique, the nurse is able to convey understanding and acceptance of what the client is or has been experiencing.

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 to make the necessary changes." "Let's 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."

Correct answer: (C) "Let's set up a meeting time with the doctor to discuss your options for home care." In family-centered care, the nurse considers the health of the family as a unit; therefore, the client and family members help determine their outcomes and goals. Setting up a meeting to discuss this with the provider will give them a sense of autonomy and foster the family-centered nursing environment. Incorrect Answers: A. In family-centered care, the family and client are the focus; therefore, the family members must decide, with the input of the health care team, which community resources to contact. The nurse should still make suggestions and offer support. B. In family-centered care, the family and client are the focus. The nurse should provide suggestions and offer support but should not make the final decision about changes to the care plan. D. In family-centered care, the family and client are the focus; therefore, the family must decide, with the nurse's input, what to do before the client goes home.

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 mL of fluid daily." "Increase your intake of refined-fiber foods." "Sit on the toilet 30 min after eating a meal." "Take a laxative every day to maintain regularity."

Correct answer: (C) "Sit on the toilet 30 min 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. Incorrect Answers: A. The nurse should instruct the client to consume a minimum of 1,500 mL of fluid to prevent constipation. B. The nurse should instruct the client to increase consumption of coarse fiber and whole grains, rather than refined-fiber foods. D. The nurse should not recommend intake of daily laxatives because consistent use hinders natural defecation habits and can cause constipation.

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 answer: (C) "Tilt your head back and swallow." To examine the thyroid gland, the nurse should instruct the client to extend her head backward and to swallow. The nurse should be able to feel the thyroid gland ascend as the client swallows and observe any enlargement of the gland. Incorrect Answers: A. To palpate the supraclavicular lymph nodes, the nurse should instruct the client to tilt her head forward and relax her shoulders. B. To palpate the trachea for any deviation to the side, the nurse should instruct the client to keep her head in an erect, neutral position. D. To evaluate the strength of the neck muscles, the nurse should place a hand on the side of the client's head and ask her to turn her head against the resistance from the hand. The nurse should then repeat this step on the other side of the client's head.

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

Correct answer: (C) (D) Dried peas and beans, including black beans, are high in fiber. Whole grains consist of the entire kernel and are also high in fiber. Incorrect Answers: A. Canned fruits, including peaches, are recommended for clients on a low-fiber diet. Fresh fruits contain more fiber. B. White rice is recommended for clients on a low-fiber diet. Brown rice is higher in fiber. E. Canned juices, with the exception of prune juice, are recommended for clients on a low-fiber diet.

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 each drop of the medication directly onto the client's cornea

Correct answer: (C) Apply pressure to the puncta after instilling the medication. instill the medication into the conjunctival sac and apply pressure to the puncta for 1 to 2 minutes afterward to prevent systemic absorption of the medication. Incorrect Answers: A. close the eyes gently and to avoid blinking after instillation to prevent any loss of the medication out of the eye and promote absorption. B. look upward toward the ceiling during instillation of the medication to allow proper placement of the medication and to suppress the client's blink reflex. D. instill the medication into the client's conjunctival sac and should take measures to protect the client's cornea during administration.

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

Correct answer: (C) Compare the medical record number and name on the MAR with the client's identification band. The Joint Commission requires the use of 2 client identifiers when administering medications. The nurse should compare the medical record number and name on the MAR with the client's identification band. Incorrect Answers: A. The client's room and bed numbers are not acceptable identifiers. B. This client cannot respond to her name. D. A visitor is not an acceptable source for identification.

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

Correct answer: (C) Cotton wisps. The trigeminal nerve has both sensory and motor capabilities. To assess its sensory function, the nurse uses a safety pin to assess for recognition of pain and a cotton wisp to evaluate recognition of touch sensations. To test motor abilities of cranial nerve (CN) V, the nurse should ask the client to clench the teeth. Incorrect Answers: A. The nurse should use sugar to test the function of the facial nerve (CN VII). B. The nurse should use coffee to test the function of the olfactory nerve (CN I). D. The nurse should use the Snellen chart to test the function of the optic nerve (CN II).

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 circumstances. Magical thinking helps avoid thoughts of death. Death is viewed as an interruption of what might have been. Death is a natural consequence of a deteriorating body.

Correct answer: (C) Death is viewed as an interruption of what might have been. Young adults tend to see a whole life ahead of them, so death is often seen as interrupting that life. Young adults do not typically welcome death at this time. Incorrect Answers: A. Adolescents tend to reject the end of life, especially their own. B. Preschoolers tend to avoid thoughts of death by employing magical thinking. D. Accepting the deterioration of the body is more likely among older adults, some of whom might consider death a relief from chronic or terminal illness.

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

Correct answer: (C) Depressed deep-tendon reflexes. total calcium level of 12.7 mg/dL is above the expected reference range. Manifestations of hypercalcemia include depressed deep tendon reflexes, nausea, vomiting, bone pain, lethargy, and weakness. Incorrect Answers: A. Muscle tremors are manifestations of hypocalcemia, not hypercalcemia. B. Positive Chvostek's and Trousseau's signs are manifestations of hypocalcemia, not hypercalcemia. D. Numbness and tingling around the mouth and in the extremities are manifestations of hypocalcemia, not hypercalcemia.

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

Correct answer: (C) Depression. During the stage of depression, the client has realized the full impact of the loss and might express hopelessness and despair. Incorrect Answers: A. During the stage of anger, the client shows resistance or blames other people, a higher power, or the situation itself. B. During the stage of bargaining, the client stalls awareness of the loss by trying to keep it from occurring. D. During the stage of acceptance, the client will integrate the loss (e.g. by making final arrangements).

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

Correct answer: (C) Diuresis. Diuresis or polyuria is the excretion of a high volume of urine. This condition has many causes, including metabolic and hormonal imbalances and diuretic therapy for treating renal, cardiovascular, and pulmonary disorders. Incorrect Answers:A. Retention is an accumulation of urine in the bladder as a result of incomplete emptying of the bladder or a cessation of the ability to urinate. B. Oliguria is a diminishing urine output despite an acceptable fluid intake. D. Dysuria is painful or difficult urination, often as a result of a urinary tract infection or injury.

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 to the client? Make eye contact with the interpreter. Break sentences into shorter segments to allow time for interpretation. Ensure the interpreter and the client speak the same dialect. Speak in a loud tone of voice.

Correct answer: (C) Ensure the interpreter and the client speak the same dialect. To encourage effective communication and promote client understanding, the nurse should first ensure the interpreter and the client speak the same dialect. Incorrect Answers: A. To enhance the nurse-client relationship, the nurse should direct information, instructions, and questions to the client, not to the interpreter. B. The nurse should make every effort to speak in short sentences but should not break sentences into fragments to allow time for interpretation. D. The nurse should speak slowly and distinctly and avoid the use of metaphors that might be challenging to translate. The nurse should speak clearly, not loudly.

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 this client's routine health screening? Annual Papanicolaou (Pap) testing Mammogram every 2 years Eye examination every 2 years Annual colonoscopy

Correct answer: (C) Eye examination every 2 years. This is essential not only for monitoring vision but also for checking for glaucoma. The client should have annual eye examinations from the age of 65 onward. Incorrect Answers: A. Women ages 30 to 65 years should have a Pap test every 3 years. B. Women ages 45 years and older should have an annual mammogram. At age 55, clients may decide to change this schedule every 2 years or continue with annual mammograms. D. The client should have a colonoscopy every 10 years. If the client has risk factors for colorectal cancer, testing should occur more often and with other evaluations.

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

Correct answer: (C) Hct 55%. elevated hematocrit indicates hypovolemia. Other indications weak pulse, tachycardia, hypotension, tachypnea, slow capillary refill, elevated BUN, increased urine specific gravity, decreased urine output. Incorrect Answers: A. This BUN falls within the expected reference range; therefore, it does not indicate hypovolemia. B. This capillary refill time is within the expected reference range. With dehydration, it tends to be longer. D. This low urine specific gravity indicates hypervolemia, not hypovolemia.

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 magnetic resonance imaging (MRI)? Coronary artery stents Aneurysm clip Hearing aids Automated internal defibrillator

Correct answer: (C) Hearing aids. client who has hearing aids can undergo MRI because the hearing aids can be removed. The powerful magnetic field of the MRI system could damage the hearing aids, so they should be removed prior to the client undergoing MRI. Incorrect Answers: A. A coronary artery stent is a contraindication for undergoing MRI. The powerful magnetic field of the MRI system could pull on the metal stent and dislodge it. B. An aneurysm clip is a contraindication for undergoing MRI. The powerful magnetic field of the MRI system could pull on the metal clip and dislodge it. D. An automated internal defibrillator is a contraindication for undergoing MRI. The powerful magnetic field of the MRI system could damage the defibrillator and cause it to malfunction.

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 8 cm (3.1 in) Hold the enema container 61 cm (24 in) above the rectum

Correct answer: (C) 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 avoid injury to the rectal mucosa. Incorrect Answers: A. The nurse should lubricate 5 to 8 cm (2 to 3 in) of the tip of the rectal tube before inserting it to decrease the risk of irritation or injury to the mucosa. B. 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. D. 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 teaching a group of unit nurses about the experiences of clients who are having surgery. In which phase of care is the client transferred to the surgical suite table before being transferred to the PACU? Preoperative Postoperative Intraoperative Admission

Correct answer: (C) Intraoperative. Intraoperative care begins when the client is transferred to the surgical suite table and ends when the client is admitted to the PACU. Incorrect Answers: A. Preoperative care begins when the client agrees to have surgery and ends when the client is transferred to the surgical suite table. B. Postoperative care begins when the client is admitted to the PACU and ends when healing is complete. D. The client's admission to the facility where the surgery is to take place is part of the preoperative phase and typically occurs outside of the surgical suite.

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

Correct answer: (C) Lentils. Incomplete proteins are missing 1 or more of the essential amino acids necessary for the synthesis of protein in the body. Examples of incomplete proteins include lentils, vegetables, grains, nuts, and seeds. Incorrect Answers: A. B. D. Complete proteins such as eggs, soybeans, and yogurt contain all of the essential amino acids necessary for the synthesis of protein in the body.

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

Correct answer: (C) PC for after meals. The nurse can use this abbreviation because it is approved and not error-prone. Incorrect Answers: A. The nurse should avoid using this abbreviation because it can be mistaken for BID, which means twice daily. Instead, the nurse should use the word "bedtime." B. The nurse should avoid using this abbreviation because it can be mistaken for sublingual. Instead, the nurse should use "subcut" or "subcutaneously." D. The nurse should avoid this abbreviation and use "half-strength" instead.

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 are practicing the Buddhist faith have the female family members prepare the body following death.

Correct answer: (C) People who practice Judaism stay with the body of the deceased until burial. In the Jewish faith, a family member often stays with the body until burial occurs. Incorrect Answers: A. For those who practice the Islamic faith, the body of the deceased is washed and wrapped during a ritual and then buried as soon as possible following death. B. People who practice the Hindu faith may place the body with the head facing north following death. However, cremation rather than burial is practiced by those of the Hindu faith. D. Male family members prepare the body following death for individuals practicing the Buddhist faith.

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 (6 in) apart.

Correct answer: (C) Place the wheelchair at a 45-degree angle to the bed. Positioning the wheelchair at a 45-degree angle allows the client to pivot, lessening the amount of rotation required. Incorrect Answers: A. 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. B. 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. D. 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 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

Correct answer: (C) Remove the IV catheter. This client's manifestations suggest phlebitis. The nurse should stop the infusion and remove the IV catheter immediately. The nurse should then apply warm compresses to the site. Incorrect Answers: A. These manifestations do not suggest that the infusion tubing is punctured, contaminated, occluded, or expired. B. This action could worsen the complication suggested by the client's manifestations. D. Warm, moist heat is part of the treatment protocol for the complication suggested by the client's manifestations.

A home health nurse is visiting an older adult client with severe dementia. The client's son, who serves as her primary caregiver, reports being "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

Correct answer: (C) Respite care. Respite care is a service for caregivers who need time to rest from multiple responsibilities related to the care of a family member who needs assistance. Incorrect Answers: A. Rehabilitation programs help clients return to optimal functioning after an illness or injury. However, severe dementia will not improve with rehabilitative services. B. An assisted living facility provides independence for clients who need only limited personal care. A client who has severe dementia needs total care. D. Although adult day care facilities do help family caregivers maintain some aspects of their lifestyle and independence, these facilities provide care and supervision for clients who need minimal assistance (e.g. taking medication, receiving physical therapy, or receiving counseling). They do not provide care for clients who have severe dementia.

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 answer: (C) Sitting. The costovertebral angle is the area where the spine and the twelfth rib intersect. A sitting position promotes relaxation and allows access to the back for percussion of that region. Incorrect Answers:A. Sims' position is used for rectal examinations and procedures. B. Supine positioning is used for other types of assessment, such as thoracic and abdominal examinations. D. A standing position is used for observation of the client's posture.

A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for the client? Perform tracheostomy care using medical asepsis Allow enough slack under the tracheostomy ties to insert three 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

Correct answer: (C) Soak the inner cannula of the tracheostomy tube in normal saline. The inner cannula of the tracheostomy tube should be soaked in normal saline or a mixture of normal saline and hydrogen peroxide to loosen secretions. Incorrect Answers: A. Tracheostomy care for a client with a new tracheostomy should be performed using surgical asepsis (sterile technique). B. The nurse should allow room to insert 1 or 2 fingers under the tracheostomy ties; this ensures they are not too restrictive. D. A cut gauze pad should not be used near a tracheostomy tube because the client can aspirate loose threads. The nurse should use a commercially prepared tracheostomy dressing under the tracheostomy tube.

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

Correct answer: (C) Starch. Salivary amylase begins the process of digestion in the mouth with the initial breakdown of starches. The majority of starch breakdown occurs in the small intestine with pancreatic amylase. Incorrect Answers: A. Lipase breaks down fats. B. Pepsin breaks down proteins. D. Fiber is not digestible, but fermentation occurs in the large intestine by intestinal microbes, which results in the release of methane, hydrogen, water, and fatty acids.

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 answer: (C) Use the index finger to insert the suppository. To ensure adequate distribution of the vaginal medication, the nurse should insert the suppository until the length of the nurse's index finger is inside the vagina or as far inside as possible. Incorrect Answers: A. The nurse should wear clean gloves for this procedure, not sterile gloves. B. The nurse should use the nondominant hand to retract the labia and the dominant hand to insert the suppository. D. The nurse should ease the suppository along the posterior vaginal wall.

A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take? Use a 10 mL 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

Correct answer: (C) Warm the irrigating solution to 37°C (98.6°F). The nurse should prepare about 200 mL of irrigating solution and warm it to body temperature to minimize discomfort and vascular constriction. Incorrect Answers: A. The nurse should use a syringe that has at least a 30 mL capacity. B. The nurse should use an 18- or 19-gauge catheter. A smaller catheter will exert too much pressure on the wound. D. The nurse should administer an analgesic 20 to 30 minutes before the irrigation to give the medication enough time to provide pain management during the procedure.

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

Correct answer: (C) Wear a gown when in the client's room. apply a gown at all times when in the client's room to maintain contact precautions. This client who has MRSA should be placed in contact isolation, which includes the use of gloves and a gown when providing care. Incorrect Answers: A. The nurse should place the client in a private room when a wound is contaminated with a virulent or multi-drug-resistant organism such as MRSA. B. The nurse should wear a mask when a client has an infection that can be transmitted via airborne or droplet routes. When splashing or spraying of body fluids is anticipated, the nurse will require full-face protection. D. The nurse should use moisture-resistant single bags to collect linen. The nurse should not overfill and should tie the bag securely to prevent the transmission of microorganisms. The nurse should double bag the initial bag if the outside becomes contaminated. The linens should be properly sanitized and reused.

A nurse is teaching a client who is using 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? "I'll limit pushing the button so I don't get an overdose." "If I push the button and still have pain after 2 minutes, I'll push it again." "I'll ask my niece to push the button when I am sleeping." "I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button."

Correct answer: (D) "I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button." The nurse should encourage the client to utilize nonpharmacological methods of pain management such as transcutaneous electrical nerve stimulation (TENS) while using a PCA pump to reduce the amount of opioid dosing the client needs. Incorrect Answers: A. PCA devices have a timing control or lockout mechanism that allows a preset minimum interval between medication doses and limits the total dose per hour. This safety feature prevents analgesic overdosing. B. PCA devices have a timing control or lockout mechanism that usually allows dosing every 6 to 8 minutes. If the client pushes the button after 2 minutes, the pump will not deliver any medication. C. The client is the only one who should operate the PCA pump. When someone else operates the pump, it bypasses a safety feature that requires the client to be awake and to decide whether more medication is needed.

charge nurse is providing teaching to newly licensed nurse abt removing sutures from client's laceration. Which of the following statements by newly licensed nurse indicates understanding of 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 n pull it through from other side."

Correct answer: (D) "I will clip each suture close to the skin n pull it through from other side." Clipping close to the skin n pulling suture from other side does not disrupt the wound-healing process. Incorrect Answers: A. staple remover is used to remove staples, not sutures. B. Bandage scissors r ineffective in removing sutures, as the tips of scissors r too large n blunt to capture suture material. Special suture scissors with short, curved tip r used to remove sutures. C. Retention sutures r placed more deeply within body than regular sutures. Agency policy will determine if nurses r allowed to remove them. Tweezers, however, can be used to remove all types of sutures, not just retention sutures.

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 range-of-motion exercises while in bed

Correct answer: (D) Advise the client to perform range-of-motion exercises while in bed. Performing range-of-motion exercises will help the client maintain mobility until her pain is under control and she is able to ambulate without excessive discomfort. Incorrect Answers: A. This is a nontherapeutic response that implies the client should do what the provider wants and suggests the client has no input or control over her situation. B. Allowing the client to remain in bed could place the client at risk of complications of immobility, such as thrombus formation. C. Having the family perform ADLs for the client limits the client's independence.

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 the 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

Correct answer: (D) Apply light pressure to the scanner head once it is in position. The nurse should apply light pressure and hold the scanner steadily while pointing it slightly down toward the client's bladder. Incorrect Answers:A. The nurse should instruct the client to urinate 10 minutes before the bladder scanning procedure. The nurse should then document the amount of urine the client passed at that time. B. For the bladder scanning procedure, the nurse should assist the client into a supine position with the head slightly elevated. C. The nurse should position the scanner head 2.5 to 4 cm (1 to 1.6 in) above the symphysis pubis.

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.

Correct answer: (D) Ask the adolescent to sign the consent form. Unemancipated minors (i.e. those who do not live on their own, are not married, and are not in the military) can legally give informed consent for diagnostic procedures and treatment in some situations. These situations include treatment for STIs and substance use disorders. Incorrect Answers: A. Ideally, a parent or legal guardian should give informed consent for an unemancipated minor to undergo invasive diagnostic and therapeutic procedures. However, in the case of an infection that could be worsening, a delay is not advisable. B. A parent or legal guardian must give consent for an unemancipated minor. Unless the grandmother is the child's legal guardian, the nurse should not tell the grandmother she may give consent. C. Implied consent is pertinent in an emergency situation when an adult client is unable to sign (e.g. due to unconsciousness) and no one is available to give informed consent. This circumstance does not apply to this situation.

A nurse in an emergency department is caring for a client who reports developing severe right 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

Correct answer: (D) Ask the client about first aid performed at the scene. The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to assess the first aid that was performed at the scene to determine if eye irrigation was administered. Incorrect Answers: A. The nurse should instill proparacaine hydrochloride eyedrops, after assessing for client allergies, to promote relief of eye pain; however, there is another action that the nurse should take first. B. The nurse should prepare for and quickly perform ocular irrigation when a foreign body in the eye is suspected; however, there is another action that the nurse should take first. C. The nurse should place the client in a supine position with the head turned toward the affected eye to promote drainage of irrigation fluid during ocular irrigation; however, there is another action that the nurse should take first.

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 25º angle Massage the area of injection following removal of the needle Circle the injection area with a pen

Correct answer: (D) Circle the injection area with a pen. Circling the area with a pen ensures the nurse will examine the correct site when reading the test 48 to 72 hours later. Incorrect Answers:A. A 25- to 27-gauge needle is used for intradermal injections. B. The needle should be inserted at an angle of 10° to 15°. This ensures the solution will be injected into the intradermal area. C. The area of injection should not be massaged because this can spread the medication into the tissue or out through the insertion site.

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

Correct answer: (D) 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. Incorrect Answers: A. The nurse should use a fresh urine specimen obtained near the indwelling urinary catheter to prevent contamination. B. The nurse should cleanse the collection port with an antimicrobial swab to prevent contamination. C. The nurse should place the specimen in a sterile specimen cup to prevent contamination.

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

Correct answer: (D) Clean the drain site from the center outward. The nurse should clean the drain site from the center outward to avoid introducing microorganisms from the periphery of the wound into the center of the wound. Incorrect Answers: A. The nurse should clean the incision from top to bottom to prevent any contamination of the area that has already been cleansed. The top of an incision is cleaner because drainage tends to collect at the bottom of the wound. B. The nurse should apply sterile gloves after opening dressing packages. To open the packages, the nurse must touch the nonsterile outside packaging of the sterile supplies. If the nurse donned the sterile gloves prior to opening the packages, opening the package would contaminate the gloves. C. The nurse should pull the tape toward the wound to avoid straining the wound and its sutures, which could lead to dehiscence.

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 serially, starting at 100 Describe a previous illness Explain what to do if a fire happened in his bedroom Discuss the meaning of a common proverb

Correct answer: (D) Discuss the meaning of a common proverb. This part of the mental-status examination evaluates the client's ability to think abstractly. Incorrect Answers:A. This part of the mental-status examination evaluates the client's attention span. B. This part of the mental-status examination evaluates the client's remote memory. C. This part of the mental-status examination evaluates the client's judgment.

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

Correct answer: (D) Gait. Inspection is the technique of looking or observing. Gait inspection involves watching the client's walking movements and observing any unusual findings. Incorrect Answers: A. Evaluating liver size requires palpation. B. Evaluating pedal edema requires palpation. C. Evaluating skin texture requires palpation.

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

Correct answer: (D) Gait. Inspection is the technique of looking or observing. Gait inspection involves watching the client's walking movements and observing any unusual findings. Incorrect Answers: A. Evaluating liver size requires palpation. B. Evaluating pedal edema requires palpation. C. Evaluating skin texture requires palpation.

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.

Correct answer: (D) Granulation tissue fills the wound during healing. A beefy, red tissue called granulation tissue fills the wound during healing. The wound is left open to drain and heal by secondary intention, which should occur within 5 to 21 days. Open wounds increase the risk of wound infection. Incorrect Answers: A. Primary intention involves the closing of the wound using sutures or staples at the time the incision is made; the suture line edges become well-approximated during healing. B. Tertiary intention includes using sutures to close an open wound at a later date after the wound drains and starts to heal. C. 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.

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 Halo of erythema on the surrounding skin

Correct answer: (D) 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 (e.g. purulent drainage, swelling, warmth, or a strong odor) should be reported to the provider. Incorrect Answers: A. Tenderness when touched is an expected finding in a postoperative wound that is healing by secondary intention. Severe pain might indicate infection or underlying tissue destruction and should be reported. B. 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. C. Serosanguineous drainage, which is made up of RBCs and plasma, is an expected finding in a postoperative wound healing by secondary intention. Purulent drainage suggests infection and should be reported.

A nurse is caring for a client who is 48 hr 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? A. Blood loss B. NPO status after surgery C. Nasogastric tube suctioning D. impaired peristalsis of the intestine

Correct answer: (D) Impaired peristalsis of the intestines. Normal bowel function is delayed for up to several days following bowel resection. When peristalsis is absent or sluggish, intestinal gas builds up, producing pain n abdominal distention. plan to help the client ambulate to promote peristalsis. Incorrect Answers: A. Blood loss can cause shock but does not contribute to the findings demonstrated by this client. B. NPO status after surgery can cause dehydration but does not contribute to the findings demonstrated by this client. C. Nasogastric tube suctioning keeps the stomach and intestines decompressed and can help prevent the findings demonstrated by this client.

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 to apply pressure to the inside corner of the eye after instillation.

Correct answer: (D) Instruct the client to apply pressure to the inside corner of the eye after instillation. The client should apply gentle pressure over the nasolacrimal duct to prevent the medication from flowing into the nasal passages where systemic absorption could result. Incorrect Answers: A. One of the actions the client performed is incorrect. B. The nurse should instruct the client to look up when instilling the eye drops. C. The client may use a tissue to remove excess medication after instillation.

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 temperatures Offer the client low-density foods Make sure the client lies supine after meals Limit drinking liquids with food

Correct answer: (D) Limit drinking liquids with food. Drinking beverages with food leads to early satiety and bloating, which results in the client consuming fewer calories. Incorrect Answers: A. The nurse should make sure the client receives cold or room-temperature foods. B. To increase the nutritional value of the food and the client's caloric intake, the nurse should make sure that the client receives high-protein, high-calorie, nutrient-dense foods. The client should also eat nutrient-dense foods first during meals. C. To reduce nausea, the client should sit upright for 1 hour after meals. The client should also rest before meals to conserve energy for eating and digesting food.

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.

Correct answer: (D) Perform hand hygiene. According to evidence-based practice, nurse should first perform hand hygiene before touching client or performing any skills, like tracheostomy care. This is vital bec. contamination of nurse's hands is primary source of infection. Incorrect Answers: A. The nurse should open all sterile supplies and solutions prior to providing tracheostomy care. However, there is another action the nurse should take first. B. nurse should stabilize tracheostomy tube to prevent accidental extubation while providing tracheostomy care. However, there's another action nurse should take first C. nurse should put on sterile gloves prior to providing tracheostomy care to reduce transmission of organisms. However, there is another action nurse should take first.

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

Correct answer: (D) Pericardial friction rub. A pericardial friction rub has a high-pitched scratching, grating, or squeaking leathery sound that is 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 like rheumatic fever. A client who develops pericarditis typically has chest pain that becomes worse with inspiration or coughing and may be relieved by sitting up and leaning forward. Incorrect Answers: A. An audible clicking sound occurs in clients who have undergone prosthetic valve replacement surgery. B. 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. C. A third heart sound (S3) is a low-pitched noise 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.

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 (3 in) above the popliteal artery Place the bladder of the cuff over the posterior aspect of the thigh

Correct answer: (D) Place the bladder of the cuff over the posterior aspect of the thigh. This is the correct position for the bladder of the cuff when the nurse is measuring lower-extremity blood pressure. Incorrect Answers: A. The nurse should auscultate the blood pressure at the popliteal artery. B. The nurse should measure the blood pressure with the client prone if possible. Otherwise, the client should lie supine with the knee flexed. C. The nurse should position the cuff 2.5 cm (1 in) above the popliteal artery.

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

Correct answer: (D) 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 on the container and the bag for easy identification. This will also prevent contamination with microorganisms. Incorrect Answers:A. 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. B. The nurse should place the stool specimen a clean container using a tongue depressor. C. The nurse should send the collected stool specimen immediately to the laboratory after labeling the specimen properly to prevent contamination with microorganisms and keep the specimen from getting cold.

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

Correct answer: (D) Plasma volume expanders. Dextran and albumin are plasma volume expanders that help correct hypovolemia in emergency situations, such as after hemorrhage or burns. Incorrect Answers: A. Dextran is not a skeletal muscle relaxant. Examples of skeletal muscle relaxants are cyclobenzaprine and metaxalone. B. Dextran is not a beta-adrenergic blocker. Examples of beta-adrenergic blockers are propranolol and carvedilol. C. Dextran is not a broad-spectrum anti-infective agent. Examples of broad-spectrum anti-infective agents include ampicillin and cefixime.

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

Correct answer: (D) Purulent exudate. Purulent exudate on the client's dressings includes thick yellow, green, or brown drainage and usually indicates wound sloughing or infection. Incorrect Answers: A. Sanguineous exudate drainage on the client's dressings indicates an accumulation of RBCs from the plasma that appears bright red on the dressings. B. Serous exudate drainage on the client's dressings indicates plasma from the blood and appears watery and clear to light yellow in color. C. Serosanguineous exudate drainage on the client's dressings indicates plasma mixed with light bloody drainage, which is typically pale yellow to blood-tinged. Watery drainage may also be evident.

A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis. 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 halfway up the calf Turn the stocking inside out up to the heel before applying

Correct answer: (D) 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 fewer constrictive wrinkles. Incorrect Answers:A. 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. B. The nurse should remove the stockings once every shift to inspect the skin and check circulation. C. The nurse should slide the top of the stocking up over the client's calf all at once to lessen constrictive wrinkles, which can decrease venous return.

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.

Correct answer: (D) Wear cotton clothing to avoid static electricity. The use of cotton clothing will limit the buildup of static electricity. Oxygen is a highly combustible gas. The use of oxygen in high concentrations has great combustion potential and readily fuels fire. Although it will not spontaneously burn or cause an explosion, it can easily cause a fire in a client's room if it contacts a spark. Incorrect Answers: A. Electrical equipment in good condition with no frayed wires is acceptable for personal care when oxygen is administered. B. Most oils and petroleum products are flammable when used on the body, which is a contraindication for use because oxygen is a highly combustible gas. C. As long as the television is in proper working order, there is no oxygen-related need to remove it from the client's bedroom.

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

Correct answer: (D) Wrap the client's finger in a warm washcloth. Warmth helps increase the blood flow to the client's finger. Incorrect Answers: A. Smearing the blood on the reagent strip will lead to an inaccurate result. B. To improve blood flow, the nurse should keep the client's hand in a dependent position. C. Massaging can hemolyze the specimen, leading to an inaccurate result.

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

Correct answer: (D) Young adulthood. The developmental task of young adulthood is intimacy vs. isolation. Incorrect Answers: A. The developmental task of middle adulthood is generativity vs. self-absorption and stagnation. B. The developmental task of adolescence is identity vs. role confusion. C. The developmental task of school-age children is industry vs. inferiority.

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

Correct: Ventrogluteal According to evidence-based practice, the ventrogluteal site is the safest injection site for all adults because it contains thick gluteal muscles and does not contain major nerves or blood vessels. Incorrect Answers:A. The vastus lateralis is safe for adults because it is thick and away from major blood vessels and nerves. However, according to evidence-based practice, it is not the safest injection site. B. The dorsogluteal site is close to the sciatic nerve, as well as the superior gluteal nerve and artery. Therefore, according to evidence-based practice, it is not the safest injection site. C. The deltoid site is easy to access. However, according to evidence-based practice, it is not the safest site because the muscle is small and sometimes poorly developed. Additionally, it is close to numerous arteries and nerves.

A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take? A. administer aspirin b. tilt the child's head and apply the pressure c. have the child lie down and rest d. apply continuous pressure to the lower part of the child's nose

d. apply continuous pressure to the lower part of the child's nose with the child sitting up and breathing through the mouth, apply continuous pressure with thumb n forefinger to the soft lower area of the nose for 10 min. most bleeding from the nose stops within this period incorrect Aspirin can increase bleeding from the site due to its antithrombotic action tilting head back allows blood to flow down the back of throat, causing nausea lying down increases risk of aspirating blood

https://quizlet.com/305816668/health-assessment-hesi-flash-cards/ https://quizlet.com/240445058/fundamentals-practice-quiz-2-flash-cards/ https://quizlet.com/118516707/ati-questions-unit-1-flash-cards/ https://quizlet.com/425615087/learning-system-rn-30-nursing-care-of-children-final-quiz-flash-cards/ https://quizlet.com/292507760/ati-fundamentals-2-quiz-flash-cards/

https://quizlet.com/245633609/fndmntls-fnl-501-flash-cards/ https://quizlet.com/416902711/fundamentalsf-flash-cards/ https://quizlet.com/224545220/nurse-logic-priority-setting-frameworks-advanced-test-flash-cards/ vvIMP= https://www.easynotecards.com/print_list/99184