Exam 5

A client has received an oil retention enema. The nurse should instruct the client that the enema will take effect within

1. 1 to 3 hours.

The home care nurse is reviewing a list of clients prior to making visits. For which client should the nurse plan interventions to decrease the risk of developing constipation?

1. An adult who is on bed rest

A client with end-stage renal disease knows that he is dying but refuses to talk about it with his spouse. At times the spouse talks with the nursing staff about the clients condition but adamantly refuses to discuss death with the client. What will be the outcomes of this situation?

1. Client has dignity 2. Client has privacy 5. Client burdened with no one to confide in With mutual pretense, the client, family, and health care personnel know that the prognosis is terminal but do not talk about it and make an effort not to raise the subject. Mutual pretense places a heavy burden on the dying person, who then has no one in whom to confide.

The nurse is planning a perioperative clients needs upon discharge. What should be included when determining these needs?

1. Clients abilities to provide self-care 4. Financial resources 5. Need for home health care services Rationale 1: Discharge planning incorporates an assessment of the clients abilities for self-care. Rationale 4: Discharge planning incorporates an assessment of the clients financial resources. Rationale 5: Discharge planning incorporates an assessment of the clients need for home health care.

The nurse determines that a client, after learning of the death of a close family member, is demonstrating normal signs of grief. What did the nurse assess in this client?

1. Crying 3. Inability to sleep 4. No appetite 5. Inability to concentrate on conversations

A clients urine pH is 8.0. What further assessments would be indicated for this client?

1. Intake of fruits and vegetables 5. Symptoms of a urinary tract infection Rationale 1: Alkaline urine might indicate a diet high in fruits and vegetables. Rationale 5: Alkaline urine might indicate a urinary tract infection.

The nurse has removed the sutures from a clients surgical wound. What should the nurse document about this procedure?

1. Number of sutures removed 2. Appearance of the incision 3. Client teaching 4. Client tolerance of the procedure Rationale 1: The nurse should document the number of sutures removed. Rationale 2: The nurse should document the appearance of the incision. Rationale 3: The nurse should document any client teaching.Rationale 4: The nurse should document the clients tolerance of the procedure.

The nurse is preparing to assess a clients fecal elimination status. Which activity will the nurse complete during this assessment?

1. Obtain a nursing history. Rationale 1: Assessment of fecal elimination includes a nursing history and also a review of any data from the clients records.

The nurse is caring for a client who is having surgery and is currently being transported to the operating room suite. The nurse should document that the client is in which operative phase?

1. Preoperative phase Rationale 1: The preoperative phase begins when the decision to have surgery is made and ends when the client is transferred to the operating table.

The nurse who is teaching a client breast self-examination describes inspection of the breasts before a mirror. Which findings should the nurse tell the client should be evaluated by a health care provider?

1. Puckering of the skin 2. Flattening of the breast from the side view 5. Change in shape

The nurse is concerned that a client is at risk for the development of urinary tract infections. What did the nurse assess to come to this conclusion?

1. The client is wearing tight clothing. Rationale 1: Tight-fitting pants or other clothing can cause irritation to the urethra and prevent ventilation of the perineal area, leading to an infection.

The nurse is caring for an 80-year-old client preparing for surgery. The nurse realizes this client is at increased risk for which reason?

1. The physiological deficits of aging increase the surgical risk for older adults. Rationale 1: The older adult has more physiological deficits, such as decreased kidney function and decreased thirst, and is at greater risk for fluid and electrolyte imbalances.

When discussing the orgasmic phase of the sexual response cycle, what should the nurse include as physiological changes that affect both sexes?

1. The respiratory rate can increase up to 40 breaths per minute .2. Involuntary muscle spasms occur throughout the body. 4. Systolic blood pressure can increase 2030 mm Hg above normal. Rationale 1: Physiological changes that affect both sexes during the orgasmic phase of the sexual response cycle include an increase in respiratory rate of up to 40 breaths per minute. Rationale 2: Physiological changes that affect both sexes during the orgasmic phase of the sexual response cycle include involuntary muscle spasms throughout the body. Rationale 4: Physiological changes that affect both sexes during the orgasmic phase of the sexual response cycle include an increase of systolic blood pressure of 2030 mm Hg above normal.

A client in the postanesthesia care unit is to have suction applied through a nasogastric tube. When documenting, the nurse should include which information?

1. The time suction was started 3. Pressure on the suction 5. Color and consistency of drainage Rationale 1: For the nasogastric tube placed to suction, the nurse should document the time suction was started. Rationale 3: For the nasogastric tube placed to suction, the nurse should document the pressure on the suction Rationale 5: For the nasogastric tube placed to suction, the nurse should document the color and consistency of the drainage..

The nurse is planning to conduct a spiritual self-assessment. What questions would the nurse include in this assessment?

1. What makes me joyful? 2. What causes me to feel despair? 4. What is my purpose in life? 5. What feeds my spirit? Rationale 1: What makes me joyful? is a question used for spiritual self-assessment. Rationale 2: What causes me to feel despair? is a question used for spiritual self-assessment. Rationale 4: What is my purpose in life? is a question used for spiritual self-assessment. Rationale 5: What feeds my spirit? is a question used for spiritual self-assessment.

During an assessment, the nurse notes that a client frequently refers to his Native American heritage. The nurse determines that this heritage is a strong part of the clients

1. personal identity. Rationale 1: Self-concept consists of personal identity, body image, role performance, and self-esteem. Personal identity consists of name, sex, age, race, ethnic origin or culture, occupation or roles, talents, and other situational characteristics.

What nursing diagnosis should the nurse select as appropriate to address bowel evacuation for a client who is on bed rest?

2. Constipation Rationale 2: Lack of activity, as in bed rest, is a major contributor to constipation. Lack of movement slows bowel movements.

A client who has just been diagnosed with a slowly progressive terminal illness asks the nurse about the availability of hospice services. What information should the nurse share with this client?

2. Hospice services are generally reserved for those who have a life expectancy of 6 months or less. Rationale 2: Hospice services are generally provided only to those who are expected to live less than 6 months. Those clients whose conditions improve after receiving hospice care may be removed from those services.

While caring for a client who is approaching death, the nurse notices the clients facial expression of extreme sadness. What should the nurse do?

3. Acknowledge the clients expression, and ask whether the client would like to talk about her feelings. Rationale 3: The nurse should establish a communication relationship that shows concern for and commitment to the client. Communication strategies include describing observations and asking whether the client would like to talk about feelings.

The nurse has just inserted a nasogastric tube for gastric suction. What is the most reliable test for confirming tube placement?

3. Aspirate stomach contents and check the acidity using a pH test strip. Rationale 3: Aspirating stomach contents and checking the acidity using a pH test strip is the most reliable test to confirm tube placement.

The nurse is reviewing kidney function with a client experiencing renal failure. Identify the area in the nephron where solutes such as glucose are reabsorbed.

HOTSPOT Solutes such as glucose are reabsorbed in the loop of Henle.

The nurse is caring for the family of a terminally ill client. The family members have been tearful and sad since the diagnosis was given. What is the best nursing diagnosis problem statement for this family?

1. Anticipatory Grieving Rationale 1: Grieving prior to the actual loss is termed anticipatory grieving.

The nurse has completed care with a client who has a new ostomy. What should the nurse document about the care provided?

1. Any change in stoma size 2. Condition of the skin around the stoma 3. Amount and type of drainage 4. Clients response to the procedure

The nurse working in a long-term care facility notices that one of the residents has had a recent decline in self- esteem. What intervention would be appropriate for this resident?

1. Ask the resident for advice in setting up an activity in the dayroom. Rationale 1: Asking the client for advice in setting up an activity in the dayroom validates the clients usefulness and worth.

A client is scheduled for lung resection surgery. What should the nurse keep in mind when determining this clients degree of risk for this major surgical procedure?

1. Age 2. Medications 3. General health 5. Nutritional status

The high school student tells the school nurse that during biology the class learned that alcohol is associated with erectile dysfunction. The student wonders why so many girls get pregnant during evenings when alcohol is consumed. The nurse should plan a response based upon which concept?

1. Alcohol is a central nervous system depressant that affects judgment. Rationale 1: Alcohol is implicated in behaviors leading to undesired pregnancy because it is a central nervous system depressant and affects judgment.

Which characteristic of self-esteem will make it difficult for the nurse to plan interventions for a client?

2. A focus on problems Rationale 2: Clients with low self-esteem often have difficulty identifying strengths and focus more on their limitations and problems.

The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the P section of this format?

3. Acknowledge the clients spoken and unspoken sexual concerns when providing care. Rationale 3: The P section of this format reflects permission giving. This giving of permission refers to acknowledging the clients spoken and unspoken sexual concerns and giving the client permission to be a sexual being.

After reviewing a list of prescribed medications, the nurse plans to complete a sexual history with the client. Which medications in the clients list caused the nurse to make this clinical decision?

3. Cardiotonics 4. Beta-blockers

The nurse is determining a clients level of psychosocial development according to Eriksons stages. Place the developmental tasks in order according to Eriksons stages of psychosocial development.

Choice 1. Expressing ones own opinion Choice 4. Working well with others Choice 3. Asserting independence Choice 2. Guiding others

Which assessment technique will the nurse use first when examining a client with a fecal elimination problem?

Inspection Rationale 2: The nurse will first inspect the clients abdominal region.

The nurse is assessing a clients urinary elimination. Which factor should the nurse keep in mind as influencing this elimination?

1. Age Rationale 1: Development factors such as how old the client is influence urinary elimination.

The nurse is caring for a client with a fecal incontinence pouch. What should the nurse do when caring for this client?

1. Assess perianal skin. 3. Maintain the drainage system. 4. Change the bag every 72 hours. 5. Explain the purpose of the system to the client.

The nurse wants to delegate the application of a condom catheter to unlicensed assistive personnel (UAP). What must the nurse assess prior to delegating this task?

1. Assess whether the client has unique needs. Rationale 1: Applying a condom catheter may be delegated to UAP. However, the nurse must determine whether the specific client has unique needs, such as impaired circulation or latex allergy, that would require special training of the UAP in the use of the condom catheter.

The parent of a 20-month-old is very concerned because the baby touches the genital area during diaper changes. How should the nurse respond to this concern?

1. At 20 months this touching is not a sexual experience. Rationale 1: At 20 months, exploration and touching of the genital area is no different than exploration and touching of fingers and toes. This touching is not considered a sexual experience.

A nurse colleague learns that a grandchilds day-care center is planning a class on sexuality for 3- and 4-year- olds. Discussion of this plan should include what concept?

1. At this age, education regarding sexuality should come from parents. Rationale 1: Although all of these statements are true, the primary consideration is that early childhood education on sex should come primarily from parents.

A client is rushed to the emergency department with what the physicians suspect to be necrosis of the urinary diversion stoma. What evidence presented by the client leads to this conclusion?

1. Black with sloughing Rationale 1: Black color to the stoma and sloughing are signs of necrosis of the stoma.

The nurse is documenting the insertion of a retention catheter for a client. What should be included in this documentation?

1. Catheter size 3. Amount of urine that drained after insertion 5. Client tolerance of the procedure

The family members of a client who has just died want to spend time with the client. What should the nurse do to prepare the client for the family?

1. Check the clients religion to make sure care is in compliance with religious expectations. 2. Remove equipment from the room. .4. Change the linens .5. Place the client in a natural body position. Rationale 1: Because care of the body can be influenced by religious law, the nurse should check the clients religion and make every attempt to comply. Rationale 2: It is important to make the environment as clean and pleasant as possible, so equipment should be removed from the room. . Rationale 4: It is important to make the environment as clean and pleasant as possible, so the linens should be changed. Rationale 5: It is important to make the environment as clean and pleasant as possible, so the clients position should appear natural and comfortable.

During the assessment of a client recovering from surgery, the nurse notes decreased breath sounds in both lower lobes bilaterally. What should the nurse do?

1. Coach the client to deep-breathe and cough. Rationale 1: The reduction of breath sounds could indicate the pooling of secretions in the lower lobes. The nurse should coach the client to deep-breathe and cough.

The nurse is obtaining preoperative assessment data. What should be included in this assessment?

1. Current health status 2. Allergies 3. Current medications 4. Mental status Rationale 1: The clients current health status should be obtained when completing a preoperative assessment. Rationale 2: The clients allergies should be obtained when completing a preoperative assessment.Rationale 3: The clients current medications should be obtained when completing a preoperative assessment. Rationale 4: The clients mental status should be obtained when completing a preoperative assessment.

The nurse is completing a preoperative assessment with a client. What should this assessment include?

1. Current health status 2. Allergies 3. Current medications 4. Mental status Rationale 1: When documenting the current health status, essential information includes general health status and the presence of any chronic diseases that might affect the clients response to surgery or anesthesia. Rationale 2: When documenting allergies, the nurse should include allergies to prescription and nonprescription drugs, food allergies, and allergies to tape, latex, soaps, or antiseptic agents. Rationale 3: All current medications should be listed. Herbal remedies and over-the-counter preparations are also a part of this assessment. Rationale 4: The clients current mental status is a part of this assessment.

A client tells the nurse about the need to get up several times throughout the night to void. The nurse suspects the client is experiencing nocturia due to which factor?

1. Decrease in bladder tone Rationale 1: Nocturia is voiding frequently at night. An increased intake of fluid causes some increase in the frequency of voiding. Conditions such as urinary tract infection (UTI), stress, and pregnancy can cause frequent voiding of small quantities of urine. Total fluid intake and output may be normal.

Which statement should the nurse make first when assessing a clients self-concept?

1. Describe yourself as a person. Rationale 1: The first information the nurse gathers when assessing self-concept should focus on the clients personal identity (Describe yourself as a person).

A client has a spinal cord injury at the cervical spine area. The nurse realizes that this injury will affect which aspect of urinary elimination in the client?

1. Elimination of urine from the bladder Rationale 1: The bladder contains the detrusor muscle, which is responsible for expulsion of urine from the bladder. If the client has a cervical spine injury, muscle function will be affected below the level of the injury, resulting in an impaired ability to eliminate urine from the bladder.

The nurse is assisting a client in setting goals as a strategy to reinforce strengths. What intervention should the nurse employ?

1. Encourage the client to set attainable goals, even if small. Rationale 1: When attempting to reinforce client strengths, it is important to help the client set attainable goals, even if the goals are small at first.

The spouse of a dying client is sitting quietly in the clients room, looking at the floor. What can the nurse do to help the client and spouse during this time?

1. Encourage the spouse to move closer to the client, if desired. 3. Leave the spouse and client in the room alone together as much as possible. 5. Suggest the spouse read to the client, if desired. Rationale 1: The dying and the family must be allowed as much privacy as they desire in order to meet their needs for physical and emotional intimacy. Rationale 5: Family members should be encouraged to participate in the physical care of the dying person as much as they wish to and are able. The nurse can suggest they assist with bathing, speak or read to the client, and hold hands.

A client has occasional bouts of constipation, and asks the nurse what can be done to prevent these episodes in the future. What should the nurse instruct the client to do?

1. Establish a regular exercise regimen. 2. Include high-fiber foods, such as vegetables, fruits, and whole grains, in the diet. 3. Maintain fluid intake of 2000 to 3000 mL a day. 4. Do not ignore the urge to defecate.

The nurse assesses that a client is experiencing spiritual distress. What should be the nurses primary intervention?

1. Establish a trusting nurseclient relationship. Rationale 1: The first step in successfully working with a client with spiritual distress is establishing a trusting nurseclient relationship.

A client is prescribed a saline enema. Because this solution is hypertonic, the nurse would expect the enema to cause which action?

1. Exerts osmotic pressure and draws fluid from the interstitial space into the colon

During a sexual assessment, a client tells the nurse about a preference for oralgenital sex. How should the nurse instruct this client?

1. Explain the need to follow safe sex practices. Rationale 1: Oralgenital sex is not completely free of the potential for sexually transmitted illness transmission, and safe sex practices must be used.

A client is diagnosed with a terminal illness and is demonstrating anxiety. What intervention can the nurse use to help the client at this time?

1. Explore the clients history with other stressful life events and how successful coping was at that time. Rationale 1: It is most helpful for the nurse to know how the client has dealt with previous stressful life events so that support of positive coping mechanisms can occur. The client who has received a terminal diagnosis needs to discuss the future and the implications of the diagnosis.

The nurse and client had set the following expected outcome: At the next clinic visit, the client will report participation in three activities to increase self-esteem. At todays visit, the client is unable to meet the stated outcome. What should be the nurses next action?

1. Explore the possible reasons for not meeting the outcome. Rationale 1: The nurses first action should be to explore possible reasons the outcome was not met.

The nurse is concerned that the spouse of a recently deceased client is experiencing spiritual distress. What did the nurse observe to come to this clinical decision?

1. Expressing anger toward God 5. Refusing comfort from family Rationale 1: Defining characteristics of spiritual distress include expressing anger toward God. Rationale 5: Defining characteristics of spiritual distress include refusing comfort from family.

Which statement made by a new mother would indicate to the nurse that there is potential for lowered self- esteem due to role ambiguity?

1. I dont know if I know how to be a mom. Rationale 1: Role ambiguity occurs when expectations are unclear or a person does not know how to fulfill the role. In this case, the clearest indication of role ambiguity is I dont know if I know how to be a mom.

The nurse suspects that a client is having difficulty with specific self-esteem. Which client statements caused the nurse to have this concern?

1. I hate my hair. 3. My hips are too big. 4. I wish I had that nose job 2 years ago. Rationale 1: Specific self-esteem is how much one approves of a certain part of oneself. The client hating her hair demonstrates an issue with specific self-esteem. Rationale 3: Specific self-esteem is how much one approves of a certain part of oneself. The client stating that her hips are too big demonstrates an issue with specific self-esteem. Rationale 4: Specific self-esteem is how much one approves of a certain part of oneself. The client wishing that a nose job was done 2 years ago demonstrates an issue with specific self-esteem.

The nurse determines that a middle-aged client has developed spiritually. What client statement caused the nurse come to this conclusion?

1. I listen to and learn from others who talk about beliefs in God or a Supreme Being. Rationale 1: The client who listens and learns from others about God or a supreme being is demonstrating openness to others truths, which is a characteristic of spiritual development in middle adulthood.

The nurse is taking care of a client who states that he ignores the urge to defecate when he is at work. Which response should the nurse make to explain why this practice should be changed?

1. If you continue to ignore the urge to defecate, the urge is ultimately lost. Rationale 1: When the normal defecation reflexes are inhibited, these conditioned reflexes tend to be progressively weakened. When the urge to defecate is ignored, water continues to be reabsorbed, making the feces hard and difficult to expel. Ignoring the urge repeatedly will eventually cause the urge to be lost.

When observing an older clients response upon learning of the death of a close family friend, the nurse realizes that the significance of the loss to the client is dependent upon which factors

1. Importance of the person to the client 2. Amount of changes that will occur because of the loss 3. The clients beliefs 4. The clients values Rationale 1: The importance of the lost person to the client affects the significance of the loss. Rationale 2: The degree of change required because of the loss affects the significance of the loss. Rationale 3: The clients beliefs affect the significance of the loss.Rationale 4: The clients values affect the significance of the loss.

The nurse is caring for a client with a urinary diversion. For which type of diversion should the nurse plan care for this client?

1. Incontinent urinary diversion Rationale 1: This is an incontinent urinary diversion (ileal conduit).

The nurse is developing strategies for the relief of menstrual cramping to teach a group of young clients. What should be the focus of these strategies?

1. Increase of blood flow to the uterine muscle Rationale 1: Menstrual cramping is a result of the muscle ischemia that occurs when the client experiences powerful uterine contractions. Increase of blood flow to the uterine muscle through rest, some exercises, application of heat to the abdomen, and presence of milder uterine contractions (such as those associated with orgasm) can decrease pain and cramping.

The nurse is preparing to conduct preoperative teaching. What should be included in this teaching?

1. Information related to what will happen to the client Rationale 1: The nurse should provide information related to what will happen to the client, when, and what the client will experience.

During an assessment, the nurse notes that a clients stool is black. Which medication should the nurse consider as causing this clients change in stool color?

1. Iron 2. Aspirin 5. Pepto-Bismol Rationale 1: Iron salts lead to black stool because of the oxidation of the iron.Rationale 2: Any drug that causes gastrointestinal bleeding, such as aspirin, can cause the stool to be black. Rationale 5: Pepto-Bismol causes stools to be black.

After an assessment, the nurse determines that a client has strong sexual health. What did the nurse assess in the client?

1. Knowledge about sexual behavior 3. Utilization of birth control method that fits lifestyle 5. Discussing sexual problems with healthcare provider Rationale 1: Characteristics of sexual health include knowledge about sexuality and sexual behavior. Rationale 3: Characteristics of sexual health include the right to make free and responsible reproductive choices. Rationale 5: Characteristics of sexual health include the ability to access sexual health care for sexual concerns, problems, and disorders.

The nurse is caring for a client in the immediate postoperative period (PACU). Which intervention should the nurse implement to reduce the risk of thrombophlebitis?

1. Leg exercises Rationale 1: Leg exercises may be implemented in the PACU to help prevent thrombophlebitis.

The nurse is admitting a client to the medical-surgical unit following a cholecystectomy. Which assessment should the nurse perform first?

1. Level of consciousness Rationale 1: The nurse should assess the clients level of consciousness first.

The nurse is instructing a client on ways to manage stress urinary incontinence. What should be included in this clients teaching?

1. Limit intake of caffeine. 2. Limit intake of alcohol. 4. Limit evening fluid intake. Rationale 1: Clients with stress incontinence should be instructed to limit the intake of caffeine. Rationale 2: Clients with stress incontinence should be instructed to limit the intake of alcohol. Rationale 4: Clients with stress incontinence should be instructed to limit evening fluid intake.

The nurse is planning care to help a client work through the grieving process. What would be appropriate to include in this plan of care?

1. Listen to the client. 2. Clarify and reflect the clients feelings. 3. Reassure the client that all will be well.

An older female client with a history of urinary tract infections has an indwelling urinary catheter. What should the nurse do to reduce this clients risk of developing an infection because of the catheter?

1. Maintain a sterile closed drainage system. 3. Ensure the catheter and tubing are not kinked. 4. Wash his or her hands before manipulating the catheter. 5. Keep the collection bag below the level of the bladder.

The nurse has identified the goals of maintaining client safety and homeostasis during the intraoperative phase of client care. What nursing activities would support these goals?

1. Maintain the sterile field. 2. Perform instrument counts. 4. Position the client appropriately for surgery. 5. Perform preoperative skin preparation. Rationale 1: Maintaining the sterile field will support the goals of maintaining client safety and homeostasis. Rationale 2: Performing instrument counts will support the goals of maintaining client safety and homeostasis. Rationale 4: Positioning the client appropriately for surgery will support the goals of maintaining client safety and homeostasis. Rationale 5: Performing preoperative skin preparation will support the goals of maintaining client safety and homeostasis.

The nurse is preparing to complete a physical assessment before surgery. Which assessments should the nurse obtain?

1. Mini mental status 2. Assessment of hearing 3. Assessment of the respiratory system 4. Gastrointestinal assessment Rationale 1: A brief or mini mental status examination provides valuable baseline data for evaluating the clients mental status and alertness after surgery. It is also important to evaluate the clients ability to understand what is happening. Rationale 2: Assessment of hearing helps guide the effectiveness of perioperative teaching.Rationale 3: Respiratory assessment not only provides baseline data for evaluating the clients postoperative status but may alert care providers to a problem that may affect the clients response to surgery and anesthesia. Rationale 4: The gastrointestinal status provides baseline data.

The nurse is teaching a class of young adult men and women. What self-examination schedules should the nurse instruct these participants to follow?

1. Monthly breast self-exams for women 4. Monthly breast self-exams for men

An older client tells the nurse that in order to have a daily bowel movement, the client uses laxatives most days of the week. What should the nurse tell this client?

1. Normal patterns of elimination are different for everyone. 2. Increase fiber intake to 2035 grams a day. 3. Engage in enjoyable exercise. 5. Drink six to eight glasses of fluid daily.

The nurse is preparing educational materials to be used when instructing clients on testicular and breast self- examination. What would be applicable for both sets of instructions?

1. Perform palpation in the shower. Rationale 1: One optional method to palpate the breasts is to perform the self-examination in the shower. For the testicular self-examination, the examination should be done in the bath or the shower.

The nurse is preparing a 23-year-old female client for surgery. The nurse should anticipate which diagnostic test to be prescribed for this client?

1. Pregnancy test Rationale 1: A pregnancy test is done on all female clients of childbearing age.

The nurse is delegating activities regarding fecal elimination to unlicensed assistive personnel (UAP). Which activity can UAP safely perform to meet a clients fecal elimination needs?

1. Provide a fracture pan to a client on bed rest.

The nurse is preparing to assess a clients sexual health. What will the nurse include in this assessment?

1. Sexual self-concept 2. Body image 3. Gender identity Rationale 1: Sexual self-concept is a component of sexual health.Rationale 2: Body image is a component of sexual health.Rationale 3: Gender identity is a component of sexual health.

A client recovering from back surgery is seen crying softly in bed. Upon assessment, the nurse learns that the client has been told of the future inability to perform certain sports, activities, and employment types because of the surgery. The nurse interprets this clients reaction as a response to which type of loss?

1. Situational loss Rationale 1: The loss of functional ability because of acute illness or injury is a situational loss.

A client who is devoutly Jewish is hospitalized during Yom Kippur, a time when many of the Jewish faith fast. The client expresses a desire to follow this religious pattern. How should the nurse respond to this wish?

1. Support the clients desires to the extent possible. Rationale 1: The nurse should support the clients desires to the extent possible.

A nursing student has just received an evaluation that indicates difficulties with time management and prioritization in the care of clients. How should the student react to this input?

1. Take the feedback seriously and use it to guide personal growth. Rationale 1: The student should take the feedback seriously and use it to guide personal growth. Issues with time management and prioritization are common with students and should be addressed. The student should introspectively look at the situation and use it for growth.

The nurse is caring for a child who is dying. What is the most important communication strategy for the nurse to use at this time?

1. Talk to the child at the appropriate level of understanding. Rationale 1: Although it is very important to be open and honest with the child and may be appropriate to encourage the family to talk with the child about impending death, the most important strategy is to talk with the child at the appropriate level of understanding. Without recognition of this concept, none of the other options will be effective. The nurse should not avoid discussing death with the child if the child brings up the subject.

A client asks the nurse why expelled flatus is foul-smelling. What should the nurse respond?

1. The actions of microorganisms within the gastrointestinal tract are responsible for the odor .

The nurse is determining whether interventions to address the diagnosis of Spiritual Distress for a client newly diagnosed with a chronic illness have been effective. What outcome would indicate that interventions have been effective for this client?

1. The client has talked with the church priest twice during the hospitalization. Rationale 1: Evidence that interventions to address the diagnosis of Spiritual Distress have been effective would be the clients talking with the church priest, as evidence of spiritual health is connecting with a spiritual leader.

An adult client who has been a successful writer in the past has been experiencing low self-esteem over the last year. Which behaviors indicate that the client is attempting to make positive changes?

1. The client joined a library book club. 3. The client states that she no longer reads Facebook to compare her life with her friends lives. 4. The client works with the local Wheels on Meals to deliver meals once a week to older community members. 5. The client shared a letter from a magazine publisher that is going to print her short story in the next edition. Rationale 1: Joining a book club demonstrates spending time with positive supportive people. Rationale 3: Avoiding comparisons with other people helps develop self-esteem. Rationale 4: Helping others will help develop the clients self-esteem.Rationale 5: Having success will help develop the clients self-esteem

The nurse determines that a clients fecal elimination is pale in color. This finding supports which client behavior obtained during the health history?

1. The client rarely eats animal protein, and ingests milk and cheese at several meals each day. Rationale 1: Stool that is pale in color is seen in those who ingest a diet high in milk and milk products and low in meat.

Which goals should the nurse identify as appropriate for a client with the nursing diagnosis Urinary Pattern Alteration related to an enlarged prostate?

1. The client will avoid bladder distention. Rationale 1: Avoiding bladder distention will help eliminate stasis of urine in the bladder, which contributes to urinary tract infections, a possible complication of urine flow being obstructed from an enlarged prostate.

A rare malignancy will require the amputation of an adolescent clients leg. The client refuses the surgery, stating: I would rather die than have my leg amputated. What information should the nurse use to plan future interventions for this client?

1. The knowledge that adolescents are very concerned about body image Rationale 1: Adolescents are very concerned about body image and will make decisions based upon peer or media opinion even if it puts their health at risk. The nurses further interventions should be planned with this thought in mind.

The nurse has identified that many of the clients in the long-term care facility have spiritual concerns and distress. What is the nurses first step in becoming a competent provider for these clients?

1. The nurse must possess a healthy spiritual self-awareness. Rationale 1: The first step of becoming a competent provider for clients who have spiritual distress is for the nurse to possess a healthy spiritual self-awareness.

A client recovering from surgery asks the nurse why turning, deep breathing, and coughing exercises need to be done. What should the nurse respond?

1. These exercises help prevent pneumonia. Rationale 1: By increasing lung expansion and preventing accumulation of secretions, deep breathing helps prevent pneumonia and atelectasis.

A research article the nurse is reading discusses the prevalence of androgyny in persons 20 to 30 years old. What should the nurse keep in mind when caring for clients who are androgynous?

1. They do not limit behaviors to one gender over the other. Rationale 1: Androgyny means flexibility in gender roles. Androgynous individuals do not limit behaviors to one gender over another.

The nurse is preparing to instruct a client on leg exercises to be used when recovering from abdominal surgery. What should the nurse determine before beginning this teaching?

1. Type of surgery 2. Time of surgery 4. Preoperative orders 5. Name of the surgeon

A client is complaining of pain with urination. The nurse realizes that the client needs to be assessed for which health problems?

1. Urethral stricture 3. Urethral injury 4. Bladder injury 5. Urinary infection

The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the SS section of this format?

1. Use the nurses knowledge about how disease affects sexuality to offer specific suggestions for the client. Rationale 1: SS represents specific suggestions. The nurse should use specialized knowledge and skill about how sexuality and functioning are affected by the disease process or therapy to offer specific suggestions for intervention.

A client who has AIDS tells the nurse, I dont know why I should even keep trying. This disease is so horrible and so many people die from it. It will get me, too. The nurse recognizes this statement as being

1. an indication of hopelessness that should be further evaluated for treatment. Rationale 1: This statement reflects hopelessness. Hopelessness is not an expected feeling at end of life and can and should be treated. Despite the inevitability of death, the goal is for the client to continue to express hope of some nature. This hope might take the form of short-term completion of goals prior to death, for peacefulness at the time of death, or for attainment of the individuals personal belief about the afterlife.

The nurse is concerned that a client is experiencing complicated grieving after the unexpected death of a son. The nurse most likely assessed

1. the clients denying the sons death. 2. depression. 3. sudden weight loss because of not eating. 5. verbalizing the desire to not live anymore.

The emergency department nurse contacts the admissions office to request a bed for a bed-bound client who is a practicing Muslim. In acting as an advocate for the client, what request should the nurse make of the admission clerk?

2. A bed that faces east will be best. Rationale 2: Because this bed-bound client is a practicing Muslim and this religion has a sacred practice of five daily prayers performed while facing east, the logical bed assignment for this client is one that faces east.

A young adult single mother of a second-grade child has to make a decision regarding the teacher her child will have in third grade and asks the nurse for advice. All other variables being equal, which choice is best?

2. A man who is 40 years old Rationale 2: If all other variables are equal, the best choice is the 40-year-old male, as this child needs role modeling from both females (the mother) and males (this teacher).

The nurse has completed closed irrigation of a clients retention catheter. What specific information should the nurse document about this procedure?

2. Abnormal drainage, such as blood clots, pus, or mucous shreds

The nurse is conducting a sexual health history with a client. What questions should the nurse ask during this history?

2. Are you currently sexually active? 3. Do you experience any pain with sexual interaction? 4. Do you have difficulty with sexual desire? Rationale 2: Asking whether the client is sexually active is appropriate for the nurse. Rationale 3: Asking whether the client has any pain with sexual interaction is appropriate . Rationale 4: Asking whether the client has any difficulty with sexual desire is appropriate

The family of a dying client has informed the nurse that their religion requires that a ritual bath be given by members of the faith after death. Because the hospital unit is very busy and there is an acute need for every bed, how should the nurse respond to this request?

2. Arrange for supplies and privacy for the family. Rationale 2: When a client is dying, much of the nursing care shifts from the client to support of the family. The nurse should allow this bath and should provide supplies and privacy for the family to complete the ritual.

During labor, it becomes apparent that the male infant will survive only a short time after birth. Because this babys parents are Catholic, what planning should the nurse consider?

2. Ask the hospital chaplain to be present in the delivery room. Rationale 2: In this situation, the best choice is to have the hospital chaplain present in the delivery room.

During a routine physical, an 11-year-old tells the nurse that many students in school are doing it. How should the nurse respond to this statement?

2. Ask what doing it means to this client. Rationale 2: The nurse should ask what doing it means to this 11-year-old client. It is important that the nurse and the client are talking about the same thing before additional information is shared.

The nurse is preparing to apply antiembolic stockings to a postoperative client. What should be done first, before applying the stockings?

2. Assess for circulatory problems. Rationale 2: Before applying antiembolic stockings, determine any potential or present circulatory problems and the surgeons orders involving the lower extremities.

The daughters of an 80-year-old man who is aphasic after suffering a cerebrovascular accident (stroke) express concern that their father is always exposing and playing with himself and his catheter while they are in the room. Upon assessment, the nurse finds the client pulling on and rubbing his penis. What is the nurses priority action?

2. Assess the clients penis for irritation from the catheter. Rationale 2: The nurse should assess whether this client has irritation of the penis that is causing his actions. The nurse needs to determine if there is a physical reason such as irritation that the client is trying to communicate.

The nurse is planning care for a client during the postoperative period. What should the nurse identify as the goal of care for this client?

2. Assist the client to achieve the most optimal health status possible. Rationale 2: The goal of postoperative care is to assist the client to achieve the most optimal health status possible.

A hospitalized client tells the nurse of the inability to have a bowel movement because too many people are around. What should the nurse do to promote normal fecal elimination for this client?

2. Assist the client to the bathroom to ensure privacy. Rationale 2: Privacy during defecation is extremely important to many people. The nurse should therefore provide as much privacy as possible for such clients, but might need to stay with those who are too weak to be left alone.

While administering an enema, the client complains of abdominal cramping. What should the nurse do?

2. Clamp the flow for 30 seconds, and restart at a slower rate. Rationale 2: If the client complains of fullness or pain, lower the container or use the clamp to stop the flow for 30 seconds, and then restart the flow at a slower rate. Administering the enema slowly and stopping the flow momentarily decreases the likelihood of intestinal spasm and premature ejection of the solution.

The nurse suspects that a client is experiencing compromised gastrointestinal function. What assessment data did the nurse use to make this clinical decision?

2. Clay-colored stool Rationale 2: Clay-colored stools would be an indication of a problem in the GI tract. Clay color is a sign of the absence of bile pigment (bile obstruction).

The nurse is caring for the stoma of a client who has a colostomy. Which action is the most appropriate?

2. Clean the stoma and pat dry.

During the assessment interview, the client is quiet and answers questions only minimally. What action should the nurse take about the clients reluctance to share information?

2. Consider any cultural implications of these actions. Rationale 2: The nurse should always consider that there could be a cultural implication of behavior.

The nurse determines that an adult clients feces are normal. What did the nurse assess to come to this conclusion?

2. Cylindrical in shape because it takes the shape of the rectum.

The client tells the nurse, I dont know what to do. The treatment plan my physician has suggested is against some of my religious beliefs. What nursing diagnosis problem statement should the nurse identify as appropriate for this client?

2. Decisional Conflict Rationale 2: For this situation, the best nursing diagnosis problem statement is Decisional Conflict. This client will be called upon to make a decision between two highly regarded but conflicting plans.

Which nursing intervention would be helpful when caring for a client who has negative self-esteem?

2. Design a series of small successes for the client. Rationale 2: Clients who have negative self-esteem may have a history of failures and disappointments. Designing a series of small successes for the client will help foster a more positive attitude.

A client is having issues with urinary elimination. What should the nurse instruct this client to promote urinary elimination?

2. Drink 8 to 10 glasses of water daily Rationale 2: Drinking 8 to 10 glasses of water daily will encourage the need for bladder emptying, keeping the system flushed..

The nurse is assessing an abdominal wound in the postoperative period. Which sign should indicate to the nurse that an infection is present?

2. Edges warm to the touch Rationale 2: If the wound becomes warm, red, and edematous, the nurse should suspect an infection and notify the physician.

The female client has experienced recurrent candidiasis with intense vaginal itching and excoriation. After treatment the client is reexamined, and the nurse practitioner finds presence of a white, cheesy discharge. What recommendation is necessary?

2. Examination and treatment of sexual partner Rationale 2: Candidiasis is a sexually transmitted infection. It may be that this womans sexual partner is also infected with candidiasis and that the couple is transmitting the infection between them.

The family of a young adult client who has recently been diagnosed with a rapidly progressing terminal illness tells the nurse, This cannot be happening. There must be some mistake in the testing. What should be the nurses first step in assisting this family?

2. Examine the nurses own feelings to ensure denial is not shared. Rationale 2: The nurse must first self-examine feelings to ensure that the nurses behaviors do not demonstrate denial of the situation.

An older client has just relocated from home to an assisted living facility. The nurse is concerned because the client has been withdrawn and is crying periodically throughout the day. What type of loss is this client demonstrating?

2. Familiar environment Rationale 2: Separation from an environment and people who provide security can result in a sense of loss, such as in the client who has relocated from home to an assisted living facility.

The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the LI section of this format?

2. Give the client accurate but concise information in regard to any sexual questions that might be asked. Rationale 2: LI represents limited information. The nurse should give accurate but concise information regarding sexual matters.

A client experiencing hard, dry feces is scheduled for an enema. The nurse recognizes that what type of solution would be best for the client?

2. Hypotonic 5. Isotonic Rationale 2: Hypotonic enema solutions soften the feces. Rationale 5: Isotonic enema solutions soften the feces.

The nurse is working with a father and his three children, ages 10, 14, and 17. The mother recently died after a long illness. The children are doing poorly in school, and the father is having a difficult time keeping up with household chores. He has recently taken on a second job to help pay his late wifes hospital bills. Which nursing diagnoses should the nurse consider in planning care for this family?

2. Impaired Family Processes 3. Impaired Adjustment 4. Caregiver Role Strain 5. Hopelessness There may be numerous nursing diagnoses that should be investigated in planning care for this grieving family. This list may not be all inclusive, as problems with sleep, nutrition, self-concept, and role adjustment are common following the long illness and death of a loved one.

The nurse should incorporate which instructions into the teaching plan for a client with a urinary diversion?

2. Increase fluid intake Rationale 2: Increasing the fluid intake helps to flush out sediment and mucus and prevents clogging of the stoma..

A client tells the nurse that her spouse expects the client to maintain the home and children as well as have a job to help with household expenses. The client is demonstrating fatigue and inadequacy. The nurse identifies which nursing diagnosis as appropriate for the client at this time?

2. Ineffective Role Performance Rationale 2: The client has many role expectations that could be in conflict. The client is expected to maintain the home, care for the family, and earn money. The clients symptoms of fatigue and inadequacy indicate Ineffective Role Performance.

A client recovering from a transurethral resection of the prostate (TURP) with a three-way indwelling catheter expresses the need to urinate. Which action should the nurse take to help this client?

2. Irrigate the catheter. Rationale 2: Blood clots give the client the sensation to urinate when they obstruct the urine outflow; therefore, irrigation will have to remedy the problem.

The nurse caring for wheelchair-dependent residents of a long-term care environment has developed a care plan that includes taking the clients outside and assisting them in planting and maintaining a garden. What is the best rationale for this plan?

2. Keeping in touch with nature is a form of spiritual care. Rationale 2: Keeping in touch with nature is a form of spiritual care for these residents.

A client has been admitted with incontinence. What should the nurse expect to assess in this client?

2. Leakage of urine occurs when client laughs. Rationale 2: Incontinence involves a small leakage of urine when a client laughs.

A client is prescribed to receive a cleansing enema. What should the nurse instruct the client prior to administering this enema?

2. Lie in the left lateral position. Rationale 2: The client lies in the left lateral position in order to clean the rectum and sigmoid.

The nurse is caring for a 5-year-old child. How can the nurse best support the spiritual development of this client?

2. Listen to the childs routine bedtime prayer. Rationale 2: The nurse should support the routine spiritual practices encouraged by the family. If the client says routine bedtime prayers, the nurse can support this practice by listening to the prayer.

After eating dinner, a client asks for help to get to the bathroom because of an extreme urge to defecate. The nurse realizes that the client has experienced which physiological function of the colon?

2. Mass peristalsis Rationale 2: Mass peristalsis involves a wave of powerful muscular contraction that moves over large areas of the colon. Mass peristalsis most commonly occurs after eating, stimulated by the presence of food in the stomach and small intestine. In adults, mass peristaltic waves occur only a few times a day.

As a part of care planning, the nurse considers the clients spiritual needs. What is the rationale for this concern?

2. Meeting the clients spiritual needs can decrease suffering. Rationale 2: The nurse is concerned about the clients spiritual health because meeting spiritual needs can decrease suffering.

While the nurse is measuring blood pressure, the client lifts his hand and fondles the nurses breast. What should the nurse do about this behavior?

2. Move the clients hand away. 3. Refocus the client on appropriate behavior. 4. Tell the client to stop performing the behavior. 5. Communicate that the behavior is not acceptable.

A client hospitalized for injuries from a motor vehicle crash is diagnosed with higher brain death. What findings support this clients diagnosis?

2. No cephalic reflexes 3. Not breathing spontaneously 5. Electroencephalogram showed no activity for 30 minutes Rationale 3: Evidence of higher brain death includes apnea. Rationale 5: Evidence of higher brain death includes absence of cephalic reflexes, apnea, and an isoelectric electroencephalogram for at least 30 minutes.

The nurse critically evaluates various models of grief used for terminally ill clients and their families. What should the nurse recognize when applying these models to individual cases?

2. No clear timetables exist, nor are there clear-cut stages of grief. Rationale 2: Although the models of grief are useful in guiding nursing care of clients who are experiencing loss, there are no clear-cut stages of grief, nor are there exact timetables.

A client is prescribed propranolol (Inderal). What should the nurse instruct the client about this medication?

2. Notify the physician if you experience urinary retention. Rationale 2: A beta-adrenergic blocker such as propranolol can cause urinary retention; therefore, it would be of the utmost importance to notify the physician.

The nurse is providing postmortem care for a client whose family would like to view the body before it is transported to the morgue. What interventions are necessary for this preparation?

2. Place absorbent pads beneath the body. 5. Place a pillow under the head.

The nurse is preparing a 6-year-old child for a tonsillectomy. Which strategy should the nurse use for teaching this client?

2. Play Rationale 2: Play is an effective teaching tool with children.

A client is anxious about receiving general anesthesia for a surgical procedure. What should the nurse explain are the advantages of having this type of anesthesia?

2. Respiratory rate can be regulated easily. 4. The anesthesia can be adjusted to the length of the operation. Rationale 2: An advantage of general anesthesia is that the respiratory rate can be regulated easily. Rationale 4: An advantage of general anesthesia is that the anesthesia can be adjusted to the length of the procedure.

The nurse is preparing a care plan for a client about to undergo surgery. Which nursing diagnosis would take priority during the intraoperative phase of surgery?

2. Risk for Aspiration Rationale 2: This is the priority nursing diagnosis for the client having surgery. The risk for aspiration would impact the clients airway and breathing.

Which nursing diagnosis would be appropriate for a client who has a retention catheter if the drainage bag is found lying on the floor?

2. Risk for Infection related to improper handling Rationale 2: The floor is the dirtiest place, so the drainage device should never be placed on the floor.

The nurse enters the room and finds the adult client masturbating. What action should the nurse take?

2. Say excuse me and leave the room.

The spouse tells the nurse that the client is not making progress in developing a more positive self-esteem. What should the nurse respond to the spouse?

2. Self-esteem work takes time and is not easily evaluated. Rationale 2: It would be appropriate to respond that self-esteem work takes time and that improvement is sometimes not easy to evaluate.

The nurse is caring for an older client with end-stage renal disease. What actions should the nurse take to support this clients spiritual development?

2. Suggest the client view losses as liberations. 3. Encourage the client to reminisce about life events. 4. Ask open-ended questions about the clients life purpose. Rationale 2: A nursing action to support the older clients spiritual development includes supporting the client to reframe losses of aging as liberations. Rationale 3: A nursing action to support the older clients spiritual development includes encouraging the client to conduct a life review or reminisce. Rationale 4: A nursing action to support the older clients spiritual development includes asking open-ended questions to encourage open discussion about the clients life.

A client asks the RN why it is more difficult to use a bedpan for defecating than sitting on the toilet. Which would be the nurses best response?

2. The sitting position increases the downward pressure on the rectum, making it easier to pass stool. Rationale 2: Normal defecation is facilitated by thigh flexion, which increases the pressure within the abdomen, and a sitting position, which increases the downward pressure on the rectum.

In discussion with teenagers, the nurse chooses to use the term sexually transmitted infection rather than sexually transmitted disease. What is the rationale for this choice?

2. The word disease may elicit guilt, shame, and fear in the client. Rationale 2: The term sexually transmitted disease can elicit guilt, shame, and fear in the client.

The nurse is discussing the resolution phase of the sexual response cycle with a group of students in a health education class. What should be included as a physiological change that affects males only?

2. There is a refractory period during which the body will not respond to sexual stimulation Rationale 2: During the resolution phase of the sexual response cycle, the physiological change that affects males only is a refractory period during which the body will not respond to sexual stimulation..

The parents tell the nurse that their preschooler demands to wear specific clothing. They are concerned that the day-care workers might think they are negligent because the preschooler often wears mismatched clothing. What should be the nurses response to this concern?

2. This is normal and the preschooler is just practicing skills needed later in life Rationale 2: The nurse should accept that the parents are concerned and then tell them that this is normal behavior at this age. Preschoolers often begin to exert independence and to practice picking out clothing, cooking with play toys, and parenting dolls.

A client has received a return-flow enema. What should the nurse document about this procedure?

2. Type of solution. 3. Length of time the solution was retained. 4. The amount, color, and consistency of the return. 5. Client relief of flatus and abdominal distention.

The nurse is providing emotional support to a client who just learned the outcome of a biopsy. What actions will be the best for the nurse to provide at this time?

2. Use therapeutic communication techniques. 3. Offer choices that promote client autonomy. 4. Provide information about community resources or support groups. 5. Acknowledge the grief of the client. Rationale 2: Therapeutic communication techniques let the client know that the nurse acknowledges the clients feelings. Rationale 3: Offering choices that promote autonomy helps the client have a sense of some control at a time when much control might not be possible. Rationale 4: Providing information about community resources or support groups provides the client with sources of additional information. Rationale 5: Acknowledging the grief of the client is helpful when providing emotional support.

The nurse is planning to remove the sutures from a clients surgical wound. What should the nurse do before removing the sutures?

2. Verify the order for suture removal. 4. Read the order to determine whether a dressing is to be applied after removal. 5. Remove the dressing and clean the incision. Rationale 2: Before removing skin sutures, the nurse should verify that there is an order for suture removal. Rationale 4: Before removing skin sutures, the nurse should verify whether a dressing is to be applied following the suture removal. Rationale 5: Before removing skin sutures, the nurse should remove the dressing and clean the incision.

The nurse is planning to assess a clients family relationships. What questions should the nurse ask to obtain this information?

2. What is your home like? 4. How well do you feel you accomplish what is expected of you? Rationale 2: The question What is your home like? is an appropriate question for the nurse to ask to assess a clients family relationships. Rationale 4: The question How well do you feel you accomplish what is expected of you? is an appropriate question for the nurse to ask to assess a clients family relationships.

The 70-year-old client with terminal lung cancer tells the nurse, I am dying because I sinned by smoking cigarettes. What is the nurses best response to this dying client?

2. When you started smoking cigarettes we didnt know about the problems they cause. It is not your fault. Rationale 2: This client is in distress and is seeking forgiveness. The nurse should offer this forgiveness and a reason the forgiveness is valid.

A client who has recently lost 75 pounds continues to dress in loose, baggy clothing and frequently talks about being fat. The nurse realizes this finding most likely indicates

2. body image disturbance. Rationale 2: The most likely interpretation of this finding is that the client continues to see himself as fat, which is a body image disturbance.

A client has a bowel movement of hard, dry, but formed stool. The nurse associates these characteristics with

2. constipation.

The nurse is performing urinary catheterization for a client. After using the nondominant hand to separate the clients labia for cleansing, the nurse will maintain this hand as being

2. contaminated. Rationale 2: When performing urinary catheterization, the nondominant hand is considered contaminated once it touches the clients skin.

The mother of a 5-year-old tells the nurse that her daughter has always been closer to her than to her husband. The mother expresses concern that, over the last 2 months, the little girl wants to spend all of her time with her father instead of with the mother. The nurse recognizes that this behavior

2. is a normal expectation of a preschooler developing sexuality. Rationale 2: A part of the normal sexual development of a preschooler is a time in which the child focuses love on the parent of the other gender. The same-gender parent may feel excluded during this time, but can be assured that the behavior is normal.

The nurse is discussing different types of ostomy appliances with a client with a new ostomy. During this discussion, the nurse should keep in mind that an ostomy appliance should

2. protect the skin. 3. collect stool. 4. control odor.

The client states, I dont know what all this fuss is about religion. God died years ago. The nurse does believe in God and has a strong inclination to share reasons for that belief with the client. What is the best question for the nurse to consider before responding to the clients remark?

3. Am I meeting my needs or the clients? Rationale 3: The nurse should first determine if it is the nurses needs or the clients needs that would be met by a response. Only after that determination is made would the nurse move on to the other questions in formulating the response.

The nurse realizes that which client is at risk for difficulty in urinary elimination?

3. An 80-year-old male reporting frequent urination at night Rationale 3: The client who is 80 years old with frequent urination at night is having problems with his prostate. Older male adults experience urinary retention due to prostate enlargement causing an alteration in urinary elimination.

A client is concerned because he was unable to achieve an erection during his last sexual encounter with his wife. He tells the nurse that he has worried about becoming impotent because he had a sexually transmitted infection as a young adult. What is the nurses best response to this clients concerns?

3. An occasional incident like this is normal and common and there is no reason to be concerned. Rationale 3: This client is concerned about his masculinity and sexual abilities. The correct answer at this point is to tell him that it is common and normal for men to experience occasional erectile difficulties.

During assessment, the client says that it has been a long time since she has thought very much about religion. The nurse caring for this client has a strong belief in God and the healing power of prayer. What action should be taken by the nurse?

3. Ask the client if there are any spiritual needs with which the staff can assist. Rationale 3: The client can be asked general questions to elicit information about what beliefs and practices are important to the present health care situation, and what, if anything, the client would like from the health care team to support spiritual health.

The nurse is counseling a family in which a member is terminally ill. The family has children of varying ages. What should the nurse teach the family about the reactions of children to death?

3. At about age 9, children begin to understand that death is inevitable. Rationale 3: At about age 9, childrens concept of death matures and most understand that death is an inevitable part of life.

A client experienced female circumcision as a puberty ritual while living in Africa as a child. For which health problem should the nurse monitor the client as an adult?

3. Chronic urinary tract infection Rationale 3: Female circumcision increases the possibility that the client will suffer chronic urinary tract infection.

The 15-year-old female tells the nurse that she makes her boyfriend stop intercourse before she has an orgasm so she will not get pregnant. What teaching is necessary for this client?

3. Conceiving is not related to whether or not the female partner experiences an orgasm.' Rationale 3: Conceiving is not related to experiencing orgasm.

The nurse is concerned that an older client with a retention catheter is developing a urinary tract infection. What assessment finding caused this concern?

3. Confusion Rationale 3: In the older client, confusion can be an early sign of urinary tract infection.

A client is diagnosed with an elevated aldosterone level. The nurse realizes that this finding will affect what aspect of urinary elimination?

3. Decreased urine output Rationale 3: When aldosterone is released from the adrenal cortex, sodium and water are reabsorbed in greater quantities, increasing the blood volume and decreasing urinary output.

The client tells the nurse that she has been having problems sleeping since her boss died unexpectedly 3 weeks ago. She confides that she and the boss had been having a secret extramarital affair for years. The nurse recognizes that the sleeping difficulty is most likely a result of which type of grief?

3. Disenfranchised Rationale 3: This client is unable to grieve openly for her lost relationship, as extramarital affairs are not socially sanctioned.

The nurse has developed a strong rapport with a client whose medical care necessitates transfusion of multiple units of blood. The client has a religious objection to this treatment even though it is necessary to sustain life. What action should the nurse take?

3. Encourage the client, the physician, and the clients spiritual adviser to discuss this conflict and any possible alternative therapies. Rationale 3: This is a delicate situation for a nurse who has developed a rapport and relationship with a client. The best response is to support the discussion between client, physician, and spiritual adviser. At that point, the nurse must be prepared to support whatever decision the client makes, even if it is to not permit the transfusions

The nurse is preparing an educational session on the sexual response cycle. What should be included when discussing the physiological changes in females during the excitement phase?

3. Erection of the clitoris occurs. 4. The breasts enlarge. 5. The uterus elevates. Rationale 3: Physiological changes in females during the excitement phase of the sexual response cycle include erection of the clitoris. Rationale 4: Physiological changes in females during the excitement phase of the sexual response cycle include enlargement of the breasts. Rationale 5: Physiological changes in females during the excitement phase of the sexual response cycle include elevation of the uterus.

The nurse is preparing for pelvic physical examination of a woman who has been medically diagnosed with vaginismus. What equipment should the nurse obtain for this examination?

3. Smaller-than-normal vaginal speculums Rationale 3: Clients with vaginismus experience involuntary spasm of the outer one-third of the vaginal muscles. This spasm makes internal examination, tampon use, and intercourse difficult. Use of smaller-than- normal vaginal speculums may make examination easier.

The nurse is engaging in an activity to develop spiritual self-awareness. What activities can aid the nurse in achieving this goal?

3. Explore personal end-of-life issues. 4. Create a personal loss history. 5. List significant values. Rationale 3: Exploring personal end-of-life issues is a strategy to develop spiritual self-awareness. Rationale 4: Creating a personal loss history is a strategy to develop spiritual self-awareness. Rationale 5: Listing significant values is a strategy to develop spiritual self-awareness.

A client recovering from a lumpectomy for breast cancer tells the nurse that she feels ugly. For which nursing diagnosis should the nurse plan interventions?

3. Grieving Rationale 3: The diagnosis Grieving is appropriate, because the client is expressing a feeling related to a change in physical appearance.

Which statement made by a postmenopausal client should the nurse evaluate as indicating the need for further assessment?

3. I am so glad that I dont need to worry about sex anymore. Rationale 3: The nurse would further assess the client who made the statement, I am so glad that I dont need to worry about sex anymore. This statement is unclear. Does it mean that the client is glad not to have to engage in sex anymore, or does it mean that she will not have to worry about getting pregnant anymore?

The 45-year-old client reports that she has no interest in sex and that she and her husband have not had intercourse in 16 years. How should the nurse interpret this assessment data?

3. If both partners share the same lack of desire, there is often not a problem. Rationale 3: If both members of a couple have the same lack of desire and they are comfortable, there is likely no problem with the couples sexuality.

A client has a history of an inconsistent fecal elimination pattern. What should the nurse instruct this client to improve this health problem?

3. Include more whole grains in the diet. Rationale 3: Eating more whole grains will increase fiber in the diet, which increases bulk and volume.

The nurse is caring for a client on the postoperative unit. Which nursing diagnosis is the priority for this client?

3. Ineffective Airway Clearance Rationale 3: When prioritizing, the nurse should remember the ABCs. Airway should always be the priority.

The client has a documented advance health care directive that indicates that no resuscitative measures should be employed in the event of a respiratory or cardiac arrest. The client begins to exhibit severe dyspnea and air hunger and says, Please do something, I cant breathe. What action should be taken by the nurse?

3. Initiate resuscitative measures. Rationale 3: This client has the right to change decisions about resuscitation, and has asked for help. The nurse should initiate resuscitative measures.

Which intervention would the nurse plan to help a client prevent a urinary tract infection?

3. Instruct the client to empty the bladder completely. Rationale 3: Completely emptying the bladder prevents stasis of urine, which would contribute to a urinary tract infection.

The newly hired nurse notices that coworkers routinely pray with clients and their families. The nurse has never been particularly religious or spiritual and is unaccustomed to praying, but holds no strong feeling against prayer. What is the best strategy for the nurse to plan for such situations?

3. Memorize two or three short, formal prayers to use when prayer is requested. Rationale 3: Because this nurse has no objection to praying with clients and families, the best plan is to have two or three short, formal prayers or verses memorized to use when prayer is suggested.

Which statement, made by the client, would indicate a me-centered self-concept?

3. My future is based on the decisions I make today. Rationale 3: Individuals with a positive self-concept are me-centered and value how they perceive themselves over the opinions of others and have learned to depend on themselves. This is reflected in the statement, My future is based on the decisions I make today.

The staff development instructor planning self-concept development classes for staff nurses is going to include information to improve the nurses self-concept along with information to use with clients. Why is the information for nurses important?

3. Nurses with positive self-concept are better able to help clients. Rationale 3: Nurses who have positive self-concept are better prepared to assist clients with their own understanding of needs, desires, feelings, and conflicts

A client recovering from abdominal surgery is demonstrating abdominal distention from trapped flatus. What can the nurse do to help this client?

3. Obtain an order for a rectal tube. Rationale 3: If excessive gas cannot be expelled through the anus, it might be necessary to insert a rectal tube to remove it.

A client with terminal cancer of the lung complains of being short of breath with bilateral crackles and wheezes, despite oxygen at 4 L via nasal cannula and diuretic therapy. What nursing interventions are appropriate for this client?

3. Place a fan in the room to move air around the client. 5. Elevate the head of the clients bed to a Fowlers position. 6. Consider use of a p.r.n. morphine sulfate order. Rationale 3: Placement of a fan to circulate air might relieve shortness of breath.Rationale 5: Elevating the head of the bed might relieve shortness of breath.Rationale 6: Use of morphine sulfate might relieve shortness of breath.

The nurse is teaching a class for new parents about self-esteem development in infants. What information should be included?

3. Respond to the babys needs promptly and consistently. Rationale 3: In order to develop self-esteem in their baby, parents should be taught to respond to the babys needs promptly and consistently.

The nurse is caring for a client in the recovery area. In which position should the nurse place the unconscious client during the immediate postanesthesia phase?

3. Side-lying Rationale 3: The unconscious client should be positioned on the side, with the face slightly down.

The nurse determines that a terminally ill client is nearing death. What did the nurse assess to make this clinical decision?

3. Slow, weak pulse 4. Decreased blood pressure 5. Cyanosis of the extremities

The nurse and client have spent several minutes praying together that the clients upcoming surgery will be successful. What action should the nurse take at this point?

3. Stay with the client until the emotion evoked by the prayer dissipates. Rationale 3: The nurse should stay with the client for a few minutes after the prayer has ended until the strong emotions that can be evoked by joint prayer dissipate.

The nurse is teaching a class on body development to a group of middle school girls. One of the girls asks about using tampons for sanitary protection during menstruation. What advice should the nurse include?

3. Tampons should be alternated with sanitary pads to help decrease risk for infection.

The client being prepared for a procedure asks to be allowed to wear a religious medal. The client states, I have worn this medal and have not removed it since I was a teenager. What action should the nurse take?

3. Tell the client that the nurse will explain to the procedure staff about the medal and will request that they allow the client to wear it. Rationale 3: The nurse should explain the significance of the medal to the procedure staff and request that the client be allowed to wear it during the procedure.

The nurse is identifying outcomes for a client with the nursing diagnosis Stress Urinary Incontinence. Which outcome would be related to sphincter incompetence?

3. The client will perform four to five squeezes for 5 to 10 seconds. Rationale 3: Performing four to five squeezes for 5 to 10 seconds is the goal to start with when teaching a client Kegel exercises, which are used for stress and urge incontinence.

The nurse is evaluating the effectiveness of preoperative instruction regarding leg exercises with a client recovering from surgery. Which observation indicates that the instructions were effective?

3. There is no cramping or pain with ambulation. Rationale 3: The absence of cramping or pain with ambulation indicates that leg exercises instructed prior to surgery were effective to prevent the onset of thrombophlebitis.

A recently married couple is trying to conceive a child. The husband is a collegiate athlete and his coach forbids sexual activity for 2 days prior to a game. The wife asks the nurse if abstinence before the game is necessary. What is the best response?

3. This is a common myth among athletes, but there is no basis in fact. Rationale 3: The idea that sexual activity weakens the person physically is a common misconception among athletes, but there is no evidence to support that idea.

A client needs a test to determine the amount of residual urine. The nurse realizes that this assessment is used for which reason(s)?

3. To determine the amount of retained urine after voiding 4. To determine the need for medications

A client speaks about an adult son who is a practicing homosexual and expresses concern by stating: I am so worried about him and I know he is going to hell. What is the most important fact for the nurse to consider in formulating a response to this clients concern?

3. What constitutes normal sexual expression varies among cultures and religions. Rationale 3: This nurse should remember that culture and religion have a big impact upon what a person believes to be normal sexual behavior.

During the bath, the client suddenly says, I am not going to get well. I think I am going to die. What response given by the nurse is most appropriate?

3. What makes you think you are dying? Rationale 3: The nurse should ask what it is that makes the client think about dying. This allows the nurse to collect and evaluate data before making a further response.

During the morning bath, the client asks if the nurse is religious and believes in God. What would be most helpful for the nurse to consider in formulating a response to this question?

3. Will sharing this information positively contribute to the relationship? Rationale 3: Practice guidelines regarding support of religious practices indicate that the nurse should first consider whether such self-disclosure will contribute to a therapeutic nurseclient relationship.

A client is scheduled for a cholecystectomy. The nurse realizes that the purpose for this surgery is

3. ablative. Rationale 3: When the purpose of surgery is ablative, the diseased body part is removed.

The adolescent male client who weighs 100 is considering taking some herbal stuff to increase muscle mass and strength. The nurse should interpret this statement as an indication that this client has

3. incongruence between reality and ideal self. Rationale 3: The nurse can determine that there is incongruence between reality and this clients ideal self.

A clients urinalysis is reported as being normal. What were the clients results?

3. pH 6 and no glucose present Rationale 3: Normal pH is 4.5 to 8, so a pH of 6 and no glucose present are two normal characteristics of urine.

The nurse is preparing the skin of a client for surgery. The nurse knows the purpose of the surgical skin preparation is to

3. reduce the risk of postoperative wound infection. Rationale 3: The purpose of a surgical skin preparation is to reduce the risk of postoperative wound infection.

The nurse is assigning support personnel to assist the families of clients who have died in dealing with the stress related to the loss of their family members. Which family would the nurse screen as at highest risk for complicated grief? The family of a client who

3. was killed in the robbery of a bank. Rationale 3: Although all families are different and all families can respond to grief differently, research supports a greater potential for complicated grief in families whose loved one died suddenly, violently, or unexpectedly. Of the options given, the client who was murdered best fits all three situations.

The nurse is caring for a client who is experiencing constipation. Which client behavior indicates that teaching was effective?

4. The client walks around the unit several times a day.

The female client belongs to a religious community that requires women to dress conservatively in clothing that covers the arms and the knees. This client expresses concern that her body will be exposed during a scheduled cardiac catheterization. How should the nurse respond to this concern?

4. Ask the cath lab charge nurse to come to the clients room to talk with her about the concerns. Rationale 4: The best plan is to have the cath lab charge nurse talk to the client about her concerns. The charge nurse can then assure the client that even though a small part of her body must be exposed, her modesty will be protected.

The newly graduated nurse is working with a mentor who has been a nurse for 25 years. The mentor tells the new graduate, I learn something new about nursing every day. What does this indicate about the mentors self- awareness?

4. Because self-awareness is never complete, this nurse is demonstrating desirable behavior. Rationale 4: Self-awareness takes time and energy and is never completed. This nurse is demonstrating desirable behavior in that there is still intellectual humility and a desire to learn.

The nurse determines that interventions to prevent postoperative constipation have been effective in a client recovering from surgery. What did the nurse assess to make this clinical decision?

4. Bowel movement occurred 24 hours after resuming a normal diet. Rationale 4: A bowel movement that occurs within 48 hours after resuming a normal diet is evidence that postoperative constipation has been prevented.

The nurse is identifying goals for a client experiencing diarrhea. What goal should the nurse select for this client?

4. Client will regain normal stool consistency. which would be less water in the stool and a more formed consistency.

The nurse is preparing a client for an upper GI endoscopy. For which type of anesthesia should the nurse prepare the client to receive?

4. Conscious sedation Rationale 4: Conscious sedation is often used for procedures such as endoscopies and incision and drainage of abscesses.

During an assessment, a client tells the nurse of a desire to wear clothing that is typically associated with the opposite sex. The nurse realizes this client is describing which gender identity?

4. Cross-dressing Rationale 4: Cross-dressing makes ones outward appearance consistent with their inner identity and gender role, and increases their comfort with themselves.

The nurse who is providing postmortem care for a client sees that the client is wearing a ring. What is the most important action regarding this observation?

4. Document fully whatever action is taken. Rationale 4: Depending upon the circumstances and what kind of ring it is, the nurse might take any of these actions. The most important action is to document what occurred.

The nurse is applying an external urinary device to a client. Before attaching the device to the drainage bag, what should the nurse do?

4. Ensure that the condom is not twisted. Rationale 4: The nurse should make sure that the tip of the penis is not touching the condom and that the condom is not twisted, because a twisted condom could obstruct the flow of urine.

The nurse is conducting a health history with an older client with arthritis and heart disease. When gathering the sexual history for this client, what question should the nurse ask?

4. Have there been any changes in your sexual functioning that might be related to your illness or the medications you take? Rationale 4: All nursing histories should at least include a question such as Have there been any changes in your sexual functioning that might be related to your illness or the medications you take?

During a home visit, an older male client tells the nurse that his wife died 3 years ago. What did the nurse observe as an indication that this client is experiencing complicated grief?

4. He shows the nurse his wifes craft room that remains just as she left it before she died. Rationale 4: Leaving the deceased wifes craft room and belongings intact for over 3 years is considered outside the normal limits of the grief process.

The nurse is determining tasks to delegate to unlicensed assistive personnel (UAP). Which task should the nurse question before delegating to this level of health care provider?

4. Inserting a urinary catheter into a client Rationale 4: Due to the need for sterile technique and detailed knowledge of anatomy, insertion of a urinary catheter is not delegated to UAP.

A client newly diagnosed with a terminal illness asks to talk with the hospital chaplain and requests a Bible to read. What do these client behaviors indicate to the nurse?

4. Interventions for Spiritual Distress have been effective. Rationale 4: Requesting to talk with a spiritual counselor and desiring spiritual reading material indicate that interventions for the diagnosis of Spiritual Distress have been effective.

The nurse is conducting a thorough psychosocial assessment of a client who presents with complaints of fatigue, tearfulness, and relationship difficulties. What action by the nurse would support accurate assessment?

4. Investigate the clients culture prior to the interview. Rationale 4: The nurse should consider how the clients behaviors are influenced by culture. In order to understand what is being said or seen, the nurse should investigate the clients culture prior to the interview

The parents of an adolescent report that their child has recently gotten into trouble at school for cheating on an examination and has been barred from participating in a school trip as a consequence of that action. They ask for the nurses professional opinion about the suitability of the punishment. Which answer best supports self- esteem development in this adolescent?

4. Living with the consequences of your actions is a way to help the adolescent develop good self-esteem. Rationale 4: One of the most important tasks of adolescence and a prime way to develop self-esteem is to take responsibility and to live with the consequences of actions.

A UAP has applied a condom catheter to a client. The nurse should document what information about this procedure?

4. Time and date that the condom catheter was applied 5. Integrity of the penis

After asking general assessment questions regarding spirituality, the nurse finds the client content and satisfied. How should the nurse conduct the rest of the assessment?

4. No further specific spiritual assessment is currently necessary. Rationale 4: If the client is satisfied and content with current levels of spirituality, there is no further specific spiritual assessment necessary.

The nurse is caring for a client who experiences frequent bouts of diarrhea. What should the nurse instruct the client to do?

4. Note the precipitating event. Rationale 4: Psychological stress such as anxiety, medications, food allergies, and certain diseases can cause diarrhea. Noting the event can help identify and stop the cause.

The RN is admitting a client to the medical unit for a urinary disorder. Which physical assessment techniques should the nurse use in assessing this clients urinary system?

4. Palpation and observation Rationale 4: The hands and sense of touch are used with palpation to gather data along with observation or inspection, which visually allows the nurse to observe all responses and nonverbal behavior. It is also the most frequently used technique and the most convenient.

A client who is facing a final surgery to save his life asks the nurse to stay and pray with him until the surgery begins. In which ways should the nurse demonstrate presencing with this client?

4. Praying with the client for divine intervention 5. Focusing on the client and fulfilling his needs Rationale 4: Praying with the client for divine intervention demonstrates transcendent presence because the nurse is spiritually present for the client. Rationale 5: Focusing on the client and fulfilling his needs demonstrates full presence.

The nurse wants to ensure that a client recovering from surgery does not develop thrombophlebitis. Which action should the nurse take to reduce the clients risk of this postoperative complication?

4. Provide for early ambulation. Rationale 4: Early ambulation, leg exercises, antiembolic stockings, SCDs, and adequate fluid intake are all interventions to reduce the risk for thrombophlebitis.

When arriving to a clients room to provide care, the client is praying with family. What action should the nurse take?

4. Quietly shut the door and wait in the hall until asked to enter. Rationale 4: The nurse should wait in the hall until the prayer is over and the client or family give permission to enter the room.

The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the IT section of this format?

4. Recommend intensive therapy with a qualified sex therapist. Rationale 4: IT represents intensive therapy. At this point in intervention, the nurse recognizes that the client requires therapy with a nurse who has specialized preparation and knowledge of sexual and gender identity disorders. Referral or recommendation for intensive therapy is required.

The nurse is caring for a postoperative client with an abdominal wound and a drain. What can the nurse delegate to unlicensed assistive personnel?

4. Report if the dressing is soiled. 5. Report if the dressing is loose. Rationale 4: The nurse can ask the UAP to report soiled dressings that need to be changed. Rationale 5: The nurse can ask the UAP to report if the dressing is loose and needs to be reinforced.

During morning care, a UAP notes that thick green drainage is seeping around the appliance of a clients new ostomy. What should the UAP have been instructed to do?

4. Report the drainage to the nurse. Rationale 4: Care of a new ostomy is not delegated to UAP. However, aspects of ostomy function are observed during usual care, and may be recorded by persons other than the nurse. Abnormal findings must be validated and interpreted by the nurse.

The client diagnosed with diabetes mellitus develops diabetic ketoacidosis after a religious fast. The client tells the nurse, I have fasted during this season every year since I became an adult. I am not going to stop now. The nurse is not knowledgeable about this particular religion. What is the best action for this nurse?

4. Request a consult from a diabetes educator. Rationale 4: The diabetes educator should be contacted to work with the client on strategies that might allow the fasting to occur in a safe manner.

Which nursing intervention is appropriate when caring for a client with a retention catheter?

4. Retape the catheter to the thigh. Rationale 4: Retaping the catheter to the thigh after care is given prevents trauma and pain from tension and pulling.

The nurse is instructing a client on ostomy care. What should be included in this teaching?

4. Secure the faceplate to the drainage pouch so no skin around the stoma is exposed. Rationale 4: The skin around a stoma is very susceptible to irritation and breakdown. To avoid skin irritation, the faceplate to the drainage pouch needs to fit close enough to the stoma so as not to expose any other skin.

The nurse is caring for a client whose family does not want to tell him that he is dying. What is the nurses best action according to these wishes?

4. Talk to the family about the situation and their concerns. Rationale 4: In this situation, the best and first thing the nurse should do is talk with the family about what is happening and what their concerns are. The nurse should investigate religious, cultural, and family traditions regarding telling the client about impending death.

There is disagreement among the nursing unit staff regarding how much sexual history should be included in adult admission assessments. What standard is generally the most applicable?

4. The amount of sexual information taken will vary on a case-by-case basis. Rationale 4: The amount of sexual information taken will vary on a case-by-case basis. The nurse can open the conversation by asking open-ended questions.

During assessment, the client tells the nurse, I dont believe that the existence of God has been proven. I dont see the scientific evidence I need to be certain. How should the nurse document this finding?

4. The client is agnostic. Rationale 4: Agnostics are persons who doubt the existence of God or a Supreme Being or believe the existence of God has not been proven.

A client is instructed on the care of an indwelling urinary catheter. Which returned demonstration by the client indicates that teaching has been effective?

4. The client takes a shower each day. Rationale 4: The client should take a shower rather than a tub bath because sitting in a tub allows bacteria to easily access the urinary tract.

A clients results from a urinalysis are as follows: pH 5.2, gross cloudiness, WBC 1015, glucose negative, specific gravity 1.012, and protein negative. How should the nurse interpret the results?

4. Urinary tract infection The pH, glucose, specific gravity, and protein are all within normal limits. Urine is usually clear to slightly cloudy, and WBC count can be from 0 to 4. Therefore, the gross cloudiness and WBC count of 1015 are not normal, indicating a urinary tract infection.

A client with an upper gastrointestinal disorder is experiencing seeping of liquid stool, anorexia, abdominal distention, nausea, and vomiting. The nurse suspects the client is experiencing

4. fecal impaction. Rationale 4: A client who has a fecal impaction will experience the passage of liquid fecal seepage and no normal stool. The liquid portion of the feces seeps out around the impacted mass. Symptoms include anorexia, abdominal distention, nausea, and vomiting.

A terminally ill client is demonstrating gurgling respirations. The nurse realizes that this client is

4. nearing death. Rationale 4: A clinical manifestation of impending death is noisy breathing. This is often referred to as the death rattle, and is due to collecting of mucus in the throat

A client with an indwelling urinary catheter is prescribed to receive sterile normal saline bladder irrigation at 100 mL/hr. After an 8-hour shift the nurse measures the clients output as being 1425 mL. What is the clients urine output for the 8-hour shift?

625 mL The client is to receive 800 mL of bladder irrigant for the 8-hour shift. The nurse needs to subtract the bladder irrigant total from the total output, or 1425 800 = 625 mL. This is the clients urine output for the 8- hour shift.

The nurse is performing ostomy care for a client. Place in order the steps the nurse will perform to do this care.

Choice 3. Empty the pouch and remove the ostomy barrier. Choice 1. Clean and dry the peristomal skin and stoma. Choice 4. Assess the stoma and peristomal skin. Choice 6. Place a piece of tissue or gauze over the stoma and change it as needed. Choice 2. Prepare and apply the skin barrier. Choice 5. Apply the pouch.

The spouse of a deceased client is working through the stages of grief. If the nurse applies Martocchios five clusters of grief to this situation, the spouse would progress through the clusters in which order?

Choice 4. Shock and disbelief Choice 2. Yearning and protest Choice 5. Anguish, disorganization, and despair Choice 3. Identification in bereavement Choice 1. Reorganization and restitution Martocchios five clusters of grief are: (1) shock and disbelief; (2) yearning and protest; (3) anguish, disorganization, and despair; (4) identification in bereavement; and (5) reorganization and restitution.

The nurse is preparing to change the dressing on a clients postoperative wound. Place in order the steps the nurse should perform when removing the soiled dressing.

Choice 5. Apply clean gloves. Choice 2. Remove the outer dressing. Choice 6. Place the soiled dressing in a moisture-proof bag. Choice 4. Remove the under dressing. Choice 1. Assess the location, type, and odor of wound drainage. Choice 3. Discard the under dressing in a moisture-proof bag, and remove and discard gloves.