FUNDAMENTALS FINAL EXAM

The nurse is teaching an older female patient how to manage urge incontinence at home. What is the first-line approach to reducing involuntary leakage of urine? 1) Insertion of a pessary 2) Intermittent self-catheterization 3) Bladder training 4) Anticholinergic medication

3) Bladder training

Which information provides the most reliable data about the effectiveness of airway suctioning? 1) The amount, color, consistency, and odor of secretions 2) The patient's tolerance for the procedure 3) Breath sounds, vital signs, and pulse oximetry before and after suctioning 4) The number of suctioning passes required to clear secretions

3) Breath sounds, vital signs, and pulse oximetry before and after suctioning

Which statement is best to use when instructing a patient about digoxin? 1) Obtain your radial pulse every morning before taking your digoxin dose. 2) Return to your healthcare provider for monthly laboratory studies of your digoxin levels. 3) Call your provider if you notice that objects look yellow or green. 4) Always take the same brand of medication because certain brands may not be interchangeable.

3) Call your provider if you notice that objects look yellow or green.

In order to achieve balance, body mass must be distributed around which point? 1) Center of body alignment 2) Center of balance 3) Center of gravity 4) Base of support

3) Center of gravity

A patient has a continuous IV infusion at 60 mL/hr. The right hand IV has infiltrated and the nurse has started a new IV on the left forearm. Which intervention should the nurse also perform? 1) Elevate the patient's left forearm. 2) Schedule daily dressing changes to the new IV site. 3) Change the administration set. 4) Place the patient in Fowler's position.

3) Change the administration set

According to the U.S. Department of Health and Human Services 2008 Physical Activity Guidelines for Americans, which statement about the benefits of physical activity is correct? 1) The risks of physical activity outweigh the health benefits. 2) Physical activity in excess of recommendations for age is harmful. 3) Combining aerobic and muscle-strengthening activities promotes better health. 4) Lesser amounts of activity provide little to no health benefits.

3) Combining aerobic and muscle-strengthening activities promotes better health.

A patient with a skin infection is prescribed cephalexin (an antibiotic) 500 mg orally q 12 hours. The patient complains that the last time he took this medication he had frequent episodes of loose stools. Which recommendation should the nurse make to the patient? 1) Stop taking the drug immediately if diarrhea develops. 2) Take an antidiarrheal agent, such as diphenoxylate. 3) Consume yogurt daily while taking the antibiotic. 4) Increase your intake of fiber until the diarrhea stops.

3) Consume yogurt daily while taking the antibiotic.

A patient has been vomiting for 2 days, has not been able to eat or drink anything during this time, and has not urinated for 12 hours. Physical examination reveals the following: T = 99.6°F (37.6°C) orally; P = 110 beats/min weak and thready; BP = 80/52 mm Hg. Skin and mucous membranes are dry, there is decreased skin turgor, and the patient is experiencing weakness. The following are the most recent laboratory results: Sodium 138 mEq/L Potassium 3.7 mEq/L Calcium 9.2 mg/dL Magnesium 1.8 mg/dL Chloride 99 mEq/L BUN 29 mg/dL Which is an appropriate nursing diagnosis for this patient? 1) Impaired Gas Exchange related to ineffective breathing 2) Excess Fluid Volume related to limited fluid output 3) Deficient Fluid Volume related to abnormal fluid loss 4) Electrolyte Imbalance related to decreased oral intake

3) Deficient Fluid Volume related to abnormal fluid loss

Which teaching technique is best for teaching a nursing assistant how to perform fingerstick glucose testing? 1) Provide a manufacturer's pamphlet with detailed instruction. 2) Explain the best technique for performing glucose testing. 3) Demonstrate the procedure; then ask for a return demonstration. 4) Suggest that the assistant watch a DVD showing the procedure.

3) Demonstrate the procedure; then ask for a return demonstration.

9. What position should the patient assume before the nurse inserts an indwelling urinary catheter? 1) Modified Trendelenburg 2) Prone 3) Dorsal recumbent 4) Semi-Fowler's

3) Dorsal recumbent

The nurse administers an antitussive/expectorant cough preparation to a patient with bronchitis. Which response indicates to the nurse that the medication is effective? 1) The amount of sputum decreases with each dose administered. 2) Cough is completely suppressed, and the patient is able to sleep through the night. 3) Dry, unproductive cough is reduced, but voluntary coughing is more productive. 4) Involuntary coughing produces large amounts of thick yellow sputum.

3) Dry, unproductive cough is reduced, but voluntary coughing is more productive.

15. It is a busy day on the medical-surgical floor, and the nurse must teach a patient ready for discharge about his medications. How can the nurse most efficiently utilize time and provide this education? 1) Write down instructions so the patient can read them at home. 2) Discuss the information while assisting the patient with his bath. 3) Educate the patient about his medications as each one is given. 4) Follow up with the patient after discharge with a phone call.

3) Educate the patient about his medications as each one is given.

While observing a client walk on a treadmill in the community room, the nurse notices that a client is able to carry on a conversation without any shortness of breath. What does this client's behavior indicate about the intensity of the activity? 1) Exercise is too hard. 2) Exercise is appropriate. 3) Exercise is not hard enough. 4) Exercise needs to be changed.

3) Exercise is not hard enough

3)Which food item should the nurse instruct the patient to consume to prevent or treat constipation? 1) Milk and cheese 2) Bread and pasta 3) Fruits and vegetables 4) Lean meats

3) Fruits and vegetables

A patient who underwent surgery 24 hours ago is prescribed a clear liquid diet. The patient asks for something to drink. Which item may the nurse provide for the patient? 1) Tea with cream 2) Orange juice 3) Gelatin 4) Skim milk

3) Gelatin

Which polysaccharide is stored in the liver? 1) Insulin 2) Ketones 3) Glycogen 4) Glucose

3) Glycogen

The nurse examines the electrocardiogram (ECG) tracing of a client and notes tall T waves. What electrolyte imbalance should the nurse suspect? 1) Hypokalemia 2) Hypophosphatemia 3) Hyperkalemia 4) Hypercalcemia

3) Hyperkalemia

A patient's 2:1 parenteral nutrition (PN) container infuses before the pharmacy prepares the next container. This places the patient at risk for which complication? 1) Sepsis 2) Pneumothorax 3) Hypoglycemia 4) Thrombophlebitis

3) Hypoglycemia

Which is true of synarthroses joints? 1) Freely movable 2) Capable of only limited movement 3) Immovable 4) Painful with movement

3) Immovable

During the day shift, a patient's temperature measures 97°F (36.1°C) orally. At 2000, the patient's temperature measures 102°F (38.9°C). What effect does this rise in temperature have on the patient's basal metabolic rate? 1) Increases the rate by 7% 2) Decreases the rate by 14% 3) Increases the rate by 35% 4) Decreases the rate by 28%

3) Increases the rate by 35%

A patient has a colostomy in the descending (sigmoid) colon and wants to control bowel evacuation and possibly stop wearing an ostomy pouch. What should the nurse teach so that this patient can achieve this goal? 1) Call the primary care provider if the stoma becomes pale, dusky, or black. 2) Limit the intake of gas-forming foods such as cabbage, onions, and fish. 3) Irrigate the stoma to produce a bowel movement on a schedule. 4) Avoid returning to the use of an ostomy appliance if he becomes ill.

3) Irrigate the stoma to produce a bowel movement on a schedule.

A patient has just had a chest tube inserted to dry-seal suction drainage. Which is a correct nursing intervention for maintenance? 1) Keep the head of the bed flat for 6 hours. 2) Immobilize the patient's arm on the affected side. 3) Keep the drainage system lower than the insertion site. 4) Drain condensation into the humidifier when it collects in the tubing.

3) Keep the drainage system lower than the insertion site.

A patient with type 1 diabetes mellitus is admitted with hyperglycemia and associated acidosis. Which alternative fuel in the body is responsible for the acidosis? 1) Glycogen 2) Insulin 3) Ketones 4) Proteins

3) Ketones

While assessing the costovertebral angle the client experiences pain. What does this finding indicate to the nurse? 1) Renal calculi 2) Kidney tumor 3) Kidney inflammation 4) Urinary tract infection

3) Kidney inflammation

A nurse is assessing a 74-year-old male patient for an exercise program to be offered at the local hospital. During the evaluation, the nurse notes the following vital signs: P = 72, RR = 16, BP = 132/70. After 3 minutes of moderate-intensity running on the treadmill, the patient becomes short of breath and states, "I have to stop. I can't do this anymore." The nurse measures his vital signs again: P = 152, RR = 40, BP = 172/98. She instructs him to rest. Vital signs return to baseline after 15 minutes. The nurse should recognize his symptoms as associated with which of the following? 1) Anxiety 2) Orthostatic hypotension 3) Limited activity tolerance 4) Respiratory distress

3) Limited activity tolerance

A client is admitted to the emergency department (ED) in respiratory distress. The results of his arterial blood gases are pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/L; PO2 = 80. How should the nurse interpret these results? 1) Respiratory acidosis with normal oxygen levels 2) Respiratory alkalosis with hypoxia 3) Metabolic acidosis with normal oxygen levels 4) Metabolic alkalosis with hypoxia

3) Metabolic acidosis with normal oxygen levels

The nurse plans care for a client who is bedridden. Which laxative should be avoided to treat constipation in this client? 1) Osmotic 2) Stimulant 3) Mineral oil 4) Stool softener

3) Mineral oil

A patient recovering from a bowel resection a few hours ago has a urine output of 50 mL/2 hr. Which action should the nurse take? 1) Do nothing; this is normal postoperative urine output. 2) Increase the infusion rate of the patient's IV fluids. 3) Notify the provider about the patient's oliguria. 4) Administer the patient's routine diuretic dose early.

3) Notify the provider about the patient's oliguria.

The nurse is assigned to the care of the following patients. In planning nursing care, the nurse knows to use touch cautiously when communicating with which patient? 1) Middle-aged woman just diagnosed with terminal lung cancer 2) Middle-aged man experiencing the acute phase of myocardial infarction (MI) 3) Older adult with a history of dementia admitted for dehydration 4) Young adult in the rehabilitative phase after arthroscopic surgery

3) Older adult with a history of dementia admitted for dehydration

What term is used to describe the time it takes for drug concentration to reach a therapeutic level in the blood? 1) Peak action 2) Duration of action 3) Onset of action 4) Half-life

3) Onset of action

The nurse is caring for a 25-year-old male quadriplegic patient. Which treatment should the nurse perform to decrease the risk of joint contracture and promote joint mobility? 1) Active ROM 2) Turning the patient every 2 hours 3) Passive ROM 4) Administering glucosamine supplements

3) Passive ROM

Chest percussion and postural drainage would be an appropriate intervention for which condition? 1) Congestive heart failure 2) Pulmonary edema 3) Pneumonia 4) Pulmonary embolus

3) Pneumonia

19. Which task can the nurse safely delegate to the nursing assistive personnel? 1) Palpating the bladder of a patient who is unable to void 2) Administering a continuous bladder irrigation 3) Providing indwelling urinary catheter care 4) Obtaining the patient's history and physical assessment

3) Providing indwelling urinary catheter care

The nurse notes that a patient's indwelling urinary catheter tubing contains sediment and crusting is present at the meatus. Which action should the nurse take? 1) Notify the provider immediately. 2) Flush the catheter tubing with saline solution. 3) Replace the indwelling urinary catheter. 4) Encourage fluids that increase urine acidity.

3) Replace the indwelling urinary catheter.

What is the correct method for turning an adult patient who recently sustained a spinal cord injury? 1) Ask the patient to assist with the turn by holding the siderails of the bed. 2) Place a drawsheet under the patient to assist with turning. 3) Request help from another nurse to perform the logrolling technique. 4) Use a mechanical lift for safe turning and protecting the nurse's back.What is the correct method for turning an adult patient who recently sustained a spinal cord injury? .

3) Request help from another nurse to perform the logrolling technique

A patient who speaks only French was admitted to the hospital after a motor vehicle accident. Assuming that the nurse does not speak French, what is the best way to communicate with this patient? 1) Use sign language for communicating. 2) Ask a family member to serve as an interpreter. 3) Request the services of a hospital interpreter. 4) Speak in English, but speak very slowly.

3) Request the services of a hospital interpreter.

Which nutritional goal is appropriate for a patient newly diagnosed with hypertension? 1) Limit his intake of protein. 2) Avoid foods containing gluten. 3) Restrict his use of sodium. 4) Limit his intake of potassium-rich foods.

3) Restrict his use of sodium.

The nurse is caring for a patient with a medical diagnosis of hypernatremia. The following prescriptions are written in the client's electronic health record. Which one should the nurse question? 1) Administer an IV of D5W at 125 mL/hr. 2) Strict I&O monitoring. 3) Restrict oral intake to 900 mL every 24 hr. 4) Monitor serum electrolytes every 4 hr.

3) Restrict oral intake to 900 mL every 24 hr.

Which is a nonverbal behavior that enhances communication? 1) Keeping a neutral expression on the face 2) Maintaining a distance of 6 to 12 inches 3) Sitting down to speak with the patient 4) Asking mostly open-ended questions

3) Sitting down to speak with the patient

Which electrolyte is the primary regulator of fluid volume? 1) Potassium 2) Calcium 3) Sodium 4) Magnesium

3) Sodium

The nurse suspects that a patient's intravenous solution has infiltrated into the tissues. What action should the nurse take first? 1) Aspirate, then inject 0.5 mL normal saline. 2) Restart the IV line in a different vein. 3) Stop the infusion immediately. 4) Notify the primary care provider.

3) Stop the infusion immediately.

While receiving an intravenous dose of an antibiotic, levofloxacin, a patient develops severe shortness of breath, wheezing, and severe hypotension. Which action should the nurse take first? 1) Administer epinephrine IM. 2) Give bolus dose of intravenous fluids. 3) Stop the infusion of medication. 4) Prepare for endotracheal intubation.

3) Stop the infusion of medication.

While addressing a community group, the nurse explains the importance of replacing saturated fats in the diet with mono- and polyunsaturated fats. Which complication can be reduced if this action is taken? 1) Kidney failure 2) Liver failure 3) Stroke 4) Lung cancer

3) Stroke

A client reports difficulty with smoking cessation efforts. Which direction should the nurse provide to ensure for this client's nutritional status? 1) Avoid all intake of vitamin E. 2) Reduce the intake of vitamin B each day. 3) Take a vitamin C supplement of 2,000 mg/day. 4) Increase the intake of vitamin D to 2,000 U per day.

3) Take a vitamin C supplement of 2,000 mg/day.

A patient with terminal cancer requires increasing doses of an opioid pain medication to obtain relief from pain. This patient is exhibiting signs of drug: 1) Abuse 2) Misuse 3) Tolerance 4) Dependence

3) Tolerance

What is the best intervention to protect the integument of a frail, malnourished, immobile patient? 1) Offering the patient six small meals a day 2) Assisting the patient to sit in a chair three times a day 3) Turning the patient at least every 2 hours 4) Administering fluid boluses as directed by the healthcare provider

3) Turning the patient at least every 2 hours

A patient has difficulty taking liquid medications from a cup. How should the nurse administer the medications? 1) Request that the prescriber change the order to the IV route. 2) Administer the medication by the IM route. 3) Use a needleless syringe to place the medication in the side of the mouth. 4) Add the dose to a small amount of food or beverage to facilitate swallowing.

3) Use a needleless syringe to place the medication in the side of the mouth.

The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse should explain that ingestion of which substance may cause a false-negative fecal occult blood test? 1) Vitamin D 2) Iron 3) Vitamin C 4) Thiamine

3) Vitamin C

6. Which phrase is stated as a teaching goal for a patient who had bowel resection with creation of a colostomy? 1) Empties the colostomy appliance when half filled 2) Performs skin care around the stoma site 3) Will perform ostomy self-care within 3 days after surgery 4) Applies a new ostomy appliance, making sure it adheres properly

3) Will perform ostomy self-care within 3 days after surgery

What is the best technique for obtaining a sterile urine specimen from an indwelling urinary catheter? 1) Use antiseptic wipes to cleanse the meatus prior to obtaining the sample. 2) Briefly disconnect the catheter from the drainage tube to obtain the sample. 3) Withdraw urine through the port using a needleless access device. 4) Obtain the urine specimen directly from the collection bag.

3) Withdraw urine through the port using a needleless access device.

The nurse wants to determine the amount of material that a group of clients has retained after attending a class on management of diabetes. Which approach should the nurse use? 1) Checklist 2) Interview 3) Written test 4) Direct observation

3) Written test

A patient who was prescribed furosemide (Lasix) is deficient in potassium. Therefore, the patient should be instructed to increase his intake of which foods? 1) Bananas, peaches, molasses, and potatoes 2) Eggs, baking soda, and baking powder 3) Wheat bran, chocolate, eggs, and sardines 4) Egg yolks, nuts, and sardines

1) Bananas, peaches, molasses, and potatoes

The nurse is instructing a patient about performing home testing for fecal occult blood. What food should the patient state to avoid eating for 3 days before the test? 1) Beef 2) Milk 3) Eggs 4) Oatmeal

1) Beef

A mother of a school-age child seeks healthcare because her child has had diarrhea after being ill with a viral infection. The patient states that after vomiting for 24 hours, his appetite has returned. Which recommendation should the nurse make to this mother? 1) Consume a diet consisting of bananas, white rice, applesauce, and toast. 2) Drink large quantities of water regularly to prevent dehydration. 3) Take loperamide (an antidiarrheal) as needed to control diarrhea. 4) Increase the consumption of raw fruits and vegetables.

1) Consume a diet consisting of bananas, white rice, applesauce, and toast.

What is the most significant change in kidney function that occurs with aging? 1) Decreased glomerular filtration rate 2) Proliferation of micro-blood vessels to renal cortex 3) Formation of urate crystals 4) Increased renal mass

1) Decreased glomerular filtration rate

Prior to discharge, a patient with diabetes needs to learn how to check a fingerstick blood sugar before taking insulin. Which action will best help the patient remember proper technique? 1) Encouraging the patient to check his blood sugar each time the nurse gives insulin 2) Providing feedback after the patient takes his blood sugar for the first time 3) Verbally instructing the patient about how to obtain a fingerstick blood sugar 4) Offering a brochure that describes the technique for checking blood sugar

1) Encouraging the patient to check his blood sugar each time the nurse gives insulin

18. A mother tells the nurse at an annual well-child checkup that her 6-year-old son occasionally "wets himself." Which response by the nurse is appropriate? 1) Explain that occasional wetting is normal in children of this age. 2) Tell the mother to restrict her child's activities to avoid wetting. 3) Suggest "time-out" to reinforce the importance of staying dry. 4) Inform the mother that medication is commonly used to control wetting.

1) Explain that occasional wetting is normal in children of this age.

3. Which intervention by the nurse would be best to motivate a patient newly diagnosed with hypertension to learn about the prescribed treatment plan? 1) Explain that when left untreated, hypertension may lead to stroke. 2) Ask the patient to let you know when he is ready to learn. 3) Encourage the patient to learn about various treatment options. 4) Reassure the patient that adhering to the treatment produces a good outcome.

1) Explain that when left untreated, hypertension may lead to stroke.

The nurse is providing nutrition counseling for a patient planning pregnancy. The nurse should emphasize the importance of consuming which nutrient to prevent neural tube defects? 1) Folic acid 2) Calcium 3) Protein 4) Vitamin D

1) Folic acid

A client with chronic obstructive pulmonary disease (COPD) receives supplemental oxygen at 2 L/min via nasal cannula. Which positioning technique will best assist with this client's breathing? 1) Fowler's position 2) Sims' position 3) Lateral recumbent position 4) Lateral position

1) Fowler's position

The nurse examines the site of a client's tuberculin skin test as being 5 mm induration and documents that the test is positive. Which information in the client's history did the nurse use to make this clinical determination? 1) HIV positive 2) Type 2 diabetes mellitus 3) Lives in a skilled nursing facility 4) Recent immigrant to the United States

1) HIV positive

7. The nurse measures the urine output of a patient who requires a bedpan to void. Which action should the nurse take after applying gloves? 1) Have the patient void directly into the bedpan. 2) Pour the urine into a graduated container. 3) Read the volume with the container on a flat surface at eye level. 4) Observe the color and clarity of the urine in the bedpan.

1) Have the patient void directly into the bedpan.

A patient with a history of alcoholism is disoriented and vacillates between being calm and disruptive and loud. Vital signs are BP 138/84 mm Hg; pulse 135 beats/min, regular and strong; respiratory rate 22 breaths/min; temperature 37.1°C (98.1°F). What electrolyte imbalance might the nurse suspect this patient is experiencing? 1) Hypomagnesemia 2) Hypocalcemia 3) Hyperkalemia 4) Hypernatremia

1) Hypomagnesemia

An older patient has been vomiting for 2 days and has been unable to eat or drink anything during that time. Current vital signs are T = 99.6°F (37.6°C) orally; P = 110 beats/min weak and thready; BP = 80/52 mm Hg. Skin and mucous membranes are dry, there is decreased skin turgor, and the patient is experiencing weakness. The most recent laboratory results are as follows: Sodium 138 mEq/L Potassium 3.7 mEq/L Calcium 9.2 mg/dL Magnesium 1.8 mg/dL Chloride 99 mEq/L BUN 29 mg/dL Which health problem should the nurse realize this patient is experiencing? 1) Hypovolemia 2) Hypervolemia 3) Hypernatremia 4) Hyponatremia

1) Hypovolemia

A patient on bedrest because of a high-risk pregnancy has not had a bowel movement for 5 days. What information should the nurse give the patient when explaining constipation? 1) Immobility often causes constipation. 2) A stool softener daily will relieve the problem. 3) Use of a bedpan results in bloating and constipation. 4) A low-fiber diet will resolve the problem.

1) Immobility often causes constipation.

A patient's arterial blood gas results are pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/L; PO2 = 80. What would be an appropriate nursing diagnosis for the patient? 1) Impaired Gas Exchange 2) Metabolic Acidosis 3) Risk for Impaired Gas Exchange 4) Risk for Acid-Base Imbalance

1) Impaired Gas Exchange

21. A patient is in the bathroom and asks the nurse to leave medications on the bedside table. What should the nurse do? 1) Inform the patient that she will return when he is finished in the bathroom. 2) Wait outside the bathroom door until the patient is ready for the dose. 3) Withhold the dose until the next administration time later in the day. 4) Document that the dose was omitted in the medication administration record.

1) Inform the patient that she will return when he is finished in the bathroom.

1. Which body fluid lies in the spaces between the body cells? 1) Interstitial 2) Intracellular 3) Intravascular 4) Transcellular

1) Interstitial

The nurse notices that a patient has spoon-shaped, brittle nails. This suggests that the patient is experiencing Imbalanced Nutrition: Less Than Body Requirements related to deficiency of which of the following nutrients? 1) Iron 2) Vitamin A 3) Protein 4) Vitamin C

1) Iron

A patient recovering from abdominal surgery has had a urine output greater than 60 mL/hr for the past 2 hours; however, the output suddenly drops to nothing. What should the nurse do first? 1) Irrigate the catheter with 30 mL of sterile solution. 2) Replace the patient's indwelling urinary catheter. 3) Infuse 500 mL of normal saline solution IV over 1 hour. 4) Notify the surgeon immediately.

1) Irrigate the catheter with 30 mL of sterile solution.

During a learning assessment the client says, "I love to read." Which assessment category does this information support? 1) Learning style 2) Ability to learn 3) Physical readiness 4) Emotional readiness

1) Learning style

An older patient with newly diagnosed osteoporosis asks the nurse to explain her health problem. Which is the correct description of osteoporosis? 1) Loss of bone density that increases the risk of fracture 2) Degenerative joint disease that produces pain and decreased function 3) Chronic inflammatory joint disease that must be treated with steroids 4) Acute infection in the bone that must be treated with antibiotics

1) Loss of bone density that increases the risk of fracture

A patient develops urticaria and pruritus 5 days after beginning phenytoin for treatment of seizures. Which type of reaction is the patient most likely experiencing? 1) Mild adverse reaction 2) Dose-related adverse reaction 3) Toxic reaction 4) Anaphylactic reaction

1) Mild adverse reaction

A 52-year-old man has a triceps skinfold thickness of 18 mm, and his weight exceeds the ideal body weight for his height by 23%. Which nursing diagnosis should the nurse identify for this patient? 1) Obesity 2) Risk for Imbalanced Nutrition: More Than Body Requirements 3) Imbalanced Nutrition: Less Than Body Requirements 4) Readiness for Enhanced Nutrition

1) Obesity

Which action should the nurse take when beginning bladder training using scheduled voiding? 1) Offer the patient a bedpan every 2 hours while she is awake. 2) Increase the voiding interval by 30 to 60 minutes each week. 3) Frequently ask the patient whether she has the urge to void. 4) Increase the frequency between voiding even if urine leakage occurs.

1) Offer the patient a bedpan every 2 hours while she is awake.

The nurse assesses a patient's abdomen 4 days after abdominal surgery and notes that bowel sounds are absent. This finding most likely suggests which postoperative complication? 1) Paralytic ileus 2) Small bowel obstruction 3) Diarrhea 4) Constipation

1) Paralytic ileus

How should the nurse dispose of a contaminated needle after administering an injection? 1) Place the needle in a specially marked, puncture-proof container. 2) Recap the needle, and carefully place it in the trash can. 3) Recap the needle, and place it in a puncture-proof container. 4) Place the needle in a biohazard bag with other contaminated supplies.

1) Place the needle in a specially marked, puncture-proof container.

The nurse notes that a client has a loop colostomy. What should the nurse ensure when providing care to this client? 1) Plastic rod is in place. 2) Irrigations occur every day. 3) Ostomy appliance is changed every 6 hours. 4) Bedside commode is in place for bowel evacuation.

1) Plastic rod is in place.

Teratogenic drugs should be avoided in which patient population? 1) Pregnant women 2) Elderly 3) Children 4) Adolescents

1) Pregnant women

Which action should the nurse take to assess a 2-year-old child for pinworms? 1) Press clear cellophane tape against the anal opening at night to obtain a specimen. 2) Collect a freshly passed stool from a diaper using a wooden specimen blade. 3) Place a smear of stool on a slide and add two drops of reagent. 4) Prepare the patient for a flat plate (x-ray) of the abdomen.

1) Press clear cellophane tape against the anal opening at night to obtain a specimen.

What is the rationale for wrapping petroleum gauze around a chest tube insertion site? 1) Prevents air from leaking around the site 2) Prevents infection at the insertion site 3) Absorbs drainage from the insertion site 4) Protects the tube from becoming dislodged

1) Prevents air from leaking around the site

The nurse must administer eardrops to an infant. How should this medication be given? 1) Pull the pinna down and back before instilling the drops. 2) Pull the pinna upward and outward before instilling the drops. 3) Instill the drops directly; no special positioning is necessary. 4) Position the patient supine with the head of the bed elevated 30°.

1) Pull the pinna down and back before instilling the drops.

What would be the most appropriate goal for a frail, older patient with a nursing diagnosis of Risk for Injury after hip surgery? 1) Remain free from injury or falls throughout hospital stay 2) Increase activity tolerance by discharge from hospital 3) Demonstrate effective breathing when ambulating 4) Increase mobility by discharge from hospital

1) Remain free from injury or falls throughout hospital stay

When a patient has metabolic acidosis, which body system influences the acid-base imbalance to produce the compensatory changes in the arterial blood gases? 1) Respiratory system 2) Renal system 3) Vascular system 4) Neurological system

1) Respiratory system

At the conclusion of a teaching session the nurse provides the client with an evaluation tool. What is an advantage of this method to evaluate teaching? 1) Measures retention 2) Client evaluates own progress 3) Used to reinforce client behavior 4) Evaluates data and provides feedback

2) Client evaluates own progress

The healthcare team suspects that a patient has an intestinal infection. Which action should the nurse take to help confirm the diagnosis? 1) Prepare the patient for an abdominal flat plate. 2) Collect a stool specimen that contains 20 to 30 mL of liquid stool. 3) Administer a laxative to prepare the patient for a colonoscopy. 4) Test the patient's stool using a fecal occult test.

2) Collect a stool specimen that contains 20 to 30 mL of liquid stool.

Patients may be deficient in which vitamin during the winter months? 1) A 2) D 3) E 4) K

2) D

. A patient is prescribed the narcotic hydromorphone (Dilaudid). Where should the nurse expect to retrieve this drug for administration? 1) Cabinet in the patient's room 2) Double-locked medication drawer 3) Stock supply cabinet 4) Portable medication cart

2) Double-locked medication drawer

Physical therapy suggested that a client start using a cane to aid with stability when walking. What measurement should the nurse make so that this assistive device is appropriate for the client? 1) Floor to the axilla plus 1 inch 2) Floor to the top of the hip joint 3) Distance between the elbow and the wrist 4) Distance between the heel and the anterior fold of the axilla

2) Floor to the top of the hip joint

The nurse is caring for a patient who is experiencing dyspnea. Which position would be most effective if incorporated into the patient's care? 1) Supine 2) Head of bed elevated 80° 3) Head of bed elevated 30° 4) Lying on left side

2) Head of bed elevated 80°

A patient is prescribed furosemide (Lasix), a loop diuretic, for treatment of congestive heart failure. The patient is at risk for which electrolyte imbalance associated with use of this drug? 1) Hypocalcemia 2) Hypokalemia 3) Hypomagnesemia 4) Hypophosphatemia

2) Hypokalemia

A patient on strict bedrest for 5 days has not had a bowel movement although normally this occurs every day. When determining the nursing diagnosis, what would be causing this patient's constipation? 1) Change in previous pattern 2) Immobility 3) Dietary intake 4) Change in environment

2) Immobility

Which expected outcome is best for a patient with a nursing diagnosis of Deficient Knowledge related to new drug treatment regimen? 1) After an explanation and written materials, describes the expected actions and adverse reactions of his medication 2) In 1 week after instructional session, describes the expected actions and adverse reactions of his medications 3) Follows the treatment plan as prescribed 4) Experiences no adverse effect from his prescribed treatment plan

2) In 1 week after instructional session, describes the expected actions and adverse reactions of his medications

Which patient is most likely experiencing positive nitrogen balance? 1) Third-degree burns of his legs 2) In the sixth month of a healthy pregnancy 3) Resident from a nursing home who has been refusing to eat 4) Experiencing acute pancreatitis

2) In the sixth month of a healthy pregnancy

A client is coughing and has bilateral rhonchi throughout the lung fields. Which nursing diagnosis is most appropriate for these assessment findings? 1) Impaired Gas Exchange 2) Ineffective Airway Clearance 3) Ineffective Breathing Pattern 4) Impaired Spontaneous Ventilation

2) Ineffective Airway Clearance

Which form of communication is the nurse using when interviewing the patient during the admission health history and physical assessment? 1) Small group 2) Interpersonal 3) Group 4) Intrapersonal

2) Interpersonal

A patient who just returned from the postanesthesia care unit is complaining of severe incision pain. Which drug contained in the medication administration record will offer the fastest relief? 1) Liquid acetaminophen with codeine 2) Intravenous morphine sulfate 3) Intramuscular meperidine 4) Oral oxycodone tablets

2) Intravenous morphine sulfate

Which laboratory result should alert the nurse to a potential problem? 1) Na+ = 137 mEq/L 2) K+ = 5.2 mEq/L 3) Ca2+ = 9.2 mg/dL 4) Mg2+ = 1.8 mg/dL

2) K+ = 5.2 mEq/L

Which teaching strategy is typically most effective for presenting information to large groups? 1) Distributing printed materials 2) Lecturing using audiovisual format 3) Providing online sources of information 4) Role modeling

2) Lecturing using audiovisual format

The nurse must irrigate the colostomy of a patient who is unable to move independently. How should the nurse position the patient for this procedure? 1) Semi-Fowler's position 2) Left side-lying position 3) Supine with the head of the bed lowered flat 4) Supine with the head of bed raised to 30 degrees

2) Left side-lying position

Which factor in a patient's medical history is most likely to prolong the half-life of certain drugs? 1) Heart disease 2) Liver disease 3) Rheumatoid arthritis 4) Tobacco use

2) Liver disease

A client with chest tubes needs to be repositioned in bed. What action should the nurse take first when preparing to turn this client? 1) Lower the side rails. 2) Lock the bed wheels. 3) Lower the head of the bed. 4) Raise the bed to waist level.

2) Lock the bed wheels.

Which medication class will the primary care provider most likely prescribe to increase urine output in the patient with congestive heart failure? 1) Thiazide diuretic 2) Loop diuretic 3) MAO inhibitor 4) Anticholinergic

2) Loop diuretic

How can teaching be best provided to a patient who has a different primary language than the nurse? 1) Provide written materials in the patient's primary language. 2) Make arrangements to teach using an interpreter. 3) Provide a demonstration and request a return demonstration. 4) Use visual teaching aids to convey information.

2) Make arrangements to teach using an interpreter.

17. After a physician discusses cancer treatment options, the patient asks which treatment to choose. Which response by the nurse is best? 1) "If I were you, I'd go with chemotherapy." 2) "What do you think about radiation therapy?" 3) "Why don't you see what your spouse thinks?" 4) "I'll give you some information about each option."

4) "I'll give you some information about each option."

Which urine specific gravity would be expected in a patient with dehydration? 1) 1.002 2) 1.010 3) 1.025 4) 1.030

4) 1.030

A healthy client wants to start a fitness program to increase muscle tone and strength. What advice about the U.S. Department of Health and Human Service's recommendations should the nurse provide to this client? 1) Exercise once a week 2) 30 minutes or more of moderate-intensity physical activity three times a week 3) 1 hour, three times a week of moderate-intensity physical activity 4) 150 to 300 minutes or more of moderate-intensity physical activity per week

4) 150 to 300 minutes or more of moderate-intensity physical activity per week

A patient is given furosemide 40 mg orally at 0900. The duration of action for this drug is approximately 6 hours after oral administration. At which time in military hours should the nurse no longer expect to see the effects of this drug? 1) 0930 2) 1000 3) 1100 4) 1500

4) 1500

Which process requires energy to maintain the unique composition of extracellular and intracellular compartments? 1) Diffusion 2) Osmosis 3) Filtration 4) Active transport

4) Active transport

Chloride, bicarbonate, phosphate, and sulfate are examples of what type of charged particles and why? 1) Cations, because they carry a positive charge 2) Cations, because they carry a negative charge 3) Anions, because they carry a positive charge 4) Anions, because they carry a negative charge

4) Anions, because they carry a negative charge

A frail older client is expected to ambulate with a walker after surgery to repair a fractured left hip. What action should the nurse take to support the client's use of the walker? 1) Aerobic exercise with deep breathing 2) Quadriceps and gluteal repetitions 3) Isometric toning of lower legs 4) Arm resistance training

4) Arm resistance training

Which organ relies almost exclusively on glucose for energy? 1) Liver 2) Heart 3) Pancreas 4) Brain

4) Brain

A 6-year-old child becomes upset after learning that a blood sample is needed. The child's mother scolds the child and tells him to "act your age." How should the nurse proceed? 1) Request that the mother leave the room immediately. 2) Request the help of a coworker to hold the child down. 3) Inform the child that "this won't hurt a bit." 4) Calmly approach the child and tell him what is going to happen.

4) Calmly approach the child and tell him what is going to happen.

Which blood level normally provides the primary stimulus for breathing? 1) pH 2) Oxygen 3) Bicarbonate 4) Carbon dioxide

4) Carbon dioxide

A client with a closed head injury has a respiratory pattern that progressively increases and then decreases in depth, followed by a period of apnea. What is this client's breathing pattern? 1) Biot's breathing 2) Kussmaul's respirations 3) Sleep apnea 4) Cheyne-Stokes respirations

4) Cheyne-Stokes respirations

The nurse accidentally provides a patient with 10 mg of warfarin instead of 5 mg as prescribed. Which action should the nurse take? 1) No action is necessary because an extra 5 mg of warfarin is not harmful. 2) Call the prescriber and ask her to change the order to 10 mg. 3) Document on the chart that the drug was given and indicate the drug was given in error. 4) Complete an incident report according to the facility's policy.

4) Complete an incident report according to the facility's policy.

A patient with trigeminal neuralgia is prescribed a mechanical soft diet. This diet places the patient at risk for which complication? 1) Dehydration 2) Constipation 3) Hyperglycemia 4) Diarrhea

4) Diarrhea

Which describes the passive process by which molecules of a solute move through a cell membrane from an area of higher concentration to an area of lower concentration? 1) Osmosis 2) Filtration 3) Hydrostatic pressure 4) Diffusion

4) Diffusion

A newly admitted patient states not being concerned about diagnostic tests but is shaky and tearful and does not maintain eye contact. When conducting a conversation with the client, what should the nurse encourage the client to do? 1) Explain the reason for incongruent statements 2) Engage in diversional activities to cope with stress 3) Express concerns to the primary care provider 4) Discuss concerns and fears with the nurse

4) Discuss concerns and fears with the nurse

Which action should the nurse take immediately after administering a medication through a nasogastric tube? 1) Verify correct nasogastric tube placement in the stomach. 2) Auscultate the abdomen for presence of bowel sounds. 3) Immediately administer the next prescribed medication. 4) Flush the tube with water using a needleless syringe.

4) Flush the tube with water using a needleless syringe.

A patient in respiratory distress has the following arterial blood gases (ABGs) results: pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/L; PO2 = 80. After treatment, repeat ABGs results are pH = 7.38; PCO2 = 32; HCO3 = 19 mEq/L. What should the nurse conclude from this information? 1) Respiratory acidosis; the treatment plan is ineffective. 2) Metabolic alkalosis; the treatment plan is effective. 3) Partial compensation; the treatment plan is ineffective. 4) Full compensation; the treatment plan is effective.

4) Full compensation; the treatment plan is effective.

The primary care provider prescribes furosemide 40 mg IV for a patient with heart failure. Which drug name is used in this prescription? 1) Chemical 2) Brand 3) Trade 4) Generic

4) Generic

8. Which intervention by the nurse first helps to establish a trusting nurse-patient relationship? 1) Avoiding topics that may provoke emotional responses from the patient 2) Listening to the patient while performing care activities 3) Performing care interventions quietly and respectfully 4) Greeting the patient by name whenever entering the patient's room

4) Greeting the patient by name whenever entering the patient's room

The nurse notes that a client has had significant diarrhea over the past several days. Which level in the client's arterial blood gas result will be most affected? 1) pH 2) PO2 3) PCO2 4) HCO3

4) HCO3

Which action should the nurse take to relax the vastus lateralis muscle before administering an intramuscular injection into the site? 1) Apply a warm compress. 2) Massage the site in a circular motion. 3) Apply a soothing lotion. 4) Have the client assume a sitting position.

4) Have the client assume a sitting position.

When performing a central venous catheter dressing change, which step is correct? 1) Wear sterile gloves while removing and discarding the soiled dressing. 2) Apply pressure on the catheter-hub junction when removing the soiled dressing. 3) Place a sterile transparent dressing over the site and the catheter-hub junction. 4) Have the patient wear a mask or turn his head away from the site.

4) Have the patient wear a mask or turn his head away from the site.

The nurse gathers the following data: BP = 150/94 mm Hg; neck veins distended; P = 104 beats/min; pulse bounding; respiratory rate = 20 breaths/min; T = 37°C (98.6°F). What disorder should the nurse suspect? 1) Hypovolemia 2) Hypercalcemia 3) Hyperkalemia 4) Hypervolemia

4) Hypervolemia

The nurse auscultates low-pitched infrequent bowel sounds in a patient recovering from a bowel resection. How should this finding be documented? 1) Hyperactive bowel sounds 2) Abdominal bruit sounds 3) Normal bowel sounds 4) Hypoactive bowel sounds

4) Hypoactive bowel sounds

Which intervention would help to prevent or relieve persistent nausea? 1) Assess for signs of dehydration. 2) Provide dietary supplements. 3) Have the patient sit in an upright position for 30 minutes after eating. 4) Immediately remove any food that the patient cannot eat.

4) Immediately remove any food that the patient cannot eat.

A patient has anemia. An appropriate goal for that the patient would be for him to increase the intake of which nutrient? 1) Calcium 2) Magnesium 3) Potassium 4) Iron

4) Iron

Which collaborative interventions will help prevent paralytic ileus in a patient who underwent right hemicolectomy for colon cancer? 1) Administer morphine 4 mg IV every 2 hours for pain. 2) Administer IV fluids at 125 mL/hr. 3) Insert an indwelling urinary catheter to monitor I&O. 4) Keep the nasogastric tube to low suction.

4) Keep the nasogastric tube to low suction.

Which is the most appropriate goal for a patient with the nursing diagnosis of Deficient Fluid Volume? 1) Electrolyte balance restored, as evidenced by improved levels of alertness and cognitive orientation 2) Electrolyte balance restored, as evidenced by sodium returning to normal range 3) Patient demonstrates effective coughing and deep-breathing techniques. 4) Maintains fluid balance, as evidenced by moist mucous membranes and urinating every 4 hours

4) Maintains fluid balance, as evidenced by moist mucous membranes and urinating every 4 hours

A client's pulse oximetry reading is 90%. What action should the nurse take first? 1) Raise the head of the bed. 2) Prepare to administer oxygen. 3) Notify the healthcare provider. 4) Move the sensor to another area.

4) Move the sensor to another area.

When encouraging a fitness program for older adults, what must the nurse consider? 1) Older adults should engage in 75 to 150 minutes of moderate-intensity physical activity per week. 2) More than 150 minutes of moderate-intensity physical activity can be harmful to bones. 3) Structured fitness programs achieve greater health benefits for older adults. 4) Older adults at risk for falling should do activities that maintain or improve balance.

4) Older adults at risk for falling should do activities that maintain or improve balance.

A patient with end-stage cancer is prescribed morphine sulfate to reduce pain. For which effect is this medication prescribed? 1) Supportive 2) Restorative 3) Substitutive 4) Palliative

4) Palliative

After being informed of a cancer diagnosis, the patient responds, "I'll do whatever you think I should do." Which communication style is this patient using? 1) Assertive 2) Aggressive 3) Passive aggressive 4) Passive

4) Passive

A client is scheduled for surgery to create a temporary ostomy. What should the nurse emphasize when teaching about this bowel diversion? 1) Produces solid feces 2) Creates two separate stomas 3) Bypasses the large intestine 4) Permits the bowel to rest and heal

4) Permits the bowel to rest and heal

The nurse notes that a patient's intravenous catheter site is painful, edematous, red, and warm to the touch. There is a palpable cord along the vein and the fluid infusion is sluggish. What should the nurse suspect is occurring with this patient? 1) Infiltration 2) Extravasation 3) Hematoma 4) Phlebitis

4) Phlebitis

While a patient is receiving hygiene care, the chest tube becomes disconnected from the water-seal chest drainage system (CDU). Which action should the nurse take immediately? 1) Clamp the chest tube close to the insertion site. 2) Set up a new drainage system and connect it to the chest tube. 3) Have the patient take and hold a deep breath while the nurse reconnects the tube to the CDU. 4) Place the disconnected end nearest the patient into a bottle of sterile water.

4) Place the disconnected end nearest the patient into a bottle of sterile water.

Which intervention should the nurse take first to promote micturition in a patient who is having difficulty voiding? 1) Insert an indwelling urinary catheter. 2) Notify the provider immediately. 3) Insert an intermittent, straight catheter. 4) Pour warm water over the patient's perineum.

4) Pour warm water over the patient's perineum.

A client had the cast removed because of a fractured ulna and is directed to perform isometric exercises. Which exercise complies with the healthcare provider's order? 1) Place a 5-pound dumbbell in the right hand and squeeze; hold the squeeze position for 6 to 8 seconds and repeat 5 to 10 times. 2) Grasping the right wrist with the left hand, move the right arm up, down, and side to side; hold each position for 6 to 8 seconds and repeat 5 to 10 times. 3) Grasping the right wrist with the left hand, pull the right arm across the body; hold this position for 6 to 8 seconds and repeat 5 to 10 times. 4) Press the right hand against a wall; hold this position for 6 to 8 seconds and repeat 5 to 10 times.

4) Press the right hand against a wall; hold this position for 6 to 8 seconds and repeat 5 to 10 times.

Which is the principal system for regulation of fluid and electrolyte balance? 1) Cardiac 2) Vascular 3) Pulmonary 4) Renal

4) Renal

A patient is admitted with high BUN and creatinine levels, low blood pH, and elevated serum potassium level. Based on these laboratory findings the nurse suspects which diagnosis? 1) Cystitis 2) Renal Calculi 3) Enuresis 4) Renal Failure

4) Renal Failure

The nurse administers intravenous morphine sulfate to a patient for pain control. For which adverse effect should the nurse monitor this patient? 1) Decreased heart rate 2) Muscle weakness 3) Decreased urine output 4) Respiratory depression

4) Respiratory depression

A client has a nursing diagnosis of Ineffective Breathing Pattern identified on the care plan. What should the nurse expect when assessing this client? 1) Coughing 2) Cold extremities 3) Adventitious breath sounds 4) Respiratory rate of 8 breaths/min

4) Respiratory rate of 8 breaths/min

Which nursing diagnosis is the most appropriate to ensure the safety of a frail older client with a history of emphysema who is recovering from hip replacement surgery? 1) Impaired Physical Mobility related to weakness 2) Ineffective Breathing Pattern related to disease process 3) Activity Intolerance related to injury 4) Risk for Injury related to medical condition

4) Risk for Injury related to medical condition

During advanced cardiac life support (ACLS) training, a nurse performs defibrillation using a mannequin. Which teaching strategy is being employed? 1) One-to-one instruction 2) Computer-assisted instruction 3) Role modeling 4) Simulation

4) Simulation

A patient's vital signs prior to a blood transfusion were T = 97.6°F (36.4°C); P = 72 beats/min; R = 22 breaths/min; and BP = 132/76 mm Hg. Twenty minutes after the transfusion started, the patient began complaining of feeling "itchy and hot" and a new rash is present on the patient's trunk. Vital signs are now T = 100.8°F (38.2°C); P = 82 beats/min; R = 24 breaths/min; BP = 146/88 mm Hg. Based on these findings, what is the priority intervention? 1) Administer an antihistamine (anti-allergenic) medication. 2) Flush the blood tubing with D5W immediately. 3) Prepare for emergency resuscitation. 4) Stop the blood transfusion immediately.

4) Stop the blood transfusion immediately.

10. A patient complains that urine is passed when coughing or sneezing. How should the nurse document this complaint in the patient's healthcare record? 1) Transient incontinence 2) Overflow incontinence 3) Urge incontinence 4) Stress incontinence

4) Stress incontinence

2)The nurse educates a patient about the primary risk factors for irritable bowel syndrome. Which patient behavior indicates teaching has been effective? 1) Reduces intake of gluten-containing products. 2) Does not consume foods that contain lactose. 3) Consumes only two servings of caffeinated beverages per day. 4) Takes measures to reduce stress level.

4) Takes measures to reduce stress level.

A client with a high spinal cord injury but well-developed upper body strength is hospitalized for pneumonia. Which transfer device should be used when transferring him from the bed to his wheelchair? 1) Mechanical lift 2) Transfer belt 3) Drawsheet 4) Transfer board

4) Transfer board

A patient with chronic obstructive pulmonary disease (COPD) is prescribed O2 at 24% FIO2. What is the most appropriate oxygen delivery method for this patient? 1) Nonrebreather mask 2) Nasal cannula 3) Partial rebreather mask 4) Venturi mask

4) Venturi mask

A patient with a colostomy complains to the nurse, "I am noticing really bad odors coming from my pouch." To help control odor, which foods should the nurse advise the patient to consume? 1) White rice and toast 2) Tomatoes and dried fruit 3) Asparagus and melons 4)Yogurt and Parsley

4)Yogurt and Parsley

Laboratory test results indicate that warfarin anticoagulant therapy is suddenly ineffective in a patient who has been taking the drug for an extended time. The nurse suspects an interaction with herbal medications. What type of interaction does the nurse suspect? 1) Antagonistic drug interaction 2) Synergistic drug interaction 3) Idiosyncratic reaction 4) Drug incompatibility

1) Antagonistic drug interaction

A patient with severe hemorrhoids is incontinent of liquid stool. Which intervention is contraindicated for this patient? 1) Apply an indwelling fecal drainage device. 2) Apply an external fecal collection device. 3) Place an incontinence garment on the patient. 4) Place a waterproof pad under the patient's buttocks.

1) Apply an indwelling fecal drainage device.

When using the SBAR model to communicate with a physician, what information does the nurse offer first? 1) Statement of the problem and its probable cause 2) Nurse's name, patient's name, and reason for the communication 3) History of information related to and leading up to the situation 4) A solution to the problem or what is needed from the physician

2) Nurse's name, patient's name, and reason for the communication

The nurse manager is devising a teaching schedule for the staff who are about to begin using a new type of patient bed in the ICU. Implementation is planned in 6 weeks. When is the best time for the manager to schedule the teaching sessions? 1) Immediately 2) One week before implementation 3) Two weeks before implementation 4) Four weeks before implementation

2) One week before implementation

An older client begins to faint while ambulating in the hallway with the nurse. What action should the nurse take? 1) Assist the patient to slide down the leg while being guided to a seated or lying position. 2) Grab and hold the patient under the arms and call for assistance. 3) Immediately release the transfer device and place a wheelchair behind the patient to prevent a fall. 4) Instruct the patient to grab the rail in the hallway and call for assistance.

1) Assist the patient to slide down the leg while being guided to a seated or lying position.

A patient comes to the emergency department complaining of severe substernal chest pain. Which statement by the nurse appropriately offers reassurance? 1) "I'll give you some medication to help relieve the pain." 2) "If you lie still and relax, you'll be fine in a little while." 3) "Please try not to think about the pain as best as you can." 4) "Don't worry; we're going to take good care of you."

1) "I'll give you some medication to help relieve the pain."

A mother brings her 4-month-old infant for a well-baby checkup. The mother tells the nurse that she would like to start bottle feeding her baby because she cannot keep up with the demands of breastfeeding since returning to work. Which response by the nurse is appropriate? 1) "Make sure you give your baby an iron-fortified formula to supplement any stored breast milk you have." 2) "You really need to continue breastfeeding your baby." 3) "Give your baby formula until he is 6 months old; then you can introduce whole milk." 4) "Your baby weighs 14 pounds, so he will require about 36 ounces of formula a day."

1) "Make sure you give your baby an iron-fortified formula to supplement any stored breast milk you have."

10. Which statement or question by the nurse manager demonstrates an assertive approach when communicating with the staff nurse about a patient care issue? 1) "You must assess and document pain status for every patient." 2) "Why haven't you been assessing and documenting pain for every patient?" 3) "Will you please assess and document pain status for every patient?" 4) "Explain why you haven't been assessing and documenting pain for every patient."

1) "You must assess and document pain status for every patient."

An adult patient is prescribed a unit of packed red blood cells. Which gauge needle should be inserted to administer this blood product? 1) 18 gauge 2) 22 gauge 3) 24 gauge 4) 26 gauge

1) 18 gauge

Which documentation entry related to PRN medication administration is complete? 1) 6/5/14 0900 morphine 4 mg IV given in right antecubetal fossa for pain rated 8 on a 1-10 scale, J. Williams RN 2) 0600 famotidine 20 mg IV given in right hand, S. Abraham RN 3) 9/2/14 0900 levothyroxine 50 mcg PO given 4) 1/16/14 furosemide 40 mg PO given, J. Smith RN

1) 6/5/14 0900 morphine 4 mg IV given in right antecubetal fossa for pain rated 8 on a 1-10 scale, J. Williams RN

Which term refers to the movement of a drug from the site of administration to the bloodstream? 1) Absorption 2) Distribution 3) Metabolism 4) Excretion

1) Absorption

Which portion of a nutritional assessment must the registered nurse complete? 1) Analyzing the data 2) Obtaining intake and output 3) Weighing the patient 4) Obtaining the history

1) Analyzing the data

The nurse notes that a client has a prescription for a peak expiratory flow meter. For which health problem should the nurse prepare teaching for this client? 1) Asthma 2) Pneumonia 3) Emphysema 4) Pulmonary edema

1) Asthma

A surgeon prescribes potassium chloride 20 mEq by mouth for a patient with a nasogastric (NG) tube for gastric drainage. How should the nurse proceed? 1) Seek clarification from the surgeon about the medication order. 2) Clamp the NG tube while administering the dose by mouth. 3) Instill the medication through the NG tube. 4) Withhold the oral potassium chloride elixir.

1) Seek clarification from the surgeon about the medication order.

A health center that is interested in purchasing IV infusion pumps organizes a group of nurses to evaluate pumps provided by a variety of vendors. Which type of group has been organized? 1) Short term 2) Ongoing 3) Self-help 4) Work-related social support

1) Short term

A preschool-age child is scheduled for a tonsillectomy. Which strategy might help lessen the child's anxiety before surgery? 1) Show the child a short, animated video (DVD) about the hospital visit and procedure. 2) Give the child a tour of the hospital a week before the surgery is scheduled. 3) Allow the child to use computer-assisted instruction to teach him about the procedure. 4) Provide one-to-one instruction about the care he will need after surgery.

1) Show the child a short, animated video (DVD) about the hospital visit and procedure.

After receiving diphenhydramine, a patient complains of having a dry mouth. Which drug effect is this patient experiencing? 1) Side effect 2) Adverse reaction 3) Toxic reaction 4) Supportive effect

1) Side effect

The wife of an elderly patient begins crying after she is informed that he has a terminal illness. Which intervention by the nurse is best? 1) Sit quietly with the patient's wife while she composes her thoughts. 2) Inform his wife that a chaplain is available if she would like to speak to him. 3) Remind his wife that her husband has lived a long and happy life. 4) Tell his wife there are always options and suggest she not give up hope.

1) Sit quietly with the patient's wife while she composes her thoughts.

The nurse is helping the patient to perform leg exercises after surgery to prevent thrombophlebitis. Which type of muscle is the patient using for these exercises? 1) Skeletal 2) Smooth 3) Cardiac 4) Slow-twitch fibers

1) Skeletal

The nurse identifies the diagnosis Impaired Urinary Elimination in an older adult patient admitted after a stroke. Impaired Urinary Elimination places the patient at risk for which complication? 1) Skin breakdown 2) Urinary tract infection 3) Bowel incontinence 4) Renal calculi

1) Skin breakdown

A patient with leg cramps is irritable and febrile and has dry mucous membranes. Based on these findings, the patient most likely has excess levels of which mineral? 1) Sodium 2) Potassium 3) Phosphorus 4) Magnesium

1) Sodium

During family therapy, to improve communication skills the nurse teaches family members to rehearse responses to situations involving interpersonal conflict. What is the primary drawback of using this teaching strategy? 1) Some people might have difficulty with an interactive approach when there is conflict among participants. 2) Nurses might rehearse responses that are not effective for resolving interpersonal conflict. 3) Nurses do not use the rehearsal technique because it is an inefficient use of time for participants. 4) This type of interactive teaching strategy is not as effective as dispersing information verbally or in print.

1) Some people might have difficulty with an interactive approach when there is conflict among participants.

The student nurse asks for an indwelling urinary catheter for a hospitalized patient who is incontinent. Which response should the nurse make about the use of catheters only being absolutely necessary? 1) They are the leading cause of infection. 2) They are too expensive for routine use. 3) They contain latex, increasing the risk for allergies. 4) Insertion is painful for most patients.

1) They are the leading cause of infection.

The nurse prepares to conduct anthropometric measurements with a client. Where should the nurse measure skinfold thickness? 1) Triceps 2) Quadriceps 3) Gastrocnemius 4) Gluteus maximus

1) Triceps

A patient experiences expressive aphasia after a stroke. Which expected outcome is appropriate for this patient? 1) Uses alternative methods of communication 2) Communicates effectively using a translator 3) Interprets messages accurately 4) Follows commands when asked

1) Uses alternative methods of communication

Which food provides the body with no usable glucose? 1) Wheat germ 2) Apple 3) White bread 4) White rice

1) Wheat germ

4)A patient is diagnosed with an intestinal infection after traveling abroad. The nurse should encourage the intake of which food to promote healing? 1) Yogurt 2) Pasta 3) Oatmeal 4) Broccoli

1) Yogurt

The nurse in a long-term care facility is teaching a group of residents about increasing dietary fiber. Which foods should the nurse explain are high in fiber? 1) White bread, pasta, and white rice 2) Oranges, raisins, and strawberries 3) Whole milk, eggs, and bacon 4) Peaches, orange juice, and bananas

2) Oranges, raisins, and strawberries

The nurse prepares to meet with assigned clients after receiving hand-off communication. Which statement or question demonstrates that the nurse is in the working phase with a client? 1) "I see that you live near the hospital. Have you been living here awhile?" 2) "After breakfast we can review the instructions for insulin self-injection again." 3) "I'm going to miss talking with you ever day but you are better and ready to go home now." 4) "As soon as I get your admission papers I'll be in to talk with you about your health problem."

2) "After breakfast we can review the instructions for insulin self-injection again."

A patient newly diagnosed with breast cancer tells the nurse, "I'm worried I won't live to see my children grow up." Which response by the nurse best conveys concern and active listening? 1) "There have been many advances in breast cancer treatment; hope for the best." 2) "Breast cancer is a serious disease; I can understand why you're worried." 3) "You're strong and have youth on your side to fight the breast cancer." 4) "I'd be worried, too; I've seen a lot of patients die of breast cancer."

2) "Breast cancer is a serious disease; I can understand why you're worried."

A patient who sustained a spinal cord injury will perform intermittent self-catheterization after discharge. After discharge teaching, which statement by the patient would indicate correct understanding of the procedure? 1) "I will need to replace the catheter weekly." 2) "I can use clean, rather than sterile, technique at home." 3) "I will remember to inflate the catheter balloon after insertion." 4) "I will dispose of the catheter after use and get a new one each time."

2) "I can use clean, rather than sterile, technique at home."

The nurse instructs a woman about providing a clean-catch urine specimen. Which statement indicates that the patient correctly understands the procedure? 1) "I will be sure to urinate into the 'hat' you placed on the toilet seat." 2) "I will wipe my genital area from front to back before I collect the specimen midstream." 3) "I will need to lie still while you put in a urinary catheter to obtain the specimen." 4) "I will collect my urine each time I urinate for the next 24 hours."

2) "I will wipe my genital area from front to back before I collect the specimen midstream."

The nurse must insert a nasogastric (NG) tube into a patient with a bowel obstruction. Before inserting the tube, the nurse must explain the procedure to the patient. Which explanation by the nurse is best, assuming that all provide correct information? 1) "I'm going to insert an NG tube and connect it to low Gomco to keep your stomach empty." 2) "I'm going to insert a tube through your nose into your stomach to prevent you from vomiting." 3) "I'm going to insert an NG tube through your nares to suction your secretions and prevent emesis." 4) "Lie still, please; I need to elevate the head of the bed and insert this tube."

2) "I'm going to insert a tube through your nose into your stomach to prevent you from vomiting."

The nurse manager of the medical intensive care unit formed a group to help the staff cope with stress more effectively. Which of the comments by a group member causes the manager to evaluate the group as successful? 1) "This was a good idea to form a group; I've been wanting to get to know some of the people working the other shifts." 2) "It really helps me to share feelings about how hard it is to see pain and suffering every day." 3) "I now have a group to help me when I need to work through situations in my own life causing me stress." 4) "It feels good to have a chance to get away from the unit and talk on a regular basis."

2) "It really helps me to share feelings about how hard it is to see pain and suffering every day."

While performing a physical assessment, the student nurse tells her instructor that she cannot palpate her patient's bladder. Which statement by the instructor is best? 1) "Try to palpate it again; it takes practice but you will locate it." 2) "Palpate the patient's bladder only when it is distended by urine." 3) "Document this abnormal finding on the patient's chart." 4) "Immediately notify the nurse assigned to the care of your patient."

2) "Palpate the patient's bladder only when it is distended by urine."

A 15-year-old patient complains of left ankle pain after being tackled while playing football. He asks the nurse what tests he needs to have to determine whether he has a strain or a fracture. How should the nurse reply? 1) "You don't need an x-ray; I can tell by the way your ankle looks and feels whether you have a strain or fracture." 2) "Sprains, strains, and fractures have similar symptoms at first; you will need an x-ray of the joint to be certain." 3) "We will need to get a venous Doppler study to make sure that there is not a fracture." 4) "First, we need to get an MRI to diagnose your injury as a fracture instead of strain or sprain."

2) "Sprains, strains, and fractures have similar symptoms at first; you will need an x-ray of the joint to be certain."

19. A patient being admitted in hypertensive crisis reports stopping blood pressure medication 3 weeks ago. Which response by the nurse is best? 1) "You're lucky you didn't have a stroke; you really need to take your medication." 2) "Tell me more about your experience with your high blood pressure medication." 3) "Why did you stop taking your high blood pressure medication?" 4) "It's very important to take your blood pressure medication."

2) "Tell me more about your experience with your high blood pressure medication."

The nurse is preparing a patient for a computed tomography (CT) scan of the abdomen. Which statement by the nurse is best (all contain correct information)? 1) "You will need to remain NPO for the 4 hours prior to your CT scan." 2) "You cannot have anything to eat or drink for 4 hours before your test." 3) "You will need to be NPO and drink this contrast medium before your test." 4) "You may need to void before you go down to the department for your CT scan."

2) "You cannot have anything to eat or drink for 4 hours before your test."

1)Considering normal developmental and physical maturation in children, for which age would a goal of "Achieves bowel control by the end of this month" be most realistic? 1) 18 months 2) 3 years 3) 4 years 4) 5 years

2) 3 years

The nurse assesses a client prior to teaching a new skill. On what should the nurse focus to assess the client's health beliefs and practices? 1) Manual dexterity 2) Actions taken to stay healthy 3) Reasons for the current health problem 4) Ways the problem has affected current activities

2) Actions taken to stay healthy

A young adult with a severe episode of asthma bronchoconstriction comes to the emergency department with signs of respiratory distress. When the nurse performs the admission assessment, the patient is not oriented to place or time. Which nursing diagnosis is most suitable for this patient? 1) Chronic Confusion 2) Acute Confusion 3) Impaired Verbal Communication 4) Readiness for Enhanced Communication

2) Acute Confusion

A patient with a diabetic foot ulcer will need to perform dressing changes after discharge. When should the nurse schedule the teaching sessions? 1) Within 10 minutes after his next dose of oral pain medication 2) After the patient wakes up from a restful nap 3) Before the surgeon débrides the wound 4) Before the patient undergoes flow studies of his affected leg

2) After the patient wakes up from a restful nap

A client recovering from a respiratory infection is concerned about a new onset of diarrhea. What should the nurse assess in this client? 1) Last use of steroids 2) Amount of vitamin C ingested 3) Frequency of decongestant use 4) Use of over-the-counter antitussives

2) Amount of vitamin C ingested

The primary care provider orders peak and trough levels for a patient who is receiving intravenous vancomycin every 12 hours. When should the nurse obtain a blood specimen to measure the trough? 1) With the morning routine laboratory studies 2) Approximately 30 minutes before the next dose 3) Two hours after the next dose infuses 4) While the drug infuses

2) Approximately 30 minutes before the next dose

A patient is prescribed fluoxetine 20 mg by mouth daily for treatment of depression. The nurse caring for the patient is unfamiliar with this drug. Which action should the nurse take before administering the medication? 1) Inform the prescriber that she is not comfortable administering the drug. 2) Ask a nursing colleague for relevant information about the drug. 3) Consult the drug formulary accessible to staff at the patient care unit. 4) Trust the prescriber who writes the dose and administer the drug as intended.

2) Ask a nursing colleague for relevant information about the drug.

A middle-aged patient with a history of alcohol abuse is admitted with acute pancreatitis. This patient will most likely be deficient in which nutrient? 1) Iron 2) B vitamins 3) Calcium 4) Phosphorus

2) B vitamins

A client who follows a vegan eating plan is experiencing numbness and tingling of the fingers and toes. Which supplement should the nurse recommend to this client? 1) C 2) B12 3) Zinc 4) Magnesium

2) B12

Which course of action taken by a patient with osteoporosis indicates that teaching about the health problem was effective? 1) Taking a calcium supplement every day and increasing phosphorous intake 2) Participating in an aerobic barbell strength class at the gym three times a week 3) Using a wheelchair to reduce the risk of spontaneous fractures to legs and feet 4) Seeking healthcare by scheduling a follow-up examination with bone density testing

2) Participating in an aerobic barbell strength class at the gym three times a week

Which outcome is appropriate for the patient who underwent urinary diversion surgery and creation of an ileal conduit for invasive bladder cancer? 1) Patient will resume his normal urination pattern by (target date). 2) Patient will perform urostomy self-care by (target date). 3) Patient will perform self-catheterization by (target date). 4) Patient's urine will remain clear with sufficient volume.

2) Patient will perform urostomy self-care by (target date).

A client with pulmonary hypertension and right-sided heart failure has conversational dyspnea and shortness of breath. What is the first action the nurse should take? 1) Review and implement the primary care provider's prescriptions for treatments. 2) Perform a quick physical examination of breathing, circulation, and oxygenation. 3) Gather a thorough medical history, including current symptoms, from the family. 4) Administer oxygen to the patient through a nasal cannula.

2) Perform a quick physical examination of breathing, circulation, and oxygenation.

24. The primary care provider prescribes nitroglycerin 1/150 g SL for a patient experiencing chest pain. How should the nurse administer the drug? 1) Place the drug in the cheek and allow it to dissolve. 2) Place the drug under the tongue and allow it to dissolve. 3) Inject the drug superficially into the subcutaneous tissue. 4) Give the pill and water to the patient for him to swallow the tablet.

2) Place the drug under the tongue and allow it to dissolve.

When using sterile technique to perform tracheostomy care of a new tracheostomy, which action is correct? 1) Apply sterile gloves. 2) Place the patient in semi-Fowler's position, if possible. 3) Clean the stoma under the faceplate with hydrogen peroxide. 4) Cut a slit in sterile 4 ´ 4 gauze halfway through to make a dressing.

2) Place the patient in semi-Fowler's position, if possible.

Which laboratory test result most accurately reflects a patient's nutritional status? 1) Albumin 2) Prealbumin 3) Transferrin 4) Hemoglobin

2) Prealbumin

Which nutrient deficiency increases the risk for pressure ulcers? 1) Carbohydrate 2) Protein 3) Fat 4) Vitamin K

2) Protein

A client with a tracheostomy being mechanically ventilated has a pulse oximetry reading of 85%, heart rate of 113 beats/min, and respiratory rate of 30 breaths/min. The client is restless, and crackles and rhonchi are auscultated over both lungs. Which action should the nurse take? 1) Call the respiratory therapist to check the ventilator settings. 2) Provide endotracheal suctioning. 3) Provide tracheostomy care. 4) Notify the physician of the patient's signs of fluid overload.

2) Provide endotracheal suctioning.

A nurse has been asked to design an exercise program with the goal of increasing a client's muscular strength and endurance. Which exercise program would specifically focus on meeting that goal? 1) Flexibility training 2) Resistance training 3) Aerobic conditioning 4) Anaerobic conditioning

2) Resistance training

When caring for a patient with osteoporosis, which is the most important action to take to minimize progression of the disease? 1) Take a calcium supplement twice a day. 2) Start a weight-bearing exercise program. 3) Avoid strenuous activity that puts stress on the bones. 4) Schedule regular healthcare checkups.

2) Start a weight-bearing exercise program.

An older patient is unsteady when walking about the room and reports feeling a little sore but has no complaints of weakness. What is the appropriate piece of equipment to use when helping this patient ambulate? 1) Crutches 2) Transfer belt 3) Cane 4) Walker

2) Transfer belt

The nurse must administer hepatitis B immunoglobulin 0.5 mL intramuscularly to a 3-day-old infant. Which injection site should the nurse choose to administer this injection? 1) Ventrogluteal 2) Vastus lateralis 3) Deltoid 4) Dorsogluteal

2) Vastus lateralis

The nurse records a patient's hourly urine output from an indwelling catheter as follows: 0700: 36 mL 0800: 45 mL 0900: 85 mL 1000: 62 mL 1100: 50 mL 1200: 48 mL 1300: 94 mL 1400: 78 mL 1500: 60 mL How should the nurse describe the patient's urine output? 1) Low 2) Within normal limits 3) High 4) Inconclusive

2) Within normal limits

For which patient is the nursing diagnosis Deficient Knowledge most appropriate? 1) Adolescent with Down syndrome and newly diagnosed with cardiac problem 2) Young adult admitted with acute renal failure who requires hemodialysis 3) Middle-aged woman with breast cancer receiving the last round of chemotherapy 4) Older adult with a long-standing history of type 1 diabetes admitted with a foot ulcer

2) Young adult admitted with acute renal failure who requires hemodialysis

When changing a diaper, the nurse observes that a 2-day-old infant has passed a green-black, tarry stool. What should the nurse do? Notify the provider immediately. Do nothing; this is normal. Give the baby sterile water until the mother's milk comes in. Apply a skin barrier cream to the buttocks to prevent irritation.

2)Do nothing this is normal

An older adult patient who underwent bowel resection is recovering from surgery without complication. He ambulates in the hallway and requires little analgesia for pain. During the healthcare team's morning rounds, the surgeon informs the patient that the lesion removed was cancerous. Which factor will likely be the patient's most significant obstacle for learning? 1) The patient's baseline physical condition 2) A negative environmental influence 3) Anxiety associated with the new diagnosis 4) Reduced ability to understand the diagnosis

3) Anxiety associated with the new diagnosis

A patient had surgery 6 hours ago. When the nurse enters the room to turn him, she notes that he is restless and grimacing. Considering the patient's nonverbal communication, what action should the nurse take first? 1) Administer pain medication to the patient. 2) Turn and reposition the patient. 3) Assess to determine the cause of the grimacing. 4) Leave the patient's room so he can rest quietly.

3) Assess to determine the cause of the grimacing.

Which statement or question by the nurse indicates that the nurse-patient relationship is entering the termination phase? 1) "I'll be admitting you to our nursing unit as soon as I obtain your health history." 2) "You seem upset today. Would you like to talk about whatever is bothering you?" 3) "I'm leaving for the day. Is there anything I can do for you before I leave?" 4) "Hello. My name is Leslie, and I'm going to be your nurse today."

3) "I'm leaving for the day. Is there anything I can do for you before I leave?"

A client in labor after 32 weeks' gestation is eager to deliver. Which client statement indicates that teaching provided about fetal development was effective? 1) "The baby's lungs are well developed now, but he will be at increased risk for SIDS if I deliver early." 2) "We should try to stop this labor now because the baby will be born with sleep apnea if I deliver this early." 3) "If I deliver this early my baby is at risk for respiratory distress syndrome, a condition that can be life threatening." 4) "Thanks for reassuring me; I was pretty sure there isn't much risk to the baby this far along in my pregnancy."

3) "If I deliver this early my baby is at risk for respiratory distress syndrome, a condition that can be life threatening."

A 62-year-old man with emphysema does not understand the need to stop smoking at this age because lung problems already exist. Which would be the best response to his statement? 1) "You should quit so your family does not get sick from exposure to secondhand smoke." 2) "You will need to use oxygen, but remember it is a fire hazard to smoke with oxygen in your home." 3) "Once you stop smoking, your body will begin to repair some of the damage to your lungs." 4) "You should ask your primary care provider for a prescription for a nicotine patch to help you quit."

3) "Once you stop smoking, your body will begin to repair some of the damage to your lungs."

The parents of an adolescent client recovering from a crushed pelvis are concerned about the client's lack of interest in music, television, or friends. What is the best response the nurse can make? 1) "I will inform his doctor and see if we can get your son started on an antidepressant medication." 2) "He is at a critical time in his life; teens are often moody, and being in the hospital with an injury will only make that worse." 3) "Your son had a major injury; and his immobility might be causing him to feel isolated and depressed." 4) "He is bored because he has been in the hospital for 3 weeks; I'll try to find something new for him to do."

3) "Your son had a major injury; and his immobility might be causing him to feel isolated and depressed."

How many diapers should a healthy newborn use for urine output each day? 1) 4 2) 6 3) 10 4) 15

3) 10

A healthcare provider prescribes 250 mL of 0.9% sodium chloride to be infused over 2 hours. A microdrip infusion set is being used. What is the drip rate (drops/min) that the nurse should monitor? 1) 60 2) 75 3) 125 4) 250

3) 125

A nurse is teaching wellness to a women's group. The nurse should explain the importance of consuming at least how many 8-ounce servings of fluid to promote healthy bowel function? 1) 2 to 3 2) 4 to 5 3) 6 to 8 4) 9 to 10

3) 6 to 8

A patient's digoxin level is 1.2 ng/mL; the therapeutic range for this drug is 0.5 to 2.0 ng/mL. Which action should the nurse take? 1) Notify the prescriber to reduce the dose. 2) Withhold the next dose of digoxin. 3) Administer the next dose as prescribed. 4) Notify the prescribing healthcare provider to increase the dose.

3) Administer the next dose as prescribed.

The nurse is teaching parents ways to give oral medication to their child. Which action would they implement to improve compliance? 1) Crush time-release capsules to put in his favorite food. 2) Give medication quickly before he knows what is happening. 3) Allow the child to eat a frozen pop before receiving the medication. 4) Mask the flavor of medication in a toddler cup with orange juice.

3) Allow the child to eat a frozen pop before receiving the medication

The nurse prepares teaching material for a client scheduled for an ileostomy. What information is essential to include when teaching this client? 1) It is usually temporary. 2) Irrigation can control bowel movements. 3) An ostomy device must be worn at all times. 4) Changing the diet can control bowel movements.

3) An ostomy device must be worn at all times.

Which is a key treatment intervention for the patient admitted with diverticulitis? 1) Antacid 2) Antidiarrheal agent 3) Antibiotic therapy 4) NSAIDs

3) Antibiotic therapy

What action is most important in limiting the nurse's risk of back injuries? 1) Use good body mechanics at all times. 2) Work with another nurse or an aide when lifting and turning patients. 3) Avoid manual lifting by using assistive devices as often as possible. 4) Develop a lift team at the clinical site.

3) Avoid manual lifting by using assistive devices as often as possible.

After instructing a mother about nutrition for a preschool-age child, which statement by the mother would indicate correct understanding of the topic? 1) "I usually use dessert only as a reward for eating other foods." 2) "I will hide vegetables in casseroles and stews to get my child to eat them." 3) "I do not give my child snacks; they simply spoil his appetite for meals." 4) "I know that lifelong food habits are developed during this stage of life."

4) "I know that lifelong food habits are developed during this stage of life."

A nurse has sound, scientific evidence to support changing a procedure that would reduce catheter-related infections on the unit. The nurse manager is unwilling to make the change because it would be too costly. Which response by the nurse represents assertive communication? 1) "This is a widely used practice. If you read more research, you'd probably wonder why we aren't already doing it." 2) "There is extensive evidence to support the new method, but I don't want to create an issue." 3) "Is the budget more important to the hospital than reducing infections and patient suffering?" 4) "I'd like to help gather information regarding the cost of new materials versus the savings in treating infections."

4) "I'd like to help gather information regarding the cost of new materials versus the savings in treating infections."

Which are the rights of medication administration? 1) right patient, right room, right drug, right route, right dose, and right time. 2) right drug, right dose, right route, right time, right physician, and right documentation. 3) right patient, right drug, right route, right time, right documentation, and right equipment. 4) right patient, right drug, right dose, right route, right time, and right documentation.

right patient, right drug, right dose, right route, right time, and right documentation.