Fundamentals NCLEX book Practice questions

The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? 1. "I swim 3 times a week." 2. "I have stopped smoking cigars." 3. "I drink hot chocolate before bedtime." 4. "I read for 40 minutes before bedtime."

"I drink hot chocolate before bedtime." Rationale: Many nonpharmacological sleep aids can be used to influence sleep. However, the client should avoid caffeinated beverages and stimulants such as tea, cola, and chocolate. The client should exercise regularly because exercise promotes sleep by burning off tension that accumulates during the day. A 20- to 30-minute walk, swim, or bicycle ride 3 times a week is helpful. The client should sleep on a bed with a firm mattress. Smoking and alcohol should be avoided. The client should avoid large meals; peanuts, beans, fruit, raw vegetables, and other foods that produce gas; and snacks that are high in fat because they are difficult to digest.

The nurse is developing a plan of care for a hospitalized Asian American client. The nurse should include which measures in the client's plan of care? Select all that apply. 1. Limit eye contact. 2. Clarify responses to questions. 3. Use hand gestures to communicate. 4. Maintain physical space with the client. 5. Hold the client's hand to provide comfort.

1. Limit eye contact. 2. Clarify responses to questions. 4. Maintain physical space with the client.

The nurse is caring for a client whose arterial blood gas results reveal alkalosis. What client reactions would the nurse expect to see? Select all that apply. 1. Tetany 2. Lethargy 3. Tingling 4. Confusion 5. Numbness 6. Restlessness

1. Tetany 3. Tingling 5. Numbness 6. Restlessness Rationale: A client's reaction to alkalosis causes tingling and numbness of the fingers, restlessness, and tetany caused by irritability of the central nervous system (CNS) results. If the severity of alkalosis increases, convulsions and coma may occur.

The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action? 1. Continue with the instructions, verifying client understanding. 2. Walk around the client so that the nurse constantly faces the client. 3. Give the client a dietary booklet and return later to continue with the instructions. 4. Tell the client about the importance of the instructions for the maintenance of health care.

1. Continue with the instructions, verifying client understanding. Rationale: Most Chinese Americans maintain a formal distance with others, which is a form of respect. Many Chinese Americans are uncomfortable with face-to-face communications, especially when eye contact is direct. If the client turns away from the nurse during a conversation, the best action is to continue with the conversation. Walking around the client so that the nurse faces the client is in direct conflict with this cultural practice. The client may consider it a rude gesture if the nurse returns later to continue with the explanation. Telling the client about the importance of the instructions for the maintenance of health care may be viewed as degrading.

A client has a problem with sleeping at night. The nurse encourages the client to do which measure to best enhance nighttime sleep? 1. Drink a glass of milk. 2. Eat a large bedtime snack. 3. Eat a snack with spicy ingredients. 4. Avoid caffeine products 1 hour before sleep.

1. Drink a glass of milk. Milk contains the essential amino acid tryptophan, which can enhance sleep by promoting production of the neurotransmitter serotonin in the brain. The client should avoid spicy foods and a large intake just before bedtime. The client should also avoid caffeine after noon.

The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior? 1. Reflecting a cultural value 2. An acceptance of the treatment 3. Client agreement to the required procedures 4. Client understanding of the preoperative procedures

1. Reflecting a cultural value Rationale: Nodding or smiling by a Japanese American client may reflect only the cultural value of interpersonal harmony. This nonverbal behavior may not be an indication of acceptance of the treatment, agreement with the speaker, or understanding of the procedure.

The nurse prepares to perform nail and foot care on a client. Which interventions should the nurse include in the procedure? Select all that apply. 1. Use a soft nail brush around the cuticles. 2. Soak the feet in warm water for 40 minutes. 3. Inspect the nails and feet before and after soaking and cleaning. 4. Shape nails using a nail file, being sure to file corners of toenails. 5. Clean under the nails with a plastic stick while the fingers are immersed in water.

1. Use a soft nail brush around the cuticles. 3. Inspect the nails and feet before and after soaking and cleaning. 5. Clean under the nails with a plastic stick while the fingers are immersed in water. Rationale: The nurse should first perform hand hygiene and apply gloves to perform foot and nail care. The nurse would assess the condition of the skin and nails before the procedure, paying particular attention to areas of dryness, inflammation, or cracking. The nurse would inspect areas between the toes, the heels, and the sides of the foot. The nurse would also inspect the nails and feet after the procedure to ensure cleanliness and skin integrity and to note any remaining rough edges around the nails. The feet are soaked for 10 to 20 minutes in warm water for easy removal of dead cells and easy manipulation of the cuticle. Soaking longer than this time frame can cause maceration of the skin and skin breakdown. The nurse would clean under the nails with a plastic stick while the fingers are immersed in water; this allows for easy removal of debris under the nails. The stick is used gently to remove the debris and a plastic stick rather than a wood stick is used because wood could cause splintering. A soft nail brush is used to clean around the cuticles to prevent cuticle inflammation. Nails are filed straight across; filing the corners of nails can damage tissue. The nurse would also teach the client about the procedure and document the procedure and observations.

A client is determined by blood gas analysis to be in respiratory alkalosis. Which electrolyte disorder should the nurse monitor for that could accompany the acid-base imbalance? 1. Hypokalemia 2. Hypercalcemia 3. Hypochloremia 4. Hypernatremia

1. hypokalemia Rationale: Clinical manifestations of respiratory alkalosis include tachypnea, hyperpnea, weakness, paresthesias, tetany, dizziness, convulsions, coma, hypokalemia, and hypocalcemia. The clinical picture does not include hypercalcemia, hypochloremia, or hypernatremia.

The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next? 1. Reassess the client. 2. Conduct a staff meeting to describe the fall. 3. Document in the nurse's notes that an incident report was completed. 4. Contact the nursing supervisor to update information regarding the fall.

1. reassess the client Rationale: After a client's fall, the nurse must frequently reassess the client because potential complications do not always appear immediately after the fall. The client's fall should be treated as private information and shared on a "need to know" basis. Communication regarding the event should involve only the individuals participating in the client's care. An incident report is a problem-solving document; however, its completion is not documented in the nurse's notes. If the nursing supervisor has been made aware of the incident, the supervisor will contact the nurse if status update is necessary.

The nurse is instructing a client who had a stroke and has weakness on one side how to ambulate with the use of a cane. Which instruction should the nurse provide to the client? 1. Hold the cane on the affected (weak) side. 2. Hold the cane on the unaffected (strong) side. 3. Move the cane forward first along with the unaffected (strong) leg. 4. Move the cane and the unaffected (strong) leg down first when going down stairs.

2. Hold the cane on the unaffected (strong) side. Rationale: The cane is kept on the strong side of the body. It would be hard to hold the cane on the weak side. The cane is assisting the weakened leg, so the weakened leg moves with the cane, or right after it, in ambulating or in going down stairs.

The client tells the nurse that he ingests large amounts of oral antacids on a daily basis. The nurse plans care knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

2. Metabolic alkalosis Rationale: Increases in base components occur as a result of oral or parenteral intake of bicarbonates, carbonates, acetates, citrates, or lactates. Excessive use of oral antacids containing bicarbonate can cause a metabolic alkalosis. The remaining acid-base disturbances are incorrect.

When communicating with a client who speaks a different language, which best practice should the nurse implement? 1. Speak loudly and slowly. 2. Arrange for an interpreter to translate. 3. Speak to the client and family together. 4. Stand close to the client and speak loudly.

2. Arrange for an interpreter to translate. Rationale: Arranging for an interpreter would be the best practice when communicating with a client who speaks a different language. Options 1 and 4 are inappropriate and ineffective ways to communicate. Option 3 is inappropriate because it violates privacy and does not ensure correct translation.

A client's blood gas results reveal acidosis. What are some signs and symptoms the nurse would expect to see? Select all that apply. 1. Seizures 2. Lethargy 3. Headache 4. Weakness 5. Confusion 6. Hyperactivity

2. Lethargy 3. Headache 4. Weakness 5. Confusion

The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required by the UAP? 1. Placing a safety knot(fast release) in the safety device straps 2. Safely securing the safety device straps to the side rails 3. Applying safety device straps that do not tighten when force is applied against them 4. Securing so that 2 fingers can slide easily between the safety device and the client's skin

2. Safely securing the safety device straps to the side rails Rationale: The safety device straps are secured to the bed frame and never to the side rails to avoid accidental injury in the event that the side rails are released. A half-bow or safety knot or device with a quick release buckle should be used to apply a safety device because it does not tighten when force is applied against it and it allows quick and easy removal of the safety device in case of an emergency. The safety device should be secure, and 1 or 2 fingers should slide easily between the safety device and the client's skin.

When communicating with a client who speaks a different language, which best practice should the nurse implement? 1. Speak loudly and slowly. 2. Arrange for an interpreter to translate. 3. Speak to the client and family together. 4. Stand close to the client and speak loudly.

2. arrange for an interpreter to translate Rationale: Arranging for an interpreter would be the best practice when communicating with a client who speaks a different language. Options 1 and 4 are inappropriate and ineffective ways to communicate. Option 3 is inappropriate because it violates privacy and does not ensure correct translation.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

2. metabolic alkalosis Rationale: Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. The remaining options are incorrect interpretations.

The client with a history of lung disease is at risk for developing respiratory acidosis. The nurse asks this client about which symptoms that are characteristic of this disorder? 1. "Do you have shallow breathing?" 2. "Do you feel like you have a lot of energy?" 3. "Do you have a headache or become confused?" 4. "Do you feel dizzy or have tingling sensations?"

3. "Do you have a headache or become confused?"

The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? 1. Out-of-bed activities as desired 2. Bed rest with the affected extremity kept flat 3. Bed rest with elevation of the affected extremity 4. Bed rest with the affected extremity in a dependent position

3. Bed rest with elevation of the affected extremity Rationale: For the client with deep vein thrombosis, elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. A flat or dependent position of the leg would not achieve this goal. Bed rest is indicated to prevent emboli and to prevent pressure fluctuations in the venous system that occur with walking.

The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and Hco3 of 27 mEq/L (27 mmol/L). The nurse interprets that the client has which acid-base disturbance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

3. Respiratory acidosis

The nurse is reviewing the arterial blood gas values of a client and notes that the pH is 7.31 (7.31), Paco2 is 50 mm Hg (50 mm Hg), and the bicarbonate (HCO3) level is 26 mEq/L (26 mmol/L). The nurse concludes that which acid-base disturbance is present in this client? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

3. Respiratory acidosis Rationale: In respiratory acidosis, the pH is decreased and the Paco2 level is increased. Options 1, 2, and 4 are incorrect. In respiratory alkalosis, the pH is elevated with a decrease in Paco2. In metabolic acidosis, both the pH and the HCO3 are decreased. In metabolic alkalosis, the pH and HCO3 are increased.

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? 1. Bradycardia and hyperactivity 2. Decreased respiratory rate and depth 3. Headache, restlessness, and confusion 4. Bradypnea, dizziness, and paresthesias

3. headache, restlessness, and confusion Rationale: When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.

Where should the nurse assess skin color changes in the dark-skinned patient? 1) Nailbeds 2) Any exposed area 3) Oral mucosa 4) Palm of hands

3. oral mucosa

An anxious preoperative client is at risk for developing respiratory alkalosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? 1. Headache and tachypnea 2. Hyperactivity and dyspnea 3. Muscle twitches and cyanosis 4. Lightheadedness and paresthesias

4. Lightheadedness and paresthesias Rationale: Clinical manifestations of respiratory alkalosis include a decrease in the respiratory rate and depth, headache, lightheadedness, vertigo, mental status changes, paresthesias such as tingling of the fingers and toes, hypokalemia, hypocalcemia, tetany, and convulsions. The remaining three options are not clinical manifestations of respiratory alkalosis.

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mm Hg), and HCO3- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition? 1. Metabolic acidosis with compensation 2. Respiratory acidosis with compensation 3. Metabolic acidosis without compensation 4. Respiratory acidosis without compensation

4. Respiratory acidosis without compensation Rationale: The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm). In respiratory acidosis the pH is decreased and the Pco2 is elevated. The normal bicarbonate (HCO3-) level is 21 to 28 mEq/L (21 to 28 mmol/L). Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. In addition, the pH is not within normal limits. Therefore, the condition is without compensation. The remaining options are incorrect interpretations.

Arterial blood gas analysis yields the following results: pH 7.48 (7.48), Paco2 32 mm Hg (32 mm Hg), Pao2 94 mm Hg (94 mm Hg), HCO3 level 24 mEq/L (24 mmol/L) for a client seen in the health care clinic. The nurse interprets that the client has which acid-base disturbance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

4. Respiratory alkalosis The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg, and the normal HCO3 concentration is 21 to 28 mEq/L. The pH is elevated in alkalosis and low in acidosis. In a respiratory condition, an opposite effect will be seen between the pH and the Paco2. In a metabolic condition, the pH and the bicarbonate move in the same direction.

The nurse is providing instructions to the unlicensed assistive personnel (UAP) who will be caring for a client with hand restraints. The nurse asks the UAP to repeat the instructions to ensure that the UAP understands the care. Which statement, if made by the UAP, indicates an understanding of the care for this client? 1. "I need to remove the restraints every 4 hours." 2. "I need to make sure that the restraints are securely tied to the side rails." 3. "If the family comes in to visit, I can tell them to take the restraints off if they want to." 4. "I need to remove the restraints at least every 2 hours to perform range-of-motion exercises."

4. "I need to remove the restraints at least every 2 hours to perform range-of-motion exercises." Rationale: The nurse should instruct the UAP to check restraints, circulatory status, and skin integrity every 30 minutes. Additionally, restraints need to be removed at least every 2 hours to permit muscle exercise and promote circulation. Restraints are not to be secured to the bedrails because this could cause injury to the client if the rails are lowered. The responsibility of the client should not be placed on the family members. Agency guidelines regarding the use of restraints should always be followed.

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm Hg (72 mm Hg), Paco2 = 32 mmHg (32 mm Hg), and HCO3- = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make? 1. The client has acidotic blood. 2. The client is probably overreacting. 3. The client is fluid volume overloaded. 4. The client is probably hyperventilating.

4. the client is probably hyperventilating Rationale: The ABG values are abnormal, which supports a physiological problem. The ABGs indicate respiratory alkalosis as a result of hyperventilating, not acidosis. Concluding that the client is overreacting is an insufficient analysis. No conclusion can be made about a client's fluid volume status from the information provided.

A patient reports having the urge to void, but urine starts leaking before the patient reaches the bathroom. Which treatment strategies would be helpful for this patient? Select all that apply. A. Scheduled toileting B. Absorbent products C. Electrical stimulation D. Clothing modification E. Antimuscarinic agents

A, B, D Functional incontinence is characterized by the inability to reach the bathroom in time. Scheduled toileting involves teaching the patient to void at specified times so that there is no urgency. Use of absorbent products helps prevent soiling of clothes. Clothing can be modified to make it easier to remove when there is an urgency to void. Electrical stimulation is helpful for patients with stress incontinence. Antimuscarinic agents are helpful for patients with urge incontinence.

What characteristics are associated with urge urinary incontinence? Select all that apply. A. Urgency B. Frequency C. Leakage of urine without awareness D. Diminished awareness of the urge to void E. Difficulty holding urine once the urge to void occurs

A, B, E The characteristics associated with urge urinary incontinence are urgency, frequency, and difficulty holding urine once the urge to void occurs. Leakage of urine without awareness and diminished awareness of the urge to void are associated with reflex urinary incontinence.

Which of the following nursing activities is of highest priority for maintaining medical asepsis? a. Washing hands b. Donning gloves c. Wearing a gown d. Wearing a face mask

A. washing hands

A patient is diagnosed with transient incontinence. What does the nurse explain to the patient about the cause of this type of urinary incontinence? A. "Transient incontinence is the loss of continence because of causes outside the urinary tract." B. "Transient incontinence is caused by medical conditions that are mostly treatable and reversible." C. "Transient incontinence is caused by urethral hypermobility or an incompetent urinary sphincter." D. "Transient incontinence is caused by an overdistended bladder; it is often related to bladder outlet obstruction."

B Transient incontinence is defined as incontinence caused by medical conditions that are generally treatable and reversible. Functional incontinence is continence due to causes outside the urinary tract. Stress urinary incontinence is defined as involuntary leakage of small volumes of urine associated with increased intraabdominal pressure related to either urethral hypermobility or an incompetent urinary sphincter. Urinary incontinence associated with the chronic retention of urine is the involuntary loss of urine caused by an overdistended bladder, which is often related to bladder outlet obstruction or poor bladder emptying due to weak or absent bladder contractions

A 70-year-old woman complains of involuntary passage of urine. The leakage of urine occurs in small amounts and is more frequent when she coughs. The nursing assessment reveals that the patient is obese, has had three pregnancies, and has already gone through menopause. Which nursing interventions would be helpful to this patient in reducing incontinence? Select all that apply. A. Advise the patient to suppress coughs. B. Teach the patient Kegel exercises. C. Advise the patient to avoid caffeinated drinks. D. Stress the importance of losing weight. E. Encourage lifting heavy weights to increase muscle strength.

B, C, D Kegel exercises increase the strength of muscles around the urethra and help to reduce stress incontinence. Losing weight helps to reduce stress incontinence. Cough is a reflex activity and is difficult to control voluntarily. Caffeinated drinks have a diuretic effect and increase stress incontinence. Lifting heavy weights increases abdominal pressure and thus increases incontinence; therefore, this activity should be avoided.

Which of the following behaviors indicates the highest potential for spreading infectious among patients. The nurse ___________________ a. disinfects dirty hands with antibacterial soap. b. allows alcohol-based rub to dry for 10 seconds c. washes hands only after leaving patients room d. uses cold water for medical asepsis.

C. washes hands ONLY after leaving the pt's room

All the following are associated with an increased incidence of urinary incontinence except: a. Age b. Obesity c. Chronic cough d. Indwelling catheter e. Peripheral nerve injury

D. Indwelling catheter

A cold, moist compress is prescribed to be applied to the client's right knee. Which should the nurse plan for? 1. Leave the compress on for 45 minutes. 2. Ensure that the compress material is sterile. 3. Ensure that the temperature of the compress is 15°C (59°F). 4. Expect some bluish discoloration of the skin during the application period.

Ensure that the temperature of the compress is 15°C (59°F). Rationale: The procedure for applying cold, moist compresses is the same as that for warm compresses. The cold compress is applied for 20 minutes at a temperature of 15°C (59°F) to relieve inflammation and swelling. Clean or sterile compresses can be used, although sterile may be prescribed for open wounds. When using cold compresses, the nurse needs to observe for adverse reactions such as burning or numbness, mottling of the skin, redness, extreme paleness, and a bluish skin discoloration. If these adverse reactions occur, the compress is immediately removed.

The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion? 1. Right side 2. Low Fowler's 3. High Fowler's 4. Supine with the head flat

High Fowler's Rationale: During insertion of a nasogastric tube, the client is placed in a sitting or high Fowler's position to facilitate insertion of the tube and reduce the risk of pulmonary aspiration if the client should vomit. The right side, and low Fowler's and supine positions place the client at risk for aspiration; in addition, these positions do not facilitate insertion of the tube.

A nurse working an overnight hospital shift is administering medications to her patients. Which of these is the most important thing to do prior to giving medications to her patients? Match the room and bed number to the room and bed number on the medication order. Ask the patient his or her name and match it to the one on the medication order. Identify the patient by name and date of birth on the patient's wristband and match it to the medication order. Identify the patient by name and room number and match the information on the medication order.

Identify the patient by name and date of birth on the patient's wristband and match it to the medication order. rationale: Medication errors are one of the primary areas of medical mistakes. Always identify the patient, preferably using two identifiers, to ensure the right medication is being administered to the right patient. Room and bed numbers are not reliable identifiers and should not be used to identify patients. Always follow the protocols and procedures of your facility for administering medications.

The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate action? 1. Insert the tube quickly. 2. Notify the health care provider immediately. 3. Remove the tube and reinsert it when the respiratory distress subsides. 4. Pull back on the tube and wait until the respiratory distress subsides.

Pull back on the tube and wait until the respiratory distress subsides. Rationale: During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. It is not necessary to notify the health care provider immediately or remove the tube completely. Quickly inserting the tube is not an appropriate action because, in this situation, it is likely that the tube has entered the bronchus.

The nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching? 1. Taking a rectal temperature for a client who has undergone nasal surgery 2. Taking an oral temperature for a client with a cough and nasal congestion 3. Taking an axillary temperature for a client who has just consumed hot coffee 4. Taking a temporal temperature on the neck behind the ear for a client who is diaphoretic

Taking an oral temperature for a client with a cough and nasal congestion Rationale: An oral temperature should be avoided if the client has nasal congestion. One of the other methods of measuring the temperature should be used according to the equipment available. Taking a rectal temperature for a client who has undergone nasal surgery is appropriate. Other, less invasive measures should be used if available; if not available, a rectal temperature is acceptable. Taking an axillary temperature on a client who just consumed coffee is also acceptable; however, the axillary method of measurement is the least reliable, and other methods should be used if available. If temporal equipment is available and the client is diaphoretic, it is acceptable to measure the temperature on the neck behind the ear, avoiding the forehead.

A nurse is working with a patient who has a contagious condition. In recalling the chain of infection, the nurse knows that an environment favorable for the growth and reproduction of an infectious agent is referred to as ____. a vector a susceptible host a reservoir a portal of entry

a reservoir The chain of infection has six elements: a pathogen which is an infectious agent a reservoir which is any environment that is favorable for the growth and reproduction of an infectious agent a portal of exit which is a place where an infectious agent gets out of a host a method of transmission which is the way an infectious organism is transferred from a reservoir to a host a portal of entry which is the place where an infectious agent enters a host a susceptible host which is a person who is at risk for infection A vector is an object which can spread an infection via indirect contact. It is one of the three possible methods of transmission.

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mm Hg), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? a. Metabolic acidosis, compensated b. Respiratory alkalosis, compensated c. Metabolic alkalosis, uncompensated d. Respiratory acidosis, uncompensated

b. Respiratory alkalosis

A nurse in the emergency room is taking care of a 4-year-old patient who has a suspected case of impetigo. The nurse knows that which of the following precautions is most important to prevent the spread of this infection? a. droplet precautions b. airborne precautions c. standard precautions d. contact

contact rationale: Impetigo is an infectious skin condition that is spread via skin to hand contact or indirect contact of the skin and other surfaces. Contact precautions are, therefore, necessary to limit the spread of this skin infection.

A nurse is caring for a patient admitted with a closed head injury. Which action by the nurse is appropriate when providing hygiene for this patient? 1) Avoid bathing the patient 2) Use cool water to bathe 3) Provide care in small intervals 4) Rub briskly when drying

provide care in small intervals