Fundamentals

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

C. Lentils

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

A. Airborne

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

A. Below the medial malleolus

A nurse is teaching the parent of a child who is to take 10 mL of a liquid medication. The parent has a hollow medication spoon with marks to indicate teaspoons and tablespoons. How many teaspoons should the nurse instruct the parent to give the child? (Round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

2 5 mL = 1 tsp

A nurse is monitoring a client's fluid intake. For breakfast, the client consumed 8 oz of milk, 10 oz of water, 4 oz of flavored gelatin, 1 scrambled egg, 1 crisp piece of bacon, and 2 biscuits with jelly. How many mL should the nurse record as the client's fluid intake? (Round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

660 1 oz = 30 mL

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

A. 2 mm

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

A. Cranial nerve XII The nurse is checking the function of cranial nerve XII, hypoglossal, which innervates the tongue, by observing a range of tongue movements

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

A. Decreased estrogen and testosterone production

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

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

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

A. Osteoporosis

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

A. Start chest compressions

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

A. Suction equipment

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

A. Whole milk

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

B. 2

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

B. Antagonistic

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

B. Cleanse the wound with 0.9% sodium chloride irrigation

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

B. Increased heart rate

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

B. Obtain client information

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

B. Tie the restraint with a quick-release knot

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

C. Brainstem

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

C. Elevate the head of the client's bed to 45 degrees before the feeding

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

C. Hct 55%

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

C. Nutrition

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

C. Sitting

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

C. Starch

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

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

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

D. Cerebellum

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

D. Young adulthood

A nurse is caring for a client who has a prescription for acetaminophen 325 mg PO for an oral temperature above 38.4 Celsius. Above what Fahrenheit temperature should the nurse administer acetaminophen to the client? (Round the answer to the nearest tenth, and use a leading zero if applicable. Do not use a trailing zero.)

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

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

A, C, D, E A. The client's ID number C. The client's name D. ABO compatibility E. Rh compatibility

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

A. During the admission process

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

A. Scoliosis

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

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

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

A. Bounding

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

A. Renew the prescription for the use of restraints within 24 hr

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

A. We miss our daughter so much that we are going to move closer to her

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

A. With your palm facing down, move your wrist sideways toward your thumb

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states, "All this equipment is making me nervous." Which of the following responses should the nurse offer? A. You won't need the equipment for very long B. All of this equipment can be frightening C. Why does the equipment bother you? D. Let me tell you about what each machine does

B. All of this equipment can be frightening

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

B. Ask the client to identify the specific food allergies

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

B. Auscultation of the arteries for bruits with the bell of the stethoscope

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

B. Montgomery straps Montgomery straps are adhesive strips applied to the skin on either side of a surgical wound. The adhesive strips have holes for using gauze to tie the dressing securely. When the dressing is changed, the ties are released, the dressing is replaced, and the ties are secured again without removing the adhesive strips.

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

B. Physical examination Physical findings are objective

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

B. Protein serves as an energy source when other sources are inadequate

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

B. Side hip between the iliac crest and anterior iliac spine The side hip between the iliac crest and anterior iliac spine forms the boundaries for the ventrogluteal injection

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

B. Sodium 150 mEq/L

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

C, D C. Black beans D. Whole-grain bread

A nurse is caring for a client who has terminal pancreatic cancer. When the client states, "It's devastating that I will not be here to see my child graduate," the nurse should identify that the client is in which of the following stages of grief as defined by Kubler-Ross? A. Anger B. Bargaining C. Depression D. Acceptance

C. Depression

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

C. Don gloves when entering the room and use hand sanitizer when exiting

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

C. Instruct the guard to ask the inmate

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

C. It sounds like your pain is intermittent

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

C. Keep a diary of the foods your child eats each day The nurse should encourage the parent to keep a diary of the foods the child eats throughout the day for 1 week. This can help the parent realize that the child may be eating better than expected. Evidence suggests that children can self-regulate their caloric intake. When they eat less at a meal, they can compensate by eating more at another meal or by having a snack

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

C. Oil retention

A nurse is assessing a client's thyroid gland. Which of the following instructions should the nurse give the client before inspecting and palpating this gland? A. Tilt your head slightly forward B. Keep your head straight and look ahead of you C. Tilt your head back and swallow D. Turn your head to the side against my hand

C. Tilt your head back and swallow

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

D. Palpation

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

D. Disconnect the machine and measure the blood pressure manually every 15 minutes

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

D. Request a prescription for an isotonic enteral nutrition formula

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

D. Romberg test When using the Romberg test, the nurse instructs the client to stand with the feet together and arms at the sides, first with the eyes open and then with the eyes closed. The inability to maintain balance is a positive Romberg test

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

D. Turn the stocking inside out up to the heel before applying

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

D. What is your source of strength and hope?

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

1560 1 pint= 480 mL 1 oz = 30 mL

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

2 tbsp 15 mL = 1 tbsp

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

A. Daily weight

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

A. Decreased calcium

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

A. Hold the sterile drape above the waist and away from the body

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

A. Place the client in the Trendelenburg position - The nurse should place the client in a right-sided Trendelenburg position to promote drainage from the client's left lower lobe. - The nurse should perform percussions over a single layer of clothing. - The nurse should used a cupped hand to provide percussions. - Chest percussions should not cause pain when the procedure is performed correctly.

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

A. Remove the sleeve of the gown from the arm without the IV line

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

B. Potassium 3.0 mEq/L

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

B. Raise your index finger if you need to pause during the insertion The nurse should instruct the client that the insertion of an NG tube is uncomfortable and the gag reflex will be activated during the procedure. The nurse should establish a communication technique such as having the client raise a finger or hand to indicate distress and the need to pause the insertion process

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

C. Advise the client to tuck his chin downward

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

C. Hearing aids A client who has hearing aids can undergo an MRI because the hearing aids can be removed. A patient who has a coronary artery stent, an aneurysm clip, or an automated internal defibrillator is contraindicated for undergoing an MRI. The powerful magnetic field of the MRI system could pull on the internal metal and dislodge it

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

C. Use the index finger to insert the suppository

A nurse is preparing to change a dressing on a client who is receiving negative pressure wound therapy (NPWT). What sequence of actions should the nurse plan to take? (Put the options in the correct order from first step to last. All options must be used.) A. Connect the tubing to transparent film and turn on the NPWT unit B. Apply a skin protectant or a barrier film to the skin around the wound C. Turn off the vacuum on the NPWT device and administer the prescribed analgesic D. Place prepared foam into the wound bed and cover with a transparent dressing E. Apply sterile or clean gloves and irrigate the wound F. Remove the soiled dressing and perform hand hygiene.

Correct order: C, F, E, B, D, A

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

D. Infection acquired from a diagnostic procedure Iatrogenic HAIs directly result from diagnostic or therapeutic procedures.

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

D. Plasma volume expanders Dextran and albumin are plasma volume expanders that help correct hypovolemia in emergency situation, such as after hemorrhage or burns. Examples of skeletal muscle relaxants are cyclobenzaprine and metaxalone. Examples of beta-adrenergic blockers are propranolol and carvedilol. Examples of broad-spectrum anti-infective agents include ampicillin and cefixime.

A nurse is caring for a client who has a stage 2 pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer? A. Hydrocolloid B. Collagen C. Calcium alginate D. Proteolytic enzyme

A. Hydrocolloid The nurse should apply a hydrocolloid dressing to a stage 2 pressure ulcer. This type of dressing is applied to absorb exudate and to produce a moist environment that will facilitate healing while preventing maceration of surrounding skin

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

A. Sodium

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

A. WBC 15,000 mm^3

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

D. Ventrogluteal

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

A, B, C A. Sit with your back supported B. Keep your knees at hip level C. Use an ergonomically designed computer keyboard

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

A, B, D A. Coat the tip of the tube with a water-soluble lubricant B. Ask the client to swallow water while the tube enters her throat D. Tell the client to tilt her head backward as insertion begins

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

A. Increased blood pressure

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

A. Assessment

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

A. Bear down The nurse should ask the client to "bear down" gently as if to void. This can enable the nurse to better visualize the urinary meatus and promote relaxation of the external urinary sphincter. Additionally, this will ease the passage of the catheter through the urinary meatus.

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

A. Eggs Complete proteins contain all of the essential amino acids to support growth and homeostasis. Examples of complete proteins include eggs, meat, poultry, seafood, milk, yogurt, cheese, soybeans, and soybean products

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

A. Encourage the client to listen to soft music

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

A. Gloves According to evidence-based practice, the nurse should first remove the gloves because they are the most contaminated piece of PPE. Next, the nurse should remove the goggles or face shield, then the gown, then the respirator or mask.

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

A. Hemolytic - A hemolytic reaction occurs when the client's blood is incompatible with the donor's blood. Child, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion reaction. - A febrile reaction occurs when the client's blood is sensitive to the WBCs and platelets in the donor's blood. S/S include fever, chills, headaches, and flushing. - Circulatory overload occurs when blood is administered too quickly for the client's circulatory system to handle. S/S include dyspnea, coughing, headaches, and hypertension. - Sepsis occurs when the blood is contaminated with bacteria. S/S include high fevers, vomiting, and diarrhea.

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

A. Hold the dropper 1 cm (0.5 in) above the ear canal during administration

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

A. Hold the medication bottle with the label against the palm of the hand when pouring The nurse should hold a multi dose bottle with the label against the palm of the hand when pouring to prevent contaminating the label with spilled medication that could cause information on the label to fade or become illegible

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

A. Regulation of acid-base balance - The kidneys assist with the regulation of acid-base balance in the body by retaining bicarbonate as they excrete hydrogen ions. - The small intestines absorb nutrients for cellular growth, not the kidneys. - The integumentary system, not the kidneys, helps regulate body temperature. - The anterior pituitary gland secretes somatotropin (growth hormone), which is necessary for the growth of tissues and organs

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

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

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

A. Sodium 123 mEq/L Low sodium levels can cause confusion and lead to seizures, coma, and death

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

A. The client holds the hand with the palm up

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

A. The client watches television in her bed during the day To promote sleep, the client should avoid watching television in bed. She should use the bed only for sleep or sexual activities.

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

A. Use a gait belt during ambulation - The nurse should use a gait belt to keep the client's center of gravity midline and decrease the risk of a fall - The client should wear non-skid shoes or slipper when ambulating to decrease the risk of a fall from slipping - The nurse should encourage the client to dangle the legs on the edge of the bed for 60 seconds before attempting to ambulate to decrease the risk of a fall due to orthostatic hypotension - The nurse should walk beside the client to provide physical support while ambulating and decrease the risk of a fall

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

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

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

A. Vesicular The nurse will hear vesicular sounds over the periphery of the major lung fields. These sounds are soft and low-pitched

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

A. Vitamin C and zinc The client's body needs both vitamin C and zinc to fight a wound infection. The client should receive a multivitamin and a mineral supplement of both these substances. In addition, vitamin E supplements also are needed to promote skin and wound healing

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

B. Educating clients about the recommended immunization schedule for adults

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

B, C, D B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown

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

B, C, D B. Stabilizing the position of the tube C. Preventing aspiration of secretions D. Preventing air leaks

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

B, C, D B. Verify the initial X-ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid

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

B, C, E B. Dry, brittle hair C. Edema E. Poor wound healing

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

B, D, E B. Place the client in a supine position with the hips and knees flexed D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

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

B. 116/70 mmHg This blood pressure is within the expected reference range, which is any value <120 mmHg systolic and <80 mmHg diastolic

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

B. A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an stony bag full of bright red, bloody drainage An ostomy bag full of blood indicates that the client's bowel is hemorrhaging, and the nurse must report this finding to the surgeon immediately. The client may require fluid replacement, transfusion, and additional surgery to repair the bleeding vessel. This finding poses an immediate threat to the client's circulation.

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

B. Accompany the client back to his room

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

B. Check capillary refill before applying an ice pack to the affected area - The nurse should check the affected area for adequate circulation by assessing pulses and capillary refill because a cold pack applied to an area of implied circulation can further decrease the blood supply to the area. - The nurse should avoid applying a cold pack to an area that displays edema because it can further decrease circulation. - The nurse should fill an ice pack two-thirds full with crushed ice to mold around the affected area. - The ice pack should be applied for 30-minute intervals to anesthetize and prevent further swelling of the affected area

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

B. Check the client's capillary blood glucose level every 4 hr - The nurse should check the client's blood glucose level every 4 hours or according to facility policy due to the client's risk of hyperglycemia while receiving TPN. The dextrose concentration in TPN increases the risk of this complication. - If TPN is not available, the nurse should administer 10% dextrose or 20% dextrose in water. - The client should be weighed daily while receiving TPN. - The nurse should change the IV tubing used for TPN every 24 hours to decrease the client's risk of infection

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

B. Clients who are age 65 or older are reluctant to report pain The nurse should instruct the newly licensed nurse that clients age 65 and older frequently can be reluctant to report pain because they might not want to bother or anger caregivers and might believe that pain is expected

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

B. Cold extremities The presence of cold extremities, first in the feet and then in the hands, is a physical change that occurs when a client's death is imminent. Urinary incontinence, hypotension, and a slow, weak pulse are other examples of physical changes that occur when a client's death is imminent.

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

B. Cough deeply after each use - Proper use of the incentive spirometer loosens secretions in the client's lungs. The client should cough deeply to facilitate the removal of secretions from his lungs. - The client should inhale deeply to elevate the balls in the device. - The mouthpiece should be cleaned with water and then dried after each use. - The client should use the spirometer several times every hour while awake

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

B. Document this as an expected finding The light of the otoscope reflects off the tympanic membrane, which is cone-shaped or triangular. In the right ear, it is visible in the right lower quadrant of the eardrum. In the left ear, it is visible in the left lower quadrant

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

B. Edema at the infusion site - Edema due to fluid entering subcutaneous tissue is an indication of infiltration. - Redness and warmth at the infusion site is an indication of phlebitis or infection. - Oozing of blood at the infusion site is an indication that the IV system is not intact

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

B. Excessive wax in the ear canal Factors that can make a hearing aid whistle include a poor seal with the ear mold, an ear infection, excessive wax in the ear canal, an improper fit, or a malfunction

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? A. Autonomy B. Fidelity C. Nonmaleficence D. Justice

B. Fidelity Autonomy involves ensure the client has the right to make personal decisions. Nonmaleficence involves doing no harm. Justice involves treating everyone fairly

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

B. I am going to listen to your abdomen A common reason clients experience nausea and vomiting after surgery is from delayed gastric emptying time or decreased peristalsis. The nurse should auscultate the client's abdomen to determine the presence of bowel sounds before clear liquids can be administered

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

B. I think I have done a good job with my children since they are all independent now

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

B. Kosher diets have restrictions regarding how the food must be prepared - Kosher diets are guided by a set of laws regarding the processing, preparation, and eating of food. - Ovo-vegetarian diets are primarily vegetable-based diets that exclude meat and dairy but includes eggs. - Macrobiotic diets are primarily plant-based but do include fish and seafood. - Flexitarian diets are primarily plant-based with the occasional consumption of meat, fish, and dairy products

A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing? A. Lateral thigh B. Lower abdomen C. Mid-abdominal region D. Medial thigh

B. Lower abdomen For a male client, the nurse should secure the catheter tubing to the client's upper thigh or lower abdomen

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

B. Lungs Percussion creates a vibration that helps the examiner determine the density of the underlying tissue. The lungs are hollow organs that can produce sounds such as resonance ( a hollow sound over alveoli) or dullness (a dull sound over consolidated areas of the lungs or diaphragm). The nurse also uses auscultation and palpation when evaluating the lungs

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

B. Obtaining cotton balls for tracheostomy care - Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess - A half-strength peroxide solution is used to clean the inner cannula - Tracheostomy care is a sterile procedure requiring the use of sterile gloves - Pipe cleaners or a small sterile brush can be used to remove thick or crusty secretions from the inner cannula.

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

B. Offer the client tart or sour foods first A client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which aids chewing and swallowing

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

B. Request an X-ray of the client's abdomen

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

B. Stereognosis Stereognosis is the ability to identify an object's size, shape, and texture via tactile sensation. Gustation is the ability to taste. Proprioception is the awareness of the position of the body. Kinesthesia is the ability to sense the position and movement of body parts without visualizing them

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

B. The client reports severe pain

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

C. Apply pressure to the puncta after instilling the medication The nurse should instill the medication into the conjunctival sac and apply pressure to the puncta for 1 to 2 minutes afterward to prevent systemic absorption of the medication

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

C. Bear weight on both of your legs - The client should keep 3 points on the ground at all times. Therefore, he must be able to bear weight on both legs. - Pressure on the axillae increases the risk to underlying nerves, which could result in partial paralysis of the arms - The client should keep his elbows flexed about 30 degrees - The client should move each leg alternately with each opposite crutch so that 3 points of support are on the floor at all times

A nurse is caring for a client who has a stage 3 pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? A. Obtain the prescribed irrigation solution B. Don personal protective equipment C. Check the client's pain level D. Place a waterproof pad under the client's extremity

C. Check the client's pain level

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

C. Collecting and trading game cards Collecting and trading game cards require seriation of the cards, involving what to collect, what to trade, and what has value. This is a characteristic of Piaget's concrete operational stage for ages 7 to 11 years

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

C. Death is viewed as an interruption of what might have been Young adults tend to see a whole life ahead of them, so death is often seen as interrupting that life. Young adults do not typically welcome death at this time.

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

C. Depressed deep-tendon reflexes A total calcium level of 12.7 mg/dL is above the expected reference range. Manifestations of hypercalcemia include depressed deep-tendon reflexes, nausea, vomiting, bone pain, lethargy, and weakness

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

C. Diuresis Diuresis or polyuria is the excretion of a high volume of urine. This condition has many causes, including metabolic and hormonal imbalances and diuretic therapy for treating renal, cardiovascular, and pulmonary disorders

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

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

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

C. Eye examination every 2 years Women ages 30-65 years old should have a Pap test every 3 years. Women ages 45 years and older should have an annual mammogram. At age 55, clients may decide to change this schedule to every 2 years or continue with annual mammograms. The client should have a colonoscopy every 10 years. If the client has risk factors for colorectal cancer, testing should occur more often.

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

C. Have the client demonstrate the procedure

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

C. I will shake the inhaler well right before I use it

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

C. Insert the tip of the tubing 8 cm (3.1 in) - The nurse should insert the tip of the tubing 7-10 cm (3-4 in) along the rectal wall to prevent dislodging of the tube during the procedure and avoid injury to the rectal mucosa - The nurse should lubricate 5-8 cm (2-3 in) of the tip of the rectal tube before inserting it to decrease the risk of irritation or injury - The client should be in the left side in the Sims' position to allow the solution to flow downward into the sigmoid colon and rectum and promote retention of the enema - The nurse should hold the enema container a maximum of 45 cm (18 in) above the rectum to prevent painful distention of the colon

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

C. Oxygen equipment

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

C. PC for after meals

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

C. People who practice Judaism stay with the body of the deceased until burial - Islamic faith: the body of the deceased is washed and wrapped during a ritual then buried as soon as possible following death - Hindu faith: may place the body with the head facing north following death. However, cremation rather than burial is practiced by those of Hindu faith - Buddhist faith: Male family members prepare the body following death

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

C. Pinch the NG tube while removing the tube The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration of any gastric contents

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

C. Place the wheelchair at a 45-degree angle to the bed

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

C. Taut skin around the IV catheter site that is cool to the touch

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

C. Temperature

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

C. The death was sudden Complicated grief can occur when the death of a loved one is sudden and unexpected

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

C. The nurse holds her hands higher than her elbows while washing The nurse who is performing a surgical hand washing technique should wash while holding her hands higher than the elbows so that water and soapsuds can drain away from the clean area toward the dirty area. Surgical scrubbing requires the nails be scrubbed with 15 strokes and each other part of the hand with 10 strokes. An important principle of surgical hand washing is to scrub the hands first and then work toward the elbows. Scrubbing is performed with a specially designed and premeditated brush when performing surgical hand washing. The use of mechanical friction is necessary to decontaminate the skin effectively

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

C. Try to block the urge to urinate until the next scheduled time When the client is following a schedule of voiding intervals and feels the urge to urinate before the next scheduled time, she should try slow, deep breathing to help reduce the urge. She can also try 5 or 6 strong and quick pelvic muscle exercises.

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

C. Vastus lateralis The nurse should use the vastus lateralis site over the anterior thigh for IM injections for infants and children

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

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

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

D. Clamp the tubing below the collection port The nurse should clamp the tubing below the collection port to allow fresh, uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup

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

D. 10 weeks Because 1 lb of body fat is equivalent to 3,500 calories, consuming 500 extra calories each day for 7 days would lead to a total of 3,500 calories and a 1 lb gain per week. At the rate of 1 lb per week, the client would gain 10 lb in 10 weeks

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

D. Ask the adolescent to sign the consent form Unemancipated minors (I.e. those who do not live on their own, are not married, and are not in the military) can legally give informed consent for diagnostic procedures and treatments in some situations. These situations include treatment for STIs and substance use disorders

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

D. Bear down gently

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

D. Bounding pulse

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

D. Call the provider to clarify the dosage

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

D. Ceasing to compare personal identity with others

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

D. Check the medication dose and the client's identification

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

D. Circle the injection area with a pen

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

D. Discuss the meaning of a common proverb

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

D. Donate autologous blood before the surgery

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

D. Encourage the client to cough Rhonchi are loud, low-pitched, rumbling sounds primarily detected over the trachea and bronchi. The nurse should encourage the client to cough because doing so will often clear this adventitious sound

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

D. Halo of erythema on the surrounding skin The nurse should report to the provider when the client has a ring of erythema (redness) on the surrounding skin, which might indicate underlying infection. This and any other manifestation of infection (e.g. purulent drainage, swelling, warmth, or a strong odor) should be reported to the provider

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

D. I will clip each suture close to the skin and pull it through from the other side Clipping close to the skin and pulling the suture from the other side does not disrupt the wound-healing process

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

D. Leukopenia - Leukopenia occurs when there is a decrease in the production of WBCs. This alteration places the client at an increased risk of infection. - Leukoplakia involves thick white patches in the mucosa of the mouth. These lesions can be precancerous and are often seen in clients who smoke heavily. - Leukemia involves the uncontrolled production of blast cells or immature WBCs in the bone marrow - Leukocytosis is an increase in circulating WBCs in response to WBCs exiting from the blood vessels in response to inflammation.

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

D. Liver damage

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

D. Observe the client closely

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

D. Provide a protein intake of 1.5 g/kg of body weight per day

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

D. Purulent exudate Purulent exudate on the client's dressings includes thick yellow, green, or brown drainage and usually indicates wound sloughing or infection

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

D. Second intercostal space to the right of the sternum

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

D. Skin

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

D. The signature on the preoperative consent form is the client's

A nurse observed an assistive personnel (AP) preparing to obtain a blood pressure with a regular-sized cuff for a client who is obese. Which of the following explanations should the nurse give the AP? A. The reading will be inaudible if the cuff is too small for the client B. The width of the cuff bladder should be 75% of the circumference of the client's arm C. As long as the cuff will circle the arm, the reading will be accurate D. Using a cuff that is too small will result in an inaccurately high reading Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. Blood pressure readings can be falsely high if the cuff is too small for the client

D. Using a cuff that is too small will result in an inaccurately high reading Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. Blood pressure readings can be falsely high if the cuff is too small for the client

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

D. Wrap the client's finger in a warm washcloth Warmth helps increase the blood flow to the client's finger

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

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

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

A. Air conduction is less than bone conduction in the left ear

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

A. Establish client outcomes

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

A. Hyperglycemia

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

A. Pull suction catheter back 1 cm (0.5 in) if the client starts coughing The nurse should pull the suction catheter back 1 cm (0.5 in) when the client starts to cough or resistance is met. This will remove the catheter from the mucosal wall of the trachea prior to suctioning

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

A. Test for the presence of the client's gag reflex

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

C. Intraoperative

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

C. Respite care

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

B. Average Reflexes range on a scale of 0 to 4+. Active or expected reflexes are 2+.

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

B. Faint pedal pulses Faint pedal pulses can indicate poor circulation and tissue perfusion, which puts the client at risk of impaired skin integrity

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

C. Cotton wisps

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

C. Soak the inner cannula of the tracheostomy tube in normal saline

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

C. Tachycardia

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

D. Granulation tissue fills the wound during healing

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

B. Fill the bag 2/3 full with ice The nurse should fill the bag two-thirds full with ice, which allows the bag to be molded around the client's ankle

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

B. Glaucoma

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

A. Independent moral development

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

A. Place the client in a lateral position with the head turned to the side before beginning the procedure The nurse should place the client in a lateral position with the head turned to the side to reduce the risk of aspiration of fluids and secretions

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

B. Elevate the head of the client's bed

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

B. Hold the breath for 5 sec after the goal volume is reached

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

B. It modulates the transmission of the pain impulse

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

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

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

C. Explain the procedure to the client

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

C. Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities

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

C. Provide more water with feedings

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

D. Instruct the client to apply pressure to the inside corner of the eye after instillation

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

D. Perform a blanch test The blanch test is used to check capillary refill, which is an indicator of peripheral circulation and tissue perfusion

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

D. Place the bladder of the cuff over the posterior aspect of the thigh

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

D. Temporal

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

C. Pull the NG tube back slightly

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

C. Sit on the toilet 30 min after eating a meal

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

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

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

C. Corneal light reflex

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

D. Fowler's The position of the legs does not matter, it is still Fowler's

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

D. From the wound toward the surrounding skin

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

D. Instruct the client to perform foot and leg exercises every 1-2 hr while awake to help prevent thrombophlebitis

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

A. Gown B. Gloves

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

D. I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button