NCLEX practice

Which dermatologic problem is treated by using intralesional corticosteroids? Psoriasis Cellulitis Erysipelas Carbuncles

A Psoriasis is a dermatologic problem treated by using intralesional corticosteroids. Cellulitis, erysipelas, and carbuncles are treated by using systemic antibiotics such as synthetic sulfur.

An older client with shortness of breath is admitted to the hospital. The medical history reveals hypertension in the last year and a diagnosis of pneumonia three days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention? Oxygen Saturation: 89% Body temperature: 101°F Blood Pressure: 130/80 mmHg Respiratory rate: 26 beats/minute

An oxygen saturation less than 90% observed in a client with pneumonia indicates that the client is at risk of respiratory depression. Oxygen saturation would take priority in initiating the care. The client's body temperature indicates fever due to pneumonia, which should be considered secondary to the oxygen saturation problem. The blood pressure reading is normal. The increased respiratory rate may be due to fever, which would be considered secondary to the oxygen saturation problem.

A nurse is caring for a client with hemiplegia who becomes frustrated when performing skills. How can the nurse motivate the client toward independence? Establish long-range goals for the client. Identify errors that the client can correct. Reinforce success in tasks accomplished. Demonstrate ways to promote self-reliance.

C Success is a basic motivation for learning. People receive satisfaction when a goal is reached. Progress toward long-range goals often is not apparent readily and may be discouraging. Constructive criticism is an important aspect of client teaching, but if it is not tempered with praise, it is discouraging. Demonstrating ways to promote self-reliance is an important part of teaching, but it probably will not motivate the client.

Which skin lesion in found in clients with acne? Wheal Plaque Vesicle Pustule

D Pustules are seen in such conditions as acne. A pustule is an elevated, superficial lesion filled with purulent fluid. A wheal is a firm, edematous, irregularly shaped skin lesion, formed as an inflammatory response to allergens or insect bite. A plaque is a circumscribed, elevated, superficial, solid lesion. A vesicle is a circumscribed, superficial collection of serous fluid.

Which key feature does the nurse associate with a stage 2 pressure ulcer? Presence of nonintact skin Development of sinus tracts Damage to the subcutaneous tissues Appearance of a reddened area over a bony prominence

A The skin is nonintact in stage 2 of pressure ulcers. Sinus tracts may develop during stage 4 of pressure ulcers. The subcutaneous tissue becomes damaged or necrotic during stage 3 of pressure ulcers. A reddened area over a bony surface occurs in stage 1 of pressure ulcers.

After performing an optical assessment on a client, a primary healthcare provider notices impaired near vision. Which other finding in this client confirms the diagnosis as presbyopia? Loss of elasticity of the lens Increased opacity of the lens Elevated intraocular pressure Noninflammatory changes in eyes

A Presbyopia is defined as impaired near vision caused by a loss of elasticity of the lens. This condition is reported in middle-aged and older adults. Increased opacity of the lens is seen in cataracts. Elevated intraocular pressure is associated with glaucoma. Retinopathy causes noninflammatory eye changes. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

The nurse is caring for a client who is on a low-carbohydrate diet. With this diet, there is decreased glucose available for energy and fat is metabolized for energy, resulting in an increased production of which substance in the urine? Protein Glucose Ketones Uric acid

C As a result of fat metabolism, ketone bodies are formed, and the kidneys attempt to decrease the excess by filtration and excretion. Excessive ketones in the blood can cause metabolic acidosis. A low-carbohydrate diet does not cause increased protein, glucose, or uric acid in the urine.

Which statement of the nurse at the time of discharge would reflect the decision-making skill called autonomy? "I accept the task of providing a discharge teaching plan." "I understand my task of preparing a discharge teaching plan." "I may independently develop and implement a discharge teaching plan." "I will consult with other team members to find out why the discharge teaching plan is delayed."

C The decision making skill of autonomy is demonstrated when the nurse independently develops and implements a discharge teaching plan. When the nurse accepts the commitment of providing the discharge teaching plan, he or she demonstrates accountability. The nurse takes responsibility when he or she declares that he or she understands the task of preparing a discharge teaching plan. The nurse is in an authoritative role if he or she consults other team members to find out more information about why the discharge teaching plan is delayed.

The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit (40.3 degrees Celsius). The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to do what? Promote equalization of osmotic pressures Prevent hypoxia associated with diaphoresis Promote integrity of intracerebral neurons Reduce brain metabolism and limit hypoxia

D Cooling blankets and antipyretic medications can induce hypothermia, thus decreasing brain metabolism. This in turn makes the brain less vulnerable by decreasing the need for oxygen. The integrity of intracerebral neurons and osmotic pressure equalization depend on an adequate supply of oxygen, carbon dioxide, and glucose, and may occur as a result of decreased cerebral metabolism and hypoxia. Diaphoresis does not cause hypoxia. Antipyretic medications may cause diaphoresis as vasodilation occurs.

A nurse is preparing to discharge a client who is partially paralyzed following a stroke. What should the nurse teach the client's family about recognizing caregiver role strain? The caregiver has disturbed sleep patterns. The caregiver has reduced appetite and weight. The caregiver is more concerned about personal appearance. The caregiver engages in leisure activities as often as possible. The caregiver is fearful about administering medications to the client.

A B D A family should recognize that when the caregiver has disturbed sleep patterns, the caregiver is experiencing strain. Changes in appetite, weight, and sleep patterns are all indicative of caregiver role strain. A caregiver experiences strain while learning about new therapies and administering medications to the client. A caregiver experiencing role strain is not concerned about personal appearance and may withdraw from social groups. A caregiver also does not spend time in any leisure activities if overcome by strain.

A client asks the nurse, "Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?" What is the nurse's most appropriate response? "This is a decision you alone can make." "Do not tell your partner unless asked." "You are having difficulty deciding what to say." "Tell your partner that you don't know how you became sick."

C A client asks the nurse, "Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?" What is the nurse's most appropriate response? "This is a decision you alone can make." "Do not tell your partner unless asked." "You are having difficulty deciding what to say." "Tell your partner that you don't know how you became sick."

Which finding is inferred from a grade 4 intensity of heart murmurs? Thrill is easily palpable Quiet and clearly audible thrill Loud murmur associated with thrill Moderately loud murmur without thrill

C Grade 4 indicates loud murmurs with an associated thrill. A thrill is a fine vibration that is felt by palpation. A grade 5 intensity is characterized by an easily palpable thrill. A grade 2 intensity is characterized by quiet and clearly audible murmurs. A moderately loud murmur without a thrill is noted as grade 3.

A nurse is hired to work in a facility where the nurse assumes responsibility for a number of clients' needs. What is this nursing care delivery system called? Team nursing Modular nursing Functional nursing Primary care nursing

D This is the definition of primary care nursing. In team nursing there is a mix of staff members who provide care along with a team leader who usually is a registered nurse. In modular nursing clients are assigned according to geographic location and a variety of professionals are involved; this is similar to team nursing, but the teams are smaller. In functional nursing the nurse manager makes work assignments with specific tasks for each nurse.

While caring for a client with heat stroke, the nurse measured the temperature and noted it as 109o F. Convert this temperature into Celsius and record your number using one decimal place.

42.8 Fahrenheit is converted to Celsius by subtracting 32 from the Fahrenheit reading and multiplying the obtained value by 5/9. C = (F - 32)(5/9) C = (109 - 32)(5/9) C = 42.8

The nurse assessed a client's pulse rate and recorded the score as 3+. What is the strength of the pulse? Strong Bounding Expected Diminished

A

Which question asked by the nurse is an example of open-ended questions? "How has your health been?" "Are you feeling any pain now?" "Do you think the medication is helping you?" "How would you rate your pain on a scale from 0 to 10?"

A

What is an example of third spacing in a burn injury? Blister formation Edema formation Fluid mobilization Fluid accumulation

A Blister formation is an example of third spacing in burn injuries. Edema formation and fluid mobilization generally happen in every burn injury. Fluid accumulation is formed in second spacing in a burn injury.

A nurse anticipates that a hospitalized client will be transferred to a nursing home. When should the nurse begin preparing the client for the transfer? At the time of admission After a relative gives permission When the client talks about future plans As soon as the client's transfer has been approved

A Preparation of clients for discharge to their own home or to a nursing home should begin on the day of admission. The client gives permission for transfer to a nursing home. Intervention includes talking to the family members, including them in plans, and helping them understand the importance of early preparation. The client may never talk about future plans. Waiting until the client's transfer has been approved will make the adjustment more difficult than if the client had adequate preparation time.

An adult client is receiving lactated Ringer (LR) solution for burns to the genitalia. Which percentage will the nurse calculate for total body surface area (TBSA) burned? 1% 4.5% 9% 18%

A The TBSA of the genital area is 1%; 18% refers to the anterior or posterior torso. 9% can refer to the anterior or posterior legs. 4.5% refers to the anterior or posterior head or arm areas.

A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish a normal bowel pattern? Administer a mineral oil enema. Offer 1 cup of fluid every hour. Manually remove fecal impactions. Offer a cup of prune juice.

A Prune juice does not require a primary healthcare provider's prescription and helps to promote bowel movement because it contains sorbitol that increases water retention in feces. Administration of a mineral enema requires a prescription from a primary healthcare provider. Encouraging the client's fluid intake by offering 1 cup of fluid every hour is helpful in preventing constipation but not as effective in resolving constipation as a prune juice. Removing impactions does not establish regular bowel patterns.

A dark-skinned client is suspected of having jaundice. Which part of the client should be examined for yellowish coloration to assess the client's condition? Hard palate Conjunctivae Palms and soles Sclera adjacent to conjunctiva

A The hard palate in a dark-skinned client suspected of having jaundice should be examined, as this helps in accurate assessment of jaundice. Palms and soles appear yellow if they are calloused even when jaundice is not present. Sclera around the conjunctiva may also appear yellow due to deposition of fat even when jaundice is not present.

Which approach is a comforting approach that communicates concern and support? Touch Listening Knowing the client Providing a positive presence

A Touch is a comforting approach that involves reaching out to clients to communicate concern and support. Listening is a critical component of nursing care and is necessary for meaningful interactions with clients. Knowing the client comprises both the nurse's understanding of a specific client and his or her subsequent selection of interventions. Providing presence is a person-to-person encounter that conveys a closeness and sense of caring.

While caring for a client with a burn injury and in the resuscitation phase, the nurse notices that the client is hoarse and produces audible breath sound on exhalation. Which immediate action would be appropriate for the safe care of the client? Providing oxygen immediately Notifying the rapid response team Considering it a normal observation Initiating an intravenous (IV) line and beginning fluid replacement Obtaining an electrocardiogram (ECG) of the client Eugene on target

A B Hoarseness of voice, difficulty in swallowing, or an audible breath sound on exhalation after a burn injury indicates an impaired airway. Therefore the client should be given oxygen immediately. The rapid response team should also be notified for further management. This occurrence should not be considered a normal observation. An IV line should be initiated for fluid replacement only once the client's airway is patent. An ECG is obtained when the client suffers from electrical burns.

Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? Prayer Hypnosis Medication Aromatherapy Guided imagery

A B D E rayer is an alternative therapy that may relax the client and provide strength, solace, or acceptance. The relief of pain through hypnosis is based on suggestion; also, it focuses attention away from the pain. Some clients learn to hypnotize themselves. Aromatherapy can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Guided imagery can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Analgesics, both opioid and nonopioid, long have been part of the standard medical regimen for pain relief, so they are not considered an alternative therapy.

A nurse is taking care of a client who has chronic back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? Ask the client about the acceptable level of pain. Eliminate all activities that precipitate the pain. Administer the pain medications regularly around the clock. Use a different pain scale each time to promote patient education. Assess the client's pain every 15 minutes.

A C The nurse works together with the client in order to determine the tolerable level of pain. Considering that the client has chronic, not acute, pain, the goal of the pain management is to decrease pain to the tolerable level instead of eliminating pain completely. Administration of pain medications around the clock will provide a stable level of pain medication in the blood and relieve the pain. Elimination of all activities that precipitate the client's pain is not possible even though the nurse will try to minimize such activities. The same pain scale should be used for assessment of the client's pain level because it helps ensure consistency and accuracy in the pain assessment. Only management of acute pain, such as postoperative pain, requires the pain assessment at frequent intervals.

A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? Clean the eyelid and eyelashes. Place the dropper against the eyelid. Apply clean gloves before beginning the procedure. Instill the solution directly onto the cornea. Press on the nasolacrimal duct after instilling the solution.

A C D Cleaning of the eyelids and eyelashes helps to prevent contamination of the other eye and lacrimal duct. Application of gloves helps to prevent direct contact of the nurse with the client's body fluids. Applying pressure to the nasolacrimal duct prevents the medication from running out of the eye. The dropper should not touch the eyelids or eyelashes to prevent contamination of the medication in the dropper. The medication should not be instilled directly onto the cornea, because the cornea has many pain fibers and is therefore very sensitive. The medication is to be instilled into the lower conjunctival sac.

Which assessments should the nurse perform while assisting an older adult with housing needs? Assessing financial status Assessing meaningful activities and interest Assessing environmental hazards and support systems Assessing long range plans such as wills and advance directives Assessing access to public transportation and community activities

A C E When assisting an older adult with his or her housing needs, the nurse should assess the client's financial status, environmental hazards, support systems, and access to public transportation and community activities. When an older adult is planning for retirement, the nurse should assess the client's meaningful activities and interest and long range plans including wills and advanced directives.

n advanced practice registered nurse (APRN) is caring for a pregnant woman. Which type of APRN would care for this client? Clinical nurse specialist (CNS) Certified nurse midwife (CNM) Certified nurse practitioner (CNP) Certified registered nurse anesthetist (CRNA)

B

A person sustains deep partial-thickness burns while working on a boat in a town marina and seeks advice from the nurse in the first aid station. The nurse encourages the client to seek medical attention but the client refuses. Which instruction will the nurse provide to the person? "Go see a primary healthcare provider if blisters appear." "Go see a primary healthcare provider if urinary output decreases." "Go see a primary healthcare provider if edema and redness occur." "Go see a primary healthcare provider if white patches develops."

B Decreasing urinary output indicates hypovolemia that results from a fluid shift from the vascular space to the burned area. Blisters, edema and redness, and white patches are expected with deep partial-thickness burns.

Which caring process is defined as "facilitating the other's passage through life transitions and unfamiliar events" according to Swanson's theory of caring? Knowing Enabling Doing for Being with

B The enabling process facilitates another's passage through life transitions and unfamiliar events such as birth and death. The knowing process involves understanding an event in terms of what it means to the life of another. Doing for caring involves doing for others as one would want for oneself, if possible. The caring process "being with" is defined as being emotionally present for someone else.

The nurse is providing postoperative care to a client who had an abdominal cholecystectomy and choledochostomy who has a T-tube and a nasogastric tube in place. The client refuses deep breathing and coughing exercises. Which conclusion by the nurse is the most probable reason for the noncompliance? T-tube movement increases. Pain at the incision site increases. The nasogastric tube gets irritating. The bandage on the abdomen is constricting.

B The incision is just below the diaphragm; deep breathing causes tension and pain when the thorax expands, and coughing increases intraabdominal pressure, which stresses the surgical area. The T-tube will not move because it is sutured in place. Clients with nasogastric tubes generally resort to breathing through the mouth, limiting nasal irritation. Dressings do not encircle the abdomen; they should not be tight enough to restrict respirations.

While supervising a smallpox vaccination program, a nurse manager observes a nurse cleansing the arm of a client with an alcohol swab before giving the vaccination. What should the nurse manager's first reaction be? Continue observing the vaccination. Stop the nurse from giving the vaccination. Give the nurse a povidone-iodine (Betadine) swab to use instead. Notify the members of the team about the need to use antiseptic swabs.

B Alcohol deactivates the smallpox vaccine. Cleansing of the arm should not be done before the immunization is given unless the arm is dirty; if dirty, only water should be used to cleanse the site. Observation is insufficient; the nurse manager must intervene to ensure that the vaccine is given using the correct technique. Povidone-iodine will deactivate the smallpox vaccine. The site should be dry before administering the vaccine.

A nurse is caring for a client who is experiencing the second (acute) phase of burn recovery. The common client response the nurse expects to identify during this phase of burn recovery is an increase in what? Serum sodium Urinary output Hematocrit level Serum potassium

B As fluid returns to the vascular system, increased renal flow and diuresis occur. An increase in the serum sodium level (hypernatremia) is not a common response identified during the second (acute) phase of burn recovery. An increase in the hematocrit level indicates hemoconcentration and hypovolemia; in the second phase of burn recovery, hemodilution and hypervolemia occur. During the second phase of burn recovery, potassium moves back into the cells, decreasing serum potassium.

A client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation? The dosage is kept at a minimum. Only a small part of the body is irradiated. The client's physical condition is not a risk factor. Nutritional environment of the affected cells is a risk factor.

B Current radiation therapy accurately targets malignant lesions with pinpoint precision, minimizing the detrimental effects of radiation to healthy tissue. The dose is not as significant as the extent of tissue being irradiated. When radiation therapy is prescribed, the healthcare provider takes into consideration the ability of the client to tolerate the therapy, determining that the benefit outweighs the risk. Nutritional environment of the affected cells does not influence radiation's effect.

nurse is evaluating the condition of a client with burns of the upper body. Which finding will alert the nurse of a potential respiratory obstruction? Deep breathing Hoarse quality to the voice Pink-tinged, frothy sputum Rapid abdominal breathing

B Hoarseness is a sign of potential respiratory insufficiency as a result of inhalation injury, which causes edema in the surrounding tissues, including the vocal cords. Sputum will be sooty, not frothy; pink-tinged, frothy sputum is associated with pulmonary edema. Deep breathing and rapid abdominal breathing indicate metabolic acidosis, not respiratory insufficiency.

What is the most important factor relative to a therapeutic nurse-client relationship when a nurse is caring for a client who is terminally ill? Knowledge of the grieving process Personal feelings about terminal illness Recognition of the family's ability to cope Previous experience with terminally ill clients

B To be effective in a relationship with a client, the nurse must know and understand personal feelings about terminal illness and death. Knowledge alone is not enough to ensure an effective nurse-client relationship. Although the family is an important part of a client's support system, the client's feelings are more important to the relationship. Previous experiences can be positive or negative and will not guarantee an effective nurse-client relationship.

A client with cancer has undergone treatment. The client's primary healthcare provider receives a record of the client's care from the oncologist. Which descriptions are given under the care summary received by the primary healthcare provider?

B C In the client's care record, the primary healthcare provider collects information about treatment institutions and key providers and identifies the key point of contact and coordinators who provided care. During a follow-up care plan, a description about the cancer screening, information regarding the late-long term effects of treatments, and information about possible signs of recurrence should be considered.

When should the nurse consider family members as the primary source of information? The client is an elderly adult. The client is an infant or child. The client is brought in as an emergency. The client is critically ill and disoriented. The client visits the outpatient department.

B C D The nurse interviews the parents who care for the infant or child. Thus, the parents become the primary source of information. A client who is brought to the emergency department may not be in a position to explain the circumstances that led to the visit. In this case, the family or significant others who accompany the client become the primary source of information. The family becomes the primary source of information when the client is critically ill, disoriented, and unable to answer questions. Generally, the client is the primary source of information. The elderly adult who is conscious, alert, and able to answer the nurse's questions is the primary source of information. The client who visits the outpatient department is capable of providing accurate answers to the nurse's questions. This client is the primary source of information during assessment.

To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse should change the administration set how often? Every 4 to 8 hours Every 12 to 24 hours Every 24 to 48 hours Every 72 to 96 hours

Best practice guidelines recommend replacing administration sets no more frequently than 72 to 96 hours after initiation of use in patients not receiving blood, blood products, or fat emulsions. This evidence-based practice is safe and cost effective. Changing the administration set every 4 to 48 hours is not a cost-effective practice.

A nurse is assessing the integumentary system of four clients. Which client has the least chance of a false-positive result while undergoing assessment of capillary refill time? Client with shock Client with anemia Client with epilepsy Client with peripheral vascular disease

C A client with epilepsy does not have any circulatory inadequacy. Therefore the capillary refill time of this client, as assessed in the nails, is a reliable indicator (i.e., does not reveal a false-positive result). A client with shock has decreased oxygen saturation levels that further prolong the capillary refill time. Capillary refill time is not a reliable indicator of blood circulation for clients with anemia, peripheral vascular disease, or diabetes.

When meeting the unique preoperative teaching needs of an older adult, the nurse plans a teaching program based on which principle about learning? It reduces general anxiety. It is negatively affected by aging. It requires continued reinforcement. It necessitates readiness of the learner.

C Neurologic aging causes forgetfulness and slower response time; repetition increases learning. The principle that learning reduces general anxiety is a general principle applicable to all learning. The older adult has no more difficulty learning than a younger person, although it may take longer. The principle that learning necessitates readiness of the learner is a general principle applicable to all learning.

Two days after a severely burned client is admitted to the hospital, the client begins to exhibit restlessness. Which condition does the nurse determine the client is most likely developing? Renal failure Hypervolemia Cerebral hypoxia Metabolic acidosis

C Restlessness is the main early sign of hypoxia. With renal failure the client will become progressively confused and lethargic, not restless. At this stage the client will be hypovolemic rather than hypervolemic. With metabolic acidosis the client will be lethargic, not restless.

A registered nurse teaches a nursing student about routines followed during a physical examination to help ensure that important findings are not missed. Which statement by the nursing student indicates ineffective learning? "I'll compare the two sides of the body for symmetry." "I'll record quick notes during the examination to avoid delays." "I'll perform painful procedures at the beginning of the examination." "I'll record assessments in specific terms in the electronic or paper record."

C Any painful procedures should be performed at the end of the examination. The two sides of the body should be compared for symmetry, because some asymmetries are abnormal. Recording quick notes during the examination will help prevent delays during the examination. More extensive notes may be completed at the end of the examination. Assessments should be recorded in specific terms in the electronic or paper record. This standard form allows information to be recorded in the same sequence in which it is gathered.

The nurse should place the client in which position to obtain the most accurate reading of jugular vein distention? Upright at 90 degrees Supine position Raised to 30 degrees Raised to 10 degrees

C Jugular vein pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation. This procedure is most accurate when the head of the bed is elevated between 30 and 45 degrees. The internal and external jugular veins should be inspected while the client is gradually elevated from a supine position to an upright 30-45 degrees. Jugular vein distention cannot accurately be assessed if the client is supine, at 90 degrees, or at 10 degrees.

Five days after a client has abdominal surgery a nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence? Increased bowel sounds Loosening of the sutures Serosanguineous drainage Purplish color of the incision

C Serosanguineous drainage from the wound or on the dressing forewarns about separation of the wound edges (dehiscence); dehiscence may progress to movement of abdominal organs outside of the abdominal cavity (evisceration). Bowel sounds have no relationship to wound status; bowel sounds are expected around the third or fourth postoperative day as intestinal peristalsis returns. Loosening of sutures may occur after the initial wound edema subsides but is not a sign of failure of the suture line. A purplish incision is the expected coloration of a healing wound.

Which diagnosis made by the nurse is helpful in providing the right nursing interventions for the client? The nurse understands that the client has pain due to a tracheostomy. The nurse identifies that the client is anxious about the cardiac catheterization. The nurse realizes that the client has diarrhea and needs the bedpan frequently. The nurse identifies that the client is not aware of perineal care and has impaired skin integrity.

D The nurse observes that the client has impaired skin integrity due to lack of knowledge about perineal care. The nurse identifies the need for educating the client about perineal care. This nursing diagnosis is correct as it will help enhance the client's health outcomes. The nursing diagnosis should identify the problem caused by a treatment such as tracheostomy, not the treatment itself. A tracheostomy is a medical condition and should not be included in the nursing diagnosis. This client is likely to have pain following the trauma of the surgical incision. The nursing diagnosis should contain the client's response to the medical procedure rather than the medical procedure itself. The client is probably anxious due to lack of knowledge about the need for cardiac catheterization or the outcome of the procedure rather than the catheterization itself. A correct diagnosis helps the nurse put the client at ease by providing necessary teaching. The nurse should plan nursing interventions after identifying the client's problem. Therefore, the nurse should identify that the client has diarrhea due to food intolerance. This helps the nurse select appropriate interventions rather than just one intervention of offering bedpan.

A nurse is caring for a client who has been admitted with right-sided heart failure. The nurse notes that the client has dependent edema around the area of the feet and ankles. To characterize the severity of the edema, the nurse presses the medial malleolus area, noting an 8 mm depression after release. How should the edema be documented? 1+ 2+ 3+ 4+

D Dependent edema around the area of feet and ankles often indicates right-sided heart failure or venous insufficiency. The nurse should assess for pitting edema by pressing firmly for several seconds, then releasing to assess for any depression left on the skin. The grading of 1+ to 4+ characterizes the severity of the edema. A grade of 4+ indicates an 8 mm depression. A grade of 1+ indicates a 2 mm depression. A grade of 2+ indicates a 4 mm depression. A grade of 3+ indicates a 6 mm depression.

While performing a physical assessment of a client, a nurse notices patchy areas with loss of pigmentation on the skin, hands, and arms. What is the probable etiology for this condition? Anemia Pregnancy Lung disease Autoimmune disease

D Patchy areas with loss of pigmentation on skin, hands, and arms are due to vitiligo, which is caused by an autoimmune or congenital disease. Anemia results in pallor due to a reduced amount of oxyhemoglobin. A tan-brown color of the skin is noticed in pregnancy due to an increased amount of melanin. Lung disease or heart failure can cause cyanosis due to an increased amount of deoxygenated hemoglobin. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

The registered nurse teaches a nursing student about leadership skills for prioritizing the need of the client depending on the situation. Which statement is an example of an intermediate priority need? "The teachings of home self-care." "A psychological episode of an anxiety attack." "A physiological episode of an obstructed airway." "The measures required to decrease postoperative complications."

D The nurse leader should have the ability to set the priorities of the client depending on the client's need. Intermediate priority needs includes non-emergency, non-life-threatening needs. An example of this need would be measures that are required to decrease postoperative complications. The teaching of home self-care is a low priority need. High priority needs include addressing a psychological episode of an anxiety attack and addressing a physiological episode of an obstructed airway.

Which example best demonstrates humility in a critical thinker? A nurse questions the occurrence of pneumonia in a client who has a history of smoking. A nurse finds a client in pain and asks specific and detailed questions about the pain in order to provide pain relief. A nurse in a surgical scrub touches a contaminated surface and performs the whole process of surgical scrub again. A nurse accepts his or her lack of knowledge regarding stem cell transplantation and seeks opportunities for learning.

D Humility is awareness of one's limitations, accepting them, and trying to move beyond them by acquiring knowledge. Accepting one's lack of knowledge regarding stem cell transplantation and seeking opportunities for gaining further knowledge indicates humility. A nurse questioning the occurrence of pneumonia in a smoker indicates curiosity. A nurse asking a client about pain in detail reflects discipline. A nurse performing the whole process of surgical scrub again after touching a contaminated surface indicates responsibility and accountability.

A nurse is caring for a client who is receiving radiation therapy. Which information about skin care should the nurse include in the teaching plan? "Cover the area with a sterile gauze bandage." "Put warm compresses on the site once a day." "Limit lying on the back and unaffected side when sleeping." "Avoid applying lotions and powders over the area."

D Lotions and powders can cause a skin reaction on irradiated areas and should be avoided. Gauze and tape may irritate the skin further and should be avoided. Warm compresses are contraindicated because they may precipitate skin breakdown. The client can assume a position of comfort.

Two nurses are planning to help a client with one-sided weakness move up in bed. What should the nurses do to conform to a basic principle of body mechanics? Instruct the client to position one arm on each shoulder of the nurses. Direct the client to extend the legs and remain still during the procedure. Have both nurses shift their weight from the front leg to the back leg as they move the client up in bed. Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward the head of the bed, and then move the client.

D Positioning the nurses on either side of the bed with their feet apart, gathering the pull sheet close to the client, turning toward the head of the bed, and then moving the client places both nurses in a stable position in functional alignment, thereby minimizing stress on muscles, joints, ligaments, and tendons. The client should be instructed to fold the arms across the chest; this keeps the client's weight toward the center of the mass being moved and keeps the arms safe during the move up in bed. The nurses should assist the client in flexing the knees and placing the feet flat on the bed; this enables the client to push the body upward using a major muscle group. The client's assistance to the best of his or her ability reduces physical stress on the nurses as they move the client up in bed. On the count of three, weight should be shifted from the back to the front leg, not the front to the back leg. This action generates movement in the direction that the client is being moved.

The nurse is assessing four different clients with clinical findings. Which client requires examination of the sclera near the iris? Client A with an increased urochrome level Client B with an increased serum carotene level Client C with bleeding from the vessels into the tissue Client D with an increase in total serum bilirubin level

D The increased level of total serum bilirubin in client D may be associated with jaundice. Therefore, the sclera nearest to the iris is examined. The increased urochrome level in client A may relate to uremia or chronic kidney disease. Therefore, a yellow-orange coloration is generalized on the body, but absent in the sclera and mucous membranes. In client B, increased serum carotene level is observed due to increased ingestion of carotene-containing foods during pregnancy and during thyroid deficiency. Therefore, the nurse would examine for a yellow-orange coloration on the palms, soles, ears, and nose, although this coloration would not be noted in the sclera and mucous membranes. The bleeding in client C is assessed by comparing the affected area with the same area on the unaffected body side to check for swelling or skin darkening.

A nurse is reviewing a client's plan of care. What is the determining factor in the revision of the plan? Time available for care Validity of the problem Method for providing care Effectiveness of the interventions

D When the implementation of a plan of care does not produce the desired outcome effectively, the plan should be changed. Time is not relevant in the revision of a plan of care. Client response to care is the determining factor, not the validity of the health problem. Various methods may have the same outcome; their effectiveness is most important.

Which site should be monitored for a pulse to assess the status of circulation to the foot? Carotid artery Femoral artery Popliteal artery Dorsalis pedis artery Posterior tibial artery

D E The dorsalis pedis pulse and posterior tibial pulse are sites of assessments of circulation to the foot. The carotid pulse, located along the medial edge of the sternocleidomastoid muscle in the neck, is an easily accessible site to assess physiologic shock or cardiac arrest. The femoral artery pulse and popliteal artery pulses are helpful in assessing the circulation to the lower leg.

A nurse instructs a 70-year-old client to dress warmly in cold weather. Which physical changes seen in the client necessitate this instruction? . Reduced sebum production Degeneration of elastic fibers Decreased dermal blood flow Thinning of the subcutaneous layer Decreased vasomotor responsiveness

D E Thinning of the subcutaneous layer and decreased vasomotor responsiveness will increase the risk of hypothermia. To prevent hypothermia, the nurse instructs the client to wear warm clothing. Reduced sebum production can increase the size of pores, producing comedones. Degeneration of elastin will decrease the skin turgor of the client but does not produce hypothermia. Decreased dermal blood flow will cause risk of dry skin, which does not require the intervention of warm clothing. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.