Nursing Fundamentals- A

A nurse is preparing to administer 0.9=% NaCl 750 mL IV to infuse over 7 hrs. The nurse should set the infusion pump to deliver how many mL/hr? Round the answer to the nearest whole number.

107 mL/hr

A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity? A. A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. B. A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes. C. A client who has a do-not-resuscitate order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family. D. A client who is about to undergo a painful procedure receives pain medication 30 minutes before the procedure that the nurse previously promised to administer.

A. A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? A. Gently shake the container of medication prior to administration B. Transfer the medication to a medicine cup. C. Place the client in a semi-Fowler's position prior to medication administration D. Verify the dosage by measuring the liquid before administering it.

A. Gently shake the container of medication prior to administration

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority? A. Request that a respiratory therapist discuss the technique for incentive spirometry with the client. B. Determine the reasons why the client is refusing to use the incentive spirometer. C. Document the client's refusal to participate in health restorative activities. D. Administer a pain medication to the client.

B. Determine the reasons why the client is refusing to use the incentive spirometer.

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? A. Critical pathway B. SBAR C. Transfer report D. MAR

B. SBAR

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? A. 2 cups of soup B. 1 quart of water C. 8 oz of ice chips D. 6 oz of tea

C. 8 oz of ice chips

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation? A. Urine has an unusual odor. B. Urine specific gravity is 1.035. C. Bladder scan shows 525 mL of urine. D. Urine is positive for ketones.

C. Bladder scan shows 525 mL of urine.

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? A. Wear sterile gloves when removing old dressing. B. Warm the irrigation solution to 40.5 degrees C (105 degrees F). C. Cleanse the wound from the center outward. D. Use a 20-mL syringe to irrigate the wound.

C. Cleanse the wound from the center outward.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? A. Neck vein distention B. Urine specific gravity 1.010 C. Rapid heart rate D. Blood pressure 144/82 mm Hg

C. Rapid heart rate

A nurse is planning teaching for group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? A. Role play B. Group discussions C. Question-answer meetings D. Practice sessions

D. Practice sessions

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.

1. Obtain the pronouncement of death from the provider. 2. Remove tubes and indwelling lines. 3. Wash the client's body. 4. Ask the client's family members if they would like to view the body. 5. Place a name tag on the body.

A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump?

8 mL/hr

A nurse is caring fora child who has prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take? A. Examine personal values about the issue. B. Tell the parents that this is a necessary procedure. C. Inform the parents that the staff does not require their consent. D. Contact a spiritual support person to explain the importance of the procedure.

A. Examine personal values about the issue. Rationale: Nurses should examine their own personal values about the issue in question in order to provide care that is without bias. The nurse or the provider should provide information about the procedure. Spiritual support people attend to clients' and families' spiritual needs, not their physiological needs.

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take? A. Turn the client every 2 hr. B. Administer an antiemetic every 6 hr. C. Hold oral care D. Increase the room's temperature

A. Turn the client every 2 hr. Rationale: The nurse should turn the client at least once every 2 hr to break up the secretions in the client's lungs and prevent noisy respirations. Keeping the air temperature cool by allowing air to circulate with the use of a fan or opening windows is more comfortable for a client who is dying and will decrease air hunger.

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? A. Walking briskly B. Riding a bicycle C. Performing isometric exercises. D. Engaging in high-impact aerobics

A. Walking briskly

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care? A. Wrap blankets around all 4 sides of the bed. B. Apply restraints during seizure activity. C. Place the client in a supine position during seizure activity. D. Have a tongue depressor at the client's bedside.

A. Wrap blankets around all 4 sides of the bed.

a nurse is reviewing protocol in preparation for suctioning secretions from a client who has new tracheostomy. Which of the following actions should the nurse plan to take? A. Use a resuscitation bag with 80% oxygen prior to the procedure. B. Select a suction catheter that is half the size of the lumen. C. Place the end of the suction catheter in water-soluble lubricant D. Adjust the wall suction apparatus to a pressure of 170 mm Hg

B. Select a suction catheter that is half the size of the lumen.

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? A. Place the client in high-Fower's position. B. Increase the client's intake of carbohydrates. C. Massage reddened areas with unscented lotion. D. Have the client use a trapeze bar when changing position.

D. Have the client use a trapeze bar when changing position.

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? Place the client in a room with negative-pressure airflow. Wear gloves when assisting the client with oral care. Limit each visitor to 2 hr increments Wear a surgical mask when providing client care Use antimicrobial sanitizer for hand hygiene

Place the client in a room with negative-pressure airflow. Wear gloves when assisting the client with oral care. Use antimicrobial sanitizer for hand hygiene

A nurse is preparing to delegate the client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate? A. Ambulating a client who is postoperative. B. Inserting an indwelling urinary catheter for a client. C. Demonstrating the use of an incentive spirometer to a client. D. Confirming that a client's pain has decreased after receiving an analgesic.

A. Ambulating a client who is postoperative.

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

A. Droplet

A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? A. .3 mg B. 0.3 mg C. 0.30 mg D. 3/10 mg

B. 0.3 mg

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? A. Remove the outer cannula cautiously for routine cleaning. B. Use tracheostomy covers when outdoors. C. Use sterile technique when performing tracheostomy care at home. D. Cleanse irritated skin with full-strength hydrogen peroxide.

B. Use tracheostomy covers when outdoors. Rationale: Tracheostomy covers protect the client's airway from cold air, dust, an other airborne particles. The outer cannula stabilizes the airway; therefore, the client should never remove it for cleaning. In the home environment, medical asepsis with clean technique is appropriate. Hydrogen peroxide can irritate the skin; therefore, the nurse should instruct the client and family to use 0.9% sodium chloride irrigation to cleanse the site and prevent further irritation.

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration? A. purulent exudate. B. Warmth. C. Skin blanching. D. Bleeding.

C. Skin blanching

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? A. Combine client care tasks when caring for multiple clients. B. Wait until the end of the shift to document client care. C. Use the planning step of the nursing process to prioritize client care delivery. D. Allow for interruptions in tasks to discuss client care issues with colleagues.

C. Use the planning step of the nursing process to prioritize client care delivery. Rationale: Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management. The nurse should no combine but instead complete the tasks for one client before beginning the tasks for another client to reduce fragmentation of care and avoid potential errors.

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess? A. Hypotension B. Weak, thready pulse C. Slow capillary refill D. Distended neck veins

D. Distended neck veins

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use? A. Alginate B. Gauze C. Transparent D. Hydrocolloid

D. Hydrocolloid Rationale: Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed. Transparent dressings promote healing in stage 1 pressure injuries by preventing further friction and shearing. Moistened gauze promotes healing in stage 4 or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed. Alginate dressings are used to treat stage 3 and 4 pressure injuries to absorb drainage. Alginate forms a soft gel when it comes in contact with drainage.

A nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. " I can concentrate best in the morning." B. "It is difficult to read the instructions because my glasses are at home." C. "I m wondering why I need to learn this." D. "You will have to talk to my wife about this."

A. " I can concentrate best in the morning." Rationale: The client's statement indicates a readiness to learn because he is verbalizing the best time for him to learn.

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? A. Press gently on the tragus of the client's ear B. Pack a small piece of cotton deep into the client's ear canal. C. Move the client's auricle down and back toward her head. D. Tilt the client's head backward for 5 minutes.

A. Press gently on the tragus of the client's ear Rationale: Pressing gently on the tragus of the ear will help the medication get into the inner ear. For an adult client, the nurse should move the auricle upward and backward or upward and outward to straighten the ear canal. Inserting a piece of cotton into the meatus of the canal could damage the ear. If cotton is necessary, the nurse should place it into the outer portion of the ear canal and not push it inward. The client should lie on one side with the ear that received the instillation facing upward for 2 to 5 min.

a nurse is responding to a call light and find the client lying on the bathroom floor. Which of the following actions should the nurse take first? A. check the client for injuries B. move hazardous objects away from the client C. Notify the provider D. Ask the client to describe how she felt prior to the fall

A. check the client for injuries Rationale: The first action the nurse should take when using the nursing process is to assess the client for injuries.

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? A. "I can place an extension cord across my living room to plug in my television." B. "I will hire someone to trim the tree that hangs low over the stairs of my front porch." C. "I will place my alarm clock on my bedroom dresser across the room." D. I will replace the old throw rug in my kitchen with a new one."

B. "I will hire someone to trim the tree that hangs low over the stairs of my front porch. Rationale: Clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls.

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take? A. Rinse the feeding bag with water between feedings. B. Tell the client to keep the head of the bed elevated at least 30 degrees. C. Make sure the enteral formula is at room temperature. D. Wipe the top of the formula can with alcohol.

B. Tell the client to keep the head of the bed elevated at least 30 degrees.

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? A. Describe the procedure to the client. B. Witness the client's signature on the consent form. C. Inform the client of alternatives to the procedure. D. Tell the client which team members will assist with the procedure.

B. Witness the client's signature on the consent form.

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? A. regulate the flow rate by aligning the rate with the top of the ball inside the flow meter B. regulate oxygen via nasal cannula at a flow rate of no more than 6L/MIN. C. Make sure the reservoir bag of a partial re-breathing mask remains deflated D. use petroleum jelly to lubricate the clients nares, face, and lips

B. regulate oxygen via nasal cannula at a flow rate of no more than 6L/MIN. Rationale: Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min have a drying effect and force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2). The nurse should regulate the oxygen flow rate by aligning the rate on the flow meter with the middle of the silver ball inside the meter. The reservoir bag should inflate by one-third to one-half with inspiration. If it remains deflated, it indicates that clients are breathing in too much of the carbon dioxide they exhale. Evidence-based practice supports the use of a water-soluble lubricant to protect the client's skin from the drying effects of oxygen.

A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? A. "I had a bowel movement, but I was able to save the urine." B. "I have a specimen in the bathroom from about 30 minutes ago." C. "I flushed what I urinated at 7 AM and have saved all urine since." D. "I drink a lot, so I will fill up the bottle and complete the test quickly. "

C. "I flushed what I urinated at 7 AM and have saved all urine since."

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? A. "Is your pain constant or intermittent?" B. "What would you rate your pain on a scale of 1-10?" C. "Does the pain radiate?" D. "Is your pain sharp or dull?"

D. "Is your pain sharp or dull?" Rationale:Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain. Asking the client whether the pain radiates determines the pain's location. Asking the client to rate the pain using the pain scale determines the intensity of the pain. Asking the client whether the pain is constant or intermittent determines the onset, duration, and pattern of the pain.

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? A. A client who has a history of physical abuse. B. A client who has a permanent pacemaker. C. A client who has ulcerative colitis. D. A client who has asthma

D. A client who has asthma.

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.

Inject 10 units of air into the bottle of NPH insulin. Inject 5 units of air into the bottle of regular insulin Withdraw correct dose of regular insulin from the bottle Withdraw the correct dose of NPH insulin from the bottle.

A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hr. Which of the following actions should the nurse take first?

Rationale: The first action the nurse should take using the nursing process is to assess the client. If checking the IV tubing and verifying an obstruction, the nurse might be able to facilitate the flow of fluid through the tubing. This could re-establish the infusion rate the provider prescribed.

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? A. "What could I have done to deserve this illness?" B. "I blame medical science for not curing me." C. "Where is my daughter at a time like this?" D. "Will I ever begin to feel in charge of my life again?"

A. "What could I have done to deserve this illness?"

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? A. Use a bed exit alarm system. B. Raise four side rails while the client is in bed. C. Apply one soft wrist restraint. D. Dim the lights in the client's room.

A. Use a bed exit alarm system. Rationale: The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at a risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance. Raising four side rails when the client is in bed is a form of restraint and increases the risk for falls and injury. Applying one soft wrist restraint is a physical restraint requiring a prescription. Other forms of distraction or intervention to maintain client safety should be attempted for clients who have dementia. Dimming the lights in the room for a client who has dementia can reduce visibility and increase the risk for injury.

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? A. Carry a client's soiled linens out of the room in a mesh linen bag. B. Place a client who has tuberculosis in a room with negative-pressure airflow C. Provide disposable plates and utensils for a client who is HIV-positive. D. Dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag.

B. Place a client who has tuberculosis in a room with negative-pressure airflow Rationale: A client who has tuberculosis requires airborne precautions, which include placing the client in a room that has negative-pressure airflow to reduce the risk of infection transmission. The nurse should place soiled linens in a fluid-resistant bag to reduce the risk of infection transmission. People transmit HIV mainly by blood and sexual activity; therefore, a client who is HIV-positive does not require disposable plates and utensils. Standard precautions are sufficient. The nurse should dispose of items that have a large amount of blood in a biohazard bag that is impervious to micro-organisms.

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next? A. Rock the client up to a standing position. B. Pivot on the foot that is the farthest from the chair. C. Assess the client for orthostatic hypotension. D. apply a gait belt to the client.

C. Assess the client for orthostatic hypotension.

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? A. Place the client in a side-lying position. B. Instill 15 mL of irrigation fluid into the catheter with each flush. C. Subtract the amount of irritant used from the client's urine output. D. perform the irrigation using a 20-mL syringe.

C. Subtract the amount of irritant used from the client's urine output. Rationale: The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output. For a catheter irrigation, the nurse should place the client in a supine or dorsal recumbent position for maximal access to the catheter. Open irrigation technique requires instilling 30 to 40 mL of irrigation fluid. The nurse should use a 30- to 50-mL syringe to perform open irrigation.

A home health nurse is performing a follow-up visit for a client who has gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea? A. The client is receiving formula at room temperature. B. The feedings infuse at a slow, continuous drip over 8 hr each night. C. The client's caregiver washes out the feeding bag with warm water once every 24 hr. D. The client's caregiver flushes the tubing with water before and after administering medications.

C. The client's caregiver washes out the feeding bag with warm water once every 24 hr. Rationale: Feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent bacterial contamination. The nurse should reinforce this information with the client's caregiver to avoid future contamination. Cold formula can cause gastric cramping; therefore, room temperature formula is appropriate and is likely not the cause of the client's diarrhea. Diarrhea is more likely to develop with rapid instillation of enteral formula. t is correct to flush tubing with water before and after administering medications to prevent clogging of the tube.

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include? A. "You should have an eye exam every 2 years." B. "You should receive a tetanus booster every 5 years." C. "You should have a fecal occult blood test every 2 years." D. "You should receive a pneumococcal immunization every 10 years."

D. "You should receive a pneumococcal immunization every 10 years."

A nurse is caring for a client who is postoperative period when the nurse prepares to change her dressing, she says, "every time you change my bandage, it hurts so much. "Which of the following interventions is the nurses priority action? A. encourage the client to relax and take deep breath's during the dressing change B. educate the client about the importance of dressing change to prevent infection C. Assist the client to a comfortable position for the dressing change D. administer pain medication 45 minutes before changing the clients dressing

D. administer pain medication 45 minutes before changing the clients dressing Rationale: The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's physiological need for comfort and pain relief. Therefore, the priority intervention is to administer an analgesic 30 to 60 min before changing the client's dressing. Moving the client to a comfortable position for the dressing change is important because it can help the client relax and can also reduce strain on the wound. However, there is another intervention that is the priority. Educating the client about the importance of the dressing change is important because understanding the rationale for the procedure can help the client relax. However, there is another intervention that is the priority. Encouraging the client to relax and take deep breaths during the postoperative period is important because relaxation can help reduce the client's anxiety about the procedure. However, there is another intervention that is the priority.

A nurse is imitating a protective environment for a client who has had a n allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? A. Make sure the client's room has at least 6 air exchanges per hour. B. Make sure the client wears a mask when outside her room if there is construction in the area. C. Place the client in a private room with negative-pressure airflow. D. Wear an N95 respirator when giving the client direct care.

B. Make sure the client wears a mask when outside her room if there is construction in the area. Rationale: An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment. A protective environment requires at least 12 air exchanges per hour. The nurse should place the client in a private room that provides positive-pressure airflow. The nurse should wear an N95 respirator mask when caring for clients who require airborne precautions, not a protective environment.

A nurse is it meeting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? A. protective environment B. airborne precautions C. Droplet precautions D. Contact precautions

D. Contact precautions Rationale: Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client. Clients who have a compromised immune system require a protective environment. Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including tuberculosis and measles. Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis.

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client? A. have the client wear a mask when receiving visitors. B. Limit the client's time with visitors to no more than 30 minutes. C. Assign the client to a room with negative-pressure airflow exchange. D. Wear a gown when caring for the client.

D. Wear a gown when caring for the client. Rationale: The nurse should implement contact precautions for a client who has shigella to prevent the transmission of the bacteria. The nurse should wear a gown when providing care for a client who requires contact precautions due to the risk of contact with bodily fluids and contaminated surfaces. The nurse should assign a client who has shigella to a private room; however, negative-pressure airflow is not necessary because shigella is not airborne. Limiting the client's time with visitors will not decrease the risk of spreading shigella. Clients who require isolation precautions are at risk for depression and loneliness; therefore, the nurse should encourage visitation. The client does not need to wear a mask to prevent the spread of the infection because shigella does not require airborne or droplet precautions.

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply). Lacrimal apparatus Pupil clarity Appearance of bulbar conjunctivae Visual fields Visual acuity

-Pupil clarity -Visual fields -Visual acuity Rationale: Lacrimal apparatus is incorrect. If clients have an impairment in the ability to produce tears, it should not affect their fall risk. The nurse tests this by palpating the tear duct at the lower eyelid to see if any tears emerge.Pupil clarity is correct. Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly.Appearance of bulbar conjunctivae is incorrect. The nurse should examine the bulbar conjunctivae by gently retracting the lower and upper lids to evaluate color and texture and assess for the presence of infection. However, the condition of the conjunctivae will not impede the client's safety.Visual fields is correct. The nurse should use a finger to test the client's peripheral vision by moving the finger out of range and then back into the visual field to determine when the client sees the finger. Clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall.Visual acuity is correct. The nurse should use a Snellen chart to assess distance vision and a handheld card to assess near vision. Clients who wear eyeglasses should wear them during the assessments. Clients who have impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall.

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? A. Administer the medication with the needle at a 45degree angle B. Administer the medication into the client's nondominant arm. C. The Z-track technique involves displacing the skin laterally or downward prior to administration of an IM injection. D. Massage the injection site after administration

A. Administer the medication with the needle at a 45degree angle Rationale: The nurse should insert the needle at a 45° to 90° angle for a subcutaneous injection. he nurse should administer enoxaparin into the abdomen, at least 5 cm (2 in) from the umbilicus. The Z-track technique involves displacing the skin laterally or downward prior to administration of an IM injection. The nurse should not massage the injection site following the injection of an anticoagulant due to the risk for bruising.

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? A. Advocacy ensures clients' safety, health, and rights. B. Advocacy ensures that nurses are able to explain their own actions. C. Advocacy ensures that nurses follow through on their promises to clients. D. Advocacy ensures fairness in client care delivery and use of resources.

A. Advocacy ensures clients' safety, health, and rights. Rationale: Advocacy is a key component of professional nurses' code of ethics. As a client advocate, the nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care. Accountability, not advocacy, is the responsibility of nurses to explain their own actions to their clients and employer. Fidelity, not advocacy, is an agreement by nurses to follow through with promises made to clients. Justice, not advocacy, is fairness in client care delivery, including the distribution of resources and care.

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? A. Ask another nurse to observe the medication wastage. B. Notify the pharmacy when wasting the medication C. Lock the remaining medication in the controlled substances cabinet. D. Dispose of the vial with the remaining medication in a sharps container.

A. Ask another nurse to observe the medication wastage. Rationale: A second nurse must witness the disposal of any portion of a dose of a controlled substance. Pharmacies do not require notification of the disposal of a portion of a dose of a controlled substance. The nurse should not lock the remaining controlled substance in the cabinet because this is a violation of the Controlled Substances Act. The nurse should not dispose of the remaining controlled substance in the sharps container because this is a violation of the Controlled Substances Act.

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when 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. After consulting with the client's family.

A. During the admission process Rationale: Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility. Although it is appropriate to defer client teaching until the client is stable and receptive to learning, the initiation of discharge planning does not depend on the client's physiological stability. eam conferences facilitate discharge planning, but they are not essential for initiating the planning process. The nurse should only consult with the client's family if the client gives the nurse permission to share that information. In the case of a client who has an exacerbation of heart failure, delaying discharge planning until this time could result in overlooking essential care needs.

A nurse is on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? A. Pad the client's wrist before applying the restraints. B. Evaluate the client's circulation every 8 hr after application. C. Remove the restraints every 4 hr to evaluate the client's status. D. Secure the restraint ties to the bed's side rails.

A. Pad the client's wrist before applying the restraints. Rationale: The use of restraints without padding can abrade the client's skin, resulting in client injury. The nurse should evaluate the client's circulation, range of motion, vital signs, and overall status every 15 min after initial application of restraints. The nurse should remove the restraints at least every 2 hr to reposition the client and assess needs for hygiene and toileting. The nurse should secure the restraint ties to a part of the bed frame that moves with the client to reduce the risk of injury.

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? A. Use the complete name of the medication magnesium sulfate. B. Delete the space between the numerical dose and the unit of measure. C. Write the letter U when noting the dosage of insulin D. Use the abbreviation SC when indicating an injection.

A. Use the complete name of the medication magnesium sulfate. Rationale: The Institute for Safe Medication Practices designates that nurses and providers write the complete medication name for magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate. The Institute for Safe Medication Practices recommends including a space between the dose and the unit of measure, such as in 10 mg, to avoid confusion when documenting medication dosages. The Institute for Safe Medication Practices designates "unit(s)" as the correct term for use in medication documentation. The Institute for Safe Medication Practices designates either "subcut" or "subcutaneously" as the correct terms for use in medication documentation.

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.) -Assist the client with a partial bed bath. -Measure the client's BP after the nurse administers an antihypertensive medication. -Test the client's swallowing ability by providing thickened liquids. -Use a communication board to ask what the client wants for lunch. -Irrigate the client's indwelling urinary catheter.

Assist the client with a partial bed bath Measure the client's BP after the nurse administers an antihypertensive medication Use a communication board to ask what the client wants for lunch Rationale: Assist the client with a partial bed bath is correct. Assisting a client with a bed bath poses minimal risk to the client and is within the AP's range of function.Measure the client's BP after the nurse administers an antihypertensive medication is correct. Measuring a client's BP poses minimal risk to the client and is within the AP's range of function.Test the client's swallowing ability by providing thickened liquids is incorrect. Assessing the client's swallowing ability places the client at risk for aspiration and is not within the AP's range of function. Nurses perform tasks that require assessment.Use a communication board to ask what the client wants for lunch is correct. Using a communication board poses minimal risk to the client and is within the AP's range of function.Irrigate the client's indwelling urinary catheter is incorrect. Irrigating the client's indwelling urinary catheter is an invasive procedure and is not within the AP's range of function.

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make? A. "We would consult the person appointed by your health care proxy to make decisions." B. "We would give you oxygen through a tube in your nose." C. You would be unable to change your previous wishes about your care." D. We would insert a breathing tube while we evaluate your condition."

B. "We would give you oxygen through a tube in your nose." Rationale: Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula. ntubation is a resuscitative measure. The staff should not implement this intervention for a client who declines resuscitation in their living will. Clients determine advance directives ahead of time to guide decision-making at the time of an emergency event. If the client initiates a change, the staff must honor it. Otherwise, staff must honor the decisions the client has documented in the advance directives. The staff must honor the client's wishes as stated in their living will; therefore, it would not be necessary to consult the person appointed by the client's health care proxy to make decisions about the client's care.

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? A. Insert the suctions catheter while the client is swallowing. B. Apply intermittent suction when withdrawing the catheter. C. Place the catheter in a location that is clean and dry for later use. D. Hold the suction catheter with her clean, nondominant hand.

B. Apply intermittent suction when withdrawing the catheter. Rationale: The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise. The nurse should insert the suction catheter while the client is inhaling not when swallowing to avoid inserting the catheter into the esophagus. The nurse should discard the suction catheter after use to eliminate the risk of reintroducing pathogens into the respiratory tract. The nurse should hold the suction catheter with her dominant hand after donning a sterile glove.

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? A. Contact B. Droplet C. Airborne D. Protective

B. Droplet Rationale: Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 1 m (3 feet) of the client who has a disorder requiring droplet precautions. Contact precautions are a requirement for clients who have infections that spread via direct contact or from environmental contact. Examples are vancomycin-resistant enterococci and herpes simplex infections. Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles. Clients who have a compromised immune system, such as those who have received an allogeneic stem cell transplant, require a protective environment. This precaution keeps them from acquiring infections from others.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? A. Insert the catheter at a 45 degree angle. B. Place the client's arm in a dependent position. C. Shave excess hair from the insertion site. D. Initiate IV therapy in the veins of the hand.

B. Place the client's arm in a dependent position. Rationale: The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity. Generally, the nurse should insert the catheter at a 10° to 30° angle. However, for an older adult client, an angle of 10° to 15° is preferable because veins are closer to the skin surface as aging diminishes subcutaneous tissue. The nurse should clip excess hair from the IV insertion site and avoid shaving the area because shaving can cause breaks and cuts in the skin that could place the client at risk for infection. The nurse should avoid using the fragile veins of an older adult's hands because the loss of subcutaneous tissue can allow those veins to roll away from the needle. Also, having an IV catheter in the client's hand can interfere with the client's performance of activities of daily living and can diminish an older adult's sense of independence and mobility.

A nurse is perfuming a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? A. The client uses a wool blanket on their bed. B. The client identifies the location of a fire extinguisher C. The client stores an extra oxygen tank on its side under their bed. D. The client has a weekly inspection checklist for oxygen equipment.

B. The client identifies the location of a fire extinguisher Rationale: The client should be able to identify the location of fire extinguishers in the home and be aware of how to use them. The client should use a cotton blanket instead of a wool blanket to avoid generating static electricity that could ignite the oxygen. The client should store extra oxygen tanks in an upright position to maintain safety. The client or caregiver should inspect oxygen equipment daily.

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? A. "I think I should take pain medication more often, since it is not controlling my pain." B. Breathing faster will help me keep my mind off of the pain." C. "It might help me to listen to music while I'm laying in bed." D. I don't want to walk today because I have some pain. "

C. "It might help me to listen to music while I'm laying in bed."

A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make? A. "You would have so much more time to spend with your family." B. "You should consider a part-time job or doing volunteer work." C. "Let's talk about how the change in your job status will affect you." D. Why wouldn't you want to retire and relax?"

C. "Let's talk about how the change in your job status will affect you." Rationale: This response is therapeutic because the nurse is encouraging the client to verbalize feelings about the life transition of retirement.

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? A. A lesion with uniform pigmentation B. New appearance of petechiae C. A mole with an asymmetrical appearance D. The presence of a papule

C. A mole with an asymmetrical appearance

A nurse is providing discharge teaching to a client about self administering heparin. Which of the following instruction should the nurse include in the teaching? A. insert the needle at a 15° angle B. aspirate for blood return prior to administration C. Administer the medication into the abdomen D. massage the site following the injection

C. Administer the medication into the abdomen Rationale: The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue. The nurse should instruct the client to insert the needle at a 45° to 90° angle to administer the medication into the subcutaneous tissue. The nurse should instruct the client not to aspirate for blood return because this can cause tissue damage and bruising. he nurse should instruct the client not to massage the site because this can cause tissue damage and bruising.

A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? A. Bladder distention B. Decreased blood pressure C. Calf swelling D. Diminished bowel sounds

C. Calf swelling Rationale: Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility. A client who requires bed rest can develop postural hypotension, which is a drop in blood pressure when the client moves from a lying to a sitting position. The nurse should also assess the client for an increase in pulse rate and dizziness. Urinary retention, which causes bladder distention, is a common complication of bed rest due to a loss of muscle tone in the bladder and detrusor muscles. A decrease in bowel sounds reflects slowed peristalsis. Constipation is a common complication of immobility.

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? A. Verify the client's name on their identification bracelet with the medication administration record. B. Call the pharmacy to determine whether the client's medications are available. C. Compare the client's home medications with the provider's prescriptions. D. Place the client's home medication bottles in a secure location.

C. Compare the client's home medications with the provider's prescriptions. Rationale: The nurse should compare the client's home medications with the provider's prescriptions when performing medication reconciliation. The nurse should verify the client's name on their identification bracelet when administering medication; however, this action is not a part of performing medication reconciliation. The nurse should call the pharmacy if the client's medications are not available to administer at the appropriate time; however, this action is not a part of performing medication reconciliation. The nurse should place the client's home medications in a secure location to ensure safe handling of prescribed medications; however, this action is not a part of performing medication reconciliation.

A nurse is administering 1 L of 0.9% NaCl to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? A. Increase in hematocrit. B. Increase in respiratory rate. C. Decrease in heart rate. D. Decrease in capillary refill time.

C. Decrease in heart rate. Rationale: Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range. Fluid volume deficit causes an increase in hematocrit level due to depletion of extracellular fluid. With correction of the imbalance, the hematocrit level should decrease. luid volume deficit causes an increase in respiratory rate. With correction of the imbalance, the respiratory rate should return to the expected range. Fluid volume deficit slows capillary refill. With correction of the imbalance, capillary refill time should return to the expected range.

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take? A. Assist the client into a prone position. B. Place a sleeve over the top of each leg with the opening at the knee. C. Make sure two fingers can fit under the sleeves. D. Set the ankle pressure at 65 mm Hg.

C. Make sure two fingers can fit under the sleeves. Rationale: The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate. The nurse should place the client in a dorsal recumbent or semi-Fowler's position to facilitate application of the sleeves. he nurse should place the sleeve under each leg with the opening at the knee and then wrap the sleeve around the leg so that it is secure. The nurse should set the ankle pressure between 35 and 55 mm Hg to achieve a therapeutic effect while also preventing damage to the client's skin and circulatory impairment.

A nurse is talking with a partner of a client who has dementia. The client partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role performance stress? A. role ambiguity B. sick role C. Role overload D. role conflict

C. Role overload Rationale: The partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage. Role conflict develops when a person must assume multiple roles that have opposing expectations. Sick role refers to the expectations placed on the individual who has the alteration in health, rather than the caregiver. Role ambiguity occurs when people are unclear about the expectations of their role in a given situation.

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? A. The top of the cane is parallel to the client's waist B. When walking, the client moves the cane 46 cm (18 in) forward. C. The client holds the cane on the stronger side of the body D. The client moves her stronger limb forward with the cane.

C. The client holds the cane on the stronger side of the body Rationale: The client should hold the cane on the stronger side of her body to increase support and maintain alignment. The top of the cane should be parallel to the client's greater trochanter. To maintain balance, the client should advance the cane about 15 to 30 cm (6 to 12 in) at a time. The client should move her weaker leg forward with the cane. This divides the client's body weight between the cane and the stronger leg.

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? A. Numbness of the extremities. B. Bradycardia. C. Positive Chvostek's sign D. Abdominal cramping

D. Abdominal cramping Rationale: This client has hyponatremia, which is a low sodium level. Manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea. Numbness of the extremities is a manifestation of hyperkalemia. Tachycardia is a manifestation of hyponatremia along with hypovolemia. A positive Chvostek's sign is a manifestation of hypomagnesemia and hypocalcemia.

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies? A. Biofeedback B. Aloe C. Feverfew D. Acupuncture

D. Acupuncture Rationale: The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk of further infection. everfew is a complementary and alternative therapy that helps promote wound healing. Anticoagulant therapy is a contraindication for taking feverfew. However, herpes zoster is not a contraindication for the use of this type of therapy. Aloe is a complementary and alternative therapy that can help improve disorders and can have wound healing effects. Herpes zoster is not a contraindication for the use of this type of therapy. Biofeedback is a complementary and alternative therapy to assist clients with stroke recovery, smoking cessation, headaches, and many other disorders. Herpes zoster is not a contraindication for the use of this mind-body technique.

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? A. Position the client with the head of the bed elevated to 30 degrees prior to insertion of the NG tube. B. Remove the NG tube if the client begins to gag or choke. C. Apply suction to the NG tube prior to insertion. D. Have the client take sips of water to promote insertion of the NG tube into the esophagus.

D. Have the client take sips of water to promote insertion of the NG tube into the esophagus. Rationale: Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea. The client should be sitting in high-Fowler's position with the head of the bed elevated to 90° to reduce the risk for aspiration. The nurse should withdraw the NG tube slightly, not remove it, if the client gags or chokes to reduce the risk of injury to the client. The nurse should not apply suction until the NG tube is in place with x-ray verification of its position in order to reduce the risk of injury to the client.

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next? A. Document the provider's statement in the medical record. B. Complete an incident report. C. Consult the facility's risk manager. D. Notify the nursing manager.

D. Notify the nursing manager. Rationale: The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care. The nurse should document the provider's directions in the medical record for later reference; however, another action is the nurse's priority. The nurse should prepare an incident report detailing the delay in treatment for later review and action for prevention of future occurrences; however, another action is the nurse's priority. The nurse should discuss the situation with the facility's risk management department to help determine the need for preventive actions; however, another action is the nurse's priority.

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? A. BUN is 15 mg/dL B. Creatinine 0.8 mg/dL C. Sodium 143 mEq/L D. Potassium 5.4 mEq/L

D. Potassium 5.4 mEq/L Rationale: This value is above the expected reference range of 3.5 to 5 mEq/L, so the nurse should report this finding to the provider. This client is at risk for dysrhythmias. Sodium: This value is within the expected reference range of 136 to 145 mEq/L. Creatinine: This value is within the expected reference range of 0.5 to 1.1 mg/dL for women 41 to 60 years of age and 0.6 to 1.3 mg/dL for men 41 to 60 years of age. Even for clients within younger and older age ranges (with the exception of newborn through 9 years of age), 0.8 mg/dL is within the expected reference range for creatinine. BUN: This value is within the expected reference range of 10 to 20 mg/dL.

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? A. Discuss the risk factors for colon cancer. B. Focus teaching on what the client will need to do in the future got manage his illness. C. Provide the client with written information about the phases of loss and grief. D. Reassure the client that this is an expected response to grief.

D. Reassure the client that this is an expected response to grief. Rationale: During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis. During the anger stage of the client's psychosocial adaptation to illness, the nurse should focus teaching on the present. The client is not yet ready to face the future.

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self injury, which of the following actions should the nurse take when lifting this object? A. bend at the waist B. keep his feet close together C. Use his back muscles for lifting D. stand close to the cabinet when lifting it

D. stand close to the cabinet when lifting it Rationale: This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching.