HESI Fundamentals Guide 12 Latest Versions Verified Questions and Answers latest Updated 2022,100% CORRECT

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HESI Fundamentals Guide 12 Latest VersionsVerified Questions and Answers latest Updated 2022 HESI FUNDAMENTALS A policy requiring the removal of acrylic nails by all nursing personnel was imple... mented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved. Number of staff induced injury Client satisfaction survey Health care-associated infectionrate. Rate of needle-stick injuries bynurse. The nurse is preparing to assist a newly admitted client with personal hygiene measures. The client...the client’s gag reflex. Which action should the nurse include? Offer smalls sips of water through astraw Place tongue blade on back half oftongue Use a penlight to observe back of oral cavity Auscultate breath sounds after client swallows The nurse explains to an older adult male the procedure for collecting a 24-hour urine specimen for creatinine clearance. Assess the client for confusion and reteach the procedure Check the urine for color and texture Empty the urinal contents into the 24-hour collection container Discard the contents of the urinal A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most Ask her how she would like to participate in the client’s care Provide the wife with information about hospice Encourage the wife to visit after painful treatments are completed Refer her to support group for family members of those dying of cancer A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend? Plan low carbohydrate and high proteinmeals Engage in strenuous activity for an hourdaily Keep a record of food and drinks consumed daily Participated in a group exercise class 3 times a week The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurse observe? Tops of the ear Bridge of the nose Around the nostrils Over the cheeks Across the forehead The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client’s foot in a basin of warm water placed on the bed. What action should the nurse take? Remove the basin of water from the client’s bed immediately Remind the UAP to dry between the client’s toes completely Advise the UAP that this procedure is damaging to the skin Add skin cream to the basin of water while the foot is soaking The nurse in the emergency department observes a colleague viewing the electronic health record (EHR) of a client who holds an elected position in the community. The client is not a part of the colleague’s assignment. Which action should the nurseimplement? Communicate the colleague’s actions to the unit charge nurse Send an email to facility administration reporting the action Write an anonymous complaint to a professional website Post a comment about the action on a staff discussion board At 0100 on a male client’s second postoperative night, the client states he is unstable to sleep and plans to read until feeling sleepy. What action should the nurse implement? Leave the room and close the door to the client’s room Assess the appearance of the client’s surgical dressing Bring the client a prescribed PRN sedative-hypnotic Discuss symptoms of sleep deprivation with the client The nursing staff in the cardiovascular intensive care unit are creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy? Remove identifying information of the clients who participated Recall that authored content may be legally discoverable Share material from credible, peer reviewed sources only Respect all copyright laws when adding website content A male client with unstable angina needs a cardiac catheterization, so the healthcare provider explains the risks and benefits of the procedure, and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take? Answer the client’s specific questions with a short understandable explanation Postpone the procedure until the client understands the risks and benefits Call the client’s next of kin and ask them to provide verbal consent Page the healthcare provider to return and provide additional explanation The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform? Tilt the pelvis forwards and backwards bend the arm by flexing the ulnar to the humerus Turn the head to the right and left Extend the arm at the ide and rotate in circles A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What actions should the nurse take first? Access for side effects of the medication. Document the client’s responses. complete a medication error report. Determine if the pain was relieved. When assessing a male client, the nurse finds that he is fatigue, and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client’s laboratory values to validate the existence of which? Hyperphosphatemia Hypocalcemia Hypermagnesemia Hypokalemia A female client’s significant other has been at her bedside providing reassurances and support for the past 3days, as desired by the client. The client’s estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement? Obtain a perception from the healthcare provider regarding visitation privileges Request a consultation with the ethics committee for resolution of the situation Encourage the client to speak with her husband regarding his disruptive behavior Communicate the client’s wishes to all members of the multidisciplinary team When measuring vital signs, the nurse observes that a client is using accessory neck muscles during respirations. What follow-up action should the nurse take first? Determine pulse pressure Auscultate heart sounds Measure oxygen saturation Check for neck vein distention To avoid nerve injury, what location should the nurse select to administer a 3 mL IM injection? Ventrogluteal outer upper quadrant of the buttock Two inches below the acromion process Vastus lateralis Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia? Monitor daily urine output volume Drink plenty of water whenever thirsty Use salt tablets for sodium content Review food labels for sodium content While changing a client’s post operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive MRSA, which is the most important action for the nurse totake? Force oral fluids Request a nutrition consult Initiate contact precautions Limit visitors to immediate family only To prepare a client for the potential side effects of a newly prescribed medication, what action should the nurse implement? Assess the client for health alterations that may be impacted by the effects of the medication Teach the client how to administer the medication to promote the best absorption Administer a half dose and observe the client for side effects before administering a full dosage Encourage the client to drink plenty of fluids to promote effective drug distribution A client is 2 days post-op from a thoracic surgery and is complaining of incisional pain. The client last received pain medication 2 hours ago. He is rating his pain a 5 on a 1-10 scale. After calling the provider, what is the nurse's next action? instruct the client to use guided imagery and slow rhythmic breathing Provide at least 20 minutes of back massage and gentle effleurage Encourage the client to watch TV. Place a hot water circulation device, such as an Aqua K pad, to operative site A client with cirrhosis and ascites is receiving furosemide 40 mg BID. The pharmacy provides 20 mg tablets. How many tablets should the client receive each day? [Enter numeric value only] 4 tablets An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What action should the nurse implement first? Establish a toileting schedule to decrease episodes of incontinence Complete a functional assessment of the client’s self-care abilities Apply a barrier ointment to intact areas that may be exposed to moisture Determine the size and depth of skin breakdown over the sacral area While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview? The client’s comfort level is increased when the nurse breaks eye contact to type notes into the record The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace The nurse has limited ability to observe nonverbal communication while entering the assessment electronically Completing the electronic record during an interview is a legal obligation of the examining nurse A female client with chronic back pain has been taking muscle relaxants and analgesics to manage the discomfort, but is now experiencing an acute episode of pain that is not relieved by this medication regime. The client tells the nurse that she does not want to have back surgery for a herniated intervertebral disk, and reports that she has found acupuncture effective in resolving past acute episodes. Which response is best for the nurse to provide? Surgery removes the disk and is the only treatment that can totally resolve the pain The medication regimen you previously used should be re-evaluated for dose adjustment Massage and hot pack treatments are less invasive and can provide temporary relief Acupuncture is a complementary therapy that is often effective for management of pain The nurse is providing wound care to a client with stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states “clean the wound and then apply collagenase.” collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the nurse cleanse the pressure ulcer? Lightly coat the wound with povidone-iodine solution Irrigate the wound with sterile normal saline Flush the wound with sterile hydrogen peroxide Remove the eschar with a wet-to-dry dressing A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement? Document the client’s circadian rhythms Assess for flushed, warm skin regularly Measure temperature at regularintervals Vary sites for temperature measurement When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first? Position the client supine for a few minutes Assist the client to stand at thebedside Apply the blood pressure cuffsecurely Record the client’s pulse rate and rhythm The nurse retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM 6 hours PRN severe pain. How many mL should the nurse administer to the client? (Enter the numerical value only. If rounding is required , round to the nearest tenth) Ans: 0.8 The unlicensed assistive personnel (UAP) describes the appearance of the bowel movement of several clients. Which description warrants additional follow up by the nurse? (select all that applies). Solid with red streaks. Brown liquid. Multiple hard pellets. Formed but soft. e. Tarry appearance. A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment...she has not yet been fitted for a particulate filter mask.Which action should the nurse take? Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client Before changing assignments, determine which staff members have fitted particulate filter masks In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative nurse is arranging for discharge, the client verbalizes concerns about pain. What action should the nurse implement? Explain the respiratory problems that can occur with morphine use. Teach family how to evaluate the effectiveness of analgesics. Recommend asking the healthcare professional for a patient-controlled analgesic (PCA) pump. Provide client with a schedule of around-the-clock prescribed analgesic use. What assessment finding places a client at risk for problems associated with impaired skin integrity? Scattered macula of the face Capillary refill 5 seconds Smooth nail texture Absence of skin tenting When evaluating the effectiveness of a client’s nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next? Determine if the expected outcomes were realistic Obtain current client data to compare with expected outcomes Modify the nursing interventions to achieve the client’s goals Review related professional standards of care The nurse attaches a pulse oximeter to a client’s fingers and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading? BP 142/88 mmHg 2+ edema of fingers and hands Radial pulse volume is +3 Capillary refill time is 2 seconds The nurse is caring for a hospitalized client who was placed in restraints due to confusion. The family removes the restraints while they are with the client. When the family leaves, what action should the nurse take first? Apply the restraints to maintain the client’s safety. Reassess the client to determine the need for continuing restraints. Document the time the family left and continue to monitor the client. Call the healthcare provider for a new prescription. The nurse is discharging an adult woman who was hospitalized for 6 days for treatment of pneumonia. While the nurse is reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement? Instruct the client to repeat the medication plan Encourage client to take a PRN antianxiety drug Provide written instructions that are easy to follow Include a family member in the teaching session What instruction should the nurse provide for an UAP caring for a client with MRSA who has a prescription for contact precautions? Do not allow visitors until precautions are discontinued Wear sterile gloves when handling the client’s body fluid Have the client wear a mask whenever someone enters the room Don a gown and gloves when entering the return While suctioning a client’s nasopharynx the nurse observes that the client’s oxygen saturation remains at 94% which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding? Complete the intermittent suction of the nasopharynx. Reposition the pulse oximeter clip to obtain a new reading. Stop suctioning until the pulse oximeter reading is above 95%. Apply an oxygen mask over the client’s nose and mouth UAP has lowered the head of the bed to change the lines for a client who is bedless. Which observation...most immediate intervention by the nurse? A feeding is infusing at 40 mL/hr through an enteral feeding tube The urine meter attached to the urinary drainage bag is completely full There is a large dependent loop in the client’s urinary drainage tubing Purulent drainage is present around the insertion site of the feeding tube A male client presents to the clinics stating that he has a high stress job and is having difficulty falling asleep at night. .The client reports having a constant headache and is seeking medication to help the sleep. Which intervention should the nurse implement? Determine the client’s sleep and activity pattern Obtain prescription for client to take when stressed Refer client for a sleep study and neurological follow-up Teach coping strategies to use when feeling stressed The nurse is teaching a client about use of the syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precaution? Remove needle before discarding used syringes Wear gloves to dispose of the needle and syringe Done a face mask before administering the medication Washes hands before handling the needle and syringe The nurse observes an UAP positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. Which action should the nurse implement? Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows Ensure that the UAP has placed pillows effectively to protect the client Ask the UAP to use some pillows to prop the client in a side-lying position Assume responsibility for placing the pillows while the UAP complete another task A cerebrovascular accident is placed on a ventilator. The client’s daughter arrives with a durable power of attorney, and a living will that indicates the...extraordinary life saving measures. What action should the nurse take? Refer to the risk manager Notify the healthcare provider Discontinue the ventilator Review the medical record Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway outside her room. What is the best action? Ask the family to wait in the cafeteria when the next of kin makes the necessary arrangements Provide space and privacy for the family to share their concerns about the client’s discharge Ask the social worker to encourage the family to clear the hallway Explain to the family the client’s need for privacy so that she can make independent decisions A client with rheumatoid arthritis is experiencing chronic pain in both hands and wrists. Which information about the client is most important for the nurse to obtain when planning care? Amount of support provided by family members Measurement of pain using a scale of 0 to 10 The ability to perform ADLs Nonverbal behaviors exhibited when pain occurs A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that the chronic constipation and had not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the nurse to implement? Evaluate the stool samples for presence of blood Assess for the presence of an impaction Determine what home remedies were used Obtain list of prescribed home medication Which assessment data reflects the need for the nurses to include the problem, “Risk for falls” in a client’s plan of care? Recent serum hemoglobin level of 16g/dL Opioid analgesic received one hour ago Stooped posture with a steady gait Expressed feelings of depression The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL, for the previous 6 hour shift. Which intervention should the nurse implement first? Check the drainage tubing for akink Review the intake and output record Notify the healthcare provider Give the client 8 oz of water to drink The nurse is conducting an initial admission assessment for a woman who is Mexican-American and who is scheduled to deliver a baby by C-section in the next 24 hours. What should the nurse include in the assessment? Provider an interpreter to convey the meaning of words and messages in translation Commend the client for her patience after a long wait in the admission process Arrange for the hospital chaplain to visit the client during her hospital stay Rely on cultural norms as the basis for providing nursing care for this client During the admission assessment of a terminally ill male client that he is an agnostic. What is the best nursing action in response to this statement? Provide information about the hours and location of the chapel Document the statement of the client’s spiritual assessment Invite the client to a healing service for people of all religions Offer to contact a spiritual advisor of the client’s choice The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client states that the permit should include… Notify the OR staff of the client’s confusion Have the client sign a new surgical permit Add the additional information to the permit Inform the surgeon about the client’s concern The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed. Administer nasal oxygen at a rate of 5 L/min Help the client to lie back down in the bed Quickly pivot the client to the chair and elevate the legs Check the client’s blood pressure and pulse deficit When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the nurse take divert the client’s attention Call for additional help from staff Document the planned action Re-assess the client situation HESI FUNDAMENTALS A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the LPN/LVN implement? Give an around-the-clock schedule for administration of analgesics. Administer analgesic medication as needed when the pain is severe. Provide medication to keep the client sedated and unaware of stimuli. Offer a medication-free period so that the client can do daily activities. Correct Answer: A When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the LPN implement first? Loosen the right wrist restraint. Apply a pulse oximeter to the right hand. Compare hand color bilaterally. Palpate the right radial pulse. Correct Answer: A The LPN/LVN is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A college-age track runner with a sprained ankle. A lactating woman nursing her 3-day-old infant. A school-aged child with Type 2 diabetes. An elderly man being treated for a peptic ulcer. Correct Answer: B A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the LPN/LVN to implement? Contact the healthcare provider and complete a medication variance form. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. Notify the charge nurse and complete an incident report to explain the missed dose. Give the missed dose at 1300 and change the schedule to administer daily at 1300. Correct Answer: D While instructing a male client's wife in the performance of passive range- of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the LPN/LVN implement? Acknowledge that she is supporting the arm correctly. Encourage her to keep the joint covered to maintain warmth. Reinforce the need to grip directly under the joint for better support. Instruct her to grip directly over the joint for better motion. Correct Answer: A What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? It is more difficult to find a superficial vein in the feet and ankles. A decreased flow rate could result in the formation of a thrombosis. A cannulated extremity is more difficult to move when the leg or foot is used. Veins are located deep in the feet and ankles, resulting in a more painful procedure. Correct Answer: B The LPN observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? Tell the UAP to use a larger cuff at the next scheduled assessment. Reassess the client's blood pressure using a larger cuff. Have the unit educator review this procedure with the UAPs. Teach the UAP the correct technique for assessing blood pressure. Correct Answer: B A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The LPN plans to administer the IVPB dose over 20 minutes. For how many ml/ hr should the infusion pump be set to deliver the secondary infusion? Correct Answer: 150 Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the LPN/LVN? That means you have derived the maximum benefit, and the heat can be removed. Your blood vessels are becoming dilated and removing the heat from the site. We will increase the temperature 5 degrees when the pad no longer feels warm. The body's receptors adapt over time as they are exposed to heat. Correct Answer: D The LPN is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? If I exercise at least two times weekly for one hour, I will lower my cholesterol. I need to avoid eating proteins, including red meat. I will limit my intake of beef to 4 ounces per week. My blood level of low density lipoproteins needs to increase. Correct Answer: C The UAPs working on a chronic neuro unit ask the LPN/LVN to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? Place the chair at a right angle to the bed on the client's left side before moving. Assist the client to a standing position, then place the right hand on the armrest. Have the client place the left foot next to the chair and pivot to the left before sitting. Move the chair parallel to the right side of the bed, and stand the client on the right foot. Correct Answer: D An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the LPN/LVN provide the UAP? Position the client on the right side of the bed in reverse Trendelenburg. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. Reposition in a Sim's position with the client's weight on the anterior ilium. Raise the side rails on both sides of the bed and elevate the bed to waist level. Correct Answer: C A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the LPN have for planning care in terms of the client's beliefs? Autopsy of the body is prohibited. Blood transfusions are forbidden. Alcohol use in any form is not allowed. A vegetarian diet must be followed. Correct Answer: B The LPN/LVN observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? Observe the appearance of the skin under the ice pack. Instruct the client regarding the need for the covering. Reapply the covering after filling with fresh ice. Ask the client how long the ice was applied to the skin. Correct Answer: A The LPN/LVN mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? 31 gtt/min. 62 gtt/min. 93 gtt/min. 124 gtt/min. Correct Answer: D A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the LPN/LVN to take? Record the coughing incident. No further action is required at this time. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. Correct Answer: C A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the LPN advise the client to follow? 9 a.m., 1 p.m., and 5 p.m. 8 a.m., 4 p.m., and midnight. Before breakfast, before lunch and before dinner. With breakfast, with lunch, and with dinner. Correct Answer: B A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the LPN/LVN set the client's intravenous infusion pump? 13 ml/hour. 63 ml/hour. 80 ml/hour. 125 ml/hour. Correct Answer: B An obese male client discusses with the LPN/LVN his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? Be sure to have a complete physical examination before beginning your planned exercise program. Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation. Correct Answer: A The LPN is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? Immediately after exhalation. During the inhalation. At the end of three inhalations. Immediately after inhalation. Correct Answer: B The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the LPN/LVN plan to administer? ½ tablet. 1 tablet. 1½ tablets. 2 tablets. Correct Answer: C The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the LPN/LVN administer? 1 ml. 1.5 ml. C. 1.75 ml. D. 2 ml. Correct Answer: B Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? 11,000 units. 13,000 units. 15,000 units. 17,000 units. Correct Answer: A The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the LPN/LVN administer? 0.5 ml. 1 ml. 1.5 ml. 2 ml. Correct Answer: A The LPN prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? 80 8 21 25 Correct Answer: C Which action is most important for the LPN/LVN to implement when donning sterile gloves? Maintain thumb at a ninety degree angle. Hold hands with fingers down while gloving. Keep gloved hands above the elbows. Put the glove on the dominant hand first. Correct Answer: C A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the LPN/LVN to take? Ask about any past history of drug abuse or addiction. Measure the pulse volume and capillary refill distal to the infiltration. Compress the infiltrated tissue to measure the degree of edema. Evaluate the extent of ecchymosis over the forearm area. Correct Answer: B An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? Prone. Fowler's. Sims'. Supine. Correct Answer: B A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the LPN/LVN include in this client's teaching plan? In 8 weeks you will be able to bend at the waist to reach items on the floor. Place a pillow between your knees while lying in bed to prevent hip dislocation. It is safe to use a walker to get out of bed, but you need assistance when walking. Take pain medication 30 minutes after your physical therapy sessions. Correct Answer: B A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the LPN/LVN implement first? Assist the ambulating client back to the bed. Encourage the client to ambulate to resolve pneumonia. Obtain a prescription for portable oxygen while ambulating. Move the oximetry probe from the finger to the earlobe. Correct Answer: A A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the LPN/LVN take? Commend the client for selecting a high biologic value protein. Remind the client that protein in the diet should be avoided. Suggest that the client also select orange juice, to promote absorption. Encourage the client to attend classes on dietary management of CRF. Correct Answer: A A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the LPN to include during the preoperative assessment? What is your daily calorie consumption? What vitamin and mineral supplements do you take? Do you feel that you are overweight? Will a clear liquid diet be okay after surgery? Correct Answer: B During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the LPN/LVN implement? Provide additional coffee on the client's breakfast tray. Exchange the client's grape juice for cranberry juice. Bring the client additional fruit at mid-morning. Encourage additional oral intake of juices and water. Correct Answer: D Which intervention is most important for the LPN/LVN to implement for a male client who is experiencing urinary retention? Apply a condom catheter. Apply a skin protectant. Encourage increased fluid intake. Assess for bladder distention. Correct Answer: D A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the LPN/LVN to implement? Obtain the pre-transfusion hemoglobin level. Prime the tubing and prepare a blood pump set-up. Monitor vital signs q15 minutes for the first hour. Ensure the accuracy of the blood type match. Correct Answer: D Which snack food is best for the LPN/LVN to provide a client with myasthenia gravis who is at risk for altered nutritional status? Chocolate pudding. Graham crackers. Sugar free gelatin. Apple slices. Correct Answer: A The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the LPN that this client understands the dietary restrictions? Tossed salad, low-sodium dressing, bacon and tomato sandwich. New England clam chowder, no-salt crackers, fresh fruit salad. Skim milk, turkey salad, roll, and vanilla ice cream. Macaroni and cheese, diet Coke, a slice of cherry pie. Correct Answer: C Which nutritional assessment data should the LPN/LVN collect to best reflect total muscle mass in an adolescent? Height in inches or centimeters. Weight in kilograms or pounds. Triceps skin fold thickness. Upper arm circumference. Correct Answer: D An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the LPN/LVN implement first? Reaffirm the client's desire for no resuscitative efforts. Transfer the client to a hospice inpatient facility. Prepare the family for the client's impending death. Notify the healthcare provider of the family's request. Correct Answer: D After completing an assessment and determining that a client has a problem, which action should the LPN/LVN perform next? Determine the etiology of the problem. Prioritize nursing care interventions. Plan appropriate interventions. Collaborate with the client to set goals. Correct Answer: A An elderly client who requires frequent monitoring fell and fractured a hip. Which LPN/LVN is at greatest risk for a malpractice judgment? A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. The nurse assigned to care for the client who was at lunch at the time of the fall. The nurse who transferred the client to the chair when the fall occurred. The charge nurse who completed rounds 30 minutes before the fall occurred. Correct Answer: C A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client asks relevant questions regarding the dressing change. states he will be able to complete the wound care regimen. demonstrates the wound care procedure correctly. has all the necessary supplies for wound care. Correct Answer: C When evaluating a client's plan of care, the LPN determines that a desired outcome was not achieved. Which action will the LPN implement first? Establish a new nursing diagnosis. Note which actions were not implemented. Add additional nursing orders to the plan. Collaborate with the healthcare provider to make changes. Correct Answer: B The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The LPN/LVN plans to set the flow rate at how many gtt/min? 42 gtt/min. 83 gtt/min. 125 gtt/min. 250 gtt/min. Correct Answer: B Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the LPN/LVN plan to administer? 0.5 tablet. 1 tablet. 1.5 tablets. 2 tablets. Correct Answer: B Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? Aspirating gastric contents to assure a pH value of 4 or less. Hearing air pass in the stomach after injecting air into the tubing. Examining a chest x-ray obtained after the tubing was inserted. Checking the remaining length of tubing to ensure that the correct length was inserted. Correct Answer: C The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the LPN/LVN take? Infuse normal saline at a keep vein open rate. Discontinue the IV and flush the port with heparin. Infuse 10 percent dextrose and water at 54 ml/hr. Obtain a stat blood glucose level and notify the healthcare provider. Correct Answer: C When assisting an 82-year-old client to ambulate, it is important for the LPN/LVN to realize that the center of gravity for an elderly person is the Arms. Upper torso. Head. Feet. Correct Answer: B In developing a plan of care for a client with dementia, the LPN/LVN should remember that confusion in the elderly is to be expected, and progresses with age. often follows relocation to new surroundings. is a result of irreversible brain pathology. can be prevented with adequate sleep. Correct Answer: B An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The LPN knows that the best position for this client during administration of the feedings is prone. Fowler's. Sims'. supine. Correct Answer: B The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the LPN take? Talk directly to the child instead of the mother. Continue asking the mother questions about the child. Ask another nurse to interview the mother now. Tell the mother politely to look at you when answering. Correct Answer: B When conducting an admission assessment, the LPN should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? Complimentary healing practices interfere with the efficacy of the medical model of treatment. Conventional medications are likely to interact with folk remedies and cause adverse effects. Many complimentary healing practices can be used in conjunction with conventional practices. Conventional medical practices will ultimately replace the use of complimentary healing practices. Correct Answer: C A young mother of three children complains of increased anxiety during her annual physical exam. What information should the LPN/LVN obtain first? Sexual activity patterns. Nutritional history. Leisure activities. Financial stressors. Correct Answer: B Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the LPN that it is much bigger than he expected. What is the best response by the nurse? Reassure the client that he will become accustomed to the stoma appearance in time. Instruct the client that the stoma will become smaller when the initial swelling diminishes. Offer to contact a member of the local ostomy support group to help him with his concerns. Encourage the client to handle the stoma equipment to gain confidence with the procedure. Correct Answer: B At the time of the first dressing change, the client refuses to look at her mastectomy incision. The LPN tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel. Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery. It is OK if you don't want to talk about your surgery. I will be available when you are ready. I will ask a woman who has had a mastectomy to come by and share her experiences with you. Correct Answer: C HESI FUNDAMENTALS During the initial physical assessment of a newly admitted client with a pressure ulcer, a LPN observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate? A The nurse also should have instituted a plan to increase activity. B The nurse provided supportive nursing care for the well-being of the client. C Debridement of the pressure ulcer should have been done before the dressing was applied. D Treatment should not have been instituted until the health care provider's prescriptions were received. Correct Answer: B A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight and that the client is now lying unconscious on the floor. What is the most important action the LPN/LVN needs to take? A Ask the client if he is okay. B Call security from the room. C Find out if there is anyone else in the room. D Ask security to make sure the room is safe Correct Answer: D To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the LPN should change the administration set every: A 4 to 8 hours B 12 to 24 hours C 24 to 48 hours D 72 to 96 hours Correct Answer: D A LPN/LVN is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? Select all that apply. A Ask the client what is the client's acceptable level of pain. B Eliminate all activities that precipitate the pain. C Administer the pain medications regularly around the clock. D Use a different pain scale each time to promote patient education. E Assess the client's pain every 15 minutes Correct Answer: A, C The LPN/LVN is preparing to administer eardrops to a client that has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply. A Allergy to the medication B Itching in the ear canal C Drainage from the ear canal D Tympanic membrane rupture E Partial hearing loss in the affected ear Correct Answer:A,C,D What clinical indicators should the LPN/LVN expect a client with hyperkalemia to exhibit? Select all that apply. A Tetany B Seizures C Diarrhea D Weakness E Dysrhythmias Correct Answer:C,D,E A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the LPN give the client about this medication? A Prolonged use can cause dark concentrated urine. B The medication is best absorbed when taken on an empty stomach. C Take the medication with aluminum hydroxide to minimize GI upset. D Drinking alcohol daily can cause drug-induced hepatitis Correct Answer:D To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what does the LPN/LVN expect the dietary plan to include? A Low in fat B High in iron C High in fluids D Low in residue Correct Answer:C A postoperative client says to the nurse, "My neighbor, I mean the person in the next room, sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the LPN/LVN best handle this situation? A Tell the neighboring client to stop singing. B Close the doors to both clients' rooms at night. C Give the complaining client the prescribed as needed sedative. D Move the neighboring client to a room at the end of the hall Correct Answer:D The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The LPN should monitor for what complication associated with this type of surgery? A Occipital headache B Periorbital crepitus C Expectoration of blood D Changes in vocalization Correct Answer:C A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the LPN/LVN question? A Oral psyllium (Metamucil) B Oral potassium supplement C Parenteral half normal saline D Parenteral albumin (Albuminar) Correct Answer:D A client is to have mafenide (Sulfamylon) cream applied to burned areas. For which serious side effect of mafenide therapy should the LPN/LVN monitor this client? A Curling ulcer B Renal shutdown C Metabolic acidosis D Hemolysis of red blood cells Correct Answer:C A LPN is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? Select all that apply. A Clean the eyelid and eyelashes. B Place the dropper against the eyelid. C Apply clean gloves before beginning of procedure. D Instill the solution directly onto cornea. E Press on the nasolacrimal duct after instilling the solution. Correct Answer:A,C,E The LPN/LVN recognizes that which are important components of a neurovascular assessment? Select all that apply. A Orientation B Capillary refill C Pupillary response D Respiratory rate E Pulse and skin temperature F Movement and sensation Correct Answer: B,E,F A client reaches the point of acceptance during the stages of dying. What response should the LPN/LVN expect the client to exhibit? A Apathy B Euphoria C Detachment D Emotionalism Correct Answer: C A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the LPN/LVN primarily use nonverbal interventions? A Anger B Denial C Bargaining D Acceptance Correct Answer: D When a client files a lawsuit against a LPN for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as: A Evidence B Tort discovery C Proximate cause D Common cause Correct Answer:C Following a surgery on the neck, the client asks the LPN why the head of the bed is up so high. The LPN should tell the client that the high-Fowler position is preferred for what reason? A To avoid strain on the incision B To promote drainage of the wound C To provide stimulation for the client D To reduce edema at the operative site Correct Answer: D The LPN is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication? A Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care. B Develop a chart for the client, listing the times the medication should be taken. C Contact the primary health care provider and discuss the possibility of simplifying the medication regimen. D Instruct the client and client's children to put medications in a weekly pill organizer Correct Answer: C The LPN/LVN expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. A Dyspnea B Flushed face C Precordial pain D Increased pulse rate E Increased blood pressure Correct Answer: B,D The LPN/LVN should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may: A Force urine to back up into the kidneys. B Suppress production of urine. C Cause the device to pull away from the skin. D Tear the ileal conduit Correct Answer: C A LPN is reviewing studies to answer a clinical question as part of an evidence-based practice project. The study design determines the level of evidence. Place each methodology in order from the most reliable to the least reliable. A Meta-analysis B Randomized controlled trial C Expert opinion based on scientific principles D Cohort study E Controlled trial without randomization Correct Answer: A Client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the LPN emphasize when informing the client about exposure to radiation? A The dosage is kept at a minimum. B Only a small part of the body is irradiated. C The client's physical condition is not a risk factor. D Nutritional environment of the affected cells is a risk factor. Correct Answer: B The triage LPN in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last? A Multipara in active labor B Middle-aged woman with substernal chest pain C Older adult male with a partially amputated finger D Adolescent boy with an oxygen saturation of 91% Correct Answer: C Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include? A Encouraging daily physical exercise B Performing yearly physical examinations C Providing hypertension screening programs D Teaching a person with diabetes how to prevent complications Correct Answer: A A LPN/LVN who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. The nurse observes that the client requested a do not publish (DNP) order on any information regarding condition or presence in the hospital. What is the best response by the LPN/LVN? A "We have no record of that client on our unit. Thank you for calling." B "The new privacy laws prevent me from providing any client information over the phone." C "The client has requested that no information be given out. You'll need to call the client directly." D "It is against the hospital's policy to provide you with any information regarding any of our clients." Correct Answer: A When being interviewed for a position as a registered professional LPN, the applicant is asked to identify an example of an intentional tort. What is the appropriate response? A Negligence B Malpractice C Breach of duty D False imprisonment Correct Answer: D The LPN/LVN plans care for a client with a somatoform disorder based on the understanding that the disorder is: A A physiological response to stress B A conscious defense against anxiety C An intentional attempt to gain attention D An unconscious means of reducing stress Correct Answer: D A LPN is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? A Droplet precautions B Reverse isolation C Surgical asepsis D Medical asepsis Correct Answer: C 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? Select all that apply. A Prayer B Hypnosis C Medication D Aromatherapy E Guided imagery Correct Answer:A,B,D,E A LPN is teaching an adolescent about type 1 diabetes and self- care. Which questions from the client indicate a need for additional teaching in the cognitive domain? Select all that apply. A "What is diabetes?" B "What will my friends think?" C "How do I give myself an injection?" D "Can you tell me how the glucose monitor works?" E"How do I get the insulin from the vial into the syringe? Correct Answer:A,D Place each step of the nursing process in the order that it should be used. Correct A Obtain client's nursing history. Correct B State client's nursing needs. Correct C Identify goals for care. Correct D Develop a plan of care. Correct E Implement nursing interventions. Correct Answer:A,B,C,D,E In what position should the LPN/LVN place a client recovering from general anesthesia? A Supine B Side-lying C High Fowler E Trendelenburg Correct Answer: B Which age-related change should the LPN/LVN consider when formulating a plan of care for an older adult? Select all that apply. A Difficulty in swallowing B Increased sensitivity to heat C Increased sensitivity to glare D Diminished sensation of pain E Heightened response to stimuli Correct Answer: C,D The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a Durable Power of Attorney for Healthcare. What action should the LPN/LVN take? A Institute the prescribed blood transfusion because the client's survival depends on volume replacement. B Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. C Phone the health care provider for an administrative prescription to give the transfusion under these circumstances. D Give the spouse a treatment refusal form to sign and notify the health care provider that a court order now can be sought Correct Answer: D Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby out of the hospital. Staff members are unable to contact her health care provider. The client arrives at the nursery and asks that her infant be given to her to take home. What is the most appropriate nursing action? A Give the infant to the client and instruct her regarding the infant's care. B Explain to the client that she can leave, but her infant must remain in the hospital. C Emphasize to the client that the infant is a minor and legally must remain until prescriptions are received. D Tell the client that hospital policy prevents the staff from releasing the infant until ready for discharge Correct Answer:A A client reports fatigue and dyspnea and appears pale. The LPN/ LVN questions the client about medications currently being taken. In light of the symptoms, which medication causes the nurse to be most concerned? A Famotidine (Pepcid) B Methyldopa (Aldomet) C Ferrous sulfate (Feosol) D Levothyroxine (Synthroid) Correct Answer:B The LPN/LVN assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is: A faint, barely detectable. B slightly weak, palpable. C normal. D bounding. Correct Answer:C A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the LPN puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted? A Limits had to be set to control the child's crying. B The child had a right to remain in the room with the other children. C The child had to be removed because the other children needed to be considered. D Segregation of the child for more than half an hour was too long a period of time Correct Answer: B An older client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which interventions have specific gerontologic implications the LPN must consider? Select all that apply. A Assessment of skin turgor B Documentation of vital signs C Assessment of intake and output D Administration of antiemetic drugs E Replacement of fluid and electrolytes Correct Answer:A,D,E What should the LPN/LVN consider when obtaining an informed consent from a 17-year-old adolescent? A If the client is allowed to give consent B The client cannot make informed decisions about health care. C If the client is permitted to give voluntary consent when parents are not available D The client probably will be unable to choose between alternatives when asked to consent Correct Answer: A Which nursing activities are examples of primary prevention? Select all that apply. A Preventing disabilities B Correcting dietary deficiencies C Establishing goals for rehabilitation D Assisting with immunization program E Stopping smoking Correct Answer: D,E An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls what expected sensory losses associated with aging? Select all that apply. A Difficulty in swallowing B Diminished sensation of pain C Heightened response to stimuli D Impaired hearing of high-frequency sounds E Increased ability to tolerate environmental heat Correct Answer: B,D A nurse receives a subpoena in a court case involving a child. The nurse is preparing to appear in court. In addition to the state Nurse Practice Act and the American Nursing Association (ANA) Code for Nurses, what else should the nurse review? A Nursing's Social Policy Statement B State law regarding protection of minors C ANA Standards of Clinical Nursing Practice D References regarding a child's right to consent Correct Answer: C A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical indicators should the LPN monitor the client? Select all that apply. A Tremors B Lethargy C Palpitations D Visual disturbances E Decreased pulse rate Correct Answer: A,C A client asks about the purpose of a pulse oximeter. The LPN/LVN explains that it is used to measure the: A Respiratory rate. B Amount of oxygen in the blood. C Percentage of hemoglobin-carrying oxygen. D Amount of carbon dioxide in the blood Correct Answer: C A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past two days. The first thing the LPN/LVN should do when caring for this client is to: A Encourage fluids. B Administer oxygen. C Take the temperature. D Collect a sputum specimen Correct Answer: E A LPN/LVN is preparing a community health program for senior citizens. The nurse teaches the group that the physical findings that are typical in older people include: A A loss of skin elasticity and a decrease in libido B Impaired fat digestion and increased salivary secretions C Increased blood pressure and decreased hormone production D An increase in body warmth and some swallowing difficulties Correct Answer: E A client has been diagnosed as brain dead. The LPN/LVN understands that this means that the client has: A No spontaneous reflexes B Shallow and slow breathing C No cortical functioning with some reflex breathing D Deep tendon reflexes only and no independent breathing Correct Answer: D A LPN/LVN cares for a client that has been bitten by a large dog. A bite by a large dog can cause which type of trauma? A Abrasion B Fracture C Crush injury D Incisional laceration Correct Answer: C A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the LPN consider about how gamma globulin provides passive immunity? A It increases production of short-lived antibodies. B It accelerates antigen-antibody union at the hepatic sites. C The lymphatic system is stimulated to produce antibodies. D The antigen is neutralized by the antibodies that it supplies Correct Answer: D A LPN is caring for a client with an impaired immune system. Which blood protein associated with the immune system is important for the nurse to consider? A Albumin B Globulin C Thrombin D Hemoglobin Correct Answer: B A LPN discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self- help groups such as AA meet to be successful? A Trust B Growth C Belonging D Independence Correct Answer: C What type of interview is most appropriate when a LPN/LVN admits a client to a clinic? A Directive B Exploratory C Problem solving D Information giving Correct Answer: A A client reaches the point of acceptance during the stages of dying. What response should the LPN/LVN expect the client to exhibit? A Apathy B Euphoria C Detachment D Emotionalism Correct Answer: C HESI FUNDAMENTALS When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety? A. Securely grasp the client's arm and leg. B. Put bed rails up on the side of bed opposite from the nurse. C. Correctly position and use a turn sheet. D. Lower the head of the client's bed slowly. Rationale: Because the nurse can only stand on one side of the bed, bed rails should be up on the opposite side to ensure that the client does not fall out of bed. Option A can cause client injury to the skin or joint. Options C and D are useful techniques while turning a client but have less priority in terms of safety than use of the bed rails. The nurse identifies a potential for infection in a client with partial- thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection? A. Administration of plasma expanders B. Use of careful handwashing technique C. Application of a topical antibacterial cream D. Limiting visitors to the client with burns Rationale: Careful handwashing technique is the single most effective intervention for the prevention of contamination to all clients. Option A reverses the hypovolemia that initially accompanies burn trauma but is not related to decreasing the proliferation of infective organisms. Options C and D are recommended by various burn centers as possible ways to reduce the chance of infection. Option B is a proven technique to prevent infection. The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition? A. Low serum albumin level B. Low serum transferrin level C. High hemoglobin level D. High cholesterol level Rationale: Long-term protein deficiency is required to cause significantly lowered serum albumin levels. Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not significantly alter serum levels. Option B is a serum protein with a half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C and D are not clinical measures of protein malnutrition. In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next? A. Witness the client's signature to the permit. B. Answer the client's questions about the surgery. C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery. D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered. Rationale: The surgeon should be informed immediately that the permit is not signed. It is the surgeon's responsibility to explain the procedure to the client and obtain the client's signature on the permit. Although the nurse can witness an operative permit, the procedure must first be explained by the health care provider or surgeon, including answering the client's questions. The client's questions should be addressed before the permit is signed. The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery? A. Taking birth control pills for the past 2 years B. Taking anticoagulants for the past year C. Recently completing antibiotic therapy D. Having taken laxatives PRN for the last 6 months Rationale: Anticoagulants increase the risk for bleeding during surgery, which can pose a threat for the development of surgical complications. The health care provider should be informed that the client is taking these drugs. Although clients who take birth control pills may be more susceptible to the development of thrombi, such problems usually occur postoperatively. A client with option C or D is at less of a surgical risk than with option B. When assisting a client from the bed to a chair, which procedure is best for the nurse to follow? A. Place the chair parallel to the bed, with its back toward the head of the bed and assist the client in moving to the chair. B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair. C. Assist the client to a standing position by gently lifting upward, underneath the axillae. D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair. Rationale: Option B describes the correct positioning of the nurse and affords the nurse a wide base of support while stabilizing the client's knees when assisting to a standing position. The chair should be placed at a 45-degree angle to the bed, with the back of the chair toward the head of the bed. Clients should never be lifted under the axillae; this could damage nerves and strain the nurse's back. The client should be instructed to use the arms of the chair and should never place his or her arms around the nurse's neck; this places undue stress on the nurse's neck and back and increases the risk for a fall. Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply.) A. Place the client in a side-lying position. B. Pull the auricle upward and outward. C. Hold the dropper 6 cm above the ear canal. D. Place a cotton ball into the inner canal. E. Pull the auricle down and back. Rationale: The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E). The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug? A. "Fill your lungs with air through your mouth and then compress the inhaler." B. "Compress the inhaler while slowly breathing in through your mouth." C. "Compress the inhaler while inhaling quickly through your nose." D. "Exhale completely after compressing the inhaler and then inhale." Rationale: The medication should be inhaled through the mouth simultaneously with compression of the inhaler. This will facilitate the desired destination of the aerosol medication deep in the lungs for an optimal bronchodilation effect. Options A, C, and D do not allow for deep lung penetration A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first? A. Accept and document the client's wish to refrain from bathing. B. Offer to give the client a bed bath, avoiding the perineal area. C. Obtain written brochures about menstruation to give to the client. D. Teach the importance of personal hygiene during menstruation with the client. Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client should receive teaching first, respecting any personal beliefs such as cultural or spiritual values. After client teaching, the client may still choose option A or B. Brochures reinforce the teaching. While reviewing the side effects of a newly prescribed medication, a 72-year- old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse? A. "How will this affect your present sexual activity?" B. "How active is your current sex life?" C. "How has your sex life changed as you have become older?" D. "Tell me about your sexual needs as an older adult." Rationale: Option A offers an open-ended question most relevant to the client's statement. Option B does not offer the client the opportunity to express concerns. Options C and D are even less relevant to the client's statement. The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next? A. Document that the client responds to painful stimulus. B. Observe the client's response to verbal stimulation. C. Place the client on seizure precautions for 24 hours. D. Report decorticate posturing to the health care provider. Rationale: The client has demonstrated a purposeful response to pain, which should be documented as such. Response to painful stimulus is assessed after response to verbal stimulus, not before. There is no indication for placing the client on seizure precautions. Reporting decorticate posturing to the health care provider is nonpurposeful movement. The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? (Round to the nearest tenth.) A. 0.2 mL B. 0.8 mL C. 1.25 mL D. 2.0 mL Rationale: (1 mL × 4 mg)/5 mg = 0.8 mL The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct? (Select all that apply.) A. Place the client in a high Fowler position. B. Help the client assume a left side-lying position. C. Measure the tube from the tip of the nose to the umbilicus. D. Instruct the client to swallow after the tube has passed the pharynx. E. Assist the client in extending the neck back so the tube may enter the larynx. Rationale: (A and D) are the correct steps to follow during nasogastric intubation. Only the unconscious or obtunded client should be placed in a left side-lying position (B). The tube should be measured from the tip of the nose to behind the ear and then from behind the ear to the xiphoid process (C). The neck should only be extended back prior to the tube passing the pharynx and then the client should be instructed to position the neck forward (E). The nurse teaches the use of a gait belt to a male caregiver whose wife has right-sided weakness and needs assistance with ambulation. The caregiver performs a return demonstration of the skill. Which observation indicates that the caregiver has learned how to perform this procedure correctly? A. Standing on his wife's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed. B. Standing on his wife's weak side, the caregiver provides security by holding the gait belt from the back. C. Standing behind his wife, the caregiver provides balance by holding both sides of the gait belt. D. Standing slightly in front and to the right of his wife, the caregiver guides her forward by gently pulling on the gait belt. Rationale: His wife is most likely to lean toward the weak side and needs extra support on that side and from the back to prevent falling. Options A, C, and D provide less security for her. Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter?. A. Self-care deficit B. Functional incontinence C. Fluid volume deficit D. High risk for infection Rationale: Indwelling urinary catheters are a major source of infection. Options A and B are both problems that may require an indwelling catheter. Option C is not affected by an indwelling catheter A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide? A. Decrease intake of fluids after the evening meal. B. Drink a glass of cranberry juice every day. C. Drink a glass of warm decaffeinated beverage at bedtime. D. Consult the health care provider about a sleeping pill. Rationale: Nocturia is urination during the night. Option A is helpful to decrease the production of urine, thus decreasing the need to void at night. Option B helps prevent bladder infections. Option C may promote sleep, but the fluid will contribute to nocturia. Option D may result in urinary incontinence if the client is sedated and does not awaken to void. When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled "opened" and dated 48 hours prior to the current date. Which is the best action for the nurse to take? A. Use the normal saline solution once more and then discard. B. Obtain a new sterile syringe to draw up the labeled saline solution. C. Use the saline solution and then relabel the bottle with the current date. D. Discard the saline solution and obtain a new unopened bottle. Rationale: Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded. Options A, B, and C describe incorrect procedures. Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client? A. Maintain standard precautions. B. Initiate contact isolation measures. C. Insert an indwelling urinary catheter. D. Instruct client in the use of adult diapers. Rationale: The best action to decrease the risk of infection in vulnerable clients is handwashing. Option B is not necessary unless the client has an infection. Option C increases the risk of infection. Option D does not reduce the risk of infection. When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take? A. Deflate the cuff completely and immediately reattempt the reading. B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading. C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen. Rationale: Deflating the cuff for 30 to 60 seconds allows blood flow to return to the extremity so that an accurate reading can be obtained on that extremity a second time. Option A could result in a falsely high reading. Option B reduces circulation, causes pain, and could alter the reading. Option D is not an accurate method of assessing blood pressure. 20.A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first? A. Tell the client that the blood pressure is high and that the reading needs to be verified by another nurse. B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive medication. C. Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort. D. Compare the current reading with the client's previously documented blood pressure readings. Rationale: Comparing this reading with previous readings will provide information about what is normal for this client; this action should be taken first. Option A might unnecessarily alarm the client. Option B is premature. Further assessment is needed to determine if the reading is abnormal for this client. Option C could falsely decrease the reading and is not the correct procedure for obtaining a blood pressure reading. 21.A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg amputated and sues the nurse for malpractice. Which is the most likely outcome of this lawsuit? A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case. B. The lawsuit may be settled out of court, but the nurse's license is likely to be revoked. C. There will be no judgment against the nurse, whose actions were protected under the Good Samaritan Act. D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved. Rationale: The Good Samaritan Act protects health care professionals who practice in good faith and provide reasonable care from malpractice claims, regardless of the client outcome. Although the Patient's Bill of Rights protects clients, this nurse is protected by the Good Samaritan Act. The state Board of Nursing has no reason to revoke a registered nurse's license unless there was evidence that actions taken in the emergency were not done in good faith or that reasonable care was not provided. All four elements of malpractice were not shown. When the health care provider diagnoses metastatic cancer and recommends a gastrostomy for an older female client in stable condition, the son tells the nurse that his mother must not be told the reason for the surgery because she "can't handle" the cancer diagnosis. Which legal principle is the court most likely to uphold regarding this client's right to informed consent? A. The family can provide the consent required in this situation because the older adult is in no condition to make such decisions. B. Because the client is mentally incompetent, the son has the right to waive informed consent for her. C. The court will allow the health care provider to make the decision to withhold informed consent under therapeutic privilege. D. If informed consent is withheld from a client, health care providers could be found guilty of negligence. Rationale: Health care providers may be found guilty of negligence, specifically assault and battery, if they carry out a treatment without the client's consent. The client's condition is stable, so option A is not a valid rationale. Advanced age does not automatically authorize the son to make all decisions for his mother, and there is no evidence that the client is mentally incompetent. Although option C may have been upheld in the past, when paternalistic medical practice was common, today's courts are unlikely to accept it The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the nurse to implement? A. Stay with the client while the client is standing. B. Record the findings on the graphic sheet in the chart. C. Keep the blood pressure cuff on the same arm. D. Record changes in the client's pulse rate. Rationale: Although all these measures are important, option A is most important because it helps ensure client safety. Option B is necessary but does not have the priority of option A. Options C and D are important measures to ensure accuracy of the recording but are of less importance than providing client safety. A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which intervention is best for the nurse to implement? A. Encourage the client to use a nicotine patch. B. Reassure the client that it is almost time for another break. C. Have the client leave the unit with another staff member. D. Review the schedule of outdoor breaks with the client. Rationale: The best nursing action is to review the schedule of outdoor breaks and provide concrete information about the schedule. Option A is contraindicated if the client wants to continue smoking. Option B is insufficient to encourage a trusting relationship with the client. Option C is preferential for this client only and is inconsistent with unit rules. Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? A. White blood cell count B. Albumin C. Calcium D. Sodium Rationale: Monitoring serum sodium levels for hyponatremia is indicated during prolonged NG suctioning because of loss of fluids. Changes in levels of option A, B, or C are not typically associated with prolonged NG suctioning. A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse to provide? A. Orange juice has vitamin C that deters bacterial growth. B. Apple juice is the most useful in acidifying the urine. C. Cranberry juice stops pathogens' adherence to the bladder. D. Grapefruit juice increases absorption of most antibiotics. Rationale: Cranberry juice maintains urinary tract health by reducing the adherence of Escherichia coli bacteria to cells within the bladder. Options A, B, and D have not been shown to be as effective as cranberry juice in preventing UTIs. The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate should the nurse document? A. 14 B. 16 C. 17 D. 28 Rationale: The most accurate respiratory rate is the second count obtained by the nurse, which was not interrupted by coughing. Because it was counted for 30 seconds, the rate should be doubled. Options A, C, and D are inaccurate recordings The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client? A. "Monitoring Your Blood Pressure at Home" B. "Smoking Cessation as a Lifelong Commitment" C. "Decreasing Cholesterol Levels Through Diet" D. "Stress Management for a Healthier You" Rationale: A health promotion brochure about decreasing cholesterol is most important to provide this client, because the most significant risk factor contributing to development of arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. Option A does not address the underlying causes of arteriosclerosis. Options B and D are also important factors for reversing arteriosclerosis but are not as important as lowering cholesterol. The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first? A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client. B. Sit quietly in the client's room until the client leaves the bathroom. C. Allow the client to cry alone and leave the client in the bathroom. D. Talk to the client and attempt to find out why the client is crying. Rationale: The nurse's first concern should be for the client's safety, so an immediate assessment of the client's situation is needed. Option A is incorrect; the nurse should implement the intervention. The nurse may offer to stay nearby after first assessing the situation more fully. Although option C may be correct, the nurse should determine if the client's safety is compromised and offer assistance, even if it is refused A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first? A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes. B. Notify the health care provider and request a prescription for a large-volume enema. C. Assess the client's medical record to determine the client's normal bowel pattern. D. Instruct the caregiver to increase the client's fluids top five 8-ounce glasses per day. Rationale: This client may not routinely have a daily bowel movement, so the nurse should first assess this client's normal bowel habits before attempting any intervention. Option A, B, or D may then be implemented, if warranted. 310. A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide? A. Take a vitamin supplement tablet once a day. B. Change positions in the chair at least every hour. C. Increase daily intake of water or other oral fluids. D. Purchase a newer model wheelchair. Rationale: The most important teaching is to change positions frequently because pressure is the most significant factor related to the development of pressure ulcers. Increased vitamin and fluid intake may also be beneficial and promote healing and reduce further risk. Option D is an intervention of last resort because this will be very expensive for the client. Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next? A. Clamp the catheter and recheck it in 60 minutes. B. Pull the catheter back 3 inches and redirect upward. C. Leave the catheter in place and reattempt with another catheter. D. Notify the health care provider of a possible obstruction. Rationale: It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in place will help locate the meatus when attempting the second catheterization. The client should have at least 240 mL of urine after 8 hours. Option A does not resolve the problem. Option B will not change the location of the catheter unless it is completely removed, in which case a new catheter must be used. There is no evidence of a urinary tract obstruction if the catheter could be easily inserted. The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best? A. Only refer to the client by gender. B. Identify the client only by age. C. Avoid using the client's name. D. Discuss the client another time. Rationale: The best nursing action is to discuss the client another time. Confidentiality must be observed at all times, so the nurse should not discuss the client when the conversation can be overheard by others. Details can identify the client when referring to the client by gender or age, even when not using the client's name. The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later the client reports that he is still unable to sleep, despite following the same routine every night. Which action should the nurse take first? A. Instruct the client to add regular exercise as a daily routine. B. Determine if the client has been keeping a sleep diary. C. Encourage the client to continue the routine until sleep is achieved. D. Ask the client to describe the routine he is currently following. Rationale: The nurse should first evaluate whether the client has been adhering to the original instructions. A verbal report of the client's routine will provide more specific information than the client's written diary. The nurse can then determine which changes need to be made. The routine practiced by the client is clearly unsuccessful, so encouragement alone is insufficient. Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the nurse implement next? A. Make the client comfortable and allow the client to sleep. B. Assess the client's neurologic status. C. Notify the surgeon about the comment. D. Ask the client's family to co-sign the operative permit. Rationale: This statement may indicate that the client is confused. Informed consent must be provided by a mentally competent individual, so the nurse should further assess the client's neurologic status to be sure that the client understands and can legally provide consent for surgery. Option A does not provide sufficient follow-up. If the nurse determines that the client is confused, the surgeon must be notified and permission obtained from the next of kin. A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first? A. Pulse characteristics B. Open airway C. Entrance and exit wounds D. Cervical spine injury Rationale: Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the pulse rate and regularity is a priority. Because the client is talking, he has an open airway, so that assessment is not necessary. Assessing for options C and D should occur after assessing for adequate circulation. The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take? A. Review the chart for a signed consent for hospitalization. B. Get the health care provider's permission to give the medication. C. Do not give the medication and document the reason. D. Complete an incident report and notify the parents. Rationale: The nurse should not give the medication and should document the reason because the client is a minor and needs a guardian's permission to receive medications. Permission to give medications is not granted by a signed hospital consent or a health care provider's permission, unless conditions are met to justify coerced treatment. Option D is not necessary unless the medication had previously been administered. 38.A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best? A. Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. B. Instruct the UAP not to wake the client under any circumstances during the night. C. Place a "Do Not Disturb" sign on the door and change assessments from every 4 to every 8 hours. D. Encourage the client to avoid pain medication during the day, which might increase daytime napping. Rationale: Including habitual rituals that do not interfere with the client's care or safety may allow the client to go to sleep faster and increase the quality of care. Options B, C, and D decrease the client's standard of care and compromise safety. 39. The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the priority action for the nurse to take? A. Check the client's carotid pulse. B. Encourage the client to get to the toilet. C. In a loud voice, call for help. D. Gently lower the client to the floor. Rationale: Option D is the most prudent intervention and is the priority nursing action to prevent injury to the client and the nurse. Lowering the client to the floor should be done when the client cannot support his own weight. The client should be placed in a bed or chair only when sufficient help is available to prevent injury. Option A is important but should be done after the client is in a safe position. Because the client is not supporting himself, option B is impractical. Option C is likely to cause chaos on the unit and might alarm the other clients. 40.A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond? A. Ask him to rate his pain on a scale of 1 to 10. B. Encourage him to wait until bedtime so the pill can help him sleep. C. Attend to an acutely ill client's needs first because this client is laughing. D. Instruct him in the use of deep breathing exercises for pain control. Rationale: Obtaining a subjective estimate of the pain experience by asking the client to rate his pain helps the nurse determine which pain medication should be administered and also provides a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be delayed so that it can be used as a sleep medication. Option C is judgmental. Option D should be used as an adjunct to pain medication, not instead of medication. During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse? A. Reassure the client that many obese people have concerns about sex. B. Remind the client that sexual relationships need not be affected by obesity. C. Determine the frequency of sexual intercourse. D. Ask the client to talk about specific concerns. Rationale: Option D provides an opportunity for the client to verbalize her concerns and provides the nurse with more assessment data. Options A and B may not be related to her current concern, assume that obesity is the problem, and are communication blocks. Option C may be appropriate after discussing the concerns she is having. The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement? A. Encourage the client to increase ambulation in the room. B. Offer the client a high-carbohydrate snack for energy. C. Force fluids to thin the client's pulmonary secretions. D. Determine if pain is causing the client's tachypnea. Rationale: Pain, anxiety, and increasing fluid accumulation in the lungs can cause tachypnea (increased respiratory rate). Encouraging the client to increase ambulation when the respiratory rate is rising above normal limits puts the client at risk for further oxygen desaturation. Option B can increase the client's carbon metabolism, so an alternative source of energy, such as Pulmocare liquid supplement, should be offered instead. Option C could increase respiratory congestion in a client with a poorly functioning cardiopulmonary system, placing the client at risk of fluid overload. A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment? A. Notify the friend that all medical information will be kept confidential. B. Explain the relationship to the charge nurse and ask for reassignment. C. Approach the client and ask if the assignment is uncomfortable. D. Accept the assignment but protect the client's confidentiality. Rationale: Caring for a close friend can violate boundaries for nurses and should be avoided when possible (B). If the assignment is unavoidable (there are no other nurses to care for the client) then C, A, and D should be addressed. The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction? A. Perform range-of-motion exercises to prevent contractures. B. Decrease the client's fluid intake to prevent diarrhea. C. Massage the client's legs to reduce embolism occurrence. D. Turn the client from side to back every shift. Rationale: Performing range-of-motion exercises is beneficial in reducing contractures around joints. Options B, C, and D are all potentially harmful practices that place the immobile client at risk of complications. The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home? A. Determine how the client feels about changing the dressing. B. Ask the client to describe the procedure in writing. C. Seek a family member's evaluation of the client's ability to change the dressing. D. Observe the client change the dressing unassisted. Rationale: Observing the client directly will allow the nurse to determine if mastery of the skill has been obtained and provide an opportunity to affirm the skill. Option A may be therapeutic but will not provide an opportunity to evaluate the client's ability to perform the procedure. Option B may be threatening to an older client and will not determine his ability. Option C is not as effective as direct observation by the nurse. The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client? A. Steak, baked beans, and a salad B. Broiled fish, green beans, and an apple C. Pork chops, macaroni and cheese, and grapes D. Avocado salad, milk, and angel food cake Rationale: Clients with cholecystitis (inflammation of the gallbladder) should follow a low- fat diet, such as option B. Option A is a high-protein diet, and options C and D contain high-fat foods, which are contraindicated for this client. When bathing an uncircumcised boy older than 3 years, which action should the nurse take? A. Remind the child to clean his genital area. B. Defer perineal care because of the child's age. C. Retract the foreskin gently to cleanse the penis. D. Ask the parents why the child is not circumcised. Rationale: The foreskin (prepuce) of the penis should be gently retracted to cleanse all areas that could harbor bacteria. The child's cognitive development may not be at the level at which option A would be effective. Perineal care needs to be provided daily regardless of the client's age. Option D is not indicated and may be perceived as intrusive. The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication? A. The client will experience increased tolerance to the drug's effects and may need a higher dose. B. The onset of action of the drug will occur more rapidly, resulting in a more rapid effect. C. The medication will be more highly protein- bound, increasing the duration of action. D. The therapeutic index will be increased, placing the client at greater risk for toxicity. Rationale: Because the absorptive process is eliminated when medications are administered via the IV route, the onset of action is more rapid, resulting in a more immediate effect. Drug tolerance, protein binding, and the drug's therapeutic index are not affected by the change in route from PO to IV. In addition, an increased therapeutic index reduces the risk of drug toxicity. An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement? A. Assist the client to walk to the bathroom and do not leave the client alone. B. Request that the UAP assist the client onto a bedpan. C. Ask if the client needs to have a bowel movement or void. D. Assess the client's bladder to determine if the client needs to urinate. Rationale: Barbiturates cause central nervous system (CNS) depression, and individuals taking these medications are at greater risk for falls. The nurse should assist the client to the bathroom. A bedpan is not necessary as long as safety is ensured. Whether the client needs to void or have a bowel movement, option C is irrelevant in terms of meeting this client's safety needs. There is no indication that this client cannot voice her or his needs, so assessment of the bladder is not needed. By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection? A. Mode of transmission B. Portal of entry C. Reservoir D. Portal of exit Rationale: The contaminated gloves serve as the mode of transmission from the portal of exit of the reservoir to a portal of entry Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis? A. Perform cough and deep breathing exercises hourly. B. Turn from side to side in bed at least every 2 hours. C. Dorsiflex and plantarflex the feet 10 times each hour. D. Drink approximately 4 ounces of water every hour. Rationale: To reduce the risk of venous thrombosis, the nurse should instruct the client in measures that promote venous return, such as dorsiflexion and plantar flexion. Options A, B, and D are helpful to prevent other complications of immobility but are less effective in preventing venous thrombus formation than option C. In assisting an older adult client prepare to take a tub bath, which nursing action is most important? A. Check the bath water temperature. B. Shut the bathroom door. C. Ensure that the client has voided. D. Provide extra towels. Rationale: To prevent burns or excessive chilling, the nurse must check the bath water temperature. Options B, C, and D promote comfort and privacy and are important interventions but are of less priority than promoting safety In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible? A. Daily black, sticky stool B. Daily dark brown stool C. Firm brown stool every other day D. Soft light brown stool twice a day Rationale: Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the health care provider promptly. Option C indicates constipation, which is a lesser priority. Options B and D are variations of normal. After the nurse tells an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all health care providers and nurses. How should the nurse respond? A. Ask the client to remain quiet so the procedure can be performed safely. B. Concentrate on completing the insertion as efficiently as possible. C. Calmly reassure the client that the discomfort will be temporary. D. Tell the client a joke as a means of distraction from the procedure. Rationale: The nurse should respond with a calm demeanor to help reduce the client's apprehension. After responding calmly to the client's apprehension, the nurse may implement to ensure safe completion of the procedure. One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, "I think I will plan a big party for all my friends." How should the nurse respond? A. "You may not have enough energy before long to hold a big party." B. "Do you mean to say that you want to plan your funeral and wake?" C. "Planning a party and thinking about all your friends sounds like fun." D. "You should be thinking about spending your last days with your family." Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as long as the nurse does not perpetuate a client's denial. Option A is a negative response, implying that the client should not plan a party. Option B puts words in the client's mouth that may not be accurate. The nurse should support the client's goals rather than telling the client how to spend her time. The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention? A. The cuff wraps around the girth of the leg. B. The UAP auscultates the popliteal pulse with the cuff on the lower leg. C. The client is placed in a prone position. D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm. Rationale: When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. The nurse should intervene with the UAP who has applied the cuff on the lower leg. Option A ensures an accurate assessment, and option C provides the best access to the artery. Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher than in the brachial artery. During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report? A. The occurrence of any episodes of sleep apnea B. The child's blood pressure, pulse, and respirations C. Length of rapid eye movement (REM) sleep that the child is experiencing D. Description of the family's home environment Rationale: School-age children often resist bedtime. The nurse should begin by assessing the environment of the home to determine factors that may not be conducive to the establishment of bedtime rituals that promote sleep. Option A often causes daytime fatigue rather than resistance to going to sleep. Option B is unlikely to provide useful data. The nurse cannot determine option C. The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next? A. Apply a warm compress proximal to the site. B. Check for kinks in the tubing and raise the IV pole. C. Adjust the tape that stabilizes the needle. D. Flush with normal saline and recount the drop rate. Rationale: The nurse should first check the tubing and height of the bag on the IV pole, which are common factors that may slow the rate. Gravity infusion rates are influenced by the height of the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity, client blood pressure (crying in the pediatric client), and infiltration. Venospasm can slow the rate and often responds to warmth over the vessel, but the nurse should first adjust the IV pole height. The nurse may need to adjust the stabilizing tape on a positional needle or flush the venous access with normal saline, but less invasive actions should be implemented first. Which client is most likely to be at risk for spiritual distress? A. Roman Catholic woman considering an abortion B. Jewish man considering hospice care for his wife C. Seventh-Day Adventist who needs a blood transfusion D. Muslim man who needs a total knee replacement Rationale: In the Roman Catholic religion, any type of abortion is prohibited, so facing this decision may place the client at risk for spiritual distress. There is no prohibition of hospice care for members of the Jewish faith. Jehovah's Witnesses, not Seventh-Day Adventists, prohibit blood transfusions. There is no conflict in the Muslim faith with regard to joint replacement. Which intervention is most important to include in the plan of care for a client at high risk for the development of postoperative thrombus formation? A. Instruct in the use of the incentive spirometer. B. Elevate the head of the bed during all meals. C. Use aseptic technique to change the dressing. D. Encourage frequent ambulation in the hallway. Rationale: Thrombus (clot) formation can occur in the lower extremities of immobile clients, so the nurse should plan to encourage activities to increase mobility, such as frequent ambulation in the hallway. Option A helps promote alveolar expansion, reducing the risk for atelectasis. Option B reduces the risk for aspiration. Option C reduces the risk for postoperative infection. Which nonverbal action should the nurse implement to demonstrate active listening? A. Sit facing the client. B. Cross arms and legs. C. Avoid eye contact. D. Lean back in the chair. Rationale: Active listening is conveyed using attentive verbal and nonverbal communication techniques. To facilitate therapeutic communication and attentiveness, the nurse should sit facing the client, which lets the client know that the nurse is there to listen. Active listening skills include postures that are open to the client, such as keeping the arms open and relaxed, not option B, and leaning toward the client, not option D. To communicate involvement and willingness to listen to the client, eye contact should be established and maintained. A seriously ill female client tells the nurse, "I am so tired and in so much pain! Please help me to die." Which is the best response for the nurse to provide? A. Administer the prescribed maximum dose of pain medication. B. Talk with the client about her feelings related to her own death. C. Collaborate with the health care provider about initiating antidepressant therapy. D. Refer the client to the ethics committee of her local health care facility. Rationale: The nurse should first assess the client's feelings about her death and determine the extent to which this statement expresses her true feelings. The client may need additional pain management, but further assessment is needed before implementing option A. Options C and D are both premature interventions and should not be implemented until further assessment is obtained. A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines? A. Americans with Disabilities Act of 1990 B. ANA Code of Ethics with Interpretative Statements C. ANA's Scope and Standards of Nursing Practice D. Patient's Bill of Rights of 1990 Rationale: The ANA Scope of Standards of Practice for Psychiatric–Mental Health Nursing serves to direct the philosophy and standards of psychiatric nursing practice. Options A and D define the client's rights. Option B provides ethical guidelines for nursing. While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement? A. Encourage the client to see the clinic's grief counselor. B. Determine if the client has a family history of suicide attempts. C. Inquire about whether the life partner was suffering from AIDS. D. Consult with the health care provider about the client's need for antidepressant medications. Rationale: The client is exhibiting normal grieving behaviors, so referral to a grief counselor is the most important intervention for the nurse to implement. Option B is indicated but is not a high-priority intervention. Option C is irrelevant at this time but might be important when determining the client's risk for contracting the illness. An antidepressant may be indicated, depending on further assessment, but grief counseling is a better action at this time because grief is an expected reaction to the loss of a loved one. An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client is capable of giving the daily injection. Which response by the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily injections? A. "I know you are capable of giving yourself the insulin." B. "Giving yourself the injection seems to make you nervous." C. "When I watched you give yourself the injection, you did it correctly." D. "Tell me what you want me to do to help you give yourself the injection at home." Rationale: The nurse needs to focus on the client's positive behaviors, so focusing on the client's demonstrated ability to self-administer the injection is likely to reinforce his level of competence without sounding punitive. Option A does not focus on the specific behaviors related to giving the injection and could be interpreted as punitive. Option B uses reflective dialogue to assess the client's feelings, but telling the client that he is nervous may serve as a negative reinforcement of this behavior. Option D reinforces the client's dependence on the nurse. After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond? A. Provide the client with a list of Internet sites that answer frequently asked questions about medications. B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library. C. Reassure the client that information about the medication is included in the written instructions. D. Encourage the client to call the clinic nurse or health care provider if any questions arise. Rationale: To ensure safe medication use, the nurse should encourage the client to call the nurse or health care provider if any questions arise. Options A, B, and C may all include useful information, but these sources of information cannot evaluate the nature of the client's questions and the follow-up needed. During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take? A. Assign an unlicensed assistive personnel to transport the client via a wheelchair. B. Remind the client to walk carefully down the stairs until reaching a lower floor. C. Ask the client to help by assisting a wheelchair- bound client to a nearby elevator. D. Open the closest fire doors so that ambulatory clients can evacuate more rapidly. Rationale: During evacuation of a unit because of fire, ambulatory clients should be evacuated via the stairway if at all possible and reminded to walk carefully. Ambulatory clients do not require the assistance of a wheelchair to be evacuated. Elevators should not be used during a fire, and fire doors should be kept closed to help contain the fire. After a needle stick occurs while removing the cap from a sterile needle, which action should the nurse implement? A. Complete an incident report. B. Select another sterile needle. C. Disinfect the needle with an alcohol swab. D. Notify the supervisor of the department immediately. Rationale: After a needle stick, the needle is considered used, so the nurse should discard it and select another needle. Because the needle was sterile when the nurse was stuck and the needle was not in contact with any other person's body fluids, the nurse does not need to complete an incident report or notify the occupational health nurse. Disinfecting a needle with an alcohol swab is not in accordance with standards for safe practice and infection control. When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next? A. Record the amount on the client's fluid output record. B. Encourage the client to increase oral fluid intake. C. Notify the health care provider of the findings. D. Palpate the client's bladder for distention. Rationale: The amount and appearance of the client's urine output is within normal limits, so the nurse should record the output, but no additional action is needed. The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure? A. Dilute each of the medications with sterile water prior to administration. B. Mix the medications in one syringe before opening the feeding tube. C. Administer water between the doses of the two liquid medications. D. Withdraw any fluid from the tube before instilling each medication. Rationale: Water should be instilled into the feeding tube between administering the two medications to maintain the patency of the feeding tube and ensure that the total dose of medication enters the stomach and does not remain in the tube. These liquid medications do not need to be diluted when administered via a feeding tube and should be administered separately, with water instilled between each medication. The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take? A. Consult with the pharmacist about the need to continue the medication. B. Administer the antihypertensive medication as prescribed preoperatively. C. Withhold the medication until the client is fully alert and vital signs are stable. D. Contact the health care provider to renew the prescription for the medication. Rationale: Medications prescribed preoperatively must be renewed postoperatively, so the nurse should contact the health care provider if the antihypertensive medication is not included in the postoperative prescriptions. The pharmacist does not prescribe medications or renew prescriptions. The nurse must have a current prescription before administering any medications. A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse do first? A. Clamp the nasogastric tube. B. Confirm placement of the tube. C. Use a syringe to instill the medications. D. Turn off the intermittent suction device. Rationale: The nurse should first turn off the suction and then confirm placement of the tube in the stomach before instilling the medications. To prevent immediate removal of the instilled medications and allow absorption, the tube should be clamped for a period of time before reconnecting the suction. The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify placement of the IV access? A. Left brachial vein B. Right cephalic vein C. Dorsal side of the right wrist D. Right upper extremity Rationale: The cephalic vein is large and superficial and identifies the anatomic name of the vein that is accessed, which should be included in the documentation. The basilic vein of the arm is used for IV access, not the brachial vein, which is too deep to be accessed for IV infusion. Although veins on the dorsal side of the right wrist are visible, they are fragile and using them would be painful, so they are not recommended for IV access. Option D is not specific enough for documenting the location of the IV access. The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order? A. "At home I take my pills at 8:00 am." B. "It costs a lot of money to buy all of these pills." C. "I get so tired of taking pills every day." D. "This is a new pill I have never taken before." Rationale: The client's recognition of a "new" pill requires further assessment to verify that the medication is correct, if it is a new prescription or a different manufacturer, or if the client needs further instruction. The time difference may not be as significant in terms of its effect, but this should be explained. Although comments about cost should be considered when developing a discharge plan, option D is a higher priority. The client's feelings C should be acknowledged, but observation of the five rights of medication administration is most essential. Which action should the nurse implement when providing wound care instructions to a client who does not speak English? A. Ask an interpreter to provide wound care instructions. B. Speak directly to the client, with an interpreter translating. C. Request the accompanying family member to translate. D. Instruct a bilingual employee to read the instructions. Rationale: Wound care instructions should be given directly to the client by the nurse with an interpreter who is trained to provide accurate and objective translation in the client's primary language, so that the client has the opportunity to ask questions during the teaching process. The interpreter usually does not have any health care experience, so the nurse must provide client teaching. Family members should not be used to translate instructions because the client or family member may alter the instructions during conversation or be uncomfortable with the topics discussed. The employee should be a trained interpreter to ensure that the nurse's instructions are understood accurately by the client. HESI Fundamentals a nurse in a clinical is caring for a middle age adult who states, "the doctor says that since I am at an average risk for colon cancer, I should have a routine screening. what does that involve?" which of the following responsesshould the nurse make? "I'll get a blood sample from you and send it for a screening test." "beginning at age 60, you should have a colonoscopy." "you should have a decal occult blood test every year." "the recommendation is to have a sigmoidoscopy every 10 years." "You should have a fecal occult blood test every year." Colorectal cancer screening for clients at average risk begins at age 50. Oneoption for screening is a fecal occult blood test annually. a nurse is caring for a client who is having difficulty breathing. the client is laying in bed with a nasal cannula delivering oxygen. which of the followingintervention should the nurse take first? suction the client's airway administer a bronchodilator increase the humidity in the client's room assist the client to an upright position assist the client to an upright position When providing client care, the nurse should first use the least invasive intervention. Therefore, the nurse should elevate the head of the client's bed tothe semi-Fowler's or high Fowler's position to facilitate maximal chest expansion. Sitting upright improves gas exchange and prevents pressure on thediaphragm from abdominal organs. 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? gently shake the container of medication prior to administration transfer the medication to a medicine cup place the client in a semi-fowlers position to medication administration verify the dosage by measuring the liquid before administering it Gently shake the container of medication prior to administration. The nurse should gently shake the liquid medication to ensure the medication ismixed. a nurse is planning care to improve self-feeding for a client who has visionloss. which of the following interventions should the nurse include in the plan of care? tell the client which food she should eat first provide small-handle utensils for the client thicken liquids on the client's tray use a clock pattern to describe food on the client's plate Use a clock pattern to describe food on the client's plate. Use a clock pattern to describe food on the client's plate.MY ANSWERDescribing the location of the food on the plate by using a clock patternallows the client to have greater independence during meals. a nurse is teaching an older adult client who is at risk for osteoporosis aboutbeginning a program of regular physical activity. which of the following types of activity should the nurse recommend? walking briskly riding a bicycle performing isometric exercises engaging in high-impact aerobics walking briskly Weight-bearing exercises are essential for maintaining bone mass, which helps toprevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy. a nurse is assessing a client's readiness to learn about insulin administration.which of the following statements should the nurse identify as an indication that the client is ready to learn? "I can concentrate best in the morning." "it is difficult to read the instructions because my glasses are at home." "I'm wondering why I need to learn this." "you will have to talk to my wife about this." "I can concentrate best in the morning." The client's statement indicates a readiness to learn because he is verbalizing thebest time for him to learn. a nurse is giving discharge instructions to a client who will require oxygen therapy at home. which of the following statements should the nurse identifyas an indication that the client understands how to manage this therapy at home? "I'll make sure that, when my friend comes by, she smokes at least 6 feetaway from my oxygen tank." "I'll use a woolen blanket if I get chilly while I'm using my oxygen." "I'll check the wires and cables on my TV to make sure they are in goodworking order." "I'll lay my oxygen tank down on the floor when the grandchildren visit so they don't knock it over." "I'll check the wires and cables on my TV to make sure they are in good workingorder." Oxygen is a highly flammable gas. The client should make sure any electricalequipment in the room where she is using supplemental oxygen is functioningproperly so it does not create any electrical sparks. a nurse is caring for a client who is reporting difficulty falling asleep. whichof the following measures should the nurse recommend? drink a cup of hot cocoa before bedtime exercise 1 hr before going to bed use progressive relaxation techniques at bedtime reflect on the day's activities before going to bed Use progressive relaxation techniques at bedtime. Progressive relaxation promotes sleep by decreasing stress and reducing muscletension. a nurse is assisting a client who is postoperative with the use of an incentivespirometer. into which of the following positions should the nurse place theclient? side-lying supine semi-fowlers trendelenburg Semi-Fowler's Positioning the client in semi-Fowler's or high-Fowler's position allows formaximum expansion of the lungs. a nurse is assessing an adult client who has been immobile for the past 3 week. the nurse should identify that which of the following findings requiresfurther intervention? erythema on pressure points lower-extremity pulse strength on 2+ fluid intake of 3,000 mL per day a bowel movement every other day Erythema on pressure points Erythema on pressure points requires prompt relief of pressure and additionalmeasures to protect the skin from further breakdown. a nurse is caring for a client who requires a 24-hour urine collection. which of the following statement by the client indicates an understanding of the teaching? "I had a bowel movement, but I was able to save the urine." "I have a specimen in the bathroom from about 30 minutes ago." "I flushes what I urinated at 7 am and have saved all urine since." "I drink a lot, so I will fill up the bottle and complete the txt quickly." "I flushed what I urinated at 7:00 a.m. and have saved all urine since." For a 24-hr urine collection, the client should discard the first voiding and saveall subsequent voidings. a nurse is caring for a client who has herpes zoster and asks the runs aboutthe use of complementary and alternative therapies for pain control. the nurse should inform inform the client that his condition is a contraindication for which of the following therapies? biofeedback aloe feverfew acupuncture Acupuncture The nurse should inform the client that the use of acupuncture is contraindicatedfor a client who has herpes zoster, or any skin infection, to prevent an open portal on the skin's surface, which could increase the risk of further infection. a nurse is preparing to transfer a client who has right-sided weakness fromthe bed to a chair. in what order should the nurse take the following actionsto assist the client? ask the client is he can bear weight use the stand-pivot technique to move the client to the chair position the chair on the left side of the bed have the client sit and dangle his feet at the bedside 1. ask the client is he can bear weight position the chair on the left side of the bed have the client sit and dangle his feet at the bedside 2. use the stand-pivot technique to move the client to the chair a nurse is preparing to administer an injection of an opioid medication to aclient. the nurse draws out 1 mL of the medication from a 2 mL vial. which of the following actions should the nurse take? ask another nurse to observe the medication wastage notify the pharmacy when eating the medication lock the remaining medication in the controlled substance cabinet dispose of the vial with the remaining medication in a sharps container Ask another nurse to observe the medication wastage. A second nurse must witness the disposal of any portion of a dose of a controlledsubstance. a nurse is preparing a herparing infusion for a client who was hospitalizedwith deep- vein thrombosis. the orders read: 25,000 units of heparin in 250mL of 0.9% sodium chloride to infuse at 800 units/hr. at what rate should the nurse set the infusion pump? (round to the nearest whole number) 8mL/hr a nurse is caring for a client who has a prescription for 5 units of regularinsulin and 10 units of NPH insulin to mix together and administer subcutaneously. determine the correct order of steps for this procedure. inject 5 units of air into the bottle of regular insulin withdraw the correct dose of NPH insulin from the bottle inject 10 units of air into the bottle of NPH insulin withdraw the correct dose of regular insulin from the bottle 3. inject 10 units of air into the bottle of NPH insulin 1. inject 5 units of air into the bottle of regular insulin 4. withdraw the correct dose of regular insulin from the bottle 2. withdraw the correct dose of NPH insulin from the bottle a nurse is caring for a client who is postoperative and refused to use anincentive spirometer following major abdominal surgery. which of the following is the nurse's priority action? request that a respiratory therapist discuss the technique for incentive spirometer determine the reasons why the client is refusing to use the onetime spirometer document the client's refusal to participate in health restorative activities administer a pain medication to the client Determine the reasons why the client is refusing to use the incentive spirometer. The first action the nurse should take when using the nursing process is to assessthe client; therefore, the priority action is for the nurse to determine why the client is refusing the treatment. a nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." which of the following components ofthe prescription should the runs question? the medication the route the dose the frequency The dose The dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer. 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 preventskin breakdown? place the client in high-flowers position increase the client's intake of carbohydrates massage the reddened areas with unscented lotion have the client use a trapeze bar when changing positions Have the client use a trapeze bar when changing position. By using a trapeze bar to assist with repositioning and transferring, the clientavoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure- ulcer development. 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 on the client's medical record? .3 mg 0.3 mg 0.30 mg 3/10 mg 0.3 mg The use and placement of a decimal point can cause a medication error. A zero should precede a decimal point (0.3 mg), but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg. a nurse is caring for a client receiving fluid through a peripheral IV catheter.which of the following filings at the IV site should the nurse identify as infiltration? purulent exudate warmth skin blanching bleeding Skin blanching Skin blanching, edema, and coolness at the IV site indicate infiltration. a nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. which of the following actions should the nurse planto take? dissolve each medication in 5 mL of sterile water draw up medication together in the syringe push the syringe plunger gently when feeling resistance flush the tube with 15 mL of sterile water Flush the tube with 15 mL of sterile water. The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feedingtube with 30 to 60 mL of sterile water following the administration of the last medication. a nurse is planning an education session for an older adult client who hasjust learned that she has type 2 diabetes mellitus. which of the following strategies should the nurse plan to use with this client? allow extra time for the client to respond to questions expect the client to have difficulty understanding the information avoid references to the lento's past experiences keeping the learning session private and one-on-one Allow extra time for the client to respond to questions. Older adult clients often process information at a slower rate than younger clients; therefore, the nurse should plan for extra time to allow the client to askquestions and absorb the information. a nurse is evaluating a client's use of a cane. which of the following actionsshould the nurse identify as an indication of correct use? the top of the cane is parallel to the client's waist when walking, the client move the cane 46 cm (18 in) forward the client holds the cane on the stronger side of her body the client moves her stronger limb forward with the cane The client holds the cane on the stronger side of her body. The client should hold the cane on the stronger side of her body to increasesupport and maintain alignment. a nurse is caring for a client who has had his diet prescription changed to amechanical soft diet. which of the following food items should the nurse remove from the client's breakfast tray? smoothie sliced banana pancakes sunny side up (fired) eggs sunny side up (fired) eggs Evidence-based practice indicates the nurse should remove fried eggs from theclient's tray. Fried eggs are not a part of a mechanical soft diet. Eggs that are poached or scrambled are an acceptable replacement for this item. a nurse is caring for a client who asks about the purpose of advance directives. which of the following statements should the nurse make? "they allow the court to overrule an adult client's refusal of medical treatment." "they indicate the form of treatment a client is willing to accept in theevent of a serious illness." "the permit a client to withhold medical information from heath care personnel." "they allow heath care personnel in the emergency department tostabilize a client's condition." "They indicate the form of treatment a client is willing to accept in the event of aserious illness." Advance directives include a living will, which permits the client to directtreatment in the event of a terminal illness. a nurse is assessing a client who has been on bed rest for the past month.which of the following findings should the nurse identify as an indicationthat the client has developed thrombophlebitis? bladder distention decreased blood pressure calf swelling diminished bowel sounds Calf swelling Swelling, redness, and tenderness in a calf muscle are manifestations ofthrombophlebitis, a common complication of immobility. a nurse is caring for a client who report pain. when documenting the qualityof the client's pain on an initial pain assessment, the nurse should record which of the following client statements? "I'm having mild pain." "the pain is like a dull ache in my stomach." "I notice that the pain gets worse after I eat." "the pain makes me feel nauseous." "The pain is like a dull ache in my stomach." The client is describing the quality of the pain, which is how the pain feels in herown words. a nurse is administering an otic medication to an older adult client. which ofthe following actions should the nurse take to ensure that the medication reaches the inner ear? press gently on the tarsus of the client's ear pack a small piece of cotton deep into the cent's ear canal move the client's auricle down and back toward her head tilt the client's head backward for 5 min Press gently on the tragus of the client's ear. Pressing gently on the tragus of the ear will help the medication get into theinner ear. a nurse in a long-term care facility is planning to perform hygiene care for anew resident. which of the following assessment questions is the nurse's priority before beginning this procedure? "when do you usually bathe, in the morning or evening?" "do you prefer a bath or a shower?" "at what temperature do you prefer your bath water?" "are you able to help with you hygiene care?" "Are you able to help with your hygiene care?" The greatest risk to the client's safety is an injury resulting from an overestimation of the client's ability to help with hygiene care; therefore, thenurse's priority is to assess the client's ability to assist with her hygiene care. a charge nurse is discussing the responsibility of nurses caring for clients who have a clostridium difficile infection. which of the following informationshould the nurse include in the teaching? assign the client to a room with a negative air-flow system use alcohol-based hand sanitizer when leaving he client's room clean contaminated surfaces in the client's room with a phone solution have family members wear gown and gloves when visiting Have family members wear a gown and gloves when visiting. Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Caregiversmust also wear gowns and gloves. a nurse is assessing an older adult client's risk for falls. which of the following assessments would the nurse use to identify the cent's safety needs? (Select all that apply). lacrimal apparatus pupil clarity appearance of bulbul conjuctivae visual fields visual acuity B. pupil clarity D. visual fields E. visual acuity a nurse is caring for a client who is expressing anger over his diagnosis ofcolorectal cancer. which of the following actions should the nurse take? discuss the risk factors for colon cancer focus teaching on what the client will need to do in the future to managehis illness provide the client with written information about the phases of loss andgrief reassure the client that this is an expected response to grief Reassure the client that this is an expected response to grief. During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and ensure him that this is an expected reactionto a cancer diagnosis. a nurse is planning to insert a peripheral IV catheter for an older adultclient. which of the following actions should the nurse plan to take? insert the other at a 45º angle place the client's arm in a dependent position shave excess hair from the insertion site initiative IV therapy in the veins of the hand place the client's arm in a dependent position The nurse should place the client's arm in a dependent position because the veinswill dilate due to gravity. a nurse is lifting a bedside cabinet to move it closer to a client who is sittingin a chair. to prevent self-injury, which of the following actions should the nurse take when lifting this object? bend at the waist keep his feet close together use his back muscles for lifting stand close to the banner when lifting it Stand close to the cabinet when lifting it. This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching. a nurse is providing care to four clients. which of the following situationsrequires the nurse to complete an incident report? a nurse tied a client's restraints straps to the moveable part of the bedframe an assuétude personnel placed a surgical mask on a client who has TBbefore transporting her to radiology a nurse administer a medication to a client 30 min before the dose is due a client who has an IV infusion pump receives an additional 250 mL of IVfluid A client who has an IV infusion pump receives an additional 250 mL of IV fluid. The nurse should complete an incident report if an IV infusion pump malfunctions to assist in compiling information for risk management todetermine actions to take to prevent further similar incidents. a nurse manager is preparing to review medication documentation with a group of newly licensed nurses. which of the following statements should thenurse manger plan to include in the teaching? "use the complete name of the medication magnesium sulfate." "delete the space between the numerical dose and the unit of measure." "write the letter U when noting the dosage of insulin." "use the abbreviation SC when indicating an injection." "Use the complete name of the medication magnesium sulfate." The Institute for Safe Medication Practices designates that nurses and providerswrite the complete medication name magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate a nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. in preparation for the client's procedure, which ofthe following precautions should the nurse take? ensure sterilization of non disposable items with ethylene oxide wrap monitoring cords with stockinette and tape them in place cleanse latex pots on IV tubing with chlorohexidine before injection medication wear hypoallergenic latex gloves that contain powder Wrap monitoring cords with stockinette and tape them in place. Many monitoring devices and cords contain latex. The nurse should prevent anycontact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them. a nurse is caring for a client who requires an NG tube for stomach decompression. which of the following actions should the nurse take wheninserting the NG tube? position the client with the head of the bed elevated to 30º prior toinsertion of the NG tube remove the NG tube if the client begins to gag of choke apply suction to the NG tube prior to insertion have the client take sips of water to promote insertion of the NG tube intothe esophagus Have the client take sips of water to promote insertion of the NG tube into theesophagus. Taking sips of water as the NG tube passes through the oropharynx will close theepiglottis over the trachea and prevent the tube's passage into the trachea. a nurse is admitting a client who has an abdominal wound with a largeamount of purulent drainage. which of the following types of transitionprecautions hold the nurse initiate? protective environment airborne precautions droplet precautions contact precautions Contact precautions Major wound infections require contact precautions, which mean the nurse should admit the client to a private room. All caregivers should wear a gown andgloves during direct contact with this client. a nurse is caring for a client who has a prescription for wound irrigation.which of the following actions should the nurse take? wear sterile gloves when removing the old dressing warm the irrigation solution of 40.5ºc (105ºF) cleanse the wound from the center outward use a 20 mL syringe to irrigate the wound Cleanse the wound from the center outward. The nurse should clean the wound from the center outward to preventintroduction of micro- organisms from the outer skin surface. a nurse is caring for a client who requires bed rest and has a prescription foranti embolic stocking. which of the following actions should the nurse take? apply the stockings so the creases are on the front of the leg apply the stockings while the client's legs are in a dependent position remove the stockings at least once per shift remove the stockings while the client is sitting in a reclining chair Remove the stockings at least once per shift. The nurse should remove the stocking once per shift to check the client'scirculation and skin integrity. 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 actionsshould the nurse take first? rinse the feeding bag with water between feedings tell the client to keep the head of the bed elevated at least 30º make sure the enteral formula is at room temperature wipe the top of the formula can with alcohol Tell the client to keep the head of the bed elevated at least 30°. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteralformula; therefore, the priority intervention is to keep the head of the bedelevated at least 30° to prevent reflux of the formula backward into the esophagus. a nurse is caring for a client who has tuberculosis. which of the followingactions should the nurse take? (Select all that apply) place the client in a rom with negative pressure airflow wear gloves the assisting the client with oral care limit each visitor to 2 hour increments wear a surgical mask when providing client care use antimicrobial sanitizer for hand hygiene place the client in a rom with negative pressure airflow wear gloves the assisting the client with oral care E. use antimicrobial sanitizer for hand hygiene a nurse is responding to a call light and finds a client lying on the bathroomfloor. which of the following actions should the nurse take first? check the client for injuries move hazardous objects away from the client notify the provider ask the client to describe how she felt prior to the fall Check the client for injuries. The first action the nurse should take when using the nursing process is to assess the client for injuries. a nurse is talking with the partner of an older adult male client who has dementia. the client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. the nurse should identify that he is going through which of the following types of role-performing stress? role ambiguity sick role role overload role conflict Role overload 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 perform. a nurse is administering IV fluid to an older adult client. the nurse shouldperform which priority assessment to monitor for adverse effects? auscultate lung sounds masure urine output monitor blood pressure readings monitor serum electrolyte levels Auscultate lung sounds. The priority assessment the nurse should make when using the airway, breathing,circulation approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid volumeexcess include moist crackles heard in lung fields, dyspnea, and shortness of breath. a nurse is performing a peripheral vascular assessment for a client. whenplacing the bell on the stethoscope on the client's neck, she heads the following sound: audible vascular sound associated with turbulent bloodflow. this sound indicates which of the following? narrowed arterial lumen distended jugular veins impaired ventricular contraction asynchronous closure of the aortic and pulmonic valve Narrowed arterial lumen Arterial bruits are blowing sounds resulting from blood flowing through occludedor narrowed arteries. a nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. which of the following assessment findings should the nurse expect? neck vein distention urine specific gravity 1.010 rapid heart rate blood pressure 144/82 mm Hg Rapid heart rate Tachycardia indicates fluid-volume deficit, which is an expected finding for aclient who has had vomiting and diarrhea for 3 days. a nurse is caring for a client who has terminal live cancer. which of thefollowing statements should the nurse identify as an indication that the client is experiencing spiritual distress? "what could I have done to deserve this illness?" "I blame medical science for not curing me." "where is my daughter at a time like this?" "will I ever begin to feel in charge of my life again?" "What could I have done to deserve this illness?" The client's terminal illness might prompt him to review his life and question itsmeaning. A manifestation of the client's spiritual distress is asking why this illness is happening to him. a nurse is using an open irrigation technique to irrigate a client's indwellingurinary catheter. which of the following actions should the nurse take? place the client in a side-lying position instill 15 mL of irrigation fluid into the catheter with each flush subtract the amount of irritant used from the client's urine output perform the irrigation using a 20 mL syringe Subtract the amount of irrigant used from the client's urine output. The nurse should calculate the fluid used for irrigation and subtract it from theclient's total urinary output. a nurse is caring for a client who is refusing a blood transfusion for religiousreasons. the client's partner wants the client to have the blood transfusion. which of the following actions should the nurse take? ask the client to consider a direct donation withhold the blood transfusion request a consolation with the ethics committee ask the client's family to intervene Withhold the blood transfusion. The principle of autonomy ensures that a client who is competent has the right to refuse treatment. a nurse is reviewing a client's fluid and electrolyte status. which of thefollowing findings should the nurse report to the provider? BUN 15 mg/dL Creatinine 0.8 mg/dL Sodium 143 mg/dL Potassium 5.4 mg/dL Potassium 5.4 mEq/L The value is above the expected reference range and the nurse should report thisfinding. This client is at risk for dysrhythmias. a nurse is admitting a client who has influenza. which of the following typesof transmission precautions hold the nurse initiate? airborne droplet contact protective environment Droplet Droplet precautions are a requirement for clients who have infections that spreadvia droplet nuclei that are larger than 5 microns in diameter, including influenza,rubella, meningococcal pneumonia, and streptococcal pharyngitis. a nurse is caring for a client who is terminally ill. which of the following statements should the nurse identify as an indication that the client's familymember is coping effectively with the situation? "we are not worried. we still have hope that everything will be ok." "this is a difficult time, but we are helping each other though this." "after he comes home, we can plan out family reunion." "we don't need to talk about funeral arraignments at this time." "This is a difficult time, but we are helping each other through this." An effective coping strategy is talking with others in the family and supportingeach other. This statement displays effective coping skills because the family isusing social supports to assist them throughout the grief process. a nurse is reviewing practice guidelines with a group of newly licensed nurses. which of the following interventions should the nurse include that iswithin the RN scope of practice? insert an implanted port close a laceration with sutures place an endotracheal tube initiate an enteral feeding though a gastrostomy tube Initiate an enteral feeding through a gastrostomy tube. It is within the RN scope of practice for nurses to initiate enteral feedingsthrough nasoenteric, gastrostomy, and jejunostomy tubes. a nurse manager is overseeing the care on a unit. which of the followingshould the nurse manager identify as a violation of HIPAA guidelines? a nurse who is caring for a client reviews the client's medical chart withthe nursing student who is working with the nurse a nurse asks a nurse from another unit to assist with her documentation a nurse who is caring for a client returns a call to the client's durablepower of attorney for health care designee to discuss the client's care a nurse discusses a client's status with the physical therapies that iscaring for the client's bedside A nurse asks a nurse from another unit to assist with her documentation. Only health care professionals directly caring for a client may access medicalinformation; therefore, this is a violation of HIPAA guidelines. a nurse is reviewing protocol in preparation for suctioning secretions from client who has a new tracheostomy. which of the following actions should thenurse plan to take? use a resuscitation bag with 80% oxygen prior to the procedure select a suction catheter that is half of the size of the lumen place the end of the function catheter in water-soluble lubricant adjust the wall suction apparatus to a pressure of 170 mm Hg Select a suction catheter that is half the size of the lumen. The nurse should select a suction catheter that is half the size of the lumen toprevent hypoxemia and trauma to the mucosa. a nurse is performing a Romberg's test during the physical assessment of aclient. which of the following techniques should the nurse use? touch the face with a cotton ball apply a vibrating tuning fork to the clients forehead have the client stand with her arms at her side and her feet together perform direct percussion over the area of the kidneys Have the client stand with her arms at her side and her feet together. Romberg's test helps identify alterations in balance. The nurse should have theclient stand with her arms at her sides and her feet together to observe her forswaying and a loss of balance. a nurse is preparing a change-of-shift report. which of the of the following tools or documents should the nurse use to communicate continuity of care? critical pathway SBAR transfer report medication administration record (MAR) Situation, background, assessment, and recommendation (SBAR) SBAR is a communication tool used to relate a client's status during a change-of-shift report. A nurse is administering 1 L of 0.9% sodium chloride 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? Increase in hematocrit Increase in respiratory rate Decrease in heart rate Decrease in capillary refill time Decrease in heart rate Fluid-volume deficit causes tachycardia. With correction of the imbalance, theheart rate should return to the expected range. A nurse working in the emergency department is witnessing the signing ofinformed consent forms for the treatment of multiple clients during her shift. Which of the following individuals' signatures may the nurse legallywitness? (Select all that apply.) A teacher who brings in a 7-year-old student A 16-year-old client who is married A 27-year-old client who has schizophrenia An adoptive parent who brings in his 8-year-old son A 17-year-old mother who brings in her toddler A 16-year-old client who is married is correct. A minor who is married is emancipated and can give consent for his own treatment. A 27-year-old client who has schizophrenia is correct. An adult client who requires psychiatric care can give consent for her own care unless the court hasdetermined the client to be incompetent. An adoptive parent who brings in his 8-year-old son is correct. The adoptiveparent of a child is a parent and legal guardian and can sign to give consent for the child's care. A 17-year-old mother who brings in her toddler is correct. A custodial parent who is a minor can legally give consent for the medical treatment of her child. A nurse is caring for a client who has a respiratory infection. Which of thefollowing techniques should the nurse use when performing nasotracheal suctioning for the client? Insert the suction catheter while the client is swallowing. Apply intermittent suction when withdrawing the catheter. Place the catheter in a location that is clean and dry for later use. Hold the suction catheter with her clean, nondominant hand. Apply intermittent suction when withdrawing the catheter. The nurse should apply intermittent suction during the withdrawal of the catheterto prevent injury to the mucosa. Suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise. A nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following foods should the nurse suggestthat the client add to his diet? Beef liver Shellfish Egg yolks Avocados Avocados Avocados contain no cholesterol. Plant foods contain no cholesterol; foods fromanimals contain cholesterol. A nurse is preparing to transfer a client who can bear weight on one legfrom the bed to a chair. After securing a safe environment, which of thefollowing actions should the nurse take next? Rock the client up to a standing position. Pivot on the foot that is the farthest from the chair. Assess the client for orthostatic hypotension. Apply a gait belt to the client. Assess the client for orthostatic hypotension. The first action the nurse should take using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting her to sit and dangle her feet on the side of the bed. Thenurse should assess her for dizziness and a significant drop in blood pressure before assisting her to stand and transfer into the chair. A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? Carry a client's soiled linens out of the room in a mesh linen bag. Place a client who has tuberculosis in a room with negative-pressureairflow. Provide disposable plates and utensils for a client who is HIV-positive. Dispose of a client's blood-saturated dressing in a trash bag inside asecond trash bag. Place a client who has tuberculosis in a room with negative-pressure airflow. A client who has tuberculosis requires airborne precautions, which include placing the client in a room that has negative-pressure airflow to reduce the riskof infection transmission. A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of thefollowing actions should the nurse take? Talk directly to the client, instead of the interpreter, when speaking. Use a family member as the client's interpreter. Make sure that the interpreter has a college degree. Avoid asking the client personal questions through the interpreter. Talk directly to the client, instead of the interpreter, when speaking. When using an interpreter, the nurse should speak directly to the client andobserve the client when the interpreter is translating. A nurse is caring for a client who has an indwelling urinary catheter. Whichof the following assessment findings indicates that the catheter requires irrigation? Urine has an unusual odor. Urine specific gravity is 1.035. Bladder scan shows 525 mL of urine. Urine is positive for ketones. Bladder scan shows 525 mL of urine. A client who has an indwelling urinary catheter should have continuous urine flow without an accumulation of urine in the bladder; therefore, the nurse shouldirrigate the catheter to resolve a blockage. A nurse is caring for a client who has diarrhea due to shigella. Which of thefollowing precautions should the nurse take? Have the client wear a mask when receiving visitors. Wash her hands before and after contact with the client. Assign the client to a room with negative-pressure airflow exchange. Instruct all visitors to limit their time with the client. Wash her hands before and after contact with the client. Shigella requires the nurse to perform contact precautions to prevent the transmission of the bacteria. The nurse should also use standard precautions, which require the nurse to perform hand hygiene before and after direct contactwith every client, regardless of their diagnosis. A nurse on a medical unit is preparing to discharge a client to home. Whichof the following actions should the nurse take as part of the medication reconciliation process? Seal unused hospital medications in a plastic bag. Evaluate the client's ability to self-administer medications. Report an identified discrepancy to The Joint Commission. Compare prescriptions with medications the client received during hospitalization. Compare prescriptions with medications the client received during hospitalization. When performing medication reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with thosethe provider has prescribed for the client to take after discharge. A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should thenurse implement to prevent infection? Thread the IV catheter so that the hub rests at the insertion site. Shave excess hair from around the insertion site. Cleanse the site with hydrogen peroxide before IV catheter insertion. Palpate the site carefully just before inserting the IV catheter. Thread the IV catheter so that the hub rests at the insertion site. Inserting the catheter up to the hub reduces the risk of contamination along thelength of the catheter. A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should thenurse recommend as a good source of complete protein? Oat cereal Refried beans Peanut butter Cheddar cheese Cheddar cheese Complete proteins contain enough of all nine of the essential amino acids that help maintain and promote nitrogen balance. Cheese, poultry, and fish are examples of foods that are good sources of complete protein. A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select allthat apply.) Check the cord routinely for frays or tearing. Keep the unit at least 4 feet away from a gas stove. Consider purchasing a generator for power backup. Observe for signs of hypoxia. Select synthetic clothing and bedding. Check the cord routinely for frays or tearing is correct. Oxygen concentratorsrequire electrical power. Safe use of this delivery system includes assessing the electrical function of the device; therefore, the nurse should instruct the client to routinely check the condition of the cord. Consider purchasing a generator for power backup is correct. Loss of electricity prevents the oxygen concentrator from functioning and could deprivethe client of the oxygen he needs. The nurse should also instruct the family to explore getting the client on their municipality's priority list for restoring powerafter an outage occurs. Observe for signs of hypoxia is correct. The nurse should instruct the family toobserve for and report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and respirations, pallor, and cyanosis. Even with supplemental oxygen, the client's status can worsen, and he can develop hypoxia. A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hr. Which ofthe following actions should the nurse take first? Reposition the client. Document the client's IV intake in the medical record. Request a new IV fluid prescription. Check the IV tubing for obstruction. Check the IV tubing for obstruction. The first action the nurse should take using the nursing process is to assess the client. By checking the IV tubing for obstruction, the nurse might be able to facilitate the flow of fluid through the tubing. This could re-establish the infusionrate the provider prescribed. A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first? Reduce dietary sodium Administer a loop diuretic Evaluate electrolytes Restrict intake of oral fluids Evaluate electrolytes. The first action the nurse should take when using the nursing process is to assessthe client's electrolytes; therefore, the nurse should evaluate the client's laboratory results, including sodium, potassium, BUN, Hgb, Hct, and protein, toguide the planning of interventions to correct the imbalances. A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take? Insert the IV catheter into the back of the client's hand. Massage the area of the venipuncture site vigorously. Insert the IV catheter without using a tourniquet. Apply traction to the skin proximal to the insertion site to stabilize thevein. Insert the IV catheter without using a tourniquet. The nurse should insert the IV catheter using the tourniquet minimally or not atall to avoid injury of fragile skin or veins. A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the followinglocations should the nurse place the bell of the stethoscope? Second intercostal space at the left sternal border Fourth intercostal space at the right sternal border Fourth intercostal space at the left sternal border Second intercostal space at the right sternal border Second intercostal space at the left sternal border This is the area over the pulmonary valve. The nurse should listen over this, theapex, and the other valve areas for rate and rhythm, as well as gallops and murmurs. A nurse is caring for a client who has a terminal illness and is approaching death. The client's respirations are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take? Turn the client every 4 hr. Elevate the head of the client's bed. Hold oral care. Increase the room's temperature. Elevate the head of the client's bed. This action promotes postural drainage and also allows maximal chest expansion, which makes it easier for the client to breathe and decreases noisyrespirations. A nurse is caring for a client who has a terminal diagnosis and whose healthis declining. The client requests information about advance directives. Which of the following responses should the nurse make? "We can talk about advance directives, and I can also give you some brochures about them." "You should set up a time to talk with your provider about that." "Let's discuss how you are feeling today, and we'll save the planning forwhen you are feeling a little better." "Why do you want to discuss this without your partner here to plan thiswith you?" "We can talk about advance directives, and I can also give you some brochuresabout them." With this statement, the nurse offers to provide the information the client needs ina direct and simple way. A nurse is assessing a client who reports increased pain following physicaltherapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? "Is your pain constant or intermittent?" "What would you rate your pain on a scale of 0 to 10?" "Does the pain radiate?" "Is your pain sharp or dull?" "Is your pain sharp or dull?" Asking the client whether the pain is sharp, dull, crushing, throbbing, aching,burning, electric- like, or shooting helps determine the quality of the pain. A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information isthe priority for the nurse to provide? Admitting diagnosis Breath sounds Body temperature Diagnostic test results Breath sounds When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status ofthe client's breath sounds. A nurse is reviewing the medical records of a client who has a pressure ulcer.Which of the following findings should the nurse expect? Albumin level of 3 g/dL HDL level of 90 mg/dL Norton scale score of 18 Braden scale score of 20 Albumin level of 3 g/dL An albumin level below 3.5 g/dL indicates protein deficiency, placing the client atrisk for pressure ulcer formation and poor wound healing. A nurse is completing an admission assessment of an older adult client.Which of the following findings should the nurse identify as a potentialindication of abuse? Loss of skin turgor on the back of the hands Varicosities on the lower extremities Thick, discolored nails with ridges Bruises on the arms in various stages of healing Bruises on the arms in various stages of healing Bruises in various stages of healing is an indicator of abuse. Other indicators include burns, abrasions, fractures, bite marks, dried blood, and pressure ulcers. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vital signs every 15 min and call him back in1 hr. From a legal perspective, which of the following actions should the nurse take next? Document the provider's statement in the medical record. Notify the nursing manager. Consult the facility's risk manager. Complete an incident report. Notify the nursing manager. The greatest risk to the client is not receiving timely intervention for his deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure the necessary care is providedto the client. A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. After which of the following observations should the nurse remove the IV catheter? Small air bubbles are in the IV tubing. IV flow stops when the client bends her arm. Swelling and coolness are observed at the IV site. Blood is visible in the IV catheter and tubing. Swelling and coolness are observed at the IV site. Swelling and coolness are indications of IV infiltration, which warrant removingthe catheter and restarting the IV infusion with a new catheter at a different site. A client who is nonambulatory notifies the nurse that his trash can is on fire.After the nurse confirms the fire, which of the following actions should the nurse take next? Activate the emergency fire alarm. Extinguish the fire. Evacuate the client. Confine the fire. Evacuate the client. According to the RACE mnemonic, the first action in response to a fire is torescue the clients, moving them to a safe area. A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time shewas taking an antibiotic. Which of the following information should the nurse give the client? "Rashes are very common, especially if you have dry skin. Did it go awayon its own?" "Virtually all medications have adverse effects. It sounds like this couldhave been an adverse effect of the antibiotic." "It's unlikely that your doctor will prescribe an antibiotic for what seemsto be a minor viral infection, so we shouldn't be concerned about that rash." "We need to document the exact medication you were taking because youmight be allergic to it." "We need to document the exact medication you were taking because you mightbe allergic to it." If there is any possibility that a client had an allergic reaction to a medication, itis imperative that the provider be aware and does not prescribe that same medication again. Subsequent allergic reactions could be life-threatening. A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurseconsult the provider before using this complementary therapy? A client who has a history of physical abuse A client who has a permanent pacemaker A client who has ulcerative colitis A client who has asthma A client who has asthma Some essential oils can cause bronchospasm; therefore, the nurse should consultthe client's provider before using this therapy. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should thenurse take? Pad the client's wrist before applying the restraints. Evaluate the client's circulation once per shift after application. Remove the restraints every 4 hr to evaluate the client's status. Secure the restraint ties to the client's bed side rails.Pad the client's wrist before applying the restraints. Restraints without padding can abrade the client's skin. A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compressiondevice. Which of the following actions should the nurse take? Assist the client into a prone position. Place a sleeve over the top of each leg with the opening at the knee. Make sure two fingers can fit under the sleeves. Set the ankle pressure at 65 mm Hg. Make sure two fingers can fit under the sleeves. Less space than two fingers between the sleeves and the legs can inhibitcirculation when the sleeves inflate. A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV toinfuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 107 mL/hr A nurse is initiating a protective environment for a client who has had anallogeneic stem cell transplant. Which of the following precautions shouldthe nurse plan for this client? Make sure the client's room has at least 6 air exchanges per hour. Make sure the client wears a mask when outside her room if there is construction in the area. Place the client in a private room with negative-pressure airflow. Wear an N95 respirator when giving the client direct care. Make sure the client wears a mask when outside her room if there is constructionin the area. An allogeneic stem cell transplant compromises the client's immune system,putting her at high risk for infection. The client will need protection from breathing in any pathogens in the environment. A nurse is preparing to administer enoxaparin subcutaneously to a client.Which of the following actions should the nurse take? Administer the medication with the needle at a 45° angle. Administer the medication into the client's nondominant arm. Pull the client's skin laterally or downward prior to administration. Massage the injection site after administration. Administer the medication with the needle at a 45° angle. The nurse should insert the needle for a subcutaneous injection at a 45° to 90°angle. A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of thefollowing actions should the nurse take? Examine personal values about the issue. Tell the parents that this is a necessary procedure. Inform the parents that the staff does not require their consent. Contact a spiritual support person to explain the importance of the procedure. Examine personal values about the issue. The nurse should examine her own personal values about the issue to help herprovide care that is without bias. A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake andoutput record as 120 mL of fluid? 2 cups of soup 1 quart of water 8 oz of ice chips 6 oz of tea 8 oz of ice chips The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. Four oz of liquid water equals120 mL of fluid. A nurse is planning teaching for a group of adolescents who each recentlyhad surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? Role play Group discussions Question-answer meetings Practice sessions Practice sessions Practice sessions require psychomotor skills when learning. 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 nurseinclude in the teaching? Remove the outer cannula cautiously for routine cleaning. Use tracheostomy covers when outdoors. Use sterile technique when performing tracheostomy care at home. Cleanse irritated skin with full-strength hydrogen peroxide. Use tracheostomy covers when outdoors. Tracheostomy covers protect the client's airway from cold air, dust, and otherairborne particles. A nurse is educating a client who has a terminal illness about her request todecline resuscitation in her living will. The client asks what would happen ifshe arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide? "We will determine who the durable power of attorney for health careform has designated." "We will apply oxygen through a tube in your nose." "We will ask if you have changed your mind." "We will insert a breathing tube while we evaluate your condition." "We will apply oxygen through a tube in your nose." Oxygen can provide comfort and is not resuscitative when the nurse delivers itvia nasal cannula. A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of thefollowing actions should the nurse include? Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. Make sure the reservoir bag of a partial rebreathing mask remainsdeflated. Use petroleum jelly to lubricate the client's nares, face, and lips. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2). 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 assignto 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 is correct. Assisting a client with abed bath poses minimal risk to the client and fits 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 clientand fits within the AP's range of function. 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 fits within the AP's range of function. A charge nurse is observing a newly licensed nurse prepare a sterile field.Which of the following actions should the charge nurse identify as contaminating the sterile field? The nurse opens the sterile field on a wet surface. The nurse opens the first fold away from his body. The nurse holds sterile objects above the waist. The outer edge of the sterile field is touching a bottle. The nurse opens the sterile field on a wet surface. Opening a sterile field on a wet surface contaminates it because capillary action can wick bacteria through the sterile drape. A nurse is performing a skin assessment of a client who has a lesion on hisanterior thigh and expresses concern about skin cancer. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy? Uniform pigmentation A regular border An uneven shape A diameter smaller than 6 mm An uneven shape An uneven shape is a possible indication of a cutaneous malignancy. Each half ofthe lesion looks different from the other half. A nurse is caring for a client who has an aggressive form of prostate cancer.The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? "I will return shortly after I document this in your record." "Most men live a long time with prostate cancer." "I am available to talk if you should change your mind." "I will make a referral to a cancer support group for you." "I am available to talk if you should change your mind." When a client does not wish to share his feelings with the nurse, it is importantfor the nurse to convey a willingness to be available when he needs her. 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'splan of care? Wrap blankets around all four sides of the bed. Apply restraints during seizure activity. Place the client in a supine position during seizure activity. Have a tongue depressor at the client's bedside. Wrap blankets around all four sides of the bed. The nurse should affix linens or blankets around the head, foot, and side rails ofthe bed to pad them and prevent injury for a client who has been having frequenttonic-clonic seizures. A nurse is caring for a client who has a sodium level of 125 mEq/L. Which ofthe following findings should the nurse expect? Numbness of the extremities Bradycardia Positive Chvostek's sign Abdominal cramping Abdominal cramping The client has hyponatremia, a low sodium level. Manifestations includeabdominal cramping, weakness, headache, and nausea. 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 principleof veracity? A client unaware of her recent cancer diagnosis asks the nurse if she hascancer, and the nurse responds affirmatively. A client who has a prescription for a nasogastric tube refuses it, and thenurse complies with the client's wishes. A client with a do-not-resuscitate (DNR) status has a cardiac arrest, andthe nurse does not perform CPR despite requests from the client's family. A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse promised she wouldgive her. A client unaware of her recent cancer diagnosis asks the nurse if she has cancer,and the nurse responds affirmatively. Following the ethical principle of veracity, the nurse must tell the truth at alltimes and never deceive others. A nurse is auscultating the anterior chest of a client newly admitted to a medical- surgical unit. Listen to the audio clip of what the nurse auscultatesthrough his stethoscope and identify the type of breath sounds he hears. Crackles Rhonchi Friction rub Normal breath sounds Normal breath sounds These are normal bronchovesicular breath sounds, characteristically of moderate intensity and sounding like blowing as air moves through the largerairways on inspiration and expiration. A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which ofthe following practices should the nurse intervene? The client is receiving formula at room temperature. The feedings infuse at a slow, continuous drip over 8 hr each night. The family member washes out the feeding bag with warm water onceevery 24 hr. The family member flushes the tubing with water before and after giving medications. The family member washes out the feeding bag with warm water once every 24hr. The family member should wash out the feeding bag at each refilling throughoutthe day (every 4 to 8 hr) and replace it with a new feeding bag every 24 hr to prevent bacterial contamination. Therefore, the nurse should reinforce this information with the family member. A nurse has just inserted an NG tube for a client. Which of the followingassessment findings should the nurse expect to confirm correct tube placement? The tube aspirate has a pH of 7. An x-ray shows the end of the tube above the pylorus. Bowel sounds are present on auscultation. The client reports relief of nausea. An x-ray shows the end of the tube above the pylorus. An abdominal x-ray showing the end of the tube above the pylorus indicatesgastric placement. A nurse has an order to remove sutures from a client. After retrieving thesuture remover kit and applying sterile gloves, which of the following actions should the nurse take next? Clean sutures along the incision site. Grasp at the knot of the sutures with forceps. Cut the sutures close to the skin on one side. Pull out the sutures with forceps in one piece. Clean sutures along the incision site. The greatest risk to this client is injury from infection; therefore, the first actionthe nurse should take is to clean the incision to minimize the risk of infection. A nurse in a long-term care facility is caring for a client who dies during thenurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Place a name tag on the body Obtain the pronouncement of death from the provider Remove tubes and indwelling lines Wash the client's body Ask the client's family members if they would like to view the body Obtain the pronouncement of death from the provider Remove tubes and indwelling lines Wash the client's body Ask the client's family members if they would like to view the body 1) Place a name tag on the body The first step is to obtain the death pronouncement from the provider. Next, thenurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer. A nurse in a provider's office is assessing the deep tendon reflexes of a client.Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex? Back of foot (heel) Knee cap Elbow Back of elbow Knee cap The nurse should identify this image as assessing the client's patellar reflex. To elicit the expected response of lower leg extension, the nurse should allow the client's legs to hang freely over the side of the examination table while seated and quickly tap the patellar tendon just below the kneecap using a reflex hammer. A nurse is caring for a client who is postoperative. When the nurse preparesto change her dressing, she says, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priorityaction? Encourage the client to relax and take deep breaths during the dressingchange. Educate the client about the importance of the dressing change to prevent infection. Assist the client to a comfortable position for the dressing change. Administer pain medication 45 min before changing the client's dressing. Administer pain medication 45 min before changing the client's dressing. 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 minbefore changing the client's dressing. A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indicationthat the client understands the teaching? "When descending stairs, I will first shift my weight to my right leg." "I should place my crutches 12 inches in front and to the side of eachfoot." "As I sit down, I will hold one crutch in each hand." "I will make sure the shoulder rests are snug against my armpits. "When descending stairs, I will first shift my weight to my right leg." To descend stairs, the client should first shift his body weight to his right(unaffected) leg. A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she receivedabout pain management? "I think I should take my pain medication more often, since it is not controlling my pain." "Breathing faster will help me keep my mind off of the pain." "It might help me to listen to music while I'm lying in bed." "I don't want to walk today because I have some pain." "It might help me to listen to music while I'm lying in bed." Listening to music is an effective nonpharmacological intervention for the management of mild pain. A nurse is caring for a client who has pharyngeal diphtheria. Which of thefollowing types of transmission precautions should the nurse initiate? Contact Droplet Airborne Protective Droplet Droplet precautions are a requirement for clients who have infections that spreadvia 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 ft) of the client who has a disorder requiring droplet precautions. 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? During the admission process As soon as the client's condition is stable During the initial team conference After consulting with the client's family During the admission process Discharge planning should begin as soon as the client is undergoing admission. The nurse should begin to assess the client's needs and plan for care during andafter hospitalization. A middle adult client tells the nurse, "I feel so useless now that my childrendo not need me anymore." Which of the following responses should the nurse make? "Most people are happy when their children grow up and leave home." "You should be proud that your children are becoming independent." "Maybe you should consider why you are feeling useless." "People in middle adulthood often find satisfaction in nurturing andguiding young people." "People in middle adulthood often find satisfaction in nurturing and guidingyoung people." According to Erik Erikson, the task of middle adulthood is generativity versus self- absorption and stagnation. The focus of this task is on offering support andguidance to future generations. The nurse should explore with the client opportunities for mastering the developmental tasks of this stage, such as volunteering and mentoring young people. A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell overthe bedrail onto the floor. Which of the following statements should the nurse document about this incident? "Incident report completed." "Client climbed over the bedrails." "Client found lying on floor." "Client was trying to get out of bed." "Client found lying on floor." The nurse should include documentation that is descriptive, objective information about what she actually observed, without any opinions or judgmentabout motive or cause. A nurse is caring for a client who has recently started using a behind-the-earhearing aid. Which of the following statements should the nurse identify as an indication that she understands the use of this assistive device? "This type of hearing aid does not allow for fine tuning of volume." "I shouldn't have trouble keeping the hearing aid in place during exercise." "I expect to hear a whistling sound when I first insert the hearing aid." "I will be sure to remove my hearing aid before taking a shower." "I will be sure to remove my hearing aid before taking a shower." The client should remove any hearing device before showering because exposureto water can damage the hearing aid. HESI FUNDAMENTALS A nurse is reaching a client and his family how to care for the client’s tracheostomy at home. Which of the following should the nurse include in the teaching? Use tracheostomy covers when outdoors A home health nurse is performing a follow-up visit for a client who has a 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? The client’s care giver washed out the feeding bag once every 24 hours with warm water 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? Let’s talk about how the change in your hob status will affect you. A nurse is assessing a client who reports increased pain following pt. Which of the following questions should t15he nurse ask hen assessing the quality of the client’s pain? Sharp & dull 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? Reassure the client that this is an expected response to grief. A nurse 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? Pad the client’s wrist before applying the restraints A nurse is performing 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? The client uses no acetone nail polish remover. Nurse caring for a client who has a respiratory infection. What technique should she use when preforming nasotracheal suctioning? Apply intermittent suction when withdrawing the catheter. Nurse is preparing for change of shift. Which document or tools should the nurse use to communicate? SBAR Nurse is planning care for a client who had a stroke. What should be assigned to the assistive personal? (SATA) -Assist the client with a partial bed bath. -Measure the client’s BP after the nurse administers antihypertensive meds. -Use a communication board to ask what the client wants for lunch. Nurse caring for a client who has dementia. What interventions should be taken to minimize risk for injury? Use bed exit alarm system Nurse performing a skin assessment for a client who expresses concern about skin cancer. What findings should the nurse identify as a potential indication of a skin malignancy? A mole with an asymmetrical appearance Nurse is administering optic ear medication on an adult client. Which action should be done to ensure the medication reached the inner ear? Press gently on the tragus of the client’s ear. Nurse is planning strategies to manage time effectively for client care. What should the nurse implement? Use the planning step of the nursing process to prioritize client care delivery. Nurse caring for a client who has a sodium level of 125. What findings should the nurse expect? Abdominal cramping Nurse is preparing an education program for staff about advocacy. What information should the nurse include? Advocacy ensures clients’ safety, health, and rights. Nurse is preparing to administer enoxaparin subcutaneously. Which of the following actions should the nurse take? Administer the medication with the needle at a 45-degree angle. A nurse is initiating a protective environment for a client who has had an allogenic stem cell transplant. Which precaution should the nurse plan for this client? Make sure the client wears a mask when outside her room if there is construction in the area. Nurse providing discharge instructions for client who will be using a walker. Which statement indicates an understanding of the teaching? I will hire someone to trim the tree that hands low over the stairs of my front porch. Nurse planning to insert IV for an older adult client. What actions should the nurse plan to take? Place the client’s arm in a dependent position. 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? During the admission process 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 ED and I had a difficulty breathing?” Which of the following responses should the nurse make? We would give you oxygen through a tube in your nose. 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? Help the client take sips of water to promote insertion of the NG tube Nurse auscultating anterior chest who is newly admitted. Listen Normal breathing sounds Caring for a client who died Obtain order Remove tubes Wash client Ask family Place the tags A nurse is providing discharge teaching to a client about self-administering heparin. Administer medication in abdomen A nurse caring for a client who asks about the purpose of advance directives Indicate form of treatment a client is willing to accept Nurse is assessing an older adult for risk for falls (SATA) Pupil clarity, visual fields, visual acuity Nurse assessing a client who is on bed rest for past month. Indication of thrombophlebitis Calf Swelling Deep tendon reflex -- patellar reflex Knee picture Postop client with fluid volume deficit. Changes indicate successful treatment Decrease in heart rate Nurse is reviewing EBP about administration of O2 therapy Regulate O2 via nasal canula no more than 6L Nurse responding to call light and finds client on bathroom floor. FIRST Check client for injuries Nurse caring for client prescribed blood transfusion. Parents refuse due to religious beliefs. What should the nurse do? Examine personal values about the issues. Nurse caring for client approaching death. SOB, noisy respirations. What should they do? Turn client 2 hours Nurse is assessing readiness to learn about insulin self-administration. What indicates the client is ready to learn? I can concentrate best in morning. Nurse receives report about a client getting IV fluids infusing 125ml/hr but notes he has only gotten 80 mL over the last 2 hours. What should nurse do first? Check IV tubing for obstruction A nurse is preparing an injection for opioid medication. Draws 1mL from 2mL vial, what should the nurse do? Ask another nurse to observe medication waste? Nurse caring for a group of clients. Prevent spread of infection Place a client with TB in negative pressure room. Nurse caring for client at end of life. Which statement by client’s partner is effective coping? I am relying on support from out family during this time Nurse caring for postop client following knee arthroplasty and requires thigh high compression sleeves. What should the nurse do? Make sure two fingers can fit under the sleeve. Nurse using an open irrigation technique for client’s catheter. What action should nurse take? Subtract amount of irritant used from client’s urine output. Nurse is caring for a client who has pharyngeal diphtheria. Transmission precautions? Droplet Postop, signs of hemorrhagic shack. Nurse notifies surgeon and he said to continue to monitor vitals every 15 minutes and report in one hour. What should the nurse do next? Notify nurse manager Reviewing client’s fluid and electrolytes status. What should nurse report to provider? Potassium 5.4 Nurse caring for client postop. When nurse prepares to change dressing, client says it hurts. Which intervention is the nurse’s priority action? Administer pain meds 45 minutes prior to dressing change. Nurse admitting new client. Medication reconciliation? Compare the client’s home medications to the providers prescriptions Nurse admitting client with abdominal wound. Which precaution? Contact precaution Nurse lifting bedside cabinet. Prevent self-injury by? Standing close to cabinet when lifting Preparing to apply dressing to stage 2 pressure injury. Which type of dressing should the nurse use? Hydrocolloid Nurse talking with a client’s partner. She is having frustrations about managing responsibilities and care. What type of role performance stress is this? Role overload Nurse is evaluating a client’s use of cane. What is the correct use? Client holds the cane on the stronger side of the body. Math Question – 7 hours 107 mL/hr. Nurse manager is reviewing medication documentation. Which of the following statements should the nurse plan to include in teaching? Use the complete name of the medication magnesium sulfate. Nurse caring for client who has herpes zoster. Client asks about complementary and alternative therapies for pain control. Nurse should inform client that this condition is a contraindication for which of the following therapies? Acupuncture Nurse caring for a client who has the poops due to shigella. Precautions to implement? Wear a gown when caring for the client. Nurse caring for client postop refuses to use incentive spirometer following major abdominal surgery. Nurse’s priority? Determine the reason why the client is refusing to use IS. Client postop is verbalizing pain at a 2 on a scale from 0-10. Indication that client understands pain management? It might help me to listen to music while lying in bed. A nurse is assessing 4 adult clients. Which of the following physical assessment techniques should the nurse use? Ensure the bladder of the BP cuff surrounds 80% of their arm. Nurse caring for client who has prostate cancer. Provider discusses treatment options and leaves room. Client declines to talk about concerns. Which of the following statements should the nurse make? I am available to talk if you should change your mind. HESI FUNDAMENTALS A nurse is caring for a client who has left lower atelectasis. in which of the following positions should the nurse place the client for postural drainage? Supine and low-Fowler's position Right lateral in Trendelenburg position Side lying with the right side of the chest elevated Prone with pillows under the extremities A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse? “This test will indicate if you are at risk for developing blood clots “This test will determine if your heart is performing properly” “This test will provide information about the function of your liver” Rationale: ALT test measures amount of enzyme in blood. ALT mainly found in liver Rationale: Leadership 7.0. ALT and AST measure you liver function. Creatinine and BUN measure your kidney function “This test is used to check how your kidneys are working” . A nurse is caring for a client who has a prescription for morphine 5mg IM accidentally administers the whole 10 mg from the single-dose vial. Which of the following actions should the nurse take first? Notify the client‟s provider. Report the incident to the pharmacy. Complete an incident report. Measure the client’s respiratory rate. Rationale: morphine OD = pulmonary edema  fills lungs w/ fluid  leading cause of death for OD Rationale: Morphine can cause respiratory depression if given too much. Also you should ALWAYS ASSESS the patient first when a med error is performed to make sure med error doesn‟t put the client‟s health in risk. A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who has difficulty swallowing pills. Available is diphenhydramine 12.5 mg/5 mL oral syrup. Which of the following images shows the correct # of mL the nurse should administer? (Round the answer to the nearest whole number.) Click on the syringe that has 8 mL of med. 20 mg x (5mL/12.5mg) = 8 mL A nurse is caring for a 6-year-old child who has a new prescription for cefoxitin 80 mg/kg/day administered intravenously every 6 hour. The child weighs 20 kg. How much cefoxitin should the nurse administer with each dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) So it says each dose for the final answer, but we are given 80 mg/kg/day. 80 x 20 = 1600 / 4 (dose is given every 6 hours a day) =400 mg  Rationale: 80 mg x 20 kg = 1,600  1,600/4 x day (q6h) = 400 mg A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first? Label the pump with a defective equipment sticker. Unplug the pump. Obtain a replacement pump. Notified the biomedical department to fix the pump.  Rationale: Prioritization question. YOU WILL FIRST UNPLUG the IV pump to avoid causing a fire. A nurse is caring for a client who has a surgical wound. Which of the following laboratory values places the client at risk for poor wound healing? Serum albumin 3 g/dL Total lymphocyte count 2400 mm3 HCT 42% HGB 16g/dL  Rationale: Albumin in low. Normal range is 3.5 to 5.5 g/dL. Low albumin places the client at risk forpoor wound healing. The other lab values are within normal limits. A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take? Chapter 27 Vitals signs page 244 Apply the cuff above the client‟s antecubital fossa. Use a cuff with a width that is about 60% of the client's arm circumference. - width of the cuff should be 40 % of arm circumference How the clients sit with his arm resting above the level of his heart. - MUST BE AT HEART LEVEL Release the pressure on the client's arm 5 to 6 mm per second. - pressure release should not be more than 2 to 3 mm hg per second  Rationale: ATI FUNDA says 40% of the arm circumference pg. 139. Release the pressure no faster than 2 to 3 mm Hg per second. Apply the BP cuff 2.5 cm (1 in) above the antecubital space with the brachial artery in line with the marking on the cuff.Apply the BP cuff 2.5 cm (1 in) above the antecubital space with the brachial artery in line with the marking on the cuff. A nurse is preparing to perform nasal tracheal suctioning for a client. Which of the following is an appropriate action for the nurse to take? Chapter 53 Airway management page 563 Hold the suction catheter with the clean non-dominant hand. Apply suctioning for 20 to 30 seconds.- 10 -15 seconds is the maximum. Place the catheter in a location that is clean and dry for later use new line.- NEVER EVER REUSE THE SUCTION CATHETER . you throw it away after being used. Use surgical asepsis when performing the procedure.- book say medical asepsis which is maybe the same thing . Rationale: sterile technique for trachea Rationale: ATI FUNDA. PG. 316 Use surgical asepsis for all types of suctioning. No longer than 10-15 seconds to avoid hypoxemia A nurse is documenting client care. Which of the following abbreviations should the nurse use?ati book was not thorough so i had to go on different sites for charts - not confident with this, please double check. “SS” for sliding scale “BRP” for bathroom privileges “OJ” for orange juice- do not “SQ” for subcutaneous- do not MISSING A nurse is collecting A blood pressure reading from a client who is sitting in a chair period the nurse determines that the clients BP is 158/96 mmhg. which of the following actions should the nurse take? Ensure that the width of the BP cuff is 50% of the client‟s upper arm circumference. It says 40% Reposition the client Supine and recheck her BP. BP. → ORTHOSTATIC HYPOTENSION Recheck the clients BP and her other arm for comparison. Request that another nurse check the the clients BP in 30 minutes. → 15 minutes A nurse is caring for a client who has left lower atelectasis. in which of the following positions should the nurse place the client for postural drainage? Chapter 53 Airway Management page 562 Supine and low-Fowler's position Right lateral in Trendelenburg position Side lying with the right side of the chest elevated Prone with pillows under the extremities A nurse is receiving the prescription for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify? Dietitian consult Speech therapy referral Oral suction at the bedside Clear liquids- liquids must be THICK. Clear liquids can cause aspiration  Rationale: ATI MS. Pg. 83 food levels for dysphagia include pureed, mechanically altered, advanced/mechanically soft, and regular. A nurse is administering a large volume enema to a client. Identify the sequence of steps the nurse should follow after preparation and lubricating the enema set.(ati funds video enema) Administer the enema solution.(2) Remove the enema tube from the clients rectum.(4) Wrap the end of the enema tube with a disposable tissue.(5) Insert the enema tube into the client's rectum.(1) Clamp the enema tube.(3) nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse take to verify proper placement of the tube? Place the end of the NG tube in water to observe for bubbling. Auscultate 2.5 cm (1 in) above the umbilicus while injecting 15 mL of sterile water. AIR NOT WATER OR BY ASPIRATING GASTRIC FOR PH. Assess the client's gag reflex. Measure the pH of the gastric aspirate. A nurse is teaching a group of newly licensed nurses about the Braden Scale. Which of the following responses by the newly licensed nurse indicates an understanding of the teaching? “The client‟s age is part of the measurement.” - rationale is same as b. “The scale measures six elements.”  Rationale: The six elements are 1. Sensory Perception, 2. Moisture, 4. activity, 5. mobility ,6. nutrition , 7. friction and shear. “The higher the score, the higher the pressure ulcer risk.”- the higher the score the better chance the patient has of NOT getting an ulcer . score of 12 or less is high risk. Anything above 18 is healthy. “Each element has a range from 1 to 5 points.”- each elements is scored from 1-4 actually . A nurse is caring from a client who has a tracheostomy. Which of the following actions should the nurse take? Clean the skin around the stoma with normal saline. Secure the tracheostomy ties with one finger to fit snugly underneath. → 2 snug fingers widths under neck strap Soak the outer cannula in warm tap water. STERILE NS Use a cotton tip applicator to clean the inside in the inner cannula. <to clean OUTER cannula surfaces, cllity- approved solution>ean the inside with the faci  Rationale: according to POTTER, funda pg. 866 using NS-saturated cotton-tipped sterile swabs and 4x4 gauze, clean exposed outer cannula surfaces and soma under faceplate, extending 5-10cm (2-4in) in all directions from stoma. A nurse is documenting in a client‟s medical record . Which of the following entries should the nurse record? “Incision without redness or drainage.” “Drink adequate amounts of fluid with meals.” WHATS THE AMOUNT “Oral temperature slightly elevated at 0800.” WHATS THE TEMP “Administered pain medication.” <Any action & change to the client‟s condition should be recorded> A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the nurse include? “Use full-length side rails on the client‟s bed.” “Check on the client frequently while he is in the restroom.” “Encourage physical activity throughout the day to expand energy.” “Remove clocks from the client‟s room.” A nurse in an emergency department is assessing a client who reports RIGHT lower quadrant pain, nausea and vomiting for the past 48 hr. Which of the following actions should the nurse take first? Auscultate bowel sounds. Administer an antiemetic. Offer a pain med. Palpate the abdomen. Possible appendicitis “nausea/vomiting” with RLQ pain. (IAPP) INSPECTION. AUSCULTATE. PERCUSS. PALPATE- FOR BOWEL A nurse is assessing a client‟s extraocular eye movements. Which of the following should the nurse take? Instruct the clients to follow a finger through the six cardinal fields of gaze.  Rationale: Cardinal fields of gaze test for cranial nerves 3, 4, and 6 which are for eye movement Hold a finger 46 cm (18 in) in front of the client‟s eyes. Ask the clients to cover her right eye during assessment of her left eye. Position the client‟s 6.1 m (20 feet) away from the Snellen chart. (This is for cranial nerve 2) A nurse is providing a teaching to a client who had a new medication prescription. Which of the following manifestations of a mild allergic reaction should the nurse include? Urticaria Ptosis Nausea Hematuria A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessments findings should the nurse identify as a contraindication to the application of cold? Cap refill 4 seconds-ITS CONTRAINDICATED TO USE APPLICATION OF COLD 7.5 cm (3 in) diameter bruise on the ankle IT HELPS ON BRUISE Warts on the affected ankle 2+ pitting edema -HELPS REDUCE INFLAMMATION (EDEMA) A nurse is caring for a client who has TB. Which of the following precautions should the nurse plan to implement when working with the client? Chapter 11 fundamentals 9.0 infection control page 52 Airborne  Rationale:measle, varicella, pulmonary or laryngeal tuberculosis Droplet-streptococcal pharyngitis or pneumonia, Haemophilus influenzae type B, scarlet fever, rubella, pertussis, mumps, mycoplasma pneumonia, meningococcal pneumonia and sepsis, pneumonic plague). Protective Contact A nurse is performing a dressing change on a client and observes granulation tissue. Which of the following findings should the nurse document? Chapter 55 Pressure ulcers, wounds and wound management? fundamentals pdf page 330 Stringy, white tissue- same as slough. Means that it is sepatated from the body. Translucent, red tissue- red means healthy and its healing Soft, yellow tissue= means presence of slough and drainage. Thick, black tissue- black is necrotic = eschar is present and needs removal A nurse is screening several clients at a neighborhood health fair. Which of the following assessments findings is the priority for referral for further care? Blood glucose 45 mg/dL Rationale: low/hypoglycemia may lead to shock level is abnormally low, [74-106 mmol/L] Blood pressure 148/92 mm Hg STAGE 1 HYPERTENSION Body mass index 28 kg/m2 OVERWEIGHT Heart rate 105/min A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care? Obtain a random blood glucose daily. Change the PN infusion bag every 48 hr. CHANGE Q24HR Prepare the client for a central venous line. Administer the PN and fat emulsion separately. ATI FUNDA PG. 298 Administer separate IV line below the filter using a Y-connector or as a admixture to PN solution (3-in-1 admixture consisting dextrose, AA, and Lipids A nurse is providing teaching about health promotion guidelines to a group of young adult male clients. Which of the following guidelines should the nurse include? “Obtain a tetanus booster every 5 years.” “Obtain a herpes zoster immunization by age 50.” “Have a dental examination every 6 months.”(funds atipg 201 says they need dental cause they are prone to infection) “Have a testicular examination every 2 years.” A home health nurse is teaching a new caregiver how to care for a client who has had a tracheostomy for 1 year. Which of the following instructions should the nurse include? “Use tracheostomy covers when going outdoors.” Google “Maintain sterile technique when performing tracheostomy care.” “Remove the outer cannula for routine cleaning.” “Clean around the stoma with povidone-iodine.” NS A nurse in the emergency department is measuring a client‟s oral temperature using an electronic thermometer. Which of the following actions should the nurse take? Chapter 27 Vital sigsn p.133 Provide oral hygiene prior to measuring the client‟s temperature. Ask the client if he has smoked within the past 30 min Attach the red tip probe to the thermometer unit. Place the tip of the probe along the client‟s buccal mucosa.- must be unde the tongue in the posterior sublingual pocket lateral to the center of the lower jaw. A nurse is caring for a client who had a stroke and requires assistance with morning ADLs. Which of the following interprofessional team members should the nurse consult? Registered dietician- helps with healthy food planning. Occupational therapistchapter 2 page 7 the interprofessional team. Speech-language pathologist- yes the question said stroke , but the question wants who will help him with every day ADLS. speech patho help them if they have a hard time swallowing. Physical therapist- is used of the patients cannot even move his muscles. MISSING A nurse overhears a colleague informing a client that he will administer her medication by injection if she refuses to swallow her pills. The nurse should recognize that the colleague is committing which of the following torts? a.) Defamation- you embarass someone by making fun of them. b.) Malpractice- you did something by accident c.) Assault- verbal threatening d.) Battery- actually causing physical harm or trauma. A nurse is caring for clients who is prescribed a buccal medication. Which of the following client statements indicates that the client understands how to take this medication? “I will first dissolve the tablet in water.” “I will insert the tablet between my cheek and teeth.” “I will place the tablet under my tongue.”- this is sublingual “I will chew the tablet.”- this is oral A nurse is admitting a client who is malnourished. The client states my wedding ring is loose and I'm worried I will lose it if it falls off. Which of the following is an appropriate response by the nurse? “I can pin it to your hospital gown, so you won't lose it.” “I will place it in your drawer, so it won't get lost.” “I will hold onto it until a family member can take it home.” “I can put it in a locked storage unit for you.” A nurse is changing a client's colostomy pouch and notices peristomal skin irritation. Which of the following actions should the nurse take? Change the pouch once every 24 hour. Apply the pouch while the skin Barrier is still damp.(no ) Rub the peristomal skin dry after cleaning. (No it will irritate skin more ) d. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma. rationale : ATI FUNDA PG 241 A nurse is preparing change of shift report after the night shift using one sbar communication tool. which of the following data should the nurse include when reporting background information? “Blood pressure 160/92 mm Hg”- part of ASSESSMENT “Start first dose of penicillin at 1200”- “Pain rating of 5 on a scale from 0 to 10” “Code status: do-not-resuscitate” A nurse is caring for a client who has extracellular fluid volume deficit. Which of the following findings should the nurse expect? Chapter 57 fluid volume imbalances page 343. Postural hypotension Distended neck veins Dependent edema Bradycardia - would be TACHY since SNS system kicks in when detects low blood volume TACHYCARDIA is for fluid overload. Isnt wherever the water goes the sodium follows. The lady on ati gave me a remediation hw about manifestation of hypernatremia: hyperthermia, tachycardia, and orthostatic hypotension. Therefore it‟s opposite→ bradycardia. TBC by the group A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely increase the client‟s motivation to learn? The nurse empathy about the client having to self-inject The client's belief that his needs will be met through education The client seeking family approval by agreeing to a teaching plan The nurse explaining the need for education to the client A nurse is conducting a Weber test on a client. Which of the following is an appropriate action for the nurse to take? Deliver a series of high-pitched sounds at random intervals. Place an activated tuning fork in the middle of the client's forehead. Hold and activated tuning fork against the client's mastoid process. Whisper a series of words softly into one ear. A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply. “I need to check my medications for expiration dates.” “I will use the grab bars when getting in and out of the bathtub.” c. “I need to have a fire escape plan with my family.” “I need to set my hot water heater to 140 degrees Fahrenheit.”- no more than 120 degrees “I will apply tapes over frayed areas of electrical cord.” A nurse is caring for a client who has a prescription for a stool specimen to be sent to the laboratory to be tested for ova and parasites. Which of the following instructions regarding specimen collection should the nurse provide to the assistive personnel? Collect at least 2 inches of formed stool. Wear sterile gloves while obtaining the specimen. Use a culturette for specimen collection. Record the date and time the stool was collected.(funds ati pg423) A nurse is caring for a client who has restraints to each extremity. Which of the following assessments should the nurse perform first? Peripheral pulses ABCS always first Comfort level Elimination needs Skin integrity A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG Tube. Which of the following actions should the nurse take? Remove the restraints every 4 hr. Attach the restraints securely to the side of the client's bed. Apply the restraints to allow as little movement as possible. Allow room for two fingers to fit between the client's skin and the restraints.- for circulation A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse take?Page 244 and 240 chapter 44 urinary elimination THIS IS CONFUSING. 244 SAYS FOR CLIENTS WHO MUST REMAIN SUPINE BUT 240 SAYS THAT CLIENTS MUST HAVE Hob UP AT 30 DEGREES. Place the shallow end of the fracture pan under the client's buttocks. Hyperextend the client's back while the fracture pan is in place. Keep the bed flat while the client is on the fracture pan- head of bed must be 30 degrees. page 240 Encourage the client to try to defecate for 20 min while on the fracture pan. A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend? Exercise 1 hr before bedtime. Eat a light carbohydrate snack before bedtime. This was on the fundamentals practice test on ATI funds 2013 Drink a cup of hot cocoa before bedtime. Take a 30 min nap daily. A nurse is performing an admission assessment of a client. Which of the following actions should the nurse take when recording the client's medication? Council the client about medication adherence. Assess the client for medication reactions. Compile a list of the client's current medications. Evaluate the client's understanding of medications. During an admission history a client tells a nurse that she is under a lot of stress. Which of the following physiological responses should the nurse expect to increase as a result of stress? Blood glucose- common stress response. Tiamson said it Intestinal peristalsis → per padgham? Not sure Peripheral blood vessels diameter- should be constricted since youll have HIGH blood pressure . Urine output A nurse is teaching a client who has diabetes mellitus about mixing regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching? “I should roll the NPH between my hands before drawing it up.”- it says ROLL so that makes sense , this would be wrong if it said SHAKE becasue that will break up the proteins. “I should wait 10 minutes after mixing the insulin to inject it.”- i believe it is up to 5 minutes but ima double check. “I should draw up the NPH insulin before the regular insulin.”- nope its clear to cloudy always so you must draw up regular beofre NPH “I should inject air into the vial of regular insulin first.”- nope, when doing clear to cloudy, you inject AIR into NPH first A nurse is caring for a client who is grieving the loss of her partner. The client states I don't see the point of living anymore. which of the following actions should the nurse take? Request the client's family provide additional support. Ask the client if she plans to harm herself.- safety first Tell the client that this is a normal response to grief. Recommend that the client seek spiritual guidance. A nurse is providing discharge teaching about safety considerations to an older adult client who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching? Chapter 19 pharm p. 145 “I will take a hot bath before going to bed.”- they are old also, so sensation is impaired. “I will take my new medication in the evening.”- this is a diueretic so this must be in the MORNING “I will leave a light on in my bathroom at night.”-some clients might have to take it twice per day usually last dose taken before 1400. You leave a light on in the bathroom because they might have to go urinate at night time ( since nocturia is a possible side effect ) “I will weigh myself once weekly.”- patients must weight themselves ONCE per day usually upon awakening. A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include? Monitor the client for pain in the suprapubic region. Ensure the client is free of metal objects. Administer 240 mL (8 oz) of oral contrast before the procedure. d. Assist the client with a bowel cleansing. Fundamentals Textbook pg 1114 IVP = imaging of the urinary tract after iv injection of iodine Prep – assess allergies & dehydration, cleanse bowel, restrict food 4 hrs prior To ensure client safety a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is a nurse manager functioning? Case manager- they do no provide direct client care ,over see case load of clients Client educator Client advocate A nurse is caring for a client who has right-sided paralysis following a cerebrovascular accident. which of the following prescriptions should the nurse anticipate to prevent a plantar flexion contracture of the affected extremity?P .222 chapter 40 mobility and immobility Ankle-foot orthotic Continuous passive motion machine- range of motion prevents ankylosis ( permanant fixation of a joint ). Abduction splint Sequential compression device A nurse is planning to use non formal logical pain methods for a client who reports still having mild back pain after receiving analgesia 1 hour ago. Which of the following actions should the nurse include in the plan? Apply an ice pack to the client's back for 1 hr. Cold therapy = reduced inflammation & slows down nerve impulses Heat therapy = stimulates blood flow & inhibits pain messages Avoid long applications of either cold or heat b/c results in tissue damage Remove distractions from the client‟s room. Instruct the client to take deep rhythmic breaths. Encourage the client to apply a heating pad for 2 hr at a time.- 2 hours seems too long A nurse is caring for a client who is on bed rest following an abdominal surgery. Which of the following findings indicates the need to increase the frequency of position changes? Sacrum , buttock and heals are prone for ulcers. NON blanckingerthyema in merks manual . blanching is considered good since that means tissue perfusion Flat rash on the client's ankle Non blanching red area over my clients trochanter Ecchymosis on the clients left shoulder Petechiae on the client's right anterior thigh A nurse is assessing a client whose therapy has included bed rest for several weeks. Which of the following findings should the nurse identify as the priority?Chapter 40 mobiltiy page 220 Musculoskeletal weakness Loss of appetite Increased heart rate during physical activity Left lower extremity tenderness- warmth and tenderness = DVT= PE if it dislodges!!! Effects on the heart and blood Like the muscular system, the cardiovascular system functions best when the body is in an upright position, working against gravity. After just a few days of bed rest, blood starts to pool in the legs. On standing, this can lead to dizziness and falls. Immobility also causes the heart to beat more quickly, and the volume of blood pumped is lower. The volume of blood generally in the body is lower, and there is less oxygen uptake by the body. This results in poorer aerobic fitness and fatigue sets in more easily. The blood also becomes thicker and stickier, which increases the risk of a blood clot forming, especially in the legs (deep vein thrombosis) and the lungs (pulmonary embolism). A nurse is assessing a client's ability to balance. Which of the following actions is appropriate when the nurse conducts a Romberg test? Page 168 chapter 31 musculosketal and neuro systems Ask the client to extend her arms in front of her body. Ask the client to walk in a straight line heel To toe. Have the client stand with her feet together.- also with eyes closed. There should not be swaying How the client place her hands on her hips. A nurse is providing care for a client who is to undergo total laryngectomy. which of the following interventions is the nurse‟s priority? Schedule a support session for the client. Explain the techniques of esophageal speech. Review the use of artificial larynx with the client. Determine the client's reading ability. ESOPHAGEAL SPEECH is based on the technique in which the patient transports a small amount of air into the esophagus. MISSING A nurse at an assisted living facility is preparing an in-service for residents about electrical safety. Which of the following instructions should the nurse include? Avoid taping electrical cords to the floor. Clean electrical equipment prior to disconnection. Cover exposed wires with tape before used. Disconnect electrical equipment by grasping the plug. A nurse is caring for a client who has a tracheostomy collar. As the nurse is performing tracheal suctioning, the client‟s heart rate and oxygen saturation decrease. which of the following actions should the nurse take? Elevate the head of the bed. Remove the inner cannula. Irrigate the stoma. Discontinued suctioning. A nurse is caring for a client who has a new diagnosis of terminal cancer. Which of the following interventions is a priority? Teach the client to use progressive relaxation techniques. Help the client to find a local support group. Discuss the client's prior coping mechanism. Develop a list of goals with the client. A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. the stop should include that the nurse signature on the form confirms which of the following requirements? (Select all that apply.) The client was not coerced. The client does not have a mental health condition. The client Signed in the nurse‟s presence. The client speaks the same language as the nurse. The client has legal authority to do so. ATI: FUNDA PG. 17 A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following tasks should the nurse delegate to an assistive personnel? Teach deep breathing and coughing to the client.- Teaching is always RNS job Assist the client to select food choices from the menu. Evaluate the client‟s response to pain medication. NURSING PROCESS is always RNS job Monitor the characteristics of the client's chest tube drainage.- Evaluating treatment, is part of nursing process and is always RNS job. A community health nurse is caring for a group of families. The nurse should identify that which of the following families is experiencing a maturational loss? A family whose only child recently died due to cancer. A family whose head of household lost her job. A family whose house was destroyed in a fire. A family whose oldest child is moving away for college Rationale: Flashcardmachine: Maturational loss- experienced as a result of natural developmental processes. E.g. The first child may experience a loss of status when her sibling is born. Also, happens when sending children off to kindergarten or college. A nurse on a medical-surgical unit is dividing care for four clients. The nurse should identify which of the following situations as an ethical dilemma? A client who has a new colostomy refuses to take instructions from the ostomy therapist because she “doesn't like him.” A surgeon who removed the wrong kidney during a surgical procedure refuses to take responsibility for her actions. The family of a client who has a terminal illness as the provider not to tell the client the diagnosis. A client who has Crohn's disease reports that his prescription drug plan will not pay for his medications. Rationale: ATI FUNDA pg. 11 it involves between two moral imperatives; answer will have a profound effect on the situation and the client. A nurse is caring for a client who has chronic back pain and asked about receiving acupuncture for relief. Which of the following findings should the nurse identify as a contraindication to receiving this shipment? Obesity Hypertension Migraines Cellulitis Rationale: Google: You can‟t have acupuncture in a very swollen area e.g. Cellulitis; and it‟s a risk for infection Rationale: Contraindicated in people who have bleeding disorders and skin infections. Fundamentals pg 694 A nurse is auscultating a client's abdomen. The nurse hears a blowing sound over the aorta. The nurse should identify this sound as which of the following? Gallop Bruit Thrill Murmur Rationale: Bruit- turbulent blood flow within the aorta. HESI FUNDAMENTALS A nurse is providing teaching to a client who has a new med prescription. Which of the following manifestations of a mild allergic reaction should the nurse include? Ptosis Hematuria Urticaria Nausea A nurse is providing teaching to a client who has diabetes mellitus about performing a capillary blood glucose test. Which of hte following instructions should the nurse include in the teaching? Don sterile gloves prior to puncturing the site Puncture site after cleansing and before antiseptic dries. Gently squeeze the puncture site until a large droplet of blood forms Hold the finger to puncture above the level of the heart A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching? I will perform ankle and knee exercises every hour- ROM is needed to prevent contractures . I will hold my breath when rising from a sitting position I will remove my antiembolic stockings while I am in bed I will have my partner help me change positions every 4 hours A nurse is monitoring a client who is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phelbitisat the IV site? Erythema along the path of the vein Pitting edema at the insertion site- infiltration since water is probably displaced. Coolness of the client‟s left forearm - infiltration Pallor of the client‟s left forearm A nurse is planning care for a client who reports insomnia. Which of the following actions should the nurse perform shortly before bedtime? Provide a late supper Offer a wet washcloth for the client to wash her face Perform range of motion excercise Prepare a hot cocoa or tea for the client A nurse is providing teaching to a newly licensed nurse about the care of a client who has MRSA. Which of the following statements by the newly licensed nurse indicates an understanding of teaching? I will place the client in a private room I will tell the client‟s visitors to wear a mask when they are within 3 feet of the client I will remove my gown after leaving the client‟s room I will wear an N95 respirator mask when caring for the client A nurse is teaching a client who requires maximal support about how to use a two wheeled walker. Which of the following actions by the client indicates an understanding of teaching. The client moves the walker ahead 25.4cm with each step The client picks up the walker with each step The client stands with her elbow slightly while holding the walker The client stoops slightly forward when moving the walker A nurse in a provider‟s office is caring for a client who states “I always have trouble sleeping”. Which of the following actions should the nurse take first? Teach the client stress reduction techniques Recommend that the client avoid caffeine intake in the evening Identify the client typical bedtime routine Encourage the client to exercise regularly during day time hours. A nurse is admitting an older adult client who is Hispanic. Which of the following cultural should the nurse include when developing the plan of care? The hispanic culture views late adulthood as a negative time in the client‟s life The hispanic culture identifies the eldest female family member as the decision maker The Hispanic culture expects individuals to make their own decisions when death is imminent. The hispanic culture expects adult children to care for older adult parents. A nurse is teaching about home safety with a client. Which of the following instructions should the nurse include? Unplug electronics by grasping the cord Use electrical tape to secure extension cords next to baseboards on the floor To use a fire extinguisher, aim high at the top of the flames. Replace carpeted floors with tile A nurse is preparing to perform an admission assessment for a client who reports abdominal pain. Which of the following actions should the nurse take? a.) Perform deep palpation at the end of the admission assessment b.) Auscultate the client‟s abdomen before palpation c.) Begin palpation of the abdomen at the site of pain d.) Assess the client‟s bowel sounds using the bell of the stethoscope <inspect - auscultate - palpate - percuss> A nurse is caring for a client who is 6 hr postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take? a.) Allow the client to hear running water while attempting to void b.) Provide the client a bedpan while lying supine c.) Insert an indwelling urinary catheter and connect it to gravity drainage d.) Encourage fluid intake up to 1,000 mL daily <least invasive first, bedpan doesn‟t promote independence, fluid intake more than 2L> A nurse on a medical surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first? a. ) A client who has new onset of dyspnea 24 hr after a total hip arthroplasty0 can mean dvt b.) A client who has acute abdominal pain of 4 on a scale from 0 to 10 c.) A client who has a UTI and low-grade fever d.) A client who has pneumonia and an oxygen saturation of 96% <always look for new onset of anything, other findings are normal also.> A nurse is caring for a client who is nauseated and unable to eat after taking her antibiotic. Identify the steps the nurse should take to address the nausea. a.) Identify possible nursing interventions that address the client‟s nausea (1) b.) Review the potential benefits and consequences of each intervention (2) c.) Select an intervention that provides the greatest benefit and least risk (4) d.) Determine the probability of intervention-related complications (3) <I am sure, it goes (a) to (b), but I am uncertain whether it is (d) first or © first, what do you guys think?> A nurse is caring for an adolescent client who has full-thickness burns on his leg. The client expresses concern about his future. Which of the following is therapeutic response by the nurse? a.) “You‟re concerned about what will happen when you leave the hospital?” b.) “If you work hard on your physical therapy, you won‟t need to worry” c.) “You shouldn‟t worry about the future so you can concentrate on getting well” d.) “Why are you concerned even though everyone is here to help you?” A nurse is assessing the breath sounds of an adult client who has pneumonia. Which of the following actions should the nurse take? a.) Follow a systematic pattern from side-to-side moving down the client‟s chest b.) Ask the client to breathe in deeply through his nose c.) Instruct the client to sit erect with his head tilted slightly backward d.) Place the bell of the stethoscope on the client‟s chest A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (select ALL) a.) “I need to set my hot water heater to 140 degrees Fahrenheit” b.) “I will use the grab bars when getting in and out of the bathtub” c.) “I will apply tape over frayed areas of electrical cords” d.) “I need to have a fire escape plan with my family” e.) “I need to check my medications for expiration dates” A nurse is caring for a client preoperatively who has given informed consent for an appendectomy. Which of the following statements by the client should the nurse address first? a.) “I am afraid to walk if it hurts too much” b.) “I don‟t understand why I need this surgery” c.) “I don‟t want my family helping me after the surgery” d.) “I am afraid the scar will make me look disfigured” A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse take? a.) Place the shallow end of the fracture pan under the client‟s buttocks b.) Encourage the client to try to defecate for 20 min while on the fracture pan c.) Keep the bed flat while the client is on the fracture pan d.) Hyperextend the client‟s back while the fracture pan is in place <fundamentals pg. 240;; head of the bed to 30, never leave a client lying flat on bedpan,... A nurse is teaching a client who has diabetes mellitus about mixing regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching? a.) “I should roll the NPH vial between my hands before drawing it up” b.) “I should draw up the NPH insulin before the regular insulin” c.) “I should inject air into the vial of regular insulin first” d.) “I should wait 10 minutes after mixing the insulin to inject it” <NPH - regular - regular - NPH> A nurse is caring for a client who is confused and pulling at the tubing of her IV. Which of the following actions should the nurse take before requesting a prescription for restraints from the provider? a.) Place the client in a room away from the nurses‟ station b.) Limit the client‟s visitors c.) Give the client washcloths to fold d.) Close the door of the client‟s room A nurse at a long-term facility is providing a change-of-shift report to an oncoming nurse about an older adult client who has shingles. Which of the following information should the nurse include in the report? a.) Where the client ate his breakfast b.) The times for routine vital sign measurements c.) The exact times the client had visitors d.) The type of transmission-based precautions in place A nurse on a med-surg unit is teaching newly licensed nurse about tasks to delegate to AP. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a.) “An AP may take orthostatic blood pressure measurements from a client who reports dizziness” - RNs job since this requires ASESSMENT due to episode of adverse effect. b.) “An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids”- monitoring is part of assessment since it is using judgment c.) “An AP may perform a central line dressing change for a client who is ready for discharge” d.) “An AP may count the respirations of a client who is going to have surgery later the same day”- the client has surgery LATER that day, so this should mean that the patients condition is not that urgent A nurse on a med-surg unit is providing care for four clients. The nurse should identify which of the following situations as an ethical dilemma? a.) A surgeon who removed the wrong kidney during a surgical procedures refuses to take responsibility of her actions- please double check anyone b.) A client who has a new colostomy refuses to take instructions from the ostomy therapist because she “doesn‟t like him” c.) The family of a client who has a terminal illness asks that the provider not tell the client the diagnosis d.) A client who has Crohn‟s disease reports that his prescription drug plan will not pay for his medications A charge nurse on an acute care unit is planning care for a client. Which of the following actions should the nurse take to promote the client‟s continuity of care? a.) Plan to assign a different nurse to the client each shift b.) Limit the number of interdisciplinary team members managing the client‟s care c.) Request that the client complete a satisfaction survey at discharge d.) Start discharge planning on the day of admission A nurse is caring for a client who begins to experience a generalized seizure while standing in her room. Which of the following actions should the nurse take? a.) Place a pad under the client‟s head b.) Hold the client‟s limbs tightly to prevent injury c.) Lift the client into bed with the help of other staff members (You assist them to fall) d.) Insert a bite block into the client‟s mouth <DOUBLE-CHECK this> Rationale: PDF p 58: Advise all caregivers and family not to restrain the client during a seizure but to lower him to the floor or bed, protect his head, remove nearby furniture, provide privacy, put him on his side with his head flexed slightly forward if possible, and loosen his clothing. A nurse is caring for a client who is grieving the loss of her partner. The client states, “I don‟t see the point of living anymore.” Which of the following actions should the nurse take? a.) Recommend that the client seek spiritual guidance b.) Request that the client‟s family provide additional support c.) Tell the client that this is a normal response to grief d.) Ask the client if she plans to harm herself A nurse is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse include in the plan? a.) Empty the drainage bag at least every 8 hr b.) Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) Tape the catheter to the lower abdomen A nurse is providing teaching to an older adult client about home safety. Which of the following information should the nurse include? a.) “Keep a nightlight on the bathroom” b.) “Set room temperature to 68 degrees Fahrenheit” c.) “Place throw rugs over electrical cords” d.) “Use chairs without arm rests” A nurse is planning care for a client who has a prescription for extremity restraints to both wrists. Which of the following actions should the nurse include in the plan of care” (select ALL) a.) Secure restrains to allow three fingers to slide under the restrains (1-2 fingers) b.) Ensure that the bed is in the lowest position c.) Tie each restraint with a quick-release knot d.) Attach the client‟s restraints to the bed rail (to the bed frame) e.) Remove the client‟s restraints every 2 hr A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client‟s son tells the nurse, “I don‟t know what to tell my dad if he asks how he is going to die.” Which of the following is an appropriate response by the nurse? a.) “Let‟s talk more about your dad‟s condition” <???????? I think this is more for the physician b.) “The social worker will help you answer those questions” c.) “I think that you should discuss this with the hospice nurse” d.) “Try to help your dad enjoy this time as much as he can” A nurse is caring for a client who will receive intermittent enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take when administering a feeding? (select ALL) a.) Keep the client sitting upright for 15 min following administration b.) Instill the formula over a period of 30 to 45 min c.) Heat the formula to 80F prior to administration d.) Check for residual volumes by aspirating stomach contents e.) Place the client into the Fowler‟s position A nurse is preparing to administer metoprolol 25 mg PO every 12 hr. Available is metoprolol 50 mg/scored tablet. How many tablets should the nurse administer with each dose? (nearest tenth) -> Answer;; 25mg x (1 tablet/50mg) = 0.5 tablet A nurse is assessing a client who is receiving tube feedings via NG tube. Which of the following findings should the nurse report to the provider? a.) Potassium 5.5 mEq/L b.) Irritation of nasal mucosa c.) Sodium 144 mEq/L d.) Loose stools A nurse is caring for a client who consumed 4 oz of juice, 16 oz of milk, 8 oz of coffee, and 200 mL of water over an 8-hr period. Calculate the client‟s intake for that 8-hr period using millilters. (nearest whole number) 1oz=30mL -> Answer;; 120mL (juice) + 480mL (milk) + 240mL (coffee) + 200mL (water) = 1,040mL A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take? a.) Use proper medical terms when giving instructions to the client. b.) Offer written instructions in the client‟s language c.) Direct verbal discharge instructions to the interpreter (No, supposed to address the pt) d.) Request that an assistive personnel interpret that instructions for the client <DOUBLE-CHECK it for me, confused between B&C> Rationale PDF p175: Address the client directly when the interpreter is present, Provide educational materials and instructions in the client‟s language. A nurse is preparing to perform a sterile dressing change for a client. Which of the following actions should the nurse plan to take? a.) Don sterile gloves prior to opening sterile dressing supplies b.) Set up the sterile field above waist level c.) Consider 5.08cm (2 in) of the sterile field‟s border to be contaminated d.) Place the cap of a sterile solution inside the sterile field A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse take to verify proper placement of the tube? a.) Assess the client for a gag reflex b.) Measure the pH of the gastric aspirate c.) Place the end of the NG tube in water to observe for bubbling d.) Auscultate 2.5cm (1 in) above the umbilicus while injecting 15 mL of sterile water A nurse is documenting in a client‟s medical record. Which of the following entries should the nurse record? a.) “Incision without redness or drainage” b.) “Drank adequate amounts of fluid with meals” c.) “Administered pain medication” d.) “Oral temperature slightly elevated at 0800” 2013 - Folder 2 A nurse is caring for a client who has an incisional wound and a prescription for wound care. Which of the following images indicates the proper method of cleaning a wound site. PDF p 330: Perform wound cleansing. For clean wounds, such as a surgical incision, cleanse from the least contaminated (the incision) toward the most contaminated (the surrounding skin). Use gentle friction when cleansing or applying solutions to the skin to avoid bleeding or further injury to the wound. Although the provider might prescribe other mild cleansing agents, isotonic solutions remain the preferred cleansing agents. -Never use the same gauze to cleanse across an incision or wound more than once. -Do not use cotton balls and other products that shed fibers. If irrigating, use a piston syringe or a sterile straight catheter for deep wounds with small openings. Apply 5 to 8 psi of pressure. A 30 to 60 mL syringe with a 19‑gauge needle provides approximately 8 psi. Use normal saline, lactated Ringer‟s, or an antibiotic/antimicrobial solution -Remove sutures and staples. Administer analgesics and monitor for effective pain management. Administer antimicrobials (topical, systemic) and monitor for effectiveness (reduced fever, increase in comfort, decreasing WBC count). -Document the location and type of wound and incision, the status of the wound and type of drainage, the type of dressing and materials, client teaching, and how the client tolerated the procedure. A nurse is caring for a client who has a closed wound drainage system. Which of the following actions should the nurse take? Press straight down on the container to create a vacuum Wear sterile gloves when emptying the container Reset the container with the drainage port closed Maintain the drain in a dependent position to facilitate drainage A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corn And calluses on her toes. Which of the following statements by the client indicates an understanding of the teaching? I can place an oval corn pad over toes that have corns as long asi remove the pad weekly I should soak my feet in warm water daily to soften corns and calluses I can apply lotion to soften calluses as long asidont put lotion between my toes I should use an over the counter liquid medication to remove corns Rationale PDF p205: A qualified professional should perform foot care for clients who have diabetes mellitus to evaluate the feet and prevent injury. Instruct clients at risk for injury to do the following: inspect the feet daily, paying specific attention to the area between the toes; Use lukewarm water, and dry the feet thoroughly; Apply moisturizer to the feet, but avoid applying it between the toes; Avoid over‑the‑counter products that contain alcohol or other strong chemicals; Avoid self‑treating corns or calluses; Do not apply heat unless prescribed. A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include? Remove clocks from the clients room Use full length side rails on the clients bed (considered a restraint) Check on the client frequently while he is in the restroom (safety) Encourage physical activity throughout the day to expend energy A nurse is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the nurse plan to initiate? Contact Droplets Airborne Protective environment A nurse is planning to use nonpharmacological pain methods for a client who reports still having mild back pain after receiving analgesia 1 hour ago. Which of the following actions should the nurse include in the plan? Encourage the client to apply a heating pad for 2 hours at a time Apply an ice pack to the clients back for 1 hour Remove distractions from the client‟s room (distraction is good for the pt to get mind off of pain) Instruct the client to take deep, rhythmic breaths Rationale PDF p 223: Avoid long applications of either heat or cold because this can result in tissue damage, burns, and reflex vasodilation (with cold therapy). PDF p.233: Breathwork: Reduces stress and increases relaxation through various breathing patterns A nurse is teaching a client how to use an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching? I will try not to cough after using the spirometer (it‟s good to cough up sputum) I will use the spirometer three times a day (3-5x an hour) I will initially hold my breath for 15 seconds (for inhalers) I will seal my lips around the mouthpiece A nurse is preparing to provide foot care for a client. Identify the order in which the nurse should perform the steps of foot care Test the temperature of the water Soak the client's feet in warm water Use an orange stick to clean under the nails Apply lotion to the client's feet A charge nurse is assigning tasks to nurse and assistive personnel for a group of clients. Which of the following tasks should the charge nurse delegate to the AP? Report ABG results to the provider Instruct a client about how to use an incentive spirometer Administer an enteral feeding to a client who has an established gastrostomy tube Monitor the color of a client‟s urinary output A nurse is interviewing a family as part of a family assessment. The nurse identifies the family unit as a husband, a wife, and three children. One child is biological from this marriage and the other two are from the wife‟s previous marriage. The nurse should identify this as which of the following family forms? Extended Blended Nuclear Alternative A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first? Obtain a replacement pump Notify the biomedical department to fix the pump Label the pump with a defective equipment sticker Unplug the pump- unplugging will remove the source of potential fire started . A nurse is preparing to insert IV catheter for an adult client. Which of the following actions should the nurse take? Choose the most proximal site on the extremity selected (distal first) Apply a cool compress for several minutes before insertion of the IV catheter (warm it) Stroke the extremity for several minutes before insertion of the IV catheter Place the tourniquet below the proposed insertion site (above it) A nurse is providing teaching about preventing back strain to the caregiver of a client who is immobile and requires assistance to reposition in bed. Which of the following statements by the caregiver indicates an understanding of the teaching I will place the bed in the lowest position (place at your hip level) I will tighten my abdominal muscles prior to moving I will keep my legs straight to provide more power in the lift (bend) I will twist at the waist while pulling the draw sheet (avoid) Rationale PDF p71: Avoid twisting your thoracic spine and bending your back while your hips and knees are straight; When lifting an object from the floor, flex your hips, knees, and back; tighten the abdominal muscles to increase support to the back muscles A nurse in an acute care facility is preparing to transfer a client to a long term care facility. Which of the following information should the nurse include in the hand off report? Frequency of previous vital sign measurement Number of family members who have visited Time of the clients last bath Effectiveness of the last dose of pain medication Rational PDF p39: Transfer documentation: -Medical diagnosis and care providers Demographic information -Overview of health status, plan of care, and recent progress Alterations that can precipitate an immediate concern -Notification of assessments or care essential within the next few hours -Most recent vital signs and medications, including PRN Allergies Diet and activity orders -Specific equipment or adaptive devices (oxygen, suction, wheelchair) -Advance directives and emergency code status Family involvement in care and health care proxy, if applicable A nurse is assessing a client‟s bowel sounds. Which of the following actions should the nurse take? Listen to the bowel sounds after performing abdominal palpation (inspect, auscultate, percuss palpate) Auscultate for 2 min to determine if bowel sounds are absent (at least 5 minutes) Place the diaphragm of the stethoscope over each quadrant Ask the client to cough upon auscultation (for lung assessment) A nurse is delegating client care to an assistive personnel. Which of the following tasks should the nurse delegate? Evaluating healing of an incision Inserting a NG Tube Performing a simple dressing change. Changing IV tubing. A nurse is screening several clients at a neighborhood health fair. Which of the following assessment findings is the priority for referral for further care? HR 105/min BMI 25 kg/m2 C. BP 148/92 D. Glucose 45mg/dl A nurse is assessing a client‟s extraocular eye movements. Which of the following actions should the nurse take? Position the client 6.1m(20ft) away from the Snellen chart. Instruct the client to follow finger through the six cardinal position of gaze, Ask the client to cover her right eye during assessment of her left eye. Hold a finger 46cm (18inch) in front of the client‟s eye. nurse is planning care for a client who has prescription of knee-length antibolic stockings. Which of the following actions should the nurse take? Remove the client‟s stockings at least once each shift. Roll the top of the client‟s stocking down to just below the knee. Seat the client in a chair for 30min prior to applying stockings Measure the length of the client‟s leg from the heel to gluteal fold. A nurse is assessing a client‟s oculomotor nerve functions. Which of the following actions should the nurse take? Check the client‟s pupillary reaction to light Ask the client to read print from the Snellen chart Ask the client to identify diff scents Use cotton to touch the client‟s cornea lightly. A nurse is planning to perform ear irrigation on an adult client who has impacted cerumen. Whichof the following should the nurse plan to take? Wear sterile gloves while performing irrigation Position the client with the affected side down following irrigation Use cool fluid to irrigate the ear canal. Pull the pinna downward during irrigation. A nurse is preparing to administer gentamicin 2mg/kg via IV bolus to a client who weighs 220lb. How many mg should the nurse administer? 200mg A nurse is caring for a client who reports a pain level of 5 on a scale from 0-10. The client informs the nurse that pain medication are not option for managing pain. Which of the following is an appropriate response by the nurse? Im sure it will work if you just give it a chance? You may take any herbal remedies you bring from home Why do you think pain medication is not going to help you Would you like me to give you a back massage? A nurse is planning to discharge a client who has diabetes mellitus and a new prescription for insulin. Which of the following actions should the nurse plan to complete first? Provide the client with contact number for diabetes education specialist. Obtain printed information on insulin self-administration Make a copy of the medication reconciliation from for the client Determine whether the client can afford the insulin administration supplies A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take? Allow the client to slide down his outstretched leg. Place his arms around the client to prevent her fall. Remain upright as the client falls toward him Move quickly to a position in front of the client. A nurse is preparing to use the Z-track method to administer iron dextran to a client who has iron-deficiency anemia. The client asks why this method of injection is necessary. Which of the following responses should the nurse make? It decreases the risk of injecting medication into a blood vessel. It delays medication absorption It minimizes tissue irrigation It accelerates medication excretion A nurse is conducting a health assessment for a client who take herbal supplements. Which of the following statement by the client indicates an understand of the use of the supplements? I use garlic for my menopausal symptoms. I use ginger when I get car sick I take ginkgo biloba for headache 11 Proven Ginkgo Biloba Benefits Increases Concentration. ... Reduces Risk for Dementia and Alzheimer's. ... Helps Fight Anxiety and Depression. ... Fights Symptoms of PMS. ... Helps Maintain Vision and Eye Health. ... Helps Prevent or Treat ADHD. ... Improves Libido. ... Helps Treat Headaches and Migraines. I take echinacae to control cholesterol A nurse is caring for a client who has C-diff infection Which of the following actions should the nurse take? Give the client chlorhexidine gluconate for hand hygiene. Remove the protective gown first when exiting the client's room Use alcohol-based hand rub when caring for the client Initiate contact precautions when providing client care A nurse is caring for a client who is scheduled for hip surgery in hr. Which of the following actions is the nurse‟s priority? Ensure that the client has signed the consent form. Lock the client‟s valuable in a safe location Verify that the client‟s lab values are in the medical record. Administer the prescribed preoperative sedative. A nurse is caring for a client who has prescription for morphine 5mg IM accidentally administers the whole 10mg from the single dose vial. Which of the following actions should the nurse take first? Complete an incident report Measure the client‟s respiratory rate Report the incident to the pharmacy. Notify the client's provider HESI FUNDAMENTALS A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective? "I should expect my heart rate to take longer to return to normal after excessive as I get older." A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the following abdominal assessments should the nurse expect? Absent bowel sounds with distention A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft contender abdomen, and census overdue by 2 days. Which of the following findings should be the nurse's priority? Temperature A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? Administe analgesics to the child on a routine schedule throughout the day and night. A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse wth inspiration. the nurse auscultates a high-pitched scratching sound during both systole and diastole with diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? Pericardial friction rub A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? "There are times I should use soap and water rather than alcohol based hand rub to clean my hands." A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? Discontinue the machine, and measure the blood pressure manually every 15 min. A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? The involvement of the client in planning the change A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature? Temporal A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? The signature on the preoperative consent form is the client's A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first? Assessment A nurse on a medical-surgical unit is washing her hands prior to assisting with surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique? The nurse washes with her hands held higher than her elbows A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? Second intercostal space to the right of the sternum A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make? "What worries you about being without your teeth?" A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? Encourage the client to express his thoughts about death and dying A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make? "Tell me what I can do to help you overcome your fear of giving yourself injections." A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? Confirm unresponsiveness A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention? Screening groups of older adults in nursing care facilities for early influenza manifestations A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? Perform hand hygiene A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? Place the bladder of the cuff over the posterior aspect of the thigh A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? Identify the client using two identifiers A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? "Sit on the toilet 30 minutes after eating a meal." A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process? Obtain client information A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use? Place the wheelchair at a 45 degree angle to the bed A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? Attempt to increase the client's self-motivation A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? Remove the restraints one at a time A nurse is caring for a client who is in terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? Sit and hold the client's hand A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? "I keep having nightmares about my upcoming surgery." A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment. Inspect, Auscultate, Percuss, Palpate A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? Obtaining cotton balls for the tracheostomy care A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? Evaluate pedal pulses A nurse is preparing a client who is scheduled for hysterectomy for transport to the operating room when the client states she no longer wants to have surgery. Which of the following actions should the nurse take? Notify the provider about the client's decision A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client? Donate autologous blood before the surgery A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? The client reports severe pain A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP "Using a cuff that is too small will result in an inaccurately high reading." A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? Carefully remove the gloves and follow with hand hygiene A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from stretcher to the bed? Lock the wheels on the bed and stretcher A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? Raise the level of the bed A nurse is caring for a client who is incontinent of loose stool and is reporting a painful perineum. Which of the following is the priority nursing action? Check the client's perineum A nurse is caring for a client who is 3 days post-op following a cholecystectomy. The nurse suspects a wound infection because the drainage on the dressing is yellow and thick. The nurse identifies this type of drainage as: Purulent A nurse is collecting a urine specimen for a client to test via urine dipstick the urine's specific gravity. The nurse knows the result will indicate the amount of: Solutes in the urine When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should: Cleanse the entry port priot to withdrawing urine. A client returning from the surgical suite following a vaginal hysterectomy is awake and asking for something to drink. Her post-op diet prescription reads: " clear liquids, advance diet as tolerated." Which of the following is appropriate for the nurse to tell the patient? I am going to listen to your abdomen A nurse is caring for a client who is post-op following a partial colectomy. THe patient has a NG tube set on low continuous suction. The client tells his nurse that his throat is sore and asks the nurse when the NG tube will be taken out. Which of the following responses by the nurse is appropriate at this time? When the GI tract is working again, in about three to five days, the tube can be removed. A client develops a fecal impaction. Before digital removal of the mass, which type of enema should the nurse give to loosen the feces? Oil Retention When a nurse makes an initial assessment of a client who is post-op following gastric resection, the client's NG tube is not draining. The nurse's attempt to irrigate the tube with 10ml 0.9% NaCl was unsuccessful, so she determines that the tube was obstructed. Which of the following actions should the nurse take? Notify the surgeon. A nurse takes an older adult lient who has dysphagia following a CVA to the dining room for dinner. When assisting the client at mealtime, the nurse should: Offer the client tart or sour foods. (This makes it easier for them to swallow) A client is admitted for evaluation and control of HTN. Several hours after the client's admission, the nurse discovers the client supine on the floor, unresponsive to verbal or painful stimuli. The nurse's first reaction at this time is to: Establish an airway A nurse is caring for several clients who are receiving O2 therapy. Which client should the nurse assess most frequently for manifestations of oxygen toxicity? 100% oxygen via partial rebreathing mask A client is hospitalized for an infection of a surgical wound following abd surgery. To promote healing and fight wound infection the nurse plans to arrange to increase the client's intake of: Vitamin C and Zinc When communicating with a client who is hearing impaired, the nurse should Face the client and speak slowly An older adult client has been hospitalized on bed rest for 1 week. The client reports elbow pain. Which of the following is an appropriate initial action for the nurse caring for this client to take Examine the elbow A nurse is caring for a client who has a new prescription for tube feeding. The nurse understands that the provider prescribed tube feeding because the client: Is unable to swallow foods by mouth CPR has been initiated for the client in the ER. The nurse understands that a critical concept related to effective cardiac chest compressions is the need to: Push hard and deep on the chest A nurse is caring for a client who has just had a mastectomy and has a closed wound suction device (hemovac) in place. Which nursing action will ensure proper operation of the device? Collapsing the device whenever its 1/2-2/3 full of air. A client being discharged following abdominal surgery will be performing his own dressing changes at home. It is most important for the nurse to include which of the following in the discharge plan? Demonstration of appropriate hand hygeine The nurse is caring for an adult who has fluid volume excess. When weighing the client, the nurse should Weight the client upon rising. A nurse is planning to collect a liquid stool specimen from a client for ova and parasites. Inaccurate test results may result if the nurse: Refrigerates the collected specimen When replacing a client's surgical dressing, the nurse should: Don clean gloves to remove the old dressing A nurse is preparing to instert a NG tube for a client admitted with bowel obstruction. Which of the following should the nurse do first? Explain the procedure to the client. A nurse is assisting a client with a meal. The client suddenly grabs at her neck with both hands and appears frightened. The appropriate nursing action is to Ask if the patient is choking Which nursing action prevents injury to a client's eye during the administration of eye drops Holding the tip of the container above the conjunctival sac When ambulating a frail, older adult client, the nurse should Use the transfer belt if the client is unsteady A client is recovering fromgallbladder surgery performed under general anesthesia. The nurse should encourage the client to use the incentive spirometer how many times per hour? 4-5 times per hour A client is recovering from an appendectomy for a ruptured appendix has a surgical wound healing by secondary intention. When changing the client's dressing, which observation should the nurse report to the client's surgeon? A halo of erythemia on the surrounding skin While changing the linen on the client's bed, the nurse should Hold the linen away from his body and clothing. A nurse is caring for a client who is receiving an IV that has infiltrated. Which of the following would be an unexpected finding when the nurse assesses the client's infusion line and insertion site? The area around the injection site feels warm when touched. A post-op nurse has an indwelling catheter in place to gravity drainage. The nurse notes that the client's urine bag has been empty for 2 hours. The first action the nurse shoudl take is to: Check to see if the tubing was kinked. A client's provider has ordered that sputum specimen be collected for culture and sensitivity. The nurse plans to collect this specimen... In the morning upon rising. The mother of a toddler calls the nurse "Help! My baby is choking on his food!" The nurse determines that the heimlich maneuver is necessary based on which finding: Inability of the toddler to cry or speak A client returns from surgery with two penrose drains in place. Anticipating frequent dressing changes, what should the nurse use around the incision site? Montgomery straps A client who is post-op following laparotomy is reporting pain and dry mouth. The client has morphine sulfate ordered to control the pain. Before administrering the morphine sulfate prescribed for the client the nurse should first Measure the client's vital signs. A nurse is teaching a lient with a new colostomy about how to irrigate the ostomy. The nurse realizes that the client needs further teaching when the client Positions the irrigating solution bag 30 inchees above the stoma A nurse is performing an eye irrigation for the client who has been exposed to smoke and ash. Which of the following nursing actions should receive the highest priority during the irrigation? Wearing gloves during the procedure. In planning care for a client with surgical wound helating by secondary intention, the nurse can anticipate that the client will Be at an increased susceptibility for infection. A nurse is assessing a client admitted with sudden onset of severe back pain of unknow origin. Which statement would be most effective for the nurse to use to elicit further information from this client about his pain? Tell me how you are feeling right now. A nurse has inserted an indwelling catheter for a male patient. Where should the nurse tape the catheter to prevent pressure on the client's urethra at the penoscrotal junction? Lower abdomen A nurse is in a public building when someone cries out "Help! I think he is having a heart attack!" The nurse responds to the scene and finds the unconcious adult lying on the floor. Another bystander has obtained an AED. The nurse's first action, after making certain someone has called for EMS, should be to Administer cardiac compressions. A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report? Assessment A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? Washing dishes A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? Tachycardia A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first? Inspection A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include? A 10-month-old infant can pull up to a standing position. A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? Observe the rate, depth, and character of the client's respirations. A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make? "I can see that this is upsetting you." An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? The AP hangs the collection bag at the level of the bladder. A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? A client who has a prescription for a transfusion of packed red blood cells. A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? Provide a protein intake of 1.5 g/kg of body weight per day. A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? Tie the restraint with a quick-release knot. A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? Romberg test A nurse is caring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? Oil retention A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? Daily weight A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication? Impaired peristalsis of the intestines A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? Cough deeply after each use. A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching? "Bear weight on both of your legs." A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? Fidelity A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? Remove the safety pin from the extinguisher. A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? Hemolytic A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take? Consult the medication reference book available on the unit. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated? Cover the incision with a moist sterile dressing. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? Position the client on his left side. A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? "It must be difficult to care for someone who is confined to bed." A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? Place the client in Trendelenburg's position. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? Edema at the infusion site A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take? Lower the client the floor and place a pad under the client's head. A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client? Ventrogluteal A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? Sit at the bedside while feeding the client. A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? Loss A nurse is providing education about cultural and religious traditions and rituals related to death for the assistive personnel on the unit. Which of the following information should the nurse include? People who practice Judaism status with the body of the deceased until burial. A nurse in a provider's office is collecting information from an older adult who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects? Liver damage A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent? Cold extremities A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? PC for after meals A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? Decreased calcium A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection? WBC 15,000 mm3 A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first? Airway A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take? Repeat each joint motion five times during each session. A nurse is caring for a client who has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take? Wear gloves when changing the client's gown. A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention? Educating clients about the recommended immunization schedule for adults A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning? Have the client demonstrate the procedure. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family? Wear cotton clothing to avoid static electricity. A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess? Bounding pulse A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse make? "All of this equipment can be frightening." A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? Place the client in a lateral position with the head turned to the side before beginning the procedure. An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make? "Tell me more about how your friends discourage you." A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? Fill the bag two-thirds full with ice. A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include? When lifting an object, spread your feet apart to provide a wide base of support. A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching? Gelatin A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply) Provide oral hygiene frequently Measure the drainage from the NG tube every shift Secure the NG tube to the client's gown HESI FUNDAMENTALS A nurse is administering 1 L of 0.9% sodium chloride 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? Decrease in heart rate Fluid volume deficit causes tachycardia A nurse working in the emergency department is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following signatures may the nurse legally witness? A 16 y/o client who is married A 27 y/o who has schizophrenia An adoptive parent who brings in his 8 yo son A 17 year old mother who brings in her toddler. 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? Appy intermittent suction when withdrawing the catheter A nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following foods should the nurse suggest that the client add to his diet? Avocados Avocados contain no cholesterol 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? Assess the client for orthostatic hypotension The first action should be to assess the patient and determine if the patient is at risk for falling or fainting during the transfer. A nurse is caring for a group of clients. Which of the following should the nurse take to prevent the spread of infection. Place a client who has TB in a room with negative pressure airflow A client who has TB requires airborne precautions A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of the following actions should the nurse take? Talk directly to the client, instead of the interpreter, when speaking. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation? Bladder scan shows 525 mL or urine A client who has an indwelling catheter should have continuous urine flow w/o an accumulation of urine in the bladder A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take? Wash her hands before and after contact with the client Shigella requires the nurse to perform contact precautions to prevent the transmission of the bacteria A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? Compare prescriptions with medications the client received during hospitalization. When performing reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. A nurse is preparing to insert an IV catheter into a client’s arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection? Thread the catheter up to the hub reduces the risk of contamination along the length of the catheter. Inserting the catheter up to the hub reduces the risk of contamination along the length of the catheter A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein? Cheddar cheese Complete proteins contain enough of all nine of the essential amino acids that help maintain and promote nitrogen balance. Cheese, poultry, and fish are good sources of complete protein. A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? Check the cord routinely for frays or tearing Consider purchasing a generator for power backup Observe for signs of hypoxia Clothing and bedding should not be made from synthetic fabric b/c it can generate static electricity, the client should wear cotton instead. Oxygen equipment should be at least 10 feet away from open flames (gas stove, fireplace). A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first? Check the IV tubing for obstruction A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first? Evaluate electrolytes Assess the client’s electrolytes first/lab results, including sodium, potassium, BUN, Hgb, Hct, and protein, to guide the planning of interventions to correct the imbalances. You should not restrict intake of oral fluids first. A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take? Insert the IV catheter w/o using a tourniquet. The nurse should use the tourniquet minimally or not at all to avoid injury to f \ragile skin or veins. A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the following locations should the nurse place the bell of the stethoscope? Second intercostal space at the left sternal border A nurse is caring for a client who has a terminal illness and is approaching death. The client's respirations are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take? Elevate the head of the client's bed A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make? "We can talk about advance directives, and I can also give you some brochures about them." 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? Is your pain sharp or dull? Asking this type of question helps determine the quality of the pain. A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide? Breath sounds A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the nurse expect? Albumin level of 3 g/dL An albumin level below 3.5 indicates protein deficiency, placing the client at risk for pressure ulcer formation and poor wound healing. The braden scale measures the patient’s risk for developing a pressure ulcer. A nurse is completing an admission assessment of an older adult client. Which of the following findings should the nurse identify as a potential indication of abuse? Bruised on the arms in various stages of healing. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minute and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next? Notify the nursing manager. The greatest risk to the client is not receiving timely intervention for his deterioration in physiological status; therefore the nurse should activate the chain of command to ensure proper patient care. A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. After which of the following observations should the nurse remove the IV catheter? Swelling and coolness are observed at the IV site. A client who is non-ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next? Evacuate the client RACE mnemonic (Rescue first) A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give to the client? "We need to document the exact medication you were taking because you might be allergic to it." If there is any possibility that the client is allergic to a medication, it is imperative that the provider does not prescribe the same medication again. A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy? A client who has asthma. A nurse 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? Pad the client’s wrist before applying the restraints. Restraints w/o padding can abrade the client’s skin. The nurse should remove the restraints at least every 2 hours to reposition the client and assess his need for hygiene and toileting. A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh- length sequential compression device. Which of the following actions should the nurse take? Make sure two fingers can fit under the sleeves. A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hours. The nurse should set the pump to deliver how many mL/Hr? 107 ml/hr A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? Make sure the client wears a mask when outside her room if there is construction in the area. An allogeneic stem cell transplant compromises the client’s immune system, putting her at risk for infection. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? Administer the medication with the needle at a 45 degree angle. A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take? Examine personal values about the issue. The nurse should examine her own personal values about the issue to help her provide care that is w/o bias. 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? 8 oz of ice chips A nurse is planning teaching for a 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? Practice sessions 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? Use tracheostomy covers when outdoors. Tracheostomy covers protect the client’s airway from cold air, dust, and other airborne particles. In the home environment, medical asepsis with clean technique is appropriate. A nurse is educating a client who has a terminal illness about her request to decline resuscitation in her living will. The client asks what would happen if she arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide? “We will apply oxygen through a tube in your nose.” Oxygen can provide comfort and is not resuscitative when the nurse delivers it via nasal cannula. 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? Regulate oxygen via nasal cannula at a flow rate no more than 6l/min 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)? 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 A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field? The nurse opens the sterile field on a wet surface. A nurse is performing a skin assessment of a client who has a lesion on his anterior thigh and expresses concern about skin cancer. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy? An uneven shape A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? “I am available to talk if you should change your mind.” 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? Wrap blankets around all four sides of the bed. A nurse is caring for a client who has a sodium level of 125mEq/L. Which of the following findings should the nurse expect? Abdominal cramping The client has hyponatremia, manifestations include abdominal cramping, weakness, headache, and nausea. 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 client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responded affirmatively. Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others. A nurse is auscultating the anterior chest wall of a client newly admitted to a medical-surgical unit. Identify the type of breath sounds. Normal breath sounds A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene? The family member washes out the feeding bag with warm water once every 24 hours. You should wash out the feeding bag at each refilling throughout the day (every 4-8 hours) and replace it with a new feeding bag every 24 hours to prevent bacterial contamination. A nurse has just inserted an NG tube for a client. Which of the following assessment findings should the nurse expect to confirm correct tube placement? An x-ray shows the end of the tube above the pylorus. A nurse has an order to remove sutures from a client. After retrieving the suture removal kit and applying sterile gloves, which of the following actions should the nurse take next? Clean sutures along the incision site. 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. Obtain the pronouncement of death from the provider Remove tubes and indwelling lines Wash the client's body Ask the client's family members if they would like to view the body Place a name tag on the body A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex? Tap just below the knee A nurse is caring for a client who is postoperative. 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 nurse's priority action? Administer pain meds 45 minutes before changing the client’s dressing. 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. A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? "When descending stair, I will first shift my weight to my right (unaffected) leg." 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? "It might help me to listen to music while I'm lying in bed." Listening to music is an effective non-pharmacological intervention for the management of mild pain. A nurse is caring for a client who has a pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? Droplet 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? During the admission process A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make? "People in middle adulthood often find satisfaction in nurturing and guiding young people." According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore with the client opportunities for mastering the developmental tasks of this stage, such as volunteering and mentoring young people. A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client fell out of bed. Which of the following statements should the nurse document? “Client found lying on the floor.” A nurse is caring for a client who has recently started using a behind the ear hearing aid. Which of the following statements should the nurse identify as an indication that she understands the use of assistive devices? “I will be sure to remove my hearing aid before taking a shower.” HESI FUNDAMENTALS A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective? "I should expect my heart rate to take longer to return to normal after excessive as I get older." A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the following abdominal assessments should the nurse expect? Absent bowel sounds with distention A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft contender abdomen, and census overdue by 2 days. Which of the following findings should be the nurse's priority? Temperature A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? Administer analgesics to the child on a routine schedule throughout the day and night. A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse wth inspiration. the nurse auscultates a high-pitched scratching sound during both systole and diastole with diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? Pericardial friction rub A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? "There are times I should use soap and water rather than alcohol based hand rub to clean my hands." A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? Discontinue the machine, and measure the blood pressure manually every 15 min. A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? The involvement of the client in planning the change A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature? Temporal 10. A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? The signature on the preoperative consent form is the client’s 11. A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client’s record first? Assessment 12. A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing techniques? The nurse washes with her hands held higher than her elbows. 13. A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? Second intercostal space to the right of the sternum 14. A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. 15. A nurse is caring for an older adult client who becomes agitated when the nurse requests the client’s dentures be removed prior to surgery. Which of the following responses should the nurse make? “What worries you about being without your teeth?” 16. A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse’s religious beliefs related to death and dying. Which of the following actions should the nurse take? Encourage the client to express his thoughts about death and dying 17. A nurse is caring for a client who has Type 1 diabetes mellitus and is resistant to learning self- injection of insulin. Which of the following statements should the nurse make? “Tell me what I can do to help you overcome your fear of giving yourself injections.” 18. A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? Confirm unresponsiveness. 19. A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention? Screening groups of older adults in nursing care facilities for early influenza manifestations 20. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? Perform hand hygiene 21. A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? Place the bladder of the cuff over the posterior aspect of the thigh 22. A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? Identify the client using two identifiers 23. A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back 24. A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? "Sit on the toilet 30 minutes after eating a meal." 25. A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process? Obtain client information 26. A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use? Place the wheelchair at a 45 degree angle to the bed 27. A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? Attempt to increase the client's self-motivation 28. A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? Remove the restraints one at a time 29. A nurse is caring for a client who is in terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? Sit and hold the client's hand 30. A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? "I keep having nightmares about my upcoming surgery." 31. A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment. Inspect, Auscultate, Percuss, Palpate 32. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? Obtaining cotton balls for the tracheostomy care 33. A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? Evaluate pedal pulses 34. A nurse is preparing a client who is scheduled for hysterectomy for transport to the operating room when the client states she no longer wants to have surgery. Which of the following actions should the nurse take? Notify the provider about the client's decision 35. A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client? Donate autologous blood before the surgery 36. A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? The client reports severe pain 37. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP "Using a cuff that is too small will result in an inaccurately high reading." 38. A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? Carefully remove the gloves and follow with hand hygiene 39. A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from stretcher to the bed? Lock the wheels on the bed and stretcher 40. A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? Raise the level of the bed HESI FUNDAMENTALS Before donning gloves to perform a procedure, proper hand hygiene is essential. The nurse understands that the most important aspect of had hygiene is the amount of friction A nurse is demonstrating postoperative deep breathing and coughing exercise to a client about to undergo emergency abdominal surgery for appendicitis. The nurse realizes the client may be unprepared to learn if the client  reports severe pain A client comes to the emergency department reporting that he has had diarrhea for 4 days and is urinating less than usual. When assessing the client‟s skin turgor, the nurse should  grasp a fold of the skin on the chest under the clavicle, release it, and not the depth of the impression A nurse is planning interventions for a group of clients who are obese. What can the nurse do to improve their commitment to a long-term goal of weight loss?  attempt to develop the client‟s self-motivation When admitting a client, the nurse records which information in the client‟s record first?  assessment of the client A nurse tells a client that the provider has prescribed IV fluids. The client appears to be upset about the IV catheter insertion, but says nothing to the nurse. Which of the following is an appropriate nursing response?  Is there something about this procedure that concerns you? A client who is unstable and requires frequent vital signs has an electronic blood pressure machine automatically measuring his blood pressure every 15 min. However, the machine is reading the client‟s blood pressure at more frequent intervals, and the readings are not similar. The nurse checks the machine settings and observes the additional readings, but the problem continues. Which of the following is the appropriate nursing action? --> Disconnect the machine, and measure the blood pressure manually every 15 min. A nurse is caring for a client just diagnosed with type 1 diabetes mellitus. The client is resistant to learning self-injection of insulin and asks the nurse to administer all the injections. The nurse explains the importance of learning self-care and appropriately adds which of the following statements?  Tell me what I can do to help you overcome your fear of giving yourself injections. An assistive personnel says to the nurse, “This client is incontinent of stool three or four times a day. I get angry, and I think that the client is doing it just to get attention. I think we should put adult diapers on her.” Which is the appropriate nursing response?  It is very upsetting to see an adult client regress. A nurse‟s neighbor is scheduled for elective surgery. The neighbor‟s provider indicated that a moderate amount of blood loss is expected during the surgery, and the neighbor is anxious about acquiring an infection from a blood transfusion. Which of the following is appropriate for the nurse to suggest?  donating autologous blood before the surgery At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart murmur due to aortic stenosis. To auscultate the aortic valve, the nurse should place the stethoscope at which location? Second intercostals space to the right of the sternum A client is admitted to the hospital with decreased circulation in the left leg. During the admission assessment, which is the most important nursing action initially?  evaluate the pedal pulses A nurse is caring for a client who requires rectal temperature monitoring. Available at the client‟s bedside is a thermometer is with a long, slender tip. Which of the following is the appropriate action for the nurse to take? obtain a thermometer with a short, blunt insertion end. A nurse is teaching a client who has cardiovascular disease how to reduce his intake of sodium and cholesterol. The nurse understands that the most significant factor in planning dietary changes for this client is the  involvement of the client in planning the change A nurse is caring for an older adult client who is confused and continually grabs at the nurses. Which of the following is an nursing action?  firmly tell the client not to grab An assistive personnel tells the nurse, “I am unable to find a large blood pressure cuff for a client who is obese. Can I just use the regular cuff if I can get it to stay on?” The nruse replies that taking the blood pressure of a morbidly obese client with a regular blood pressure cuff will result in a reading that is  high Which of the following should the nurse do first when preparing to provide tracheostomy care? --> perform hand hygenie A 3-year old child has had multiple tooth extractions while under general anesthesia. The client returns from the postanesthesia care crying, but awake, from the recovery room. Which approach is likely to be successful?  Examine the mouth last A nruse admits a client to a same-day surgery center for an exploratory laparotomy procedure this morning. The client‟s surgeon asks the nurse to witness the signing of the preoperative consent form. In signing the form as a witness, the nurse affirms that  the signature on the preoperative consent form is the client‟s. To use proper body mechanics while making an occupied bed for a client on bed rest, the nurse should  place the bed in a high horizontal position Which of the following should a group of community health nurses plan as part of a primary prevention program for occupational pulmonary diseases? --> elimination of the exposure When initiating cardiopulmonary resuscitation (CPR), the nurse must confirm which of the following assessment findings prior to beginning chest compression?  absence of pulse A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a back injury, which of the following techniques should the nurse use?  bend at the knees while maintaining a wide stance and a straight back, with the client‟s hands on the nurse‟s shoulders, and the nurse‟s hands under the client‟s axillae. An older adult client appears agitated when the nurse requests that the client‟s dentures be removed prior to surgery and states, “I never go anywhere without my teeth.” Which of the following is an appropriate nursing response?  You seem worried. Are you concerned someone may see you without your teeth? To use the nursing process correctly, the nurse must first  obtain information about the client A postoperative client has been diagnosed with paralytic ileus. When performing auscultation of the client‟s abdomen, the nurse expects the bowel sounds to be  absent While starting an intravenous infusion (IV) for a client, the nurse notices that her gloved hands get spotted with blood. The client has not been diagnosed with any infection transmitted via the bloodstream. Which of the following should the nurse do as soon as the task is completed?  Remove the gloves carefully and follow with hand hygiene A nurse is precepting a newly licensed nurse who is preparing to help a client perform tracheotomy care. The nurse should intervene if the equipment the preceptee gathered included  cotton balls A nurse is caring for a client diagnosed with a terminal illness. The client asks several questions about the nurse‟s religious beliefs related to death and dying/ An appropriate nursing response is to  encourage the client to express his thoughts about death and dying When assessing a client‟s heart sounds, the nurse hears a scratching sound during both systole and diastole. These sounds become more distinct when the nurse has the client sit up and lean forward. The nurse should document the presence of a pericardial friction rub A client admitted with abdominal pain tells the nurse that her father died recently, and she begins crying while talking about him. The nurse determines that the client‟s temperature is 39.2C (102.6F), her abdomen is soft without tenderness, and her menses is overdue by 2 days. To which observation should the nurse give priority attention?  The client‟s menses is overdue At the surgical scrub sink, a surgical nurse demonstrated the proper surgical handwashing technique by scrubbing  with her hands held higher than her elbows A client scheduled for a hysterectomy has not yet signed the operative consent form. When the nurse approaches the client and asks that she review and sign the form, the client says she no longer wants to have the surgery. At this time, which action should the nurse take?  ask the client why she has changed her mind. A nurse prepares to admit a client who is immediately postoperative to the unit following abdominal surgery. When transferring the client from the gurney to the bed, the nurse should  lock the wheels on the bed and stretcher A client is admitted to the hospital in the terminal stage of cancer. The nurse enters the client‟s room to administer medications and finds the client crying/ The appropriate nursing is to  sit and hold the client‟s hand. Steps used for abdominal assessment  inspection, auscultation, percussion, palpation While measuring a client‟s vital signs, the nurse notices an irregularity in the heart rate. Which nursing action is appropriate?  count the apical pulse rate for 1 full min, and describe the rhythm in the chart. A nurse is caring for a client who has hypertension. Which approach is the priority when the nurse is measuring the client‟s blood pressure?  obtain the blood pressure under the same conditions each time. A hospitalized client needs a chest x-ray. The radiology department calls the nursing unit and says that they are sending a transporter for the client. When entering the client‟s room, the priority action is to  check the client‟s identification bracelet. An older adult client just diagnosed with colon cancer asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour. Which of the following nursing actions is appropriate?  help the client write down the questions to ask the provider, so that the client doesn‟t forget. HESI FUNDAMENTALS Chapter 1 A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply.) Home health care Rehabilitation facilities Diagnostic centers Skilled nursing facilities Oncology centers A nurse is explaining the various types of health care coverage clients might have to a group of nurses. Which of the following health care financing mechanisms should the nurse include as federally funded? (Select all that apply.) Preferred provider organization (PPO) Medicare Long-term care insurance Exclusive provider organization (EPO) Medicaid A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? Collaborating with providers to perform obesity screenings during routine office visits. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity. Providing specialized intraoperative training in surgical treatments for obesity. Educating acute care nurses about postoperative complications related to obesity. A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? Monitoring evidence-based practice for clients who have a specific diagnosis. Ensuring that health care providers comply with regulations. Setting quality standards for accreditation of health care facilities. Determining whether medications are safe for administration to clients. A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (Select all that apply.) Intensive care unit Oncology treatment center Burn center Cardiac rehabilitation Home health care Chapter 2 A nurse is caring for a group of clients on a medical surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply.) A client who has terminal cancer requests hospice care in the home. A client asks about community resources available for older adults. A client states, “I would like to have my child baptized before surgery.” A client requests an electric wheelchair for use after discharge. A client states, “I do not understand how to use a nebulizer.” A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional care team? Social worker Certified nursing assistant Registered dietitian Occupational therapist A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication prescribed for pain managements. Which of the following members of the interprofessional care team can assist the client in understanding the medication‟s effects? (Select all that apply.) Provider Certified nursing assistant Pharmacist Registered nurse Respiratory therapist A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? Social worker Certified nursing assistant Occupational therapist Speech-language pathologist A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When providing examples of the types of tasks CNAs can perform, which of the following client activities should the nurse include? (Select all that apply.) Bathing Ambulating Toileting Determining pain level Measuring vital signs Chapter 3 A nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. The nurse understands that this client‟s choice is an example of which of the following ethical principles? Fidelity Autonomy Justice Nonmaleficence A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? Fidelity Autonomy Justice Beneficence A nurse is instructing a group of newly license nurses about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurses should understand that this aspect of care delivery is an example of which of the following ethical principles? Fidelity Autonomy Justice Nonmaleficence A nurse questions a medication prescription as too extreme in light of the client‟s advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? Fidelity Autonomy Justice Nonmaleficence A nurse is instructing a group of newly licensed nurses how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurses identify as an ethical dilemma? A nurse on a medical-surgical unit demonstrates signs of chemical impairment. A nurse overhears another nurse telling an older adult client that if he doesn‟t stay in bed, she will have to apply restraints. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. A client who is terminally ill hesitates to name their partner on their durable power of attorney form. Chapter 4 A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing? Assault Battery False imprisonment Invasion of privacy A nurse is caring for a competent adult client who tells the nurse, “I am leaving the hospital this morning whether the doctor discharges me or not.” The nurse believes that this is not in the client‟s best interest, and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. Which of the following types of tort is the nurse about to commit? Assault False imprisonment Negligence Breach of confidentiality A nurse in a surgeon‟s office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that “I plan to prepare my advance directives before I come to the hospital.” Which of the following statements mad by the client should indicate to the nurse an understanding of advance directives? “I‟d rather have my brother make decisions for me, but I know it has to be my wife.” “I know they won‟t go ahead with the surgery unless I prepare these forms.” “I plan to write that I don‟t want them to keep me on a breathing machine.” “I will get my regular doctor to approve my plan before I hand it in at the hospital.” A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select all that apply.) Make sure the surgeon obtained the client‟s consent. Witness the client‟s signature on the consent form. Explain the risks and benefits of the procedure. Describe the consequences of choosing not to have the surgery. Tell the client about alternatives to having the surgery. A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, the nurse was found asleep in a chair in the break room not during a break time. Which of the following actions should the nurse take? Alert the American Nurses Association. Fill out an incident report. Report the observations to the nurse manager on the unit. Leave the nurse alone to sleep. Chapter 5 A nurse is preparing information for a change-of-shift report. Which of the following information should the nurse include in the report? Input and output for the shift Blood pressure from the previous day Bone scan scheduled for today. Medication routine from the medication administration record A nurse manager is discussing the HIPAA Privacy Rule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? (Select all that apply.) A single electronic record passwords is provided for nurse on the same unit. Family members should provide a code prior to receiving client health information. Communication of client information can occur at the nurses‟ station. A client can request copy of their medical record. A nurse can photocopy a client‟s medical record for transfer to another facility. A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines sold be followed when documenting in a client‟s record? (Select all that apply.) Cover errors with correction fluid and write in the correct information. Put the date and time on all entries. Document objective data, leaving out opinions. Use as many abbreviations as possible. Wait until the end of the shift to document. A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (Select all that apply.) Medication error Needlesticks Conflict with provider and nursing staff Omission of prescription Missed specimen collection of a prescribed laboratory test A nurse is receiving a provider‟s prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply.) Repeat the details of the prescription back to the provider. Have another nurse listen to the telephone prescription. Obtain the provider‟s signature on the proscription within 24 hr. Decline the verbal prescription because it is not an emergency situation. Tell the charge nurse that the provider has prescribed morphine by telephone. Chapter 6 A nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? Updating the plan of care for a client who is postoperative Reinforcing teaching with a client who is learning to walk using a quad cane Reapplying a condom catheter for a client who has urinary incontinence Applying a sterile dressing to a pressure injury A nurse manager is assigning care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members? Charge nurse Registered nurse (RN) Practical nurse (PN) Assistive personnel (AP) A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP? (Select all that apply.) The roommate ambulates independently. The client ambulates wearing slippers over antiembolic stockings. The client uses a front-wheeled walker when ambulating. The client had pain medication 30 min ago. The client is allergic to codeine. A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assign to a PN? Creating a plan of care for a client who is recovering following a stroke. Assessing a pressure injury on a client who is on bed rest. Providing nasopharyngeal suctioning for a client who has pneumonia. Teaching a client who has asthma to use a metered-dose inhaler. A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation? (Select all that apply.) Right place Right supervision and evaluation Right direction and communication Right documentation Right circumstances Chapter 7 By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? Reassess the client to determine the reasons for inadequate pain relief. Wait to see whether the pain lessens during the next 24 hr. Change the plan of care to provide different pain relief interventions. Teach the client about the plan of care for managing the pain. A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client‟s MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? Assessment Planning Intervention Evaluation A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply.) Respiratory rate is 22/min with even, unlabored respirations. The client‟s partner states, “They said they hurt after walking about 10 minutes.” The client‟s pain rating is 3 on a scale of 0 to 10 The client‟s skin is pink, warm, and dry. The assistive personnel reports that the client walked with a limp. A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider‟s prescription. Which of the following interventions should the charge nurse include? Writing a prescription for morphine sulfate as needed for pain Inserting a nasogastric (NG) tube to relieve gastric distention Showing a client how to use progressive muscle relaxation Performing a daily bath after the evening meal Repositioning a client every 2 hr to reduce pressure injury risk A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process? “I will determine the most important client problems that we should address.” “I will review the past medical history on the client‟s record to get more information.” “I will carry out the new prescriptions from the provider.” “I will ask the client if their nausea has resolved.” Chapter 8 A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquid well, has active bowel sounds, and is expressing a desire for “real food.” The nurse tells the client “I will call the surgeon and ask for a change in diet.” The surgeon hears the nurse‟s report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? Basic Commitment Complex Integrity A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client‟s medical record, discovers that the client is allergic to the antibiotic, and call the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? Fairness Responsibility Risk-taking Creativity A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? (Select all that apply.) Find a mentor. Use a journal to write about the outcomes of clinical judgments. Review articles about evidence-based practice. Limit consultations with other professionals involved in a client‟s care. Make quick decisions when unsure about a client‟s needs. A nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? Knowledge Experience Intuition Competence A nurse uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking did the nurse demonstrate? Confidence Perseverance Integrity Discipline Chapter 9 A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review od systems, which of the following actions is a priority for the nurse? Orient the client to their room. Conduct a client care conference. Review medical prescriptions. Develop a plan of care. A nurse is admitting a client who has acute cholecystitis to a medical-surgical unit. Which of the following actions are essential steps of the admission procedure? (Select all that apply.) Explain the roles of other care delivery staff. Begin discharge planning. Inform the client that advance directives are required for hospital admission. Document the client‟s wishes about organ donation. Introduce the client to their roommate. A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse at the transferring facility? (Select all that apply.) Ensure that the client has possession of their valuables. Confirm that the rehabilitation center has a room available at the time of transfer. Assess how the client tolerates the transfer. Give a verbal transfer report via telephone. Complete a transfer form for the receiving facility. A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary? (Select all that apply.) Advance directive status. Follow-up care. Instructions for diet and medications. Most recent vital sign data. Contact information for the home health care agency. As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client‟s family? Body mass index Usual times for meals and snacks Favorite foods Any difficulty swallowing Chapter 10 When entering a client‟s room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? Keep the sterile field at least 6 ft away from the client‟s bedside. Instruct the client to refrain from coughing and sneezing during the dressing change. Place a mask on the client to limit the spread of microorganisms into the surgical wound. Keep a box of facial tissue for the client to use during the dressing change. A nurse as removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? The flap closest to the body The right side flap The left side flap The flap farthest from the body A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) A bottle containing a sterile solution The edge of the sterile drape at the base of the field The inner wrapping of an item on the sterile field An irrigation syringe on the sterile field One gloved hand with the other gloved hand A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) Apply 3 to 5 mL of liquid soap to dry hands. Wash the hands with soap and water for at least 15 seconds. Rinse the hands with hot water. Use a clean paper towel to turn off hand faucets. Allow the hands to air dry after washing. A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) The provider drops a sterile instrument onto the near side of the sterile field. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. The procedure is delayed 1 hr because the provider receives an emergency call. The nurse turns and speak to someone who enters through the door behind the nurse. The client‟s hand brushes against the outer edge of the sterile field. Chapter 11 A nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.) Planning and evaluating control and prevention strategies. Determining public health priorities. Ensuring proper medical treatment. Identifying endemic disease. Monitoring for common-source outbreaks. A nurse is caring for a client who has a cough for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions? Allergic reaction Ringworm Systemic lupus erythematosus Tuberculosis A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? Prodromal Incubation Convalescence Illness A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. Which of the following are manifestations of a systemic infection? (Select all that apply.) Fever Malaise Edema Pain or tenderness Increase in pulse and respiratory rate A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include? (Select all that apply.) Place the client in a room that as a negative air pressure of at least six exchanges per hour. Wear a mask when providing care within 3 ft of the client. Place a surgical mask on the client if transportation to another department is unavoidable. Use sterile gloves when handling soiled linens. Wear a gown when performing care that might result in contamination from secretions. Chapter 12 A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) Place a belt restraint on the client when they are sitting on the bedside commode. Keep the bed in its lowest position with all side rails up. Make sure that the client‟s call light is within reach. Provide the client with nonskid footwear. Complete a fall-risk assessment. A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? “I will place the client on their side.” “I will go to the nurses‟ station for assistance.” “I will note the time that the seizure begins.” “I will prepare to insert an airway.” A nurse observes smoke coming from under the door of the staff‟s lounge. Which of the following actions is the nurse‟s priority? Extinguish the fire. Activate the fire alarm. Move clients who are nearby. Close all open doors on the unit. A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse‟s priority? Complete a fall-risk assessment. Educate the client and family about fall risks. Eliminate safety hazards from the client‟s environment. Make sure the client uses assistive aids in their possession. A nurse discovers a small paper fire in a trash can in a client‟s bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take? Open the windows in the client‟s room to allow smoke to escape. Obtain a class C fire extinguisher to extinguish the fire. Remove all electrical equipment from the client‟s room. Place wet towels along the base of the door to the client‟s room. Chapter 13 A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include? (Select all that apply.) Family members who smoke must be at least 10 ft from the client when oxygen is in use. Nail polish should not be used near a client who is receiving oxygen. A “No Smoking” signs should be placed on the front door. Cotton bedding and clothing should be replaced with items made from wool. A fire extinguisher should be readily available in the home. A nurse educator is presenting module on basic first aid for newly licensed home health nurses. The client who has heat stroke will have which of the following? Hypotension Bradycardia Clammy skin Bradypnea A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicated understanding? “I will set my water heater at 130oF.” “Once my baby can sit up, they should be safe in the bathtub.” “I will place my baby on their stomach to sleep.” “Once my infant starts to push up, I will remove the mobile from over the crib.” A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include? Carbon monoxide has a distinct odor. Water heaters should be inspected every 5 years. The lungs are damaged from carbon monoxide inhalation. Carbon monoxide binds with hemoglobin in the body. A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include? (Select all that apply.) Most food poisoning is caused by a virus. Immunocompromised individuals are at increased risk for complications from food poisoning. Clients who are at high risk should eat or drink only pasteurized dairy products. Healthy individuals usually recover from the illness in a few weeks. Handling raw and fresh food separately can prevent food poisoning. Chapter 14 A nurse is caring for a client who is receiving enteral feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client? Supine Semi-Fowler‟s Semi-prone Trendelenburg A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse‟s priority at this time? Obtain a walker for the client to use to transfer back to bed. Call for additional staff to assist with the transfer. Use a transfer belt to assist the client back into bed. Determine the client‟s ability to help with transfer. A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make? “Lie on your back with our head and shoulders supported by a pillow.” “Have your head turned to the side while you lie on your stomach.” “Have a table beside your bed so you can sit on the bedside and rest your arms on the table.” “Lie on your side with your top arm resting on the bed and your weight on your hip.” A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (Select all that apply.) Request assistance when repositioning a client. Avoid twisting your spine or bending at the waist. Keep your knees slightly lower than your hips when sitting for long periods of time. Use smooth movements when lifting and moving clients. Take a break from repetitive movements every 2 to 3 hr to flex and stretch your joints and muscles. A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (Select all that apply.) “My line of gravity should fall outside my base of support.” “The lower my center of gravity, the more stability I have.” “To broaden my base of support, I should spread my feet apart.” “When I lift an object, I should hold it as close to my body as possible.” “When pulling an object, I should move my front foot forward.” Chapter 15 A nurse is caring for multiple clients during a mass casualty event. Which of the following clients is the nurse‟s priority? A client who received crush injuries to the chest and abdomen and is expected to die. A client who has a 4-inch laceration to the head. A client who has partial-thickness and full-thickness burns to his face, neck and chest. A client who has a fractured fibula and tibia. A nurse educator is teaching staff members about facility protocol in the event of a tornado. Which of the following should the nurse include? (Select all that apply.) Open doors to client rooms. Place blankets over clients who are confined to beds. Move beds away from the windows. Draw shades and close drapes. Instruct ambulatory clients in the hallways to return to their rooms. An occupational health nurse is caring for an employee who was exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? Irrigate the affected area with running water. Wash the affected area with antibacterial soap. Brush the chemical off the skin and clothing. Leave the clothing in place until emergency personnel arrive. A security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses. Which of the following statements by a nurse indicates understanding? “I will get the caller off the phone as soon as possible so I can alert the staff.” “I will begin evacuating clients using the elevators.” “I will not as any questions and just let the caller talk.” “I will listen for background noises.” A nurse on a medical surgical unit is informed that a mass casualty event occurred in the community and that is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? (Select all that apply.) A client who is dehydrated and receiving IV fluid and electrolytes. A client who has a nasogastric tube to treat a small bowel obstruction. A client who is scheduled for elective surgery. A client who has chronic hypertension and blood pressure 135/85 mmHg. A client who has acute appendicitis and is scheduled for an appendectomy. Chapter 16 A nurse is caring for a young adult at a college health clinic. Which of the following actions should the nurse take first? Give the client information about immunization against meningitis. Tell the client to have a TB skin test every 2 years. Determine the client‟s health risks. Teach the client about exercise recommendations. A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? (Select all that apply.) Help the client see the benefits of their actions. Identify the client‟s support systems. Suggest and recommend community resources. Devise and set goals for the client. Teach stress management strategies. A nurse in a health clinic is caring for a 210year client who tells the nurse that their last physical exam was in high school. Which of the following health screenings should the nurse expect the provider to perform for this client? Testicular examination Blood glucose Fecal occult blood Prostate-specific antigen A nurse at a health department is planning strategies related to heart disease. Which of the following activities should the nurse include as part of primary prevention? Providing cholesterol screening Teaching about a healthy diet Providing information about antihypertensive medications Developing a list of cardiac rehabilitation programs A nurse at a provider‟s office is talking about routine screenings with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed? “So I don‟t need the colon cancer procedure for another 2 or 3 years.” “For now, I should continue to have a mammogram each year.” “Because the doctor just did a Pap smear, I‟ll come back next year for another one.” “I had my glucose test last year, so I won‟t need it again for 4 years.” Chapter 17 A nurse is observing a client drawing up and mixing insulin. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place? The client is able to discuss the appropriate technique. The client is able to demonstrate the appropriate technique. The client states an understanding of the process. The client is able to write the steps on a piece of paper. A nurse in a provider‟s office is collecting data from the caregiver of a 12-month-old infant who asks if the child is old enough for toilet training. Following an educational session with the nurse, the client agrees to postpone toilet training until the child is older. Learning has occurred in which of the following domains? Cognitive Affective Psychomotor Kinesthetic A nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn? “I don‟t want my spouse to see my incision.” “Will you give me pain medicine after the surgery” “Can you tell me about how long the surgery will take?” “My roommate listens to everything I say.” A nurse is preparing an instructional session for a client about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client? Encourage the client to participate actively in learning. Select instructional materials. Identify goals the nurse and the client agree are reasonable. Determine what the client knows about stress incontinence. A nurse is evaluating how well a client learned the information presented in an instructional session about following a heart-healthy diet. Which of the following actions should the nurse take to evaluate the client‟s learning? Encourage the client to ask questions. Ask the client to explain how to select or prepare meals. Encourage the client to fill out an evaluation form about how the nurse presented the information. Ask whether the client has resources for further instruction on this topic. Chapter 18 A nurse is talking with the parents of a 6-month-old infant about gross motor development. Which of the following gross motor skills are expected findings in the next 3 months? (Select all that apply.) Rolls from back to front Bears weight on legs Walks holding onto furniture Sits unsupported Sits down from standing position A nurse is reviewing safety measures with the parent of an 8-month-old infant. Which of the following statements by the parent indicates an understanding of safety for the infant? “My baby loved to play with the crib gym, but I took it out of the crib.” “I just bought a soft mattress so my baby will sleep better.” “My baby really likes sleeping on the fluffy pillow we just got.” “”I put the baby‟s car seat out of the way on the table after I put him in it.” A nurse is reviewing car seat safety with the parents of a 1-month-old infant. When reviewing car seat use, which of the following instructions should the nurse include? Use a car seat that has a three-point harness system. Position the car seat so that the infant is rear-facing. Secure the car seat in the front passenger seat of the vehicle. Convert to a booster seat after 12 months. A nurse is assessing a 2-week-old newborn during a routine checkup. Which of the following findings should the nurse expect? Sleeps 14 to 16 hr each day. Posterior fontanel closed. Pincer grasp present. Hands remain in a closed position. Current weight same as birth weight. The mother of a 7-month-old infant tells the nurse at the pediatric clinic that her baby has been fussy with occasional loose stools since she started feeding him fruits and vegetables. Which of the following responses should the nurse make? (Select all that apply.) “It might be good to add bananas, as they can help with loose stools.” “Let‟s make a list of the foods your baby is eating so we can spot any problems.” “Did the changes begin after you started one particular food?” “Has your baby been vomiting since starting these new foods?” “Most babies react with a little indigestion when you start new foods.” Chapter 19 A nurse is giving a presentation about accident to a group of parents of toddlers. Which of the following accident-prevention strategies should the nurse include? (Select all that apply.) Store toxic agents in locked cabinets. Keep toilet seats up. Turn pot handles toward the back of the stove. Place safety gates across stairways. Make sure balloons are fully inflated. A nurse is planning diversionary activities for toddlers on an inpatient unit. Which of the following activities should the nurse include? (Select all that apply.) Building models. Working with clay. Filling and emptying containers. Playing with blocks. Looking at books. A nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest? Establish consistent boundaries for the toddler. Place the toddler in a room with the door closed. Inform the toddler how you feel when he misbehaves. Use favorite snack to reward the toddler. A mother tells the nurse that her 2-year-old toddler has temper tantrums and says “no” every time the mother tries to help them get dressed. The nurse should recognize the toddler is manifesting which of the following stages of development? Trying to increase her independence. Developing a sense of trust. Establishing a new identity. Attempting to master a skill. A nurse is reviewing nutritional guidelines with the parents of a 2-year-old toddler. Which of the following parent statements should indicate to the nurse an understanding of the teaching? “I should keep feeding my son whole milk until he is 3 years old.” “It‟s okay for me to give my son a cup of apple juice with each meal.” “I‟ll give my son about 2 tablespoons of each food at mealtimes.” “My son loves popcorn, and I know it is better for him than sweets.” Chapter 20 A nurse is talking with the guardian of a 4-year-old child who reports that the child is waking up with nightmares. Which of the following interventions should the nurse suggest? Offer the child a large snack before bedtime. Allow the child to watch an extra 30 min of TV in the evening. Have the child go to bed at a consistent time every day. Increase physical activity before bedtime. A nurse is planning diversionary activities for preschoolers on an inpatient pediatric unit. Which of the following activities should the nurse include? (Select all that apply.) Assembling puzzles. Pulling wheeled toys. Using musical toys. Playing with puppets. Coloring with crayons. A nurse is preparing to administer medications to a preschooler. Which of the following strategies should the nurse implement to increase the child‟s cooperation in taking medications? (Select all that apply.) Reassure the child an injection will not hurt. Mix oral medications in a large glass of milk. Offer the child choices when possible. Have the guardians bring in a favorite toy from home. Engage the child in pretend play with a toy medical kit. A nurse is reviewing the Centers for Disease Control and Prevention‟s (CDC) immunization recommendations with the guardian of preschoolers. Which of the following vaccines should the nurse include in this discussion? (Select all that apply.) Heamophilus influenzae type B Varicella Polio Hepatitis A Seasonal influenza A nurse is talking with guardians who are concerned about several issues with their preschooler. Which of the following issues should the nurse identify as the priority? “My child mimics the way my partner and I dress.” “My child has temper tantrums every time we tell them to do something they don‟t want to do.” “I think my child truly believes that toys have personalities and can talk.” “I feel bad when I see my child trying so hard to button their shirt.” Chapter 21 A nurse is talking with caregivers of a 12-year-old child. Which of the following issues verbalized by the caregivers should the nurse identify as the priority? “We just don‟t understand why our child can‟t keep up with the other kids in simple activities like running and jumping.” “Our child keeps trying to find ways around our household rules. They always want to make deals with us.” “We think our child is trying too hard to excel in math just to get the top grades in the class.” “Our child likes to sing and worries it will make the other kids want to laugh.” A nurse is planning diversionary activities for school-age children on an inpatient pediatric unit. Which of the following activities should the nurse include? (Select all that apply.) Building models. Playing video games. Reading books. Using toy carpentry tools. Playing board games. A nurse is evaluating teaching about nutrition with the guardians of an 11-year-old child. Which of the following statements should indicate to the nurse an understanding of the teaching? “Our child wants to eat as much as we do, but we‟re afraid It will lead to becoming overweight.” “Our child skips lunch sometimes, but we figure it‟s okay as long as we eat a healthy breakfast and dinner.” “We limit fast-food restaurant meals to three times a week now.” “We reward school achievements with a point system instead of pizza or ice cream.” A nurse is talking with the caregivers of a 10-yeaar-old child who is concerned that their child is becoming secretive, including closing the door when showering and dressing. Which of the following responses should the nurse make? “Perhaps you should try to find out what is happening behind those closed doors.” “Suggest that the door be left ajar for safety reasons.” “At this age, children tend to become modest and value their privacy.” “You should establish a disciplinary plan to stop this behavior.” A nurse is planning a health promotion and primary prevention class for the caregivers of school-age children. Which of the following actions should the nurse plan to take? (Select all that apply.) Provide information about the risk of childhood obesity. Discuss the danger of substance use disorder. Promote discussion about sexual issues. Recommend the school-age child sit in the front seat of the car. Reinforce stranger awareness. Chapter 22 A nurse is teaching the guardian of a 12-year-old male client about manifestations of puberty. The nurse should explain that which of the following physical changes occur first? Appearance of downy hair on the upper lip Hair growth in the axillae Enlargement of the testes and scrotum Deepening of the voice A nurse on a pediatric unit is caring for an adolescent who has multiple fractures. Which of the following interventions should the nurse take? (Select all that apply.) Suggest that the guardians bring in video games to play. Provide a television and movies for the adolescent to watch. Limit visitors to the adolescent‟s immediate family. Involve the adolescent in treatment decisions when possible. Allow the adolescent to perform morning self-care. A nurse is reviewing CDC‟s immunization recommendations with the guardians of an adolescent. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) Rotavirus Varicella Herpes zoster Human papilloma virus Seasonal influenza A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority? “I kind of like this boy in my class, but he doesn‟t like me back.” “I want to hang out with the kids in the science club, but the jocks pick on them.” “I am so fat, I skip meals to try to lose weight.” “My dad wants me to be a lawyer like him, but I just want to dance.” A nurse is preparing a wellness presentation for families about health screening for adolescents. Which of the following information should the nurse include? (Select all that apply.) Obtain a periodic mental evaluation. Discuss prevention of sexually transmitted infections. Regularly screen for tuberculosis. Provide education about drug and alcohol use. Teach monthly breast examination. Chapter 23 A nurse is instructing a young adult client about health promotion and illness prevention. Which of the following statements indicates understanding? “I already had my immunizations as a child, so I‟m protected in that area.” “It is important to schedule routine health care visits even if I a feeling well.” “I will just go to an urgent care center for my routine medical care.” “There‟s no reason to seek help if I am feeling stressed because it‟s just part of life.” A nurse is reviewing CDC immunization recommendations with a young adult client. Which of the following vaccines should the nurse recommend as routine, rather than catch-up, during young adulthood? (Select all that apply.) Influenza Measles, mumps, rubella Pertussis Tetanus Polio A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the charge nurse include as a developmental task for a young adult? Becoming actively involved in providing guidance to the next generation. Adjusting to major changes in roles and relationships due to losses. Devoting time to establishing an occupation. Finding oneself “sandwiched” between and being responsible for two generations. A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following statements should the nurse identify as the priority to assess further? “I have my own apartment not, but it‟s not easy living away from my guardians.” “It‟s been so stressful for me to even think about having my own family.” “I don‟t even know who I am yet, and now I‟m supposed to know what to do.” “My partner is pregnant, and I don‟t think I have what it takes to be a good parent.” A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include to address common health risks for this age group? (Select all that apply.) Install bath rails and grab bars in bathrooms. Wear a helmet while skiing. Install a carbon monoxide detector. Secure firearms in a safe location. Remove throw rugs from the home. Chapter 24 A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the nurse include as a developmental task for middle adulthood? The client evaluates their behavior after a social interaction. The client states they are learning to trust others. The client wishes to find meaningful friendships. The client expresses concerns about the next generations. A nurse is collecting data to evaluate a middle adult‟s psychosocial development. The nurse should expect middle adults to demonstrate which of the following developmental tasks? (Select all that apply.) Develop an acceptance of diminished strength and increased dependence on others. Spend time focusing on improving job performance. Welcome opportunities to be creative and productive. Commit to finding friendship and companionship. Become involved with community issues and activities. A nurse is collecting history and physical examination data from a middle adult. The nurse should expect to find decreases in which of the following physiologic functions? (Select all that apply.) Metabolism Ability to hear low-pitched sounds. Gastric secretions Far vision Glomerular filtration A nurse is preparing a health promotion course for a group of middle adults. Which of the following strategies should the nurse recommend? (Select all that apply.) Eye examination every 1 to 3 years Decrease intake of calcium supplements DXA screening for osteoporosis Increase intake of carbohydrate in the diet Screening for depressive disorders A nurse is counselling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further? “I am struggling to accept that my parents are aging and need so much help.” “It‟s been so stressful for me to think about having intimate relationships.” “I know I should volunteer my time for a good cause, but maybe I‟m just selfish.” “I love my grandchildren, but my child expects me to relive my parenting days.” Chapter 25 A nurse is counselling an older adult who describes having difficulty with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? “I spent my whole life dreaming about retirement, and now I wish I had my job back.” “It‟s been so stressful for me to have to depend on my child to help around the house.” “I just heard my friend Al died. That‟s the third one in 3 months.” “I keep forgetting which medications I have taken during the day.” A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) since the last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) “Eat three large meals a day.” “Eat your meals in front of the television.” “Eat foods that are easy to eat, such as finger foods.” “Invite family members to eat meals with you.” “Exercise every day to increase appetite.” A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? (Select all that apply.) HPV immunization Pneumococcal immunization Yearly eye examination Periodic mental health screening Annual fecal occult blood A nurse is talking with an older adult client about improving nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply.) Increase protein intake to increase muscle mass. Decrease fluid intake to prevent urinary incontinence. Increase calcium intake to prevent osteoporosis. Limit sodium intake to prevent edema. Increase fiber intake to prevent constipation. A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? (Select all that apply.) Skin thickening Decreased height Increased saliva production Nail thickening Decreased bladder capacity Chapter 26 A nurse provides and introduction to a client as the first step of comprehensive physical examination. Which of the following strategies should the nurse use with this client? (Select all that apply.) Address the client with the appropriate title and their last name. Use a mix of open- and closed-ended questions. Reduce environmental noise. Have the client complete a printed history form. Perform the general survey before the examination. A nurse is a provider‟s office is documenting findings following an examination performed for a client new to the practice. Which of the following parameters should the nurse include as part of the general survey? (Select all that apply.) Posture Skin lesions Speech Allergies Immunization status A nurse is collecting data for a client‟s comprehensive physical examination. After inspecting the client‟s abdomen, which of the following skill of the physical examination process should the nurse perform next? Olfaction Auscultation Palpation Percussion A nurse is preparing to perform a comprehensive physical examinations of an older adult client. Which of the following interventions should the nurse use in consideration of the client‟s age? (Select all that apply.) Expect the session to be shorter than for a younger client. Plan to allow plenty of time for position changes. Make sure the client has any essential sensory aids in place. Tell the client to take their time answering questions. Invite the client to use the bathroom before beginning the examination. A nurse in a provider‟s office is performing a physical examination of an adult client. Which part of the hands should the nurse use during palpation for optimal assessment of skin temperature? Palmar surface Fingertips Dorsal surface Base of the fingers Chapter 27 A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3oC (101oF), pulse rate 114/min, and respiratory rate 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take? (Select all that apply.) Obtain culture specimens before initiating antimicrobials. Restrict the client‟s oral fluid intake. Encourage the client to rest and limit activity. Allow the client to shiver to dispel excess heat. Assist the client with oral hygiene frequently. A nurse is instructing an AP about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring vital signs for this client? “Do not measure the client‟s temperature rectally.” “Count the client‟s radial pulse for 30 seconds and multiply it by 2.” “Do not let the client know you are counting their respirations.” “Let the client rest for 5 minutes before you measure their BP.” A nurse is instructing a group of assistive personnel in measuring a client‟s respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply.) Place the client in semi-Fowler‟s position. Have the client rest an arm across the abdomen. Observe one full respiratory cycle before counting the rate. Count the rate for 30 sec if it is irregular. Count and report any sighs the client demonstrates. A nurse is measuring BP of a client who has a fractured femur. BP is 140/94 mmHg, and the client denies any history of HTN. Which of the following actions should the nurse take first? Request a prescription for an antihypertensive medication. Ask the client if they are having pain. Request a prescription for an antianxiety medication. Return in 30 min to recheck the client‟s BP. A nurse is performing an admission assessment on a client. The nurse determines the client‟s radial pulse rate is 68/min and the simultaneous apical pulse is 84/min. what is the client‟s pulse deficit (per minutes)? 16 Chapter 28 A nurse is a provider‟s office is preparing to test a client‟s cranial nerve function. Which of the following should the nurse include when testing cranial nerve V? (Select all that apply.) “Close your eyes.” “Tell me what you can taste.” “Clench your teeth.” “Raise your eyebrows.” “Tell me when you feel a touch.” A nurse is assessing a client‟s thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) Palpating the thyroid in the lower half of the neck. Visualizing the thyroid on inspection of the neck. Hearing a bruit when auscultating the thyroid. Feeling the thyroid ascend as the client swallows. Finding symmetric extension off the traches on both sides of the midline. A nurse is assessing an adult client‟s internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions should the nurse take? (Select all that apply.) Pull the auricle down and back. Insert the speculum slightly down and forward. Insert the speculum 2 to 2.5 cm (0.8 to 1 in) Make sure the speculum does not touch the ear canal. Use the light to visualize the tympanic membrane in a cone shape. A nurse is caring for a client who asks what their Snellen eye test results mean. The client‟s visual acuity is 20/30. Which of the following responses should the nurse make? “Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet.” “Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet.” “Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet.” “Your left eye can see the chart clearly at 20 feet, and your right eye can see the chart clearly at 30 feet.” A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect? (Select all that apply.) Reddened gums Lowered vocal pitch Tooth loss Glare intolerance Thickened eardrums Chapter 29 A nurse in a provider‟s office is preparing to perform a breast examination for an older adult client who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply.) Smaller nipples Less adipose tissue Nipple discharge More pendulous Nipple inversion A nurse in a provider‟s office is preparing to auscultate and percuss a client‟s thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) Rhonchi Crackles Resonance Tactile fremitus Bronchovesicular sounds During an abdominal examination, a nurse in a provider‟s office determines that a client has abdominal distention. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect? Fat Fluid Flatus Hernias During a cardiovascular examination, a nurse in a provider‟s office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following data is the nurse attempting to auscultate? (Select all that apply.) Ventricular gallop Closure of the mitral valve Closure of the pulmonic valve Apical heart rate Murmur A nurse in a provider‟s office is preparing to auscultate and percuss a client‟s abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) Tympany High-pitched clicks Borborygmi Friction rubs Bruits Chapter 30 A nurse in a provider‟s office is preparing to assess a client‟s skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) Capillary refill less than 3 seconds 1+ pitting edema in both feet Pale nail beds in both hands Thick skin on the soles of the feet Numerous macules on the face darker than the surrounding skin color A nurse is assessing an older adult client who has significant tenting of the skin over the forearm. Which of the following factors should the nurse consider as a cause for this finding? (Select all that apply.) Thin, parchment-like skin Loss of adipose tissue Dehydration Diminished skin elasticity Excessive wrinkling A nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. The nurse should test which of the following? (Select all that apply.) Range of motion Skin color Edema Skin lesions Skin temperature A nurse is performing skin assessment on a group of clients. Which of the following lesions should the nurse identify as vesicles (Select all that apply.) Acne Warts Psoriasis Herpes simplex Varicella A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention? Pallor Cyanosis Jaundice Erythema Chapter 31 A nurse in a provider‟s office is preparing to assess a young adult client‟s musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply.) Concave thoracic spine posteriorly Exaggerated lumbar curvature Concave lumbar spine posteriorly Exaggerated thoracic curvature Muscle slightly larger on the dominant side A nurse, who is assessing a client‟s neurologic system, should ask the client to close their eyes and identify which of the following items? A word the nurse whispers 30cm from the ear A number the nurse traces on the palm of the hand The vibration of a tuning fork the nurse places on the foot A familiar object the nurse places in the hand A nurse is caring for a client who reports pain with internal rotation of the right shoulder. This discomfort can affect the client‟s ability to perform which of the following activities? Exercising the deltoid muscle when using hand weights Brushing the hair on the back of the head Fastening or zipping closures on the back while dressing Reaching into cabinet above the sink A nurse is performing a neurologic examination for a client. Which of the following assessments should the nurse perform to test the client‟s balance? (Select all that apply.) Romberg test Heel-to-toe walk Snellen test Spinal accessory function Rosenbaum test A nurse is collecting data from an older adult client as part of a neurologic examination. Which of the following findings should the nurse expect as changes associated with aging? (Select all that apply.) Slower light touch sensation Some vision and hearing decline Slower fine finger movement Some short-term memory decline Decreased risk of depression Chapter 32 A nurse is caring for a client who states, “I have to check with my partner and see if they think I am ready to go home.” The nurse replies, “How do you feel about going home today?” Which clarifying technique is the nurse using to enhance communication with the client? Pacing Reflecting Paraphrasing Restating Which of the following actions should the nurse take when demonstrating an empathic presence to a client? (Select all that apply.) Use an open posture. Write down what the client says to avoid forgetting details. Establish and maintain eye contact Nod in agreement with the client throughout the conversation. Sit facing the client. A nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being an avid swimmer. Which of the following statements should the nurse make? (Select all that apply.) “You will do great! You just have to get used to it.” “Why are you worried about going home?” “Your daily routines will be different when you get home.” “Tell me about the support system you‟ll have after you leave the hospital.” “It sounds like you are not sure how to having a colostomy will affect swimming.‟ Which of the following strategies should a nurse use to establish a helping relationship with a client? Make sure the communication is equally distributed between the nurse‟s and client‟s desires. Encourage the client to communicate their thoughts and feelings. Give the nurse-client relationship communication no time limits. Allow communication to occur spontaneously throughout the nurse-client relationship. A nurse is caring for a school-age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? Touch the child‟s arm. Sit at eye level with the child. Stand facing the child. Stand with a relaxed posture. Chapter 33 A nurse is caring for a client whose partner passed away 4 months ago. The client has a recent diagnosis of DM. the client is tearful and states, “How could you possibly understand what I am going through?” Which of the following responses should the nurse make? “It takes time to get over the loss of a loved one.” “You are right. I cannot really understand. Perhaps you‟d like to tell me more about what you‟re feeling.” “Why don‟t you try something to take your mind off your troubles, like watching a funny movie.” “I might not share your exact situation, but I do know what people go through when they deal with a loss.” A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client‟s vital signs and notes an elevation in BP and HR. the nurse should recognize this response as which part of general adaptation syndrome (GAS)? Exhaustion stage Resistance stage Alarm stage Recovery stage A nurse is caring for a client who has left-sided hemiplegia resulting from a CVA accident. The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following describes the client‟s role problem? Role conflict Role overload Role ambiguity Role strain A nurse is caring for a client who has a new diagnosis of type 2 DM. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? (Select all that apply.) Suggest coping skills for the client to use in this situation. Allow the client to provide input in the treatment plan. Assist the client with time management, and address the client‟s priorities. Provide extensive instructions on the client‟s treatment regimen. Encourage the client in the expression of feelings and concerns. A nurse is caring for a family who is experiencing crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis? Prescribing tasks unilaterally. Delegating care to one member Speaking to the primary client privately Convening a family meeting Chapter 34 A nurse in an ambulatory care clinic is caring for a client who had a mastectomy 6 months ago. The client tells the nurse that there has been a decreased desire for sexual relations since the surgery, stating “My body is so different now.” Which of the following responses should the nurse make? “Really, you look just fine to me. There‟s no need to feel undesirable.” “I‟m interested in finding out more about how your bod feels to you.” “Consider an afternoon at a spa. A facial will make you feel more attractive.” “It‟s still too soon to expect to feel normal. Give it a little more time.” A nurse is caring for a group of clients on a medical surgical unit. Which of the following clients are at increased risk for body-image disturbances? (Select all that apply.) A client who had a laparoscopic appendectomy. A client who had a mastectomy. A client who had a left above-the-knee amputation. A client who had a cardiac catheterization. A client who had a stroke with right-sided hemiplegia. A nurse is caring for a client who is 3 days postoperative following a below-the-knee amputation as a result of a motor-vehicle crash. Which of the following statements indicates that the client has a distorted body image? “I‟ll be able to function exactly as I did before the accident.” “I just can‟t stop crying.” “I am so mad at that guy who hit us. I wish he lost a leg.” “I don‟t even want to look at my leg. You can check the dressing.” A nurse is caring for a client who is recovering from a MI and a cardiac catheterization. The client states: “I am concerned that things might be a little, you know, „different‟ with my partner when I got home.” Which of the following statements should the nurse make? “Sounds like something you should discuss with them when you get home.” “It sounds like your are concerned about sexual functioning. Let‟s discuss your concerns.” “Oh, I wouldn‟t be too concerned. Things will be fine as soon as we get you home.” “Just make sure you take your medication as directed, and you should be fine.” A nurse is teaching a group of clients how to care for their colostomies. Which of the following statements indicates as issue with self-concept? “I was having difficulty with attaching the appliance at first, but my partner was able to help.” “I‟ll never be able to care for this at home. Can‟t you just send a nurse to the house?” “I met a neighbor who also has a colostomy, and they taught me a few things.” “It can take me a while to get the hang of things. I have to admit, I am pretty nervous.” Chapter 35 A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and family member? (Select all that apply.) Talk to the interpreter about the family while the family is in the room. Determine client understanding several times during the conversation. Look at the interpreter when asking the family questions. Use lay terms if possible. Do not interrupt the interpreter and the family as they talk. A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients? Members of the same religion share similar feelings about their religion. A shared religion background generates mutual regard for one another. The same religious beliefs can influence individuals differently. The nurse and client should discuss the differences and commonalities in their beliefs. A nurse enters the room of a client who is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take? Contact the hospital‟s spiritual services. Ask what is making the client cry. Ensure no visitors or staff enter the room for a short time period. Turn on the television for a distraction. A nurse is discussing the plan of care for a client who reports following Islamic practices. Which of the following statements by the nurse indicates culturally responsive care to the client? “I will make sure the menu includes kosher options.” “I will ask the client if the want to schedule some times to pray during the day.” “I will avoid discussing care when the client‟s family is around.” “I will make sure daily communion is available for this client.” A nurse is caring for a client who tells the nurse that based on religious values and mandates, a blood transfusion is not acceptable treatment option. Which of the following responses should the nurse make? “I believe in this case you should make an exception and accept the blood transfusion.” “I know your family would approve of your decision to have a blood transfusion.” “Why does your religion mandate that you cannot receive any blood transfusions?” “Let‟s discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution.” Chapter 36 A nurse is caring for a client who has terminal lung cancer. The nurse observes the client‟s family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family? Allowing the client to function independently will strengthen muscles and promote healing. The client needs privacy at times for self-reflecting and organizing life. The client‟s sense of loss can be lessened through retaining control of some areas of life. Performing ADLs is a requirement prior to discharge from an acute care facility. A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states, “I told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my child‟s wedding.” Based on the Kubler-Ross model, which stage of grief is the client experiencing? Anger Denial Bargaining Acceptance A nurse is consoling the partner of a client who just died after a long battle liver cancer. The grieving partner states, “I hate them for leaving me.” Which of the following statements should the nurse make to facilitate mourning for the partner? (Select all that apply.) “Would you like to contact the chaplain to come and speak with you?” “You will feel better soon. You have been expecting for a while now.” “Let‟s talk about your children and how they are going to react.” “You know, it is quite normal to feel anger toward your loved one at this time.” “Tell me more about how are you feeling.” A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client‟s family is at the bedside and asks the nurse what to expect at this time. Which of the following findings should the nurse include? Regular breathing pattern. Warm extremities. Increased urine output. Decreased muscle tone. A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? (Select all that apply.) Remove the dentures from the body. Make sure the body is lying completely flat. Apply fresh linens and place a clean gown on the body. Remove all equipment from the bedside. Dim the lights in the room. Chapter 37 A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? Turn the client‟s head to the side. Place two fingers in the client‟s mouth to open it. Brush the client‟s teeth once per day. Inject a mouth rinse into the center of the client‟s mouth. A nurse is instructing a client who has DM about foot care. Which of the following guidelines should the nurse include? (Select all that apply.) Inspect the feet daily. Use moisturizing on the feet. Wash the feet with warm water and left them air dry. Use OTC products to treat abrasions. Wear cotton socks. A nurse is planning care for a client who develops dyspnea and feels tired after completing morning care. Which of the following actions should the nurse include in the client‟s plan of care? Schedule rest periods during morning care. Discontinue morning care for 2 days. Perform all care as quickly as possible. Ask a family member to come in to bathe the client. A nurse is beginning a complete bed bath for a client. After removing the client‟s gown and placing a bath blanket over the body, which of the following areas should the nurse wash first? Face Feet Chest Arms A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? Pull down and out at the back of the upper denture to remove. Brush the dentures with a toothbrush and denture cleaner. Rinse the dentures with hot water after cleaning them. Place the dentures in a clean, dry storage container after cleaning them. Chapter 38 A nurse in a provider‟s office is caring for a client who states that, for the past week, “I have felt tired during the day and cannot sleep at night.” Which of the following responses should the nurse ask when collecting data about the client‟s difficulty sleeping? (Select all that apply.) “Have your working hours changed recently?” “Do you feel confused in the late afternoon?” “Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?” “Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?” “Tell me about you personal stress you are experiencing.” A nurse is talking with a client about ways to help sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? (Select all that apply.) Practice muscle relaxation techniques. Exercise each morning. Take an afternoon nap. Alter the sleep environment for comfort. Limit fluid intake at least 2 hr before bedtime. A nurse is caring for a client who has been following the facility‟s routine and bathing in the morning. However, at home, the client always takes a warm bath just before bedtime. Now the client is having difficulty sleeping at night. Which of the following actions should the nurse take first? Rub the client‟s back for 15 min before bedtime. Offer the client warm milk and crackers at 2100. Allow the client to take a bath in the evening. Ask the provider for a sleeping medication. A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining REM sleep, which of the following characteristics should the nurse include? (Select all that apply.) REM sleep provides cognitive restoration. REM sleep lasts about 90 min. It is difficult to awaken a person in REM sleep. Sleepwalking occurs during REM sleep. Vivid dreams are common during REM sleep. A nurse is instructing a client who has a narcolepsy about measures that might help with self- management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? “I‟ll add plenty of carbohydrates to my meals.” “I‟ll take a short nap whenever I feel a little sleepy.” “I‟ll make sure I stay warm when I am at my desk at work.” “It‟s okay to drink alcohol as long as I limit it to one drink per day.” Chapter 39 A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? Give the client thing liquids. Instruct the client to tuck their chin when swallowing. Have the client use a straw. Encourage the client to lie down and rest after meals. A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy? Fat Protein Glycogen Carbohydrates A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client‟s meal tray? Cooked barley Pureed broccoli Vanilla custard Lentil soup A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate the BMI and determine whether the client‟s BMI indicates a healthy weight, underweight, overweight, or obese. A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply.) Older adults are more prone to dehydration that younger adults are. Older adults need the same amount of most vitamins and minerals as younger adults do. Many older men and women need calcium supplementation. Older adults need more calories that they did when they were younger. Older adults should consume a diet low in carbohydrates. Chapter 40 A nurse is caring for a client who has been sitting in a chair for 1 hr. which of the following complications is the greatest risk to the client? Decreased subcutaneous fat Muscle atrophy Pressure injury Fecal impaction A nurse is caring for client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.) Instruct the client not to perform the Valsalva maneuver. Apply elastic stockings. Review laboratory values for total protein level. Place pillows under the client‟s knees and lower extremities. Assist the client to change positions often. A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? Encourage the client to perform antiembolic exercises every 2 hr. Instruct the client to cough and deep breathe every 4 hr. Restrict the client‟s fluid intake. Reposition the client every 4 hr. A nurse is evaluating a client‟s understanding of the use of a sequential compression device. Which of the following client statements indicates client understanding? “This device will keep me from getting sores on my skin.” “This device will keep the blood pumping through my leg.” “With this device on, my leg muscles won‟t get weak.” “This device is going to keep my joints in good shape.” A nurse is instructing a client, who has an injury of the left lower extremity, about the use of cane. Which of the following instructions should the nurse include? (Select all that apply.) Hold the cane on the right side. Keep two points of support on the floor. Place the cane 38 cm (15 in) in front of the feet before advancing. After advancing the cane, move the weaker leg forward. Advance the stronger leg so that it aligns evenly with the cane. Chapter 41 A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client if there has been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine? Presence of associated manifestations. Location of the pain Pain quality Aggravating and relieving factors A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client‟s pain? Ask the client what precipitates the pain. Question the client about the location of the pain. Offer the client a pain scale to measure their pain. Use open-ended questions to identify the client‟s pain sensations. A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? A client who has a broken femur and reports hip pain. A client who has incisional pain 72 hr following pacemaker insertion. A client who has food poisoning and reports abdominal cramping. A client who has episodic back pain following a fall 2 years ago. A nurse is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the nurse identify as an adverse effect of opioids? (Select all that apply.) Urinary incontinence Diarrhea Bradypnea Orthostatic hypotension Nausea A nurse is caring for a client who is receiving morphine via PCA infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? “I‟ll wait to use the device until it‟s absolutely necessary.” “I‟ll be careful about pushing the button too much so I don‟t get an overdose.” “I should tell the nurse if the pain doesn‟t stop while I am using this device.” “I will ask my adult child to push the dose button when I am sleeping.” Chapter 42 A nurse is caring for a client scheduled for abdominal surgery. The client reports being worried. Which of the following actions should the nurse take? Offer information on a relaxation technique and ask if they are interested in trying it. Request a social worker to see the client to discuss meditation. Attempt to use biofeedback techniques with the client. Tell the client many people feel the same way before surgery and to think of something else. A nurse is assessing a client as part of an admission history. The client reports drinking an herbal tea every afternoon at work to relieve stress. Tea includes which of the following ingredients? Chamomile Ginseng Ginger Echinacea A nurse is reviewing complementary and alternative therapies with a group of a newly licensed nurses. Which of the following interventions are mind-body therapies? (Select all that apply.) Art therapy Acupressure Yoga Therapeutic touch Biofeedback A nurse is teaching a group of newly licensed nurses on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage them to use? (Select all that apply.) Guided imagery Massage therapy Meditation Music therapy Therapeutic touch A nurse is planning to use healing intention with a client who is recovering from a lengthy illness. Which of the following is the priority action to take before attempting this particular mind-body intervention? Tell the cli3nt the goal of therapy is to promote healing. Ask whether the client is comfortable with using prayer. Encourage the client to participate actively for best results. Instruct the client to relax during the therapy. Chapter 43 A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should be included when explaining the procedure to the client? Eating more protein is optimal prior to testing. One stool specimen is sufficient for testing. A red color change indicates a positive test. The specimen cannot be contaminated with urine. A nurse is providing dietary teaching for a client who reports constipation. Which of the following foods should the nurse recommend? Macaroni and cheese One medium apple with skin One cup of plain yogurt Roast chicken and white rice A nurse is assessing a client who has had diarrhea for 4 days. Which of the following findings should the nurse expect? (Select all that apply.) Bradycardia Hypotension Elevated temperature Poor skin turgor Peripheral edema While a nurse is administering a cleansing edema, the client reports abdominal cramping. Which of the following actions should the nurse take? Have the client hold their breath briefly and bear down. Clamp the enema tubing. Remind the client that cramping is common at this time. Raise the level of the enema fluid container. A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? (Select all that apply.) Warm the enema solution prior to instillation. Position the client on the left side with the right leg flexed forward. Lubricate the rectal tube or nozzle. Slowly insert the rectal tube about 5 cm (2 in). Hang the enema container 61 cm (24 in) above the client‟s anus. Chapter 44 A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? (Select all that apply.) Limit total daily fluid intake. Decrease or avoid caffeine. Take calcium supplements. Avoid drinking alcohol. Used the Cred maneuver. A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? Check to see whether the catheter is patent. Reassure the client that it is not possible for them to urinate. Re-catheterize the bladder with a larger-gauge catheter. Collect a urine specimen for analysis. A nurse is caring for a client who has a prescription for a 24-hr urine collection. Which of the following actions should the nurse take? Discard the first voiding Keep the urine in a single container at room temperature. Dispose of the last voiding. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container. A nurse is reviewing factors that increase the risk of UTIs with a client who has recurrent UTIs. Which of the following factors should the nurse include? (Select all that apply.) Frequent sexual intercourse Lowering of testosterone levels Wiping from front to back to clean the perineum Location of the urethra closer to the anus Frequent catheterization A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (Select all that apply.) Restrict the client‟s intake of fluids during the daytime. Have the client record urination time. Gradually increase the urination intervals. Remind the client to hold urine until the next scheduled urination time. Provide a sterile container for urine. Chapter 45 A nurse is caring for a client who has a stroke and has aphasia. Which of the following interventions should the nurse use to promote communications with this client? (Select all that apply.) Speak at a higher volume to the client. Make sure only one person speaks at a time. Avoid discouraging the client by indicating that they cannot be understood. Allow plenty of time for the client to respond. Use brief sentences with simple words. A nurse is caring for a client who has an amphetamine toxicity and has sensory overload. Which of the following interventions should the nurse implement? Immediately complete a thorough assessment. Encourage visitors to distract the client. Provide a private room, and limit stimulation. Speak at a higher volume to the client. A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (Select all that apply.) Weber test showing lateralization to the right ear Light reflex at 10 o‟clock in the left ear Indications of obstruction in the left ear canal Rinne tests showing less time for air and bone conduction Rinne test showing air conduction less than bone conduction in the left ear A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications the client currently takes should alert the nurse to a further risk for ototoxicity? (Select all that apply.) Furosemide Ibuprofen Cimetidine Simvastatin Amiodarone A nurse is reviewing instructions with a client who has a searing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? “I use the damp cloth to clean the outside part of my hearing aids.” “I clean the ear molds of my hearing aids with rubbing alcohol.” “I keep the volume of my hearing aids turned up so I can hear better.” “I take the batteries out of my hearing aids when I take them off at night.: Chapter 46 A nurse is caring for a client who is 1-day postoperative and reports a pain level of 10 on a scale of 0 to After reviewing the client‟s medication administration record, which of the following medications should the nurse administer? Meperidine 75 mg IM Fentanyl 50 mcg/hr transdermal patch Morphine 2 mg IV Oxycodone 10 mg PO A nurse is teaching a client about medications at discharge. Which of the following statements should the nurse identify as an indication that the client understands the instructions? “I can open the time-release capsule with the beads in it and sprinkle them on my oatmeal.” “If I am having difficulty swallowing, I will add the liquid medication to a prepared package of pudding.” “I can crush the enteric coated pill, if needed.” “I will eat two crackers with the pain pills.” A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include? “Flush the tube before and after each medication.” “Mix your medications with your enteral feeding.” “Push tablets through the tube slowly.” “Mix all the crushed medications prior to dissolving them in water.” A nurse is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the nurse take? Use a 22-gauge needle. Select a site on the client‟s abdomen. Use the Z-track technique to displace the skin on the injection site. Observe for bleb formation to confirm proper placement. A nurse is teaching an adult client how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands? “I will straighten my ear canal by pulling my ear down and back.” “I will gently apply pressure with my finger to the front part of my ear after putting in the drops.” “I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in.” “After the drops are in, I will place a cotton ball all the way into my ear canal.” Chapter 47 A nurse prepares an injection of morphine to administer to a client who reports pain, then asks a second nurse to give the injection because another assigned client needs to use a bedpan. Which of the following actions should the second nurse take? Offer to assist the client who needs the bedpan. Administer the injection the other nurse prepared. Prepare another syringe and administer the injection. Tell the client who needs the bedpan to wait while the nurse gives someone else medication. A nurse is reviewing a client‟s prescribed medications at the beginning of the day shift. Which of the following 0900 medications can be given anytime between 0700 and 1100? (Select all that apply.) A once-daily multivitamin Eye drops prescribed every 3 hr An antibiotic prescribed every 8 hr A blood pressure pill prescribed twice daily A subcutaneous injection prescribed once weekly A nurse orienting a newly licensed nurse is reviewing the procedure for taking a telephone prescription. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands the process? “A second nurse enters the prescription into the client‟s medical record.” “Another nurse should listen to the phone call.” “The provider can clarify the prescription when they sign the health record.” “I should omit the „read back‟ if this is a one-time prescription.” A nurse educator is teaching newly licensed nurses about safe medication administration. Which of the following statements indicates understanding? (Select all that apply.) “I will observe for adverse effects.” “I will monitor for therapeutic effects.” “I will prescribe the appropriate dose.” “I will change the dose if adverse effects occur.” “I will refuse to give a medication if I believe it is unsafe.” A nurse reviewing a client‟s health record notes a new prescription for lisinopril 10 mg PO once every day. The nurse should identify this as which of the following types of prescription? Single Stat Routine Now Chapter 48 A nurse is preparing to administer methylprednisolone 10 mg by IV bolus. The amount available is methylprednisolone injection 40-mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Do not use a trailing zero.) 0.3mL A nurse is preparing to administer lactated Ringer‟s (LR) IV 100 mL over 15 min. The nurse should set the IV infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Do not use a trailing zero.) 400mL/hr A nurse is preparing to administer 0.9% sodium chloride (0.9% NaCl) 250 mL IV to infuse over 30 min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Do not use a trailing zero.) 83 gtt/min A nurse is preparing to administer metoprolol 200-mg PO daily. The amount available is metoprolol 100 mg/tablet. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Do not use a trailing zero.) 2 tablets A nurse is preparing to administer ketorolac 0.5 mg/kg IV bolus every 6 hr to a school-age child who weighs 66 lb. The amount available is ketorolac injection 30-mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 0.5 mL A nurse is preparing to administer dextrose 5% in water (D5W) 1,000-mL IV to infuse over 10 hr. The nurse should set the IV infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Do not use a trailing zero.) 100 mL/hr A nurse is preparing to administer acetaminophen 320 mg PO every 4-hr PRN for pain. The amount available is acetaminophen liquid 160-mg/5-mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 10 mL A nurse is preparing to administer dextrose 5% in lactated Ringer‟s (D5LR) 1,000 mL to infuse over 6-hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Do not use a trailing zero.) 42 gtt/min Chapter 49 A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure? “I will thread the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood.” “I will insert the needle into the client‟s skin at an angle of 10 to 30 degrees with the bevel up.” “I will apply pressure approximately 1.2-inches below the insertion site prior to removing the needle.” “I will choose a vein in the antecubital fossa for IV insertion due to its size and easily accessible location.” A nurse is collecting data from a client who is receiving IV therapy and reports pain in the arm, chills, and “not feeling well.” The nurse notes warmth, edema, induration, and red streaking on the client‟s arm close to the IV insertion site. Which of the following actions should the nurse plan to take first? Obtain a specimen for culture. Apply a warm compress. Administer analgesics. Discontinue the infusion. During new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of the preventive strategies? “I will leave the IV catheter in place after the client completes the course of IV antibiotics.” “As long as I am working with the same client, I can use the same IV catheter for my second insertion attempt.” “If my client needs to use the rest room, it would be safer to disconnect their IV infusion as long as I clean the injection port thoroughly with an antiseptic swab.” “I will replace any IV catheter when I suspect contamination during insertion.” A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply.) “The temperature around the IV site is cooler.” “The rate of the infusion increases.” “The skin at the IV site is red.” “The IV dressing is damp.” “The tissue around the venipuncture site is swollen.” A nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride IV at 120 mL/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? (Select all that apply.) “I feel lightheaded.” “I feel as though my heart is racing.” “I feel a little short of breath.” “The nurse technician told me that my blood pressure was 150 over 90.” “I think my ankles are less swollen.” Chapter 50 A nurse is collecting data from a client who takes haloperidol to treat schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms (EPSs)? (Select all that apply.) Orthostatic hypotension Tremors Acute dystonia Decreased level of consciousness Restlessness A nurse is teaching a client who has a new prescription for oxybutynin about managing the medication‟s anticholinergic effects. Which of the following instructions should the nurse include? (Select all that apply.) Take sips of water frequently. Wear sunglasses when outdoors in sunlight. Use a soft toothbrush when brushing teeth. Take the medication with an antacid. Urinate prior to taking the medication. A nurse is reviewing a client‟s medications. They include cimetidine and imipramine. Knowing that cimetidine decreases the metabolism of imipramine, the nurse should identify that this combination is likely to result in which of the following effects? Decreased therapeutic effects of cimetidine Increased risk of imipramine toxicity Decreased risk of adverse effects of cimetidine Increased therapeutic effects of imipramine A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client? “Get up and change positions slowly.” “Avoid eating aged cheese and smoked meat.” “Report any usual bruising or bleeding to the doctor immediately.” “Eat the same amount of foods that contain vitamin K every day.” A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering the medication, which of the following actions is the nurse‟s priority? Teaching the client about the purpose of the medication Giving the medication at the administration time the provider prescribed Identifying the client‟s medication allergies Documenting the client‟s anxiety level Chapter 51 To promote adherence with medication self-administration, a nurse is making recommendations for an older adult client. Which of the following instructions should the nurse include? (Select all that apply.) Adjust dosages according to daily weight. Place pills in daily pill holders. Ask for liquid forms if the client has difficulty swallowing pills. Ask a relative to assist periodically. Request child-resistant caps on medication containers. A client in a provider‟s office tells the nurse that “I fast for several days each week to help control my weight.” The client takes several medications for various chronic issues. The nurse should explain to the client that which of the following mechanisms that results from fasting puts her at risk for medication toxicity? Increasing the metabolism of the medications over time Increasing the protein-binding response Increasing medications‟ transit time through the intestines Decreasing the excretion of medications A nurse is preparing medications for a preschooler. Which of the following factors should the nurse identify as altering how a medication affects children? (Select all that apply.) Increased gastric acid production Immature liver Higher body water content Increased absorption of topical medications Increased gastric emptying time A nurse is teaching a client who is lactating about taking medications. Which of the following actions should the nurse recommend to minimize in the entry of medication into breast milk? Drink 8 oz of milk with each dose of medication. Use medications that have an extended half-life. Take each dose right after breastfeeding. Pump breast milk and freeze it prior to feeding to the newborn. A nurse in an outpatient clinic is teaching a client who is in the first trimester of pregnancy. Which of the following statements should the nurse make? “You will need to get a rubella immunization if you haven‟t had one prior to pregnancy.” “You can safely take over-the-counter medications.” “You should avoid any vitamin preparations containing iron.” “Your provider can prescribe medication for nausea if you need it.” Chapter 52 A nurse is reviewing the medical record of a client who has a blood glucose of 260 mg/dL and no documented history of diabetes mellitus. Which of the following types of medications can cause hyperglycemia as an adverse effect? (Select all that apply.) Diuretics Corticosteroids Oral anticoagulants Opioid analgesics Antipsychotics A nurse teaching a client how to check blood glucose levels. The nurse should include which of the following instructions about transferring blood onto the reagent portion of the test strip? Smear the blood onto the strip. Squeeze the blood onto the strip. Touch the puncture to stimulate bleeding. Hold the test strip next to the blood on the fingertip. A nurse attempting to collect a capillary blood specimen via finger stick for blood glucose monitoring is unable to obtain an adequate drop of blood for the reagent strip. Which of the following actions should the nurse take first? Puncture another finger to obtain a capillary specimen. Test the urine with a urine reagent strip. Wrap the hand in a warm, moist cloth. Perform a venipuncture to obtain a venous sample. A nurse is teaching self-monitoring of blood glucose (SMBG) to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply.) Perform SMBG once daily at bedtime. Wipe the hand with an alcohol swab. Hold the hand in a dependent position prior to the puncture. Place the puncturing device perpendicular to the site. Prick the outer edge of the fingertip for the blood sample Chapter 53 A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply.) Restlessness Tachypnea Bradycardia Confusion Hypertension A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.) Apply petroleum jelly around and inside the nares. Remove the nasal cannula during mealtimes. Check the position of the cannula frequently. Report any nausea or difficulty breathing. Post “No Smoking” signs in prominent locations. A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse‟s priority? Increase the oxygen flow. Assist the client to Fowler‟s position. Promote removal of pulmonary secretions. Obtain a specimen for arterial blood gases. A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? (Select all that apply.) Apply suction while withdrawing the catheter. Perform suctioning on a routine basis every 2 to 3 hr. Maintain medical asepsis during suctioning. Use a new catheter for each suctioning attempt. Apply suction for 10 to 15 seconds. A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (Select all that apply.) Apply the oxygen source loosely if the SpO2 decreases during the procedure. Use surgical asepsis to remove and clean the inner cannula. Clean the outer cannula surfaces in a circular motion from the stoma site outward. Replace the tracheostomy ties with new ties. Cut a slit in gauze squares to place beneath the tube holder. Chapter 54 A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make? “Water helps clear the tube so it doesn‟t get clogged.” “Flushing helps make sure the tube stays in place.” “This will help you get enough fluids.” “Adding water makes the formula less concentrated.” A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? Auscultate breath sounds. Stop the feeding. Obtain a chest x-ray. Initiate oxygen therapy. A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse‟s highest assessment priority before performing this procedure? Check how long the feeding container has been open. Verify the placement of the NG tube. Confirm that the client does not have diarrhea. Make sure the client is alert and oriented. A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply.) Auscultate bowel sounds. Assist the client to an upright position. Test the pH of gastric aspirate. Warm the formula to body temperature. Discard any residual gastric contents. A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (Select all that apply.) Review a signal the client can use if feeling any distress. Lay a towel across the client‟s chest. Administer oral pain medication. Obtain a Dobhoff tube for insertion. Have a petroleum-based lubricant available. Chapter 55 A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (Select all that apply.) Extremes in age Chronic illness Low hemoglobin Malnutrition Poor wound care A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (Select all that apply.) Increase in incisional pain Fever and chills Reddened wound edges Increase in serosanguineous drainage Decrease in thirst A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply.) Stage 3 pressure injury Sutured surgical incision Casted bone fracture Laceration sealed with adhesive Open burn area A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (Select all that apply.) Cover the area with saline-soaked sterile dressings. Apply an abdominal binder snugly around the abdomen. Use sterile gauze to apply gentle pressure to the exposed tissues. Position the client supine with the hips and knees bent. Offer the client a warm beverage (herbal tea). A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client‟s skin? (Select all that apply.) Keep the head of the bed elevated 30°. Massage the client‟s bony prominences frequently. Apply cornstarch liberally to the skin after bathing. Have the client sit on a gel cushion when in a chair. Reposition the client at least every 3 hr while in bed. Chapter 56 A nurse is discussing direct and indirect contact modes of transmission of infection at a staff education session. Which of the following incidents should the nurse include as examples of the direct mode of transmission? (Select all that apply.) Blood spurting from an arterial wound splashes into a nurse‟s eye. A nurse has a needlestick injury. A mosquito bites a hiker in the woods. A nurse finds a hole in their glove while handling a soiled dressing. A person fails to wash their hands after using the bathroom and touches a client. A nurse in a residential care facility is assessing an older adult client. Which of the following findings should the nurse identify as atypical indications of infection in this client? (Select all that apply.) Urinary incontinence Malaise Acute confusion Fever Agitation A nurse is preparing to admit a client who is suspected to have pulmonary tuberculosis. Which of the following actions should the nurse plan to perform first? Implement airborne precautions. Obtain a sputum culture. Administer antituberculosis medications. Recommend a screening test for family members. A nurse in a primary care clinic is assessing a client who has a history of herpes zoster. Which of the following findings suggests that the client has postherpetic neuralgia? Linear clusters of vesicles on the right shoulder Purulent drainage from both eyes Decreased white blood cell count Report of continued pain following resolution of the rash A charge nurse is teaching a newly licensed nurse about the care of a client who has methicillin- resistant Staphylococcus aureus (MRSA). Which of the following statements should the charge nurse identify as an indication that the newly licensed nurse understands the teaching? “I should obtain a specimen for culture and sensitivity after the first dose of an antimicrobial.” “MRSA is usually resistant to vancomycin, so another antimicrobial will be prescribed.” “I will protect others from exposure when I transport the client outside the room.” “To decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile.” Chapter 57 A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (Select all that apply.) Distended neck veins Hyperthermia Tachycardia Syncope Decreased skin turgor A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? A client who has nasogastric suctioning A client who has chronic constipation A client who has syndrome of inappropriate antidiuretic hormone A client who took an toxic dose of sodium bicarbonate antacids A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should identify which of the following findings is a manifestation of dehydration? (Select all that apply.) Hct 55% Blood osmolarity 260 mOsm/kg Blood sodium 150 mEq/L Urine specific gravity 1.035 Blood creatinine 0.6 mg/dL A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction? A client who has a new diagnosis of adrenal insufficiency A client who has heart failure A client who is receiving treatment for diabetic ketoacidosis A client who has abdominal ascites A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? Administer antihypertensive on schedule. Check the client‟s weight each morning. Notify the provider of a urine output greater than 30 mL/hr. Encourage independent ambulation four times a day. Chapter 58 A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care? Infuse hypotonic IV fluids. Implement a fluid restriction. Increase sodium intake. Administer sodium polystyrene sulfonate. A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as a risk factor for the development of this electrolyte imbalance? Crohn‟s disease Postoperative following appendectomy History of bone cancer Hyperthyroidism A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/L. When notifying the provider, the nurse should expect which of the following actions? Starting an IV infusion of 0.9% sodium chloride Consulting with dietitian to increase intake of potassium Initiating continuous cardiac monitoring Preparing the client for gastric lavage A nurse is collecting data from a client who has hypercalcemia as a result of long-term use of glucocorticoids. Which of the following findings should the nurse expect? (Select all that apply.) Hyperreflexia Confusion Positive Chvostek‟s sign Bone pain Nausea and vomiting A nurse is providing education for a client who has severe hypomagnesemia and is prescribed oral magnesium sulfate. Which of the following information should the nurse include in the teaching? “Avoid green, leafy vegetables while taking this medication.” “You should receive a prescription for a thiazide diuretic to take with the magnesium.” “You should eliminate whole grains from your diet until your magnesium level increases.” “Report diarrhea while taking this medication.” [Show More]

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