ATI Fundamentals Proctored Exam Test Bank

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? A. Instruct the client to defecate into the toilet bowl B. Transfer the specimen to a sterile container C. Refrigerate the collected specimen D. Place the stool specimen collection container in a biohazard bag - ANSWER>>D. Place the stool specimen collection container in a biohazard bag The nurse should place the specimen collection container in a biohazard bag with the client label on the container and the bag for easy identification. This will also prevent contamination with microorganisms. A nurse in a provider's office is talking with an older adult client who reports having trouble sleeping. Which of the following statements should the nurse identify as a possible cause of the client's sleeping difficulties? A. "I take a warm shower when getting ready for bed." B. "I often have a cup of coffee with my dessert before going to bed." C. "I usually read a chapter in a book before I go to bed." D. "I make sure I do my exercises in the morning." - ANSWER>>B. "I often have a cup of coffee with my dessert before going to bed." 5 Page 6 of 211 The client should avoid beverages that contain caffeine in the late afternoon and evening because caffeine stimulates the CNS and can result in sleep disturbances. Caffeine is also a diuretic and can cause nighttime awakenings for urination. A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? A. Abdominal binder B. Montgomery straps C. Hypoallergenic tape D. Plastic tape - ANSWER>>B. Montgomery straps The nurse should apply the least-restrictive priority-setting framework, which assigns priority to nursing interventions that are the least restrictive to the client, as long as those interventions do not jeopardize client safety. Least-restrictive interventions promote client safety without using restraints. The nurse should only use physical or chemical restraints when the safety of the client, staff members, or others is at risk. The nurse should plan to use Montgomery straps to minimize irritation of the skin near the incisional area. Montgomery straps are adhesive strips applied to the skin on either side of the surgical wound. The adhesive strips have holes for using gauze to tie the dressing securely. When the dressing is changed, the ties are released, the dressing is replaced, and the ties are secured again without removing the adhesive strips A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client's insomnia? 6 Page 7 of 211 A. The client watches television in her bed during the day. B. The client drinks warm milk before bedtime. C. The client goes to bed at 2200 every night. D. The client gets up to use the bathroom once during the night. - ANSWER>>A. The client watches television in her bed during the day. To promote sleep, the client should avoid watching television in bed. She should use the bed only for sleep or sexual activities. As a nurse is preparing to administer liquid medication from a bottle to a client. Which of the following actions should the nurse take? A. Hold the medication bottle with the label against the palm of the hand when pouring B. Place the cap with the inside facing down on a hard surface C. Fill the cup until the medication is even with the edge of the dosage scale D. Pour any excess liquid back into the bottle after measuring - ANSWER>>A. Hold the medication bottle with the label against the palm of the hand when pouring The nurse should hold a multi-dose bottle with the label against the palm of the hand when pouring to prevent contaminating the label with spilled medication that could cause information on the label to fade or become illegible. 7 Page 8 of 211 A nurse is caring for a group of clients in a long-term care facility. One of the clients is walking along the hallway and bumping into walls and does not respond to his name. Which of the following actions should the nurse take first? A. Offer the client a nutritious snack B. Accompany the client back to his room C. Reorient the client to his surroundings D. Administer a PRN anti-anxiety medication - ANSWER>>B. Accompany the client back to his room The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC prioritysetting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, the nurse should first escort the client back to his room to protect him from injury due to wandering. A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in which of the following positions for evaluation? A. Sims' B. Supine C. Sitting D. Standing - ANSWER>>C. Sitting 8 Page 9 of 211 The costovertebral angle is the area where the spine and the twelfth rib intersect. A sitting position promotes relaxation and allows access to the back for percussion of that region. A nurse is teaching a client who has low back pain about heat therapy. Which of the following statements by the client indicates an understanding of the teaching? A. "I need to place a towel between the heating pad and my skin." B. "I'll need to turn up the temperature if I can't feel the heat." C. "I'll sleep on top of the heating pad to increase the heat penetration." D. "Keeping the heat continuously on my back will help it heal." - ANSWER>>A. "I need to place a towel between the heating pad and my skin." The nurse should instruct the client to place a towel between the heating pad and the skin to reduce the risk of burns. 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? A. Loss B. Trust C. Self-disclosure 9 Page 10 of 211 D. Risk-taking - ANSWER>>A. Loss At the close of a relationship, even when planned, loss is an expected feeling for both the client and the nurse. It is important for both the nurse and the client to terminate the relationship without feelings of guilt or anxiety. As part of a neurological examination, a nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique? A. Gustation B. Stereognosis C. Proprioception D. Kinesthesia - ANSWER>>B. Stereognosis Stereognosis is the ability to identify an object's size, shape, and texture via tactile sensation. A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying? A. "Now that we have talked about your medications, let's talk about your pain." B. "Are you having other symptoms?" C. "It sounds like your pain is intermittent." 10 Page 11 of 211 D. "It seems as though you have really had a rough time these past few weeks." ANSWER>>C. "It sounds like your pain is intermittent." This response by the nurse reflects the communication technique of clarifying. The nurse should use this technique to ensure an understanding of the client's message. A nurse is teaching a middle-aged adult client about health promotion and disease prevention. The nurse should inform the client that which of the following changes could occur? A. Decreased estrogen and testosterone production B. Increased tone of the large intestines C. Increased percentage of the body's muscle mass D. Decreased incidence of chronic illnesses - ANSWER>>A. Decreased estrogen and testosterone production Both estrogen and testosterone levels start to decrease in middle age. A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? A. Autonomy B. Fidelity 11 Page 12 of 211 C. Nonmaleficence D. Justice - ANSWER>>B. Fidelity The nurse is demonstrating the ethical principle of fidelity by keeping a promise that was made. A nurse in a same-day procedure unit is caring for several clients who are undergoing different types of procedures. The nurse should anticipate that the client who has which of the following devices can safely undergo magnetic resonance imaging (MRI)? A. Coronary artery stents B. Aneurysm clip C. Hearing aids D. Automated internal defibrillator - ANSWER>>C. Hearing aids A client who has hearing aids can undergo MRI because the hearing aids can be removed. The powerful magnetic field of the MRI system could damage the hearing aids, so they should be removed prior to the client undergoing MRI. A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure? A. "Inhale forcefully during insertion." 12 Page 13 of 211 B. "Raise your index finger if you need to pause during the insertion." C. "Bear down during insertion." D. "Avoid making any swallowing motions during the insertion." - ANSWER>>B. "Raise your index finger if you need to pause during the insertion." The nurse should instruct the client that the insertion of an NG tube is uncomfortable and the gag reflex will be activated during the procedure. The nurse should establish a communication technique such as having the client raise a finger or hand to indicate distress and the need to pause the insertion process. A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique? A. Applying sterile gloves to open catheter package B. Wiping the labia minora in an anteroposterior direction C. Spreading the labia with the dominant hand D. Using a cotton ball to wipe the right and left labia majora - ANSWER>>B. Wiping the labia minora in an anteroposterior direction The nurse should wipe anteroposteriorly both the right and left labia minora with separate cotton swabs to destroy any microorganisms in the area that would contaminate the catheter. 13 Page 14 of 211 A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who is scheduled for emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? A. The client asks the nurse to repeat the instructions before attempting the exercises. B. The client reports severe pain. C. The client asks the nurse how often deep breathing should be done after surgery. D. The client tells the nurse that this exercise will probably be painful after surgery. ANSWER>>B. The client reports severe pain. A client who is experiencing severe pain is not able to concentrate and is not ready to learn a new activity. A nurse is preparing to administer 40 mL of 0.9% sodium chloride IV to infuse over 20 min. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.) - ANSWER>>30 GTT A nurse is teaching a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes? A. Identify the risks of nonadherence B. Schedule learning sessions to demonstrate the psychomotor skills the client will need C. Provide clearly written and easy-to-understand materials 14 Page 15 of 211 D. Help the client identify ways that these changes will result in positive personal outcomes - ANSWER>>D. Help the client identify ways that these changes will result in positive personal outcomes According to evidence-based practice, the motivation to change must precede taking steps to make the change. Therefore, helping clients identify ways that the changes will promote positive outcomes should precede other educational strategies for making the changes. The client should first see how the changes directly affect his/her life, thus enhancing the motivation to make the changes. A nurse is assessing a client's pulses of the lower extremities. The nurse should identify which of the following as the location of the most distal pulse? A. Popliteal B. Posterior tibial C. Dorsalis pedis D. Femoral - ANSWER>>C. Dorsalis pedis The nurse should identify that the dorsalis pedis pulse is located on the top of the foot, following the groove between the tendons of the great toe. It is best felt by moving the fingertip between the first and second toe and slowly moving up the dorsum of the foot. However, this pulse is congenitally absent in some clients. A nurse is caring for a client who has injuries resulting from a motor-vehicle crash. Which of the following client statements should the nurse address first? 15 Page 16 of 211 A. "I'm afraid this injury will cause me to lose my job." B. "I can't sleep well because whenever I move in my sleep, the pain wakes me up." C. "I don't know what I will do if my car isn't safe or even drivable after the crash." D. "I wonder how I am going to be able to take care of my family." - ANSWER>>B. "I can't sleep well because whenever I move in my sleep, the pain wakes me up." The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's physiological need for comfort. The nurse should re-evaluate the client's pain management plan immediately. A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin discharge planning? A. One week prior to the client's discharge B. Upon the client's admission to the care facility C. Once the discharge date is identified D. When the client addresses the topic with the nurse - ANSWER>>B. Upon the client's admission to the care facility The nurse should begin discharge planning at the time that the client is admitted to the facility. A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? 16 Page 17 of 211 A. Apply a fecal collection system B. Apply a barrier cream C. Cleanse and dry the area D. Check the client's perineum - ANSWER>>A nurse is caring for a client who has major fecal incontinence and reports irritation in the peri-anal area. Which of the following actions should the nurse take first? A. Apply a fecal collection system B. Apply a barrier cream C. Cleanse and dry the area D. Check the client's perineum A nurse is caring for a client who reports not sleeping at night, which interferes with her ability to function during the day. Which of the following interventions should the nurse suggest to this client? A. Avoid beverages that contain caffeine B. Take a sleep medication regularly at bedtime C. Watch television for 30 min in bed to relax prior to falling asleep D. Advise the client to take several naps during the day - ANSWER>>A. Avoid beverages that contain caffeine 17 Page 18 of 211 Caffeine is a stimulant. The nurse should suggest that the client avoid caffeinated beverages. A nurse is monitoring a client's fluid intake. For breakfast, the client consumed 8 oz of milk, 10 oz of water, 4 oz of flavored gelatin, 1 scrambled egg, 1 crisp piece of bacon, and 2 biscuits with jelly. How many mL should the nurse record as the client's fluid intake? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.) ANSWER>>660 mL A nurse is teaching a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups is responsible for movement at the knee joint? A. Antigravity B. Antagonistic C. Synergistic D. Skeletal - ANSWER>>B. Antagonistic The nurse should teach the client that the antagonistic muscle group is responsible for movement of the knee joint by contracting while other muscles relax. A nurse is caring for a client who has a BMI of 29 and expresses a desire to lose weight. Which of the following actions should the nurse take first? A. Refer the client to a nutritionist B. Discuss eating strategies with the client C. Determine the client's intention to change current eating habits 18 Page 19 of 211 D. Instruct the client to perform 30 min of vigorous exercise daily - ANSWER>>C. Determine the client's intention to change current eating habits When using the nursing process, the nurse should first assess the client's readiness to commit to a change in behavior. A nurse is witnessing a client sign an informed consent form for surgery. What is the nurse affirming by this action? A. The client fully understands the provider's explanation of the procedure. B. The client has been informed about the risks and benefits of the procedure. C. The nurse witnessed the provider's explanation of the procedure. D. The signature on the preoperative consent form is the client's. - ANSWER>>D. The signature on the preoperative consent form is the client's. The nurse acts as a witness to confirm that the client's signature is present on the preoperative consent form. It is the responsibility of the provider who will perform the procedure to obtain consent by explaining the procedure along with the associated risks and benefits. A nurse is assessing a client's nutritional status. The nurse determines the client is consuming 500 calories more per day than his energy level requires. If his dietary habits do not change, how long will it take the client to gain 4.5 kg (10 lb)? A. 10 months 19 Page 20 of 211 B. 5 months C. 5 weeks D. 10 weeks - ANSWER>>D. 10 weeks Because 1 lb of body fat is equivalent to 3,500 calories, consuming 500 extra calories each day for 7 days would lead to a total of 3,500 calories and a 1 lb gain per week. At the rate of 1 lb per week, the client would gain 10 lb in 10 weeks. A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume? A. Sodium B. Calcium C. Potassium D. Magnesium - ANSWER>>A. Sodium Sodium regulates extracellular fluid balance, nerve impulse transmission, acid-base balance, and various other cellular activities. A nurse is assisting a client who has right-sided weakness while ambulating using a cane. Which of the following client actions should indicate to the nurse that the client understands the procedure of cane walking? A. The client holds the cane on the affected side. 20 Page 21 of 211 B. The client advances the unaffected leg followed by the cane. C. The client supports this weight on the unaffected leg when moving the cane forward. D. The client keeps 2 points of support on the ground. - ANSWER>>D. The client keeps 2 points of support on the ground. When ambulating with a cane, the client should keep 2 points of support on the ground at all times. 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 handwashing technique? A. The nurse washes each part of her hands with 5 strokes. B. The nurse washes from the elbows down to her hands. C. The nurse holds her hands higher than her elbows while washing. D. The nurse uses minimal friction when washing her hands. - ANSWER>>C. The nurse holds her hands higher than her elbows while washing. The nurse who is performing a surgical handwashing technique should wash while holding her hands higher than the elbows so that water and soapsuds can drain away from the clean area toward the dirty area. A nurse is supervising a newly licensed nurse who is suctioning a client's tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? 21 Page 22 of 211 A. Using clean technique to perform the procedure. B. Applying suction while inserting the catheter. C. Lubricating the suction catheter with an oil-based lubricating jelly. D. Administering high-flow oxygen prior to the procedure. - ANSWER>>D. Administrating high-flow oxygen prior to the procedure. The nurse should instruct the newly licensed nurse to administer 3 to 4 breaths of 100% oxygen via a resuscitation bag before suctioning to the client to reduce risk of hypoxia. A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take? A. Continue the teaching, but check afterward with the surgeon about informed consent. B. Stop the teaching and check with the surgeon about informed consent. C. Stop the teaching and ask the client to sign an informed consent form. D. Continue the teaching and check with the client's medical record afterward for a signed consent form. - ANSWER>>B. Stop the teaching and check with the surgeon about informed consent. The client's statement indicates that she has not given informed consent; therefore, the nurse should interrupt the teaching and notify the surgeon. 22 Page 23 of 211 A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care-associated infections (HAIs). Which of the following routes of infection should the manager identify as an iatrogenic HAI? A. Infection acquired from improper hand hygiene. B. Infection acquired by drug resistance. C. Infection acquired by inappropriate waste disposal. D. Infection acquired from a diagnostic procedure. - ANSWER>>D. Infection acquired from a diagnostic procedure. Iatrogenic HAIs directly result from diagnostic or therapeutic procedures. A charge nurse is providing teaching to a newly licensed nurse about removing sutures from a client's laceration. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I will use a staple remover and remove each suture individually." B. "Bandage scissors are used to cut the sutures." C. "Tweezers are necessary only for removing retention sutures." D. "I will clip each suture close to the skin and pull it through from the other side." ANSWER>>D. "I will clip each suture close to the skin and pull it through from the other side." 23 Page 24 of 211 Clipping close to the skin and pulling the suture from the other side does not disrupt the wound-healing process. A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment? (Select All That Apply) A. Gingivitis B. Dry, brittle hair C. Edema D. Spoon-shaped nails E. Poor wound healing - ANSWER>>B. Dry, brittle hair C. Edema E. Poor wound healing Dry, brittle hair that falls out easily suggests inadequate protein intake and malnutrition. Edema can occur when albumin levels are lower than the expected reference range and indicates protein-calorie malnutrition. Adequate wound healing depends on the ingestion of sufficient protein, calories, water, vitamins (especially C and A), iron and zinc. A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take? A. Use a 10 mL syringe 24 Page 25 of 211 B. Attach a 22-gauge catheter to the syringe C. Warm the irrigating the solution to 37°C (98.6°F) D. Administer an analgesic 10 min before the irrigation - ANSWER>>C. Warm the irrigating the solution to 37°C (98.6°F) The nurse should prepare 200 mL of irrigating solution and warm it to body temperature to minimize discomfort and vascular constriction. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? A. Obtaining hydrogen peroxide for tracheostomy care B. Obtaining cotton balls for tracheostomy care C. Obtaining sterile gloves for tracheostomy care D. Obtaining a sterile brush for tracheostomy care - ANSWER>>B. Obtaining cotton balls for tracheostomy care Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess. The charge nurse should intervene for this action. A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following? (Select All That Apply) 25 Page 26 of 211 A. Allowing the client to speak B. Stabilizing the position of the tube C. Preventing aspiration of secretions D. Preventing air leaks E. Preventing tracheal injury - ANSWER>>B. Stabilizing the position of the tube C. Preventing aspiration of the secretions D. Preventing air leaks An inflated cuff helps prevent movement of the endotracheal tube, reduces the risk of aspiration of oropharyngeal secretions, and keeps air from leaking around the outer portion of the endotracheal tube. A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside. Which of the following actions should the nurse take? A. Hold the sterile drape above the waste and away from the body B. Drop sterile objects toward the edges of the sterile field C. Hold packaged supplies 7.6 cm (3 in) above the sterile field D. Hold sterile objects over the field before setting them down on the field ANSWER>>A. Hold the sterile drape above the waste and away from the body Contamination occurs when the nurse holds any object that will be part of the sterile field below the waist or allows it to touch anything other than a sterile object. 26 Page 27 of 211 A nurse is calculating the protein needs of a young adult client who weighs 132 lb. The RDA for protein for an adult who has no medical conditions is 0.8g/kg. How many grams of protein per day should the nurse recommend for this client? - ANSWER>>48 Grams 132/2.2=60 kg 60 kg x 0.8 g = 48 g A nurse is reviewing a client's laboratory results and notes a WBC count of 3,600/mm^3. The nurse should identify this result as which of the following conditions? A. Leukoplakia B. Leukemia C. Leukocytosis D. Leukopenia - ANSWER>>D. Leukopenia Leukopenia occurs when there is a decrease in the production of WBCs. The alteration places the client at an increased risk of infection. A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP indicates that further teaching is required? A. "I should not leave all 4 side rails up unless there is a prescription for restraints." B. "An alert client will be safest if I raise the 2 upper side rails at the head of the bed." C. "If the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself." 27 Page 28 of 211 D. "If a client is sedated, I should raise all 4 side rails to prevent a fall out of bed." ANSWER>>C. "If the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself." Raising all 4 side rails can put the client at greater risk for injury. For example, the client might try to climb over the side rails, which could results in a fall. A nurse is caring for a client who just received a diagnosis of cancer. The client states, "I just don't know what I'm going to do now." Which of the following responses should the nurse make? A. "In time you'll know the right thing to do." B. "I am sorry. Would you like me to call someone for you?" C. "There are multiple treatment options for you to consider." D. "Can you explain the concerns you're having right now?" - ANSWER>>D. "Can you explain the concerns you're having right now?" This response uses the therapeutic communication technique of asking a relevant question. By using an open-ended question to ask the client to explain any present concerns, the nurse is encouraging the client to respond and provide additional information. A nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? 28 Page 29 of 211 A. "I'll limit pushing the button so I don't get an overdose." B. "If I push the button and still have pain after 2 minutes, I'll push it again." C. "I'll ask my niece to push the button while I am sleeping." D. "I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button." - ANSWER>>D. "I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button." The nurse should encourage the client to utilize nonpharmacological methods of pain management such as transcutaneous electrical nerve stimulation (TENS) while using a PCA pump to reduce the amount of opioid dosing the client needs. A nurse is planning an in-service training session about various dietary practices. Which of the following pieces of information should the nurse include in the teaching? A. Ovo-vegetarian diets exclude eggs. B. Kosher diets have restrictions regarding how the food must be prepared. C. Macrobiotic diets are plant-based and exclude all animals and seafood D. Flexitarian diets exclude the consumption of dairy products. - ANSWER>>B. Kosher diets have restrictions regarding how the food must be prepared. Kosher diets are guided by a set of laws regarding the processing, preparation, and eating of food. A client has 1L of dextrose 5% in 0.45% sodium chloride infusing IV at 125 mL/hr. How many hours will it take for the liter to infuse? - ANSWER>>8 hours 29 Page 30 of 211 1 L = 1000 mL 1000 mL/125 mL = 8 mL A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? A. Decreased urine specific gravity B. Increased heart rate C. Decreased hematocrit D. Increased skin turgor - ANSWER>>B. Increased heart rate An increased heart rate should indicate to the nurse that the client is experiencing fluid volume deficit. Other findings can include an increased BUN level, dry mucous membranes, and dark yellow urine. A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage? A. Sanguineous exudate B. Serous exudate 30 Page 31 of 211 C. Serosanguineous exudate D. Purulent exudate - ANSWER>>D. Purulent exudate Purulent exudate on the client's dressings includes thick yellow, green, or brown drainage and usually indicates wound sloughing or infection. A nurse is measuring a client's vital signs. The client's heart rate is 105/min. The nurse should document this finding as which of the following alterations? A. Palpitation B. Bradycardia C. Tachycardia D. Dysrhythmia - ANSWER>>C. Tachycardia Tachycardia is a heart rate over 100/min in adults. A nurse is caring for a group of clients in a long-term care facility. The nurse should understand that which of the following clients is eligible for hospice services at this time? A. A client who has multiple sclerosis and uses a wheelchair B. A client who has end-stage cirrhosis C. A client who has hemiplegia due to a stroke 31 Page 32 of 211 D. A client who has cancer and receives weekly radiation therapy - ANSWER>>B. A client who has end-stage cirrhosis A client who has end-stage cirrhosis likely has a life expectancy of <6 months. Therefore, this client is eligible for hospice services A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein? A. Eggs B. Cereal C. Peanut Butter D. Pasta - ANSWER>>A. Eggs Complete proteins contain all of the essential amino acids to support growth and hemostasis. Examples of complete proteins include eggs, meat, seafood, milk, yogurt, cheese, soybeans, and soybean products. A nurse is evaluating the development of a group of clients. According to Erikson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development? A. Middle adulthood B. Adolescence 32 Page 33 of 211 C. Childhood D. Young adulthood - ANSWER>>D. Young adulthood The developmental task of young adulthood is intimacy vs. isolation 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? A. "Let's get the process over with because you won't get better without this tube." B. "You should talk to your provider about your fears." C. "Why don't you want the tube inserted?" D. "I can see that this is upsetting you." - ANSWER>>D. "I can see that this is upsetting you." This response uses the therapeutic communication techniques of reflecting and restating, which encourages further communication by the client. A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps relieve pain. Which of the following responses should the nurse make? A. "It provides a distraction from the pain." B. "It modulates the transmission of the pain impulse." 33 Page 34 of 211 C. "It promotes increased circulation to the painful area." D. "It elicits a relaxation response." - ANSWER>>B. "It modulates the transmission of the pain impulse." The nurse should inform the client that a TENS unit applies low-voltage electrical stimulation directly over a location of pain at an acupressure point. It modulates the transmission of the pain impulse and can also cause a release of endorphins to assist with pain relief. A nurse is monitoring a client's laboratory results. Which of the following results should the nurse report to the provider? A. Sodium 140 mEq/L B. Potassium 3.0 mEq/L C. Chloride 100 mEq/L D. Magnesium 2.0 mEq/L - ANSWER>>B. Potassium 3.0 mEq/L The potassium level is below the expected reference range of 3.5-5.5, indicating hypokalemia. The nurse should report this finding to the provider for instructions about preventing muscle weakness that could affect respiration. A nurse is teaching the parent of a child who is to take 10 mL of a liquid medication. The parent has a hallow medication spoon with marks to indicate teaspoons and tablespoons. How many teaspoons should the nurse instruct the parent to give the child? - ANSWER>>2 teaspoons 34 Page 35 of 211 5 mL = 1 teaspoon 10 mL = 2 teaspoons A nurse is planning an in-service training session about nutrition. Which of the following pieces of information should the nurse include? A. Fat breaks down into amino acids B. Protein serves as an energy source when other sources are inadequate C. Glucose breaks down into ammonia D. Carbohydrates provide 9 cal/g of energy - ANSWER>>B. Protein serves as an energy source when other sources are inadequate. Protein is used as an energy source for the body when carbohydrates and fat stores are unavailable or depleted. A middle-aged adult client is discussing future plans with the nurse. Which of the following statements should the nurse identify as an indication that the client is having difficulty achieving Erikson's developmental task for this age group? A. "We miss our daughter so much that we are going to move closer to her." B. "I think this year I can plan on managing the funding at church." C. "I really wish I could lose some of this weight." 35 Page 36 of 211 D. "I find I am spending more time at work now that my son is at college." ANSWER>>A. "We miss our daughter so much that we are going to move closer to her." According to Erikson, the stage of psychosocial development for middle adults is generativity vs. stagnation. Accepting the independence of adult children is part of the developmental task of middle age. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse perform first after discovering that the client's wound has eviscerated. A. Cover the incision with a moist sterile dressing B. Have the client lie on his back with his knees flexed C. Call the client's surgeon D. Reassure the client - ANSWER>>A. Cover the incision with a moist sterile dressing. The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC prioritysetting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. 36 Page 37 of 211 An open wound increased the risk of peritonitis, and any exposed organ tissue could dry out. Therefore, covering the wound with a moist sterile dressing is the first action the nurse should take to protect the client. A nurse is preparing to administer a partial dose of a prefilled opioid analgesic parenterally to a client. Which of the following actions should the nurse plan to take? A. Return the unused portion of the medication to the pharmacy. B. Dispose of the wasted medication into a sharps container C. Record the amount of medication wasted on the controlled substance inventory record D. Ask an assistive personnel (AP) to witness the wasting of the controlled substance. ANSWER>>C. Record the amount of medication wasted on the controlled substance inventory record Two nurses should sign the controlled substance inventory record to document the amount of medication wasted. A nurse is teaching a client who has asthma about the proper use of an albuterol inhaler. Which of the following client statements indicates an understanding of the teaching? A. "I should rinse my mouth out right before I use the inhaler." B. "After the first puff, I will wait 10 seconds before taking the second puff." C. "I will shake the inhaler well right before I use it." 37 Page 38 of 211 D. "I will tilt my head forward while inhaling the medication." - ANSWER>>C "I will shake the inhaler well right before I use it." The nurse should instruct the client to shake the inhaler vigorously for 3 to 5 seconds, which will mix the medication with the inhaler evenly. A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) items should the nurse don prior to providing client care? (Select All That Apply) A. Gown B. Gloves C. Mask D. Hair Cover E. Goggles - ANSWER>>A. Gown B. Gloves The nurse should follow standard precautions when caring for a client who has AIDS. Because the bed linens might be soiled, the nurse should done a gown. Because the nurse's hands will come in contact with the soiled bed linens, the nurse should don clean gloves in addition to other necessary PPE.` A nurse is implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take? 38 Page 39 of 211 A. Apply a cold pack to the edematous area B. Check capillary refill before applying an ice pack to the affected area C. Half-fill an ice pack with crushed ice D. Apply an ice pack for 60 min intervals - ANSWER>>B. Check capillary refill before applying an ice pack to the affected area The nurse should check the affected area for adequate circulation by assessing pulses and capillary refill because a cold pack applied to an area of impaired circulation can further decrease the blood supply to the area. A nurse is assessing a client who has fluid-volume excess. Which of the following findings should the nurse expect? A. Crackles in the lung fields B. Flat neck veins C. Postural hypotension D. Dark yellow urine - ANSWER>>A. Crackles in the lung fields Manifestations of fluid-volume excess include crackles in the lungs, dependent edema, full neck veins when the client is upright, elevated blood pressure, and sudden weight gain. A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take? 39 Page 40 of 211 A. Don clean gloves to remove the old dressing B. Loosen the dressing by pulling the tape away from the wound C. Remove the entire old dressing at once D. Open sterile supplies after applying sterile gloves - ANSWER>>A. Don clean gloves to remove the old dressing The nurse should use standard precautions by applying clean gloves when faced with the possibility of coming into contact with secretions. Removing a soiled dressing is a procedure that requires wearing clean gloves. Sterile gloves are not necessary until the nurse applies the new sterile dressing. A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet. A. Vitamin C and zinc B. Vitamin D C. Vitamin K and iron D. Calcium - ANSWER>>A. Vitamin C and zinc The client's body needs both vitamin C and zinc to fight a wound infection. The client should receive a multivitamin and a mineral supplement of both these substances. In addition, vitamin E supplements also are needed to promote skin and wound healing. 40 Page 41 of 211 A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states, "All this equipment is making me nervous." Which of the following responses should the nurse offer? A. "You won't need the equipment for very long." B. "All of this equipment can be frightening." C. "Why does the equipment bother you?" D. "Let me tell you about what each machine does." - ANSWER>>B. "All of this equipment can be frightening." This statement is therapeutic because the nurse is reflecting the client's statement. The client is feeling fearful, and this response shows the nurse understands those feelings, which will encourage the client to communicate more. A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? A. Daily weight B. Blood pressure C. Specific gravity D. Intake and output - ANSWER>>A. Daily weight 41 Page 42 of 211 According to the evidence-based priority-setting framework, daily weight provides important information about the client's fluid status. A gain or loss of 1 kg (2.2 lb.) indicates a gain or of 1 L of fluid; therefore, weighing the client daily will provide the most accurate fluid status measurement. A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? A. Irrigate the tubing with sterile normal water once during each shift B. Cleanse the opening with soap and water after emptying C. Maintain the tubing above the level of the surgical incision D. Collapse the device to remove air after emptying - ANSWER>>D. Collapse the device to remove air after emptying The nurse should collapse the device to remove air after emptying the contents periodically. This will create enough suction to pull fluid exudate into the collection area of the device. A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? A. Renew the prescription for the use of restraints within 24 hours B. Secure the restraint with the buckle side next to the client's skin C. Ensure 4 fingers can be inserted under the secured restraint 42 Page 43 of 211 D. Remove the restraint every 3 hours - ANSWER>>A. Renew the prescription for the use of restraints within 24 hours The nurse should plan to renew the prescription for the restraints within 24 hours, only after the provider evaluated the client. A nurse on a medical-surgical unit is caring for a client who is at risk of experiencing seizures. Which of the following pieces of equipment must be available at the client's bedside at all times? A. Suction equipment B. Clean gloves C. Blankets D. Oxygen - ANSWER>>A. Suction equipment The greatest risk to a client who is having a seizure is an injury from aspirating secretions or emesis; therefore the nurse must have suction equipment available for clearing the mouth of secretions or emesis to reduce this risk. After assessing a client's radial pulses, the nurse documents "radial pulses 4+ bilaterally." The nurse should document this finding when a client's pulses have which of the following qualities. A. Bounding B. Full 43 Page 44 of 211 C. Variable D. Weak - ANSWER>>A. Bounding A pulse of 4+ is bounding and does not disappear with moderate pressure. Pulse strength ranges from absent (0) to bounding (4+). A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative. Which of the following clients should the nurse see first? A. A client who is 1 day postoperative following a lobectomy for small-cell carcinoma and has a chest tube with 35-mL/hr of bright red, bloody drainage B. A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage C. A client who is 2 days postoperative following the excision of an abdominal mass and has a portable wound suction device with 20 mL/hr of serosanguinous drainage D. A client who is 1 day postoperative following the excision of a bladder wall tumor and prostate and has continuous bladder irrigation with 300 mL/hr reddish-pink urine ANSWER>>B. A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage. An ostomy bag full of blood indicates the client's bowel is hemorrhaging and nurse must report this finding to the surgeon immediately. The client may require fluid replacement, transfusion, and additional surgery to repair the bleeding vessel. The finding poses an immediate threat to the client's circulation. 44 Page 45 of 211 A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? A. 2-point discrimination test B. Glasgow coma scale C. Babinski reflex D. Romberg test - ANSWER>>D. Romberg Test When using the Romberg test, the nurse instructs the client to stand with the feet together and arms at the sides, first with the eyes open and then with the eyes close. The inability to maintain balance is a positive Romberg test. A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client's HIV infection status. Which of the following actions should the nurse take? A. Inform the guard that the warden must request this information B. Ask the guard to sign a release of information form C. Instruct the guard to ask the inmate D. Complete an incident report - ANSWER>>C. Instruct the guard to ask the inmate 45 Page 46 of 211 The nurse is not able to supply this information to the guard. In order for the guard to obtain the information, the client must offer the information freely. Therefore, the nurse should instruct the guard to ask the client for this information. A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. Which of the following actions should the nurse perform immediately following the transfer? A. Administer pain medication B. Check the client's vital signs C. Instruct the client to use the incentive spirometer every 1 hr D. Provide ice chips as per provider prescription - ANSWER>>B. Check the client's vital signs The greatest risk to this client is an injury from unstable vital signs after receiving anesthesia and medication. Therefore, the first action the nurse should take is to check the client's vital signs and compare them with the readings during the PACU stay. A nurse is teaching a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching? A. The client holds the cane on the unaffected side B. The client walks by stepping with the unaffected leg before the affected leg C. The client holds the cane directly next to the foot 46 Page 47 of 211 D. The client holds the cane with a straight elbow - ANSWER>>A. The client holds the cane on the unaffected side. The nurse should instruct the client to hold the cane on the unaffected side to provide a wide base of support and stability A nurse is preparing to administer a bolus feeding to a client through an NG tube and observes that the exit mark on the tube has moved since the last feeding. Which of the following actions should the nurse plan to take? A. Auscultate over the stomach while injecting air B. Request an X-ray of the client's abdomen C. Place the head of the client's bed in a flat position D. Administer the feeding if the pH of the aspirated contents is >6 - ANSWER>>B. Request an X-ray of the client's abdomen The nurse should request an X-ray to verify the placement of the NG tube both after the initial insertion of the tube and if displacement of the tube is suspected. The nurse should verify NG tube placement prior to administering a bolus feeding. A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following entries should the nurse enter into the client's medical record? A. The client refused to take the medication today 47 Page 48 of 211 B. The client stated, "I will not take this pill." C. The client seemed angry and hostile D. The client threw the medication on the floor - ANSWER>>D. The client threw the medication on the floor The nurse should document exactly what took place for an accurate, factual account of the events. The nurse should document the client's actions in the medical record. A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors increases the client's risk of developing complicated grief? A. The deceased was a close friend. B. The client lived far from the deceased. C. The death was sudden D. The client has not visited the deceased in a long time. - ANSWER>>C. The death was sudden Complicated grief can occur when the death of a loved one is sudden and unexpected A nurse documents the presence of clubbing of the fingernails for a client who has emphysema. Which of the following is an underlying cause of this finding? A. Trauma B. Severe Infection 48 Page 49 of 211 C. Iron-deficiency anemia D. Chronic hypoxemia - ANSWER>>D. Chronic hypoxemia Clubbing of the nails of the fingers and toes is the result of chronic hypoxemia (low oxygen supply) such as with COPD. It is a change in the angle between the nail and the nail base, often with enlargement of the fingertips. 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 ADLs. Which of the following activities should the nurse recommend to the client? A. Sweeping the floor B. Shoveling snow C. Cleaning windows D. Washing dishes - ANSWER>>D. Washing dishes Washing dishes requires a low level of activity and is appropriate for this client A nurse is preparing to administer oral phenytoin to a client who has a seizure disorder. Before administering the medication, which of the following actions should the nurse take? A. Document the administration of the medication B. Count the amount of available medication on hand and sign for it 49 Page 50 of 211 C. Measure the client's respiratory rate D. Check the medication dose and the client's identification - ANSWER>>D. Check the medication dose and the client's identification The "rights" of medication administration include verifying the right client and the right dose. A nurse is reviewing a client's lab report. The client's ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3 24 mEq/L. The nurse should determine that the client has which of the following acid base imbalances? A. Respiratory alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Metabolic alkalosis - ANSWER>>A. Respiratory Alkalosis The client's pH is elevated above the expected reference range of 7.35 to 7.45 indicating alkalosis. Additionally, the client's PaCO2 is below the expected reference range of 35 to 45 mmHg, which indicates a respiratory origin. Hence the nurse should conclude that the client's elevated pH and decreased PaCO2 indicates respiratory alkalosis. A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings is another clinical manifestation of fluid volume excess? 50 Page 51 of 211 A. Sunken eyeballs B. Hypotension C. Poor skin turgor D. Bounding pulse - ANSWER>>D. Bounding pulse A bounding pulse is an expected finding of fluid volume excess. 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 readings are inconsistent. Which of the following actions should the nurse take? A. Turn on the machine every 15 min to measure the client's blood pressure. B. Record only the blood pressure readings needed for 15-min intervals C. Obtain manual and automatic readings and compare them D. Disconnect the machine and measure the blood pressure manually every 15 min ANSWER>>D. Disconnect the machine and measure the blood pressure manually every 15 minutes. If the nurse questions the reliability of the monitoring equipment, a manual process should be used. Also, malfunctioning equipment can pose a safety risk for the client, so it must be tagged and removed. A nurse is communicating with a group of clients about what to expect during the postoperative phase of a total hip arthroplasty. Which of the following elements of the 51 Page 52 of 211 communication process should the nurse identify as an evaluation of effective communication? A. The motivation for communication is evident B. Feedback is provided C. A message is communicated to the group of clients D. Multiple channels are used by the sender - ANSWER>>B. Feedback is provided Feedback in verbal and/or nonverbal forms is evidence of successful communication. Feedback can indicate to the nurse whether the meaning of the message was understood by the recipient. A nurse preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? A. Maintain suction while removing the NG tube B. Instill 100 mL of air in the NG tube before removal C. Pinch the NG tube while removing the tube D. Instruct the client to breathe in and out during the removal of the NG tube ANSWER>>C. Pinch the NG tube while removing the tube Pinching the tube decreases the risk of aspiration of any gastric contents. 52 Page 53 of 211 A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? A. Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube B. Position the client on the right side C. Insert the tip of tubing 8 cm (3.1 in) D. Hold the enema container 61 cm (24 in) above the rectum - ANSWER>>C. Insert the tip of the tubing 8 cm (3.1 in) The nurse should insert the tip of the tubing 7 to 10 cm along the rectal wall to prevent dislodging of the tube during the procedure and avoid injury to the rectal mucosa. 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? A. Inspection B. Auscultation C. Percussion D. Palpation - ANSWER>>A. Inspection According to evidence-based practice, the nurse should inspect the abdomen first by observing the contour of the abdomen, the condition of the skin 53 Page 54 of 211 An adolescent client in an outpatient mental health facility tells the nurse that he struggles to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make? A. "Don't worry; teenagers often have friends who give bad advice." B. "I think you should stop seeing those friends since they discourage you from following your treatment plan." C. "Tell me more about how your friends discourage you." D. "Where did you meet these friends." - ANSWER>>C. "Tell me more about how your friends discourage you." The nurse should ask an open-ended question that encourages the client to elaborate on these problems. A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a form of secondary prevention? A. Holding a community clinic to administer influenza immunizations B. Screening groups of older adults in nursing care facilities for early influenza manifestations C. Educating parents of young children about the dangers of influenza D. Finding rehabilitation programs for older adults who have complications related to influenza - ANSWER>>B. Screening groups of older adults in nursing care facilities for early influenza manifestations. 54 Page 55 of 211 Secondary prevention is focused on preventing complications of an illness or providing care to prevent an illness from becoming severe. A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of incomplete protein? A. Eggs B. Soybeans C. Lentils D. Yogurt - ANSWER>>C. Lentils Incomplete proteins are missing 1 or more of the essential amino acids necessary for the synthesis of protein in the body. A nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. Which of the following actions should the nurse take? A. Change the tube feeding bag every 48 hours B. Chill the formula prior to administration C. Increase the infusion rate. D. Request a prescription for an isotonic enteral nutrition formula - ANSWER>>D. Request a prescription for an isotonic enteral nutrition formula 55 Page 56 of 211 Isotonic formula can be easier for patients to digest and can decrease diarrhea. A nurse discovers that a client received the wrong medication. Which of the following actions should the nurse take first? A. Complete a medication error report. B. Notify the prescribing provider C. Assess the client D. Notify the charge nurse - ANSWER>>C. Assess the client The greatest risk to the client's safety is adverse effects. The nurse should assess the client first for any possible adverse effects. This assessment also serves as a baseline for further monitoring. 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? A. "A lot of clients who are cared for at home have the same problem." B. "Don't worry about. He will get a bath, and that will take care of the odor." C. "It must be difficult to care for someone who is confined to bed." D. "When was the last time that he had a bath?" - ANSWER>>C. "It must be difficult to care for someone who is confined to bed." 56 Page 57 of 211 This response addresses the feelings of the partner by reflecting her feelings, which facilitates therapeutic communication because it is nonjudgmental and encourages the partner to express her feelings. 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' commitment to a long-term goal of weight loss? A. Attempt to increase the clients' self-motivation B. Keep detailed records of each client's progress C. Test client learning after each training session D. Avoid discussing topics that might increase the clients' anxiety - ANSWER>>A. Attempt to increase the clients' self-motivation Motivation to learn is a key part of improving a client's commitment to achieving a health goal, as well as increasing the amount and speed of learning. A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take? A. Instruct the client to blink several times after instilling the medication B. Ask the client to look straight ahead during the instillation of the medication C. Apply pressure to the puncta after instilling the medication D. Place each drop of the medication directly onto the client's cornea - ANSWER>>C. Apply pressure to the puncta after instilling the medication 57 Page 58 of 211 The nurse should instill the medication into the conjunctival sac and apply pressure to the puncta for 1 to 2 minutes afterward to prevent systemic absorption of the medication. A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. Which of the following actions should the nurse plan to take? A. Hold the dropper 1 cm (0.5 in) above the ear canal during administration B. Apply pressure to the nasolacrimal duct following administration C. Place a cotton ball into the inner ear canal for 30 min following administration D. Straighten the ear canal by pulling the auricle down and back prior to administration ANSWER>>A. Hold the dropper 1 cm (0.5 in) above the ear canal during administration A nurse is caring for a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect injury to which of the following areas of the brain? A. Hypothalamus B. Cerebral cortex C. Pituitary D. Cerebellum - ANSWER>>D. Cerebellum 58 Page 59 of 211 The nurse should suspect injury to the cerebellum if the client is experiencing difficulty controlling balance and coordination. A client's movements can become uncoordinated, unsure, and clumsy following an injury to this part of the brain. A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse perform? A. Place the soiled linens on the chair while making the bed B. Hold the linens away from the body and clothing C. Place the linens on the floor until a linen bag is available D. Shake the clean linens to unfold - ANSWER>>B. Hold the linens away from the body and clothing Microorganisms present on the nurse's clothing can expose other clients to microoganisms. After assessing a client, the nurse documents "1+ pedal edema bilaterally." This indicates that the nurse observed an indentation of which of the following depths after applying pressure? A. 2 mm B. 4 mm C. 6 mm D. 8 mm - ANSWER>>A. 2 mm 59 Page 60 of 211 2 mm - 1+ 4 mm - 2+ 6 mm - 3+ 8 mm - 4+ A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurse take? (Select All That Apply) A. Carefully reinsert the intestine through the opening in the wound B. Place the client in a supine position with the hips and knees flexed C. Leave the room to call the surgeon D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock - ANSWER>>B. Place the client in a supine position with the hips and knees flexed D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock B - This position can help to prevent further tearing of the incision and wound evisceration by lessening tension on the wound 60 Page 61 of 211 D - The nurse should cover the protruding intestine with a sterile dressing that is moistened with 0.9% sodium chloride to prevent further contamination of the wound and to keep the protruding intestine from drying out. E - The nurse should monitor the client for a physiological stimulus or a psychological stimulus, which can increase the risk of shock. Monitor for increased heart rate and respiratory rate, changes in blood pressure or mentation, and cool/clammy skin. A nurse is taking a client's vital signs. Which of the following findings should the nurse identify as outside the expected reference range? A. Pulse rate 90/min B. Rectal temperature 38°C (100.4°F) C. Pulse oximetry 95% D. BP 145/90 mmHg - ANSWER>>D. 145/90 mmHg A nurse is reviewing a client's 24 hr dietary recall. The client reports eating a slice of toasted white bread with butter, a banana, a glass of milk, and a cup of coffee for breakfast; grilled chicken, a baked potato, and a glass of milk for lunch; an apple and cheddar cheese for a snack; and 2 servings of chicken, 2 cups of steamed broccoli, and a glass of milk for dinner. This client's diet is deficient in which of the following food groups? A. Dairy B. Vegetables C. Fruits D. Grains - ANSWER>>D. Grains 61 Page 62 of 211 This client only consumed 1 serving of grains on the day of the 24-hour dietary recall. USDA dietary guidelines recommend 3 or more ounce-equivalents of whole-grain products per day. Additionally, the choice of white bread is low in fiber, which can lead to constipation and an increased risk of developing hyperlipidemia. The USDA guidelines recommend that at least half of the grains consumed should be whole grain. While admitting a client to the medical unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able." The nurse should identify that the client is referring to which of the following documents? A. Informed consent form B. Living will document C. Do-not-resuscitate (DNR) directive D. Durable power of attorney document - ANSWER>>D. Durable power of attorney document A durable power of attorney for health care document, or health care proxy, names a surrogate who can make health care decisions for the client if he is unable to do so. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following pieces of information must the nurse verify with another nurse prior to the administration? (Select all that apply.) A. The client's ID number 62 Page 63 of 211 B. The client's room number C. The client's name D. ABO compatibility E. Rh compatibility - ANSWER>>A. The client's ID number C. The client's name D. ABO compatibility E. Rh compatibility Two nurses must verify this information, including the client's facility identification number, name, ABO compatibility, and RH compatibility, to prevent transfusion reactions due to human error. A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take? A. Establish client outcomes. B. Collect information about past health problems. C. Determine whether the client has met specific goals. D. Identify the client's specific health problems. - ANSWER>>A. Establish client outcomes. The planning phase of the nursing process includes developing goals and outcomes that help the nurse create the client's plan of care. 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.) 63 Page 64 of 211 A. Set the suction machine at 120 mmHg B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown E. Apply petroleum jelly to the client's nares - ANSWER>>B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown Frequent oral hygiene provides comfort for the client since mucous membranes become dry and uncomfortable when a client cannot drink fluids. Measuring the drainage at least every shift helps the provider calculate fluid loss and prescribe appropriate replacement therapy. An unsecured NG tube can irritate the nares if the tube is pulled or caught on the bed or other equipment. The tube can also be dislodged if not secured appropriately. A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. The nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. Which of the following actions should the nurse take? A. Change the infusion tubing B. Flush the IV catheter 64 Page 65 of 211 C. Remove the IV catheter D. Apply a cool compress to the site - ANSWER>>C. Remove the IV catheter This client's manifestations suggest phlebitis. The nurse should stop the infusion and remove the IV catheter immediately. The nurse should then apply warm compresses to the site. A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? A. Encourage the child to cough frequently to clear congestion from anesthesia. B. Place a heating pad on the child's neck for comfort. C. Administer analgesics to the child on a routine schedule throughout the day and night. D. Provide the child with ice cream when oral intake is initiated. - ANSWER>>C. Administer analgesics to the child on a routine schedule throughout the day and night. To soothe the client's throat following a tonsillectomy, the nurse should administer pain medication routinely. The nurse can provide the medication rectally or intravenously to avoid the oral route. A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect? A. Frequent bowel sounds with flatus B. Absent bowel sounds with distention C. Hyperactive bowel sounds with diarrhea 65 Page 66 of 211 D. Normal bowel sounds with increased peristalsis - ANSWER>>B. Absent bowel sounds with distention Paralytic ileus is an immobile bowel. In this disorder, bowel sounds are absent, and the abdomen is distended. A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take? A. Hyperoxygenate the client before suctioning B. Insert the catheter during exhalation C. Apply suction during insertion of the catheter D. Apply suction for no more than 15 sec - ANSWER>>A. Hyperoxygenate the client before suctioning The nurse should use a manual resuscitation bag to hyperoxygenate the client for several minutes prior to suctioning. A nurse is reviewing the laboratory values of a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? A. Decreased calcium B. Decreased potassium C. Increased potassium 66 Page 67 of 211 D. Increased calcium - ANSWER>>A. Decreased calcium Calcium is necessary for nerve conduction and muscle contractions. When the client's total calcium level is <8.4 mg/dL, tetany and muscle spasms may occur. The nurse should tap the facial nerve in front of the client's ear. If facial muscle twitching follows this stimulus, it is a positive Chvostek's sign and an indication of hypocalcemia. A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching? A. The wound edges are well-approximated. B. The wound is closed at a later date. C. A skin graft is placed over the wound bed. D. Granulation tissue fills the wound during healing. - ANSWER>>D. Granulation tissue fills the wound during healing. A beefy, red tissue called granulation tissue fills the wound during healing. The wound is left open to drain and heal by secondary intention, which should occur within 5 to 21 days. Open wounds increase the risk of wound infection. A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the child's temperature? A. Rectal 67 Page 68 of 211 B. Tympanic C. Oral D. Temporal - ANSWER>>D. Temporal The temporal artery route, while not as accurate as the rectal route for obtaining a precise body temperature, is noninvasive and can be used to obtain a temperature in a toddler who might have an ear infection and who is having diarrhea. The nurse should place the probe behind the ear if the client is diaphoretic but should avoid placing it over an area covered with hair. A nurse is helping a client change his hospital gown. The client has an IV infusion via an infusion pump. Which of the following actions should the nurse take first? A. Remove the sleeve of the gown from the arm without the IV line B. Slow the infusion using the roller clamp C. Disconnect the IV line from the pump D. Bring the IV solution and tubing from the outside to the inside of the sleeve of the gown - ANSWER>>A. Remove the sleeve of the gown from the arm without the IV line According to evidence-based practice, the nurse should first remove the gown from the client's arm without the IV line. Beginning this process will enable the nurse to move the gown fully off the client before stopping the system to remove the gown from the line, resulting in minimal interruption of the IV flow. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take? 68 Page 69 of 211 A. Administer 0.9% sodium chloride until TPN is available from the pharmacy B. Check the client's capillary blood glucose level every 4 hr C. Obtain the client's weight each week D. Change the IV tubing every 3 days - ANSWER>>B. Check the client's capillary blood glucose level every 4 hr The nurse should check the client's capillary blood glucose level every 4 hours or according to facility policy due to the client's risk of hyperglycemia while receiving TPN. The dextrose concentration in TPN increases the risk of this complication. A nurse is auscultating a client's lungs and identifies rhonchi over the trachea and bronchi. Which of the following actions should the nurse take? A. Limit the client's fluid intake B. Assist the client into a supine position C. Administer oxygen at 2 L/min D. Encourage the client to cough - ANSWER>>D. Encourage the client to cough Rhonchi are loud, low-pitched, rumbling sounds primarily detected over the trachea and bronchi. The nurse should encourage the client to cough because doing so often clears this adventitious sound. 69 Page 70 of 211 A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the client's risk of aspiration? A. Irrigate the tubing with 30 mL of sterile water B. Elevate the head of the bed to 30° or 45° C. Suggest changing the feeding to lactose-free formula D. Warm the enteral formula to room temperature before feeding - ANSWER>>B. Elevate the head of the bed to 30° or 45° Elevating the head of the bed to at least 30° and preferably 45° helps prevent the gravitational reflux of gastric contents, thereby decreasing the risk of aspiration. A nurse is assessing a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields? A. Vesicular B. Bronchial C. Rhonchi D. Bronchovesicular - ANSWER>>A. Vesicular The nurse will hear vesicular sounds over the periphery of the major lung fields. These sounds are soft and low-pitched. 70 Page 71 of 211 A nurse is caring for a client who has a Clostridium difficile infection and is in contact isolation. Which of the following actions should the nurse take? A. Wear gloves when changing the client's gown. B. Use alcohol-based sanitizer to cleanse the hands. C. Wear a mask when assisting the client with his meal tray. D. Place the client on complete bed rest. - ANSWER>>A. Wear gloves when changing the client's gown. The nurse should wear gloves when handling articles that have the potential to contaminate the hands when caring for a client in contact isolation. A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states, "It's too late for me to quit." Which of the following actions should the nurse take? A. Assist the client in finding local smoking-cessation assistance programs B. Tell the client that she will be all right after receiving medical care C. Inform the client that she must stop smoking or the provider will not be able to care for her D. Advocate for the client by supporting her statement about not quitting ANSWER>>A. Assist the client in finding local smoking-cessation assistance programs 71 Page 72 of 211 Smoking cessation slows the progression of chronic obstructive pulmonary disease (COPD). It is not "too late" for this client to stop smoking, and the nurse should encourage the client to do so. A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make? A. "You look just fine to me." B. "Nobody expects you to look beautiful in the hospital." C. "I understand how you feel. I would feel the same way." D. "Would you like to talk about how you feel?" - ANSWER>>D. "Would you like to talk about how you feel?" This is a therapeutic response that will encourage the client to talk about his concerns and feelings. A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? A. Fifth intercostal space just medial to the midclavicular line B. Second intercostal space to the left of the sternum C. Fifth intercostal space to the left of the sternum D. Second intercostal space to the right of the sternum - ANSWER>>D. Second intercostal space to the right of the sternum 72 Page 73 of 211 The aortic valve is located in the second intercostal space to the right of the sternum. Aortic stenosis produces a mid-systolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward. A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? A. Evaluate pedal pulses B. Obtain a medical history C. Measure vital signs D. Assess for leg pain - ANSWER>>A. Evaluate pedal pulses For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse perform to transfer the client from the stretcher to the bed? A. Lock the wheels on the bed and stretcher. B. Instruct the client to raise his arms above his head. C. Elevate the stretcher 2.5 cm (1 in) above the height of the bed. 73 Page 74 of 211 D. Log-roll the client. - ANSWER>>A. Lock the wheels on the bed and stretcher. Locking the wheels prevents the client from falling on the floor by not allowing the cart or bed to move apart or away from the client. A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. Which of the following actions should the nurse take? A. Tell the client the provider does not want her to remain in bed B. Allow the client to remain in bed until her pain subsides C. Instruct the family to perform ADLs for the client D. Advise the client to perform range-of-motion exercises while in bed - ANSWER>>D. Advise the client to perform range-of-motion exercises while in bed Performing range-of-motion exercises will help the client maintain mobility until her pain is under control and she is able to ambulate without excessive discomfort. A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take? A. Clean the incision from bottom to top B. Apply sterile gloves prior to opening dressing packages C. Remove the tape by pulling away from the wound 74 Page 75 of 211 D. Clean the drain site from the center outward - ANSWER>>D. Clean the drain site from the center outward The nurse should clean the drain site from the center outward to avoid introducing microorganisms from the periphery of the wound into the center of the wound. A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? A. Lower medial quadrant of the buttock near the coccyx B. Side hip between the iliac crest and anterior iliac spine C. Tissue of the posterior upper arm D. Lower inner thigh 4 finger-widths above the patella - ANSWER>>B. Side hip between the iliac crest and anterior iliac spine The side hip between the iliac crest and anterior iliac spine forms the boundaries for a ventrogluteal injection; therefore, this is an appropriate site for the nurse to select. This site is preferred for intramuscular injections for an adult client. The nurse should prepare for injection by placing a hand on the client's greater trochanter (e.g. right hand on left hip) with the first 2 fingers touching the iliac crest and anterior superior iliac spine, forming a "V" shape. A nurse is assessing a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings? A. Peripheral pulses equal bilaterally at a rate of 60/min B. Radial, brachial, and pedal pulses bilaterally weak 75 Page 76 of 211 C. Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities D. Brachial, radial, popliteal, and dorsalis pedis pulses regular, 58, and bilaterally palpable - ANSWER>>C. Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities The nurse does not evaluate the peripheral pulses routinely when measuring vital signs. Peripheral pulse evaluation is for specific clinical indications such as circulatory impairment to an extremity or during a comprehensive physical examination. A full evaluation of peripheral pulses typically includes palpation of the radial, brachial, ulnar, femoral, popliteal, tibial, and dorsalis pedal pulses. Documentation of peripheral pulse evaluation should include the strength of pulsations as well as their equality and symmetry in all 4 extremities. A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? A. Give the client a glass of water B. Assist the client into a sitting position C. Explain the procedure to the client D. Measure the length of tubing to be inserted - ANSWER>>C. Explain the procedure to the client The nurse should apply the least invasive priority-setting framework when caring for this client, which assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive. 76 Page 77 of 211 This reduces the number of organisms introduced into the body, decreasing the number of facility-acquired infections. Informing the client about the procedure reduces fear and assists in gaining the client's cooperation, which is important for NG tube insertion and is the priority nursing intervention. 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? A. Cream of rice B. Cottage cheese C. Gelatin D. Ice cream - ANSWER>>C. Gelatin Foods allowed on a clear liquid diet are clear and liquid at room temperature. A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of impaired skin integrity? A. 3+ Achilles reflex B. Faint pedal pulses C. Feet warm to the touch bilaterally D. Capillary refill of <2 sec - ANSWER>>B. Faint pedal pulses 77 Page 78 of 211 Faint pedal pulses can indicate poor circulation and tissue perfusion, which puts the client at risk of impaired skin integrity. A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? A. Place the client supine. B. Keep both side rails up. C. Raise the level of the bed. D. Inspect the client's mouth using a finger sweep. ANSWER>>C. Raise the level of the bed. The nurse should raise the bed to allow the use of proper body mechanics and reduce the risk of self-injury. A community health nurse is conducting a class about body mechanics for county office workers. Which of the following instructions should the nurse include? (Select all that apply.) A. "Sit with your back supported." B. "Keep your knees at hip level." C. "Use an ergonomically designed computer keyboard." D. "Keep your elbows away from your body." E. "Adjust the monitor screen so that you have to tilt your head slightly to look at it." ANSWER>>A. "Sit with your back supported." 78 Page 79 of 211 B. "Keep your knees at hip level." C. "Use an ergonomically designed computer keyboard." Using lumbar support in a straight-back chair helps maintain good posture and prevent back pain. Keeping the knees at the level of the hip or higher helps reduce the risk of lordosis, which is an exaggeration of the curve of the lumbar spine. Using a keyboard that maintains ergonomic positioning of the wrists can help prevent carpal tunnel syndrome. A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur? A. Hyperglycemia B. Hypotension C. Heightened immune response D. Bleeding tendencies - ANSWER>>A. Hyperglycemia Stress causes an increased secretion of cortisol, which can lead to hypertension and hyperglycemia. A nurse on a surgical unit is receiving a client who had abdominal surgery from the post-anesthesia care unit. Which of the following assessments should the nurse make first? 79 Page 80 of 211 A. Pain level B. Hydration status C. Airway D. Urinary output - ANSWER>>C. Airway The nurse should apply the ABC priority-setting framework when caring for this client. This framework emphasizes the basic core of human functioning and prioritizes having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life. Therefore, this is the nurse's priority concern. A nurse is preparing to perform postural drainage for a client. Which of the following actions should the nurse take? A. Give the client a bronchodilator immediately after the procedure B. Position the client for drainage of secretions by gravity C. Schedule postural drainage following meals D. Instruct the client regarding the importance of fluid restrictions - ANSWER>>B. Position the client for drainage of secretions by gravity Postural drainage consists of providing drainage, positioning, and turning the client. The positioning can help to drain secretions from the affected lung segments and bronchi into the trachea. 80 Page 81 of 211 A nurse is preparing to administer a unit of packed RBCs to a client when she discovers that the IV line is no longer patent. The IV team informs her that someone can come to initiate a new line in 30 min. Which of the following actions should the nurse take? A. Return the blood to the laboratory B. Place the blood in the medication room C. Place the blood in the refrigerator D. Leave the blood at the client's bedside - ANSWER>>A. Return the blood to the laboratory Because the nurse knows that the delay will be more than a few minutes, she should return the unit of packed RBCs immediately to the laboratory where the technician will maintain it at the appropriate temperature until the client is ready to receive it. A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? A. Warm, dry skin B. Increased urinary output C. Tachycardia D. Bradypnea - ANSWER>>C. Tachycardia Due to the decreased circulating blood volume that occurs with internal bleeding, the oxygen-carrying capacity of the blood is reduced. The body attempts to relieve the 81 Page 82 of 211 hypoxia by increasing the heart rate and cardiac output while increasing the respiratory rate. A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis? A. "I'll wrap the old dressing in a paper bag and put it in the trash." B. "I'll wash my hands before I remove the old dressing and again before putting on the new one." C. "I'll need to take a pain pill 30 minutes before I change the dressing." D. "I'll wear sterile gloves when I apply the new dressing." - ANSWER>>Answer: B. "I'll wash my hands before I remove the old dressing and again before putting on the new one." It is essential that the client understands the importance of hand hygiene before, during, and after any handling of the wound or its dressings. A nurse is performing a neurological assessment of a client. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests? A. Romberg B. Kinesthetic sensation C. 2-point discrimination 82 Page 83 of 211 D. Weber - ANSWER>>A. Romberg A Romberg test evaluates standing balance, first with the client's eyes open and then with them closed. The nurse should remain nearby because the client could fall during this test. A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first? A. Start chest compressions B. Provide breaths with a manual resuscitation bag C. Administer oxygen D. Establish an airway - ANSWER>>A. Start chest compressions The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC prioritysetting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The nurse should perform cardiopulmonary resuscitation, which starts with chest compressions followed by opening the airway and breathing for adults and pediatric clients; evidence indicates a great survival rate when chest compressions are started before a breath is initiated. A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning how to self-inject insulin. Which of the following statements should the nurse make? 83 Page 84 of 211 A. "Tell me what I can do to help you overcome your fear of giving yourself injections." B. "Your provider will not be pleased that you refuse to give yourself insulin injections." C. "It's okay. I'm sure your partner will be able to learn how to give you the insulin injections." D. "You won't be able to go home unless you learn to give yourself insulin injections." ANSWER>>Answer: A. "Tell me what I can do to help you overcome your fear of giving yourself injections." This response illustrates the therapeutic communication technique of clarifying and offering self. The nurse should allow the client to express feelings and fears and support the client in learning how to give the injections. A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? A. Hemolytic B. Febrile C. Circulatory overload D. Sepsis - ANSWER>>A. Hemolytic A hemolytic reaction occurs when the client's blood is incompatible with the donor's blood. Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion reaction. 84 Page 85 of 211 A nurse is preparing to instill a vaginal medication in suppository form to a client. Which of the following actions should the nurse take during this procedure? A. Don sterile gloves B. Use the dominant hand to retract the labia C. Use the index finger to insert the suppository D. Ease the suppository along the anterior vaginal wall - ANSWER>>C. Use the index finger to insert the suppository To ensure adequate distribution of the vaginal medication, the nurse should insert the suppository until the length of the nurse's index finger is inside the vagina or as far inside as possible. A nurse in a provider's clinic is taking a client's age, height, weight, and vital signs. The nurse should identify this action as part of which of the following components of the nursing process? A. Planning B. Evaluation C. Assessment D. Implementation - ANSWER>>C. Assessment 85 Page 86 of 211 Collecting this data is included in the assessment portion of the nursing process. In addition, the nurse should explore the client's health history and perform a physical examination. A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? A. Auscultate the blood pressure at the dorsalis pedis artery B. Measure the blood pressure with the client sitting on the side of the bed C. Place the cuff 7.6 cm (3 in) above the popliteal artery D. Place the bladder of the cuff over the posterior aspect of the thigh - ANSWER>>D. Place the bladder of the cuff over the posterior aspect of the thigh This is the correct position for the bladder of the cuff when the nurse is measuring a lower-extremity blood pressure. A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take? A. Measure the pulse using a Doppler ultrasound stethoscope B. Check the client's pedal pulses C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart D. Take the pulse at each peripheral site and count the rate for 30 sec - ANSWER>>C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart 86 Page 87 of 211 If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 60 seconds to obtain an accurate rate. Then, the nurse should document the irregularity in the client's medical record. A nurse is caring for a client who has a fecal impaction. Before the digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? A. Carminative B. Hypertonic C. Oil retention D. Sodium polystyrene sulfate - ANSWER>>C. Oil retention The nurse should administer an oil retention enema prior to the removal of a fecal impaction to soften the stool. This makes the procedure less painful for the client. A nurse is assessing a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries? A. Palpation of both carotid arteries simultaneously B. Auscultation of the arteries for bruits with the bell of the stethoscope C. Palpation of the arteries for murmurs bilaterally D. Auscultation of the arteries for thrills with the diaphragm of the stethoscope ANSWER>>B. Auscultation of the arteries for bruits with the bell of the stethoscope 87 Page 88 of 211 The bell of the stethoscope is more effective than the diaphragm in transmitting blowing or swishing sounds, such as those from turbulence in blood vessels A nurse is teaching a client how to perform range-of-motion exercises of the wrist. To perform adduction, which of the following instructions should the nurse include? A. "With your palm facing down, move your wrist sideways toward your thumb." B. "Move your palm toward the inner part of your forearm." C. "With your palm facing down, move your wrist sideways toward your little finger." D. "Bring the back of your hand as far back toward the wrist as you can." ANSWER>>A. "With your palm facing down, move your wrist sideways toward your thumb." This motion describes adducting the wrist. The client should be able to move her wrist 30º to 50º with this motion. A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for this client? A. BUN 18 mg/dL B. Capillary refill 1.5 sec C. Hct 55% D. Urine specific gravity 1.001 - ANSWER>>C. Hct 55% 88 Page 89 of 211 An elevated hematocrit indicates hypovolemia. Other indications of hypovolemia are a weak pulse, tachycardia, hypotension, tachypnea, slow capillary refill, elevated BUN, increased urine specific gravity, and decreased urine output. A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear? A. Air conduction is less than bone conduction in the left ear. B. Air conduction is greater than bone conduction in the left ear. C. Sound is lateralizing to the right ear. D. Sound is lateralizing to the left ear. - ANSWER>>A. Air conduction is less than bone conduction in the left ear. This finding indicates conductive hearing loss of the left ear. A nurse is caring for a client who has a deficiency of vitamin D. Which of the following foods should the nurse recommend the client include in his diet? A. Whole milk B. Chicken C. Oranges D. Dried peas - ANSWER>>A. Whole milk 89 Page 90 of 211 The fat-soluble vitamins (A, D, E, and K) require fatty substances or tissues to be dissolved and also require the presence of bile in the small intestine for absorption. Whole milk contains vitamins A and K and is often fortified with vitamin D. A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks both the client's native language and the nurse's, arrives to drive the client home. Which of the following actions should the nurse take? A. Ask the client's neighbor to call a family member to interpret. B. Ask the client's neighbor to translate the information. C. Obtain the services of an interpreter. D. Document the inability to provide discharge instructions. - ANSWER>>C. Obtain the services of an interpreter. Federal mandates require that a professional medical interpreter translate the client's health care information into the client's native language. 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 provide? A. "It's for your safety. Dentures can slip and block your airway during surgery." B. "You wouldn't want your teeth to be lost or broken during surgery, would you?" C. "The anesthesiologist requires all clients to remove their dentures." 90 Page 91 of 211 D. "What worries you about being without your teeth?" - ANSWER>>D. "What worries you about being without your teeth?" This response by the nurse is therapeutic because it validates the client's feelings of agitation and seeks a reason. A nurse is caring for client who has terminal pancreatic cancer. When the client states, "It's devastating that I will not be here to see my child graduate," the nurse should identify that the client is in which of the following stages of grief as defined by KublerRoss? A. Anger B. Bargaining C. Depression D. Acceptance - ANSWER>>C. Depression During the stage of depression, the client has realized the full impact of the loss or impending death and might express hopelessness and despair. A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions? A. Shaking soiled linen before putting it in a hamper 91 Page 92 of 211 B. Removing a face mask when standing 0.5 m (1.6 ft) from the client C. Assigning another client with the same infection to share the room with the client D. Allowing the client to visit a family member in the lobby of the facility - ANSWER>>C. Assigning another client with the same infection to share the room with the client The nurse can place clients who are infected with the same pathogen in the same room if a private room is not available. A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test? A. Sugar B. Coffee C. Cotton wisps D. Snellen chart - ANSWER>>C. Cotton wisps The trigeminal nerve has both sensory and motor capabilities. To assess its sensory function, the nurse uses a safety pin to assess for recognition of pain and a cotton wisp to evaluate recognition of touch sensations. To test motor abilities of cranial nerve (CN) V, the nurse should ask the client to clench the teeth. A nurse is supervising a newly licensed nurse who is administering a controlled substance. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? 92 Page 93 of 211 A. Placing an unused portion of the medication in a sharps box B. Asking another nurse to observe the disposal of an unused portion of the medication C. Counting the inventory of the available narcotic after administering the medication D. Ensuring that another nurse signs the control inventory form after disposal of an unused portion of medication - ANSWER>>B. Asking another nurse to observe the disposal of an unused portion of the medication The nurse should ask another nurse to witness the disposal of a controlled substance to maintain safe control of the narcotic. 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? A. Blood loss B. NPO status after surgery C. Nasogastric tube suctioning D. Impaired peristalsis of the intestines - ANSWER>>D. Impaired peristalsis of the intestines Normal bowel function is delayed for up to several days following a bowel resection. When peristalsis is absent or sluggish, intestinal gas builds up, producing pain and abdominal distention. The nurse should plan to help the client ambulate to promote peristalsis. 93 Page 94 of 211 A nurse is caring for a postoperative client who has an indwelling urinary catheter for gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first? A. Check to determine if the catheter tubing is kinked B. Palpate the bladder C. Obtain a prescription to irrigate the catheter with 0.9% sodium chloride D. Encourage the client to drink more fluids - ANSWER>>A. Check to determine if the catheter tubing is kinked The nurse should apply the least invasive priority-setting framework when caring for this client, which assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. This approach reduces the number of organisms introduced into the body, decreasing the number of facilityacquired infections. Hence, the first action the nurse should take is to inspect the tubing carefully, straighten any kinks, and ensure there are no dependent loops. A lack of drainage is often due to a kink in the tubing or the client lying on it. A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse that the AP understands how to perform this task? A. Locking the brakes on the bed and the wheelchair before moving the client B. Lowering the footplates of the wheelchair before the transfer C. Placing the wheelchair perpendicular to the bed 94 Page 95 of 211 D. Placing the wheelchair on the client's weaker side prior to the transfer ANSWER>>A. Locking the brakes on the bed and the wheelchair before moving the client Prior to starting the transfer, the AP should make sure that both the wheelchair and the bed are stationary and will not shift when the client moves into the chair. A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing? A. Cranial nerve XII B. Cranial nerve X C. Cranial nerve VIII D. Cranial nerve V - ANSWER>>A. Cranial nerve XII The nurse is checking the function of cranial nerve XII (hypoglossal), which innervates the tongue, by observing a range of tongue movements. A nurse on a medical unit is caring for a client who has difficulty sleeping. Which of the following actions should the nurse take to promote the client's ability to fall asleep? A. Encourage the client to ambulate in the hallway just before bedtime B. Allow the client to maintain the same bedtime routine as at home C. Keep the room temperature warm 95 Page 96 of 211 D. Offer the client a cup of hot chocolate before bedtime - ANSWER>>B. Allow the client to maintain the same bedtime routine as at home For many clients in an acute care facility, disrupting the usual sleep routine is the primary reason for a client's inability to sleep. Maintaining the home bedtime routine promotes sleep in ways that are effective for the client. Those whose usual bedtime routines include warm milk, massages, or pharmacological sleep aids might need and appreciate those interventions in inpatient settings. A nurse is preparing to administer a feeding via a gastrostomy tube to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding? A. Warm the feeding in a microwave oven B. Elevate the head of the client's bed C. Flush the tube with 0.9% sodium chloride for irrigation D. Verify that the client's gastric pH is above 4 - ANSWER>>B. Elevate the head of the client's bed Clients who have a brain injury are typically unable to swallow effectively and thus cannot protect their airway from aspiration. Even though this route bypasses the nasopharynx, it is still possible for the client to cough or vomit enteral formula into the oral cavity. Consequently, the nurse should strive to prevent aspiration by elevating the head of the bed prior to initiating the feeding. 96 Page 97 of 211 A nurse is initiating seizure precautions for a client who has a seizure disorder. Which of the following pieces of equipment should the nurse have readily available at the client's bedside? A. Vest restraint B. Tongue blade C. Oxygen equipment D. Neck brace - ANSWER>>C. Oxygen equipment The nurse should have oxygen equipment at the bedside of a client who is on seizure precautions. The nurse should be able to apply oxygen via mask or nasal cannula to a client who experiences a seizure. A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? A. Blow into the spirometer to elevate the balls in the device B. Cough deeply after each use C. Clean the mouthpiece with an alcohol swab after each use D. Use the spirometer every 8 hr - ANSWER>>B. Cough deeply after each use Proper use of the incentive spirometer loosens secretions in the client's lungs. The client should cough deeply to facilitate the removal of secretions from his lungs. 97 Page 98 of 211 A nurse is assessing a client who is unconscious. Family members are present and answer the nurse's questions about the client's medical history. The nurse should document this information as which of the following types of data? A. Secondary-source data B. Experiential data C. Primary-source data D. Quantitative data - ANSWER>>A. Secondary-source data Information provided by someone other than the client is secondary-source data. A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate? A. Airborne B. Droplet C. Contact D. Protective environment - ANSWER>>A. Airborne Airborne precautions are required for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles. 98 Page 99 of 211 A nurse is performing a physical assessment of a client. Which of the following actions should the nurse take to assess the client's tissue perfusion? A. Perform a Romberg test B. Check nails for Beau's lines C. Palpate for respiratory excursion D. Perform a blanch test - ANSWER>>D. Perform a blanch test The blanch test is used to check capillary refill, which is an indicator of peripheral circulation and tissue perfusion. A nurse is teaching a group of unit nurses about the experiences of clients who are having surgery. In which phase of care is the client transferred to the surgical suite table before being transferred to the PACU? A. Preoperative B. Postoperative C. Intraoperative D. Admission - ANSWER>>C. Intraoperative Intraoperative care begins when the client is transferred to the surgical suite table and ends when the client is admitted to the PACU. 99 Page 100 of 211 A nurse is teaching a group of older adults about expected age-related changes. Which of the following statements by a group member indicates that the teaching has been effective? A. "I should expect my heart rate to take longer to return to normal after exercise as I get older." B. "Urinary incontinence is something I will have to live with as I grow older." C. "I can expect to have less ear wax as I get older." D. "My stomach will empty more quickly after meals as I grow older." - ANSWER>>A. "I should expect my heart rate to take longer to return to normal after exercise as I get older." Older adults experience decreased cardiac output, which causes an increased pulse rate during exercise. The pulse rate also takes longer to return to normal after exercise. A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client? A. Vastus lateralis B. Dorsogluteal C. Deltoid D. Ventrogluteal - ANSWER>>D. Ventrogluteal 100 Page 101 of 211 According to evidence-based practice, the ventrogluteal site is the safest injection site for all adults because it contains thick gluteal muscles and does not contain major nerves or blood vessels. A nurse is beginning a therapeutic relationship with a client. Which of the following actions should the nurse take to convey empathy when using the therapeutic communication technique of active listening? A. Assume an open position B. Sit upright and lean back into the chair C. Avoid direct eye contact until the client initiates it D. Sit next to the client - ANSWER>>A. Assume an open position The nurse should sit with arms and legs uncrossed. Crossing them suggests a defensive posture. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? A. Redness at the infusion site B. Edema at the infusion site C. Warmth at the infusion site D. Oozing of blood at the infusion site - ANSWER>>B. Edema at the infusion site 101 Page 102 of 211 Edema due to fluid entering subcutaneous tissue is an indication of infiltration. A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? A. Place the client in the Trendelenburg position B. Perform percussions directly over the client's bare skin C. Use a flattened hand to perform percussions D. Remind the client that chest percussions can cause mild pain - ANSWER>>A. Place the client in the Trendelenburg position The nurse should place the client in a right-sided Trendelenburg position to promote drainage from the client's left lower lobe. A nurse is providing discharge teaching for a client who has type 2 diabetes mellitus and will be caring for herself at home. The client expresses concerns about preparing an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse offer? A. "The home health dietitian will visit and help you learn to cook all over again." B. "The dietitian will give you a list of foods and dietary choices to keep your diabetes under control." C. "The dietitian will help you choose foods you are used to that also meet your health needs." 102 Page 103 of 211 D. "It may be difficult, but I know you can change your eating and cooking habits with some help from the dietitian." - ANSWER>>C. "The dietitian will help you choose foods you are used to that also meet your health needs." This response shows respect for the client's food preferences and cultural needs by offering choices from among the client's usual foods. A nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following? A. Retention B. Oliguria C. Diuresis D. Dysuria - ANSWER>>C. Diuresis Diuresis or polyuria is the excretion of a high volume of urine. This condition has many causes, including metabolic and hormonal imbalances and diuretic therapy for treating renal, cardiovascular, and pulmonary disorders. A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect? A. Increased blood pressure B. Decreased blood glucose level 103 Page 104 of 211 C. Decreased oxygen use D. Increased gastrointestinal motility - ANSWER>>A. Increased blood pressure The nurse should expect a client who is experiencing stress and anxiety to manifest an increase in blood pressure and heart rate as a result of sympathetic stimulation. A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. The client states she slipped while getting out of bed. Which of the following actions should the nurse take first? A. Complete an incident report B. Check the client for injuries C. Make sure the client has skid-free footwear D. Remind the client to ask for help when getting out of bed - ANSWER>>B. Check the client for injuries Using the nursing process, the nurse should first evaluate the client for any injuries or physiological changes. The nurse should also notify the provider to determine the need for any further examination or intervention. A nurse is caring for a client who reports using several herbal medicines. Which of the following actions should the nurse take? A. Discourage the use of unregulated medications and supplements B. Verify the herbal supplements do not interact with medications the provider has prescribed 104 Page 105 of 211 C. Tell the client to limit the number of herbal supplements to no more than 2 D. Describe the dangers of taking plant-derived medications and supplements ANSWER>>B. Verify the herbal supplements do not interact with medications the provider has prescribed Many herbal products interact with other prescription and nonprescription medications. Valerian, for example, interacts with antihistamines as well as barbiturates and other sleep-promoting medications. The nurse should report any potential interactions to the provider. A nurse in a provider's office is teaching a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching? (Select all that apply.) A. Canned peaches B. White rice C. Black beans D. Whole-grain bread E. Tomato juice - ANSWER>>C. Black beans D. Whole-grain bread Dried peas and beans, including black beans, are high in fiber. Whole grains consist of the entire kernel and are also high in fiber. 105 Page 106 of 211 A nurse rates a client's biceps reflex as 2+. Which of the following characteristics should the nurse document about the client's reflexes? A. Diminished B. Average C. Brisk D. Hyperactive - ANSWER>>B. Average Reflexes range on a scale of 0 to 4+. Active or expected reflexes are 2+. A provider is planning an immunization clinic for older adults. At which of the following times should an older adult client receive the influenza vaccine? A. Once during the client's lifetime B. Every 10 years C. Every 5 years D. Annually in the fall - ANSWER>>D. Annually in the fall The nurse should recommend that older adult clients receive the influenza vaccine annually. Influenza outbreaks occur annually, and the influenza virus changes constantly. Consequently, an influenza vaccine from a previous year will not protect a client exposed to this year's influenza strain. Influenza in older adults can result in the development of primary viral influenza pneumonia, which causes several deaths a year. 106 Page 107 of 211 An influenza vaccine given in the fall, prior to the onset of flu season, will be most effective in preventing influenza in this target population. A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement? (Select all that apply.) A. Auscultate injected air B. Verify the initial X-ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid E. Check the aspirated fluid for glucose - ANSWER>>B. Verify the initial X-ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid The nurse should confirm the NG tube placement by checking the X-ray results following the insertion of the NG tube. In addition, the nurse should check the length of the NG tube that is exposed by comparing the markings on the tube to the client's nose to verify tube placement. Finally, the nurse should check the pH of aspirated fluid to verify the tube placement. A nurse is assessing a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect? A. Muscle tremors 107 Page 108 of 211 B. Positive Chvostek's sign C. Depressed deep-tendon reflexes D. Numbness around the mouth - ANSWER>>C. Depressed deep-tendon reflexes A total calcium level of 12.7 mg/dL is above the expected reference range. Manifestations of hypercalcemia include depressed deep-tendon reflexes, nausea, vomiting, bone pain, lethargy, and weakness. During the insertion of a urinary catheter for a client, the tip of the catheter brushes against the nurse's arm. Which of the following actions should the nurse take? A. Wipe the catheter with povidone-iodine and continue the catheter insertion. B. Soak the catheter in chlorhexidine for 15 min and then reattempt insertion. C. Continue with the catheter insertion. D. Obtain a new catheter and reattempt insertion. - ANSWER>>D. Obtain a new catheter and reattempt insertion. The insertion of a urinary catheter is a sterile procedure. The only way to ensure sterility of the catheter the nurse plans to insert is by obtaining a new sterile catheter and following surgical asepsis throughout the insertion procedure. During a physical examination of a client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect additional data? 108 Page 109 of 211 A. Confrontation test B. Symmetry of palpebral fissures C. Corneal light reflex D. Accommodation test - ANSWER>>C. Corneal light reflex The corneal light reflex requires the nurse to shine a penlight at the client's eyes and visualize whether the light shines on the same spot bilaterally. This test will indicate the alignment of the client's eyes as well as any deviation inward or outward. With strabismus, the eyes will not align when the client focuses. A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider? A. Calcium 9.5 mg/dL B. Sodium 150 mEq/L C. Potassium 4 mEq/L D. Magnesium 1.5 mEq/L - ANSWER>>B. Sodium 150 mEq/L A sodium level of 150 mEq/L is greater than the expected reference range of 135 to 145 mEq/L. This client is at risk for dehydration due to diarrhea. Hypernatremia is a manifestation of dehydration, and the nurse should report this finding to the provider. A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen? 109 Page 110 of 211 A. Collect the specimen when the client rises in the morning B. Force fluids during the day and collect the specimen in the evening C. Collect the specimen after antibiotics have been started D. Collect 2 mL of sputum before sending the specimen to the laboratory ANSWER>>A. Collect the specimen when the client rises in the morning The nurse should plan to collect the sputum specimen when the client arises in the morning because the client will be able to cough up the secretions that have accumulated during the night. Generally, the deepest specimens are obtained in the early morning, and it is preferable to collect the specimen before breakfast. The nurse should instruct the client to rinse the mouth, take a deep breath, and cough prior to expectorating into the sterile container. A nurse is providing teaching to a client with heart failure about reducing 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? A. The involvement of the client in planning the change B. The emphasis the provider places on the dietary changes C. The learning theory the nurse uses to teach the dietary changes D. The extent of the dietary changes planned for the client - ANSWER>>A. The involvement of the client in planning the change According to evidence-based practice, client involvement in planning dietary changes is the most important factor in the client's ability to learn new habits. 110 Page 111 of 211 A nurse is discussing fire safety with newly hired nurses. Which of the following actions is the priority if a fire occurs in the health care facility? A. Close the fire doors on the unit B. Use a fire extinguisher on the fire C. Pull the nearest fire alarm D. Evacuate clients from the unit - ANSWER>>D. Evacuate clients from the unit The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC prioritysetting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The greatest risk during a fire is injury to clients; therefore, the nurse's priority action is to evacuate clients from the unit. The nurse should follow the RACE protocol when responding to a fire: rescue, activate, confine, and extinguish. 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? A. Explain the X-ray procedure to the client. B. Help the client into a wheelchair before the transporter arrives. C. Ask if the client has any questions. D. Identify the client using 2 identifiers. - ANSWER>>D. Identify the client using 2 identifiers. 111 Page 112 of 211 The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC prioritysetting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. A nurse is admitting a client who is experiencing an exacerbation of heart failure. At which of the following times should the nurse initiate discharge planning? A. During the admission process B. As soon as the client's condition is stable C. During the initial team conference D. On the day prior to discharge - ANSWER>>A. During the admission process The nurse should initiate discharge planning as soon as the client is admitted to the facility. This is intended to ensure the continuity of care and meet the client's care needs. This process should include each member of the client's health care team. A nurse is caring for a middle-aged adult client. The nurse should identify which of the following statements as an indication that the client has completed Erikson's developmental task for her age group? A. "I am comfortable with my decision to choose a lifelong partner." B. "I think I have done a good job with my children since they are all independent now." 112 Page 113 of 211 C. "As I look back over my life, I can see that I have achieved most of the goals I set for myself." D. "I love my work so much that it is difficult to think about retirement." - ANSWER>>B. "I think I have done a good job with my children since they are all independent now." According to Erikson, the developmental task for middle adults is generativity vs. stagnation. Middle adults help shape future generations through community involvement, parenting, mentoring, and teaching. This statement about helping her children achieve independence indicates that the client has accomplished this developmental task. A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care? A. "Social services can contact various community resources that will be helpful." B. "I will review the care plan to make the necessary changes." C. "Let's set up a meeting time with the doctor to discuss your options for home care." D. "I will make a list of things we need to do before discharge." - ANSWER>>C. "Let's set up a meeting time with the doctor to discuss your options for home care." In family-centered care, the nurse considers the health of the family as a unit; therefore, the client and family members help determine their outcomes and goals. Setting up a meeting to discuss this with the provider will give them a sense of autonomy and foster the family-centered nursing environment. 113 Page 114 of 211 A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first? A. Gloves B. Gown C. Eyewear D. Mask - ANSWER>>A. Gloves According to evidence-based practice, the nurse should first remove the gloves because they are the most contaminated piece of PPE. Next, the nurse should remove the goggles or face shield and then the gown. Finally, the nurse should remove the respirator or mask because it is the least contaminated piece of PPE. A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take? A. Repeat each joint motion 5 times during each session B. Move the joint to the point of considerable resistance C. Sit approximately 2 ft from the side of the bed closest to the joint being exercised D. Exercise the smaller joints first - ANSWER>>A. Repeat each joint motion 5 times during each session 114 Page 115 of 211 To maintain the client's joint mobility, the nurse should repeat each motion 3 to 5 times. A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse implement? A. Place the client in a semi-private room B. Wear a mask when providing care C. Wear a gown when in the client's room D. Dispose of all bed linens used by the client - ANSWER>>C. Wear a gown when in the client's room The nurse should apply a gown at all times when in the client's room to maintain contact precautions. This client who has MRSA should be placed in contact isolation, which includes the use of gloves and a gown when providing care. A nurse is caring for a client who has a dysrhythmia. Which of the following techniques should the nurse to use to assess for a pulse deficit? A. Obtain the apical and radial rates simultaneously B. Check the blood pressure in the left and right arms C. Compare the pulse strength in the upper extremities D. Palpate the pulses in the lower extremities - ANSWER>>A. Obtain the apical and radial rates simultaneously 115 Page 116 of 211 To assess for a pulse deficit, the nurse and a second person assess the client's radial and apical pulses simultaneously and the compare both rates. To calculate the pulse deficit, the nurse should subtract the difference between the apical and radial pulse rates. A nurse is measuring a client's vital signs. The client's resting radial pulse rate is 55/min. Which of the following actions should the nurse take next? A. Document the finding B. Measure the client's apical pulse rate C. Talk with the client about factors that can affect the pulse rate D. Notify the provider about the client's radial pulse rate - ANSWER>>B. Measure the client's apical pulse rate The first action the nurse should take using the nursing process is to assess or collect data from the client. This pulse rate is below the expected reference range for an adult. The nurse and a coworker should measure the apical and radial pulse rates simultaneously to determine if there is a pulse deficit. If the client's radial pulse rate is lower than the apical rate, the client might have a cardiovascular disorder. A nurse is assessing a client who is experiencing stress following a near fall out of bed. Which of the following physiological responses should the nurse expect due to the fightor-flight response? A. Decreased respiratory rate B. Pinpoint pupils 116 Page 117 of 211 C. Increased blood pressure D. Bronchial constriction - ANSWER>>C. Increased blood pressure The nurse should expect a client who is experiencing the fight-or-flight response to manifest an increase in arterial blood pressure, heart rate, and cardiac output due to arousal of the central nervous system. A nurse is caring for a client who is well-hydrated and has no visible evidence of nutritional deficiencies. A laboratory result within the expected reference range for which of the following substances indicates adequate protein uptake and synthesis? A. Albumin B. Calcium C. Sodium D. Potassium - ANSWER>>A. Albumin The nurse should identify that an albumin level within the expected reference range is an indication that the client has adequate protein uptake and synthesis. Albumin levels measure protein status. They are useful for identifying long-term protein depletion rather than short-term or acute changes in nutritional status A nurse is providing teaching about nutritious diets to a group of adult women. Which of the following statements should the nurse include? A. "Include at least 3 g of sodium in your daily diet." 117 Page 118 of 211 B. "Limit wine consumption to 230 mL daily." C. "Include 2.5 cups of vegetables in your daily diet." D. "Limit water intake to 1.5 L each day." - ANSWER>>C. "Include 2.5 cups of vegetables in your daily diet." Nutritious diets contain a variety of foods to ensure the required daily allowance of nutrients is ingested. The nurse should instruct the women to include 2.5 cups of vegetables and 2 cups of fruit in their daily diets. Fruits and vegetables should be a variety of colors to provide an assortment of nutrients. A nurse is caring for a client who is postoperative following vascular surgery on the left femoral artery. The nurse should identify that the surgical wound should be cleansed in which of the following directions? A. From the middle of the thigh toward the wound B. From the left lower abdominal quadrant toward the wound C. From the left hip toward the wound D. From the wound toward the surrounding skin - ANSWER>>D. From the wound toward the surrounding skin The nurse should cleanse a surgical wound from the least contaminated location (the inside of the wound) toward the most contaminated (the surrounding skin). A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month and may require a blood transfusion. The client expresses concern 118 Page 119 of 211 about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse share with the client? A. "Ask your provider to prescribe epoetin before the surgery." B. "You should ask your provider about taking iron supplements prior to the surgery." C. "Ask a family member to donate blood for you." D. "Donate autologous blood before the surgery." - ANSWER>>D. "Donate autologous blood before the surgery." Autologous blood transfusion is the collection and reinfusion of the client's blood. With preoperative autologous blood donation, the blood is drawn from the client 3 to 5 weeks before an elective surgical procedure and stored for transfusion at the time of the surgery. Autologous blood is the safest form of blood transfusion because exclusive use of a client's own blood eliminates exposure to a transfusion-transmitted infection. A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give to the dietary assistant? A. Don a gown before entering the room and remove it before exiting. B. Wear a mask while in the client's room. C. Don gloves when entering the room and use hand sanitizer when exiting. 119 Page 120 of 211 D. Take no special precautions unless engaging in direct contact with the client. ANSWER>>C. Don gloves when entering the room and use hand sanitizer when exiting. Clients who have a MRSA infection require contact precautions. In addition to the use of standard precautions and meticulous hand hygiene, contact precautions require any staff member who will have contact with the client's environment to don gloves prior to entering the room. Additional precautions, such as a gown, are required for contact with the client; a mask and goggles are needed if secretions from the infected area could spray into the worker's face. Delivering the tray will require contact with the client's environment; therefore, the dietary assistant must wear gloves. A nurse is performing an otoscopic examination of a client's right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding? A. Obtain an audiology referral B. Document this as an expected finding C. Irrigate the ear with warm water D. Document mild inflammation - ANSWER>>B. Document this as an expected finding The light of the otoscope reflects off the tympanic membrane, which is cone-shaped or triangular. In the right ear, it is visible in the right lower quadrant of the eardrum. In the left ear, it is visible in the left lower quadrant. 120 Page 121 of 211 A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? A. Encourage the client to drink fluids before swallowing food B. Offer the client tart or sour foods first C. Tilt the client's head backward when swallowing D. Turn on the television - ANSWER>>B. Offer the client tart or sour foods first A client who has impaired pharyngeal swallowing should consume tart and sour foods at the beginning of the meal to stimulate saliva production, which aids chewing and swallowing. A nurse is providing nutrition counseling to a middle-aged adult client who has a sedentary job. Which of the following factors should the nurse consider? A. The risk of eating disorders increases at this age. B. The client's basal metabolic rate could decrease. C. Daily vitamins will be become necessary to meet nutritional needs. D. Limiting the intake of fish to once per week reduces cardiovascular risks. ANSWER>>B. The client's basal metabolic rate could decrease. 121 Page 122 of 211 The basal metabolic rate decreases as adipose tissue replaces skeletal muscle mass. This places the client at risk of weight gain if a healthy diet is not maintained. A nurse in a provider's office is measuring a client and notes a loss in height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders? A. Osteoporosis B. Scoliosis C. Kyphosis D. Lordosis - ANSWER>>A. Osteoporosis A loss of height is often an early indication of osteoporosis. This occurs due to loss of calcium in the vertebrae, which can cause them to fracture and collapse. A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. This manifestation is consistent with which of the following eye disorders? A. Retinopathy B. Glaucoma C. Cataracts D. Macular degeneration - ANSWER>>B. Glaucoma 122 Page 123 of 211 The nurse should identify that an obstruction of the flow of the vitreous humor of the eye is a manifestation of glaucoma. This obstruction leads to an increase in intraocular pressure, resulting in damage to the eye. A nurse is beginning her shift and reviewing the medication administration records (MARs) for her clients. She notes a dosage of a medication above the safe range and sees that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take? A. Call the nurse to verify that the client received that dosage. B. Give the medication in a safe dosage. C. Give the dose the provider prescribed. D. Call the provider to clarify the dosage. - ANSWER>>D. Call the provider to clarify the dosage. After assessing the client for adverse effects of the medication, the nurse should notify the provider about her observations to determine the next step. A nurse is assisting a client who has dysphagia at mealtimes. Which of the following actions should the nurse take? A. Assist the client into a semi-sitting position B. Have the client lean slightly backward C. Advise the client to tuck his chin downward 123 Page 124 of 211 D. Instruct the client to tilt his head slightly backward - ANSWER>>C. Advise the client to tuck his chin downward To help the client swallow safely, the nurse should have the client sit upright, lean slightly forward, tilt his head forward, and tuck his chin. This position helps move the food downward without lodging in the throat, where the client could aspirate it. A client who has glaucoma of the right eye self-administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following actions should the nurse take? A. Confirm that the client performed the procedure correctly. B. Instruct the client to look at the floor while instilling the eye drop. C. Remind the client to avoid using a facial tissue after instillation. D. Instruct the client to apply pressure to the inside corner of the eye after instillation. ANSWER>>D. Instruct the client to apply pressure to the inside corner of the eye after instillation. The client should apply gentle pressure over the nasolacrimal duct to prevent the medication from flowing into the nasal passages where systemic absorption could result. A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the client's body? 124 Page 125 of 211 A. Heart B. Lungs C. Thyroid gland D. Skin - ANSWER>>B. Lungs Percussion creates a vibration that helps the examiner determine the density of the underlying tissue. The lungs are hollow organs that can produce sounds such as resonance (a hollow sound over alveoli) or dullness (a dull sound over consolidated areas of the lungs or diaphragm). The nurse also uses auscultation and palpation when evaluating the lungs. A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first? A. Provide oxygen B. Place the client in a side-lying position C. Provide privacy D. Lower the client to the floor - ANSWER>>D. Lower the client to the floor The nurse should apply the safety and risk reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC prioritysetting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, if a client begins to have a seizure while sitting or 125 Page 126 of 211 standing, the nurse should first lower the client to the floor to protect the client from injury. A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching? A. "I will have the steps to my house painted a dark color." B. "I will put a night-light in the hallway." C. "I will put on socks when I get out of bed." D. "I will secure any wires in my home under rugs." - ANSWER>>B. "I will put a nightlight in the hallway." The nurse should instruct the client to use night-lights in and around the home as an important safety measure to reduce the risk of falls in the home. Physiological changes associated with aging can affect an older adult client's ability to see surroundings. Older adults and infants are at an increased risk of serious injury from falls, and most falls occur in the client's home. During a client care staff meeting, a nurse manager discusses potential problems with data security that affect confidential client information. Which of the following environments should the nurse manager identify as an acceptable place for discussing clients' information? A. Areas with no public access B. Outside the door of a client's room 126 Page 127 of 211 C. In the cafeteria during break D. In the hallway near the nurses' station ANSWER>>A. Areas with no public access Nurses should only discuss clients' information in private areas where no one else can overhear. For example, a unit medication room is a non-public area where nurses can privately discuss information that pertains to the client's care. A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastrostomy tube for enteral feedings. Which pieces of information are critical to communicate to the next nurse who will be caring for this client? (Select all that apply.) A. Room temperature B. New prescriptions C. Number of visitors D. Arterial blood gas results E. Tracheal secretion characteristics - ANSWER>>B. New prescriptions D. Arterial blood gas results E. Tracheal secretion characteristics The nurse should report any changes in the client's treatment in the nursing handoff report. For a client who is receiving mechanical ventilation, the latest arterial blood gas results reflect the client's current respiratory and ventilatory status and are an essential part of the nursing handoff report. Additionally, tracheal secretion characteristics provide 127 Page 128 of 211 important information about the client's current respiratory and ventilatory status and are an essential part of the nursing handoff report. A nurse is caring for a toddler at a well-child visit when the mother calls, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction? A. Flushing of the skin B. Inability to cry or speak C. Presence of nausea and mild emesis D. Capillary refill time of 1.5 sec - ANSWER>>B. Inability to cry or speak When the client has no sound passing through the vocal cords, a complete airway obstruction is evident. The nurse should use the Heimlich maneuver to dislodge whatever is obstructing the trachea. A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief? A. Encourage the client to listen to soft music B. Instruct the client to practice tai chi C. Place a jasmine-scented air freshener in the client's room D. Offer the client ginger tea - ANSWER>>A. Encourage the client to listen to soft music 128 Page 129 of 211 The nurse should encourage the client to use music therapy to reduce anxiety, provide a distraction, and relieve pain. A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of information should the nurse include in the teaching? A. Exhale slowly to reach the goal volume B. Hold the breath for 5 sec after goal volume is reached C. Continue to breathe deeply between each cycle D. Limit the repeat pattern of breathing to 5 breaths - ANSWER>>B. Hold the breath for 5 sec after goal volume is reached The nurse should instruct the client to hold the breath for 3 to 5 seconds after reaching maximal inspiratory volume. This decreases the collapse of alveoli, which helps prevent the risk of atelectasis and pneumonia. A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take? A. Deliver the formula at a slower rate B. Request a lower-fat formula C. Provide more water with feedings D. Instill a lactose-free formula - ANSWER>>C. Provide more water with feedings 129 Page 130 of 211 The elevation in the client's specific gravity indicates dehydration. The nurse should provide more fluids either by adding free water to feedings or by instilling water between feedings. Another strategy is to request a formula that contains less protein. A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing? A. Lateral thigh B. Lower abdomen C. Mid-abdominal region D. Medial thigh - ANSWER>>B. Lower abdomen After inserting an indwelling urinary catheter, the nurse should secure the catheter tubing to the client's upper thigh or lower abdomen, by using adhesive tape or catheter securement device. This location will decrease tension and trauma to the urethra. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse perform first? A. Open all sterile supplies and solutions. B. Stabilize the tracheostomy tube. C. Put on sterile gloves. D. Perform hand hygiene. - ANSWER>>D. Perform hand hygiene. 130 Page 131 of 211 According to evidence-based practice, the nurse should first perform hand hygiene before touching the client or performing any skills, such as tracheostomy care. This is vital because contamination of the nurse's hands is a primary source of infection. A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent? A. Urinary retention B. Cold extremities C. Hypertension D. Tachycardia - ANSWER>>B. Cold extremities The presence of cold extremities, first in the feet and then in the hands, is a physical change that occurs when a client's death is imminent. A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse perform? A. Wear sterile gloves when collecting the specimen B. Cleanse the wound with 0.9% sodium chloride irrigation C. Allow the collection swab to absorb old exudate D. Rotate the collection swab over the edges of the wound - ANSWER>>B. Cleanse the wound with 0.9% sodium chloride irrigation 131 Page 132 of 211 The nurse should cleanse the wound with sterile water or 0.9% sodium chloride irrigation to remove any surface debris or old exudate. A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? A. Place the client in a lateral position with the head turned to the side before beginning the procedure B. Use the thumb and index finger to keep the client's mouth open C. Rinse the client's mouth with an alcohol-based mouthwash following the procedure D. Cleanse the client's mucous membranes with lemon-glycerin sponges ANSWER>>A. Place the client in a lateral position with the head turned to the side before beginning the procedure The nurse should place the client in a lateral position with the head turned to the side to reduce the risk of aspiration of fluids and secretions. A nurse is caring for a client who has a temperature of 38.7°C (101.7°F). Which of the following actions should the nurse take? A. Apply an alcohol-water solution to the client's skin B. Keep the client's bed linens dry C. Apply ice packs to the groin 132 Page 133 of 211 D. Limit the client's fluid intake to 1183 mL (40 oz) of fluid per day - ANSWER>>B. Keep the client's bed linens dry The nurse should maximize the client's heat loss by keeping the client's clothes and bed linens dry. The nurse should also reduce external coverings on the client's bed without causing shivering. A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? A. Stand toward the client's stronger side. B. Instruct the client to lean backward from the hips. C. Place the wheelchair at a 45-degree angle to the bed. D. Assume a narrow stance with the feet 15 cm (6 in) apart. - ANSWER>>C. Place the wheelchair at a 45-degree angle to the bed. Positioning the wheelchair at a 45-degree angle allows the client to pivot, lessening the amount of rotation required. A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for the client? A. Perform tracheostomy care using medical asepsis B. Allow enough slack under the tracheostomy ties to insert three fingers 133 Page 134 of 211 C. Soak the inner cannula of the tracheostomy tube in normal saline D. Cut a sterile gauze pad to place between the neck and tracheostomy tube ANSWER>>C. Soak the inner cannula of the tracheostomy tube in normal saline The inner cannula of the tracheostomy tube should be soaked in normal saline or a mixture of normal saline and hydrogen peroxide to loosen secretions. A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the following functional classifications? A. Skeletal muscle relaxants B. Beta-adrenergic blockers C. Broad-spectrum anti-infective agents D. Plasma volume expanders - ANSWER>>D. Plasma volume expanders Dextran and albumin are plasma volume expanders that help correct hypovolemia in emergency situations, such as after hemorrhage or burns. A nurse is assessing a client who is postoperative. Which of the following findings should the nurse identify as an indication that the client is experiencing pain? A. Diarrhea B. Pupillary constriction 134 Page 135 of 211 C. Flushing D. Grimacing - ANSWER>>D. Grimacing Besides the client's self-report of pain, facial expressions such as grimacing, clenching the jaw, and lip biting can be indications of pain. A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? A. Auscultate bowel sounds after each feeding B. Ensure the formula is cold before administering C. Elevate the head of the client's bed to 45° before the feeding D. Flush the tubing with 15 mL of water after the enteral feeding - ANSWER>>C. Elevate the head of the client's bed to 45° before the feeding The nurse should elevate the client's head of bed between 30° and 45° to prevent aspiration. A nurse is assessing a client's thyroid gland. Which of the following instructions should the nurse give the client before inspecting and palpating this gland? A. "Tilt your head slightly forward." B. "Keep your head straight and look ahead of you." C. "Tilt your head back and swallow." 135 Page 136 of 211 D. "Turn your head to the side against my hand." - ANSWER>>C. "Tilt your head back and swallow." To examine the thyroid gland, the nurse should instruct the client to extend her head backward and to swallow. The nurse should be able to feel the thyroid gland ascend as the client swallows and observe any enlargement of the gland. A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview? A. Client's level of comfort and ability to participate in the interview B. Previous illnesses and surgeries C. Events surrounding the client's recent illness D. Sociocultural history - ANSWER>>A. Client's level of comfort and ability to participate in the interview The nurse should assess the client's level of comfort and establish a rapport during the introductory or orientation phase. The nurse should engage in active listening and present a relaxed attitude to place the client at ease and encourage client participation. This will assist the nurse in gaining the necessary data to formulate appropriate nursing diagnoses and outcomes. A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse use next when assessing the client's abdomen? 136 Page 137 of 211 A. Auscultation B. Light palpation C. Percussion D. Deep palpation - ANSWER>>A. Auscultation According to evidence-based practice, the nurse should listen for bowel sounds in all 4 quadrants before palpating the client's abdomen. Palpation and percussion can stimulate the bowel and increase the frequency of bowel sounds, leading to false results. A nurse is caring for a client who is receiving IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? A. Redness at the IV catheter entry site B. Palpable cord along the vein used for the infusion C. Taut skin around the IV catheter site that is cool to the touch D. Bleeding at the IV insertion site - ANSWER>>C. Taut skin around the IV catheter site that is cool to the touch A client who has taut skin around the IV catheter site that is cool to the touch might have an infiltrated IV site. The nurse should stop the IV infusion, elevate the extremity, and apply a warm moist compress or a cold compress (according to the type of infiltration). 137 Page 138 of 211 A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? A. Obtain the prescribed irrigation solution B. Don personal protective equipment C. Check the client's pain level D. Place a waterproof pad under the client's extremity - ANSWER>>C. Check the client's pain level The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should determine the client's level of pain prior to the procedure to evaluate the need for administration of an analgesic. Medicating the client approximately 30 minutes prior to wound care will decrease pain and increase comfort. A nurse is preparing to change a dressing on a client who is receiving negative pressure wound therapy (NPWT). What sequence of actions should the nurse plan to take? ANSWER>>Step 1: The nurse should turn off the vacuum on the NPWT device to loosen the dressing and administer the prescribed analgesic. Step 2: The nurse should gently remove the soiled dressing and perform hand hygiene. 138 Page 139 of 211 Step 3: The nurse should apply sterile or clean gloves and irrigate the wound to remove debris. Step 4: The nurse should apply a skin protectant or a barrier film to the surrounding skin to ensure an airtight seal and protect the skin. Step 5: The nurse should place foam in the wound bed and cover it with a transparent dressing to provide an airtight seal. Step 6: The nurse should attach the drainage tube to the transparent dressing and turn on the NPWT unit. Step 7: The nurse should check for air leaks and patch the dressing as needed with transparent film. A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source for this sound? A. Low battery power B. Excessive wax in the ear canal C. A volume setting that is too low D. A crack in the ear tube - ANSWER>>B. Excessive wax in the ear canal Factors that can make a hearing aid whistle include a poor seal with the ear mold, an ear infection, excessive wax in the ear canal, an improper fit, or a malfunction. A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment? 139 Page 140 of 211 A. The client places a crutch on each side when assuming a sitting position. B. The client moves the unaffected leg onto a step first when descending stairs. C. The client places weight on the axillae when walking. D. The client has slightly flexed elbows when ambulating with the crutches. ANSWER>>D. The client has slightly flexed elbows when ambulating with the crutches. The client should have slightly flexed elbows when ambulating with crutches. This allows the client to bear weight on the hands and not on the axillae. A nurse is developing a plan of care for a client. Which of the following pieces of information should the nurse consider when planning care that is culturally congruent? A. Illness is not influenced by culture. B. The meaning of disease can vary widely across cultures. C. Assigning clients to specific cultural categories facilitates communication. D. Predetermined criteria should generate client care activities. - ANSWER>>B. The meaning of disease can vary widely across cultures. A client may define and react to disease based on his or her unique cultural perspective. The nurse should seek to understand a client's culture and life experiences in order to provide care that is effective, evidence-based, and culturally congruent. A nurse is obtaining a capillary blood sample to determine a client's blood glucose level. The nurse prepares and punctures the client's finger for the procedure but does not 140 Page 141 of 211 obtain an adequate amount of blood. Which of the following actions should the nurse take next? A. Smear the small amount of blood onto the testing strip B. Hold the finger above heart level C. Massage the client's fingertip D. Wrap the client's finger in a warm washcloth - ANSWER>>D. Wrap the client's finger in a warm washcloth Warmth helps increase the blood flow to the client's finger. A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask B. A client who has emphysema and is receiving oxygen at 3L/min via transtracheal oxygen cannula C. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar D. A client who has COPD and is receiving oxygen at 2 L/min via nasal cannula ANSWER>>A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask 141 Page 142 of 211 The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. The nurse should frequently check the bag on a rebreather mask to ensure it inflates properly. If the bag is deflated, the client will rebreathe exhaled carbon dioxide instead of receiving the prescribed oxygen dose. Therefore, the nurse should first see the client who has heart failure and is receiving 100% oxygen via partial rebreather mask. Oxygen is a gas that can cause toxicity and is highly combustible, and higher concentrations of oxygen increase the risk of client injury. A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? A. "Drink a minimum of 1,000 mL of fluid daily." B. "Increase your intake of refined-fiber foods." C. "Sit on the toilet 30 min after eating a meal." D. "Take a laxative every day to maintain regularity." - ANSWER>>C. "Sit on the toilet 30 min after eating a meal." Increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 min after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation. A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take? 142 Page 143 of 211 A. Assign the client to a private room B. Keep 4 side rails up while the client is in bed C. Monitor the client at least once every hour D. Request a PRN prescription for restraints - ANSWER>>C. Monitor the client at least once every hour The nurse should monitor the client frequently as a means of reducing the client's fall risk. Other measures can include keeping the client's bed in a low position, creating elimination schedules, and using a gait belt when the client is ambulating. While in the hospital, a client who has a terminal illness tells the nurse, "I can't believe I'm dying. A lot of bad people in the world are healthy, and here I am dying!" Which of the following responses should the nurse provide? A. "Everyone dies sometimes; some die sooner than others." B. "Who do you think deserves to die more than you?" C. "It does seem unfair, doesn't it?" D. "Tell me more about how you feel about dying." - ANSWER>>D. "Tell me more about how you feel about dying." This therapeutic response from the nurse seeks more information to form an accurate assessment of the client's feelings. 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 pieces of information should the nurse include? 143 Page 144 of 211 A. A 2-month-old infant can turn from his abdomen to his back. B. A 10-month-old infant can pull up to a standing position. C. A 4-month-old infant can sit up without support. D. A 6-month-old infant can crawl on his hands and knees. - ANSWER>>B. A 10month-old infant can pull up to a standing position. An 8 to 10 month-old infant can pull up to a standing position. A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops? A. Drop the eye medication into the lower conjunctival sac B. Apply gentle pressure to the outer opening of the eye for 2 min C. Hold the eyedropper 0.5 cm (0.2 in) from the cornea D. Instruct the client to close the eyes tightly after administration - ANSWER>>A. Drop the eye medication into the lower conjunctival sac The nurse should drop the eye medication in the lower conjunctival sac to avoid placing the drops on the cornea and causing damage. A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? (Select all that apply.) A. Coat the tip of the tube with a water-soluble lubricant 144 Page 145 of 211 B. Ask the client to swallow water while the tube enters her throat C. Place the coiled tube in ice chips prior to insertion D. Tell the client to tilt her head backward as insertion begins E. Instruct the client to bear down during insertion - ANSWER>>A. Coat the tip of the tube with a water-soluble lubricant B. Ask the client to swallow water while the tube enters her throat D. Tell the client to tilt her head backward as insertion begins Lubricating the tube eases its passage. A water-based gel because will dissolve if the tube slips into the client's airway, while using petroleum jelly could cause respiratory problems. Swallowing water reduces the risk of gagging and aspiration and helps propel the tube down the esophagus. Hyperextending the neck reduces the curvature of the nasopharynx, which facilitates the insertion of the NG tube. 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? A. Call for assistance. B. Begin chest compressions. C. Confirm unresponsiveness. D. Give rescue breaths. - ANSWER>>C. Confirm unresponsiveness. 145 Page 146 of 211 The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, he or she must first collect adequate data from the client to obtain the knowledge needed to make an appropriate decision. Establishing unresponsiveness is required before beginning CPR. If a client is unresponsive, the nurse should activate the emergency response team. A nurse is planning an in-service training session about nutrition. Which of the following statements should the nurse include in the teaching? A. "Fats provide energy." B. "Carbohydrates repair body tissue." C. "Fats regulate fluid balance." D. "Carbohydrates prevent interstitial edema." - ANSWER>>A. "Fats provide energy." Fat serves as a stored energy source for the body, providing 9 cal/g of energy. A nurse in a long-term care facility is in the dining room while residents are eating lunch. One resident begins to choke and is coughing strongly. Which of the following actions should the nurse take? A. Assist the client to the floor B. Perform an abdominal thrust C. Open the airway with a head-chin tilt 146 Page 147 of 211 D. Observe the client closely - ANSWER>>D. Observe the client closely The nurse should observe the client closely at this point in time. As long as the client is able to cough strongly, the nurse does not need to intervene. 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? A. "My parents are retired, and they have come to help with our children." B. "I am going to ask my husband to go to counseling with me." C. "I keep having nightmares about my upcoming surgery." D. "My girlfriends bought me a nice wig." - ANSWER>>C. "I keep having nightmares about my upcoming surgery." Nightmares and sleep disturbances are manifestations of anxiety and post-traumatic stress disorder. These indicate a risk of experiencing psychological distress. A nurse is teaching a middle-aged female client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of this client's routine health screening? A. Annual Papanicolaou (Pap) testing B. Mammogram every 2 years 147 Page 148 of 211 C. Eye examination every 2 years D. Annual colonoscopy - ANSWER>>C. Eye examination every 2 years This is essential not only for monitoring vision but also for checking for glaucoma. The client should have annual eye examinations from the age of 65 onward. A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take? A. Remove the NG tube B. Advance the NG tube quickly C. Pull the NG tube back slightly D. Ask the client to tilt his head backward - ANSWER>>C. Pull the NG tube back slightly The nurse should slightly pull back the NG tube and instruct the client to breathe slowly. Once the client relaxes, the nurse should gently advance the tube as the client swallows. A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations? A. Increased intestinal motility B. Respiratory alkalosis 148 Page 149 of 211 C. Decreased cardiac output D. Hypocalcemia - ANSWER>>C. Decreased cardiac output During immobility, the client's heart rate increases to compensate for increased venous pooling. The reduction in circulating volume increases the workload of the heart, resulting in orthostatic hypotension and decreased cardiac output. Incorrect Answers A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse have the client perform just before inserting the catheter? A. Swallow water B. Prepare for a painful sensation C. Hold her breath D. Bear down gently - ANSWER>>D. Bear down gently Bearing down helps the nurse visualize the urinary meatus and relaxes the external sphincter, which facilitates the insertion of the catheter. Incorrect Answers: A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? 149 Page 150 of 211 A. Place an oxygen mask on the client B. Check the client's pulse C. Determine whether the client is able to breathe D. Wrap arms around the client from behind - ANSWER>>C. Determine whether the client is able to breathe Caring for this client requires the application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge needed to make an appropriate decision. This client is demonstrating a universal choking gesture. If the client is unable to move air in or out, severe airway obstruction is present. The client would need emergency interventions to clear a partial obstruction, as indicated by stridor or minimal airway passage. As long there is good air exchange and the client can cough and breathe spontaneously, the nurse should stay with the client and monitor her condition. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? A. Insert the rectal tube 15.2 cm (6 in) B. Wear sterile gloves to insert the tubing C. Position the client on his left side 150 Page 151 of 211 D. Hold the solution bag 91 cm (36 in) above the client's rectum - ANSWER>>C. Position the client on his left side Positioning is an important aspect of administering an enema. Having the client lie on his left side facilitates the flow of the enema solution into the sigmoid and descending colon. A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring? A. Right task B. Right circumstance C. Right person D. Right communication - ANSWER>>D. Right communication The situation could have been avoided if the right communication was given by the nurse to the AP. The right communication entails providing clear, concise instructions regarding the task, including the objective, limits, and expectations. A nurse is administering medication to a client who asks the nurse to leave the medication at the bedside to be taken at a later time. Which of the following responses should the nurse make? 151 Page 152 of 211 A. "Call me when you are ready, and I will return with the medication." B. "Since you were taking this medication at home, I will leave it for you to take." C. "I will come back in 30 minutes to check that you took the medication so I can chart the time." D. "If you refuse to take the medication now, I can't give it again until your next scheduled time." - ANSWER>>A. "Call me when you are ready, and I will return with the medication." The nurse is responsible for administering the medication and for following professional standards by adhering to the 6 rights of medication administration. A nurse is instructing a client about collecting a 24-hr urine specimen for creatinine clearance. Which of the following statements should the nurse identify as an indication that the client understands the procedure? A. "The next time I urinate will be the first specimen of the collection." B. "I'll make sure to keep the collection bottle in the container of ice they gave me." C. "Once the container is half full, I no longer have to add any more urine." D. "It's okay if a piece of toilet paper gets in the bottle. The lab people will remove it when they do the test." - ANSWER>>B. "I'll make sure to keep the collection bottle in the container of ice they gave me." The urine collection must remain chilled to prevent any change in urine composition during the collection. 152 Page 153 of 211 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? A. "There are times I should use soap and water rather than an alcohol-based rub to clean my hands." B. "I will use cold water when I wash my hands to protect my skin from becoming too dry." C. "I will apply friction for at least 10 seconds while washing my hands." D. "After washing my hands, I will dry them from the elbows down." - ANSWER>>A. "There are times I should use soap and water rather than an alcohol-based rub to clean my hands." While alcohol-based hand rubs are as effective as soap and water in providing proper hand hygiene, the Centers for Disease Control and Prevention recommend washing hands with soap and water at certain times, such as when the hands are visibly soiled with dirt or body fluids. A nurse is caring for a group of clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? A. Provide oral care to a client who cannot take oral fluids B. Check a client's IV insertion site for manifestations of infiltration C. Assess a client's ability to ambulate D. Demonstrate the use of a glucometer to a client who has diabetes mellitus ANSWER>>A. Provide oral care to a client who cannot take oral fluids 153 Page 154 of 211 Providing oral care to a client who cannot take oral fluids is within the range of function for an AP. Therefore, the nurse can assign this task to the AP. A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client's bedside and perform which of the following verification procedures? A. Check the client's name and medical record number on the MAR against the room and bed number B. Call the client by name and check the name on her identification band against the MAR C. Compare the medical record number and name on the MAR with the client's identification band D. Ask the client's visitor to identify the client by name and to state the client's birth date - ANSWER>>C. Compare the medical record number and name on the MAR with the client's identification band The Joint Commission requires the use of 2 client identifiers when administering medications. The nurse should compare the medical record number and name on the MAR with the client's identification band. Incorrect Answers: 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? 154 Page 155 of 211 A. Change the topic because the client is trying to divert attention from the illness B. Encourage the client to express thoughts about death and dying C. Tell the client that religious beliefs are a personal matter D. Offer to contact the client's minister or the facility's chaplain - ANSWER>>B. Encourage the client to express thoughts about death and dying The nurse should recognize the client's need to talk about impending death and encourage the client to discuss thoughts on the subject. This is the therapeutic technique of reflecting. Depending on the situation, the nurse can also share some thoughts on this topic. Self-disclosure is a communication skill that can encourage sharing when appropriate. If the nurse does not want to share personal beliefs, offering self and listening to the client's thoughts are appropriate. 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? A. Wash the gloved hands and then throw the gloves away. B. Prepare an incident report to document the event. C. Carefully remove the gloves and proceed with hand hygiene. D. Ask the provider to order a blood culture to determine the risk of infection. ANSWER>>C. Carefully remove the gloves and proceed with hand hygiene. Standard precautions require the use of gloves and hand hygiene in the care of all clients. 155 Page 156 of 211 A nurse is caring for a client who has a temperature of 38.7°C(101.7°F). Which of the following actions should the nurse take? A. Apply an alcohol-water solution to the client's skin B. Keep the client's bed linens dry C. Apply ice packs to the groin D. Limit the client's fluid intake to 1183 mL (40 oz) of fluid per day - ANSWER>>B. Keep the client's bed linens dry The nurse should maximize the client's heat loss by keeping the client's clothes and bed linens dry. The nurse should also reduce external coverings on the client's bed without causing shivering. A nurse is teaching a newly licensed nurse about pain management in clients age 65 and older. Which of the following pieces of information should the nurse include in the teaching? A. Clients who are age 65 or older experience a decreased ability to perceive pain compared to young adult clients. B. Clients who are age 65 or older are reluctant to report pain. C. Clients who are age 65 or older should not receive opioid narcotics. D. Clients who are age 65 or older experience a shorter duration of action with medications than young adult clients. - ANSWER>>B. Clients who are age 65 or older are reluctant to report pain. 156 Page 157 of 211 The nurse should instruct the newly licensed nurse that clients age 65 and older frequently can be reluctant to report pain because they might not want to bother or anger caregivers and might believe that pain is expected. A nurse is admitting a client who has tuberculosis. In addition to standard precautions, which of the following transmission-based precautions should the nurse add to the client's plan of care? A. Protective B. Airborne C. Droplet D. Contact - ANSWER>>B. Airborne Tuberculosis requires airborne precautions, which are protocols that prevent the spread of infections via very small droplets (e.g. measles and varicella). Incorrect Answers: A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? A. Pull suction catheter back 1 cm (0.5 in) if the client starts coughing B. Allow 30 sec between suctioning passes C. Hyperventilate the client with 50% oxygen for 30 sec 157 Page 158 of 211 D. Perform a maximum of 4 passes with the suction catheter - ANSWER>>A. Pull suction catheter back 1 cm (0.5 in) if the client starts coughing The nurse should pull the suction catheter back 1 cm (0.5 in) when the client starts to cough or resistance is met. This will remove the catheter from the mucosal wall of the trachea prior to suctioning. A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger-stick blood sample. Which of the following actions by the AP requires the nurse to intervene? A. Elevating the finger above heart level B. Rubbing the fingertip with an alcohol pad C. Puncturing the side of the fingertip D. Wrapping the finger in a warm cloth - ANSWER>>A. Elevating the finger above heart level The nurse should intervene if the client elevates the finger above the level of the heart. Holding the finger below the level of the heart in a dependent position will help increase blood flow to the area and ensure an adequate specimen for collection. A nurse is teaching a client who is postoperative about the importance of turning, coughing, and breathing deeply. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "If I do this often, I won't experience muscle wasting." 158 Page 159 of 211 B. "If I do this often, I won't get pneumonia." C. "If I do this often, I won't get constipation." D. "If I do this often, I won't have a fast heartbeat." - ANSWER>>B. "If I do this often, I won't get pneumonia." Turning, coughing, and breathing deeply help prevent respiratory complications such as pneumonia by promoting lung expansion and secretion removal. A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication of an infection? A. WBC 15,000 mm^3 B. Erythrocyte sedimentation rate (ESR) 15 mm/hr C. Urine pH 7.2 D. Urine specific gravity 1.0063 - ANSWER>>A. WBC 15,000 mm^3 This finding is above the expected reference range and is an indication of infection. A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes? A. Allows minimal treatment B. Benefits the client's family 159 Page 160 of 211 C. Offers hope for a cure D. Supports self-determination - ANSWER>>D. Supports self-determination The nurse must honor the client's autonomy and ability to make health care decisions. The client has the right to refuse treatment; as the client's advocate, the nurse must support that right. A nurse is applying anti-embolitic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings? A. Roll the stocking partially down if too long B. Remove the stocking once per day C. Bunch and pull the stocking halfway up the calf D. Turn the stocking inside out up to the heel before applying - ANSWER>>D. Turn the stocking inside out up to the heel before applying The nurse should turn the stocking inside out up to the client's heel to make the application of the stocking easier and cause fewer constrictive wrinkles. A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift in which the client received Atenolol instead of Allopurinol. Which of the following interventions is the nurse's priority? A. Measure the client's apical pulse 160 Page 161 of 211 B. Administer the Allopurinol to the client C. Inform the nurse manager D. Complete an incident report - ANSWER>>A. Measure the client's apical pulse The first action the nurse should take using the nursing process is to assess the client by measuring the client's apical pulse. Atenolol is a beta blocker and can decrease the client's heart rate. A nurse is admitting a client who has a hearing aid. Which of the following actions should the nurse take before beginning the interview process? A. Sit beside the client during the interview B. Make sure the device is functioning C. Make sure lighting in the room is soft D. Provide a lengthy interview process to allow adequate time to answer questions ANSWER>>B. Make sure the device is functioning The nurse should ensure that all of the client's assistive devices are working before beginning the interview process. A nurse is providing teaching about proper care to a client who has a new colostomy. Which of the following pieces of information should the nurse include in the teaching? A. Change the colostomy bag following breakfast 161 Page 162 of 211 B. Cleanse the skin around the stoma with warm water C. Change the pouch every day D. Place an aspirin in the ostomy pouch to decrease odor - ANSWER>>B. Cleanse the skin around the stoma with warm water The nurse should instruct the client to cleanse the skin around the stoma with warm water, as using soap can leave a residue on the skin and cause poor adherence of the pouch. 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 him. Which of the following actions should the nurse take? A. Consult the medication reference book available on the unit B. Ask a more experienced nurse for information about the medication C. Call the client's provider and verify the prescription D. Ask the client if she takes this medication at home - ANSWER>>A. Consult the medication reference book available on the unit A nurse must have knowledge about medications to administer them safely. The nurse should become familiar with the medication by looking it up in the medication reference on the unit. A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first? 162 Page 163 of 211 A. Instill proparacaine hydrochloride eye drops B. Perform ocular irrigation of the right eye C. Place the client in a supine position with the head turned toward the affected side D. Ask the client about first aid performed at the scene - ANSWER>>D. Ask the client about first aid performed at the scene The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to assess the first aid that was performed at the scene to determine if eye irrigation was administered. A nurse is planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first? A. Use the pain scale to determine the client's pain level B. Discuss the adverse effects of pain medication with the client C. Obtain the client's vital signs D. Check the client's allergies - ANSWER>>A. Use the pain scale to determine the client's pain level 163 Page 164 of 211 The nurse should consider Maslow's hierarchy of needs, which includes 5 levels of priority. The levels are as follows: physiological needs, safety and security needs, love and belonging needs, personal achievement and self-esteem needs, and achieving full potential and the ability to problem-solve and cope with life situations. When applying Maslow's hierarchy of needs priority-setting framework, the nurse should review physiological needs first and then address the client's needs by following the remaining hierarchal levels. The nurse should also consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. To meet the client's physiological needs, the nurse should begin pain management by asking the client to describe her pain. A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take? A. Tie a secure knot with the restraint straps B. Attach the restraints' straps to the bedside rails C. Make sure 3 fingers fit beneath the restraints D. Remove the restraints at least every 2 hr - ANSWER>>D. Remove the restraints at least every 2 hr The nurse should remove the restraints at least every 2 hours to reposition the client, provide fluids and nutrients, assist with range-of-motion exercises, and evaluate the client's overall wellbeing. A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse include? 164 Page 165 of 211 A. Serve foods at warm or hot temperatures B. Offer the client low-density foods C. Make sure the client lies supine after meals D. Limit drinking liquids with food ANSWER>>D. Limit drinking liquids with food Drinking beverages with food leads to early satiety and bloating, which results in the client consuming fewer calories. A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? A. Fasten the ties on the restraint to the side rails of the bed. B. Tie the restraint with a quick-release knot. C. Allow a finger between the restraint and the client's chest. D. Place the restraint under the client's clothing. - ANSWER>>B. Tie the restraint with a quick-release knot. The nurse should use a quick-release knot that can be untied easily in case the client's well-being requires quickly removing the restraints. A nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student should the nurse identify as a potential problem with achieving Erikson's developmental task for this age group? 165 Page 166 of 211 A. "I am in no hurry to get married. I think I'll enjoy single life for a while." B. "I go home on the weekends to be with my family because I do not have any good friends here on campus." C. "I am interested in politics and may consider becoming an elected official." D. "I am looking forward to finishing school and going to work for my family's business." - ANSWER>>B. "I go home on the weekends to be with my family because I do not have any good friends here on campus." According to Erikson, the stage of psychosocial development for young adults is intimacy vs. isolation. This statement indicates that the student is having difficulty establishing relationships outside of the immediate family. Incorrec A nurse is using a portable ultrasound bladder scanner to measure a client's post-void residual volume. Which of the following actions should the nurse take? A. Have the client urinate 20 min before the scan B. Assist the client into a semi-Fowler's position C. Position the scanner head at the symphysis pubis D. Apply light pressure to the scanner head once it is in position - ANSWER>>D. Apply light pressure to the scanner head once it is in position The nurse should apply light pressure and hold the scanner steadily while pointing it slightly down toward the client's bladder 166 Page 167 of 211 A client who reports shortness of breath requests the nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? A. Encourage the client to take deep breaths B. Observe the rate, depth, and character of the client's respirations C. Prepare to administer oxygen D. Give the client a back rub to promote relaxation - ANSWER>>B. Observe the rate, depth, and character of the client's respirations The nurse should apply the nursing process priority-setting framework when caring for this client in order to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge needed to make an appropriate decision; therefore, the nurse should first assess the client's respiratory status. 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? A. Aim the hose at the base of the fire. B. Squeeze the handle of the extinguisher. 167 Page 168 of 211 C. Remove the safety pin from the extinguisher. D. Sweep the hose from side to side to dispense material. - ANSWER>>C. Remove the safety pin from the extinguisher. Evidence-based practice indicates removing the safety pin from the extinguisher is the first action to take when using a fire extinguisher; therefore, this is the action the nurse should instruct the client to perform first. A nurse in an urgent-care center is caring for a 15-year-old client whose symptoms suggest a sexually transmitted infection (STI). The client's parent is unavailable, but the client's grandmother accompanied the client to the clinic. Which of the following actions should the nurse take? A. Explain that the treatment can wait until the parent is available. B. Inform the grandmother that she may give consent for the treatment. C. Invoke the principle of implied consent and prepare the client for treatment. D. Ask the adolescent to sign the consent form. - ANSWER>>D. Ask the adolescent to sign the consent form. Unemancipated minors (i.e. those who do not live on their own, are not married, and are not in the military) can legally give informed consent for diagnostic procedures and treatment in some situations. These situations include treatment for STIs and substance use disorders. A nurse is performing a mental-status examination on a client who has manifestations of dementia. Which of the following directions should the nurse give the client when evaluating the client's ability to think abstractly? 168 Page 169 of 211 A. Subtract by 7 serially, starting at 100 B. Describe a previous illness C. Explain what to do if a fire happened in his bedroom D. Discuss the meaning of a common proverb - ANSWER>>D. Discuss the meaning of a common proverb This part of the mental-status examination evaluates the client's ability to think abstractly. A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first? A. Document the client's food allergies in the medical record B. Ask the client to identify the specific food allergies C. Monitor the client for indications of anaphylaxis D. Have epinephrine available for administration - ANSWER>>B. Ask the client to identify the specific food allergies The nurse should apply the nursing process priority-setting framework in order to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, the nurse must first collect adequate data from the client. 169 Page 170 of 211 Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse should first assess the client's allergies and identify the specific allergens to ensure the specific foods are not offered to the client during meals. A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning? A. Ask the client if he wants to self-administer his insulin B. Have the client list the steps of the procedure C. Have the client demonstrates the procedure D. Ask the client if he understands the purpose of insulin - ANSWER>>C. Have the client demonstrates the procedure Having the client demonstrate the procedure provides the nurse the ability to evaluate the client's understanding within the psychomotor domain of learning. A new resident provider asks the charge nurse for an access code to review clients' online records. The resident is not scheduled to attend the facility's orientation computer class until next week. Which of the following actions should the nurse take? A. Explain that it is against policy to share access codes and refer the resident to his supervisor. B. Access the clients' online data and monitor the resident as he reads them. C. Access the online system and allow the resident to locate clients' data. 170 Page 171 of 211 D. Ask each client to give permission for the resident to access medical records. ANSWER>>A. Explain that it is against policy to share access codes and refer the resident to his supervisor. Staff members should never share access codes and passwords or allow people who do not have their own access code to use the system. Allowing unauthorized access is a breach of federal guidelines for data security and client confidentiality. A nurse is teaching a client with lower extremity weakness how to use a 4-point crutch gait. Which of the following instructions should the nurse include in the teaching? A. "Support the majority of your weight on the axillae." B. "Keep your elbows extended." C. "Bear weight on both of your legs." D. "Move both crutches forward at the same time." - ANSWER>>C. "Bear weight on both of your legs." The client should keep 3 points on the ground at all times. Therefore, he must be able to bear weight on both legs. A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider? A. Respiratory alkalosis 171 Page 172 of 211 B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis - ANSWER>>D. Metabolic acidosis A pH of 7.25 indicates acidosis. If the cause is respiratory, pH and PaCO2 values will deviate in opposite directions. Since the PaCO2 is within the expected reference range, despite the low pH, the cause must be metabolic. Therefore, the nurse should report to the provider that the client has metabolic acidosis. A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? A. Contact the family and ask someone to stay with the client B. Offer to call the client's minister C. Sit and hold the client's hand D. Leave the room and allow the client to cry privately - ANSWER>>C. Sit and hold the client's hand This action uses the therapeutic communication techniques of silence, touch, and offering of self to the client. A nurse is teaching range-of-motion exercises to a client who has osteoarthritis. Which of the following client positions demonstrates an understanding of supination of the hand? 172 Page 173 of 211 A. The client holds the hand with the palm up. B. The client holds the hand with the palm down. C. The client points the fingers toward the floor. D. The client points the fingers toward the ceiling. - ANSWER>>A. The client holds the hand with the palm up. The nurse should identify the client holding the hand with the palm up as a demonstration of supination of the hand. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular-sized cuff for a client who is obese. Which of the following explanations should the nurse give the AP? A. "The reading will be inaudible if the cuff is too small for the client." B. "The width of the cuff bladder should be 75% of the circumference of the client's arm." C. "As long as the cuff will circle the arm, the reading will be accurate." D. "Using a cuff that is too small will result in an inaccurately high reading." ANSWER>>D. "Using a cuff that is too small will result in an inaccurately high reading." Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a reliable measurement. Blood pressure readings can be falsely high if the cuff is too small for the client. A nurse is teaching a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group? 173 Page 174 of 211 A. Independent moral development B. Acceptance of body changes C. Strengthening ties with the family of origin D. Development of concrete reasoning ANSWER>>A. Independent moral development According to Kohlberg's theory of moral development, making individual decisions about moral issues is a function of the highest level of moral development, the postconventional level. Young adults who have reached this level separate themselves from the rules and tenets of others and make their own decisions according to personal beliefs and principles. A nurse is caring for a client in a long-term care facility. Which of the following findings should alert the nurse to the possibility that the client has developed delirium? A. Gradual memory loss B. Reduced level of consciousness C. Difficulty with abstract thought D. Verbalized feelings of hopelessness - ANSWER>>B. Reduced level of consciousness When a client has delirium, the nurse should expect a reduced level of consciousness, sudden memory impairment, illogical thinking, and sleep disturbances. A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client? 174 Page 175 of 211 A. Speak directly into the client's impaired ear B. Exaggerate lip movements C. Speak loudly D. Face the client when speaking Check Answer Question Feedback Show Explanation Grade Pause Previous - ANSWER>>D. Face the client when speaking The nurse should directly face the client who has a hearing impairment and stand or sit at the same level to maximize communication. Many clients who are hearing-impaired combine lip reading with their residual hearing when communicating. A nurse on a medical-surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client's record first? A. Assessment B. Plan of care C. Nursing interventions performed D. Evaluation of progress - ANSWER>>A. Assessment When caring for a client, the nurse should apply the nursing process priority-setting framework. The nursing process is used to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, he or she must first collect adequate data from the client. Assessing or collecting 175 Page 176 of 211 additional data will provide the nurse with the knowledge to make an appropriate decision. A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following sites should the nurse select? A. Select a vein in the client's dominant arm B. Choose the most proximal vein in the extremity C. Choose a vein that is soft on palpation D. Select a site distal to previous venipuncture attempts - ANSWER>>C. Choose a vein that is soft on palpation The nurse should select a vein that is soft and has a "bouncy" feeling when pressure is released upon palpation. A nurse is caring for a client who has chronic kidney disease. The kidneys regulate body fluids as well as assisting with which of the following functions? A.Regulation of acid-base balance B. Reabsorption of nutrients for cellular growth C. Regulation of body temperature D. Secretion of hormones needed for growth - ANSWER>>A. Regulation of acid-base balance 176 Page 177 of 211 The nurse should identify that the kidneys assist with the regulation of acid-base balance in the body by retaining bicarbonate as they excrete hydrogen ions. A nurse is teaching a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching? A. "I'll wear nonsterile gloves." B. "I'll use adhesive remover each time." C. "I'll take my pain pill after I change the dressing." D. "I'll fold the dressing with the soiled surface facing outward." - ANSWER>>A. "I'll wear nonsterile gloves." Wearing gloves prevents the spread of microorganisms outside of the dressings and onto the client's hands. The gloves the client uses can be clean and do not need to be sterile unless the provider specifically prescribes sterile gloves for dressing changes. A nurse is preparing to assist an older adult client with ambulation following bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall? A. Use a gait belt during ambulation B. Ensure the client is wearing socks before ambulating C. Instruct the client to sit on the edge of the bed for 15 sec before ambulating D. Walk 2 ft behind the client during ambulation - ANSWER>>A. Use a gait belt during ambulation 177 Page 178 of 211 The nurse should use a gait belt to keep the client's center of gravity midline and decrease the risk of a fall. A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? A. Hold the irrigator 1.25 cm (0.5 in) above the eye B. Direct the irrigation solution up toward the upper eyelid C. Exert pressure on the bony prominences when holding the eyelids open D. Direct the irrigation from the outer canthus to the inner canthus of the eye ANSWER>>C. Exert pressure on the bony prominences when holding the eyelids open The nurse should hold the upper lid against the eyebrow and the lower lid against the cheekbone when irrigating the eye. A nurse is caring for an adult client who communicates an unmet spiritual need. Which of the following client statements should indicate to the nurse that the client is experiencing spiritual distress? A. "Life has its ups and downs." B. "I believe that I control my own destiny." C. "God is punishing me for something." 178 Page 179 of 211 D. "I like to keep my rosary beads in bed with me." - ANSWER>>C. "God is punishing me for something." Spiritual distress is an impaired ability to integrate meaning and purpose in life through various means, including belief systems and relationships. Manifestations of spiritual distress can include a feeling that a higher power is punishing the individual for some behavior. A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a longterm care facility. Using this scale, which of the following parameters should the nurse evaluate? A. Incontinence B. Mental state C. Nutrition D. General physical condition - ANSWER>>C. Nutrition Nutrition, sensory perception, moisture, activity, mobility, and friction and shear are the parameters on the Braden scale for determining a client's risk of developing pressure ulcers. A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use? A. Deltoid 179 Page 180 of 211 B. Ventrogluteal C. Vastus lateralis D. Dorsogluteal - ANSWER>>C. Vastus lateralis The nurse should use the vastus lateralis site over the anterior thigh for IM injections for infants and children. A nurse is presenting an in-service training session about nutrition. Which of the following simple sugars should the nurse identify as the carbohydrate found in milk A. Lactose B. Sucrose C. Maltose D. Fructose - ANSWER>>A. Lactose The nurse should identify that lactose is a form of sugar that is found in milk. A nurse in a provider's office is collecting information from an older adult client who reports taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects? A. Constipation B. Gastric ulcers 180 Page 181 of 211 C. Respiratory depression D. Liver damage - ANSWER>>D. Liver damage Acetaminophen in large doses can be toxic to the liver. Daily intake should be limited to less than 3 to 4 grams per day for healthy individuals and 2.4 grams per day for older adults and those with a history of liver impairment. A nurse is preparing to administer a medication to a client. Which of the following administration schedules should the nurse identify as a prescription to administer the medication once and as soon as possible? A. Stat prescription B. PRN prescription C. Standing prescription D. Single prescription - ANSWER>>A. Stat prescription A stat medication prescription is carried out immediately or as soon as possible and for one time only. A nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to assess which of the following? A. Liver size B. Pedal edema 181 Page 182 of 211 C. Skin texture D. Gait - ANSWER>>D. Gait Inspection is the technique of looking or observing. Gait inspection involves watching the client's walking movements and observing any unusual findings. A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? A. "Does the medication you're taking relieve the pain?" B. "Can you point to where the pain is the worst?" C. "What do you think caused the onset of your pain?" D. "Changing positions makes your pain worse, right?" - ANSWER>>C. "What do you think caused the onset of your pain?" The nurse is using an open-ended question that allows the client to respond with a wide range of information by using more than a few words. A nurse is teaching a client who has urinary incontinence about bladder retraining. Which of the following instructions should the nurse include? A. "Wake up every 2 hr to urinate during the night." B. "Drink citrus juices throughout the day." 182 Page 183 of 211 C. "Try to block the urge to urinate until the next scheduled time." D. "Limit fluids to no more than 1 L (34 oz) during waking hours." - ANSWER>>C. "Try to block the urge to urinate until the next scheduled time." When the client is following a schedule of voiding intervals and feels the urge to urinate before the next scheduled time, she should try slow, deep breathing to help reduce the urge. She can also try 5 or 6 strong and quick pelvic muscle exercises. A nurse on a medical unit is caring for a client who has been coughing intermittently during meals, attempting to clear her throat repeatedly, and eating only a small portion of each meal. The nurse should recommend a referral to which of the following members of the interprofessional team to evaluate the client for dysphagia? A. Speech-language pathologist B. Social worker C. Physical therapist D. Occupational therapist - ANSWER>>A.Speech-language pathologist A speech-language pathologist can perform a thorough evaluation of the client for dysphagia and help the client learn to eat safely. For example, a speech-language pathologist can instruct the client in learning the supraglottic swallow: take a breath, hold the breath while swallowing, cough after swallowing, and swallow again to clear the mouth. A nurse is assessing the pH of a client's gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect 183 Page 184 of 211 A. 6 B. 2 C. 10 D. 8 - ANSWER>>B. 2 A pH of 2 is within the expected reference range of 0 to 4 for gastric secretions. An assistive personnel (AP) is helping a nurse care for a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? A. The AP uses soap and water to clean the perineal area. B. The AP tapes the catheter to the client's inner thigh. C. The AP hangs the collection bag at the level of the bladder. D. The AP ensures there are no kinks in the drainage tubing. - ANSWER>>C. The AP hangs the collection bag at the level of the bladder. The AP should place the drainage bag below the level of the bladder to ensure proper drainage by gravity. A nurse is collecting health history data from a client who is deaf and uses American Sign Language (ASL) to communicate. The nurse will be working with an ASL 184 Page 185 of 211 interpreter. Which of the following actions should the nurse take when working with the interpreter? A. Face away from the client to avoid distraction. B. Pace speech to allow time for the interpreter to convey the words. C. Make eye contact with the interpreter when explaining the procedure. D. Stand in the background while the interpreter translates the message. ANSWER>>B. Pace speech to allow time for the interpreter to convey the words. The nurse should speak clearly and allow time for the interpreter to convey the message and for the client to receive it. 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. A client who has a prescription for a transfusion of packed red blood cells B. A client who is being transported for a radiograph of the kidneys, ureters, and bladder C. A client who has a prescription for a tuberculin skin test D. A client who has a distended bladder and needs urinary catheterization ANSWER>>A. A client who has a prescription for a transfusion of packed red blood cells 185 Page 186 of 211 Administration of blood is a procedure that carries risk; therefore, the client must sign a consent form prior to the procedure. A nurse is caring for a client who has terminal cancer. The client is proceeding with plans to build a new home. The nurse should identify that this behavior typically indicates which of the following stages of grief? A. Acceptance B. Bargaining C. Anger D. Denial - ANSWER>>D. Denial During the denial stage of grief, a client is unable to accept the reality of the loss. A client who has a terminal disease has a limited amount of time, so building a house is unrealistic and denies reality. A nurse is performing a spiritual assessment of a client. Which of the following questions should the nurse ask A. "When did you start to believe in your faith?" B. "How often do you perform religious rituals?" C. "Which church do you regularly attend?" D. "What is your source of strength and hope?" - ANSWER>>D. "What is your source of strength and hope?" 186 Page 187 of 211 This is a broad, open-ended question that encourages the client to express feelings without any assumptions on the nurse's part. It correctly focuses on a global view of spirituality as a complex concept that encompasses the client's life experiences and beliefs about strength, love, and hope. A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room. The client states she no longer wants to have the surgery. Which of the following actions should the nurse take? A. Tell the client it is too late for her to change her mind because the surgery is already scheduled. B. Telephone the operating room and cancel the surgery. C. Inform the client's family about the situation. D. Notify the provider of the client's decision. - ANSWER>>D. Notify the provider of the client's decision. While acting as the client's advocate, the nurse should support her decision and notify the provider. A nurse is explaining Piaget's theory of cognitive development to a group of daycare providers for employees' children at an acute care facility. Which of the following activities should the nurse include as an example of concrete operational thinking? A. Playing in the sand B. Playing dress-up with old clothes 187 Page 188 of 211 C. Collecting and trading game cards D. Describing interpersonal relationships - ANSWER>>C. Collecting and trading game cards Collecting and trading game cards require seriation of the cards, involving what to collect, what to trade, and what has value. This is a characteristic of Piaget's concrete operational stage for ages 7 to 11 years. A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an assistive personnel (AP). The nurse later observes the AP emptying the bag without wearing gloves. Which of the following actions should the nurse take? A. Notify the charge nurse about the incident B. Insist that the AP attend an in-service training about standard precautions C. Talk with the AP about the technique used D. Observe the AP a second time and intervene if the technique remains the same ANSWER>>C. Talk with the AP about the technique used The nurse who delegates a task is responsible for providing the right supervision and evaluation. The nurse is responsible for providing feedback to the AP and should reinforce the correct procedure for this task with the AP, which includes wearing gloves. A nurse is caring for a client who has xerostomia with a lack of saliva. Which of the following nutrients will be affected by the lack of salivary amylase 188 Page 189 of 211 A. Fat B. Protein C. Starch D. Fiber - ANSWER>>C. Starch Salivary amylase begins the process of digestion in the mouth with the initial breakdown of starches. The majority of starch breakdown occurs in the small intestine with pancreatic amylase. A nurse is caring for a middle-aged adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks? A. Managing a home B. Establishing a sense of self in the adult world C. Forming new friendships D. Ceasing to compare personal identity with others - ANSWER>>D. Ceasing to compare personal identity with others Middle-aged adults usually feel more comfortable with themselves and cease to make comparisons with others. A nurse is leading an education session about disposing of biohazardous materials. Which of the following instructions should the nurse include in the teaching? 189 Page 190 of 211 A. Use isopropyl alcohol to clean blood spills. B. Discard empty blood bags in a bedside trash can. C. Break used needles before discarding. D. Place soiled linen in a single linen bag. - ANSWER>>D. Place soiled linen in a single linen bag. Soiled linen should be placed in a single bag that is tightly secured to reduce the risk of transmission of microorganisms. A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? A. Tenderness when touched B. Pink, shiny tissue with a granular appearance C. Serosanguineous drainage D. Halo of erythema on the surrounding skin - ANSWER>>D. Halo of erythema on the surrounding skin The nurse should report to the provider when the client has a ring of erythema (redness) on the surrounding skin, which might indicate underlying infection. This and any other manifestation of infection (e.g. purulent drainage, swelling, warmth, or a strong odor) should be reported to the provider. 190 Page 191 of 211 A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make? A. "During this phase, feed your child anything that she will eat." B. "Increase the amount of calories and water your child consumes." C. "Keep a diary of the foods your child eats each day." D. "Provide a large variety of fruit juices for your child to choose from." - ANSWER>>C. "Keep a diary of the foods your child eats each day." The nurse should encourage the parent to keep a diary of the foods the child eats throughout the day for 1 week. This can help the parent realize that the child may be eating better than expected. Evidence suggests that children can self-regulate their caloric intake. When they eat less at a meal, they can compensate by eating more at another meal or by having a snack. A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of primary prevention? A. Teaching clients to perform self-examinations of breasts and testicles B. Educating clients about the recommended immunization schedule for adults C. Teaching clients who have type 1 diabetes mellitus about care of the feet 191 Page 192 of 211 D. Recommending that clients over the age of 50 have a fecal occult blood test annually - ANSWER>>B. Educating clients about the recommended immunization schedule for adults Primary prevention includes health education about disease prevention. A nurse is performing a physical examination for a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques? A. Percussion B. Auscultation C. Inspection D. Palpation - ANSWER>>D. Palpation With palpation, the nurse uses touch to help detect unusual or expected sensations including texture, temperature, masses, or moisture. A client is being discharged home with oxygen therapy delivered through a nasal cannula. Which of the following instructions should the nurse provide to the client and family members? A. Use battery-operated equipment for personal care. B. Apply mineral oil to protect the facial skin from irritation. C. Remove the television set from the client's bedroom. 192 Page 193 of 211 D. Wear cotton clothing to avoid static electricity. - ANSWER>>D. Wear cotton clothing to avoid static electricity. The use of cotton clothing will limit the buildup of static electricity. Oxygen is a highly combustible gas. The use of oxygen in high concentrations has great combustion potential and readily fuels fire. Although it will not spontaneously burn or cause an explosion, it can easily cause a fire in a client's room if it contacts a spark. A nurse is teaching a client how to use an albuterol metered-dose inhaler. After removing the cap from the inhaler and shaking the canister, what sequence of instructions should the nurse give the client? - ANSWER>>Step 1: The client should hold the mouthpiece 2 to 4 cm (1 to 2 in) from the mouth Step 2: The client should tilt the head back slightly, and then open the mouth. Step 3: The client should depress the medication canister while taking a deep breath to facilitate the delivery of the medication through the airway. Step 4: After holding this breath for 10 seconds, the client should resume a usual breathing pattern. A nurse on a medical-surgical unit observes smoke billowing from a client's room. Which of the following actions should the nurse take first? A. Close the door to the client's room. B. Evacuate the client from the room. C. Sound the fire alarm. D. Activate the fire extinguisher. - ANSWER>>B. Evacuate the client from the room. 193 Page 194 of 211 The acronym RACE can help nurses remember the order of the actions to take in the event of a fire. The components of RACE are rescue, activate, confine, and extinguish. The first priority is rescuing or removing the client from immediate danger. The second action is activation of the fire alarm system. The third action is confining the fire by closing doors and windows. The final action is extinguishing the fire, if possible, using an available fire extinguisher. If attempts to extinguish a fire could compromise the safety of clients or staff members, the nurse should await the arrival of emergency fire personnel. A nurse is caring for a client who requires ventilator assistance with breathing following a motor vehicle crash. The nurse should suspect an injury to which of the following parts of the brain? A. Hypothalamus B. Cerebral cortex C. Brain stem D. Cerebellum - ANSWER>>C. Brain stem The nurse should identify an injury to the medulla and pons of the brain stem for a client who is experiencing difficulty with breathing. The brain stem serves as the respiratory control center, and a neurological injury can impair this center and inhibit respiratory effort. 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? 194 Page 195 of 211 A. Limit total caloric intake to 25 kcal/kg of body weight B. Provide an intake of 500 mg/day of vitamin E C. Limit fluid intake to 20 mL/kg of body weight per day D. Provide a protein intake of 1.5 g/kg of body weight per day - ANSWER>>D. Provide a protein intake of 1.5 g/kg of body weight per day A protein intake of 1 to 1.5 g/kg of body weight per day is necessary to maintain a positive nitrogen balance, which promotes wound healing. A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. People who practice the Islamic faith pray over the deceased for a period of 5 days before burial. B. People who practice the Hindu faith bury the deceased with their head facing north. C. People who practice Judaism stay with the body of the deceased until burial. D. People who are practicing the Buddhist faith have the female family members prepare the body following death. - ANSWER>>C. People who practice Judaism stay with the body of the deceased until burial. In the Jewish faith, a family member often stays with the body until burial occurs. A home health nurse is visiting an older adult client with severe dementia. The client's son, who serves as her primary caregiver, reports being "exhausted" from working part- 195 Page 196 of 211 time and caring for his mother at home. Which of the following options should the nurse suggest to the caregiver? A. Rehabilitation B. Assisted living facility C. Respite care D. Adult day care facility - ANSWER>>C. Respite care Respite care is a service for caregivers who need time to rest from multiple responsibilities related to the care of a family member who needs assistance. A nurse is preparing to administer sotalol to a client with a prescription for 320 mg/day divided equally every 12 hr. The medication is available in 80 mg tablets. How many tablets should the nurse administer per dose? - ANSWER>>2 Tablets A nurse in an acute care facility is planning care for a client who is alert but temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse plan to take to prevent a complication of immobility? A. Move the client from supine to a low Fowler's position every 2-3 hr to help prevent orthostatic hypotension B. Limit fluid intake to 1 L (33.8 oz) in 24 hr to help prevent dependent edema C. Encourage the client to turn from side to side every 3-4 hr to help prevent respiratory complications 196 Page 197 of 211 D. Instruct the client to perform foot and leg exercises every 1-2 hr while awake to help prevent thrombophlebitis - ANSWER>>D. Instruct the client to perform foot and leg exercises every 1-2 hr while awake to help prevent thrombophlebitis Antiembolic exercises (e.g. flexion of the knees and rolls and pumps of the feet and ankles) every 1-2 hours help prevent thrombophlebitis, which is a complication of immobility. A nurse is screening a client who has an S-shaped spinal column with unequal shoulder heights. The nurse should identify these findings as manifestations of which of the following abnormalities? A. Scoliosis B. Lordosis C. Torticollis D. Kyphosis - ANSWER>>A. Scoliosis The nurse should identify the finding of an S-shaped or C-shaped spinal column and uneven shoulder or hip heights as manifestations scoliosis. A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take? A. Raise the enema bag if the client experiences cramping B. Lubricate 2.54 cm (1 in) of the tip of the rectal tube prior to insertion 197 Page 198 of 211 C. Place the client in a left Sims' position D. Don sterile gloves prior to the procedure - ANSWER>>C. Place the client in a left Sims' position The nurse should place the client into a left Sims' position for the insertion of an enema. This left lateral position facilitates the flow of the enema solution into the sigmoid and descending colon. The anus is exposed by flexing the right leg. A nurse is caring for a client who has a terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first? A. Ask why the client is refusing the pain medication B. Administer a PRN antianxiety medication C. Help the client change positions D. Offer the client a heat or cold pack to place on painful areas - ANSWER>>A. Ask why the client is refusing the pain medication Using the nursing process, the nurse should first assess the reason for the client's refusal of the opioid pain medication. A nurse is preparing to administer a tuberculin skin test to a client. After performing hand hygiene, which of the following actions should the nurse take? A. Select a 23-gauge needle 198 Page 199 of 211 B. Insert the needle into the skin at a 25º angle C. Massage the area of injection following removal of the needle D. Circle the injection area with a pen - ANSWER>>D. Circle the injection area with a pen Circling the area with a pen ensures the nurse will examine the correct site when reading the test 48 to 72 hours later. A nurse is caring for a client who is receiving dextrose 5% in water IV at 150 mL/hr and has ingested 4 oz of water and ½ pint of milk. What is the total 8-hr fluid intake in milliliters that the nurse should document for this client? - ANSWER>>1560 mL 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? A. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink B. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back C. Press the skin above the ankle for 5 seconds, release it, and note the depth of the impression D. Measure the skinfold thickness on the upper arm using a pair of calibrated skinfold calipers - ANSWER>>B. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back 199 Page 200 of 211 The nurse should use this technique to assess skin turgor. If the client has good turgor and is properly hydrated, the skin will immediately return to normal; in dehydration, the skin will remain tented. The nurse can also assess turgor by grasping a skinfold on the back of the forearm. Incorrect Answers: A nurse is caring for a client who starts to experience a seizure while sitting in a chair. Which of the following actions should the nurse take? A. Place a padded tongue blade in the client's mouth B. Lower the client to the floor and place a pad under the client's head C. Seek the help of a coworker and lift the client back into bed D. Use an oropharyngeal airway to keep the upper airway passages open ANSWER>>B. Lower the client to the floor and place a pad under the client's head To reduce the risk of injury to the client, the nurse should lower the client to the floor and place a pillow or another soft object under the client's head. A nurse is providing discharge teaching to a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching? A. "A nurse will show me how to care for my wound." B. "A nurse will stay with me at home during the day." C. "I will call the nurse to change my bed linens." 200 Page 201 of 211 D. "I will call the nurse to help me bathe in the morning." - ANSWER>>A. "A nurse will show me how to care for my wound." The home health nurse will provide wound care as prescribed and educate the client about wound care and illness management. A nurse is caring for a client who has the head of his bed elevated to a 45° angle with his knees slightly flexed. Which of the following positions should the nurse document for the client? A. Sims' B. Prone C. Supine D. Fowler's - ANSWER>>D. Fowler's This describes Fowler's position. Although various definitions exist for Fowler's position, generally a low Fowler's position means 30° of elevation, semi Fowler's is 45° to 60°, and high Fowler's is 60° to 90° of elevation. A nurse asks a client to explain the statement, "A bird in the hand is worth two in the bush." Through this question, the nurse is evaluating the client's ability in which of the following intellectual functions? A. Judgment B. Short-term memory 201 Page 202 of 211 C. Attention span D. Abstract reasoning - ANSWER>>D. Abstract reasoning This exercise evaluates higher-level thinking and the ability to understand and interpret abstract thoughts. A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight? A. Calibrate the scales weekly B. Use a different scale each time C. Weigh the client on arising D. Weigh the client without clothing - ANSWER>>C. Weigh the client on arising The nurse should weigh the client on arising each day, after voiding, and before breakfast. An accurate weight requires the client to be weighed wearing the same garments and on the same carefully calibrated scale (balanced to 0 before each use). Accurate daily weights provide the easiest measurement of volume status. An increase of 1 kg (2.2 lb) is equal to 1,000 mL (1 L) of retained fluid. A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique? A. Preventing the transfer of microorganisms to the nurse 202 Page 203 of 211 B. Keeping microorganisms from entering the wound C. Applying minimal pressure to the wound D. Keeping excess moisture from entering the wound - ANSWER>>B. Keeping microorganisms from entering the wound Starting at the area of least contamination and working toward the area of greatest contamination prevents the spread of microorganisms within the wound. A nurse is providing nutritional teaching to a group of clients. Which of the following definitions for the recommended dietary allowance (RDA) should the nurse include in the teaching? A. The RDA is a comprehensive term that includes various dietary standards and scales. B. The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups. C. The RDA defines the levels of nutrients that should not be exceeded to prevent adverse health effects. D. The RDA is the daily percentage of energy intake values for fat, carbohydrate, and protein. - ANSWER>>B. The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups. The RDA represents daily requirements considered adequate for healthy people. RDAs are based on estimated amounts for each nutrient, including additional amounts for individuals such as women or infants. 203 Page 204 of 211 A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus? A. "Bear down." B. "Perform Kegel exercises." C. "Hold your breath." D. "Raise your head off of the pillow." - ANSWER>>A. "Bear down." The nurse should ask the client to "bear down" gently as if to void. This can enable the nurse to better visualize the urinary meatus and promote relaxation of the external urinary sphincter. Additionally, this will ease the passage of the catheter through the urinary meatus. A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first? A. Inspect both breasts simultaneously B. Squeeze the nipples C. Palpate the breast and tail of Spence D. Palpate the axillary lymph nodes - ANSWER>>A. Inspect both breasts simultaneously 204 Page 205 of 211 According to evidence-based practice, the nurse should first inspect both breasts with the client's arms in several different positions to look for asymmetry, masses, retraction, lesions, inflammation, and dimpling. A nurse is caring for a client who is dehydrated. The nurse should expect that insensible fluid loss of approximately 500 to 600 mL occurs each day through which of the following organs? A. Kidneys B. Lungs C. Gastrointestinal tract D. Skin - ANSWER>>D. Skin The skin can excrete approximately 500 to 600 mL of insensible fluid loss. This type of fluid loss is continuous and can increase if the client is experiencing a fever or has had a recent burn to the skin. A nurse is assessing a client's incision and observes the drainage to be blood-tinged. Which of the following terms should the nurse use to document this finding? A. Sanguineous B. Purulent C. Serous D. Hyperemia - ANSWER>>A. Sanguineous 205 Page 206 of 211 The nurse should document blood-tinged drainage as sanguineous. This type of drainage contains large amounts of red blood cells, indicating that damaged capillaries are allowing the escape of red blood cells from the plasma. A nurse is employing a thorough, systematic method while obtaining objective data about a client. Through which of the following methods should the nurse collect this information? A. Health history B. Physical examination C. Review of systems D. Interview - ANSWER>>B. Physical examination Physical findings are objective, and the nurse should collect this information in a systematic way. 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? A. Sit at the bedside while feeding the client B. Order pureed foods C. Make sure feedings are provided at room temperature 206 Page 207 of 211 D. Offer the client a drink of fluid after every bite - ANSWER>>A. Sit at the bedside while feeding the client The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client with the nurse's full attention during the feeding. A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription states "clear liquids; advance diet as tolerated." Which of the following responses should the nurse make? A. "Lunch trays should be here within the hour." B. "I am going to listen to your abdomen." C. "I'll get you some water to drink." D. "Let's wait a bit so you don't feel sick." - ANSWER>>B. "I am going to listen to your abdomen." A common reason clients experience nausea and vomiting after surgery is delayed gastric emptying time or decreased peristalsis. The nurse should auscultate the client's abdomen to determine the presence of bowel sounds before clear liquids can be administered. A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? A. Withdraw the specimen from the drainage bag 207 Page 208 of 211 B. Cleanse the collection port with soap and water C. Place the specimen in a clean specimen cup D. Clamp the tubing below the collection port - ANSWER>>D. Clamp the tubing below the collection port The nurse should clamp the tubing below the collection port to allow fresh, uncontaminated urine to collect before withdrawing the specimen through the port and placing it in a sterile specimen cup. A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client? A. Test for the presence of the client's gag reflex B. Place the client in the supine position C. Use a firm toothbrush for tooth and gum care D. Use 2 gauze-wrapped fingers to hold the mouth - ANSWER>>A. Test for the presence of the client's gag reflex The nurse is responsible for checking for the presence of a gag reflex prior to performing oral care. This is done to determine the risk of aspiration and is especially important for clients who are unconscious because many clients who have a decreased level of consciousness often do not have a gag reflex. A nurse is caring for a client who has breast cancer. The client has been receiving radiation therapy for several months and now refuses to undergo further treatment. Which of the following actions should the nurse take? 208 Page 209 of 211 A. Suggest the client talk with someone who has survived breast cancer B. Encourage the client not to give up C. Support the client's decision D. Refer the client to a counselor - ANSWER>>C. Support the client's decision The nurse has the responsibility to support the client's decision and respect the client's right of refusal. The nurse should notify the provider of the client's decision and document the refusal in the client's medical record. During the completion of a health history with a nurse, a client reports intermittent chest pain for the past week. Which of the following questions is the nurse's priority? A. "Did you report the chest pain episodes to your physician?" B. "Is there a history of heart disease in your family?" C. "Have you had this pain before?" D. "Can you tell me what the pain felt like and show me exactly where it was?" ANSWER>>D. "Can you tell me what the pain felt like and show me exactly where it was?" Using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority question for evaluating the client's pain is to quantify its characteristics, onset, duration, surrounding events, and location. This will help the nurse determine what action to take next. 209 Page 210 of 211 A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse prioritize when using the nursing process? A. Identify goals for client care B. Obtain client information C. Document nursing care needs D. Evaluate the effectiveness of care - ANSWER>>B. Obtain client information The nursing process is based on the scientific process. The first step in the scientific process is collecting data. Therefore, the first step in the nursing process is assessing and obtaining information about the client. 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? A. Tie the restraints to the side rails. B. Perform range-of-motion exercises to the wrists every 3 hr. C. Remove the restraints one at a time. D. Obtain a PRN prescription for the restraints. - ANSWER>>C. Remove the restraints one at a time. 210 Page 211 of 211 The nurse should remove one restraint at a time for a client who is violent or noncompliant. 211