Nursing Fundamentals Online Practice Answer Key

RN Fundamentals Online Practice 1. A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? a. A lesion with uniform pigmentation Variations in pigmentation are a possible indication of a skin malignancy. A lesion with uniform pigmentation is not an expected indication of a skin malignancy. b. New appearance of petechiae Petechiae are capillaries that have burst under the skin and appear as small spots on the skin. Although they can be indications of other conditions, petechiae are not an expected indication of a skin malignancy. c. A mole with asymmetrical appearance An uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part d. The presence of a papule Papules are solid elevations that are palpable in the skin and are less than 1 cm (0.39 in) in size. They are not an expected indication of a skin malignancy. 2. A nurse is assessing a client who reports pain following physical therapy. Which of the following questions should the nurse as when assessing the quality of the client’s pain? a. “Is your pain constant or intermittent?” Asking the client whether the pain is constant or intermittent determines the onset, duration, and pattern of the pain. b. “What would you rate your pain on a scale of 0 to 10?” Asking the client to rate the pain using the pain scale determines the intensity of the pain. c. “Does the pain radiate?” Asking the client whether the pain radiates determines the pain’s location. d. “Is your pain sharp or dull?” 1|Page Asking the client whether the pain is sharp or dull, crushing, throbbing, aching, burning, electric- like, or shooting helps determine the quality of the pain. 3. A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? a. Verify the client’s name on their identification bracelet with the medication administration record. The nurse should verify the client’s name on their identification bracelet when administering medication; however, this action is not a part of performing medication reconciliation. b. Call the pharmacy to determine whether the client’s medications are available. The nurse should call the pharmacy if the client’s medications are not available to administer at the appropriate time; however this action is not a part of performing medication reconciliation c. Compare the client’s home medications with the provider’s prescriptions. The nurse should compare the client’s home medications with the provider’s prescriptions when performing medication reconciliation. d. Place the client’s home medication bottles in a secure location. The nurse should place the client's home medications in a secure location to ensure safe handling of prescribed medications; however, this action is not a part of performing medication reconciliation. 4. A nurse is auscultating the anterior chest of a client who was admitted to a medicalsurgical unit. Listen to the audio clip of what the nurse auscultates through the stethoscope and identify the type of breath sounds. (Click on the audio button to listen to the clip.) a. Crackles Unlike these breath sounds, crackles (also called rales) are discontinuous sounds heard primarily during inhalation and resulting from air bubbling through fluid or mucus in the airways. b. Rhonchi 2|Page Rhonchi are dry, low-pitched, snore-like noises produced in the throat or bronchial tube due to a partial obstruction, such as by secretions. c. Friction rub Friction rub is a scratching sound that persists throughout the respiratory cycle. d. Normal breath sounds These are normal bronchovesicular breath sounds, characteristically of moderate intensity and sounding like blowing as air moves through the larger airways on inspiration and expiration. 5. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? a. Administer the medication with the needle at 45o angle. The nurse should insert the needle at 45o to 90omangle for a subcutaneous injection. b. Administer the medication into the client’s nondominant arm. The nurse should administer enoxaparin into the abdomen, at least 5cm (2 inches) from the umbilicus. c. Pull the client’s skin laterally or downward prior to administration. The Z-track technique involves displacing the skin laterally or downward prior to administration of an IM injection. d. Massage the injection site after the administration. The nurse should not massage the injection following the injection of an anticoagulant due to the risk for bruising. 6. A nurse is using an open irrigation technique to irrigate a client’s indwelling urinary catheter. Which of the following actions should the nurse take? a. Place the client in a side-lying position. b. Instill 15 mL of irrigation fluid into the catheter with each flush. c. Subtract the amount of irrigant used from the client’s urine output. d. Perform the irrigation using a 20-mL syringe. 3|Page 7. A nurse is preparing to apply a dressing for a client who has stage 2 pressure injury. Which of the following types of dressing should the nurse use? a. Alginate Alginate dressings are used to treat stage 3 and 4 pressure injuries to absorb drainage. Alginate forms a soft gel when it comes in contact with drainage. b. Gauze Moistened gauze promotes healing in stage 4 or unstageable injuries by causing debridement and allowing granulation of the wound bed. c. Transparent Transparent dressings promote healing in stage 1 pressure injuries by preventing further friction and sharing. d. Hydrocolloid Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed. 8. A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? a. Insert the needle at a 15o angle The nurse should instruct the client to insert the needle at a 45o to 90o angle to administer into the subcutaneous tissue. b. Aspirate for blood return prior to administration The nurse should instruct the client not to aspirate for blood return because this can cause tissue damage and bruising. c. Administer the medication into the abdomen The nurse should instruct the client to administer the medication into the abdomen at least 5.08cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue. d. Massage the site following the injection The nurse should instruct the client not to massage the site because this can cause tissue damage and bruising. 4|Page 9. A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? a. Pad the client’s wrist before applying restraints. The use of restraints without padding can abrade the client’s skin, resulting in client injury. b. Evaluate the client’s circulation every 8hr after application. The nurse should evaluate the client’s circulation, range of motion, vital signs, and overall status every 15 min after the initial application of restraints. c. Remove the restraints every 4hr to evaluate the client’s status. The nurse should remove the restraints at least every 2hr to reposition the client and assess needs for hygiene and toileting. d. Secure the restraint ties to the bed’s side rails. The nurse should secure the restraint ties to a part of the bed frame that moves with the client to reduce the risk of injury. 10. A nurse is initiating a protective environment for a client who has had an allogenic stem cell transplant. Which of the following precautions should the nurse plan for this client? a. Make sure the client’s room has at least six air exchanges per hour. A protective environment requires at least 12 air exchanges per hour. b. Make sure the client wears mask when outside her room if there is construction in the area. An allogenic stem cell transplant compromises the client’s immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment. c. Place the client in a private room that provides negative-pressure airflow. The nurse should place the client in a private room that provides positive-pressure airflow. d. Wear an N95 respirator when giving the client direct care. The nurse should wear an N95 respirator mask when caring for a client who require airborne precautions, not a protective environment. 5|Page 11. A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? a. Use a bed-exit alarm system The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client’s condition places them at risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance. b. Raise four side rails while the client is in bed Raising four side rails when the client is in bed is a form of restraint and increases the risk for falls and injury. c. Apply soft wrist restraint Applying one soft wrist restraint is a physical restraint requiring a prescription. Other forms of distraction or interventions to maintain client safety should be attempted for clients who have dementia. d. Dim the lights in the client’s room Dimming the lights in the room for a client who has dementia can reduce visibility and increase the risk of injury. 12. A nurse is preparing to administer 0.9% sodium chloride 750mL IV to infuse over 7 hr. the nurse should set the infusion pump to deliver how many mL/hr? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 107 mL/hr 13. A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies? a. Biofeedback 6|Page Biofeedback is complementary and alternative therapy to assist clients with stroke recovery, smoking cessation, headaches, and many other disorders. Herpes zoster is not a contraindication for the use of this mind-body technique. b. Aloe Aloe is a complementary and alternative therapy that can help improve disorders and can have wound healing effects. Herpes zoster is not a contraindication for the use of this type of therapy. c. Feverfew Feverfew is a complementary and alternative therapy that helps promote wound healing. Anticoagulant therapy is a contraindication for taking feverfew. However, herpes zoster is not a contraindication for the use of this type of therapy. d. Acupuncture The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin’s surface could increase the risk of further infection. 14. A nurse is lifting a bedside cabinet to mover closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? a. Bend at the waist. The nurse should bend the knees when lifting the cabinet. b. Keep the feet close together. The nurse should spread the feet wide apart to create a broad base of support. This promotes stability while lifting the cabinet. c. Use his back muscles for lifting. The nurse should use the arm and leg muscles when lifting the cabinet because they are generally stronger than back muscles. d. Stand close to the cabinet when lifting it. This action keeps the cabinet close to the nurse’s center of gravity and decreases back strain from horizontal reaching. 7|Page 15. A nurse is talking with an older adult client who is contemplating retirement. The client states, “I keep thinking about how much I enjoy my job. I’m not sure I want to retire.” Which of the following responses should the nurse make? a. “You would have so much more time to spend with your family.” This response is nontherapeutic because the nurse is minimizing the client’s feelings and making assumptions about the client’s relationships. b. “You should consider getting a part-time job or doing volunteer work.” This response is nontherapeutic because the nurse is minimizing the client’s feelings and offering personal advice. c. “Let’s talk about how the change in your job status will affect you.” This response is therapeutic because the nurse is encouraging the clients to verbalize feelings about the life transition of retirement. d. “Why wouldn’t you want to retire and relax?” This response is nontherapeutic because the nurse is asking a “why” question, which can provoke a defensive response form the client. 16. A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says, “Every time you change my bandage, it hurts so much.” Which of the following interventions is the nurse’s priority action? a. Encourage the client to relax and take deep breaths during the dressing change. Encouraging the client to relax and take deep breaths during the postoperative period is important because relaxation can help reduce the client’s anxiety about the procedure. However, there is another intervention that is the priority. b. Educate the client about the importance of the dressing change to prevent infection. Educating the client about the importance of the dressing change is important because understanding the rationale for the procedure can help the client relax. However, there is another intervention that is the priority. c. Assist the client to a comfortable position for the dressing change. 8|Page Moving the client to a comfortable position for the dressing change is important because it can help the client relax and can also reduce strain on the wound. However, there is another intervention that is the priority. d. Administer pain medication 45 min before changing the client’s dressing. The priority action the nurse should take when using Maslow’s hierarchy of needs is to meet the client’s physiological need for comfort and pain relief. Therefore the priority intervention is to administer an analgesic 30 to 60 min before changing the client’s dressing. 17. A nurse is assessing a client’s readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? a. “I can concentrate best in the morning.” The client’s statement indicates a readiness to learn because he is verbalizing the best time for him to learn. b. “It is difficult to read the instruction because my glasses are at home.” The client’s statement indicates the client is not ready to learn. The client has to have the tools he needs to learn and comprehend the information. c. “I’m wondering why I need to learn this.” The client’s statement indicates a reluctance to learn information he thinks he might not need to know. d. “You will have to talk to my wife about this.” With this statement the client is redirecting the nurse’s attempt to teach toward someone else, indicating that he is not ready to learn. 18. A nurse is evaluating a client’s use of a cane. Which of the following actions should the nurse identify as an indication of correct use? a. The top of the cane is parallel to the client’s waist. The top of the cane should be parallel to the client’s greater trochanter b. When walking, the client moves the cane 46cm (18 in) forward. 9|Page To maintain balance, the client should advance the cane about 15 to 30 cm (6 to 12 in) at a time. c. The client holds the cane on the stronger side of her body. The client should hold the cane on the stronger side of her body to increase support and maintain alignment. d. The client moves her stronger limb forward with the cane. The client should move her weaker leg forward with the cane. This divides the client’s body weight between the cane and the stronger leg. 19. A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? a. “Use the complete name of the medication magnesium sulfate.” The institute for Safe Medication Practices designates that nurses and providers write the complete medication name for magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate. b. “Delete the space between the numerical dose and the unit of measure.” The Institute for Safe Medications Practices recommends including a space between the dose and the unknit of measure, such as in 10 mg, to avoid confusion when documenting medication dosages. c. “Writhe letter U when noting the dosage of insulin.” The Institute for Safe Medication Practices designates “unit(s)” as the correct term for use in medication documentations. d. “Use the abbreviation SC when indicating an injection.” The Institute for Safe Medication Practices designates either “subcut” or “subcutaneously” as the correct for use in medication documentation. 20. A nurse is caring for a client who is postoperative following a knee arthroplasty and requires for use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take? a. Assist the client into a prone position. 10 | P a g e The nurse should place the client in a dorsal recumbent or semi-Fowler’s position to facilitate application of the sleeves. b. Place a sleeve over the top of each leg with the opening at the knee. The nurse should place the sleeve under each leg with the opening at the knee and then the sleeve around the leg so that it is secure. c. Make sure two finger can fit under the sleeves. The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate. d. Set the ankle pressure at 65 mmHg. The nurse should set the ankle pressure between 35 and 55 mmHg to achieve a therapeutic effect while also preventing damage to the client’s skin and circulatory impairment. 21. A nurse in a long-term care facility is caring for a client who dies during the nurse’s shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) a. Place a name tag on the body. b. Obtain the pronouncement of death from the provider. c. Remove tubes and indwelling lines. d. Wash the client’s body. e. Ask the client’s family members if they would like to view the body. Answer: B, C, D, E, A. 22. A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? a. Check the client for injuries. The first action the nurse should take when using the nursing process is to assess the client for injuries. 11 | P a g e b. Move hazardous objects away from the client. Moving hazardous objects away from the client can prevent further injury; however, there is another action the nurse should take first. c. Notify the provider. The nurse should notify the provider of the client’s fall; however, there is another action the nurse should take first. d. Ask the client to describe how she felt prior to the fall. Determining the facts that surrounded the fall is important to help prevent subsequent falls; however, there is another action the nurse should take first. 23. A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client’s room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? a. “I will return shortly after I document this in your record.” Although it is helpful to assure the client that the nurse will return, reminding him about the nurse’s need to perform certain tasks is likely to sound dismissive of his profound needs at this time. b. “Most men live a long time with prostate cancer.” This statement provides false reassurance. The nurse cannot predicts what the client’s outcome might be. c. “I am available to talk if you should change your mind.” When a client does not wish to share his feelings with the nurse, it is important for the nurse to convey a willingness to be available foe the client. d. “I will make a referral to a cancer support group for you.” Dismissing the client’s concerns by referring him elsewhere without specific intervention by the nurse it is a nontherapeutic response. 24. A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, “What would happen if I arrived at the emergency 12 | P a g e department and I had difficulty breathing?” Which of the following responses should the nurse make? a. “We would consult the person appointed by your health care proxy to make decisions.” The staff must honor the client’s wishes as stated in their living will; therefore, it would not be necessary to consult the person appointed by the client’s health care proxy to make decisions about the client’s care. b. “We would give toy oxygen through a tube in your nose.” Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula. c. “You would be unable to change your previous wishes about your care.” Clients determine advance directives ahead of time to guide decision-making at the time of an emergency event. If the client initiates a change, the staff must honor it. Otherwise, staff must honor the decisions the client has documented in the advance directives. d. “We would insert a breathing tube while we evaluate your condition.” Intubation is a resuscitative measure. The staff should not implement this intervention for a client who declines resuscitation in their living will. 25. A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client? a. Have the client wear a mask when receiving visitors. The client does not need to wear a mask to prevent the spread of the infection because shigella does not require airborne or droplet precautions. b. Limit the client’s time with visitors to no more than 30 min per day. Limiting the client’s time with visitors will not decrease the risk of spreading shigella. Clients who require isolation precautions are at risk for depression and loneliness; therefore, the nurse should encourage visitation. c. Assign the client to a room with negative pressure airflow exchange. The nurse should assign a client who has shigella to a private room; however, negative-pressure airflow is not necessary because shigella is not airborne. 13 | P a g e d. Wear a gown when caring for the client. The nurse should implement contact precautions for a client who has shigella to prevent the transmission of the bacteria. The nurse should wear a gown when providing care for a client who requires contact precautions due to the risk of contact with bodily fluids and contaminated surfaces. 26. A client who is postoperative is verbalizing pain as a 2 on a pain scale 0 to 10. Which of the following statement should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? a. “I think I should take my pain medication more often, since it is not controlling my pain.” As a 2 on a scale of 0 to 10, this client’s pain is mild. Additional analgesic medication is unnecessary at this time. b. “Breathing faster will help me keep my mind off of the pain.” Rapid breathing can lead to hyperventilation, while slow, focused breathing helps induce relaxation, which can help with managing pain. c. “It might help me to listen to music while I’m lying in bed.” Listening to music is an effective nonpharmacological intervention for the management of mild pain. d. “I don’t want to walk today because I have some pain.” Postoperative clients need to ambulate even if they are having mild pain. 27. A nurse is administering an otic medication to an older adult client. Which of the following actions should take to ensure that the medication reaches the inner ear? a. Press gently on the tragus of the client’s ear. Pressing gently on the tragus of the ear will help the medication get into the inner ear. b. Pack a small piece of cotton deep into the client’s ear canal. Inserting a piece of cotton into the meatus of the canal could damage the ear. If cotton is necessary, the nurse should place it into the outer portion of the ear canal and not push it inward. c. Move the client’s auricle down and back toward her head. 14 | P a g e For an adult client, the nurse should move the auricle upward and backward or upward and outward to straighten the ear canal. d. Tilt the client’s head backward for 5 min. The client should lie on one side with the ear that received the instillation facing upward for 2 to 5 min. 28. A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? a. The client uses a wood blanket on their bed. The client should use a cotton blanket instead of a wool blanket to avoid generating static electricity that could ignite the oxygen. b. The client uses nonacetone nail polish remover. The client should use nonflammable materials, such as nonacetone nail polish remover, while using supplemental oxygen. c. The client stores an extra oxygen tank on its side under their bed. The client should store extra oxygen tanks in an upright position to maintain safety. d. The client has a weekly inspection checklist for oxygen equipment. The client or caregiver should inspect oxygen equipment daily. 29. A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? a. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. The nurse should regulate the oxygen flow rate by aligning the rate on the flow meter with the middle of the silver ball inside the meter. b. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. Evidence-based research supports that a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min have a drying effect and force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2). 15 | P a g e c. Make sure the reservoir bag of partial rebreathing mask remains deflated. The reservoir bag should inflate by one-third to one-half with inspiration. If it remains deflated, it indicates that clients are breathing in too much of the carbon dioxide they exhale. d. Use petroleum jelly to lubricate the client’s nares, face, and lips. Evidence-based research supports the use of water soluble lubricant to protect the client’s skin from the drying effects of oxygen. 30. A nurse is reviewing a client’s fluid and electrolyte status. Which of the following findings should the nurse report to the provider? a. BUN 15 mg/dL This value is within the expected reference range of 10- 20 mg/dL. b. Creatinine 0.8 mg/dL This value is within the expected reference range of 0.5- 1.1 mg/dL for women 41- 60 years of age and 0.6- 1.3 mg/dL for men 41- 60 years of age. Even for clients within younger and older age ranges (with the exception of newborn through 9 years of age), 0.8 mg/dL is within the expected reference range for creatinine. c. Sodium 143 mEq/L This value is within the expected reference range of 136- 145 mEq/L. d. Potassium 5.4 mEq/L This value is above the expected reference range of 3.5- 5.0 mEq/L so the nurse should report this finding to the provider. This client is at risk for dysrhythmias. 31. A home health nurse is performing a follow-up visit for a client who has gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea? a. The client is receiving formula at room temperature. Cold formula can cause gastric cramping; therefore, room temperature formula is appropriate and is likely not the cause of the client’s diarrhea. b. The feedings infuse at a slow, continuous drip over 8hr each night. 16 | P a g e Diarrhea is more likely to develop with rapid instillation of enteral formula. c. The client’s caregiver washes out the feeding bag with warm water once every 24 hr. Feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent bacterial contamination. The nurse should reinforce this information with the client’s caregiver to avoid future contamination. d. The client’s caregiver flushes the tubing with water before and after administering medications. It is correct to flush tubing with water before and after administering medications to prevent clogging of the tube. 32. A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? a. Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain. The nurse should use an age-appropriate pain-rating scale, such as visual analog or numerical scale, when assessing the pain level of an adult. The FLACC pain rating scale is used for clients aged from 2 months to 7 years old. b. Ensure the bladder of the blood pressure cuff surrounds 80% of the client’s arm. The nurse should use a blood pressure cuff with a bladder that surrounds 80% of the client’s arm circumference to give an accurate reading. c. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum. The nurse should place the stethoscope at the point of maximal impulse, which is at the fifth intercostal space at the midclavicular line left of the sternum. d. Palpate the client’s abdomen before auscultating bowel sounds. When assessing and adult client’s abdomen, the nurse should auscultate bowel sounds before performing palpation in order not to change to character of the sounds. 17 | P a g e 33. A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? a. Combine client care tasks when caring for multiple clients. The nurse should complete the tasks for one client before beginning the tasks for another client to reduce fragmentation of care and avoid potential errors b. Wait until the end of their shift to document client care. Documentation should be completed in a timely manner after care is performed to reduce errors and unsafe client care. Performing documentation at the end of shift is not effective time management. c. Use the planning step of the nursing process to prioritize client care delivery. Setting up a list of goals and tasks to perform for clients can help the nurse set care and plan tasks accordingly. The priority to-do-list is an efficient tool for optimal time management. d. Allow for interruptions in tasks to discuss client care issues with colleagues. An important principle of time management is controlling interruptions to reduce errors and loss of care delivery time. 34. A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? a. Carry a client’s soiled linens out of the room in a mesh linen bag. The nurse should place soiled linens in a fluid resistant bag to reduce the risk of infection transmission. b. Place a client who has tuberculosis in a room with negative-pressure airflow. A client who has tuberculosis requires airborne precautions, which include placing the client in a room that has negative-pressure airflow to reduce the risk of infection transmission. c. Provide disposable plates and utensils for a client who is HIV-positive. People transmit HIV mainly by blood and sexual activity; therefore, a client who is HIV-positive does not require disposable plates and utensils. Standard precautions are sufficient. 18 | P a g e d. Dispose of a client’s blood-saturated dressing in a trash bag inside a second trash bag. The nurse should dispose of items that have a large amount of blood in a biohazard bag that is impervious to microorganisms. 35. A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client’s partner indicates effective coping? a. “I am not worried because I still have hope that he will be okay.” This statement reflects false hope and possible denial of the terminal nature of the client’s illness. Denial involves the blocking of painful thoughts or feelings that induce anxiety. b. “I am relying on support from our family during this time.” This statement indicates effective coping because the partner is relying on others in the family for supporting a time of crisis. c. “We can plan our family reunion once he recovers and comes home.” This statement reflects false hope and possibly denial of the terminal nature of the client’s illness. Denial involves the blocking of painful thoughts or feelings that induce anxiety. d. “We don’t see any reason to start discussing funeral arrangements right now.” This statement reflects potential false hope about possible denial of the terminal nature of the client’s illness. It also indicates the partner’s potential inability or unwillingness to address unpleasant or challenging issues related to the client’s death. 36. A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suction for the client? a. Insert the suction catheter while the client is swallowing. The nurse should insert the suction catheter while the client is inhaling to avoid inserting the catheter into the esophagus. b. Apply intermittent suction when withdrawing the catheter. 19 | P a g e The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise. c. Place the catheter in a locations what is clean and dry for later use. The nurse should discard the suction catheter after use to eliminate the risk of reintroducing pathogens into the respiratory tract. d. Hold the suction catheter with her clean, nondominant hand. The nurse should hold the suction catheter with her dominant hand after donning a sterile gloves. 37. A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take? a. Turn the client every 2 hr. The nurse should turn the client at least once every 2 hr to break up the secretions in the client’s lungs and prevent noisy respirations. b. Administer an antiemetic every 6 hr. The nurse should administer antiemetics for clients who are experiencing nausea or vomiting. However, this is not the correct actions to take when assisting a client who is experiencing respiratory difficulty at the end of life. c. Hold oral care. The nurse should provide frequent oral care in order to keep the client’s mouth moist and provide comfort. d. Increase the room’s temperature. Keeping the air temperature cool by allowing air to circulate with the use of a fan or opening windows is more comfortable for a client who is dying and will decrease air hunger. 38. A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? a. “They allow the court to overrule and adult client’s refusal of medical treatment.” 20 | P a g e A court can only overrule and adult client’s refusal of medical treatment if the client is legally competent. b. “They indicate the form of treatment a client is willing to accept in the event of a serious illness.” Advance directives include a living will, which permits clients to direct the treatment they will receive in the event of a medical emergency or serious illness. c. “They permit a client to withhold medical information from health care personnel.” The American with Disabilities Act, not advance directives, protect the privacy of client who chooses not to disclose a medical disability. d. “They allow health care personnel in the emergency department to stabilize a client’s condition.” The Emergency Medical Treatment and Active Labor Act, not advance directives, directs emergency personnel to provide screening and stabilizing care before discharging or transferring clients to another facility. 39. A nurse receives report about a client who has 0.9% sodium chloride IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hr. Which of the following actions should the nurse take first? a. Reposition the client. The nurse should reposition the client to help improve the flow rate; however, there is another action the nurse should take first. b. Document the client’s IV intake in the medical record. The nurse should document the client’s IV intake in the medical record accurately to help the team prevent or correct fluid imbalances; however, there is another action the nurse should take first. c. Request a new IV fluid prescription. The nurse should request a new IV fluid prescription to compensate for lost fluid intake; however, there is another action the nurse should take first. d. Check the IV tubing for obstruction. 21 | P a g e The first action the nurse should take using process is to assess the client. If checking the IV tubing and verifying an obstruction, the nurse might be able to facilitate the flow of fluid through the tubing. This could re-establish the infusion rate the provider prescribed. 40. A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.) a. Assist the client with a partial bed bath. Assisting a client with a bed bath poses minimal risk to the client and is within the AP’s range of function. b. Measure the client’s BP after the nurse administers an antihypertensive medication. Measuring a client’s BP poses minimal risk to the client and is within AP’s range of function. c. Test the client’s swallowing ability by providing thickened liquids. Assessing the client’s swallowing ability places the client at risk for aspiration and is not within the AP’s range of function. Nurses perform tasks that require assessment. d. Use a communication board to ask what the client wants for lunch. Using a communication board poses minimal risk to the client and is within the AP’s range of function. e. Irrigate the client’s indwelling urinary catheter. Irrigating the client’s indwelling urinary catheter is an invasive procedure and is not within the AP’s range of function. 41. A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? a. “I can place an extension cord across my living room to plug in mu television.” Extension cords should be securely fastened to the floor and should be run along the edge of the wall, if possible, to avoid the risk for tripping. 22 | P a g e b. “I will hire someone to trim the trees that hangs low over the stairs of my front porch.” Clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls. c. “I will place my alarm clock on my bedroom dresser across the room.” Frequently used items like an alarm clock, or disposable tissues should be placed within reach, such as on the client’s night stand. This helps to prevent the client from needing to get up and potentially falling in the night. d. “I will replace the old throw rug in my kitchen with a new one.” Using throw rugs increases the client’s risk for fall because they create a tripping and slipping hazard for the client. 42. A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? a. Numbness of extremities This is manifestation of hyperkalemia. b. Bradycardia Tachycardia is a manifestation of hyponatremia along with hypovolemia. c. Positive Chvostek’s sign A positive Chvostek’s sign is a manifestation of hypomagnesemia and hypocalcemia. d. Abdominal cramping This client who has hyponatremia, which is low sodium level. Manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea. 43. A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? a. Insert the catheter at a 45o angle. Generally, the nurse should insert the catheter at 10o to 30o angle. However, for an older adult client, an angle of 10o to 15o is preferable because veins are closer to the skin surface as aging diminishes subcutaneous tissue. b. Place the client’s arm in a dependent position. 23 | P a g e The nurse should place the client’s arm in a dependent position because the veins will dilate due to gravity. c. Shave excess hair from the insertion site. The nurse should clip excess hair from the IV insertion site and avoid shaving the area because shaving can cause breaks and cuts in the skin that could place the client at risk for infection d. Initiate IV therapy in the veins of the hands. The nurse should avoid using the fragile veins of an older adult’s hands because the loss of subcutaneous tissue can allow those veins to roll away from the needle. Also, having an IV catheter in the client’s hand can interfere with the client’s performance of ADLs and can diminish an older adult sense of independence and ability. 44. A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? a. Advocacy ensures client’s safety, health, and rights. Advocacy is a key component of professional nurses’ code of ethics. As a client advocate, the nurse ensures clients’ safety, health, and rights, including the right to privacy, confidentiality, and refusal of care. b. Advocacy ensures that nurses are able to explain their own actions. Accountability, not advocacy, is the responsibility of nurses to explain their own actions to their clients and employer. c. Advocacy ensures that nurses follow through on their promises to clients. Fidelity, not advocacy, is an agreement by nurses to follow through with promises made to clients. d. Advocacy ensures fairness in client care delivery and use of resources. Justice, not advocacy, is fairness in client care delivery, including the distribution of resources and care. 45. A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client’s care, when should the nurse initiate discharge planning? a. During the admission process. 24 | P a g e Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client’s needs and plan for care both during and after the client’s time in the facility. b. As soon as the client’s condition is stable. Although it is appropriate to defer client teaching until the client is stable and receptive to learning the initiation of discharge planning does not depend on the client’s physiological stability. c. During the initial team conference. Team conference facilitate discharge planning, but they are not essential for initiating the planning process. d. After consulting with the client’s family. The nurse should only consult with the client’s family if the client gives the nurse permission to share that information. In the case of a client who has an exacerbation of heart failure, delaying discharge planning until this time could result in overlooking essential care needs. 46. A nurse is talking with the partner of a client who has dementia. The client’s partner expresses finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following type of role-performance stress? a. Role ambiguity This occurs when people are unclear about the expectations of their role in a given situation. b. Sick role This refers to the expectations placed on the individual who has the alteration in health, rather than the caregiver. c. Role overload The partner’s expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage. d. Role conflict 25 | P a g e This develops when a person must assume multiple roles that have opposing expectations. 47. A nurse is teaching a client and his family how to care for the client’s tracheostomy at home. Which of the following instructions should the nurse include in the teaching? a. Remove the outer cannula cautiously for routine cleaning. The outer cannula stabilizes the airway; therefore, the client should never remove it for cleaning. b. Use tracheostomy covers when outdoors. Tracheostomy covers protect the client’s airway from cold air, dust, and other airborne particles. c. Use sterile technique when performing tracheostomy care at home. In the home environment, medical asepsis with clean technique is appropriate. d. Cleanse irritated skin with full-strength hydrogen peroxide. Hydrogen peroxide can irritate the skin; therefore, the nurse should instruct the client and family to use 0.9% sodium chloride irrigation to cleanse the site and prevent further irritation. 48. A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon who tells the nurse to continue to measure the client’s vital signs every 15 min and to report back in 1 hr. which of the following actions should the nurse take next? a. Document the provider’s statement in the medical record. The nurse should document the provider’s directions in the medical record for later reference; however, another action is the nurse’s priority. b. Complete an incident report. The nurse should prepare an incident report detailing the delay in treatment for later review and action for prevention of future occurrences; however, another action is the nurse’s priority. c. Consult the facility’s risk manager. 26 | P a g e The nurse should discuss the situation with the facility’s risk management department to help determine the need for preventive actions; however, another action is the nurse’s priority. d. Notify the nursing manager. The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chai of command to ensure that the client receives the necessary care. 49. A nurse is administering 1 L of 0.9 sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? a. Increase in hematocrit FVD cause an increase in hematocrit level due to depletion of ECF. With correction of the imbalance, the hematocrit level should decrease. b. Increase in respiratory rate FVD causes an increase in respiratory rate. With correction of the imbalance, the respiratory rate should return to the expected range. c. Decrease in heart rate FVD causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range. d. Decrease in capillary refill time FVD slows capillary refill. With correction of the imbalance, capillary refill time should return to the expected range. 50. A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? a. Contact Contact precautions are a requirement for client who have infections that spread via direct contact or from environmental contact. Examples: VRE and herpes simplex infections. b. Droplet 27 | P a g e Droplet precautions are a requirement for a clients who have infections that spread via droplet nuclei larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis the nurse should wear a mask when providing care or when within 1 m (3 feet) of the client who has a disorder requiring droplet precautions. c. Airborne Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei smaller than 5 microns in diameter, including varicella, tuberculosis, and measles d. Protective Clients who have a compromised immune system, such as those who have received allogenic stem cell transplant, require a protective environment. This precaution keep them from acquiring infections from others. 51. A nurse is caring for a child who has a prescription for a blood transfusion. The child’s parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take? a. Examine personal values about the issue. Nurses should examine their own personal values about the issue in question in order to provide care that is without bias. b. Tell the parents that this is necessary procedure. The nurse should provide parents with information about the procedure. However, telling the parents that this is a necessary procedure disregard the parents religious beliefs and their right to refuse treatments. c. Inform the parents that the staff does not require their consent. Parents must give consent for a child to receive a blood transfusion. d. Contact a spiritual support person to explain the importance of the procedure. The nurse or the provider should provide information about the procedure. Spiritual support people attend to clients and families spiritual needs, not their physiological needs. 28 | P a g e 52. A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? a. Critical pathway This is and interprofessional approach to planning all phases of client care. b. Situation, background, assessment, and recommendation (SBAR) SBAR is a communication tool nurses use to relate a client’s status during a changeof-shift report. c. Transfer report The nurse should use a transfer report when the client is moving from one health care area to another. d. Medication administration record (MAR) The nurse should use the MAR to document medication administration. 53. A nurse in a provider’s office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client’s patellar reflex? One with the knee. 54. A nurse is assessing an older adult client’s risk for fall. Which of the following assessments should the nurse use to identify the client’s safety needs? (Select all that apply.) a. Lacrimal apparatus If clients have impairment in the ability to produce tears, it should not affect their fall risk. The nurse tests this by palpating the tear duct at the lower eyelid to see if any tears emerge. b. Pupil clarity Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly. c. Appearance of bulbar conjunctivae 29 | P a g e The nurse should examine the bulbar conjunctivae by gently retracting the lower and upper lids to evaluate color and texture and assess for the presence of infection. However, the condition of the conjunctivae will not impede the client’s safety. d. Visual fields The nurse should use a finger to test the client’s peripheral vison by moving the finger out of range and then back into the visual field to determine when the client sees the finger. Clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall. e. Visual acuity The nurse should use a Snellen chart to assess distance vision and a handheld card to assess near vision. Client who wear eyeglasses should wear them during the assessments. Clients who have impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall. 55. A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse’s priority? a. Request that a respiratory therapist discuss the technique for incentive spirometry with the client. The nurse can request that another team member discuss the use of the incentive spirometer with the client to encourage the client to use it; however, this is not the priority action for the nurse to take. b. Determine the reasons why the client is refusing to use the incentive spirometer. The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action for the nurse to take is to determine why the client is refusing the treatment. c. Document the client’s refusal to participate in health restorative activities. 30 | P a g e If other interventions to promote the client’s use of the incentive spirometer are unsuccessful, the nurse must document the client’s refusal; however, this is not the priority action for the nurse to take. d. Administer a pain medication to the client. Pain or incisional complications might make the client refuse spirometry; however, administering medication is not the priority action for the nurse to take. 56. A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? a. Bladder distention Urinary retention, which causes bladder distention, is a common complication of bed rest due to a loss of muscle tone in the bladder and detrusor muscles. b. Decreased blood pressure A client who requires bed rest can develop postural hypotension, which is a drop in blood pressure when the client moved from a lying to a sitting position. The nurse should also assess the client for an increase in pulse rate and dizziness. c. Calf swelling Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility. d. Diminished bowel sounds A decrease in bowel sounds reflects slowed peristalsis. Constipation is a common complication of immobility. 57. A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? a. Discuss the risk factors for colon cancer. The client might perceive this as challenging or argumentative and react offensively. Instead, the nurse should listen to the client’s concerns and should avoid challenging him. 31 | P a g e b. Focus teaching on what the client will need to do in the future to manage his illness. During the anger stage of the client’s psychosocial adaptation to illness, the nurse should focus teaching on the present. The client is not yet ready to face the future. c. Provide the client with written information about the phases of loss and grief. Unless the client requests reading materials about loss, this is not an optimal time to provide them. At this stage, the client needs to express his feelings without any expectations for learning. d. Reassure the client that this is an expected response to grief. During the anger stage of the client’s psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis. 58. A nurse is preparing to administer an injection of an opioid to a client. The nurse draws out 1 mL of the medication from a 2 mL vial, which of the following actions should the nurse take? a. Ask another nurse to observe the medication wastage. A second nurse must witness the disposal of any portion of a dose of a controlled substance. b. Notify the pharmacy when wasting the medication. Pharmacies do not require notification of the disposal of a portion of a dose of a controlled substance. c. Lock the remaining medication in the controlled substances cabinet. The nurse should not lock the remaining controlled substance in the cabinet because this is a violation of the Controlled Substance Act. d. Dispose of the vial with the remaining medication in a sharps container. The nurse should not dispose of the remaining controlled substance in the sharps container because this is a violation of the Controlled Substance Act. 59. A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? 32 | P a g e a. Position the client with the head of the bed elevated to 30o prior to insertion of the NG tube. The client should be sitting in high-Fowler’s position with the head of the bed elevated to 90o to reduce the risk of aspiration. b. Remove the NG tube if the client begins to gag or choke. The nurse should withdraw the NG tube slightly, not remove it, if the client gags or chokes to reduce the risk of injury to the client. c. Apply suction to the NG tube prior to insertion. The nurse should not apply suction until the NG tube is in place with x-ray verification of its position in order to reduce the risk of injury to the client. d. Have the client take sips of water to promote insertion of the NG tube into the esophagus. Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea. 60. A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? a. Protective environment Clients who have a compromised immune system require a protective environment. b. Airborne precautions Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including tuberculosis and measles. c. Droplet precautions Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. d. Contact precautions 33 | P a g e Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client. 34 | P a g e