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<\/p>\n\n\n\n<\/p>\n\n\n\n
ATI Fundamentals<\/p>\n\n\n\n
Proctored Exam |<\/p>\n\n\n\n
Questions and Answers<\/p>\n\n\n\n
Complete with<\/p>\n\n\n\n
Rationales<\/p>\n\n\n\n
LATEST 2021\/ 2022<\/p>\n\n\n\n
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<\/p>\n\n\n\n
1. A nurse is planning to collect a stool specimen for ova and parasites from a client who has<\/p>\n\n\n\n
diarrhea. Which of the following actions should the nurse take when collecting the specimen?<\/p>\n\n\n\n
A. Instruct the client to defecate into the toilet bowl<\/p>\n\n\n\n
-incorrect: The nurse should have the client defecate into a bedpan or a container for stool<\/p>\n\n\n\n
collection. The toilet water can dilute and contaminate the liquid specimen.<\/p>\n\n\n\n
B. Transfer the specimen to a sterile container<\/p>\n\n\n\n
-incorrect: The nurse should place the stool specimen in a clean container using a tongue<\/p>\n\n\n\n
depressor.<\/p>\n\n\n\n
C. Refrigerate the collected specimen<\/p>\n\n\n\n
-incorrect: The nurse should send the collected stool specimen immediately to the laboratory<\/p>\n\n\n\n
after labeling the specimen properly to prevent contamination with microorganisms and keep the<\/p>\n\n\n\n
specimen from getting cold.<\/p>\n\n\n\n
D. Place the stool specimen collection container in a biohazard bag<\/p>\n\n\n\n
-The nurse should place the specimen collection container in a biohazard bag with the client<\/p>\n\n\n\n
label on the container and the bag for easy identification. This will also prevent contamination<\/p>\n\n\n\n
with microorganisms.<\/p>\n\n\n\n
2. A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the<\/p>\n\n\n\n
following actions should the nurse take?<\/p>\n\n\n\n
A. Hyper oxygenate the client before suctioning<\/p>\n\n\n\n
-The nurse should use a manual resuscitation bag to hyper oxygenate the client for several<\/p>\n\n\n\n
minutes prior to suctioning.<\/p>\n\n\n\n
B. Insert the catheter during exhalation<\/p>\n\n\n\n
-incorrect: The nurse should insert the catheter during inhalation<\/p>\n\n\n\n
C. Apply suction during insertion of the catheter<\/p>\n\n\n\n
-incorrect: Applying suction while inserting the catheter increases the risk of damage to the<\/p>\n\n\n\n
tracheal mucosa and removes oxygen from the airways.<\/p>\n\n\n\n
D. Apply suction for no more than 15 secs<\/p>\n\n\n\n
-incorrect: The nurse should apply suction for no more than 10 seconds<\/p>\n\n\n\n
3. A nurse is providing teaching to a client regarding protein intake. Which of the following<\/p>\n\n\n\n
foods should the nurse include as an example of an incomplete protein?<\/p>\n\n\n\n
A. Eggs<\/p>\n\n\n\n
-incorrect: this is a complete protein, contains all of the essential amino acids necessary for the<\/p>\n\n\n\n
synthesis of protein in the body.<\/p>\n\n\n\n
B. Soybeans<\/p>\n\n\n\n
-incorrect: this is a complete protein, contains all of the essential amino acids necessary for the<\/p>\n\n\n\n
synthesis of protein in the body.<\/p>\n\n\n\n
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<\/p>\n\n\n\n
C. Lentils<\/p>\n\n\n\n
-Incomplete proteins are missing 1 or more of the essential amino acids necessary for the<\/p>\n\n\n\n
synthesis of protein in the body. Examples of incomplete proteins include lentils, vegetables,<\/p>\n\n\n\n
grains, nuts, and seeds.<\/p>\n\n\n\n
D. Yogurt<\/p>\n\n\n\n
-incorrect: this is a complete protein, contains all of the essential amino acids necessary for the<\/p>\n\n\n\n
synthesis of protein in the body.<\/p>\n\n\n\n
4. A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation<\/p>\n\n\n\n
after a total hip arthroplasty.At which of the following times should the nurse begin discharge<\/p>\n\n\n\n
planning?<\/p>\n\n\n\n
A. One week prior to the client\u2019s discharge<\/p>\n\n\n\n
-incorrect: Beginning to plan for the client\u2019s discharge a week prior to the event might not allow<\/p>\n\n\n\n
sufficient time for planning. The nurse should begin discharge planning at the time of admission.<\/p>\n\n\n\n
B. Upon the client\u2019s admission to the care facility<\/p>\n\n\n\n
-The nurse should begin discharge planning at the time that the client is admitted to the facility.<\/p>\n\n\n\n
C. Once the discharge date is identified<\/p>\n\n\n\n
-incorrect: Beginning to plan for the client\u2019s discharge once the discharge date is identified might<\/p>\n\n\n\n
not allow sufficient time for planning. The nurse should begin discharge planning at the time of<\/p>\n\n\n\n
admission.<\/p>\n\n\n\n
D. When the client addresses the topic with the nurse<\/p>\n\n\n\n
-incorrect: Beginning to plan for the client\u2019s discharge once the discharge date is identified might<\/p>\n\n\n\n
not allow sufficient time for planning. The nurse should begin discharge planning at the time of<\/p>\n\n\n\n
admission.<\/p>\n\n\n\n
5. A nurse is preparing to administer a cleansing enema to a client. Which of the following<\/p>\n\n\n\n
actions should the nurse plan to take?<\/p>\n\n\n\n
A. Insert the rectal tube 15.2 cm (6 in)<\/p>\n\n\n\n
-incorrect: The nurse should insert the rectal tube 7 to 10 cm (3 to 4 in)<\/p>\n\n\n\n
B. Wear sterile gloves to insert the tubing<\/p>\n\n\n\n
-incorrect: The nurse should wear clean (nonsterile) gloves to prevent contamination.<\/p>\n\n\n\n
C. Position the client on his left side<\/p>\n\n\n\n
-Positioning is an important aspect of administering an enema. Having the client lie on his left<\/p>\n\n\n\n
side facilitates the flow of the enema solution into the sigmoid and descending colon.<\/p>\n\n\n\n
D. Hold the solution bag 91 cm (36 inch) above the client\u2019s rectum<\/p>\n\n\n\n
-incorrect: The nurse should hold the solution bag 30 cm (12 in) above the client\u2019s rectum for a<\/p>\n\n\n\n
low enema and 45 cm (18 in) for a high enema. If the nurse holds the solution bag too high, the<\/p>\n\n\n\n
solution might run in too fast, causing discomfort and spasms that make retaining the enema<\/p>\n\n\n\n
more difficult.<\/p>\n\n\n\n
5. A nurse is caring for a client who has bilateral cats on her hands. Which of the following<\/p>\n\n\n\n
actions should the nurse take when assisting the client with feeding?<\/p>\n\n\n\n
A. Sit at the bedside when feeding the client<\/p>\n\n\n\n
-The nurse should avoid appearing to be in a hurry. Sitting at the bedside provides the client with<\/p>\n\n\n\n
the nurse\u2019s full attention during the feeding<\/p>\n\n\n\n
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<\/p>\n\n\n\n
B. Order pureed foods<\/p>\n\n\n\n
-incorrect: Without any mouth or throat injuries that make chewing or swallowing difficult, the<\/p>\n\n\n\n
client should be served foods of an appropriate variety of textures. Pureed foods are for clients<\/p>\n\n\n\n
who cannot chew, have difficulty swallowing, or do not have teeth.<\/p>\n\n\n\n
C. Make sure feedings are provided at room temperature<\/p>\n\n\n\n
-incorrect: The nurse should ask the client if the food is the correct temperature<\/p>\n\n\n\n
D. Offer the client a drink of fluid after every bite<\/p>\n\n\n\n
-incorrect: If the client is unable to communicate, the nurse should offer the client fluids after<\/p>\n\n\n\n
every 3 or 4 mouthfuls. However, there is no indication that this client is unable to communicate.<\/p>\n\n\n\n
Therefore, the client should tell the nurse when she would like a drink.<\/p>\n\n\n\n
6. A nurse is administering an IM injection to a 5-month-old infant. Which of the following<\/p>\n\n\n\n
injection sites should the nurse use?<\/p>\n\n\n\n
A. Deltoid<\/p>\n\n\n\n
-incorrect: The nurse can use the deltoid muscle for injecting small volumes of medication for<\/p>\n\n\n\n
children 18 months of age or older, but its proximity to several nerves and arteries make it a<\/p>\n\n\n\n
riskier choice.<\/p>\n\n\n\n
B. Ventrogluteal<\/p>\n\n\n\n
-incorrect: This is a safe site for IM injections for clients older than 7 months.<\/p>\n\n\n\n
C. Vastus lateralis<\/p>\n\n\n\n
-The nurse should use the vastus lateralis site over the anterior thigh for IM injections for infants<\/p>\n\n\n\n
and children.<\/p>\n\n\n\n
D. Dorsogluteal<\/p>\n\n\n\n
-incorrect: This site is unsafe to use because of its proximity to the sciatic nerve and the superior<\/p>\n\n\n\n
gluteal nerve and artery.<\/p>\n\n\n\n
7. A nurse is caring for a client who has major fecal incontinence and reports irritation in the<\/p>\n\n\n\n
perianal area. Which of the following actions should the nurse take first?<\/p>\n\n\n\n
A. Apply a fecal collection system<\/p>\n\n\n\n
-incorrect: The nurse should apply a fecal collection system to divert the feces away from the<\/p>\n\n\n\n
area of skin irritation; however, there is another action the nurse should take first.<\/p>\n\n\n\n
B. Apply a barrier cream<\/p>\n\n\n\n
-incorrect: The nurse should apply a barrier cream to decrease skin breakdown in the perianal<\/p>\n\n\n\n
area from the feces; however, there is another action the nurse should take first.<\/p>\n\n\n\n
C. Cleanse and dry the area<\/p>\n\n\n\n
-incorrect: The nurse should cleanse and dry the perianal area to decrease skin irritation;<\/p>\n\n\n\n
however, there is another action the nurse should take first.<\/p>\n\n\n\n
D. Check the client\u2019s perineum<\/p>\n\n\n\n
-The nurse should apply the nursing process priority-setting framework to plan care and<\/p>\n\n\n\n
prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning<\/p>\n\n\n\n
with an assessment or data collection. Before the nurse can formulate a plan of action, implement<\/p>\n\n\n\n
a nursing intervention, or notify a provider of a change in the client\u2019s status, the nurse must first<\/p>\n\n\n\n
collect adequate data from the client. Assessing or collecting additional data will provide the<\/p>\n\n\n\n
nurse with knowledge to make an appropriate decision. The priority nursing action is for the<\/p>\n\n\n\n
nurse to collect more data by assessing the area of irritation.<\/p>\n\n\n\n
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<\/p>\n\n\n\n
9. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse<\/p>\n\n\n\n
should identify that which of the following findings is an indication of infiltration?<\/p>\n\n\n\n
A. Redness at the infusion site<\/p>\n\n\n\n
-incorrect: Redness at the infusion site is an indication of phlebitis or infection.<\/p>\n\n\n\n
B. Edema at the infusion site<\/p>\n\n\n\n
-Edema due to fluid entering subcutaneous tissue is an indication of infiltration.<\/p>\n\n\n\n
C. Warmth at the infusion site<\/p>\n\n\n\n
-incorrect: Warmth at the infusion site is an indication of phlebitis or infection.<\/p>\n\n\n\n
D. Oozing of blood at the infusion site<\/p>\n\n\n\n
-incorrect: Oozing of blood at the infusion site is an indication that the IV system is not intact.<\/p>\n\n\n\n
10. A nurse is caring for a client who reports not sleeping at night, which interferes with her<\/p>\n\n\n\n
ability to function during the day. Which of the following interventions should the nurse suggest<\/p>\n\n\n\n
to this client?<\/p>\n\n\n\n
A. Avoid beverages that contain caffeine<\/p>\n\n\n\n
-Caffeine is a stimulant. The nurse should suggest that the client avoid caffeinated beverages.<\/p>\n\n\n\n
B. Take a sleep medication regularly at bedtime<\/p>\n\n\n\n
-incorrect: Sleep-promoting medication is a last resort. The nurse should not suggest this type of<\/p>\n\n\n\n
medication for the client before recommending other nonpharmacological interventions.<\/p>\n\n\n\n
C. Watch television for 30 minutes in bed to relax prior to falling asleep<\/p>\n\n\n\n
-incorrect: Clients should associate going to bed with sleep. Therefore, the client should not get<\/p>\n\n\n\n
into bed until she is sleepy.<\/p>\n\n\n\n
D. Advise the client to take several naps during the day<\/p>\n\n\n\n
-incorrect: Napping in the daytime can prevent sound sleep at night<\/p>\n\n\n\n
11. A nurse is conducting an admission interview with a client. Which of the following pieces of<\/p>\n\n\n\n
assessment information should the nurse collect during the introductory phase of the interview?<\/p>\n\n\n\n
A. Clients level of comfort and ability to participate in the interview<\/p>\n\n\n\n
-The nurse should assess the client\u2019s level of comfort and establish a rapport during the<\/p>\n\n\n\n
introductory or orientation phase. The nurse should engage in active listening and present a<\/p>\n\n\n\n
relaxed attitude to place the client at ease and encourage client participation. This will assist the<\/p>\n\n\n\n
nurse in gaining the necessary data to formulate appropriate nursing diagnoses and outcomes.<\/p>\n\n\n\n
B. Previous illnesses and surgeries<\/p>\n\n\n\n
-incorrect: The nurse should assess the client\u2019s health history, including previous illnesses and<\/p>\n\n\n\n
surgeries, during the working phase of the interview.<\/p>\n\n\n\n
C. Events surrounding the client\u2019s recent illness<\/p>\n\n\n\n
-incorrect: The nurse should assess the client\u2019s health history, including events surrounding the<\/p>\n\n\n\n
recent or current illness, during the working phase of the interview.<\/p>\n\n\n\n
D. Sociocultural history<\/p>\n\n\n\n
-incorrect: The nurse should assess the client\u2019s sociocultural history during the working phase of<\/p>\n\n\n\n
the interview.<\/p>\n\n\n\n
12. A nurse is performing an abdominal assessment of a client. Which of the following positions<\/p>\n\n\n\n
should the nurse tell the client to assume for this examination?<\/p>\n\n\n\n
A. Lithotomy<\/p>\n\n\n\n
-incorrect: The lithotomy position is useful for gynecological examinations.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg6.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
B. Lateral<\/p>\n\n\n\n
-incorrect: The lateral recumbent, or side-lying position, limits access to the abdomen. This<\/p>\n\n\n\n
position is useful when auscultating the heart to detect murmurs.<\/p>\n\n\n\n
C. Supine<\/p>\n\n\n\n
-The nurse should tell the client to assume the supine position to promote relaxation of the<\/p>\n\n\n\n
abdominal muscles. Having the client bend the knees enhances relaxation of the stomach<\/p>\n\n\n\n
muscles.<\/p>\n\n\n\n
D. Sims<\/p>\n\n\n\n
-incorrect: The Sims\u2019 position limits access to the abdomen. This position is useful for rectal and<\/p>\n\n\n\n
vaginal examinations.<\/p>\n\n\n\n
13. A nurse is caring for a client who is postoperative following an abdominal surgery. Which of<\/p>\n\n\n\n
the following actions should the nurse perform first after discovering the client\u2019s wound has<\/p>\n\n\n\n
eviscerated?<\/p>\n\n\n\n
A. Cover the incision with a moist sterile dressing<\/p>\n\n\n\n
– The nurse should apply the safety and risk-reduction priority-setting framework, which assigns<\/p>\n\n\n\n
priority to the factor or situation posing the greatest safety risk to the client. When there are<\/p>\n\n\n\n
several risks to client safety, the one posing the greatest threat is the highest priority. The nurse<\/p>\n\n\n\n
should use Maslow\u2019s Hierarchy of Needs, the ABC priority-setting framework, and\/or nursing<\/p>\n\n\n\n
knowledge to identify which risk poses the greatest threat to the client. An open wound increases<\/p>\n\n\n\n
the risk of peritonitis, and any exposed organ tissue could dry out. Therefore, covering the<\/p>\n\n\n\n
wound with a moist sterile dressing is the first action the nurse should take to protect the client.<\/p>\n\n\n\n
B. Have the client lie on his back with his knees flexed<\/p>\n\n\n\n
-incorrect: The nurse should use this position to reduce pressure on the incision. However, the<\/p>\n\n\n\n
nurse should take another action first.<\/p>\n\n\n\n
C. Call the client\u2019s surgeon<\/p>\n\n\n\n
-incorrect: The nurse should notify the surgeon or direct a colleague to notify the surgeon while<\/p>\n\n\n\n
tending to the client\u2019s immediate need. However, the nurse should take another action first.<\/p>\n\n\n\n
D. Reassure the client<\/p>\n\n\n\n
-incorrect: The nurse should respond to the client\u2019s emotional needs. However, the nurse should<\/p>\n\n\n\n
take another action first.<\/p>\n\n\n\n
14. A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of<\/p>\n\n\n\n
the following actions should the nurse take first?<\/p>\n\n\n\n
A. Give the client a glass of water<\/p>\n\n\n\n
-incorrect: The nurse should provide a glass of water to facilitate swallowing during tube<\/p>\n\n\n\n
insertion of the NG tube. However, there is another action the nurse should take first.<\/p>\n\n\n\n
B. Assist the client into a sitting position<\/p>\n\n\n\n
-incorrect: The nurse should assist the client into a sitting position to insert the NG tube more<\/p>\n\n\n\n
easily and allow gravity to help facilitate the passage of the tube. However, there is another<\/p>\n\n\n\n
action the nurse should take first.<\/p>\n\n\n\n
C. Explain the procedure to the client<\/p>\n\n\n\n
-The nurse should apply the least invasive priority-setting framework when caring for this client,<\/p>\n\n\n\n
which assigns priority to nursing interventions that are least invasive to the client, as long as<\/p>\n\n\n\n
those interventions do not jeopardize client safety. The nurse should take interventions that are<\/p>\n\n\n\n
not invasive to the client before interventions that are invasive. This reduces the number of<\/p>\n\n\n\n
Document continues below<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg7.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
organisms introduced into the body, decreasing the number of facility-acquired infections.<\/p>\n\n\n\n
Informing the client about the procedure reduces fear and assists in gaining the client\u2019s<\/p>\n\n\n\n
cooperation, which is important for NG tube insertion and is the priority nursing intervention.<\/p>\n\n\n\n
D. Measure the length of tubing to be inserted<\/p>\n\n\n\n
-incorrect: The nurse should measure the length of the tubing to be inserted to ensure proper tube<\/p>\n\n\n\n
placement. However, there is another action the nurse should take first.<\/p>\n\n\n\n
15. A nurse is providing discharge teaching to a client who is recovering from lung cancer. The<\/p>\n\n\n\n
provider instructed the client that he could resume lower-intensity activities of daily living.<\/p>\n\n\n\n
Which of the following activities should the nurse recommend to the client?<\/p>\n\n\n\n
A. Sweeping the floor<\/p>\n\n\n\n
-incorrect: sweeping the floor is moderate-intensity activity<\/p>\n\n\n\n
B. Shoveling snow<\/p>\n\n\n\n
-incorrect: Shoveling snow is a high-intensity activity<\/p>\n\n\n\n
C. Cleaning windows<\/p>\n\n\n\n
-incorrect: Cleaning windows is a moderate-intensity activity<\/p>\n\n\n\n
D. Washing dishes<\/p>\n\n\n\n
-Washing dishes requires a low level of activity and is appropriate for this client.<\/p>\n\n\n\n
16. A nurse is caring for a client who is receiving dextrose 5% in water IV at 150 mL\/hr and has<\/p>\n\n\n\n
ingested 4 oz of water and \u00bd pint of milk. What is the total 8-hr fluid intake in milliliters that the<\/p>\n\n\n\n
nurse should document for this client? (round to nearest whole number)<\/p>\n\n\n\n
-1560<\/p>\n\n\n\n
17. A nurse is performing a physical examination of a client. The nurse should use percussion to<\/p>\n\n\n\n
evaluate which of the following parts of the client\u2019s body?<\/p>\n\n\n\n
A. Heart<\/p>\n\n\n\n
-incorrect: The nurse uses inspection, palpation, and auscultation to evaluate the heart.<\/p>\n\n\n\n
B. Lungs<\/p>\n\n\n\n
-Percussion creates a vibration that helps the examiner determine the density of the underlying<\/p>\n\n\n\n
tissue. The lungs are hollow organs that can produce sounds such as resonance (a hollow sound<\/p>\n\n\n\n
over alveoli) or dullness (a dull sound over consolidated areas of the lungs or diaphragm). The<\/p>\n\n\n\n
nurse also uses auscultation and palpation when evaluating the lungs.<\/p>\n\n\n\n
C. Thyroid gland<\/p>\n\n\n\n
-incorrect: The nurse uses inspection and palpation to evaluate the thyroid gland.<\/p>\n\n\n\n
D. Skin<\/p>\n\n\n\n
-incorrect: The nurse uses inspection and palpation to evaluate the skin.<\/p>\n\n\n\n
18. A nurse is supervising a newly licensed nurse who is administering a controlled substance.<\/p>\n\n\n\n
Which of the following actions by the newly licensed nurse indicates an understanding of the<\/p>\n\n\n\n
procedure?<\/p>\n\n\n\n
A. Placing an unused portion of the medication in a sharps box<\/p>\n\n\n\n
-incorrect: The nurse should not dispose of an unused portion of a controlled substance in the<\/p>\n\n\n\n
sharps container because this action does not maintain safe control of the narcotic.<\/p>\n\n\n\n
B. Asking another nurse to observe the disposal of an unused portion of the medication<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg8.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-The nurse should ask another nurse to witness the disposal of a controlled substance to maintain<\/p>\n\n\n\n
safe control of the narcotic.<\/p>\n\n\n\n
C. Counting the inventory of the available narcotic after administering the medication<\/p>\n\n\n\n
-incorrect: The nurse should count the inventory of the controlled substance before removing a<\/p>\n\n\n\n
dosage to maintain safe control of the narcotic.<\/p>\n\n\n\n
D. Ensuring that another nurse signs the control inventory form after disposal of an unused<\/p>\n\n\n\n
portion of medication<\/p>\n\n\n\n
-incorrect: Two nurses should sign the control inventory form after the disposal of a portion of a<\/p>\n\n\n\n
narcotic to maintain safe control.<\/p>\n\n\n\n
19. A nurse is caring for a client who has acute renal failure. Which of the following assessments<\/p>\n\n\n\n
provides the most accurate measure of the client\u2019s fluid status?<\/p>\n\n\n\n
A. Daily weight<\/p>\n\n\n\n
-According to the evidence-based priority-setting framework, daily weight provides important<\/p>\n\n\n\n
information about the client\u2019s fluid status. A gain or loss of 1 kg (2.2 lb) indicates a gain or loss<\/p>\n\n\n\n
of 1 L of fluid; therefore, weighing the client daily will provide the most accurate fluid status<\/p>\n\n\n\n
measurement.<\/p>\n\n\n\n
B. Blood Pressure<\/p>\n\n\n\n
-incorrect: While blood pressure can indicate a client\u2019s fluid gain or losses, it is not the most<\/p>\n\n\n\n
accurate method of measuring fluid changes.<\/p>\n\n\n\n
C. Specific gravity<\/p>\n\n\n\n
-incorrect: Specific gravity reflects the kidney\u2019s ability to concentrate urine. While specific<\/p>\n\n\n\n
gravity reflects client\u2019s fluid gains or losses, it is not the most accurate method used to measure<\/p>\n\n\n\n
fluid changes.<\/p>\n\n\n\n
D. Intake and Output<\/p>\n\n\n\n
-incorrect: Intake and output reflect a client\u2019s fluid status. However, this is not the most accurate<\/p>\n\n\n\n
method to measure fluid changes.<\/p>\n\n\n\n
20. A nurse in a long-term care facility is admitting a client who is incontinent and smells<\/p>\n\n\n\n
strongly of urine. His partner, who has been caring for him at home, is embarrassed and<\/p>\n\n\n\n
apologizes for the smell. Which of the following responses should the nurse make?<\/p>\n\n\n\n
A. \u201cA lot of clients who are cared for at home have the same problem\u201d<\/p>\n\n\n\n
-incorrect: This automatic response implies that caregivers in the home are not able to keep<\/p>\n\n\n\n
client\u2019s odor-free. It is a judgmental statement that is not therapeutic.<\/p>\n\n\n\n
B. \u201cDon\u2019t worry about it. He will get a bath, and that will take care of the odor.\u201d<\/p>\n\n\n\n
-incorrect: Telling the partner not to worry blocks communication by devaluing her feelings and<\/p>\n\n\n\n
her concern about the odor.<\/p>\n\n\n\n
C. \u201cIt must be difficult to care for someone who is confined to bed.\u201d<\/p>\n\n\n\n
-This response addresses the feelings of the partner by reflecting her feelings, which facilitates<\/p>\n\n\n\n
therapeutic communication because it is nonjudgmental and encourages the partner to express<\/p>\n\n\n\n
her feelings.<\/p>\n\n\n\n
D. \u201cWhen was the last time that he had a bath?\u201d<\/p>\n\n\n\n
-incorrect: This response implies that the odor of urine has developed because she has not bathed<\/p>\n\n\n\n
her husband for some time, which is judgmental and nontherapeutic.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg9.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
21. A nurse in an emergency department is assessing a client who reports diarrhea and decreased<\/p>\n\n\n\n
urination for 4 days. Which of the following actions should the nurse take to assess the client\u2019s<\/p>\n\n\n\n
skin turgor?<\/p>\n\n\n\n
A. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to<\/p>\n\n\n\n
become pink.<\/p>\n\n\n\n
-incorrect: This technique assesses capillary refill.<\/p>\n\n\n\n
B. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs<\/p>\n\n\n\n
back.<\/p>\n\n\n\n
-The nurse should use this technique to assess skin turgor. If the client has good turgor and is<\/p>\n\n\n\n
properly hydrated, the skin will immediately return to normal; in dehydration, the skin will<\/p>\n\n\n\n
remain tented. The nurse can also assess turgor by grasping a skinfold on the back of the<\/p>\n\n\n\n
forearm.<\/p>\n\n\n\n
C. Press the skin above the ankle for 5 seconds, release it, and note the depth of the impression.<\/p>\n\n\n\n
-incorrect: This technique determines the extent of a client\u2019s pitting edema.<\/p>\n\n\n\n
D. Measure the skinfold thickness on the upper arm using a pair of calibrated skinfold calipers.<\/p>\n\n\n\n
-incorrect: This technique determines a client\u2019s body fat percentage.<\/p>\n\n\n\n
22. A nurse discovers that a client received the wrong medication. Which of the following<\/p>\n\n\n\n
actions should the nurse take first?<\/p>\n\n\n\n
A. Complete a medication error report<\/p>\n\n\n\n
-incorrect: The nurse should follow the facility\u2019s protocol for documenting the incident;<\/p>\n\n\n\n
however, this is not the first action the nurse should take.<\/p>\n\n\n\n
B. Notify the prescribing provider<\/p>\n\n\n\n
-incorrect: The nurse should follow the facility\u2019s protocol for reporting a medication error, which<\/p>\n\n\n\n
usually involves notifying the prescribing provider; however, this is not the first action the nurse<\/p>\n\n\n\n
should take.<\/p>\n\n\n\n
C. Assess the client<\/p>\n\n\n\n
-The greatest risk to the client\u2019s safety is adverse effects from either receiving the wrong<\/p>\n\n\n\n
medication or not receiving the prescribed medication. The nurse should assess the client first for<\/p>\n\n\n\n
any possible adverse effects. This assessment also serves as a baseline for further monitoring for<\/p>\n\n\n\n
adverse effects.<\/p>\n\n\n\n
D. Notify the charge nurse<\/p>\n\n\n\n
-The nurse should follow the facility\u2019s protocol for reporting a medication error, which usually<\/p>\n\n\n\n
involves notifying the charge nurse; however, this is not the first action the nurse should take.<\/p>\n\n\n\n
23. A nurse is performing a breast examination for a female client. Which of the following<\/p>\n\n\n\n
techniques should the nurse use first?<\/p>\n\n\n\n
A. Inspect both breasts simultaneously<\/p>\n\n\n\n
-According to evidence-based practice, the nurse should first inspect both breasts with the<\/p>\n\n\n\n
client\u2019s arms in several different positions to look for asymmetry, masses, retraction, lesions,<\/p>\n\n\n\n
inflammation, and dimpling.<\/p>\n\n\n\n
B. Squeeze the nipples<\/p>\n\n\n\n
-incorrect: The nurse should compress the nipples to identify the presence of any discharge.<\/p>\n\n\n\n
However, evidence-based practice indicates that the nurse should use a different technique<\/p>\n\n\n\n
before compression.<\/p>\n\n\n\n
C. Palpate the breast and tail of Spence<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bga.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The nurse should palpate the breast and tail of Spence to determine the consistency of<\/p>\n\n\n\n
breast tissue and assess the presence of masses. However, evidence-based practice indicates that<\/p>\n\n\n\n
the nurse should use a different technique before palpation of the breast because doing so can<\/p>\n\n\n\n
alter the accuracy or effectiveness of another phase of the examination.<\/p>\n\n\n\n
D. Palpate the axillary lymph nodes<\/p>\n\n\n\n
-incorrect: The nurse should palpate the axillary lymph nodes, which become involved when<\/p>\n\n\n\n
cancerous lesions metastasize. However, evidence-based practice indicates that the nurse should<\/p>\n\n\n\n
use a different technique before palpation of the axillary lymph nodes because doing so can alter<\/p>\n\n\n\n
the accuracy or effectiveness of another phase of the examination.<\/p>\n\n\n\n
24. A nurse is helping a client change his hospital gown. The client has an IV infusion via an<\/p>\n\n\n\n
infusion pump. Which of the following actions should the nurse take first?<\/p>\n\n\n\n
A. Remove the sleeve of the gown from the arm without the IV line.<\/p>\n\n\n\n
-According to evidence-based practice, the nurse should first remove the gown from the client\u2019s<\/p>\n\n\n\n
arm without the IV line. Beginning this process will enable the nurse to move the gown fully off<\/p>\n\n\n\n
the client before stopping the system to remove the gown from the line, resulting in minimal<\/p>\n\n\n\n
interruption of the IV flow.<\/p>\n\n\n\n
B. Slow the infusion using a roller clamp<\/p>\n\n\n\n
-incorrect: The nurse should slow the infusion using the roller clamp to prevent a large volume<\/p>\n\n\n\n
infusion of IV solution while changing the gown. However, evidence-based practice indicates<\/p>\n\n\n\n
that the nurse should take a different action first.<\/p>\n\n\n\n
C. Disconnect the IV line from the pump<\/p>\n\n\n\n
-incorrect: The nurse should disconnect the IV line from the pump while removing and<\/p>\n\n\n\n
reapplying the gown quickly to maintain the infusion rate prescribed with the pump, however,<\/p>\n\n\n\n
evidence-based practice indicates that the nurse should take a different action first.<\/p>\n\n\n\n
D. Bring the IV solution and tubing from the outside to the inside of the sleeve of the gown<\/p>\n\n\n\n
-incorrect: The nurse should bring the IV solution and tubing through the outside to the inside of<\/p>\n\n\n\n
the sleeve of the gown to avoid tangling of the tubing and the gown. However, evidence-based<\/p>\n\n\n\n
practice indicates that the nurse should take a different action first.<\/p>\n\n\n\n
25. A nurse is preparing to administer a unit of packed RBC\u2019s to a client when she discovers that<\/p>\n\n\n\n
the IV line is no longer patent.The IV team informs her that someone can come to initiate a new<\/p>\n\n\n\n
line in 30 min. Which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Return the blood to the laboratory<\/p>\n\n\n\n
-Because the nurse knows that the delay will be more than a few minutes, she should return the<\/p>\n\n\n\n
unit of packed RBCs immediately to the laboratory where the technician will maintain it at the<\/p>\n\n\n\n
appropriate temperature until the client is ready to receive it.<\/p>\n\n\n\n
B. Place the blood in the medication room<\/p>\n\n\n\n
-incorrect: The unit of packed RBCs should not be at room temperature for any length of time<\/p>\n\n\n\n
because the lack of temperature control could damage the blood.<\/p>\n\n\n\n
C. Place the blood in the refrigerator<\/p>\n\n\n\n
Incorrect: Blood products require specific temperature regulation, which is not consistently<\/p>\n\n\n\n
possible in a standard nursing unit refrigerator.<\/p>\n\n\n\n
D. Leave the blood at the client\u2019s bedside<\/p>\n\n\n\n
-The nurse should never leave blood products or medication at the bedside due to the potential<\/p>\n\n\n\n
for loss, misuse, or contamination.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bgb.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
26. A hospice nurse is reviewing religious practices of a group of clients with a newly licensed<\/p>\n\n\n\n
nurse. Which of the following statements by the newly licensed nurse indicates an understanding<\/p>\n\n\n\n
of the teaching?<\/p>\n\n\n\n
A. People who practice the Islamic faith pray over the deceased for a period of 5 days before<\/p>\n\n\n\n
burial.<\/p>\n\n\n\n
-incorrect: For those who practice the Islamic faith, the body of the deceased is washed and<\/p>\n\n\n\n
wrapped during a ritual and then buried as soon as possible following death.<\/p>\n\n\n\n
B. People who practice the Hindu faith bury the deceased with their head facing north.<\/p>\n\n\n\n
-incorrect: People who practice the Hindu faith may place the body with the head facing north<\/p>\n\n\n\n
following death. However, cremation rather than burial is practiced by those of the Hindu faith.<\/p>\n\n\n\n
C. People who practice Judaism stay with the body of the deceased until burial.<\/p>\n\n\n\n
-In the Jewish faith, a family member often stays with the body until burial occurs.<\/p>\n\n\n\n
D. People who are practicing the Buddhist faith have the female family members prepare the<\/p>\n\n\n\n
body following death.<\/p>\n\n\n\n
-incorrect: Male family members prepare the body following death for individuals practicing the<\/p>\n\n\n\n
Buddhist faith.<\/p>\n\n\n\n
27. A nurse is planning an in-service training session about nutrition. Which of the following<\/p>\n\n\n\n
statements should the nurse include in the teaching?<\/p>\n\n\n\n
A. \u201cFats provide energy\u201d<\/p>\n\n\n\n
-Fat serves as a stored energy source for the body, providing 9 cal\/g of energy.<\/p>\n\n\n\n
B. \u201cCarbohydrates repair body tissue\u201d<\/p>\n\n\n\n
-incorrect: Proteins play a role in tissue repair.<\/p>\n\n\n\n
C. \u201cFats regulate fluid balance\u201d<\/p>\n\n\n\n
-incorrect: Protein is primarily responsible for regulating fluid balance.<\/p>\n\n\n\n
D. \u201cCarbohydrates prevent interstitial edema\u201d<\/p>\n\n\n\n
-incorrect: The presence of protein prevents interstitial edema. An appropriate amount of<\/p>\n\n\n\n
albumin in blood keeps interstitial edema from occurring.<\/p>\n\n\n\n
28. A nurse is caring for a client who requires fluid restriction and may drink only 1 oz of water<\/p>\n\n\n\n
with each oral medication. How many milliliters of water should the nurse document as intake<\/p>\n\n\n\n
for the 3 separate medications the client receives during 12-hour night shift? (round to the<\/p>\n\n\n\n
nearest whole number)<\/p>\n\n\n\n
90<\/p>\n\n\n\n
29. A nurse is caring for a client who is dehydrated. The nurse should expect that insensible fluid<\/p>\n\n\n\n
loss of approximately 500 to 600 mL occurs each day through which of the following organs?<\/p>\n\n\n\n
A. Kidney\u2019s<\/p>\n\n\n\n
-incorrect: The kidneys excrete approximately 1,200 to 1,500 mL of urine daily. However, urine<\/p>\n\n\n\n
is not considered insensible fluid loss. This can increase depending on the client\u2019s intake of<\/p>\n\n\n\n
water.<\/p>\n\n\n\n
B. Lungs<\/p>\n\n\n\n
-incorrect: The lungs excrete approximately 400 mL of insensible fluid loss each day.<\/p>\n\n\n\n
C. Gastrointestinal Tract<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bgc.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The GI tract loses approximately 100-200 mL of fluid each day through feces.<\/p>\n\n\n\n
However, this is not considered insensible fluid loss.<\/p>\n\n\n\n
D. Skin<\/p>\n\n\n\n
-The skin can excrete approximately 500 to 600 mL of insensible fluid loss. This type of fluid<\/p>\n\n\n\n
loss is continuous and can increase if the client is experiencing a fever or has had a recent burn to<\/p>\n\n\n\n
the skin.<\/p>\n\n\n\n
30. A nurse is caring for an adult client who communicates an unmet spiritual need. Which of the<\/p>\n\n\n\n
following client statements should indicate to the nurse that the client is experiencing spiritual<\/p>\n\n\n\n
distress?<\/p>\n\n\n\n
A. \u201cLife has its ups and downs\u201d<\/p>\n\n\n\n
-incorrect: This statement suggests the client is experiencing and incorporating a sense of<\/p>\n\n\n\n
spiritual wellbeing by accepting life\u2019s ups and downs.<\/p>\n\n\n\n
B. \u201cI believe that I control my own destiny\u201d<\/p>\n\n\n\n
-incorrect: This statement suggests the client is experiencing and incorporating a sense of<\/p>\n\n\n\n
spiritual wellbeing by being in control of personal destiny.<\/p>\n\n\n\n
C. \u201cGod is punishing me for something\u201d<\/p>\n\n\n\n
-Spiritual distress is an impaired ability to integrate meaning and purpose in life through various<\/p>\n\n\n\n
means, including belief systems and relationships. Manifestations of spiritual distress can include<\/p>\n\n\n\n
a feeling that a higher power is punishing the individual for some behavior.<\/p>\n\n\n\n
D. \u201cI like to keep my rosary beads in bed with me\u201d<\/p>\n\n\n\n
-incorrect: This statement suggests that the client is experiencing and incorporating a sense of<\/p>\n\n\n\n
spiritual wellbeing by engaging in prayer activities such as the rosary.<\/p>\n\n\n\n
31. While in the hospital, a client who has a terminal illness tells the nurse, \u201cI can\u2019t believe I\u2019m<\/p>\n\n\n\n
dying. A lot of bad people in the world are healthy and here I am dying!\u201d Which of the following<\/p>\n\n\n\n
responses should the nurse provide?<\/p>\n\n\n\n
A. \u201cEveryone dies sometimes; some die sooner than others.\u201d<\/p>\n\n\n\n
-incorrect: This is a nontherapeutic response that dismisses and minimizes the client\u2019s feelings.<\/p>\n\n\n\n
B. \u201cWho do you think deserves to die more than you?\u201d<\/p>\n\n\n\n
-incorrect: This is a nontherapeutic response that could be perceived as confrontational by the<\/p>\n\n\n\n
client.<\/p>\n\n\n\n
C. \u201cIt does seem unfair, doesn\u2019t it?\u201d<\/p>\n\n\n\n
-incorrect: While this response acknowledges the client\u2019s feelings, it is a closed-ended statement<\/p>\n\n\n\n
that does not facilitate further exploration of the client\u2019s feelings.<\/p>\n\n\n\n
D. \u201cTell me more about how you feel about dying?\u201d<\/p>\n\n\n\n
-This therapeutic response from the nurse seeks more information to form an accurate<\/p>\n\n\n\n
assessment of the client\u2019s feelings.<\/p>\n\n\n\n
32. A nurse is administering medication to a client who asks the nurse to leave the medication at<\/p>\n\n\n\n
the bedside to be taken at a later time. Which of the following responses should the nurse make?<\/p>\n\n\n\n
A. \u201cCall me when you are ready, and I will return with the medication.\u201d<\/p>\n\n\n\n
-The nurse is responsible for administering the medication and for following professional<\/p>\n\n\n\n
standards by adhering to the 6 rights of medication administration.<\/p>\n\n\n\n
B. \u201cSince you were taking this mediation at home, I will leave it for you to take.\u201d<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bgd.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: At home, the client is responsible and accountable for actions regarding self-<\/p>\n\n\n\n
administration of medications. In an inpatient setting, the nurse is responsible for administering<\/p>\n\n\n\n
medication to the client.<\/p>\n\n\n\n
C. \u201cI will come back in 30 mins to check that you took the medication so I can chart the time.\u201d<\/p>\n\n\n\n
-incorrect: If the nurse returns to the client\u2019s room in 30 minutes, the nurse will not be able to<\/p>\n\n\n\n
verify that the client took the medication since the client could have hidden or discarded the<\/p>\n\n\n\n
medication.<\/p>\n\n\n\n
D. \u201cIf you refuse to take the medication now, I can\u2019t give it again until your next scheduled<\/p>\n\n\n\n
time.\u201d<\/p>\n\n\n\n
-incorrect: The nurse is responsible for administering the medication at the scheduled time.<\/p>\n\n\n\n
Although the policy about time may vary by facility, a medication generally may be given within<\/p>\n\n\n\n
1 hour of the prescribed time.<\/p>\n\n\n\n
33. A nurse is admitting a client who will undergo a craniotomy. During the planning phase of<\/p>\n\n\n\n
the nursing process, which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Establish client outcomes<\/p>\n\n\n\n
-The planning phase of the nursing process includes developing goals and outcomes that help the<\/p>\n\n\n\n
nurse create the client\u2019s plan of care.<\/p>\n\n\n\n
B. Collect information about past health problems<\/p>\n\n\n\n
-incorrect: The nurse should collect information about the client\u2019s past health problems during<\/p>\n\n\n\n
the assessment phase of the nursing process.<\/p>\n\n\n\n
C. Determine whether the client has met specific goals<\/p>\n\n\n\n
-incorrect: The nurse should determine whether the client has met goals during the evaluation<\/p>\n\n\n\n
phase of the nursing process.<\/p>\n\n\n\n
D. Identify the client\u2019s specific health problems<\/p>\n\n\n\n
-incorrect: The nurse should identify the client\u2019s specific health problems during the analysis<\/p>\n\n\n\n
phase of the nursing process.<\/p>\n\n\n\n
34. A nurse in a provider\u2019s office is teaching a client about foods that are high in fiber. Which of<\/p>\n\n\n\n
the following food choices made by the client indicate an understanding of the teaching? (SATA)<\/p>\n\n\n\n
A. Canned peaches<\/p>\n\n\n\n
-incorrect: Canned fruits, including peaches, are recommended for clients on a low-fiber diet.<\/p>\n\n\n\n
Fresh fruits contain more fiber.<\/p>\n\n\n\n
B. White rice<\/p>\n\n\n\n
-incorrect: White rice is recommended for clients on a low-fiber diet. Brown rice is higher in<\/p>\n\n\n\n
fiber.<\/p>\n\n\n\n
C. Black beans<\/p>\n\n\n\n
-Dried peas and beans, including black beans, are high in fiber.<\/p>\n\n\n\n
D. Whole-grain bread<\/p>\n\n\n\n
-Whole grains consist of the entire kernel and are also high in fiber.<\/p>\n\n\n\n
E. Tomato juice<\/p>\n\n\n\n
-incorrect: Canned juices, with the exception of prune juice, are recommended for clients on a<\/p>\n\n\n\n
low-fiber diet.<\/p>\n\n\n\n
35. A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe<\/p>\n\n\n\n
atelectasis. Which of the following actions should the nurse plan to take?<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bge.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
A. Place the client in the Trendelenburg position<\/p>\n\n\n\n
-The nurse should place the client in a right-sided Trendelenburg position to promote drainage<\/p>\n\n\n\n
from the client\u2019s left lower lobe.<\/p>\n\n\n\n
B. Perform percussions directly over the client\u2019s bare skin<\/p>\n\n\n\n
-incorrect: The nurse should perform percussions over a single layer of clothing.<\/p>\n\n\n\n
C. Use a flattened hand to perform percussions<\/p>\n\n\n\n
-incorrect: The nurse should use a cupped hand to provide percussions.<\/p>\n\n\n\n
D. Remind the client that chest percussions can cause mild pain<\/p>\n\n\n\n
-incorrect: Chest percussions should not cause pain when the procedure is performed correctly.<\/p>\n\n\n\n
36. A middle-aged adult client is discussing future plans with the nurse. Which of the following<\/p>\n\n\n\n
statements should the nurse identify as an indication that the client is having difficulty achieving<\/p>\n\n\n\n
Erikson\u2019s developmental task for this age group?<\/p>\n\n\n\n
A. \u201cWe miss our daughter so much that we are going to move closer to her.\u201d<\/p>\n\n\n\n
-According the Erikson, the stage of psychosocial development for middle adults is generativity<\/p>\n\n\n\n
vs. stagnation. Accepting the independence of adult children is part of the developmental task of<\/p>\n\n\n\n
middle age.<\/p>\n\n\n\n
B. \u201cI think this year I can plan on managing the funding at church.\u201d<\/p>\n\n\n\n
-incorrect: Middle-aged adults should turn their focus to community and volunteer activities,<\/p>\n\n\n\n
according to Erikson\u2019s developmental task of generativity vs. stagnation for this age group.<\/p>\n\n\n\n
C. \u201cI really wish I could lose some of this weight.\u201d<\/p>\n\n\n\n
-incorrect: Metabolism slows during middle age, and clients tend to gain unnecessary weight.<\/p>\n\n\n\n
Concern about this weight gain is an expected finding.<\/p>\n\n\n\n
D. \u201cI find I am spending more time at work now that my son is at college.\u201d<\/p>\n\n\n\n
-incorrect: Middle-aged adults often focus more on work as they try to achieve Erikson\u2019s<\/p>\n\n\n\n
developmental task of generativity vs. stagnation.<\/p>\n\n\n\n
37. A nurse is caring for a client who is receiving intermittent enteral feedings through an NG<\/p>\n\n\n\n
tube. The specific gravity of the client\u2019s urine is 1.035. Which of the following actions should<\/p>\n\n\n\n
the nurse take?<\/p>\n\n\n\n
A. Deliver the formula at a slower rate<\/p>\n\n\n\n
-incorrect: Slowing the delivery rate is an intervention for diarrhea.<\/p>\n\n\n\n
B. Request a lower-fat formula<\/p>\n\n\n\n
-incorrect: Instilling a lower-fat formula is an intervention for abdominal distention and bloating.<\/p>\n\n\n\n
C. Provide more water with feedings<\/p>\n\n\n\n
-The elevation in the client\u2019s specific gravity indicates dehydration. The nurse should provide<\/p>\n\n\n\n
more fluids either by adding free water to feedings or by instilling water between feedings.<\/p>\n\n\n\n
Another strategy is to request a formula that contains less protein.<\/p>\n\n\n\n
D. Instill a lactose-free formula<\/p>\n\n\n\n
-incorrect: Instilling a lactose-free formula is an intervention for nausea and vomiting.<\/p>\n\n\n\n
38. A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin.<\/p>\n\n\n\n
Which of the following questions should the nurse ask to encourage discussion with the client?<\/p>\n\n\n\n
A. \u201cDoes the medication you\u2019re taking relieve the pain?\u201d<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bgf.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: Close-ended statements generally elicit a 1- or 2-word response and is restrictive<\/p>\n\n\n\n
when seeking more information. Closed-ended questions are used to obtain information quickly<\/p>\n\n\n\n
in an emergency situation.<\/p>\n\n\n\n
B. \u201cCan you point to where the pain is the worst?\u201d<\/p>\n\n\n\n
-incorrect: The nurse should use the pain scale or have the client describe the pain to elicit an<\/p>\n\n\n\n
open-ended conversation.<\/p>\n\n\n\n
C. \u201cWhat do you think caused the onset of your pain?\u201d<\/p>\n\n\n\n
-The nurse is using an open-ended question that allows the client to respond with a wide range of<\/p>\n\n\n\n
information by using more than a few words.<\/p>\n\n\n\n
D. \u201cChanging positions makes your pain worse, right?\u201d<\/p>\n\n\n\n
-incorrect: Closed-ended questions are used to obtain information quickly in an emergency<\/p>\n\n\n\n
situation. The nurse should ask the client to describe which position facilitates the greatest relief<\/p>\n\n\n\n
of the pain to elicit an open-ended conversation.<\/p>\n\n\n\n
39. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the<\/p>\n\n\n\n
following actions should the nurse direct the client to take first?<\/p>\n\n\n\n
A. Aim the hose at the base of the fire<\/p>\n\n\n\n
-incorrect: Evidence-based practice indicates aiming the hose of the fire extinguisher is the<\/p>\n\n\n\n
second step the client should take.<\/p>\n\n\n\n
B. Squeeze the handle of the extinguisher<\/p>\n\n\n\n
-incorrect: Evidence-based practice indicates squeezing the handle of the extinguisher is the third<\/p>\n\n\n\n
step the client should take.<\/p>\n\n\n\n
C. Remove the safety pin from the extinguisher<\/p>\n\n\n\n
-Evidence-based practice indicates removing the safety pin from the extinguisher is the first<\/p>\n\n\n\n
action to take when using a fire extinguisher; therefore, this is an action the nurse should instruct<\/p>\n\n\n\n
the client to perform first.<\/p>\n\n\n\n
D. Sweep the hose from side to side to dispense material<\/p>\n\n\n\n
-incorrect: Evidence-based practice indicates sweeping the hose from side to side to dispense<\/p>\n\n\n\n
material is the fourth step the client should take.<\/p>\n\n\n\n
40. A nurse is planning care for a client who is confused and requires a prescription for wrist<\/p>\n\n\n\n
restraints. Which of the following interventions should the nurse include in the plan of care?<\/p>\n\n\n\n
A. Renew the prescription for the use of restraints within 24 hours<\/p>\n\n\n\n
-The nurse should plan to renew the prescription for the restraints within 24 hours; only after the<\/p>\n\n\n\n
provider has evaluated the client.<\/p>\n\n\n\n
B. Secure the restraint with the buckle side next to the client\u2019s skin<\/p>\n\n\n\n
-incorrect: The nurse should secure the client\u2019s restraints with the softer side next to the client\u2019s<\/p>\n\n\n\n
skin with the buckle or Velcro closure on the outside.<\/p>\n\n\n\n
C. ensure 4 fingers can be inserted under the secured restraint<\/p>\n\n\n\n
-incorrect: The nurse should ensure 2 fingers can be inserted under the restraints to prevent the<\/p>\n\n\n\n
restraint from being too loose. If the nurse is unable to insert 2 fingers under the restraint, it<\/p>\n\n\n\n
could cause impaired circulation to the extremities.<\/p>\n\n\n\n
D. Remove the restraint every 3 hours<\/p>\n\n\n\n
-incorrect: The nurse should remove the restraint at least every 2 hours; at that time, the nurse<\/p>\n\n\n\n
should check the client\u2019s skin, change the client\u2019s position, and toilet or exercise the client.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg10.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
41. A nurse is caring for a client who has a terminal illness. The client asks several questions<\/p>\n\n\n\n
about the nurse\u2019s religious beliefs related to death and dying. Which of the following actions<\/p>\n\n\n\n
should the nurse take?<\/p>\n\n\n\n
A. Change the topic because the client is trying to divert attention from the illness.<\/p>\n\n\n\n
-incorrect: Changing the subject is a nontherapeutic communication technique that will block the<\/p>\n\n\n\n
development of an open exchange between the nurse and the client.<\/p>\n\n\n\n
B. Encourage the client to express thoughts about death and dying.<\/p>\n\n\n\n
-The nurse should recognize the client\u2019s need to talk about impending death and encourage the<\/p>\n\n\n\n
client to discuss thoughts on the subject. This is the therapeutic technique of reflecting.<\/p>\n\n\n\n
Depending on the situation, the nurse can also share some thoughts on this topic. Self-disclosure<\/p>\n\n\n\n
is a communication skill that can encourage sharing when appropriate. If the nurse does not want<\/p>\n\n\n\n
to share personal beliefs, offering self and listening to the client\u2019s thoughts are appropriate.<\/p>\n\n\n\n
C. Tell the client that religious beliefs are a personal matter.<\/p>\n\n\n\n
-incorrect: This closed-ended response is a nontherapeutic technique that will block the<\/p>\n\n\n\n
communication with this client.<\/p>\n\n\n\n
D. Offer to contact the client\u2019s minister or the facility\u2019s chaplain.<\/p>\n\n\n\n
-incorrect: This response disregards the client\u2019s issue and could create barriers to communication<\/p>\n\n\n\n
between the nurse and the client.<\/p>\n\n\n\n
42. A nurse is caring for a middle-aged adult client. The nurse should identify which of the<\/p>\n\n\n\n
following statements as an indication that the client has completed Erikson\u2019s developmental task<\/p>\n\n\n\n
for her age group?<\/p>\n\n\n\n
A. \u201cI am comfortable with my decision to choose a lifelong partner.\u201d<\/p>\n\n\n\n
-incorrect: This statement relates to Erikson\u2019s developmental task for young adults, which is<\/p>\n\n\n\n
intimacy vs. isolation.<\/p>\n\n\n\n
B. \u201cI think I have done a good job with my children since they are all independent now.\u201d<\/p>\n\n\n\n
-According to Erikson, the developmental task for middle adults is generativity vs. stagnation.<\/p>\n\n\n\n
Middle adults help shape future generations through community involvement, parenting,<\/p>\n\n\n\n
mentoring, and teaching. This statement about helping her children achieve independence<\/p>\n\n\n\n
indicates that the client has accomplished this developmental task.<\/p>\n\n\n\n
C. \u201cAs I look back over my life, I can see that I have achieved most of the goals I set for<\/p>\n\n\n\n
myself.\u201d<\/p>\n\n\n\n
-incorrect: This statement relates to Erikson\u2019s developmental task for older adults, which is<\/p>\n\n\n\n
integrity vs. despair.<\/p>\n\n\n\n
D. \u201cI love my work so much that it is difficult to think about retirement.\u201d<\/p>\n\n\n\n
-incorrect: This statement relates to Erikson\u2019s developmental task for older adults, which is<\/p>\n\n\n\n
integrity vs. despair.<\/p>\n\n\n\n
43. A nurse is inserting an NG tube into a client who begins to gag and cough. Which of the<\/p>\n\n\n\n
following actions should the nurse take?<\/p>\n\n\n\n
A. Remove the NG tube<\/p>\n\n\n\n
-incorrect: The nurse should not remove the NG tube if the client begins to cough and gag<\/p>\n\n\n\n
because this can result in increased discomfort for the client.<\/p>\n\n\n\n
B. Advance the NG tube quickly<\/p>\n\n\n\n
-incorrect: The nurse should not advance the NG tube while the client is coughing because this<\/p>\n\n\n\n
can result in inserting the tube into the client\u2019s trachea.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg11.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
C. Pull the NG tube back slightly<\/p>\n\n\n\n
-The nurse should slightly pull back the NG tube and instruct the client to breathe slowly. Once<\/p>\n\n\n\n
the client relaxes, the nurse should gently advance the tube as the client swallows.<\/p>\n\n\n\n
D. Ask the client to tilt his head backward<\/p>\n\n\n\n
-incorrect: The nurse should ask the client to tilt his head forward to aid the insertion of the NG<\/p>\n\n\n\n
tube into the esophagus.<\/p>\n\n\n\n
44. An adolescent client in an outpatient mental health facility tells the nurse that he struggles to<\/p>\n\n\n\n
follow his treatment plans because his friends discourage him. Which of the following statements<\/p>\n\n\n\n
should the nurse make?<\/p>\n\n\n\n
A. \u201cDon\u2019t worry; teenagers often have friends who give bad advice.\u201d<\/p>\n\n\n\n
-incorrect: This response is a barrier to communication. It is a stereotypical response and will not<\/p>\n\n\n\n
encourage open communication.<\/p>\n\n\n\n
B. \u201cI think you should stop seeing those friends since they discourage you from following your<\/p>\n\n\n\n
treatment plan.\u201d<\/p>\n\n\n\n
-incorrect: While the adolescent should possibly stop seeing these friends, sharing personal<\/p>\n\n\n\n
advice will probably be rejected by the adolescent and will not encourage open communication.<\/p>\n\n\n\n
C. \u201cTell me more about how your friends discourage you.\u201d<\/p>\n\n\n\n
-The nurse should ask an open-ended question that encourages the client to elaborate on these<\/p>\n\n\n\n
problems.<\/p>\n\n\n\n
D. \u201cWhere did you meet these friends?\u201d<\/p>\n\n\n\n
-incorrect: This response changes the subject, which will not encourage open communication.<\/p>\n\n\n\n
45. A nurse is teaching a client about the use of a straight-legged cane. Which of the following<\/p>\n\n\n\n
client actions indicates an understanding of the teaching?<\/p>\n\n\n\n
A. The client holds the cane on the unaffected side.<\/p>\n\n\n\n
-The nurse should instruct the client to hold the cane on the unaffected side to provide a wide<\/p>\n\n\n\n
base of support and stability.<\/p>\n\n\n\n
B. The client walks by stepping with the unaffected leg before the affected leg.<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to walk by stepping with the affected leg before<\/p>\n\n\n\n
the unaffected leg to maintain stability.<\/p>\n\n\n\n
C. The client holds the cane directly next to the foot.<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to place the cane at about 15 cm (6 in) to the side<\/p>\n\n\n\n
of the foot to provide balance and support.<\/p>\n\n\n\n
D. The client holds the cane with a straight elbow.<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to hold the cane with the elbow slightly flexed to<\/p>\n\n\n\n
provide support and stability.<\/p>\n\n\n\n
46. A nurse is preparing to administer sotalol to a client with a prescription for 320 mg\/day<\/p>\n\n\n\n
divided equally every 12 hr. The medication is available in 80 mg tablets. How many tablets<\/p>\n\n\n\n
should the nurse administer per dose? (nearest tenth)<\/p>\n\n\n\n
2<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg12.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
47. A nurse is caring for a client who had a mastectomy and has a self-suction drainage<\/p>\n\n\n\n
evacuator in place. Which of the following actions should the nurse take to ensure proper<\/p>\n\n\n\n
operation of the device?<\/p>\n\n\n\n
A. Irrigate the tubing with sterile normal water once during each shift.<\/p>\n\n\n\n
-incorrect: The nurse should keep the diaphragm of the device compressed to maintain suction<\/p>\n\n\n\n
and prevent clotting of sanguineous drainage. This drainage system is not made for irrigating.<\/p>\n\n\n\n
B. Cleanse the opening with soap and water after emptying.<\/p>\n\n\n\n
-incorrect: The nurse should cleanse the drain opening with an alcohol wipe after opening it to<\/p>\n\n\n\n
decrease the entry of microorganisms.<\/p>\n\n\n\n
C. Maintain the tubing above the level of the surgical incision.<\/p>\n\n\n\n
-incorrect: The nurse should maintain the drainage tubing below the level of the incision to<\/p>\n\n\n\n
enhance drainage.<\/p>\n\n\n\n
D. Collapse the device to remove air after emptying.<\/p>\n\n\n\n
-The nurse should collapse the device to remove air after emptying the contents periodically.<\/p>\n\n\n\n
This will create enough suction to pull fluid exudate into the collection area of the device.<\/p>\n\n\n\n
48. A nurse is planning weight-loss strategies for a group of clients who are obese. Which of the<\/p>\n\n\n\n
following actions by the nurse will improve the client\u2019s commitment to a long-term goal of<\/p>\n\n\n\n
weight loss?<\/p>\n\n\n\n
A. Attempt to increase the client\u2019s self-motivation<\/p>\n\n\n\n
-Motivation to learn is a key part of improving a client\u2019s commitment to achieving a health goal,<\/p>\n\n\n\n
as well as increasing the amount and speed of learning.<\/p>\n\n\n\n
B. Keep detailed records of each client\u2019s progress<\/p>\n\n\n\n
-incorrect: This will help each client track individual progress but does not improve client<\/p>\n\n\n\n
progress toward individual goals.<\/p>\n\n\n\n
C. Test client learning after each teaching session<\/p>\n\n\n\n
-incorrect: Testing learning helps to determine whether outcomes are reached but does not affect<\/p>\n\n\n\n
each client\u2019s commitment to the goal.<\/p>\n\n\n\n
D. Avoid discussing topics that might increase client\u2019s anxiety<\/p>\n\n\n\n
-incorrect: Anxiety can interfere with learning and should be addressed early in the teaching<\/p>\n\n\n\n
process.<\/p>\n\n\n\n
49. A nurse is teaching a client how to perform range-of-motion exercises of the wrist. To<\/p>\n\n\n\n
perform adduction, which of the following instructions should the nurse include?<\/p>\n\n\n\n
A. \u201cWith your palm facing down, move your wrist sideways toward your thumb.\u201d<\/p>\n\n\n\n
-This motion describes adducting the wrist. The client should be able to move her wrist 30 to 50<\/p>\n\n\n\n
degrees with this motion.<\/p>\n\n\n\n
B. \u201cMove your palm toward the inner part of your forearm.\u201d<\/p>\n\n\n\n
-incorrect: This motion is flexing the wrist.<\/p>\n\n\n\n
C. \u201cWith your palm facing down, move your wrist sideways toward your little finger.\u201d<\/p>\n\n\n\n
-incorrect: This motion is abducting the wrist.<\/p>\n\n\n\n
D. \u201cBring the back of your hand as far back toward the wrist as you can.\u201d<\/p>\n\n\n\n
-incorrect: This motion is hyperextending the wrist.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg13.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
50. A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of<\/p>\n\n\n\n
the following results should the nurse identify as an indication that the client has conductive<\/p>\n\n\n\n
hearing loss of the left ear?<\/p>\n\n\n\n
A. Air conduction is less than bone conduction in the left ear.<\/p>\n\n\n\n
-This finding indicates conductive hearing loss of the left ear.<\/p>\n\n\n\n
B. Air conduction is greater than bone conduction in the left ear.<\/p>\n\n\n\n
-incorrect: This finding does not indicate hearing loss of any type.<\/p>\n\n\n\n
C. Sound is lateralizing to the right ear.<\/p>\n\n\n\n
-incorrect: These are possible results of the Weber test, not the Rinne test.<\/p>\n\n\n\n
D. Sound is lateralizing to the left ear.<\/p>\n\n\n\n
-incorrect: These are possible results of the Weber test, not the Rinne test.<\/p>\n\n\n\n
51. A nurse is preparing a client who is scheduled for a hysterectomy for transport to the<\/p>\n\n\n\n
operating room. The client states she no longer wants to have the surgery. Which of the<\/p>\n\n\n\n
following actions should the nurse take?<\/p>\n\n\n\n
A. Tell the client it is too late for her to change her mind because the surgery is already<\/p>\n\n\n\n
scheduled.<\/p>\n\n\n\n
-incorrect: The client has the right to refuse a procedure after giving consent.<\/p>\n\n\n\n
B. Telephone the operating room and cancel the surgery.<\/p>\n\n\n\n
-incorrect: This is not the responsibility of the nurse but a decision the surgeon and the client<\/p>\n\n\n\n
must make.<\/p>\n\n\n\n
C. Inform the client\u2019s family about the situation.<\/p>\n\n\n\n
-incorrect: To respect the client\u2019s confidentiality, the family can be notified only after the client<\/p>\n\n\n\n
requests that the nurse do so.<\/p>\n\n\n\n
D. Notify the provider of the client\u2019s decision.<\/p>\n\n\n\n
-While acting as the client\u2019s advocate, the nurse should support her decision and notify the<\/p>\n\n\n\n
provider.<\/p>\n\n\n\n
52. A nurse is admitting a client who has decreased circulation in his left leg. Which of the<\/p>\n\n\n\n
following actions should the nurse take first?<\/p>\n\n\n\n
A. Evaluate pedal pulses<\/p>\n\n\n\n
-For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order<\/p>\n\n\n\n
to determine adequate blood supply to the foot. The nurse should apply the safety and risk<\/p>\n\n\n\n
reduction priority-setting framework. This framework assigns priority to the factor posing the<\/p>\n\n\n\n
greatest safety risk to the client. When there are several risks to client safety, the one posing the<\/p>\n\n\n\n
greatest threat is the highest priority.The nurse should use Maslow\u2019s Hierarchy of Needs, the<\/p>\n\n\n\n
ABC priority-setting framework, and\/or nursing knowledge to identify which risk poses the<\/p>\n\n\n\n
greatest threat to the client.<\/p>\n\n\n\n
B. Obtain a medical history<\/p>\n\n\n\n
-incorrect: The nurse should obtain the client\u2019s medical history. However, there is another action<\/p>\n\n\n\n
the nurse should take first.<\/p>\n\n\n\n
C. Measure vital signs<\/p>\n\n\n\n
-incorrect: The nurse should obtain baseline vital signs. However, there is another action the<\/p>\n\n\n\n
nurse should take first.<\/p>\n\n\n\n
D. Assess for leg pain<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg14.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The nurse should assess the client for pain. However, there is another action the nurse<\/p>\n\n\n\n
should take first.<\/p>\n\n\n\n
53. A new resident provider asks the charge nurse for an access code to review clients\u2019 online<\/p>\n\n\n\n
records. The resident is not scheduled to attend the facility\u2019s orientation computer class until next<\/p>\n\n\n\n
week. Which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Explain that it is against policy to share access codes and refer the resident to his<\/p>\n\n\n\n
supervisor.<\/p>\n\n\n\n
– Staff members should never share access codes and passwords or allow people who do not have<\/p>\n\n\n\n
their own access code to use the system. Allowing unauthorized access is a breach of federal<\/p>\n\n\n\n
guidelines for data security and client confidentiality.<\/p>\n\n\n\n
B. Access the clients\u2019 online data and monitor the resident as he reads them.<\/p>\n\n\n\n
-incorrect: Allowing an individual who does not have a personal access code to view the system<\/p>\n\n\n\n
is a breach of federal guidelines for data security and client confidentiality.<\/p>\n\n\n\n
C. Access the online system and allow the resident to locate clients\u2019 data.<\/p>\n\n\n\n
-incorrect: Allowing an individual to access the system without a personal access code is a<\/p>\n\n\n\n
breach of federal guidelines for data security and client confidentiality.<\/p>\n\n\n\n
D. Ask each client to give permission for the resident to access medical records.<\/p>\n\n\n\n
-incorrect: The resident should not have access to client information until he participates in the<\/p>\n\n\n\n
facility\u2019s training, which includes information about data security and client confidentiality.<\/p>\n\n\n\n
Even then, he should only have access to information directly needed to provide care to his<\/p>\n\n\n\n
specific clients.<\/p>\n\n\n\n
54. A nurse is caring for a client who has injuries resulting from a motor-vehicle crash. Which of<\/p>\n\n\n\n
the following client statements should the nurse address first?<\/p>\n\n\n\n
A. \u201cI\u2019m afraid this injury will cause me to lose my job.\u201d<\/p>\n\n\n\n
-incorrect: The client\u2019s fear of job loss is associated with the client\u2019s identity and economic<\/p>\n\n\n\n
survival. However, this is a self-esteem need; another need is the priority.<\/p>\n\n\n\n
B. \u201cI can\u2019t sleep well because whenever I move in my sleep, the pain wakes me up.\u201d<\/p>\n\n\n\n
-The priority action the nurse should take when using Maslow\u2019s hierarchy of needs id to meet the<\/p>\n\n\n\n
client\u2019s physiological need for comfort. The nurse should re-evaluate the client\u2019s pain<\/p>\n\n\n\n
management plan immediately.<\/p>\n\n\n\n
C. \u201cI don\u2019t know what I will do if my car isn\u2019t safe or even drivable after the crash.\u201d<\/p>\n\n\n\n
-incorrect: The client\u2019s concern about the vehicle is a safety and security need; however, another<\/p>\n\n\n\n
need is the priority.<\/p>\n\n\n\n
D. \u201cI wonder how I am going to be able to take care of my family.\u201d<\/p>\n\n\n\n
-incorrect: The client\u2019s need to care for family members in the same way as before is a love and<\/p>\n\n\n\n
belonging need; however, another need is the priority.<\/p>\n\n\n\n
55. A nurse is preparing a client for discharge and providing instructions about performing<\/p>\n\n\n\n
dressing changes at home. Which of the following statements should the nurse identify as an<\/p>\n\n\n\n
indication that the client understands medical asepsis?<\/p>\n\n\n\n
A. \u201cI\u2019ll wrap the old dressing in a paper bag and put it in the trash.\u201d<\/p>\n\n\n\n
-incorrect: Local regulations for disposal of contaminated items may vary. In general, placing the<\/p>\n\n\n\n
old dressing in a plastic bag and sealing it is an acceptable means of disposal in the household<\/p>\n\n\n\n
trash.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg15.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
B. \u201cI\u2019ll wash my hands before I remove the old dressing and again before putting on the<\/p>\n\n\n\n
new one.\u201d<\/p>\n\n\n\n
-It is essential that the client understands the importance of hand hygiene before, during, and<\/p>\n\n\n\n
after any handling of the wound or its dressings.<\/p>\n\n\n\n
C. \u201cI\u2019ll need to take a pain pill 30 minutes before I change the dressing.\u201d<\/p>\n\n\n\n
-incorrect: This might be a good practice if the dressing changes are painful; however, this<\/p>\n\n\n\n
statement does not address medical asepsis, only pain management.<\/p>\n\n\n\n
D. \u201cI\u2019ll wear sterile gloves when I apply the new dressing.\u201d<\/p>\n\n\n\n
-incorrect: Clean gloves and dressings are standard for clients at home. If sterile dressings are<\/p>\n\n\n\n
necessary, a home health care nurse should perform the dressing changes.<\/p>\n\n\n\n
56. A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the<\/p>\n\n\n\n
following statements by the AP indicates an understanding of the teaching?<\/p>\n\n\n\n
A. \u201cThere are times I should use soap and water rather than an alcohol-based rub to clean<\/p>\n\n\n\n
my hands.\u201d<\/p>\n\n\n\n
-While alcohol-based hand rubs are as effective as soap and water in providing proper hand<\/p>\n\n\n\n
hygiene, the Centers Disease Control and Prevention recommend washing hands with soap and<\/p>\n\n\n\n
water at certain times, such as when the hands are visibly soiled with dirt or body fluids.<\/p>\n\n\n\n
B. \u201cI will use cold water when I wash my hands to protect my skin from becoming dry.\u201d<\/p>\n\n\n\n
-incorrect: Hand hygiene should be performed with warm water, which preserves the protective<\/p>\n\n\n\n
oil of the skin better than hot water.<\/p>\n\n\n\n
C. \u201cI will apply friction for at least 10 seconds while washing my hands.\u201d<\/p>\n\n\n\n
-incorrect: Friction is required to loosen and remove dirt and pathogens from the hands. To be<\/p>\n\n\n\n
effective, friction should be applied for at least 15 to 20 seconds.<\/p>\n\n\n\n
D. \u201cAfter washing my hands, I will dry them from the elbows down.\u201d<\/p>\n\n\n\n
-incorrect: Drying should be performed from the cleanest area (fingertips) to the least clean area<\/p>\n\n\n\n
(forearms) to prevent contamination of the newly cleaned hands.<\/p>\n\n\n\n
57. A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a<\/p>\n\n\n\n
bed to a wheelchair. Which of the following techniques should the nurse use?<\/p>\n\n\n\n
A. Stand toward the client\u2019s stronger side.<\/p>\n\n\n\n
-incorrect: Safely transferring a client from a bed to a wheelchair requires the nurse to stand in<\/p>\n\n\n\n
front of the client toward the side that requires the most support. This technique will help<\/p>\n\n\n\n
maintain balance during the transfer.<\/p>\n\n\n\n
B. Instruct the client to lean backward from the hips.<\/p>\n\n\n\n
-incorrect: Safely transferring a client from a bed to a wheelchair requires the nurse to instruct<\/p>\n\n\n\n
the client to lean forward from the hips. This technique positions the client in the proper<\/p>\n\n\n\n
direction of the movement.<\/p>\n\n\n\n
C. Place the wheelchair at a 45-degree angle to the bed.<\/p>\n\n\n\n
-Positioning the wheelchair at a 45-degree angle allows the client to pivot, lessening the amount<\/p>\n\n\n\n
of rotation required.<\/p>\n\n\n\n
D. Assume a narrow stance with the feet 15 cm (6 in) apart.<\/p>\n\n\n\n
-incorrect: Safely transferring a client from a bed to a wheelchair requires the nurse to assume a<\/p>\n\n\n\n
wide stance with one foot in front of the other. This technique protects the nurse from losing<\/p>\n\n\n\n
balance during the transfer.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg16.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
58. A nurse is preparing to provide tracheostomy care for a client. Which of the following<\/p>\n\n\n\n
actions should the nurse perform first?<\/p>\n\n\n\n
A. Open all sterile supplies and solutions.<\/p>\n\n\n\n
-incorrect: The nurse should open all sterile supplies and solutions prior to providing<\/p>\n\n\n\n
tracheostomy care. However, there is another action the nurse should take first.<\/p>\n\n\n\n
B. Stabilize the tracheostomy tube.<\/p>\n\n\n\n
-incorrect: the nurse should stabilize the tracheostomy tube to prevent accidental extubation<\/p>\n\n\n\n
while providing tracheostomy care. However, there is another action the nurse should take first.<\/p>\n\n\n\n
C. Put on sterile gloves<\/p>\n\n\n\n
-incorrect: The nurse should put on sterile gloves prior to providing tracheostomy care to reduce<\/p>\n\n\n\n
the transmission of organisms. However, there is another action the nurse should take first.<\/p>\n\n\n\n
D. Perform hand hygiene<\/p>\n\n\n\n
-According to evidence-based practice, the nurse should first perform hand hygiene before<\/p>\n\n\n\n
touching the client or performing any skills, such as tracheostomy care. This is vital because<\/p>\n\n\n\n
contamination of the nurse\u2019s hands is a primary source of infection.<\/p>\n\n\n\n
59. A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of<\/p>\n\n\n\n
stool. Which of the following personal protective equipment (PPE) items should the nurse don<\/p>\n\n\n\n
prior to providing client care? (SATA)<\/p>\n\n\n\n
A. Gown<\/p>\n\n\n\n
-The nurse should follow standard precautions when caring for a client who has AIDS. Because<\/p>\n\n\n\n
the bed linens might be soiled, the nurse should don a gown. Because the nurse\u2019s hands will<\/p>\n\n\n\n
come in contact with the soiled bed linens, the nurse should don clean gloves in addition to other<\/p>\n\n\n\n
necessary PPE.<\/p>\n\n\n\n
B. Gloves<\/p>\n\n\n\n
-The nurse should follow standard precautions when caring for a client who has AIDS. Because<\/p>\n\n\n\n
the bed linens might be soiled, the nurse should don a gown. Because the nurse\u2019s hands will<\/p>\n\n\n\n
come in contact with the soiled bed linens, the nurse should don clean gloves in addition to other<\/p>\n\n\n\n
necessary PPE.<\/p>\n\n\n\n
C. Mask<\/p>\n\n\n\n
-incorrect: AIDS is not transmitted by droplets or inhalation, so a mask is not necessary when<\/p>\n\n\n\n
changing the client\u2019s bed linens.<\/p>\n\n\n\n
D. Hair cover<\/p>\n\n\n\n
-incorrect: A hair cover is not necessary when changing the client\u2019s bed linens.<\/p>\n\n\n\n
E. Goggles<\/p>\n\n\n\n
-incorrect: Goggles are not necessary since the splashing of bodily fluids is unlikely when<\/p>\n\n\n\n
changing the client\u2019s bed linens.<\/p>\n\n\n\n
60. A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA)<\/p>\n\n\n\n
infection. A dietary assistant asks the nurse what precautions are necessary for entering the<\/p>\n\n\n\n
client\u2019s room with the lunch tray. Which of the following instructions should the nurse give to<\/p>\n\n\n\n
the dietary assistant?<\/p>\n\n\n\n
A. Don a gown before entering the room and remove it before exiting<\/p>\n\n\n\n
-incorrect: Anyone who will have actual contact with this client must wear a gown. If the dietary<\/p>\n\n\n\n
assistant is just placing the lunch tray on the client\u2019s table, donning a gown is not necessary.<\/p>\n\n\n\n
B. Wear a mask while in the client\u2019s room<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg17.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: MRSA does not spread via droplet or aerosol transmission; therefore, the dietary<\/p>\n\n\n\n
assistant does not need to wear a mask.<\/p>\n\n\n\n
C. Don gloves when entering the room and use hand sanitizer when exiting<\/p>\n\n\n\n
-Clients who have MRSA infection require contact precautions. In addition to the use of standard<\/p>\n\n\n\n
precautions and meticulous hand hygiene, contact precautions require any staff member who will<\/p>\n\n\n\n
have contact with the client\u2019s environment to don gloves prior to entering the room. Additional<\/p>\n\n\n\n
precautions, such as a gown, are required for contact with the client; a mask and goggles are<\/p>\n\n\n\n
needed if the secretions from the infected area could spray into the worker\u2019s face. Delivering the<\/p>\n\n\n\n
tray will require contact with the client\u2019s environment; therefore, the dietary assistant must wear<\/p>\n\n\n\n
gloves.<\/p>\n\n\n\n
D. Take no special precautions unless engaging in direct contact with the client<\/p>\n\n\n\n
-incorrect: Infections with multidrug-resistant organisms, such as MRSA, require special<\/p>\n\n\n\n
precautions to prevent transmission of the pathogen through contact with the client and the<\/p>\n\n\n\n
client\u2019s environment.<\/p>\n\n\n\n
61. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client.<\/p>\n\n\n\n
Which of the following actions by the newly licensed nurse requires interventions?<\/p>\n\n\n\n
A. Obtaining hydrogen peroxide for tracheostomy care<\/p>\n\n\n\n
-incorrect: A half-strength peroxide solution is used to clean the inner cannula.<\/p>\n\n\n\n
B. Obtaining cotton balls for tracheostomy care<\/p>\n\n\n\n
-Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal<\/p>\n\n\n\n
abscess. The charge nurse should intervene for this action.<\/p>\n\n\n\n
C. Obtaining sterile gloves for tracheostomy care<\/p>\n\n\n\n
-incorrect: Tracheostomy care is a sterile procedure requiring the use of sterile gloves.<\/p>\n\n\n\n
D. Obtaining a sterile brush for tracheostomy care<\/p>\n\n\n\n
-incorrect: Pipe cleaners or a small sterile brush can be used to remove thick or crusty secretions<\/p>\n\n\n\n
from the inner cannula.<\/p>\n\n\n\n
62. A nurse is providing nutritional teaching to a group of clients. Which of the following<\/p>\n\n\n\n
definitions for the recommended dietary allowance (RDA) should the nurse include in the<\/p>\n\n\n\n
teaching?<\/p>\n\n\n\n
A. The RDA is a comprehensive term that includes various standards and scales.<\/p>\n\n\n\n
-incorrect: Dietary reference intakes (DRIs) include 4 nutrition-based standards that are used to<\/p>\n\n\n\n
plan dietary intake and evaluate a client\u2019s nutritional status. These dietary standards include<\/p>\n\n\n\n
RDAs, estimated average requirements (EARs), adequate intake (AI), and tolerable upper intake<\/p>\n\n\n\n
levels (ULs).<\/p>\n\n\n\n
B. The RDA defines the level of nutrient intake that meets the needs of healthy people<\/p>\n\n\n\n
in various groups.<\/p>\n\n\n\n
-The RDA represents daily requirements considered adequate for healthy people. RDAs are<\/p>\n\n\n\n
based on estimated amounts for each nutrient, including additional amounts for individuals such<\/p>\n\n\n\n
as women or infants.<\/p>\n\n\n\n
C. The RDA defines the levels of nutrients that should not be exceeded to prevent adverse health<\/p>\n\n\n\n
effects.<\/p>\n\n\n\n
-incorrect: Tolerable upper intake levels (ULs), not RDAs, are the levels of nutrients that should<\/p>\n\n\n\n
not be exceeded to prevent adverse effects.<\/p>\n\n\n\n
D. The RDA is the daily percentage of energy intake values for fat, carbohydrate, and protein.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg18.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-Acceptable macronutrient distribution ranges (AMDRs) are the daily percentage of energy<\/p>\n\n\n\n
intake values for fat, carbohydrate, and protein.<\/p>\n\n\n\n
63. A nurse is reviewing a client\u2019s 24 hr dietary recall. The client reports eating a slice of toasted<\/p>\n\n\n\n
white bread with butter, a banana, a glass of milk, and a cup of coffee for breakfast; grilled<\/p>\n\n\n\n
chicken, a baked potato, and a glass of milk for lunch; an apple and cheddar cheese for a snack;<\/p>\n\n\n\n
and 2 servings of chicken, 2 cups of steamed broccoli, and a glass of milk for dinner. This<\/p>\n\n\n\n
client\u2019s diet is deficient in which of the following food groups?<\/p>\n\n\n\n
A. Dairy<\/p>\n\n\n\n
-incorrect: The client consumed 3 servings of dairy throughout the day, which is the<\/p>\n\n\n\n
recommended daily amount according to USDA dietary guidelines.<\/p>\n\n\n\n
B. Vegetables<\/p>\n\n\n\n
-incorrect: The client consumed 2.5 cups or more of vegetables, which is the recommended daily<\/p>\n\n\n\n
amount according to USDA dietary guidelines.<\/p>\n\n\n\n
C. Fruits<\/p>\n\n\n\n
-incorrect: The client consumed 2 servings of fruit, which is the recommended daily amount<\/p>\n\n\n\n
according to USDA dietary guidelines.<\/p>\n\n\n\n
D. Grains<\/p>\n\n\n\n
-This client only consumed 1 serving of grains on the day of the 24-hour dietary recall.<\/p>\n\n\n\n
USDA dietary guidelines recommend 3 or more ounce-equivalents of whole-grain products per<\/p>\n\n\n\n
day. Additionally, the choice of white bread is low in fiber, which can lead to constipation and an<\/p>\n\n\n\n
increased risk of developing hyperlipidemia. The USDA guidelines recommend that at least half<\/p>\n\n\n\n
of the grains consumed should be whole grain.<\/p>\n\n\n\n
64. A nurse is assessing a client\u2019s pulses of the lower extremities. The nurse should identify<\/p>\n\n\n\n
which of the following as the location of the most distal pulse?<\/p>\n\n\n\n
A. Popliteal<\/p>\n\n\n\n
-incorrect: The nurse should identify that the popliteal pulse is located behind the knee. It is best<\/p>\n\n\n\n
felt with the client\u2019s knee slightly flexed and the foot resting on an examination table.<\/p>\n\n\n\n
B. Posterior Tibial<\/p>\n\n\n\n
-incorrect: The nurse should identify that the posterior tibial pulse is located on the inner side of<\/p>\n\n\n\n
the ankle. It is best felt with the client\u2019s foot relaxed and extended slightly.<\/p>\n\n\n\n
C. Dorsalis Pedis<\/p>\n\n\n\n
-The nurse should identify that the dorsalis pedis pulse is located on the top of the foot, following<\/p>\n\n\n\n
the groove between the tendons of the great toe. It is best felt by moving the fingertip between<\/p>\n\n\n\n
the first and second toe and slowly moving up the dorsum of the foot. However, this pulse is<\/p>\n\n\n\n
congenitally absent in some clients.<\/p>\n\n\n\n
D. Femoral<\/p>\n\n\n\n
-incorrect: The nurse should identify that the femoral pulse is located in the inguinal area. It is<\/p>\n\n\n\n
best felt with the client lying down and the inguinal area exposed.<\/p>\n\n\n\n
65. A nurse is screening a client who has an S-shaped spinal column with unequal shoulder<\/p>\n\n\n\n
heights. The nurse should identify these findings as manifestations of which of the following<\/p>\n\n\n\n
abnormalities?<\/p>\n\n\n\n
A. Scoliosis<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg19.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-The nurse should identify the finding of an S-shaped or C-shaped spinal column and uneven<\/p>\n\n\n\n
shoulder or hip heights as manifestations scoliosis.<\/p>\n\n\n\n
B. Lordosis<\/p>\n\n\n\n
-incorrect: The nurse should expect a client who has lordosis to exhibit manifestations of an<\/p>\n\n\n\n
exaggeration of the anterior convex curvature in the lumbar region of the spine.<\/p>\n\n\n\n
C. Torticollis<\/p>\n\n\n\n
-incorrect: The nurse should expect a client who has torticollis to exhibit manifestations of the<\/p>\n\n\n\n
head inclining toward the affected side with a contraction of the sternocleidomastoid muscle.<\/p>\n\n\n\n
D. Kyphosis<\/p>\n\n\n\n
-incorrect: The nurse should expect a client who has kyphosis to exhibit manifestations of an<\/p>\n\n\n\n
increased convex curvature in the thoracic region of the spine.<\/p>\n\n\n\n
66. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a<\/p>\n\n\n\n
regular-sized cuff for a client who is obese. Which of the following explanations should the<\/p>\n\n\n\n
nurse give the AP?<\/p>\n\n\n\n
A. \u201cThe reading will be inaudible if the cuff is too small for the client.\u201d<\/p>\n\n\n\n
-incorrect: Although the blood pressure reading for a client who is obese may be difficult to hear<\/p>\n\n\n\n
with any cuff, a cuff that is too small for the client will not yield an inaudible reading.<\/p>\n\n\n\n
B. \u201cThe width of the cuff bladder should be 75% of the circumference of the client\u2019s arm.\u201d<\/p>\n\n\n\n
-incorrect: The width of the cuff bladder should be 40% of the circumference of the client\u2019s arm.<\/p>\n\n\n\n
C. \u201cAs long as the cuff will circle the arm, the reading will be accurate.\u201d<\/p>\n\n\n\n
-incorrect: A cuff that is an incorrect size for the client will not yield an accurate reading.<\/p>\n\n\n\n
D. \u201cUsing a cuff that is too small will result in an inaccurately high reading.\u201d<\/p>\n\n\n\n
-Blood pressure cuffs come in various sizes, and the correct size cuff is necessary to obtain a<\/p>\n\n\n\n
reliable measurement. Blood pressure readings can be falsely high if the cuff Is too small for the<\/p>\n\n\n\n
client.<\/p>\n\n\n\n
67. A home health nurse is planning to provide health promotion activities for a group of clients<\/p>\n\n\n\n
in the community. Which of the following activities is an example of primary prevention?<\/p>\n\n\n\n
A. Teaching clients to perform self-examinations of breasts and testicles<\/p>\n\n\n\n
-incorrect: This activity is an example of secondary prevention, which focuses on measures that<\/p>\n\n\n\n
identify the early stages of a condition.<\/p>\n\n\n\n
B. Educating clients about the recommended immunization schedule for adults<\/p>\n\n\n\n
-Primary prevention includes health education about disease prevention.<\/p>\n\n\n\n
C. Teaching clients who have type 1 diabetes mellitus about care of the feet<\/p>\n\n\n\n
-This activity is an example of tertiary prevention, which occurs after diagnosis of a condition<\/p>\n\n\n\n
and focuses on limiting complications from the condition.<\/p>\n\n\n\n
D. Recommending that clients over the age of 50 have a fecal occult blood test annually<\/p>\n\n\n\n
-incorrect: This activity is an example of secondary prevention, which focuses on measures that<\/p>\n\n\n\n
identify the early stages of a condition.<\/p>\n\n\n\n
68. A nurse is performing an admission assessment for a client who has asthma and reports<\/p>\n\n\n\n
several food allergies. Which of the following actions should the nurse take first?<\/p>\n\n\n\n
A. Document the client\u2019s food allergies in the medical record<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg1a.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The nurse should document the client\u2019s food allergies in the medical record to<\/p>\n\n\n\n
communicate this information to other members of the health care team; however, there is<\/p>\n\n\n\n
another action that the nurse should perform first.<\/p>\n\n\n\n
B. Ask the client to identify the specific food allergies<\/p>\n\n\n\n
-The nurse should apply the nursing process priority-setting framework in order to plan client<\/p>\n\n\n\n
care and prioritize nursing actions. Each step of the nursing process builds on the previous step,<\/p>\n\n\n\n
beginning with an assessment or data collection. Before the nurse can formulate a plan of action,<\/p>\n\n\n\n
implement a nursing intervention, or notify the provider of a change in the client\u2019s status, the<\/p>\n\n\n\n
nurse must first collect adequate data from the client. Assessing or collecting additional data will<\/p>\n\n\n\n
provide the nurse with the knowledge to make an appropriate decision. Therefore, the nurse<\/p>\n\n\n\n
should first assess the client\u2019s allergies and identify the specific allergens to ensure the specific<\/p>\n\n\n\n
foods are not offered to the client during meals.<\/p>\n\n\n\n
C. Monitor the client for indications of anaphylaxis<\/p>\n\n\n\n
-incorrect: The nurse should monitor the client for indications of anaphylaxis due to allergen<\/p>\n\n\n\n
exposure; however, there is another action that the nurse should perform first.<\/p>\n\n\n\n
D. Have epinephrine available for administration<\/p>\n\n\n\n
-incorrect: The nurse should have epinephrine available for administration to treat the<\/p>\n\n\n\n
manifestations of an allergic reaction; however, there is another action that the nurse should<\/p>\n\n\n\n
perform first.<\/p>\n\n\n\n
69. A nurse is evaluating the development of a group of clients. According to Erikson, the<\/p>\n\n\n\n
developmental task of intimacy vs. isolation occurs during which of the following stages of<\/p>\n\n\n\n
development?<\/p>\n\n\n\n
A. Middle adulthood<\/p>\n\n\n\n
-incorrect: The developmental task of middle adulthood is generativity vs. self-absorption and<\/p>\n\n\n\n
stagnation.<\/p>\n\n\n\n
B. Adolescence<\/p>\n\n\n\n
-incorrect: The developmental task of adolescence is identity vs. role confusion.<\/p>\n\n\n\n
C. Childhood<\/p>\n\n\n\n
-incorrect: The developmental task of school-age children is industry vs. inferiority.<\/p>\n\n\n\n
D. Young adulthood<\/p>\n\n\n\n
-The developmental task of young adulthood is intimacy vs. isolation.<\/p>\n\n\n\n
70. A nurse is caring for a client who has cancer and refuses visitors because of his debilitated<\/p>\n\n\n\n
physical appearance. Which of the following comments should the nurse make?<\/p>\n\n\n\n
A. \u201cYou look just fine to me\u201d<\/p>\n\n\n\n
-incorrect: This statement is nontherapeutic and dismisses the client\u2019s concerns.<\/p>\n\n\n\n
B. \u201cNobody expects you to look beautiful in the hospital\u201d<\/p>\n\n\n\n
-incorrect: This response is nontherapeutic and dismisses the client\u2019s concerns.<\/p>\n\n\n\n
C. \u201cI understand how you feel. I would feel the same way.\u201d<\/p>\n\n\n\n
-incorrect: This statement is nontherapeutic and focuses on the nurse\u2019s feelings rather than the<\/p>\n\n\n\n
clients.<\/p>\n\n\n\n
D. \u201cWould you like to talk about how you feel?\u201d<\/p>\n\n\n\n
-This is a therapeutic response that will encourage the client to talk about his concerns and<\/p>\n\n\n\n
feelings.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg1b.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
71. A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian<\/p>\n\n\n\n
cancer. Which of the following statements by the client indicates she is experiencing<\/p>\n\n\n\n
psychological distress?<\/p>\n\n\n\n
A. \u201cMy parents are retired, and they have come to help with our children.\u201d<\/p>\n\n\n\n
-incorrect: Clients who have social and emotional support systems tend to experience less<\/p>\n\n\n\n
psychological distress.<\/p>\n\n\n\n
B. \u201cI am going to ask my husband to go to counseling with me.\u201d<\/p>\n\n\n\n
-incorrect: Open communication is an important method to improve relationships that might be<\/p>\n\n\n\n
strained. Seeking counseling is a positive strategy.<\/p>\n\n\n\n
C. \u201cI keep having nightmares about my upcoming surgery.\u201d<\/p>\n\n\n\n
-Nightmares and sleep disturbances are manifestations of anxiety and post-traumatic stress<\/p>\n\n\n\n
disorder. These indicate a risk of experiencing psychological distress.<\/p>\n\n\n\n
D. \u201cMy girlfriends bought me a nice wig.\u201d<\/p>\n\n\n\n
–incorrect: Clients who have social and emotional support systems tend to experience less<\/p>\n\n\n\n
psychological distress.<\/p>\n\n\n\n
72. A nurse is caring for a client who has a terminal illness. The family wants to care for the<\/p>\n\n\n\n
client at home. Which of the following statements indicates that the nurse understands family-<\/p>\n\n\n\n
centered care?<\/p>\n\n\n\n
A. \u201cSocial services can contact various community resources that will be helpful.\u201d<\/p>\n\n\n\n
-incorrect: In family-centered care, the family and client are the focus; therefore, the family<\/p>\n\n\n\n
members must decide, with the input of the health care team, which community resources to<\/p>\n\n\n\n
contact. The nurse should still make suggestions and offer support.<\/p>\n\n\n\n
B. \u201cI will review the care plan to make the necessary changes.\u201d<\/p>\n\n\n\n
-incorrect: In family-centered care, the family and client are the focus. The nurse should provide<\/p>\n\n\n\n
suggestions and offer support but should not make the final decision about changes to the care<\/p>\n\n\n\n
plan.<\/p>\n\n\n\n
C. \u201cLet\u2019s set up a meeting time with the doctor to discuss your options for home care.\u201d<\/p>\n\n\n\n
-In family-centered care, the nurse considers the health of the family as a unit; therefore, the<\/p>\n\n\n\n
client and family members help determine their outcomes and goals. Setting up a meeting to<\/p>\n\n\n\n
discuss this with the provider will give them a sense of autonomy and foster the family-centered<\/p>\n\n\n\n
nursing environment.<\/p>\n\n\n\n
D. \u201cI will make a list of things we need to do before discharge.\u201d<\/p>\n\n\n\n
-incorrect: In family-centered care, the family and client are the focus; therefore, the family must<\/p>\n\n\n\n
decide, with the nurse\u2019s input, what to do before the client goes home.<\/p>\n\n\n\n
73. A nurse is caring for a group of clients in a long-term care facility. One of the clients is<\/p>\n\n\n\n
walking along the hallway and bumping into walls and does not respond to his name. Which of<\/p>\n\n\n\n
the following actions should the nurse take first?<\/p>\n\n\n\n
A. Offer the client a nutritious snack<\/p>\n\n\n\n
-incorrect: The client is at risk of inadequate nutrition because of the fluid and calorie<\/p>\n\n\n\n
expenditure from wandering; however, there is another action that the nurse should take first.<\/p>\n\n\n\n
B. Accompany the client back to his room<\/p>\n\n\n\n
-The nurse should apply the safety and risk-reduction priority-setting framework, which assigns<\/p>\n\n\n\n
priority to the factor or situation posing the greatest safety risk to the client. When there are<\/p>\n\n\n\n
several risks to client safety, the one posing the greatest threat is the highest priority. The nurse<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg1c.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
should use Maslow\u2019s hierarchy of needs, the ABC priority-setting framework, and\/or nursing<\/p>\n\n\n\n
knowledge to identify which risk poses the greatest threat to the client. Therefore, the nurse<\/p>\n\n\n\n
should first escort the client back to his room to protect him from injury due to wandering.<\/p>\n\n\n\n
C. Reorient the client to his surroundings<\/p>\n\n\n\n
-incorrect: The client is at risk of anxiety because of possible disorientation; however, there is<\/p>\n\n\n\n
another action that the nurse should take first.<\/p>\n\n\n\n
D. Administer a PRN antianxiety medication<\/p>\n\n\n\n
-incorrect: The client is at risk of anxiety because of possible disorientation; however, there is<\/p>\n\n\n\n
another action that the nurse should take first.<\/p>\n\n\n\n
74. A nurse on a medical unit is caring for a client who has difficulty sleeping. Which of the<\/p>\n\n\n\n
following actions should the nurse take to promote the client\u2019s ability to fall asleep?<\/p>\n\n\n\n
A. Encourage the client to ambulate in the hallway just before bedtime<\/p>\n\n\n\n
-incorrect: Clients should avoid exercising for 2-3 hours before bedtime.<\/p>\n\n\n\n
B. Allow the client to maintain the same bedtime routine as at home<\/p>\n\n\n\n
-For many clients in an acute care facility, disrupting the usual sleep routine is the primary<\/p>\n\n\n\n
reason for a client\u2019s inability to sleep. Maintaining the home bedtime routine promotes sleep in<\/p>\n\n\n\n
ways that are effective for the client. Those whose usual bedtime routines include warm milk,<\/p>\n\n\n\n
massages, or pharmacological sleep aids might need and appreciate those interventions in<\/p>\n\n\n\n
inpatient settings.<\/p>\n\n\n\n
C. Keep the room temperature warm<\/p>\n\n\n\n
-incorrect: A cool room temperature is generally more conducive to sleep.<\/p>\n\n\n\n
D. Offer the client a cup of hot chocolate before bedtime<\/p>\n\n\n\n
-incorrect: Although the warm milk in hot cocoa or hot chocolate can promote sleep, the<\/p>\n\n\n\n
chocolate contains caffeine, which is stimulant and can keep the client awake.<\/p>\n\n\n\n
75. A nurse is caring for a client who has cancer and is experiencing pain. The nurse should<\/p>\n\n\n\n
implement which of the following interventions to assist the client with pain relief?<\/p>\n\n\n\n
A. Encourage the client to listen to soft music<\/p>\n\n\n\n
-The nurse should encourage the client to use music therapy to reduce anxiety, provide a<\/p>\n\n\n\n
distraction, and relieve pain.<\/p>\n\n\n\n
B. Instruct the client to practice tai chi<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to practice tai chi to stimulate the immune system<\/p>\n\n\n\n
and to improve joint function and mobility. However, it is not effective for pain management.<\/p>\n\n\n\n
C. Place a jasmine-scented air freshener in the client\u2019s room<\/p>\n\n\n\n
-incorrect: The nurse can use aromatherapy to promote the client\u2019s comfort and healing.<\/p>\n\n\n\n
However, jasmine is used to. Improve mood and is not effective for pain management.<\/p>\n\n\n\n
D. Offer the client ginger tea<\/p>\n\n\n\n
-incorrect: The nurse should offer the client ginger tea, if it is not contraindicated, to reduce<\/p>\n\n\n\n
nausea. However, it is not effective for pain management.<\/p>\n\n\n\n
76. A nurse is planning care for a client who has a wound infection following abdominal surgery.<\/p>\n\n\n\n
To promote healing and fight infection, which of the following vitamins and minerals should the<\/p>\n\n\n\n
nurse plan to increase in the client\u2019s diet?<\/p>\n\n\n\n
A. Vitamin C and zinc<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg1d.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-The client\u2019s body needs both vitamin C and zinc to fight a wound infection. The client should<\/p>\n\n\n\n
receive a multivitamin and a mineral supplement of both these substances. In addition, vitamin E<\/p>\n\n\n\n
supplements also are needed to promote skin and wound healing.<\/p>\n\n\n\n
B. Vitamin D<\/p>\n\n\n\n
-incorrect: Vitamin D is used with calcium to prevent osteoporosis; however, it does not assist<\/p>\n\n\n\n
with wound healing. The main function of vitamin D is to maintain calcium and phosphorus<\/p>\n\n\n\n
levels in the blood, and it may protect against cancer.<\/p>\n\n\n\n
C. Vitamin K and iron<\/p>\n\n\n\n
-incorrect: Vitamin K is important for normal blood clotting and for impaired intestinal synthesis<\/p>\n\n\n\n
caused by antibiotics. Iron is needed to rebuild RBC\u2019s; however, neither is needed directly for<\/p>\n\n\n\n
wound healing.<\/p>\n\n\n\n
D. Calcium<\/p>\n\n\n\n
-incorrect: Calcium is administered to prevent osteoporosis when used with vitamin D; however,<\/p>\n\n\n\n
it does not aid wound healing.<\/p>\n\n\n\n
77. A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the<\/p>\n\n\n\n
following actions should the nurse take?<\/p>\n\n\n\n
A. Leave the bag in place for 45 mins<\/p>\n\n\n\n
-incorrect: To reduce the risk of injury to the client\u2019s skin, the nurse should leave the ice bag ion<\/p>\n\n\n\n
place for no longer than 30 mins.<\/p>\n\n\n\n
B. Fill the bag 2\/3 full with ice<\/p>\n\n\n\n
-The nurse should fill the bag 2\/3 full with ice, which allows the bag to be molded around the<\/p>\n\n\n\n
clients ankle.<\/p>\n\n\n\n
C. Place the ice bag uncovered on the client\u2019s ankle<\/p>\n\n\n\n
-incorrect: The nurse should cover the ice bag with a towel or other type of cover before placing<\/p>\n\n\n\n
the ice bag on the client\u2019s ankle to prevent injury to the client\u2019s skin.<\/p>\n\n\n\n
D. Tell the client numbness is expected when the ice bag is in place<\/p>\n\n\n\n
-incorrect: The nurse should remove the ice bag if the client feels numbness since this is an<\/p>\n\n\n\n
indication that the client\u2019s skin is too cold and at risk for injury.<\/p>\n\n\n\n
78. A nurse is caring for a client who has a terminal illness. The client is restless and reports<\/p>\n\n\n\n
severe pain but refuses the prescribed opioid pain medication. Which of the following actions<\/p>\n\n\n\n
should the nurse take first?<\/p>\n\n\n\n
A. Ask why the client is refusing the pain medication<\/p>\n\n\n\n
-Using the nursing process, the nurse should first assess the reason for the client\u2019s refusal of the<\/p>\n\n\n\n
opioid pain medication.<\/p>\n\n\n\n
B. Administer a PRN antianxiety medication<\/p>\n\n\n\n
-incorrect: The nurse should administer a PRN antianxiety medication if it is indicated to<\/p>\n\n\n\n
complement other pain management interventions; however, there is another action the nurse<\/p>\n\n\n\n
should take first.<\/p>\n\n\n\n
C. Help the client change positions<\/p>\n\n\n\n
-incorrect: The nurse should help the client change positions to complement other pain<\/p>\n\n\n\n
management interventions; however, there is another action the nurse should take first.<\/p>\n\n\n\n
D. Offer the client a heat or cold pack to place on painful areas<\/p>\n\n\n\n
-incorrect: The nurse should offer the client a heat or cold pack to complement other pain<\/p>\n\n\n\n
management interventions; however, there is another action the nurse should take first.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg1e.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
79. A nurse is monitoring a client\u2019s fluid intake. For breakfast, the client consumed 8 oz of milk,<\/p>\n\n\n\n
10 oz of water, 4 oz of flavored gelatin, 1 scrambled egg, 1 crisp piece of bacon, and 2 biscuits<\/p>\n\n\n\n
with jelly. How many mL should the nurse record as the client\u2019s fluid intake? (Nearest whole<\/p>\n\n\n\n
number)<\/p>\n\n\n\n
-660 mL<\/p>\n\n\n\n
80. A nurse is teaching ROM exercises to a client who has osteoarthritis. Which of the following<\/p>\n\n\n\n
client positions demonstrates an understanding of supination of the hand?<\/p>\n\n\n\n
A. The client holds the hand with the palm up<\/p>\n\n\n\n
-The nurse should identify the client holding the hand with the palm up as a demonstration of<\/p>\n\n\n\n
supination of the hand<\/p>\n\n\n\n
B. The client holds the hand with the palm down<\/p>\n\n\n\n
-incorrect: Holding the hand with the palm down is a demonstration of pronation of the hand.<\/p>\n\n\n\n
C. The client points the fingers toward the floor<\/p>\n\n\n\n
-incorrect: Pointing the fingers toward the floor is a demonstration of flexion of the hand.<\/p>\n\n\n\n
D. The client points the fingers toward the ceiling<\/p>\n\n\n\n
-incorrect: Pointing the fingers toward the ceiling is a demonstration of extension of the hand.<\/p>\n\n\n\n
81. A nurse has received a prescription for dextran to administer to a client. The nurse should<\/p>\n\n\n\n
recognize that dextran belongs in which of the following functional classifications?<\/p>\n\n\n\n
A. Skeletal muscle relaxants<\/p>\n\n\n\n
-incorrect: Dextran is not a skeletal muscle relaxant. Examples of skeletal muscle relaxants are<\/p>\n\n\n\n
cyclobenzaprine and metaxalone.<\/p>\n\n\n\n
B. Beta-adrenergic blockers<\/p>\n\n\n\n
-incorrect: Dextran is not a beta-adrenergic blocker. Example of beta-adrenergic blockers are<\/p>\n\n\n\n
propranolol and carvedilol.<\/p>\n\n\n\n
C. Broad-spectrum anti-infective agents<\/p>\n\n\n\n
-incorrect: Dextran is not a broad-spectrum anti-infective agent. Examples of broad-spectrum<\/p>\n\n\n\n
anti-infective agents include ampicillin and cefixime.<\/p>\n\n\n\n
D. Plasma volume expanders<\/p>\n\n\n\n
-Dextran and albumin are plasma volume expanders that help correct hypovolemia in emergency<\/p>\n\n\n\n
situations, such as after hemorrhage or burns.<\/p>\n\n\n\n
82. A nurse is preparing to administer liquid medication from a bottle to a client. Which of the<\/p>\n\n\n\n
following actions should the nurse take first?<\/p>\n\n\n\n
A. Hold the medication bottle with the label against the palm of the hand when pouring<\/p>\n\n\n\n
-The nurse should hold a multidose bottle with the label against the palm of the hand when<\/p>\n\n\n\n
pouring to prevent contaminating the label with spilled medication that could cause information<\/p>\n\n\n\n
on the label to fade or become illegible.<\/p>\n\n\n\n
B. Place the cap with the inside facing down on a hard surface<\/p>\n\n\n\n
-incorrect: The nurse should remove the cap of the medication bottle and place it with the inside<\/p>\n\n\n\n
facing up on a hard surface to prevent contamination of the inside of the cap and to maintain<\/p>\n\n\n\n
cleanliness.<\/p>\n\n\n\n
C. Fill the cup until the medication is even with the edge of the dosage scale<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg1f.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The nurse should fill the cup until the medication is even with the surface or meniscus<\/p>\n\n\n\n
base of the dosage scale to ensure the client receives an accurate dose.<\/p>\n\n\n\n
D. Pour any excess liquid back into the bottle after measuring<\/p>\n\n\n\n
-incorrect: The nurse should discard any excess liquid medication into the sink as wasted<\/p>\n\n\n\n
medication and wipe the lip of the bottle clean after measuring.<\/p>\n\n\n\n
83. A nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to<\/p>\n\n\n\n
deliver morphine for pain management. Which of the following statements should the nurse<\/p>\n\n\n\n
identify as an indication that the client understands the instructions?<\/p>\n\n\n\n
A. \u201cI\u2019ll limit pushing the button, so I don\u2019t get an overdose.\u201d<\/p>\n\n\n\n
-incorrect: PCA devices have a timing control or lockout mechanism that allows a preset<\/p>\n\n\n\n
minimum interval between medication doses and limits the total dose per hour. This safety<\/p>\n\n\n\n
feature prevents analgesic overdosing.<\/p>\n\n\n\n
B. \u201cIf I push the button and still have pain after 2 mins, I\u2019ll push it again.\u201d<\/p>\n\n\n\n
-incorrect: PCA devices have a timing control or lockout mechanism that usually allows dosing<\/p>\n\n\n\n
every 6 to 8 minutes. If the client pushes the button after 2 mins, the pump will not deliver any<\/p>\n\n\n\n
medication.<\/p>\n\n\n\n
C. \u201cI\u2019ll ask my niece to push the button when I am sleeping.\u201d<\/p>\n\n\n\n
-incorrect: The client is the only one who should operate the PCA pump. When someone else<\/p>\n\n\n\n
operates the pump, it bypasses a safety feature that requires the client to be awake and to decide<\/p>\n\n\n\n
whether more medication is needed.<\/p>\n\n\n\n
D. \u201cI can still use my transcutaneous electrical nerve stimulation unit while I\u2019m<\/p>\n\n\n\n
pushing the PCA button.\u201d<\/p>\n\n\n\n
-The nurse should encourage the client to utilize nonpharmacological methods of pain<\/p>\n\n\n\n
management such as transcutaneous electrical nerve stimulation (TENS) while using a PCA<\/p>\n\n\n\n
pump to reduce the amount of opioid dosing the client needs.<\/p>\n\n\n\n
84. A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday<\/p>\n\n\n\n
for the administration of enteral feeding. Which of the following methods should the nurse use to<\/p>\n\n\n\n
verify correct tube placement? (SATA)<\/p>\n\n\n\n
A. Auscultate injected air<\/p>\n\n\n\n
-incorrect: Auscultating air injected into an NG tube is not a reliable method of determining<\/p>\n\n\n\n
correct NG tube placement.<\/p>\n\n\n\n
B. Verify the initial X-Ray examination<\/p>\n\n\n\n
C. Measure the length of the exposed tube<\/p>\n\n\n\n
D. Determine the pH of aspirated fluid<\/p>\n\n\n\n
-The nurse should confirm the NG tube placement by checking the X-ray results following the<\/p>\n\n\n\n
insertion of the NG tube. In addition, the nurse should check the length of the NG tube that is<\/p>\n\n\n\n
exposed by comparing the markings on the tube to the client\u2019s nose to verify tube placement.<\/p>\n\n\n\n
E. Check the aspirated fluid for glucose<\/p>\n\n\n\n
-incorrect: Checking for glucose in the aspirated fluid is not a reliable method of determining<\/p>\n\n\n\n
correct NG tube placement.<\/p>\n\n\n\n
85. A nurse is preparing to insert an NG tube for a client. Which of the following actions will<\/p>\n\n\n\n
help facilitate the insertion of the tube? (SATA)<\/p>\n\n\n\n
A. coat the tip of the tube with a water-soluble lubricant<\/p>\n\n\n\n
B. Ask the client to swallow water while the tube enters her throat<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg20.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-Lubricating the tube eases its passage. A water-based gel because it will dissolve if the tube<\/p>\n\n\n\n
slips into the client\u2019s airway, while using petroleum jelly could cause respiratory problems.<\/p>\n\n\n\n
Swallowing water reduces the risk of gagging and aspiration and helps propel the tube down the<\/p>\n\n\n\n
esophagus. Hyperextending the neck reduces the curvature of the nasopharynx, which facilitates<\/p>\n\n\n\n
the insertion of the NG tube.<\/p>\n\n\n\n
C. Place the coiled tube in ice chips prior to insertion<\/p>\n\n\n\n
-incorrect: Ice makes NG tubes rigid, increasing the risk of trauma to mucous membranes.<\/p>\n\n\n\n
D. Tell the client to tilt her head backward as insertion begins<\/p>\n\n\n\n
-Lubricating the tube eases its passage. A water-based gel because it will dissolve if the tube<\/p>\n\n\n\n
slips into the client\u2019s airway, while using petroleum jelly could cause respiratory problems.<\/p>\n\n\n\n
Swallowing water reduces the risk of gagging and aspiration and helps propel the tube down the<\/p>\n\n\n\n
esophagus. Hyperextending the neck reduces the curvature of the nasopharynx, which facilitates<\/p>\n\n\n\n
the insertion of the NG tube.<\/p>\n\n\n\n
E. Instruct the client to bear down during insertion<\/p>\n\n\n\n
-incorrect: Bearing down is helpful during the insertion of a urinary catheter, not an NG tube.<\/p>\n\n\n\n
86. A nurse is providing teaching to a group of unit nurses about wound healing by secondary<\/p>\n\n\n\n
intention. Which of the following pieces of information should the nurse include in the teaching?<\/p>\n\n\n\n
A. The wound edges are well-approximated<\/p>\n\n\n\n
-incorrect: Primary intention involves the closing of the wound using sutures or staples at the<\/p>\n\n\n\n
time the incision is made; the suture line edges become well-approximated during healing.<\/p>\n\n\n\n
B. The wound is closed at a later date<\/p>\n\n\n\n
-incorrect: Tertiary intention includes using sutures to close an open wound at a later date after<\/p>\n\n\n\n
the wound drains and starts to heal.<\/p>\n\n\n\n
C. A skin graft is placed over the wound bed<\/p>\n\n\n\n
-incorrect: Tertiary intention can include the provider placing grafted skin over the client\u2019s<\/p>\n\n\n\n
wound bed after a wound is left open to drain and start healing. Skin grafting is required for<\/p>\n\n\n\n
deeper wounds such as full-thickness burns and is only rarely required for surgical wounds that<\/p>\n\n\n\n
do not heal.<\/p>\n\n\n\n
D. Granulation tissue fills the wound during healing<\/p>\n\n\n\n
-A beefy, red tissue called granulation tissue fills the wound during healing. The wound is left<\/p>\n\n\n\n
open to drain and heal by secondary intention, which should occur within 5-21 days. Open<\/p>\n\n\n\n
wounds increase the risk of wound infection.<\/p>\n\n\n\n
87. A nurse is caring for a client who is receiving IV fluid replacement. Which of the following<\/p>\n\n\n\n
findings should the nurse identify as infiltration of the IV infusion site?<\/p>\n\n\n\n
A. Redness at the IV catheter entry site<\/p>\n\n\n\n
-incorrect: A client who has redness at the IV catheter entry site might have a local infection. The<\/p>\n\n\n\n
nurse should remove the IV, clean the site with alcohol, and start a new IV line in another<\/p>\n\n\n\n
location.<\/p>\n\n\n\n
B. Palpable cord along the vein used for the infusion<\/p>\n\n\n\n
-incorrect: A client who has a palpable cord along the vein might have phlebitis, which is<\/p>\n\n\n\n
inflammation of the inner layer of a vein. The nurse should discontinue the infusion and start a<\/p>\n\n\n\n
new IV line in another location.<\/p>\n\n\n\n
C. Taut skin around the IV catheter site that is cool to the touch<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg21.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-A client who has taut skin around the IV catheter site that is cool to the touch might have an<\/p>\n\n\n\n
infiltrated IV site. The nurse should stop the IV infusion, elevate the extremity, and apply a<\/p>\n\n\n\n
warm moist compress or a cold compress (according to the type of infiltration).<\/p>\n\n\n\n
D. Bleeding at the IV insertion site<\/p>\n\n\n\n
-Bleeding at the IV insertion site might indicate the IV system is not intact. The nurse should<\/p>\n\n\n\n
check to determine if the IV system is intact and if the catheter is within the client\u2019s vein. The<\/p>\n\n\n\n
nurse might need to start a new IV line in another location if the bleeding does not stop after<\/p>\n\n\n\n
interventions.<\/p>\n\n\n\n
88. A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric<\/p>\n\n\n\n
decompression. Which of the following actions should the nurse include in the plan of care?<\/p>\n\n\n\n
(SATA)<\/p>\n\n\n\n
A. Set the suction machine at 120 mmHg<\/p>\n\n\n\n
-incorrect: Single-lumen NG tubes are used for intermittent suction, and the machine is set at 80<\/p>\n\n\n\n
to 100 mmHg. Higher suction settings can traumatize the gastric lining.<\/p>\n\n\n\n
B. Provide oral hygiene frequently<\/p>\n\n\n\n
C. Measure the amount of drainage from the NG tube every shift<\/p>\n\n\n\n
D. Secure the NG tube to the client\u2019s gown<\/p>\n\n\n\n
-Frequent oral hygiene comfort for the client since mucous membranes become dry and<\/p>\n\n\n\n
uncomfortable when a client cannot drink fluids. Measuring the drainage at least every shift<\/p>\n\n\n\n
helps the provider calculate fluid loss and prescribe appropriate replacement therapy.An<\/p>\n\n\n\n
unsecured NG tube can irritate the nares if the tube is pulled or caught on the bed or other<\/p>\n\n\n\n
equipment. The tube can also be dislodged if not secured appropriately.<\/p>\n\n\n\n
E. Apply petroleum jelly to the client\u2019s nares<\/p>\n\n\n\n
-incorrect: The client could aspirate an oil-based lubricant like petroleum jelly into the lungs,<\/p>\n\n\n\n
which could result in lipid pneumonia. A water-soluble lubricant should be applied to the nares<\/p>\n\n\n\n
to help prevent or relieve dry skin.<\/p>\n\n\n\n
89. A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which<\/p>\n\n\n\n
of the following actions should the nurse take?<\/p>\n\n\n\n
A. Maintain suction while removing the NG tube<\/p>\n\n\n\n
-incorrect: The nurse should disconnect the NG tube from the suction apparatus before removal<\/p>\n\n\n\n
to decrease the risk of injury to the gastrointestinal mucosa.<\/p>\n\n\n\n
B. Instill 100 mL of air into the NG tube before removal<\/p>\n\n\n\n
-incorrect: The nurse should instill 50 mL of air into the tube to clear the contents of gastric<\/p>\n\n\n\n
drainage and decrease the risk of aspiration on removal of the tube.<\/p>\n\n\n\n
C. Pinch the NG tube while removing the tube<\/p>\n\n\n\n
-The nurse should pinch the NG tube while removing the tube to decrease the risk of aspiration<\/p>\n\n\n\n
of any gastric contents.<\/p>\n\n\n\n
D. Instruct the client to breathe in and out during the removal of the NG tube<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to take and hold a deep breath during the removal<\/p>\n\n\n\n
of the NG tube to close the glottis and decrease the risk of aspiration of any gastric contents.<\/p>\n\n\n\n
90. A nurse is planning care for a client who has a prescription for collection of a sputum<\/p>\n\n\n\n
specimen for culture and sensitivity. Which of the following actions should the nurse take when<\/p>\n\n\n\n
obtaining the specimen?<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg22.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
A. Collect the specimen when the client rises in the morning<\/p>\n\n\n\n
-The nurse should plan to collect the sputum specimen when the client arises in the morning<\/p>\n\n\n\n
because the client will be able to cough up the secretions that have accumulated during the night.<\/p>\n\n\n\n
Generally, the deepest specimens are obtained in the early morning, and it is preferable to collect<\/p>\n\n\n\n
the specimen before breakfast. The nurse should instruct the client to rinse the mouth, take a<\/p>\n\n\n\n
deep breath, and cough prior to expectorating into the sterile container.<\/p>\n\n\n\n
B. Force fluids during the day and collect the specimen in the evening<\/p>\n\n\n\n
-incorrect: The nurse should encourage the client to force fluids, especially clear liquids, to help<\/p>\n\n\n\n
thin respiratory secretions. However, evening hours are not the preferred time for obtaining deep<\/p>\n\n\n\n
sputum specimens.<\/p>\n\n\n\n
C. Collect the specimen after antibiotics have been started<\/p>\n\n\n\n
-incorrect: The nurse should collect the sputum specimen ordered for culture and sensitivity<\/p>\n\n\n\n
before the client receives antibiotic therapy to prevent interference with the laboratory results.<\/p>\n\n\n\n
D. Collect 2 mL of sputum before sending the specimen to the laboratory<\/p>\n\n\n\n
-incorrect: The nurse should collect 4-10 mL of sputum before sending the specimen to the<\/p>\n\n\n\n
laboratory to provide an adequate amount of sputum for culture and sensitivity.<\/p>\n\n\n\n
91. After assessing a client, the nurse documents \u201c1+ pedal edema bilaterally.\u201dThis indicates<\/p>\n\n\n\n
that the nurse observed an indentation of which of the following depths after applying pressure?<\/p>\n\n\n\n
A. 2mm<\/p>\n\n\n\n
-The nurse should document a 2mm indentation after applying and removing pressure as 1+<\/p>\n\n\n\n
pedal edema.<\/p>\n\n\n\n
B. 4mm<\/p>\n\n\n\n
-incorrect: The nurse should document a 4mm indentation after applying and removing pressure<\/p>\n\n\n\n
as 2+ pedal edema.<\/p>\n\n\n\n
C. 6mm<\/p>\n\n\n\n
-incorrect: The nurse should document a 6mm indentation after applying and removing pressure<\/p>\n\n\n\n
as 3+ pedal edema.<\/p>\n\n\n\n
D. 8mm<\/p>\n\n\n\n
-incorrect: The nurse should document an 8mm indentation after applying and removing pressure<\/p>\n\n\n\n
as 4+ pedal edema.<\/p>\n\n\n\n
92. A nurse is caring for an adult client who has an NG tube in place and a prescription for<\/p>\n\n\n\n
continuous enteral feedings. Which of the following actions should the nurse perform to reduce<\/p>\n\n\n\n
the client\u2019s risk of aspiration?<\/p>\n\n\n\n
A. Irrigate the tubing with 30 mL of sterile water<\/p>\n\n\n\n
-incorrect: Irrigating the tubing will not reduce the client\u2019s risk of aspiration. Irrigation can help<\/p>\n\n\n\n
prevent or resolve clogging of the tube.<\/p>\n\n\n\n
B. Elevate the head of the bed to 30 or 40 degrees<\/p>\n\n\n\n
-Elevating the head of the bed to at least 30 and preferably 45 degrees helps prevent the<\/p>\n\n\n\n
gravitational reflux of gastric contents, thereby decreasing the risk of aspiration.<\/p>\n\n\n\n
C. Suggest changing the feeding to lactose-free formula<\/p>\n\n\n\n
-incorrect: Changing the feeding to lactose-free formula will not decrease the client\u2019s risk of<\/p>\n\n\n\n
aspiration. It will reduce gastrointestinal irritation or upset in clients who are sensitive to lactose.<\/p>\n\n\n\n
D. Warm the enteral formula to room temperature before feeding<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg23.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: Warming the enteral formula before feeding will not decrease the client\u2019s risk of<\/p>\n\n\n\n
aspiration. It can help reduce abdominal cramping and discomfort from cold formula ingestion.<\/p>\n\n\n\n
93. A nurse is caring for a client who requires a dressing change. Which of the following actions<\/p>\n\n\n\n
should the nurse take?<\/p>\n\n\n\n
A. Clean the incision from bottom to top<\/p>\n\n\n\n
-incorrect: The nurse should clean the incision from top to bottom to prevent any contamination<\/p>\n\n\n\n
of the area that has already been cleansed. The top of an incision is cleaner because drainage<\/p>\n\n\n\n
tends to collect at the bottom of the wound.<\/p>\n\n\n\n
B. Apply sterile gloves prior to opening dressing packages<\/p>\n\n\n\n
-incorrect: The nurse should apply sterile gloves after opening dressing packages. To open the<\/p>\n\n\n\n
packages, the nurse must touch the nonsterile outside packaging of the sterile supplies. If the<\/p>\n\n\n\n
nurse donned the sterile gloves prior to opening the packages, opening the package would<\/p>\n\n\n\n
contaminate the gloves.<\/p>\n\n\n\n
C. Remove the tape by pulling away from the wound<\/p>\n\n\n\n
-incorrect: The nurse should pull the tape toward the wound to avoid straining the wound and its<\/p>\n\n\n\n
sutures, which could lead to dehiscence.<\/p>\n\n\n\n
D. Clean the drain site from the center outward<\/p>\n\n\n\n
-The nurse should clean the drain site from the center outward to avoid introducing<\/p>\n\n\n\n
microorganisms from the periphery of the wound into the center of the wound.<\/p>\n\n\n\n
94. A nurse is planning care for a group of clients receiving oxygen therapy.Which of the<\/p>\n\n\n\n
following clients should the nurse plan to see first?<\/p>\n\n\n\n
A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask<\/p>\n\n\n\n
-The nurse should apply the safety and risk-reduction priority-setting framework, which assigns<\/p>\n\n\n\n
priority to the factor or situation posing the greatest safety risk to the client. When there are<\/p>\n\n\n\n
several risks to client safety, the one posing the greatest threat is the highest priority. The nurse<\/p>\n\n\n\n
should use Maslow\u2019s hierarchy of needs, the ABC priority-setting framework, and\/or nursing<\/p>\n\n\n\n
knowledge to identify which risk poses the greatest threat to the client.<\/p>\n\n\n\n
-The nurse should frequently check the bag on a rebreather mask to ensure it inflates properly. If<\/p>\n\n\n\n
the bag is deflated, the client will rebreathe exhaled carbon dioxide instead of receiving the<\/p>\n\n\n\n
prescribed oxygen dose. Therefore, the nurse should first see the client who that can cause<\/p>\n\n\n\n
toxicity and is highly combustible, and higher concentrations of oxygen increase the risk of<\/p>\n\n\n\n
client injury.<\/p>\n\n\n\n
B. A client who has emphysema and is receiving oxygen at 3L\/min via transtracheal oxygen<\/p>\n\n\n\n
cannula<\/p>\n\n\n\n
-incorrect: Routine treatment for chronic lung conditions can include the use of a transtracheal<\/p>\n\n\n\n
oxygen cannula; therefore, there is another client the nurse should plan to see first. The client<\/p>\n\n\n\n
will learn to use the device alone, and the system can provide adequate oxygenation with a low<\/p>\n\n\n\n
flow rate of oxygen. Three liters per minute of oxygen is the equivalent of 32% oxygen delivery.<\/p>\n\n\n\n
C. A client who has an old tracheostomy and is receiving 40% humidified oxygen via<\/p>\n\n\n\n
tracheostomy collar<\/p>\n\n\n\n
-incorrect: Routine treatment for a client who has an old tracheostomy includes the<\/p>\n\n\n\n
administration of humidified oxygen or air via tracheostomy collar. Therefore, there is another<\/p>\n\n\n\n
client the nurse should plan to see first. The nurse should sue the humidification to promote<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg24.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
loosening of respiratory secretions and prevent cannula obstruction. Forty percent oxygen is the<\/p>\n\n\n\n
equivalent of administering oxygen at 6L\/min.<\/p>\n\n\n\n
D. A client who has COPD and is receiving oxygen at 2L\/min via nasal cannula<\/p>\n\n\n\n
-incorrect: Routine treatment for a client who has COPD involves the administration of low-dose<\/p>\n\n\n\n
therapy. Therefore, there is another client the nurse should plan to see first. Clients who have<\/p>\n\n\n\n
COPD depend on low oxygen level to drive their respiratory rate. Two liters per minute of<\/p>\n\n\n\n
oxygen is the equivalent of 28% oxygen delivery.<\/p>\n\n\n\n
95. A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her neck<\/p>\n\n\n\n
with both hands and appears frightened. Which of the following actions should the nurse take<\/p>\n\n\n\n
first?<\/p>\n\n\n\n
A. Place an oxygen mask on the client<\/p>\n\n\n\n
B. Check the client\u2019s pulses<\/p>\n\n\n\n
C. Determine whether the client is able to breathe<\/p>\n\n\n\n
-Caring for this client requires the application of the nursing process priority-setting framework.<\/p>\n\n\n\n
The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step<\/p>\n\n\n\n
of the nursing process builds on the previous step, beginning with an assessment or data<\/p>\n\n\n\n
collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or<\/p>\n\n\n\n
notify a provider of a change in the client\u2019s status, the nurse must first collect adequate data from<\/p>\n\n\n\n
the client. Assessing or collecting additional data will provide the nurse with the knowledge<\/p>\n\n\n\n
needed to make an appropriate decision.<\/p>\n\n\n\n
-This client is demonstrating a universal choking gesture. If the client is unable to move air in or<\/p>\n\n\n\n
out, severe airway obstruction is present. The client would need emergency interventions to clear<\/p>\n\n\n\n
a partial obstruction, as indicated by stridor or minimal airway passage. As long as there is good<\/p>\n\n\n\n
air exchange and the client can cough and breathe spontaneously, the nurse should stay with the<\/p>\n\n\n\n
client and monitor her condition.<\/p>\n\n\n\n
D. Wrap arms around the client from behind<\/p>\n\n\n\n
-incorrect: The nurse should wrap arms around the client from behind to perform an abdominal<\/p>\n\n\n\n
thrust if breathing is obstructed. However, there is another action the nurse should take first.<\/p>\n\n\n\n
96. A nurse is caring for an older adult client who has dysphagia following a cerebrovascular<\/p>\n\n\n\n
accident. Which of the following actions should the nurse take when assisting the client at<\/p>\n\n\n\n
mealtime?<\/p>\n\n\n\n
A. Encourage the client to drink fluids before swallowing food<\/p>\n\n\n\n
-incorrect: A client who has impaired pharyngeal swallowing is at risk of choking when liquids<\/p>\n\n\n\n
(especially thin fluids) are offered while eating solid foods. It is preferable to suggest \u201cdry<\/p>\n\n\n\n
swallows\u201d to clear the mouth between bites of food.<\/p>\n\n\n\n
B. Offer the client tart or sour foods first<\/p>\n\n\n\n
-A client who has impaired pharyngeal swallowing should consume tart and sour foods at the<\/p>\n\n\n\n
beginning of the meal to stimulate saliva production, which aids to chewing and swallowing.<\/p>\n\n\n\n
C. Tilt the client\u2019s head backward when swallowing<\/p>\n\n\n\n
-incorrect: A client who has impaired pharyngeal swallowing should tilt the head forward to<\/p>\n\n\n\n
promote swallowing.<\/p>\n\n\n\n
D. Turn on the television<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg25.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: A client who has impaired pharyngeal swallowing should minimize distractions at<\/p>\n\n\n\n
mealtimes to concentrate on chewing thoroughly and swallowing.<\/p>\n\n\n\n
97. A nurse is caring for a client who reports feeling a pop after coughing without properly<\/p>\n\n\n\n
splinting an abdominal incision. On assessment, the nurse notes that the client\u2019s wound has<\/p>\n\n\n\n
eviscerated. Which of the following actions should the nurse take? (SATA)<\/p>\n\n\n\n
A. Carefully reinsert the intestine through the opening in the wound<\/p>\n\n\n\n
-incorrect: The nurse should not attempt to reinsert the intestine into the client\u2019s abdominal<\/p>\n\n\n\n
cavity because this action can cause perforation of the intestine. The nurse should plan to transfer<\/p>\n\n\n\n
the client to surgery, where the surgeon will reinsert the intestine under sterile technique.<\/p>\n\n\n\n
B. Place the client in a supine position with the hips and knees flexed<\/p>\n\n\n\n
C. Leave the room to call the surgeon<\/p>\n\n\n\n
-incorrect: The nurse should delegate another person to notify the surgeon immediately.The<\/p>\n\n\n\n
nurse should stay with the client and observe for further complications such as shock.<\/p>\n\n\n\n
D. Cover the wound and intestine with a sterile, moistened dressing<\/p>\n\n\n\n
E. Monitor the client for manifestations of shock<\/p>\n\n\n\n
-The nurse should place the client in a supine position with the hips and knees flexed. This<\/p>\n\n\n\n
position can help to prevent further tearing of the incision and wound evisceration by lessening<\/p>\n\n\n\n
tension on the wound. The nurse should cover the protruding intestine with sterile dressing that is<\/p>\n\n\n\n
moistened with 0.9% sodium chloride to prevent further contamination of the wound and to keep<\/p>\n\n\n\n
the protruding intestine from drying out.<\/p>\n\n\n\n
-The nurse should monitor the client for a physiological stimulus (ex: bleeding from the tearing<\/p>\n\n\n\n
or opening of the wound) or a psychological stimulus (ex: viewing the intestine protruding<\/p>\n\n\n\n
outside the body), which can increase the risk of shock. The nurse should monitor the client for<\/p>\n\n\n\n
increased heart rate and respiratory rate, changes in blood pressure or mentation and cool or<\/p>\n\n\n\n
clammy skin.<\/p>\n\n\n\n
98. A nurse documents the presence of clubbing of the fingernails for a client who has<\/p>\n\n\n\n
emphysema. Which of the following is the underlying cause of this finding?<\/p>\n\n\n\n
A. Trauma<\/p>\n\n\n\n
-incorrect: Trauma does not cause clubbing of the fingernails. Trauma can cause Beau\u2019s lines,<\/p>\n\n\n\n
which are another type of nail alteration that involves transverse depressions in the nail. Trauma<\/p>\n\n\n\n
can also cause paronychia, an inflammation of the skin at the base of the nail.<\/p>\n\n\n\n
B. Severe infection<\/p>\n\n\n\n
-incorrect: Severe infection does not cause clubbing of the fingernails but can cause Beau\u2019s lines.<\/p>\n\n\n\n
C. Iron-deficiency anemia<\/p>\n\n\n\n
-incorrect: Iron-deficiency anemia does not cause clubbing of the fingernails. Iron-deficiency<\/p>\n\n\n\n
anemia can cause koilonychia (spoon nail), which is another type of nail alteration that involves<\/p>\n\n\n\n
concave curves in the nail.<\/p>\n\n\n\n
D. Chronic hypoxemia<\/p>\n\n\n\n
-Clubbing of the nails of the fingers and toes is the result of chronic hypoxemia (low oxygen<\/p>\n\n\n\n
supply) such as COPD. It is a change in the angle between the nail and the nail base often with<\/p>\n\n\n\n
enlargement of the fingertips.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg26.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
99. A nurse delegates the collection of a client\u2019s temperature to an AP. The nurse notes in the<\/p>\n\n\n\n
documentation that the AP obtained the client\u2019s axillary temperature; however, the nurse wanted<\/p>\n\n\n\n
an oral temperature. The nurse should identify that which of the following rights of delegation<\/p>\n\n\n\n
should have prevented this situation from occurring?<\/p>\n\n\n\n
A. Right task<\/p>\n\n\n\n
-incorrect: The nurse delegated the right task. The nurse can delegate a task to an AP that is<\/p>\n\n\n\n
repetitive, requires minimal supervision, is relatively noninvasive, has predictable results and has<\/p>\n\n\n\n
minimal potential for risk. Obtaining a client\u2019s temperature is within the range of function for an<\/p>\n\n\n\n
AP.<\/p>\n\n\n\n
B. Right circumstance<\/p>\n\n\n\n
-incorrect: The nurse correctly delegated the task in the right circumstance. This entails<\/p>\n\n\n\n
consideration of the appropriate client setting, the available resources, and other factors relevant<\/p>\n\n\n\n
to the situation.<\/p>\n\n\n\n
C. Right person<\/p>\n\n\n\n
-incorrect: The nurse delegated the taking of a client\u2019s temperature to the right person. This<\/p>\n\n\n\n
entails delegating the right task to the right person to be performed on the right person. Obtaining<\/p>\n\n\n\n
a client\u2019s temperature is within the range of function for an AP and the client\u2019s temperature was<\/p>\n\n\n\n
recorded as collected.<\/p>\n\n\n\n
D. Right communication<\/p>\n\n\n\n
-The situation could have been avoided if the right communication was given by the nurse to the<\/p>\n\n\n\n
AP. The right communication entails providing clear, concise instructions regarding the task,<\/p>\n\n\n\n
including the objectives, limits, and expectations.<\/p>\n\n\n\n
100. A nurse in a long-term care facility is in the dining room while residents are eating lunch.<\/p>\n\n\n\n
One resident begins to choke and is coughing strongly. Which of the following actions should<\/p>\n\n\n\n
the nurse take?<\/p>\n\n\n\n
A. Assist the client to the floor<\/p>\n\n\n\n
-incorrect: The nurse should assist the client to the floor if the client is losing consciousness and<\/p>\n\n\n\n
might fall to the floor.<\/p>\n\n\n\n
B. Perform an abdominal pain<\/p>\n\n\n\n
-incorrect: The nurse should perform an abdominal thrust if the client is choking and unable to<\/p>\n\n\n\n
speak or cough strongly.<\/p>\n\n\n\n
C. Open the airway with a head-chin tilt<\/p>\n\n\n\n
-incorrect: The nurse should open the airway with a head-chin tilt to look for a foreign object that<\/p>\n\n\n\n
may be impeding breathing if the client is choking and unable to speak or cough strongly.<\/p>\n\n\n\n
D. Observe the client closely<\/p>\n\n\n\n
-The nurse should observe the client closely at this point in time. As long as the client is able to<\/p>\n\n\n\n
cough strongly, the nurse does not need to intervene.<\/p>\n\n\n\n
101. A nurse in an urgent-care center is caring for a 15-year-old client whose symptoms suggest<\/p>\n\n\n\n
a sexually transmitted infection (STI). The client\u2019s parent is unavailable, but the client\u2019s<\/p>\n\n\n\n
grandmother accompanied the client to the clinic. Which of the following actions should the<\/p>\n\n\n\n
nurse take?<\/p>\n\n\n\n
A. Explain that the treatment can wait until the parent is available.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg27.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: Ideally, a parent or legal guardian should give informed consent for an unemancipated<\/p>\n\n\n\n
minor to undergo invasive diagnostic and therapeutic procedures. However, in the case of an<\/p>\n\n\n\n
infection that could be worsening, a delay is not advisable.<\/p>\n\n\n\n
B. Inform the grandmother that she may give consent for the treatment<\/p>\n\n\n\n
-incorrect: A parent or legal guardian must give consent for an unemancipated minor. Unless the<\/p>\n\n\n\n
grandmother is the child\u2019s legal guardian, the nurse should not tell the grandmother she may give<\/p>\n\n\n\n
consent.<\/p>\n\n\n\n
C. Invoke the principle of implied consent and prepare the client for treatment<\/p>\n\n\n\n
-incorrect: Implied consent is pertinent in an emergency situation when an adult client is unable<\/p>\n\n\n\n
to sign (ex: due to unconsciousness) and no one is available to give informed consent. This<\/p>\n\n\n\n
circumstance does not apply to this situation.<\/p>\n\n\n\n
D. Ask the adolescent to sign the consent form<\/p>\n\n\n\n
-Unemancipated minors (ex: those who do not live on their own, are not married, and are not in<\/p>\n\n\n\n
the military) can legally give informed consent for diagnostic procedures and treatment in some<\/p>\n\n\n\n
situations. These situations include treatment for STIs and substance use disorders.<\/p>\n\n\n\n
102. A nurse on a medical-surgical unit is admitting a client. Which of the following pieces of<\/p>\n\n\n\n
information should the nurse document in the client\u2019s record first?<\/p>\n\n\n\n
A. Assessment<\/p>\n\n\n\n
-When caring for a client, the nurse should apply the nursing process priority-setting framework.<\/p>\n\n\n\n
The nursing process is used to plan client care and prioritize nursing actions. Each step of the<\/p>\n\n\n\n
nursing process builds on the previous step, beginning with an assessment or data collection.<\/p>\n\n\n\n
Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a<\/p>\n\n\n\n
provider of a change in the client\u2019s status, he or she must first collect adequate data from the<\/p>\n\n\n\n
client. Assessing or collecting additional data will provide the nurse with the knowledge to make<\/p>\n\n\n\n
am appropriate decision.<\/p>\n\n\n\n
B. Plan of Care<\/p>\n\n\n\n
-incorrect: The nurse should document the plan of care for the client. However, there is another<\/p>\n\n\n\n
action the nurse should document first.<\/p>\n\n\n\n
C. Nursing interventions performed<\/p>\n\n\n\n
-incorrect: The nurse should document interventions performed for the client. However, there is<\/p>\n\n\n\n
another action the nurse should document first.<\/p>\n\n\n\n
D. Evaluation of progress<\/p>\n\n\n\n
-incorrect: The nurse should document the evaluation of the client\u2019s progress. However, there is<\/p>\n\n\n\n
another action the nurse should document first.<\/p>\n\n\n\n
103. A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly<\/p>\n\n\n\n
licensed nurses. Which of the following actions should the charge nurse teach as the first<\/p>\n\n\n\n
response in CPR?<\/p>\n\n\n\n
A. Call for assistance<\/p>\n\n\n\n
-incorrect: The nurse should call for assistance by activating the emergency response team.<\/p>\n\n\n\n
However, there is another action the nurse should take first.<\/p>\n\n\n\n
B. Begin chest compressions<\/p>\n\n\n\n
-incorrect: The nurse should begin chest compressions. However, there is another action the<\/p>\n\n\n\n
nurse should take first.<\/p>\n\n\n\n
C. Confirm unresponsiveness<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg28.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-The nurse should apply the nursing process priority-setting framework to plan client care and<\/p>\n\n\n\n
prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning<\/p>\n\n\n\n
with an assessment or data collection. Before the nurse can formulate a plan of action, implement<\/p>\n\n\n\n
a nursing intervention, or notify a provider of a change in the client\u2019s status, he or she must first<\/p>\n\n\n\n
collect adequate data from the client to obtain the knowledge needed to make an appropriate<\/p>\n\n\n\n
decision. Establishing unresponsiveness is required before beginning CPR. If a client is<\/p>\n\n\n\n
unresponsive, the nurse should activate the emergency response team.<\/p>\n\n\n\n
D. Give rescue breaths<\/p>\n\n\n\n
-incorrect: The nurse should give rescue breaths. However, there is another action the nurse<\/p>\n\n\n\n
should take first.<\/p>\n\n\n\n
104. A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse<\/p>\n\n\n\n
should ensure that a written consent form has been signed by which of the following clients?<\/p>\n\n\n\n
A. A client who has a prescription for a transfusion of packed RBCs<\/p>\n\n\n\n
-Administration of blood is a procedure that carries risk; therefore, the client must sign a consent<\/p>\n\n\n\n
form prior to the procedure.<\/p>\n\n\n\n
B. A client who is being transported for a radiograph of the kidneys, ureters, and bladder<\/p>\n\n\n\n
-incorrect: Clients admitted to a hospital sign a general consent form when admitted. This form<\/p>\n\n\n\n
gives consent for this diagnostic examination.<\/p>\n\n\n\n
C. A client who has a prescription for a tuberculin skin test<\/p>\n\n\n\n
-incorrect: Implied consent is given when the client cooperates through actions, such as holding<\/p>\n\n\n\n
out an arm to allow the nurse to perform the procedure.<\/p>\n\n\n\n
D. A client who has a distended bladder and needs urinary catheterization<\/p>\n\n\n\n
-incorrect: Implied consent is given when the client cooperates through actions, such as<\/p>\n\n\n\n
positioning himself\/herself to allow the nurse to perform the procedure.<\/p>\n\n\n\n
105. A nurse is providing teaching to a client about a surgical procedure that she is scheduled for<\/p>\n\n\n\n
later in the day. The client states that no one has spoken to her about the procedure before.<\/p>\n\n\n\n
Which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Continue the teaching, but check afterward with the surgeon about informed consent<\/p>\n\n\n\n
-incorrect: The client\u2019s statement indicates that she has not given informed consent; therefore,<\/p>\n\n\n\n
the nurse should interrupt the teaching.<\/p>\n\n\n\n
B. Stop the teaching and check with the surgeon about informed consent<\/p>\n\n\n\n
-The client\u2019s statement indicates that she has not given informed consent; therefore, the nurse<\/p>\n\n\n\n
should interrupt the teaching and notify the surgeon.<\/p>\n\n\n\n
C. Stop the teaching and ask the client to sign an informed consent form<\/p>\n\n\n\n
-It is not within the nurse\u2019s scope of practice to obtain informed consent from the client.<\/p>\n\n\n\n
D. Continue the teaching and check the client\u2019s medical record afterward for a signed consent<\/p>\n\n\n\n
form<\/p>\n\n\n\n
-The client\u2019s statement indicates that she has not given informed consent; therefore, the nurse<\/p>\n\n\n\n
should interrupt the teaching.<\/p>\n\n\n\n
106. A home health nurse is visiting an older adult client with severe dementia. The client\u2019s son,<\/p>\n\n\n\n
who serves as her primary caregiver, reports being \u201cexhausted\u201d from working part-time and<\/p>\n\n\n\n
caring for his mother at home. Which of the following options should the nurse suggest to the<\/p>\n\n\n\n
caregiver?<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg29.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
A. Rehabilitation<\/p>\n\n\n\n
-incorrect: Rehabilitation programs help clients return to optimal functioning after an illness or<\/p>\n\n\n\n
injury. However, severe dementia will not improve with rehabilitative services.<\/p>\n\n\n\n
B. Assisted living facility<\/p>\n\n\n\n
-incorrect: An assisted living facility provides independence for clients who need only limited<\/p>\n\n\n\n
personal care. A client who has severe dementia needs total care.<\/p>\n\n\n\n
C. Respite care<\/p>\n\n\n\n
-Respite care is a service for caregivers who need time to rest from multiple responsibilities<\/p>\n\n\n\n
related to the care of a family member who needs assistance.<\/p>\n\n\n\n
D. Adult day care facility<\/p>\n\n\n\n
-incorrect: Although adult day care facilities do help family caregivers maintain some aspects of<\/p>\n\n\n\n
their lifestyle and independence, these facilitates provide care and supervision for clients who<\/p>\n\n\n\n
need minimal assistance (ex: taking medication, receiving physical therapy, or receiving<\/p>\n\n\n\n
counseling). They do not provide care for clients who have severe dementia.<\/p>\n\n\n\n
107. A nurse is collecting health history data from a client who is deaf and uses American Sign<\/p>\n\n\n\n
Language (ASL) to communicate. The nurse will be working with an ASL interpreter.Which of<\/p>\n\n\n\n
the following actions should the nurse take when working with the interpreter?<\/p>\n\n\n\n
A. Face away from the client to avoid distraction<\/p>\n\n\n\n
-incorrect: The nurse should face the client while speaking to offer the client the opportunity to<\/p>\n\n\n\n
observe facial expressions and gestures.<\/p>\n\n\n\n
B. Pace speech to allow time for the interpreter to convey the words<\/p>\n\n\n\n
-The nurse should speak clearly and allow time for the interpreter to convey the message and for<\/p>\n\n\n\n
the client to receive it.<\/p>\n\n\n\n
C. Make eye contact with the interpreter when explaining the procedure<\/p>\n\n\n\n
-incorrect: To enhance the nurse-client relationship, the nurse should direct questions,<\/p>\n\n\n\n
instructions, and information to the client, not to the interpreter. The client\u2019s focus will be on the<\/p>\n\n\n\n
interpreter, but it is respectful to continue to address the client and not the interpreter.<\/p>\n\n\n\n
D. Stand in the background while the interpreter translates the message<\/p>\n\n\n\n
-incorrect: The nurse should sit at the same level as the client to give the client the opportunity to<\/p>\n\n\n\n
observe facial expressions and gestures.<\/p>\n\n\n\n
108. A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal<\/p>\n\n\n\n
pharyngitis and is on transmission-based precautions. Which of the following actions by the<\/p>\n\n\n\n
newly licensed nurse indicates an understanding of droplet precautions?<\/p>\n\n\n\n
A. Shaking soiled linen before putting it in a hamper<\/p>\n\n\n\n
-incorrect: The nurse should not shake soiled linen because this action can transfer<\/p>\n\n\n\n
microorganisms.<\/p>\n\n\n\n
B. Removing a face mask when standing 0.5 m (1.6 ft) from the client<\/p>\n\n\n\n
-incorrect: The nurse should wear a mask when working within 1m (3.3 ft) of a client who is on<\/p>\n\n\n\n
droplet precautions to reduce the risk of transferring the particle droplets.<\/p>\n\n\n\n
C. Assigning another client with the same infection to share the room with the client<\/p>\n\n\n\n
-The nurse can place clients who are infected with the same pathogen in the same room if a<\/p>\n\n\n\n
private room is not available.<\/p>\n\n\n\n
D. Allowing the client to visit a family member in the lobby of the facility<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg2a.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The nurse should strictly limit the client\u2019s activity outside the room to reduce the risk<\/p>\n\n\n\n
of transferring microorganisms. Whenever the client has to leave the room, the nurse should<\/p>\n\n\n\n
place a mask on the client.<\/p>\n\n\n\n
109. A nurse is receiving a client from the PACU who is postoperative following abdominal<\/p>\n\n\n\n
surgery. Which of the following actions should the nurse perform to transfer the client from the<\/p>\n\n\n\n
stretcher to the bed?<\/p>\n\n\n\n
A. Lock the wheels on the bed and stretcher<\/p>\n\n\n\n
-Locking the wheels prevents the client from falling on the floor by not allowing the cart or bed<\/p>\n\n\n\n
to move apart or away from the client.<\/p>\n\n\n\n
B. Instruct the client to raise his arms above his head<\/p>\n\n\n\n
-incorrect: The nurse should ask the client to cross his arms across his chest to avoid injuring the<\/p>\n\n\n\n
arms during transfer.<\/p>\n\n\n\n
C. Elevate the stretcher 2.5 cm (1in) above the height of the bed<\/p>\n\n\n\n
-incorrect: The stretcher should be no more than 1.3 cm (0.5in) above the height of the bed.<\/p>\n\n\n\n
D. Log-roll the client<\/p>\n\n\n\n
-incorrect: Log-rolling is a technique used to prevent injury when moving a client who requires<\/p>\n\n\n\n
immobilization of the neck, back, or spine. It is not indicated for a client following abdominal<\/p>\n\n\n\n
surgery.<\/p>\n\n\n\n
110. A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client<\/p>\n\n\n\n
transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse that the<\/p>\n\n\n\n
AP understands how to perform this task?<\/p>\n\n\n\n
A. Locking the brakes on the bed and the wheelchair before moving the client<\/p>\n\n\n\n
-Prior to starting the transfer, the AP should make sure that both the wheelchair and the bed are<\/p>\n\n\n\n
stationary and will not shift when the client moves into the chair.<\/p>\n\n\n\n
B. Lowering the footplates of the wheelchair before the transfer<\/p>\n\n\n\n
-incorrect: The AP should lower the footplates after the transfer and lift the client\u2019s feet onto<\/p>\n\n\n\n
them.<\/p>\n\n\n\n
C. Placing the wheelchair perpendicular to the bed<\/p>\n\n\n\n
-incorrect: The AP should place the wheelchair parallel to the bed.<\/p>\n\n\n\n
D. Placing the wheelchair on the client\u2019s weaker side prior to the transfer<\/p>\n\n\n\n
-incorrect: The AP should place the wheelchair on the client\u2019s stronger side prior to the transfer<\/p>\n\n\n\n
to allow the client to move toward the stronger side.<\/p>\n\n\n\n
111. A nurse is beginning her shift and reviewing the medication administration records (MARs)<\/p>\n\n\n\n
for her clients. She notes a dosage of medication above the safe range and sees that a nurse<\/p>\n\n\n\n
administered that dosage during the previous shift. Which of the following actions should the<\/p>\n\n\n\n
nurse take?<\/p>\n\n\n\n
A. Call the nurse to verify that the client received that dosage<\/p>\n\n\n\n
-incorrect: The MAR indicates what dosage the nurse administered.<\/p>\n\n\n\n
B. Give the medication in a safe dosage<\/p>\n\n\n\n
-incorrect: It is not within the nurse\u2019s scope of practice to change the medication dosage.<\/p>\n\n\n\n
C. Give the dose the provider prescribed<\/p>\n\n\n\n
-incorrect: The nurse has identified a potential problem with the prescribed dosage; therefore, the<\/p>\n\n\n\n
nurse should not give that dosage.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg2b.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
D. Call the provider to clarify the dosage<\/p>\n\n\n\n
– After assessing the client for adverse effects of the medication, the nurse should notify the<\/p>\n\n\n\n
provider about her observations to determine the next step.<\/p>\n\n\n\n
112. A nurse is assessing a client who is undergoing a physical examination. Following the<\/p>\n\n\n\n
inspection, which of the following techniques should the nurse use next when assessing the<\/p>\n\n\n\n
client\u2019s abdomen?<\/p>\n\n\n\n
A. Auscultation<\/p>\n\n\n\n
-According to evidence-based practice, the nurse should listen for bowel sounds in all 4<\/p>\n\n\n\n
quadrants before palpating the client\u2019s abdomen. Palpation and percussion can stimulate the<\/p>\n\n\n\n
bowel and increase the frequency of bowel sounds, leading to false results.<\/p>\n\n\n\n
B. Light Palpation<\/p>\n\n\n\n
-incorrect: The nurse should palpate the client\u2019s abdomen to identify any areas of tenderness.<\/p>\n\n\n\n
However, evidence-based practice indicates that the nurse should use a different technique<\/p>\n\n\n\n
before palpation.<\/p>\n\n\n\n
C. Percussion<\/p>\n\n\n\n
-incorrect: The nurse should percuss the abdomen to identify tympany or dullness. However,<\/p>\n\n\n\n
evidence-based practice indicates that the nurse should use a different technique before<\/p>\n\n\n\n
percussion.<\/p>\n\n\n\n
D. Deep palpation<\/p>\n\n\n\n
-incorrect: The nurse should palpate the abdomen to identify any areas of tenderness, but deep<\/p>\n\n\n\n
palpitation generally requires an experienced technician. However, evidence-based practice<\/p>\n\n\n\n
indicates that the nurse should use a different technique before palpation.<\/p>\n\n\n\n
113. During a physical examination of a client, the nurse suspects strabismus. Which of the<\/p>\n\n\n\n
following tests should the nurse use to collect additional data?<\/p>\n\n\n\n
A. Confrontation test<\/p>\n\n\n\n
-incorrect: A confrontation test compares the visual fields of the client with that of the examiner.<\/p>\n\n\n\n
B. Symmetry of palpebral fissures<\/p>\n\n\n\n
-incorrect: The palpebral fissure is the space between the eyelids, which is unequal in clients who<\/p>\n\n\n\n
have ptosis (ex: drooping of one or both of the eyelids)<\/p>\n\n\n\n
C. Corneal light reflex<\/p>\n\n\n\n
-The corneal light reflex requires the nurse to shine a penlight at the client\u2019s eyes and visualize<\/p>\n\n\n\n
whether the light shines on the same spot bilaterally.This test will indicate the alignment of the<\/p>\n\n\n\n
client\u2019s eyes as well as any deviation inward or outward. With strabismus, the eyes will not align<\/p>\n\n\n\n
when the client focuses.<\/p>\n\n\n\n
D. Accommodation test<\/p>\n\n\n\n
-incorrect: The test for accommodation determines whether the client\u2019s pupils constrict as they<\/p>\n\n\n\n
focus on an object the examiner brings closer to the eyes.<\/p>\n\n\n\n
114. A nurse is performing a comprehensive physical assessment of a client. The nurse should<\/p>\n\n\n\n
use inspection to assess which of the following?<\/p>\n\n\n\n
A. Liver size<\/p>\n\n\n\n
-incorrect: Evaluating liver size requires palpation<\/p>\n\n\n\n
B. Pedal edema<\/p>\n\n\n\n
-incorrect: Evaluating pedal edema requires palpation<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg2c.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
C. Skin texture<\/p>\n\n\n\n
-incorrect: Evaluating skin texture requires palpation<\/p>\n\n\n\n
D. Gait<\/p>\n\n\n\n
-Inspection is the technique of looking or observing. Gait inspection involves watching the<\/p>\n\n\n\n
client\u2019s walking movements and observing any unusual findings.<\/p>\n\n\n\n
115. A nurse is teaching a client about lifestyle changes to manage a chronic illness. Which of<\/p>\n\n\n\n
the following strategies should the nurse use first to help the client make a commitment to these<\/p>\n\n\n\n
lifestyle changes?<\/p>\n\n\n\n
A. Identify the risks of nonadherence<\/p>\n\n\n\n
-incorrect: It is important for the client to understand all aspects of the illness as well as the<\/p>\n\n\n\n
consequences of nonadherence to recommend lifestyle changes. However, when the nurse is<\/p>\n\n\n\n
trying to motivate the client to make lifestyle changes, the client might perceive warnings about<\/p>\n\n\n\n
the dangers of nonadherence as a threat. Instead, the nurse should present this information after<\/p>\n\n\n\n
the client commits to making the recommended changes.<\/p>\n\n\n\n
B. Schedule learning sessions to demonstrate the psychomotor skills the client will need<\/p>\n\n\n\n
-incorrect: Scheduling meetings about psychomotor skills is important for showing the client<\/p>\n\n\n\n
how to practice self-care. However, this is unlikely to encourage the client to make an initial<\/p>\n\n\n\n
commitment. This strategy will likely strengthen the client\u2019s adherence to the recommended life<\/p>\n\n\n\n
changes after the client has made an initial commitment to them.<\/p>\n\n\n\n
C. Provide clearly written and easy-to-understand materials<\/p>\n\n\n\n
-incorrect: It is important for the client to understand all aspects of the illness, and clearly written<\/p>\n\n\n\n
and easy-to-understand instructional materials can be helpful. However, the nurse should present<\/p>\n\n\n\n
this information after the client is committed to change.<\/p>\n\n\n\n
D. Help the client identify ways that these changes will result in positive personal outcomes<\/p>\n\n\n\n
-According to evidence-based practice, the motivation to change must precede taking steps to<\/p>\n\n\n\n
make the change. Therefore, helping clients identify ways that\u2019s the changes will promote<\/p>\n\n\n\n
positive outcomes should precede other educational strategies for making the changes. The client<\/p>\n\n\n\n
should first see how the changes directly affect his\/her life, thus enhancing the motivation to<\/p>\n\n\n\n
make the changes.<\/p>\n\n\n\n
116. A community health nurse is preparing a campaign about seasonal influenza. Which of the<\/p>\n\n\n\n
following plans should the nurse include as a form of secondary prevention?<\/p>\n\n\n\n
A. Holding a community clinic to administer influenza immunizations<\/p>\n\n\n\n
-incorrect: Administering influenza immunizations is an example of primary prevention for<\/p>\n\n\n\n
people who are healthy but in danger of becoming ill.<\/p>\n\n\n\n
B. Screening groups of older adults in nursing care facilities for early influenza<\/p>\n\n\n\n
manifestations<\/p>\n\n\n\n
-Screening older adults who have some manifestations of illness to determine if they have<\/p>\n\n\n\n
influenza is an example of secondary prevention. Secondary prevention is focused on preventing<\/p>\n\n\n\n
complications of an illness or providing care to prevent an illness from becoming severe.<\/p>\n\n\n\n
C. Educating parents of young children about the dangers of influenza<\/p>\n\n\n\n
-incorrect: Educating clients about the dangers of influenza is an example of primary prevention<\/p>\n\n\n\n
for people who are healthy but in danger of becoming ill.<\/p>\n\n\n\n
D. Finding rehabilitation programs for older adults who have complications related to influenza<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg2d.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: This is an example of tertiary prevention, which seeks to prevent complications and<\/p>\n\n\n\n
help people recover from an existing illness.<\/p>\n\n\n\n
117. A nurse is obtaining the blood pressure in a client\u2019s lower extremity. Which of the<\/p>\n\n\n\n
following actions should the nurse take?<\/p>\n\n\n\n
A. Auscultate the blood pressure at the dorsalis pedis artery<\/p>\n\n\n\n
-incorrect: The nurse should auscultate the blood pressure at the popliteal artery.<\/p>\n\n\n\n
B. Measure the blood pressure with the client sitting on the side of the bed<\/p>\n\n\n\n
-incorrect: The nurse should measure the blood pressure with the client prone if possible.<\/p>\n\n\n\n
Otherwise, the client should lie supine with the knee flexed.<\/p>\n\n\n\n
C. Place the cuff 7.6 cm (3in) above the popliteal artery<\/p>\n\n\n\n
-incorrect: The nurse should position the cuff 2.5 cm (1 in) above the popliteal artery.<\/p>\n\n\n\n
D. Place the bladder of the cuff over the posterior aspect of the thigh<\/p>\n\n\n\n
-This is the correct position for the bladder of the cuff when the nurse is measuring a lower-<\/p>\n\n\n\n
extremity blood pressure.<\/p>\n\n\n\n
118. A nurse is performing a spiritual assessment of a client. Which of the following questions<\/p>\n\n\n\n
should the nurse ask?<\/p>\n\n\n\n
A. \u201cWhen did you start to believe in your faith?\u201d<\/p>\n\n\n\n
-incorrect: This is a nontherapeutic response that assumes the client has a religion-based belief<\/p>\n\n\n\n
system. Spirituality can include religious beliefs but does not depend on their existence.<\/p>\n\n\n\n
B. \u201cHow often do you perform religious rituals?\u201d<\/p>\n\n\n\n
-incorrect: This is a nontherapeutic response that assumes the client has a religion-based belief<\/p>\n\n\n\n
system. Spirituality can include religious beliefs but does not depend on their existence.<\/p>\n\n\n\n
C. \u201cWhich church do you regularly attend?\u201d<\/p>\n\n\n\n
-incorrect: This is a nontherapeutic response that assumes the client has a religion-based belief<\/p>\n\n\n\n
system. Spirituality encompasses many aspects of the client\u2019s ideas about life and can include<\/p>\n\n\n\n
religious beliefs but does not depend on their existence.<\/p>\n\n\n\n
D. \u201cWhat is your source of strength and hope?\u201d<\/p>\n\n\n\n
-This is a broad, open-ended question that encourages the client to express feelings without any<\/p>\n\n\n\n
assumptions on the nurse\u2019s part. It correctly focuses on a global view of spirituality as a complex<\/p>\n\n\n\n
concept that encompasses the client\u2019s life experiences and beliefs about strength, love, and hope.<\/p>\n\n\n\n
119. A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a<\/p>\n\n\n\n
client who no longer requires care. Which of the following concepts should the nurse and client<\/p>\n\n\n\n
discuss in the termination phase of the relationship?<\/p>\n\n\n\n
A. Loss<\/p>\n\n\n\n
-At the close of a relationship, even when planned, loss is an expected feeling for both the client<\/p>\n\n\n\n
and the nurse. It is important for both the nurse and the client to terminate the relationship<\/p>\n\n\n\n
without feelings of guilt or anxiety.<\/p>\n\n\n\n
B. Trust<\/p>\n\n\n\n
-incorrect: The nurse should address the concept of trust during the introductory phase of the<\/p>\n\n\n\n
relationship.<\/p>\n\n\n\n
C. Self-disclosure<\/p>\n\n\n\n
-incorrect: The nurse should address the concept of appropriate self-disclosure during the<\/p>\n\n\n\n
working phase of the relationship<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg2e.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
D. Risk-taking<\/p>\n\n\n\n
-incorrect: The nurse should address the concept of risk-taking in the working phase of the<\/p>\n\n\n\n
relationship.<\/p>\n\n\n\n
120. A nurse is caring for a client who is in the terminal stage of cancer. Which of the following<\/p>\n\n\n\n
actions should the nurse take when she observes the client crying?<\/p>\n\n\n\n
A. Contact the family and ask someone to stay with the client<\/p>\n\n\n\n
-incorrect: This action does not respond to the client\u2019s immediate needs and shifts the<\/p>\n\n\n\n
responsibility of helping the client to others.<\/p>\n\n\n\n
B. Offer to call the client\u2019s minister<\/p>\n\n\n\n
-incorrect: This response uses the nontherapeutic communication block of putting the client\u2019s<\/p>\n\n\n\n
needs on hold and shifts that responsibility of helping the client to someone else.<\/p>\n\n\n\n
C. Sit and hold the client\u2019s hand<\/p>\n\n\n\n
-This action uses the therapeutic communication techniques of silence, touch, and offering of self<\/p>\n\n\n\n
to the client.<\/p>\n\n\n\n
D. Leave the room and allow the client to cry privately<\/p>\n\n\n\n
-incorrect: This is not an appropriate nursing action and fails to acknowledge the client\u2019s distress.<\/p>\n\n\n\n
121. A nurse is beginning a therapeutic relationship with a client. Which of the following actions<\/p>\n\n\n\n
should the nurse take to convey empathy when using the therapeutic communication technique<\/p>\n\n\n\n
of active listening?<\/p>\n\n\n\n
A. Assume an open position<\/p>\n\n\n\n
-The nurse should sit with arms and legs uncrossed. Crossing them suggests a defensive posture.<\/p>\n\n\n\n
B. Sit upright and lean back into the chair<\/p>\n\n\n\n
-incorrect: The nurse should lean toward the client to convey interest and involvement in the<\/p>\n\n\n\n
interactions.<\/p>\n\n\n\n
C. Avoid direct eye contact until the client initiates it<\/p>\n\n\n\n
-incorrect: The nurse should establish direct eye contact with the client to convey involvement<\/p>\n\n\n\n
and a willingness to listen.<\/p>\n\n\n\n
D. Sit next to the client<\/p>\n\n\n\n
-incorrect: To convey interest and desire to listen, the nurse should face the client.<\/p>\n\n\n\n
122. A nurse is providing oral care for a client who is unconscious. Which of the following<\/p>\n\n\n\n
actions should the nurse take?<\/p>\n\n\n\n
A. Place the client in lateral position with the head turned to the side before beginning the<\/p>\n\n\n\n
procedure.<\/p>\n\n\n\n
-The nurse should place the client in a lateral position with the head turned to the side to reduce<\/p>\n\n\n\n
the risk of aspiration of fluids and secretions.<\/p>\n\n\n\n
B. Use the thumb and index finger to keep the client\u2019s mouth open.<\/p>\n\n\n\n
-incorrect: The nurse should use a padded tongue blade, not a thumb or an index finger, to keep<\/p>\n\n\n\n
the client\u2019s mouth open. If the client suddenly bites down, the nurse\u2019s fingers could be injured.<\/p>\n\n\n\n
C. Rinse the client\u2019s mouth with an alcohol-based mouthwash following the procedure.<\/p>\n\n\n\n
-incorrect: The nurse should use either water or alcohol-free mouthwash to rinse the client\u2019s<\/p>\n\n\n\n
mouth.<\/p>\n\n\n\n
D. Cleanse the client\u2019s mucous membranes with lemon-glycerin sponges.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg2f.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The nurse should use a foam swab because lemon-glycerin swabs dry and irritate the<\/p>\n\n\n\n
mouth and can damage the teeth.<\/p>\n\n\n\n
123. A hospice nurse is visiting with the family member of a client. The family member states<\/p>\n\n\n\n
that the client has insomnia almost nightly. Which of the following practices should the nurse<\/p>\n\n\n\n
identify as contributing to the client\u2019s insomnia?<\/p>\n\n\n\n
A. The client watches television in her bed during the day.<\/p>\n\n\n\n
-To promote sleep, the client should avoid watching television in bed. She should use the bed<\/p>\n\n\n\n
only for sleep or sexual activities.<\/p>\n\n\n\n
B. The client drinks warm milk before bedtime.<\/p>\n\n\n\n
-incorrect: Warm milk provides L-tryptophan, an amino acid that promotes sleep.<\/p>\n\n\n\n
C. The client goes to bed at 2200 every night.<\/p>\n\n\n\n
-incorrect: General sleep strategies include establishing a regular sleep schedule. A nightly<\/p>\n\n\n\n
bedtime of 2200 could be part of a bedtime routine to promote sleep.<\/p>\n\n\n\n
D. The client gets up to use the bathroom once during the night.<\/p>\n\n\n\n
-incorrect: Although this can cause nighttime disruptions, waking once or twice to use the<\/p>\n\n\n\n
bathroom at night is common. Adults who do not have insomnia issues fall back to sleep readily.<\/p>\n\n\n\n
124. A nurse is preparing to administer a feeding via gastrostomy tube to a client who had a<\/p>\n\n\n\n
stroke. Which of the following actions should the nurse take prior to initiating the feeding?<\/p>\n\n\n\n
A. Warm the feeding in a microwave oven<\/p>\n\n\n\n
-incorrect: Although cold enteral formula could cause cramping, it is not necessary to warm the<\/p>\n\n\n\n
feeding prior to administration. The formula should be at room temperature to improve the<\/p>\n\n\n\n
client\u2019s tolerance of gastrostomy feedings. Also, warming the formula in a microwave oven can<\/p>\n\n\n\n
cause uneven heat distribution and excessive heat; therefore, it\u2019s not a safe way to warm enteral<\/p>\n\n\n\n
feedings.<\/p>\n\n\n\n
B. Elevate the head of the client\u2019s bed<\/p>\n\n\n\n
-Clients who have a brain injury are typically unable to swallow effectively and thus cannot<\/p>\n\n\n\n
protect their airway from aspiration. Even though this route bypasses the nasopharynx, it is still<\/p>\n\n\n\n
possible for the client to cough or vomit enteral formula into the oral cavity. Consequently, the<\/p>\n\n\n\n
nurse should strive to prevent aspiration by elevating the head of the bed prior to initiating the<\/p>\n\n\n\n
feeding.<\/p>\n\n\n\n
C. Flush the tube with 0.9% sodium chloride for irrigation<\/p>\n\n\n\n
-incorrect: The nurse should flush the tube with water prior to initiating the feeding to ensure the<\/p>\n\n\n\n
patency of the tube.<\/p>\n\n\n\n
D. Verify that the client\u2019s gastric pH is above 4<\/p>\n\n\n\n
-incorrect: Due to the acidity of gastric secretions, the pH of gastric contents should be below 4<\/p>\n\n\n\n
to indicate proper placement of the gastrostomy tube. A pH above 4 suggests that the end of the<\/p>\n\n\n\n
tube is not in the stomach.<\/p>\n\n\n\n
125. A nurse is assessing a client\u2019s nutritional status. The nurse determines the client is<\/p>\n\n\n\n
consuming 500 calories more per day than his energy level requires. If his dietary habits do not<\/p>\n\n\n\n
change, how long will it take the client to gain 4.5 kg (10lb)?<\/p>\n\n\n\n
A. 10 months<\/p>\n\n\n\n
B. 5 months<\/p>\n\n\n\n
-incorrect: At the rate of 1 lb per week, the client would gain 20-25 lb in 5 months.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg30.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
C. 5 weeks<\/p>\n\n\n\n
-incorrect: At the rate of 1 lb per week, the client would gain 5 lbs in 5 weeks<\/p>\n\n\n\n
D. 10 weeks<\/p>\n\n\n\n
– Because 1 lb of body fat is equivalent to 3,500 calories, consuming 500 extra calories each day<\/p>\n\n\n\n
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<\/p>\n\n\n\n
week, the client would gain 10 lb in 10 weeks.<\/p>\n\n\n\n
126. A nurse is caring for a client who has a deficiency of vitamin D. Which of the following<\/p>\n\n\n\n
foods should the nurse recommend the client include in his diet?<\/p>\n\n\n\n
A. Whole Milk<\/p>\n\n\n\n
-The fat-soluble vitamins (A,D,E, and K) require fatty substances or tissues to be dissolved and<\/p>\n\n\n\n
also require the presence of bile in the small intestine for absorption. Whole milk contains<\/p>\n\n\n\n
vitamins A and K and is often fortified with vitamin D.<\/p>\n\n\n\n
B. Chicken<\/p>\n\n\n\n
-incorrect: The water-soluble vitamins (B complex and C) readily dissolve in water and are<\/p>\n\n\n\n
absorbed into the bloodstream from the small intestine. Chicken contains many of the B complex<\/p>\n\n\n\n
vitamins, including B2, B3, B6, B12 and pantothenic acid.<\/p>\n\n\n\n
C. Oranges<\/p>\n\n\n\n
-incorrect: The water-soluble vitamins (B complex and C) readily dissolve in water and are<\/p>\n\n\n\n
absorbed into the bloodstream from the small intestine. Oranges are a good source of vitamin C.<\/p>\n\n\n\n
D. Dried peas<\/p>\n\n\n\n
-incorrect: The water-soluble vitamins (B complex and C) readily dissolve in water and are<\/p>\n\n\n\n
absorbed into the bloodstream from the small intestine. Dried peas are a good source of many of<\/p>\n\n\n\n
the B complex vitamins, including B1, folate, and pantothenic acid.<\/p>\n\n\n\n
127. A nurse is caring for a client whose intake and output flow sheet for 0700 to 1500 indicates<\/p>\n\n\n\n
the following: voided x3 mL, 200 mL, 150 mL; wound drainage 2 tsp; and emesis 2 oz. What<\/p>\n\n\n\n
total output in milliliters should the nurse document for this 8 hr period? (nearest whole number)<\/p>\n\n\n\n
-770mL<\/p>\n\n\n\n
128. A nurse is preparing to administer 700 mL of 0.9% sodium chloride IV to a child to infuse<\/p>\n\n\n\n
over 24 hr. The drop factor of the manual IV tubing is 60gtt\/mL. The nurse should set the manual<\/p>\n\n\n\n
IV infusion to deliver how many gtt\/min? (nearest whole number)<\/p>\n\n\n\n
– 29gtt\/min<\/p>\n\n\n\n
129. A client who has glaucoma of the right eye self-administers timolol eye drops by looking at<\/p>\n\n\n\n
the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure<\/p>\n\n\n\n
to the lower lid with a facial tissue. After observing this process, which of the following actions<\/p>\n\n\n\n
should the nurse take?<\/p>\n\n\n\n
A. Confirm that the client performed the procedure correctly<\/p>\n\n\n\n
-incorrect: One of the actions the client performed is incorrect<\/p>\n\n\n\n
B. Instruct the client to look at the floor while instilling the eye drop<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to look up when instilling the eye drops<\/p>\n\n\n\n
C. Remind the client to avoid using a facial tissue after instillation<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg31.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The client may use a tissue to remove excess mediation after instillation<\/p>\n\n\n\n
D. Instruct the client to apply pressure to the inside corner of the eye after instillation<\/p>\n\n\n\n
-The client should apply gentle pressure over the nasolacrimal duct to prevent the medication<\/p>\n\n\n\n
from flowing into the nasal passages where systemic absorption could result.<\/p>\n\n\n\n
130. A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following<\/p>\n\n\n\n
pieces of information must the nurse verify with another nurse prior to the administration?<\/p>\n\n\n\n
(SATA)<\/p>\n\n\n\n
A. The client\u2019s ID number<\/p>\n\n\n\n
B. The client\u2019s room number<\/p>\n\n\n\n
-incorrect: Nurses should never use a client\u2019s room number as an identifier because clients can<\/p>\n\n\n\n
change rooms.<\/p>\n\n\n\n
C. The client\u2019s name<\/p>\n\n\n\n
D. ABO compatibility<\/p>\n\n\n\n
E. Rh compatibility<\/p>\n\n\n\n
-Two nurses must verify this information, including the client\u2019s facility identification number,<\/p>\n\n\n\n
name, ABO compatibility, and RH compatibility, to prevent transfusion reactions due to human<\/p>\n\n\n\n
error.<\/p>\n\n\n\n
131. A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing<\/p>\n\n\n\n
to irrigate the wound, which of the following actions should the nurse take first?<\/p>\n\n\n\n
A. Obtain the prescribed irrigation solution<\/p>\n\n\n\n
-incorrect: The nurse should obtain the prescribed irrigation solution prior to performing the<\/p>\n\n\n\n
procedure; however, there is another action the nurse should take first.<\/p>\n\n\n\n
B. Don personal protective equipment<\/p>\n\n\n\n
-incorrect: The nurse should don personal protective equipment prior to performing the<\/p>\n\n\n\n
procedure to prevent exposure to blood or bodily fluids from the client\u2019s wound; however, there<\/p>\n\n\n\n
is another action the nurse should take first.<\/p>\n\n\n\n
C. Check the client\u2019s pain level<\/p>\n\n\n\n
-The nurse should apply the nursing process priority-setting framework to plan client care and<\/p>\n\n\n\n
prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning<\/p>\n\n\n\n
with an assessment or data collection. Before the nurse can formulate a plan of action, implement<\/p>\n\n\n\n
a nursing intervention, or notify the provider of a change in the client\u2019s status, the nurse must<\/p>\n\n\n\n
first collect adequate data from the client. Assessing or collecting additional data will provide the<\/p>\n\n\n\n
nurse with the knowledge to make an appropriate decision. Therefore, the nurse should<\/p>\n\n\n\n
determine the client\u2019s level of pain prior to the procedure to evaluate the need for administration<\/p>\n\n\n\n
of an analgesic. Medicating the client approximately 30 minutes prior to wound care will<\/p>\n\n\n\n
decrease pain and increase comfort.<\/p>\n\n\n\n
D. Place a waterproof pad under the client\u2019s extremity<\/p>\n\n\n\n
-incorrect: The nurse should place a waterproof pad under the client\u2019s extremity to protect the<\/p>\n\n\n\n
linens from moisture and contamination during the irrigation; however, there is another action<\/p>\n\n\n\n
the nurse should take first.<\/p>\n\n\n\n
132. A nurse is preparing to instill a vaginal medication in suppository form to a client. Which of<\/p>\n\n\n\n
the following actions should the nurse take during this procedure?<\/p>\n\n\n\n
A. Don sterile gloves<\/p>\n\n\n\n
-incorrect: The nurse should wear clean gloves for this procedure, not sterile gloves<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg32.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
B. Use the dominant hand to retract the labia<\/p>\n\n\n\n
-incorrect: The nurse should use the nondominant hand to retract the labia and the dominant hand<\/p>\n\n\n\n
to insert the suppository.<\/p>\n\n\n\n
C. Use the index finger to insert the suppository<\/p>\n\n\n\n
-To ensure adequate distribution of the vaginal medication, the nurse should insert the<\/p>\n\n\n\n
suppository until the length of the nurse\u2019s index finger is inside the vagina or as far inside as<\/p>\n\n\n\n
possible.<\/p>\n\n\n\n
D. Ease the suppository along the anterior vaginal wall<\/p>\n\n\n\n
-incorrect: The nurse should ease the suppository along the posterior vaginal wall<\/p>\n\n\n\n
133. A nurse is teaching a client who is postoperative about the importance of turning, coughing,<\/p>\n\n\n\n
and breathing deeply. Which of the following statements should the nurse identify as an<\/p>\n\n\n\n
indication that the client understands the instructions?<\/p>\n\n\n\n
A. \u201cIf I do this often, I won\u2019t experience muscle wasting.\u201d<\/p>\n\n\n\n
-incorrect: Turning, coughing, and breathing deeply do not prevent muscle wasting. Exercising<\/p>\n\n\n\n
the muscles actively or passively helps prevent muscle wasting.<\/p>\n\n\n\n
B. \u201cIf I do this often, I won\u2019t get pneumonia.\u201d<\/p>\n\n\n\n
-Turning, coughing, and breathing deeply help prevent respiratory complications such as<\/p>\n\n\n\n
pneumonia by promoting lung expansion and secretion removal.<\/p>\n\n\n\n
C. \u201cIf I do this often, I won\u2019t get constipation.\u201d<\/p>\n\n\n\n
-incorrect: Turning, coughing, and deep breathing do not prevent constipation. Resuming a<\/p>\n\n\n\n
progressive diet with an adequate fluid intake and early ambulation will help prevent<\/p>\n\n\n\n
constipation. Fiber supplements and stool softeners can also help.<\/p>\n\n\n\n
D. \u201cIf I do this often, I won\u2019t have a fast heartbeat.\u201d<\/p>\n\n\n\n
-incorrect: Turning, coughing, and deep breathing do not prevent tachycardia. A rapid heart rate<\/p>\n\n\n\n
is not usually a major postoperative concern. However, prevention includes avoiding stressors<\/p>\n\n\n\n
that might cause it such as unrelieved pain or sudden exertion. Careful pain management and<\/p>\n\n\n\n
gradual resumption of activities can also help.<\/p>\n\n\n\n
134. A nurse is taking a client\u2019s vital signs. Which of the following findings should the nurse<\/p>\n\n\n\n
identify as outside the expected reference range?<\/p>\n\n\n\n
A. Pulse rate 90\/min<\/p>\n\n\n\n
-incorrect: This pulse rate is within the expected reference range.<\/p>\n\n\n\n
B. Rectal Temp 38 C (100.4 F)<\/p>\n\n\n\n
-incorrect: This temp. is within the expected reference range.<\/p>\n\n\n\n
C. Pulse oximetry 95%<\/p>\n\n\n\n
-incorrect: This pulse oximetry is within the expected reference range.<\/p>\n\n\n\n
D. BP 145\/90 mmHg<\/p>\n\n\n\n
-This blood pressure is greater than the expected reference range and should be reported to the<\/p>\n\n\n\n
provider.<\/p>\n\n\n\n
135. A nurse is instructing a client about collecting a 24-hour urine specimen for creatinine<\/p>\n\n\n\n
clearance. Which of the following statements should the nurse identify as an indication that the<\/p>\n\n\n\n
client understands the procedure?<\/p>\n\n\n\n
A. \u201cThe next time I urinate will be the first specimen of the collection.\u201d<\/p>\n\n\n\n
-incorrect: The collection begins after the next time the client urinates.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg33.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
B. \u201cI\u2019ll make sure to keep the collection bottle in the container of ice they gave me.\u201d<\/p>\n\n\n\n
-The urine collection must remain chilled to prevent any change in urine composition during the<\/p>\n\n\n\n
collection.<\/p>\n\n\n\n
C. \u201cOnce the container is half full, I no longer have to add any more urine.\u201d<\/p>\n\n\n\n
-incorrect: The urine collection for creatinine clearance specifies the duration of collection, not a<\/p>\n\n\n\n
minimal volume of urine.<\/p>\n\n\n\n
D. \u201cIt\u2019s okay if a piece of toilet paper gets in the bottle. The lab people will remove it when they<\/p>\n\n\n\n
do the test.\u201d<\/p>\n\n\n\n
-incorrect: The presence of toilet tissue, menstrual blood and feces will contaminate the<\/p>\n\n\n\n
specimen.<\/p>\n\n\n\n
136. A nurse is performing a straight catherization for a female client who has urinary retention.<\/p>\n\n\n\n
Which of the following actions indicates the nurse is maintaining sterile technique?<\/p>\n\n\n\n
A. Applying sterile gloves to open catheter package<\/p>\n\n\n\n
-incorrect: The nurse should apply sterile gloves after opening the catheter package to maintain<\/p>\n\n\n\n
aseptic technique, as the outside of the package is not considered sterile.<\/p>\n\n\n\n
B. Wiping the labia minora in an anteroposterior direction<\/p>\n\n\n\n
-The nurse should wipe anteroposteriorly both the right and left labia minora with separate cotton<\/p>\n\n\n\n
swabs to destroy any microorganisms in the area that would contaminate the catheter.<\/p>\n\n\n\n
C. Spreading the labia with the dominant hand<\/p>\n\n\n\n
-incorrect: The nurse should use the nondominant hand to spread the labia and provide the<\/p>\n\n\n\n
optimal view of the urethral meatus. The nondominant hand is considered contaminated once the<\/p>\n\n\n\n
hand touches the client\u2019s skin.<\/p>\n\n\n\n
D. Using a cotton ball to wipe the right and left labia majora<\/p>\n\n\n\n
-incorrect: The nurse should use a separate cotton ball to wipe the right and left labia majora to<\/p>\n\n\n\n
destroy any microorganisms on the skin surface that would contaminate the catheter.<\/p>\n\n\n\n
137. A nurse is caring for a postoperative client who has an indwelling urinary catheter for<\/p>\n\n\n\n
gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions<\/p>\n\n\n\n
should the nurse take first?<\/p>\n\n\n\n
A. Check to determine if the catheter tubing is kinked<\/p>\n\n\n\n
-The nurse should apply the least invasive priority-setting framework when caring for this client,<\/p>\n\n\n\n
which assigns priority to nursing interventions that are least invasive to the client, as long as<\/p>\n\n\n\n
those interventions do not jeopardize client safety. This approach reduces the number of<\/p>\n\n\n\n
organisms introduced into the body, decreasing the number of facility-acquired infections.<\/p>\n\n\n\n
Hence, the first action the nurse should take is to inspect the tubing carefully, straighten any<\/p>\n\n\n\n
kinks, and ensure there are no dependent loops. A lack of drainage is often due to a kink in the<\/p>\n\n\n\n
tubing or the client lying on it.<\/p>\n\n\n\n
B. Palpate the bladder<\/p>\n\n\n\n
-incorrect: The nurse should obtain a prescription to irrigate the catheter to determine if the<\/p>\n\n\n\n
absent urine output is due to an obstruction from blood clots or sloughing of bladder tissue.<\/p>\n\n\n\n
However, there is another action the nurse should take first.<\/p>\n\n\n\n
C. Obtain a prescription to irrigate the catheter with 0.9% sodium chloride<\/p>\n\n\n\n
-incorrect: The nurse should obtain a prescription to irrigate the catheter to determine if the<\/p>\n\n\n\n
absent urine output is due to an obstruction from blood clots or sloughing of bladder tissue.<\/p>\n\n\n\n
However, there is another action the nurse should take first.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg34.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
D. Encourage the client to drink more fluids<\/p>\n\n\n\n
-incorrect: The nurse can encourage the client to drink more fluids or obtain a prescription to<\/p>\n\n\n\n
increase the IV fluid rate if fluid overload is not a problem for the client to help increase kidney<\/p>\n\n\n\n
profusion and filtration of urine. However, there is another action the nurse should take first.<\/p>\n\n\n\n
138. A nurse is cleaning a client\u2019s wound by swabbing from the area of least contamination to an<\/p>\n\n\n\n
area of greater contamination. Which of the following rationales should the nurse identify for<\/p>\n\n\n\n
using this technique?<\/p>\n\n\n\n
A. Preventing the transfer of microorganisms to the nurse<\/p>\n\n\n\n
-incorrect: Wearing appropriate personal protective equipment while performing wound care<\/p>\n\n\n\n
helps prevent the transfer of microorganisms from the client to the nurse.<\/p>\n\n\n\n
B. Keeping microorganisms from entering the wound<\/p>\n\n\n\n
-Starting at the area of least contamination and working toward the area of greatest<\/p>\n\n\n\n
contamination prevents the spread of microorganisms within the wound.<\/p>\n\n\n\n
C. Applying minimal pressure to the wound<\/p>\n\n\n\n
-incorrect: The cleansing sequence does not affect the amount of pressure applied to the wound.<\/p>\n\n\n\n
Pressure should be gentle. However, when necrotic tissue is removed, various methods of<\/p>\n\n\n\n
debridement are prescribed, some of which involve additional pressure being applied to the<\/p>\n\n\n\n
wound.<\/p>\n\n\n\n
D. Keeping excess moisture from entering the wound<\/p>\n\n\n\n
-incorrect: When excess moisture poses a hazard to a wound, a drain can be used to divert fluid<\/p>\n\n\n\n
away from the wound.<\/p>\n\n\n\n
139. After assessing a client\u2019s radial pulses, the nurse documents \u201cradial pulses 4+ bilaterally.\u201d<\/p>\n\n\n\n
The nurse should document this finding when a client\u2019s pulses have which of the following<\/p>\n\n\n\n
qualities?<\/p>\n\n\n\n
A. Bounding<\/p>\n\n\n\n
-A pulse of 4+ is bounding and does not disappear with moderate pressure. Pulse strength ranges<\/p>\n\n\n\n
from absent (0) to bounding (4+).<\/p>\n\n\n\n
B. Full<\/p>\n\n\n\n
-incorrect: Full pulse strength is 3+<\/p>\n\n\n\n
C. Variable<\/p>\n\n\n\n
-incorrect: Variable typically describes the pulse\u2019s rate or rhythm, not its strength.<\/p>\n\n\n\n
D. Weak<\/p>\n\n\n\n
-incorrect: A weak pulse is 1+<\/p>\n\n\n\n
140. A nurse is using a portable ultrasound bladder scanner to measure a client\u2019s post-void<\/p>\n\n\n\n
residual volume. Which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Have the client urinate 20 min before the scan<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to urinate 10 mins before the bladder scanning<\/p>\n\n\n\n
procedure. The nurse should then document the amount of urine the client passed at that time.<\/p>\n\n\n\n
B. Assist the client into a semi-fowler\u2019s position<\/p>\n\n\n\n
-incorrect: For the bladder scanning procedure, the nurse should assist the client into a supine<\/p>\n\n\n\n
position with the head slightly elevated.<\/p>\n\n\n\n
C. Position the scanner head at the symphysis pubis<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg35.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The nurse should position the scanner head 2.5-4 cm (1-1.6 in) above the symphysis<\/p>\n\n\n\n
pubis.<\/p>\n\n\n\n
D. Apply light pressure to the scanner head once it is in position<\/p>\n\n\n\n
-The nurse should apply light pressure and hold the scanner steadily while pointing it slightly<\/p>\n\n\n\n
down toward the client\u2019s bladder.<\/p>\n\n\n\n
141. A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of<\/p>\n\n\n\n
the following actions should the nurse take?<\/p>\n\n\n\n
A. Don clean gloves to remove the old dressing<\/p>\n\n\n\n
-The nurse should use standard precautions by applying clean gloves when faced with the<\/p>\n\n\n\n
possibility of coming into contact with secretions. Removing a soiled dressing is a procedure that<\/p>\n\n\n\n
requires wearing clean gloves. Sterile gloves are not necessary until the nurse applies the new<\/p>\n\n\n\n
sterile dressing.<\/p>\n\n\n\n
B. Loosen the dressing by pulling the tape away from the wound<\/p>\n\n\n\n
-incorrect: The nurse should remove the tape by loosening and pulling toward the wound or<\/p>\n\n\n\n
dressing to decrease tension or stress on the healing wound edges.<\/p>\n\n\n\n
C. Remove the entire old dressing at once<\/p>\n\n\n\n
-incorrect: The nurse should remove the old dressing a layer at a time to prevent the removal of<\/p>\n\n\n\n
drains and allow assessment of the drainage.<\/p>\n\n\n\n
D. Open sterile supplies after applying sterile gloves<\/p>\n\n\n\n
-incorrect: The nurse should open the sterile supplies after removing the old dressings and<\/p>\n\n\n\n
washing the hands and before donning sterile gloves to apply the sterile dressing. These<\/p>\n\n\n\n
measures help prevent microorganisms from contaminating the sterile field.<\/p>\n\n\n\n
142. A nurse is performing suctioning for a client who has a tracheostomy. Which of the<\/p>\n\n\n\n
following actions should the nurse take?<\/p>\n\n\n\n
A. Pull suction catheter back 1 cm (0.5 in) if the client starts coughing<\/p>\n\n\n\n
-The nurse should pull the suction catheter back 1 cm (0.5in) when the client starts to cough, or<\/p>\n\n\n\n
resistance is met. This will remove the catheter from the mucosal wall of the trachea prior to<\/p>\n\n\n\n
suctioning.<\/p>\n\n\n\n
B. Allow 30 sec between suctioning passes<\/p>\n\n\n\n
-incorrect: The nurse should allow at least 1 minute between suctioning passes to prevent<\/p>\n\n\n\n
hypoxia and to hyperventilate the client.<\/p>\n\n\n\n
C. Hyperventilate the client with 50% oxygen for 30 sec<\/p>\n\n\n\n
-incorrect: The nurse should hyperventilate the client with 100% oxygen for at least 2 mins<\/p>\n\n\n\n
before suctioning to decrease hypoxia.<\/p>\n\n\n\n
D. Perform maximum of 4 passes with the suction catheter<\/p>\n\n\n\n
-incorrect: The nurse should perform a maximum of 3 passes with the suction catheter because<\/p>\n\n\n\n
suctioning can cause hypoxia and induce dysrhythmia.<\/p>\n\n\n\n
143. A nurse is teaching a client who is postoperative following a knee arthroplasty about the<\/p>\n\n\n\n
muscles he will need to strengthen in physical therapy.Which of the following muscle groups is<\/p>\n\n\n\n
responsible for movement at the knee joint?<\/p>\n\n\n\n
A. Antigravity<\/p>\n\n\n\n
-incorrect: The antigravity muscle group is responsible for stabilizing the knee joint.<\/p>\n\n\n\n
B. Antagonistic<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg36.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-The nurse should teach the client that the antagonistic muscle group is responsible for<\/p>\n\n\n\n
movement of the knee joint by contracting while other muscles relax.<\/p>\n\n\n\n
C. Synergistic<\/p>\n\n\n\n
-incorrect: The synergistic muscle group is responsible for contracting in sync to cause the same<\/p>\n\n\n\n
movement. Therefore, 2 muscles contract as other muscles relax. However, this is not occurring<\/p>\n\n\n\n
within a joint.<\/p>\n\n\n\n
D. Skeletal<\/p>\n\n\n\n
-incorrect: The skeletal muscle group is responsible for supporting posture and producing<\/p>\n\n\n\n
voluntary movement.<\/p>\n\n\n\n
144. A nurse is preparing to irrigate a client\u2019s wound. Which of the following actions should the<\/p>\n\n\n\n
nurse take?<\/p>\n\n\n\n
A. Use a 10 mL syringe<\/p>\n\n\n\n
-incorrect: The nurse should use a syringe that has at least a 30 mL capacity.<\/p>\n\n\n\n
B. Attach a 22-gauge catheter to the syringe<\/p>\n\n\n\n
-incorrect: The nurse should use an 18- or 19-gauge catheter.A smaller catheter will exert too<\/p>\n\n\n\n
much pressure on the wound.<\/p>\n\n\n\n
C. Warm the irrigating solution to 37 C (98.6 F)<\/p>\n\n\n\n
-The nurse should prepare about 200 mL of irrigating solution and warm it to body temperature<\/p>\n\n\n\n
to minimize discomfort and vascular constriction.<\/p>\n\n\n\n
D. Administer an analgesic 10 mins before the irrigation<\/p>\n\n\n\n
-incorrect: The nurse should administer an analgesic 20 to 30 minutes before the irrigation to<\/p>\n\n\n\n
give the medication enough time to provide pain management during the procedure.<\/p>\n\n\n\n
145. A nurse in the emergency department is caring for an inmate who has a laceration and is<\/p>\n\n\n\n
bleeding. The client was brought to the facility by a guard who asks the nurse about the client\u2019s<\/p>\n\n\n\n
HIV infection status. Which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Inform the guard that the warden must request this information.<\/p>\n\n\n\n
-incorrect: The nurse cannot discuss the client\u2019s HIV status with the guard or the warden without<\/p>\n\n\n\n
the client\u2019s consent. The client can share personal medical information if desired.<\/p>\n\n\n\n
B. Ask the guard to sign a release of information form<\/p>\n\n\n\n
-incorrect: The client can sign a release of information form to obtain medical records. Asking<\/p>\n\n\n\n
the guard to sign this form does not give the nurse permission to share the client\u2019s HIV status.<\/p>\n\n\n\n
C. Instruct the guard to ask the inmate<\/p>\n\n\n\n
-The nurse is not able to supply this information to the guard. In order for the guard to obtain this<\/p>\n\n\n\n
information, the client must offer the information freely.Therefore, the nurse should instruct the<\/p>\n\n\n\n
guard to ask the client for the information.<\/p>\n\n\n\n
D. Complete an incident report<\/p>\n\n\n\n
-incorrect: The nurse would have no cause to complete an incident report in this situation.<\/p>\n\n\n\n
Incident reports are completed to record an event that is not consistent with standard procedures.<\/p>\n\n\n\n
An incident report would need to be completed if the nurse were to share the client\u2019s HIV status<\/p>\n\n\n\n
with the guard.<\/p>\n\n\n\n
146. A nurse is caring for a client who just received a diagnosis of cancer. The client states, \u201cI<\/p>\n\n\n\n
just don\u2019t know what I\u2019m going to do now.\u201d Which of the following responses should the nurse<\/p>\n\n\n\n
make?<\/p>\n\n\n\n
A. \u201cIn time you\u2019ll know the right thing to do.\u201d<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg37.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: This is a nontherapeutic response. Providing an automatic or clich\u00e9 response can be<\/p>\n\n\n\n
seen as belittling the client\u2019s feelings and can make it seem as though the nurse is not taking the<\/p>\n\n\n\n
client\u2019s concerns seriously.<\/p>\n\n\n\n
B. \u201cI am sorry. Would you like me to call someone for you?\u201d<\/p>\n\n\n\n
-incorrect: This is a nontherapeutic response. Offering sympathy can come across as pity and not<\/p>\n\n\n\n
as empathy. Offering to call someone for the client places the responsibility of addressing the<\/p>\n\n\n\n
client\u2019s concerns onto someone other than the nurse.<\/p>\n\n\n\n
C. \u201cThere are multiple treatment options for you to consider.\u201d<\/p>\n\n\n\n
-incorrect: This is a nontherapeutic response. By changing the subject, this response does not<\/p>\n\n\n\n
allow the client to express concerns about the diagnosis and shows a lack of empathy on the part<\/p>\n\n\n\n
of the nurse. This kind of response can block further communication with the client.<\/p>\n\n\n\n
D. \u201cCan you explain the concerns you\u2019re having right now?\u201d<\/p>\n\n\n\n
-This response uses therapeutic communication technique of asking a relevant question. By using<\/p>\n\n\n\n
an open-ended question to ask the client to explain any present concerns, the nurse is<\/p>\n\n\n\n
encouraging the client to respond and provide additional information.<\/p>\n\n\n\n
147. A nurse is preparing to administer an antibiotic to an adult client who has otitis media.<\/p>\n\n\n\n
Which of the following actions should the nurse plan to take?<\/p>\n\n\n\n
A. Hold the dropper 1 cm (0.5 in) above the ear canal during administration<\/p>\n\n\n\n
-The nurse should administer the otic medication by holding the dropper 1 cm (0.5in) above the<\/p>\n\n\n\n
ear canal.<\/p>\n\n\n\n
B. Apply pressure to the nasolacrimal duct following administration<\/p>\n\n\n\n
-incorrect: The nurse should apply pressure to the nasolacrimal duct following the administration<\/p>\n\n\n\n
of eye drops, not for an otic antibiotic.<\/p>\n\n\n\n
C. Place a cotton ball into the inner ear canal for 30 mins following administration<\/p>\n\n\n\n
-incorrect: If necessary, the nurse can apply a cotton ball into the outermost part of the ear canal<\/p>\n\n\n\n
and remove is after 15 mins.<\/p>\n\n\n\n
D. Straighten the ear by pulling the auricle down and back prior to administration<\/p>\n\n\n\n
-incorrect: The nurse should straighten the ear canal by pulling the auricle down and back prior<\/p>\n\n\n\n
to administering otic medication for a child who is younger than 3 years of age.<\/p>\n\n\n\n
148. A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site,<\/p>\n\n\n\n
which of the following sites should the nurse select?<\/p>\n\n\n\n
A. Select a vein in the client\u2019s dominant arm<\/p>\n\n\n\n
-incorrect: The nurse should place a peripheral IV into a client\u2019s non-dominant arm unless<\/p>\n\n\n\n
contraindicated for reasons such as mastectomy or a dialysis fistula.<\/p>\n\n\n\n
B. Choose the most proximal vein in the extremity<\/p>\n\n\n\n
-incorrect: The nurse should select a vein that is distal to areas where the tip of the catheter will<\/p>\n\n\n\n
not be at a point of flexion.<\/p>\n\n\n\n
C. Choose a vein that is soft on palpation<\/p>\n\n\n\n
– The nurse should select a vein that is soft and has a \u201cbouncy\u201d feeling when pressure is released<\/p>\n\n\n\n
upon palpation.<\/p>\n\n\n\n
D. Select a site distal to previous venipuncture attempts<\/p>\n\n\n\n
-incorrect: The nurse should avoid a site that is distal to a previous venipuncture attempt or site.<\/p>\n\n\n\n
These areas often cause infiltration around a newly place IV site. \u2018<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg38.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
149. A nurse is preparing to insert an indwelling urinary catheter. Which of the following<\/p>\n\n\n\n
instructions should the nurse give the client to ease to passage of the catheter through the urinary<\/p>\n\n\n\n
meatus?<\/p>\n\n\n\n
A. \u201cBear down\u201d<\/p>\n\n\n\n
-The nurse should ask the client to \u201cbear down\u201d gently as if to void. This can enable the nurse to<\/p>\n\n\n\n
better visualize the urinary meatus and promote relaxation of the external urinary sphincter.<\/p>\n\n\n\n
Additionally, this will ease the passage of the catheter through the urinary meatus.<\/p>\n\n\n\n
B. \u201cPerform Kegel exercises\u201d<\/p>\n\n\n\n
-incorrect: Kegel exercises are a technique used the strengthen the pelvic muscles. However,<\/p>\n\n\n\n
these exercises will not ease the passage of the catheter through the urinary meatus.<\/p>\n\n\n\n
C. \u201cHold your breath\u201d<\/p>\n\n\n\n
-incorrect: The nurse should ask the client to take slow, deep breaths to promote relaxation. This<\/p>\n\n\n\n
can help relax the sphincter, which can ease the passage of the catheter through the urinary<\/p>\n\n\n\n
meatus.<\/p>\n\n\n\n
D. \u201cRaise your head off the pillow\u201d<\/p>\n\n\n\n
-incorrect: The nurse should encourage the client to relax during the procedure. There is no need<\/p>\n\n\n\n
to ask the client to raise the head off the pillow.<\/p>\n\n\n\n
150. Anurse is providingdischarge teachingto an older adultclient about personal safety.<\/p>\n\n\n\n
Which of the following statements by the client indicates an understanding of the teaching?<\/p>\n\n\n\n
A. \u201cI will have the steps to my house painted a dark color.\u201d<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to paint or mark only the edges of the steps with a<\/p>\n\n\n\n
light color to make them more prominent. Physiological changes associated with aging can affect<\/p>\n\n\n\n
an older adult client\u2019s ability to see edges of the steps.<\/p>\n\n\n\n
B. \u201cI will put a night-light in the hallway.\u201d<\/p>\n\n\n\n
-The nurse should instruct the client to use night-lights in and around the home as an important<\/p>\n\n\n\n
safety measure to reduce the risk of falls in the home. Physiological changes associated with<\/p>\n\n\n\n
aging can affect the older adult client\u2019s ability to see surroundings. Older adults and infants are at<\/p>\n\n\n\n
an increased risk of serious injury from falls, and most falls occur in the client\u2019s home.<\/p>\n\n\n\n
C. \u201cI will put on socks when I get out of bed.\u201d<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to wear well0fitting slippers with non-skid soles<\/p>\n\n\n\n
as an important safety measure to reduce the risk of falls in the home. Physiological changes<\/p>\n\n\n\n
associated with aging can affect an older adult client\u2019s ability to balance, increasing the risk of<\/p>\n\n\n\n
falls.<\/p>\n\n\n\n
D. \u201cI will secure any wires in my home under rugs.\u201d<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client that securing wires under a rug can create an<\/p>\n\n\n\n
electrical hazard and should be avoided. Physiological changes associated with aging can affect<\/p>\n\n\n\n
an older adult client\u2019s ability to see surroundings and to react quickly to hazards when walking.<\/p>\n\n\n\n
151. A nurse in a provider\u2019s clinic is taking a client\u2019s age, height, weight, and vital signs. The<\/p>\n\n\n\n
nurse should identify this action as part of which of the following components of the nursing<\/p>\n\n\n\n
process?<\/p>\n\n\n\n
A. Planning<\/p>\n\n\n\n
-incorrect: Planning is the portion of the nursing process in which the nurse establishes goals and<\/p>\n\n\n\n
outcomes for the client and selects interventions that will help achieve those goals and outcomes.<\/p>\n\n\n\n
Planning also involves setting priorities.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg39.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
B. Evaluation<\/p>\n\n\n\n
-incorrect: Evaluation is the portion of the nursing process in which the nurse uses critical<\/p>\n\n\n\n
thinking skills to determine if goals and outcomes have been met. The nurse examines the<\/p>\n\n\n\n
results, compares the data, identifies errors, and considers the client\u2019s situation when performing<\/p>\n\n\n\n
the evaluation portion of the nursing process.<\/p>\n\n\n\n
C. Assessment<\/p>\n\n\n\n
-Collecting this data is included in the assessment portion of the nursing process. In addition, the<\/p>\n\n\n\n
nurse should explore the client\u2019s health history and perform a physical examination.<\/p>\n\n\n\n
D. Implementation<\/p>\n\n\n\n
-incorrect: Implementation is the portion of the nursing process in which the nurse provides<\/p>\n\n\n\n
client care based on assessment data and analysis and the plan of care developed in the previous<\/p>\n\n\n\n
step. The nurse also uses interpersonal and technical skills when implementing nursing<\/p>\n\n\n\n
interventions.<\/p>\n\n\n\n
152. A nurse on a medical-surgical unit is caring for a client. Which of the following actions<\/p>\n\n\n\n
should the nurse prioritize when using the nursing process?<\/p>\n\n\n\n
A. Identify goals for client care<\/p>\n\n\n\n
-incorrect: While identifying goals is an appropriate step in the nursing process, it is not the first<\/p>\n\n\n\n
step.<\/p>\n\n\n\n
B. Obtain client information<\/p>\n\n\n\n
-The nursing process is based on the scientific process. The first step in the scientific process is<\/p>\n\n\n\n
collecting data. Therefore, the first step in the nursing process is assessing and obtaining<\/p>\n\n\n\n
information about the client.<\/p>\n\n\n\n
C. Document nursing care needs<\/p>\n\n\n\n
-incorrect: While documenting the client\u2019s care needs is an appropriate step in the nursing<\/p>\n\n\n\n
process, it is not the first step.<\/p>\n\n\n\n
D. Evaluate the effectiveness of care<\/p>\n\n\n\n
-incorrect: While evaluating the effectiveness of the client\u2019s care is an appropriate step in the<\/p>\n\n\n\n
nursing process, it is not the first step.<\/p>\n\n\n\n
153. A nurse is providing discharge teaching to a client who does not speak the same language as<\/p>\n\n\n\n
the nurse. The client\u2019s neighbor, who speaks both the client\u2019s native language and the nurse\u2019s,<\/p>\n\n\n\n
arrives to drive the client home. Which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Ask the client\u2019s neighbor to call a family member to interpret<\/p>\n\n\n\n
-incorrect: Using a family member to interpret could breach the client\u2019s confidentiality. In<\/p>\n\n\n\n
addition, the family member might not be familiar enough with medical terminology to translate<\/p>\n\n\n\n
information accurately.<\/p>\n\n\n\n
B. Ask the client\u2019s neighbor to translate the information<\/p>\n\n\n\n
-incorrect: Although the neighbor can speak both languages, this action could breach the client\u2019s<\/p>\n\n\n\n
confidentiality. In addition, the neighbor might not be familiar enough with medical terminology<\/p>\n\n\n\n
to translate information accurately.<\/p>\n\n\n\n
C. Obtain the services of an interpreter<\/p>\n\n\n\n
-Federal mandates require that a professional medical interpreter translate the client\u2019s health care<\/p>\n\n\n\n
information into the client\u2019s native language.<\/p>\n\n\n\n
D. Document the inability to perform discharge instructions<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg3a.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The nurse is responsible for providing discharge instructions that the client can<\/p>\n\n\n\n
understand.<\/p>\n\n\n\n
154. A nurse is presenting an in-service training about nutrition. Which of the following simple<\/p>\n\n\n\n
sugars should the nurse identify as the carbohydrate found in milk?<\/p>\n\n\n\n
A. Lactose<\/p>\n\n\n\n
-The nurse should identify that lactose is a form of sugar that is found in milk.<\/p>\n\n\n\n
B. Sucrose<\/p>\n\n\n\n
-incorrect: Sucrose is table sugar and is also found in fruits and vegetables.<\/p>\n\n\n\n
C. Maltose<\/p>\n\n\n\n
-incorrect: Maltose is found in germinating cereals, such as barely.<\/p>\n\n\n\n
D. Fructose<\/p>\n\n\n\n
-incorrect: Fructose is found in honey and fruit.<\/p>\n\n\n\n
155. A nurse is working with the facility\u2019s language interpreter to explain a wound-care<\/p>\n\n\n\n
procedure to a client who does not speak the same language as the nurse. Which of the following<\/p>\n\n\n\n
actions should the nurse take when describing the procedure to the client?<\/p>\n\n\n\n
A. Make eye contact with the interpreter<\/p>\n\n\n\n
-incorrect: To enhance the nurse-client relationship, the nurse should direct information,<\/p>\n\n\n\n
instructions, and questions to the client, not to the interpreter.<\/p>\n\n\n\n
B. Break sentences into shorter segments to allow time for interpretation<\/p>\n\n\n\n
-incorrect: The nurse should make every effort to speak in short sentences but should not break<\/p>\n\n\n\n
sentences into fragments to allow time for interpretation.<\/p>\n\n\n\n
C. Ensure the interpreter and client speak the same dialect<\/p>\n\n\n\n
-To encourage effective communication and promote client understanding, the nurse should first<\/p>\n\n\n\n
ensure the interpreter and the client speak the same dialect.<\/p>\n\n\n\n
D. Speak in a loud tone of voice<\/p>\n\n\n\n
-incorrect: The nurse should speak slowly and distinctly and avoid the use of metaphors that<\/p>\n\n\n\n
might be challenging to translate. The nurse should speak clearly, not loudly.<\/p>\n\n\n\n
156. A nurse on a medical-surgical unit is caring for a client who has been coughing<\/p>\n\n\n\n
intermittently during meals, attempting to clear her throat repeatedly, and eating only a small<\/p>\n\n\n\n
portion of each meal. The nurse should recommend a referral to which of the following members<\/p>\n\n\n\n
of the interprofessional team to evaluate the client for dysphagia?<\/p>\n\n\n\n
A. Speech-language pathologist<\/p>\n\n\n\n
-A speech-language pathologist can perform a thorough evaluation of the client for dysphagia<\/p>\n\n\n\n
and help the client learn to eat safely. For example, a speech-language pathologist can instruct<\/p>\n\n\n\n
the client in learning the supraglottic swallow: take a breath, hold the breath while swallowing,<\/p>\n\n\n\n
cough after swallowing, and swallow again to clear the mouth.<\/p>\n\n\n\n
B. Social worker<\/p>\n\n\n\n
-incorrect: A social worker can assist the client with finding and accessing community services<\/p>\n\n\n\n
(ex: meal delivery and functional services) once the client is at home but cannot evaluate the<\/p>\n\n\n\n
skills the client needs to swallow and eat safely.<\/p>\n\n\n\n
C. Physical therapist<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg3b.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: A physical therapist can evaluate the strength and mobility of a client who has<\/p>\n\n\n\n
musculoskeletal problems but cannot evaluate the skills the client needs to swallow and eat<\/p>\n\n\n\n
safely.<\/p>\n\n\n\n
D. Occupational therapist<\/p>\n\n\n\n
-incorrect: An occupational therapist can help clients who have physical limitations or<\/p>\n\n\n\n
disabilities gain the optimal level of independence in performing ADLs but cannot evaluate the<\/p>\n\n\n\n
skills the client needs to swallow and eat safely.<\/p>\n\n\n\n
157. A nurse manager is providing teaching to a group of newly licensed nurses about ways that<\/p>\n\n\n\n
clients acquire health care-associated infections (HAIs. Which of the following routes of<\/p>\n\n\n\n
infection should the manager identify as an iatrogenic HAI?<\/p>\n\n\n\n
A. Infection acquired from improper hand hygiene<\/p>\n\n\n\n
-incorrect: Breaks in infection-control protocols, such as improper hand hygiene, are not<\/p>\n\n\n\n
considered a source of iatrogenic HAIs because they are not due to a diagnostic or therapeutic<\/p>\n\n\n\n
procedure.<\/p>\n\n\n\n
B. Infection acquired by drug resistance<\/p>\n\n\n\n
-incorrect: Drug resistance is not considered a source of iatrogenic HAIs because it is not the<\/p>\n\n\n\n
result of a diagnostic or therapeutic procedure.<\/p>\n\n\n\n
C. Infection acquired by inappropriate waste disposal<\/p>\n\n\n\n
-incorrect: Inappropriate waste disposal is not considered a source of iatrogenic HAIs because it<\/p>\n\n\n\n
is not the result of a diagnostic or therapeutic procedure<\/p>\n\n\n\n
D. Infection acquired from a diagnostic procedure<\/p>\n\n\n\n
-Iatrogenic HAIs directly result from diagnostic or therapeutic procedures.<\/p>\n\n\n\n
158. A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes<\/p>\n\n\n\n
by an electronic blood pressure machine. The nurse notices the machine begins to measure the<\/p>\n\n\n\n
blood pressure at varied intervals, and the readings are inconsistent. Which of the following<\/p>\n\n\n\n
actions should the nurse take?<\/p>\n\n\n\n
A. Turn on the machine every 15 min to measure the client\u2019s blood pressure<\/p>\n\n\n\n
-incorrect: Because the measurement and operation of the machine appear questionable,<\/p>\n\n\n\n
operating the equipment differently cannot ensure the accuracy of the readings. The nurse should<\/p>\n\n\n\n
tag the machine and remove it from use.<\/p>\n\n\n\n
B. Record only the blood pressure readings needed for 15-min intervals<\/p>\n\n\n\n
-incorrect: Although the equipment is obtaining blood pressure readings, the increased<\/p>\n\n\n\n
measurements and dissimilar results suggest that the machine is malfunctioning. Thus, all the<\/p>\n\n\n\n
readings are possibly inaccurate. The nurse should tag the machine and remove it from use.<\/p>\n\n\n\n
C. Obtain manual and automatic readings and compare them<\/p>\n\n\n\n
-incorrect: Although this option appears to provide a means of checking the machine, it is not<\/p>\n\n\n\n
operating correctly, which already suggest that the accuracy of the reading is questionable. The<\/p>\n\n\n\n
nurse should tag the machine and remove it from use.<\/p>\n\n\n\n
D. Disconnect the machine and measure the blood pressure manually every 15 mins<\/p>\n\n\n\n
-If the nurse questions the reliability of the monitoring equipment, a manual process should be<\/p>\n\n\n\n
used. Also, malfunctioning equipment can pose a safety risk for the client, so it must be tagged<\/p>\n\n\n\n
and removed.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg3c.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
159. A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical<\/p>\n\n\n\n
procedure. Which of the following actions by the nurse demonstrates proper surgical<\/p>\n\n\n\n
handwashing technique?<\/p>\n\n\n\n
A. The nurse washes each part of her hands with 5 strokes.<\/p>\n\n\n\n
-incorrect: Surgical scrubbing requires the nails be scrubbed with 15 strokes and each other part<\/p>\n\n\n\n
of the hand with 10 strokes.<\/p>\n\n\n\n
B. The nurse washes from the elbows down to the hands.<\/p>\n\n\n\n
-incorrect: An important principle of surgical handwashing is to scrub the hands first and then<\/p>\n\n\n\n
work toward the elbows.<\/p>\n\n\n\n
C. The nurse holds her hands higher than her elbows while washing<\/p>\n\n\n\n
-The nurse who is performing a surgical handwashing technique should wash while holding her<\/p>\n\n\n\n
hands higher than the elbows so that water and soapsuds can drain away from the clean area<\/p>\n\n\n\n
toward the dirty area.<\/p>\n\n\n\n
D. The nurse uses minimal friction when washing her hands.<\/p>\n\n\n\n
-incorrect: Scrubbing is performed with a specially designed and premedicated brush when<\/p>\n\n\n\n
performing surgical handwashing. The use of mechanical friction is necessary to decontaminate<\/p>\n\n\n\n
the skin effectively.<\/p>\n\n\n\n
160. A nurse is caring for an older adult client who is violent and attempting to disconnect her IV<\/p>\n\n\n\n
lines. The provider prescribes soft wrist restraints. Which of the following actions should the<\/p>\n\n\n\n
nurse take while the client is in restraints?<\/p>\n\n\n\n
A. Tie the restraints to the side rails<\/p>\n\n\n\n
-incorrect: The nurse should not tie the restraints to the side rails because this can injure the<\/p>\n\n\n\n
client if the rails are lowered.<\/p>\n\n\n\n
B. Perform ROM exercises to the wrists every 3 hours<\/p>\n\n\n\n
-incorrect: The nurse should ensure the restraints are removed and ROM exercises are performed<\/p>\n\n\n\n
every 2 hours.<\/p>\n\n\n\n
C. Remove the restraints one at a time<\/p>\n\n\n\n
-The nurse should remove one restraint at a time for a client who is violent or noncompliant.<\/p>\n\n\n\n
D. Obtain a PRN prescription for the restraints<\/p>\n\n\n\n
-incorrect: Restraint prescriptions can only be written for a 24 hours period and cannot be a PRN<\/p>\n\n\n\n
prescription.<\/p>\n\n\n\n
161. A client is being discharged home with oxygen therapy delivered through a nasal cannula.<\/p>\n\n\n\n
Which of the following instructions should the nurse provide to the client and family members?<\/p>\n\n\n\n
A. Use battery-operated equipment for personal care.<\/p>\n\n\n\n
-incorrect: Electrical equipment in good condition with no frayed wires is acceptable for personal<\/p>\n\n\n\n
care when oxygen is administered.<\/p>\n\n\n\n
B. Apply mineral oil to protect the facial skin from irritation.<\/p>\n\n\n\n
-incorrect: Most oils and petroleum products are flammable when used on the body, which is a<\/p>\n\n\n\n
contraindication for use because oxygen is a highly combustible gas.<\/p>\n\n\n\n
C. Remove the television set from the client\u2019s bedroom.<\/p>\n\n\n\n
-incorrect: As long as the television is in proper working order, there is no oxygen-related need<\/p>\n\n\n\n
to remove it from the client\u2019s bedroom.<\/p>\n\n\n\n
D. Wear cotton clothing to avoid static electricity.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg3d.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-The use of cotton clothing will limit the buildup of static electricity. Oxygen is a highly<\/p>\n\n\n\n
combustible gas. The use of oxygen in high concentrations has great combustion potential and<\/p>\n\n\n\n
readily fuels fire. Although it will not spontaneously burn or cause an explosion, it can easily<\/p>\n\n\n\n
cause a fire in a client\u2019s room if it contacts a spark.<\/p>\n\n\n\n
162. A nurse is discussing fire safety with newly hired nurses. Which of the following actions is<\/p>\n\n\n\n
the priority if a fire occurs in the health care facility?<\/p>\n\n\n\n
A. Close the fire door on the unit<\/p>\n\n\n\n
-incorrect: The nurse should close the fire doors and doors to rooms on the unit in attempt to<\/p>\n\n\n\n
confine the fire; however, there is another action that is a priority.<\/p>\n\n\n\n
B. Use a fire extinguisher on the fire<\/p>\n\n\n\n
-incorrect: The nurse should attempt to extinguish the fire; however, there is another action that<\/p>\n\n\n\n
is the priority.<\/p>\n\n\n\n
C. Pull the nearest fire alarm<\/p>\n\n\n\n
-incorrect: The nurse should activate the fire alarm and report the location of the fire; however,<\/p>\n\n\n\n
there is another action that is the priority.<\/p>\n\n\n\n
D. Evacuate clients from the unit<\/p>\n\n\n\n
-The nurse should apply the safety and risk-reduction priority-setting framework, which assigns<\/p>\n\n\n\n
priority to the factor or situation posing greatest safety risk to the client. When there are several<\/p>\n\n\n\n
risks to client safety, the one posing the greatest threat is the highest priority. The nurse should<\/p>\n\n\n\n
use Maslow\u2019s hierarchy of needs, the ABC priority-setting framework, and\/or nursing<\/p>\n\n\n\n
knowledge to identify which risk poses the greatest threat to the client. The greatest risk during a<\/p>\n\n\n\n
fire is injury to clients; therefore, the nurse\u2019s priority action is to evacuate clients from the unit.<\/p>\n\n\n\n
The nurse should follow the RACE protocol when responding to a fire: rescue, activate, confine,<\/p>\n\n\n\n
and extinguish.<\/p>\n\n\n\n
163. A nurse on a medical-surgical unit is caring for a client who is at risk of experiencing<\/p>\n\n\n\n
seizures. Which of the following pieces of equipment must be available at the client\u2019s bedside at<\/p>\n\n\n\n
all times?<\/p>\n\n\n\n
A. Suction equipment<\/p>\n\n\n\n
-The greatest risk to a client who is having a seizure is an injury from aspirating secretions or<\/p>\n\n\n\n
emesis; therefore, the nurse must have suction equipment available for clearing the mouth of<\/p>\n\n\n\n
secretions or emesis to reduce this risk.<\/p>\n\n\n\n
B. Clean gloves<\/p>\n\n\n\n
-incorrect: The nurse should have clean gloves available to check the client\u2019s mouth for injuries<\/p>\n\n\n\n
to the mucous membranes or teeth; however, other equipment is the nurse\u2019s priority.<\/p>\n\n\n\n
C. Blankets<\/p>\n\n\n\n
-incorrect: The nurse should have blankets and linens available to pad the side rails if a seizure<\/p>\n\n\n\n
begins while the client is in bed to help prevent injury; however, other equipment is the nurse\u2019s<\/p>\n\n\n\n
priority.<\/p>\n\n\n\n
D. Oxygen<\/p>\n\n\n\n
-incorrect: During and after a seizure, some clients require supplemental oxygen to maintain<\/p>\n\n\n\n
oxygen saturation; therefore, the nurse should have oxygen ready to administer. However, other<\/p>\n\n\n\n
equipment is the nurse\u2019s priority.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg3e.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
164. A nurse is preparing a sterile field for a procedure the provider will perform at the client\u2019s<\/p>\n\n\n\n
bedside. Which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Hold the sterile drape above the waist and away from the body<\/p>\n\n\n\n
-Contamination occurs when the nurse holds any object that will be part of the sterile field below<\/p>\n\n\n\n
the waist or allows it to touch anything other than a sterile object.<\/p>\n\n\n\n
B. Drop sterile objects toward the edges of the sterile field<\/p>\n\n\n\n
-incorrect: The nurse should drop sterile objects toward the center of the sterile field, as the 2.5<\/p>\n\n\n\n
cm (1 in) border around the periphery of the field is not sterile.<\/p>\n\n\n\n
C. Hold packaged supplies 7.6 cm (3 in) above the sterile field<\/p>\n\n\n\n
-incorrect: The nurse should hold packaged supplies 15cm (6in) above the sterile field before<\/p>\n\n\n\n
opening them and dropping them onto the sterile field.<\/p>\n\n\n\n
D. Hold sterile objects over the field before setting them down on the field<\/p>\n\n\n\n
-incorrect: The nurse should add sterile objects at an angle from the side of the sterile field to<\/p>\n\n\n\n
avoid reaching over the sterile field and contaminating it.<\/p>\n\n\n\n
165. A nurse is providing teaching about nutritious diets to a group of adult women. Which of<\/p>\n\n\n\n
the following statements should the nurse include?<\/p>\n\n\n\n
A. \u201cInclude at least 3g of sodium in you daily diet.\u201d<\/p>\n\n\n\n
-incorrect: The nurse should instruct the women to consume sodium in moderation. The AHA<\/p>\n\n\n\n
recommends consuming less than 2.5g of sodium daily, and the adequate intake (AI) is 1.5g.<\/p>\n\n\n\n
Excessive intake of sodium can lead to hypertension.<\/p>\n\n\n\n
B. \u201cLimit wine consumption to 230 mL daily.\u201d<\/p>\n\n\n\n
-incorrect: Although certain alcoholic beverages, such as red wine, contain phytochemicals that<\/p>\n\n\n\n
can reduce the risk of cardiovascular disease and offer anti-inflammatory properties, excessive<\/p>\n\n\n\n
intake can lead to a deficiency in other nutrients. The recommended amount of alcohol for<\/p>\n\n\n\n
women is a drink per day, which is equivalent to 350 mL (12oz) of beer, 148 mL (5oz) of wine,<\/p>\n\n\n\n
or 44 mL (1.5oz) of hard alcohol that is over 80 proof.<\/p>\n\n\n\n
C. \u201cInclude 2.5 cups of vegetables in your daily diet.\u201d<\/p>\n\n\n\n
-Nutritious diets contain a variety of foods to ensure the required daily allowance of nutrients is<\/p>\n\n\n\n
ingested. The nurse should instruct the women to include 2.5 cups of vegetables and 2 cups of<\/p>\n\n\n\n
fruit in their daily diets. Fruits and vegetables should be a variety of colors to provide an<\/p>\n\n\n\n
assortment of nutrients.<\/p>\n\n\n\n
D. \u201cLimit water intake to 1.5 L each day.\u201d<\/p>\n\n\n\n
-incorrect: Water is an important component of a nutritious diet because it is necessary for the<\/p>\n\n\n\n
digestion, absorption, and transport of nutrients. The nurse should instruct these women to drink<\/p>\n\n\n\n
between 2-3 L of water daily to maintain homeostasis, based on client comorbidities, the climate,<\/p>\n\n\n\n
and the client\u2019s activity level.<\/p>\n\n\n\n
166. A nurse is caring for a client who has a BMI of 29 and expresses a desire to lose weight.<\/p>\n\n\n\n
Which of the following actions should the nurse take first?<\/p>\n\n\n\n
A. Refer the client to a nutritionist<\/p>\n\n\n\n
-incorrect: Effective weight management involves establishing and following healthy eating<\/p>\n\n\n\n
habits. The nurse should refer the client to a nutritionist for an evaluation of the client\u2019s dietary<\/p>\n\n\n\n
needs and dietary recommendations to promote weight loss. However, this is not the first action<\/p>\n\n\n\n
the nurse should take.<\/p>\n\n\n\n
B. Discuss eating strategies with the client<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg3f.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The nurse should discuss various eating strategies, such as portion control and the<\/p>\n\n\n\n
reduction or elimination of sugar-sweetened beverages, as a means of reducing weight. However,<\/p>\n\n\n\n
this is not the first action the nurse should take.<\/p>\n\n\n\n
C. Determine the client\u2019s intention to change current eating habits<\/p>\n\n\n\n
-When using the nursing process, the nurse should first assess the client\u2019s readiness to commit to<\/p>\n\n\n\n
change in behavior.<\/p>\n\n\n\n
D. Instruct the client to perform 30 mins of vigorous exercise daily<\/p>\n\n\n\n
-incorrect: Although the nurse should recommend increasing activity to promote overall health<\/p>\n\n\n\n
and weight loss, this is not the first action the nurse should take.<\/p>\n\n\n\n
167. A nurse is performing an otoscopic examination of a client\u2019s right ear. The light reflex is<\/p>\n\n\n\n
visible in the right lower quadrant of the tympanic membrane. Which of the following actions<\/p>\n\n\n\n
should the nurse take in response to this finding?<\/p>\n\n\n\n
A. Obtain an audiology referral<\/p>\n\n\n\n
-incorrect: Difficulty hearing or understanding speech indicates the need for a referral to an<\/p>\n\n\n\n
audiologist for audiometry testing.<\/p>\n\n\n\n
B. Document this as an expected finding<\/p>\n\n\n\n
-The light of the otoscope reflects off the tympanic membrane, which is cone-shaped or<\/p>\n\n\n\n
triangular. In the right ear, it is visible in the right lower quadrant of the eardrum. In the left ear,<\/p>\n\n\n\n
it is visible in the left lower quadrant.<\/p>\n\n\n\n
C. Irrigate the ear with warm water<\/p>\n\n\n\n
-incorrect: Cerumen blocking visualization of the eardrum indicates the need for irrigation.<\/p>\n\n\n\n
D. Document mild inflammation<\/p>\n\n\n\n
-incorrect: A pink eardrum, not a visible triangle of light, indicates mild inflammation.<\/p>\n\n\n\n
168. A nurse is assessing a client\u2019s respiratory system. Which of the following breath sounds<\/p>\n\n\n\n
should the nurse expect to hear over the periphery of the major lung fields?<\/p>\n\n\n\n
A. Vesicular<\/p>\n\n\n\n
-The nurse will hear vesicular sounds over the periphery of the major lung fields. These sounds<\/p>\n\n\n\n
are soft and low-pitched.<\/p>\n\n\n\n
B. Bronchial<\/p>\n\n\n\n
-incorrect: The nurse will hear bronchial sounds over the trachea. These sounds are high-pitched,<\/p>\n\n\n\n
hollow, and loud.<\/p>\n\n\n\n
C. Rhonchi<\/p>\n\n\n\n
-incorrect: The nurse will hear rhonchi or gurgling sounds over the trachea and the bronchi if the<\/p>\n\n\n\n
airways are narrow due to secretions or swelling.<\/p>\n\n\n\n
D. Bronchovesicular<\/p>\n\n\n\n
-incorrect: The nurse will hear bronchovesicular sounds on either side of the sternal border<\/p>\n\n\n\n
anteriorly and between the scapulae posteriorly.These sounds are moderately loud with a<\/p>\n\n\n\n
medium pitch.<\/p>\n\n\n\n
169. A nurse is teaching a middle-aged female client about disease prevention and health<\/p>\n\n\n\n
maintenance. Which of the following diagnostic tests should the nurse recommend as part of this<\/p>\n\n\n\n
client\u2019s routine health screening?<\/p>\n\n\n\n
A. Annual Papanicolaou (Pap) testing<\/p>\n\n\n\n
-incorrect: Women ages 30-65 years should have a pap test every 3 years.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg40.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
B. Mammogram every 2 years<\/p>\n\n\n\n
-incorrect: Women ages 45 years and older should have an annual mammogram. At age 55,<\/p>\n\n\n\n
clients may decide to change this schedule to every 2 years or continue with annual<\/p>\n\n\n\n
mammograms.<\/p>\n\n\n\n
C. Eye examination every 2 years<\/p>\n\n\n\n
-This is essential not only for monitoring vision but also for checking for glaucoma. The client<\/p>\n\n\n\n
should have annual eye exams from the age of 65 onward.<\/p>\n\n\n\n
D. Annual colonoscopy<\/p>\n\n\n\n
-incorrect: The client should have a colonoscopy every 10 years. If the client has risk factors for<\/p>\n\n\n\n
colorectal cancer, testing should occur more often and with other evaluations.<\/p>\n\n\n\n
170. A nurse is providing nutrition counseling to a middle-aged adult client who has a sedentary<\/p>\n\n\n\n
job. Which of the following factors should the nurse consider?<\/p>\n\n\n\n
A. The risk of eating disorders increases at this age<\/p>\n\n\n\n
-incorrect: Eating disorders such as anorexia more commonly develop during adolescence and<\/p>\n\n\n\n
young adulthood.<\/p>\n\n\n\n
B. The client\u2019s basal metabolic rate could decrease<\/p>\n\n\n\n
-The basal metabolic rate decreases as adipose tissue replaces skeletal muscle mass. This places<\/p>\n\n\n\n
the client at risk of weight gain if a healthy diet is not maintained.<\/p>\n\n\n\n
C. Daily vitamins will become necessary to meet nutritional needs<\/p>\n\n\n\n
-incorrect: Daily vitamins are not necessary if middle-aged adults consume a balanced diet.<\/p>\n\n\n\n
D. Limiting the intake or fish to once per week reduces cardiovascular risks<\/p>\n\n\n\n
-incorrect: To reduce the risk of hypertension and coronary artery disease, the client should<\/p>\n\n\n\n
consume fish at least twice per week.<\/p>\n\n\n\n
171. A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in<\/p>\n\n\n\n
the next month and may require a blood transfusion. The client expresses concern about the risk<\/p>\n\n\n\n
of acquiring an infection from the blood transfusion. Which of the following statements should<\/p>\n\n\n\n
the nurse share with the client?<\/p>\n\n\n\n
A. \u201cAsk your provider to prescribe epoetin before the surgery.\u201d<\/p>\n\n\n\n
-incorrect: Epoetin is a hematopoietic growth factor used for the treatment of anemia. While<\/p>\n\n\n\n
taking epoetin prior to surgery can boost the client\u2019s hematocrit levels, it is inappropriate if the<\/p>\n\n\n\n
client already has an adequate hematocrit level. Furthermore, this action might not eliminate the<\/p>\n\n\n\n
need for a blood transfusion and its related risks.<\/p>\n\n\n\n
B. \u201cYou should ask your provider about taking iron supplements prior to the surgery.\u201d<\/p>\n\n\n\n
-incorrect: While taking an iron supplement prior to surgery can boost the client\u2019s hemoglobin<\/p>\n\n\n\n
levels, it is inappropriate if the client already has an adequate hemoglobin level and dietary<\/p>\n\n\n\n
intake of iron. Furthermore, this action might not eliminate the need for a blood transfusion and<\/p>\n\n\n\n
its related risks.<\/p>\n\n\n\n
C. \u201cAsk a family member to donate blood for you.\u201d<\/p>\n\n\n\n
-incorrect: A blood donation from a family member does not eliminate the risk of acquiring an<\/p>\n\n\n\n
infection.<\/p>\n\n\n\n
D. \u201cDonate autologous blood before the surgery.\u201d<\/p>\n\n\n\n
-Autologous blood transfusion is the collection and reinfusion of the client\u2019s blood. With<\/p>\n\n\n\n
preoperative autologous blood donation, the blood is drawn from the client 3 to 5 weeks before<\/p>\n\n\n\n
an elective surgical procedure and stored for transfusion at the time of surgery. Autologous blood<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg41.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
is the safest form of blood transfusion because exclusive use of a client\u2019s own blood eliminates<\/p>\n\n\n\n
exposure to a transfusion-transmitted infection.<\/p>\n\n\n\n
172. A nurse is teaching a group of older adults about expected age-related changes. Which of<\/p>\n\n\n\n
the following statements by a group member indicates that the teaching has been effective?<\/p>\n\n\n\n
A. \u201cI should expect my heart rate to take longer to return to normal after exercise as I get<\/p>\n\n\n\n
older.\u201d<\/p>\n\n\n\n
-Older adults experience decreased cardiac output, which causes an increased pulse rate during<\/p>\n\n\n\n
exercise. The pulse rate also takes longer to return to normal after exercise.<\/p>\n\n\n\n
B. \u201cUrinary incontinence is something I will have to live with as I grow older.\u201d<\/p>\n\n\n\n
-incorrect: Although bladder capacity decreases in older adults, urinary incontinence is not an<\/p>\n\n\n\n
expected finding, and older adults should report incontinence so that it can be investigated and<\/p>\n\n\n\n
treated.<\/p>\n\n\n\n
C. \u201cI can expect to have less ear wax as I get older.\u201d<\/p>\n\n\n\n
-incorrect: Older adults have an increased buildup of cerumen in the ears, which may increase<\/p>\n\n\n\n
problems with hearing loss.<\/p>\n\n\n\n
D. \u201cMy stomach will empty more quickly after meals as I grow older.\u201d<\/p>\n\n\n\n
-incorrect: Decrease gastric emptying is an expected finding in older adults.<\/p>\n\n\n\n
173. A nurse is assessing a client. Which of the following findings should the nurse identify as<\/p>\n\n\n\n
an indication of protein-calorie malnourishment? (SATA)<\/p>\n\n\n\n
A. Gingivitis<\/p>\n\n\n\n
-incorrect: Gingivitis is a manifestation of Vitamin C deficiency<\/p>\n\n\n\n
B. Dry, brittle hair<\/p>\n\n\n\n
C. Edema<\/p>\n\n\n\n
D. Spoon-shaped nails<\/p>\n\n\n\n
-incorrect: Spoon-shaped nails are a manifestation of iron deficiency<\/p>\n\n\n\n
E. Poor wound healing<\/p>\n\n\n\n
-Dry, brittle hair that falls out easily suggests inadequate protein intake and malnutrition. Edema<\/p>\n\n\n\n
can occur when albumin levels are lower than expected reference range and indicates protein-<\/p>\n\n\n\n
calorie malnutrition. Adequate wound healing depends on the ingestion of sufficient protein,<\/p>\n\n\n\n
calories, water, vitamins (especially C and A), iron and zinc.<\/p>\n\n\n\n
174. A nurse is assessing a client\u2019s thyroid gland. Which of the following instructions should the<\/p>\n\n\n\n
nurse give the client before inspecting and palpating this gland?<\/p>\n\n\n\n
A. \u201cTilt your head slightly forward.\u201d<\/p>\n\n\n\n
-incorrect: To palpate the supraclavicular lymph nodes, the nurse should instruct the client to tilt<\/p>\n\n\n\n
her head forward and relax her shoulders.<\/p>\n\n\n\n
B. \u201cKeep your head straight and look ahead of you.\u201d<\/p>\n\n\n\n
-incorrect: To palpate the trachea for any deviation to the side, the nurse should instruct the client<\/p>\n\n\n\n
to keep her head in an erect, neutral position.<\/p>\n\n\n\n
C. \u201cTilt your head back and swallow.\u201d<\/p>\n\n\n\n
-To examine the thyroid gland, the nurse should instruct the client to extend her head backward<\/p>\n\n\n\n
and to swallow. The Nurse should be able to feel the thyroid gland ascend as the client swallows<\/p>\n\n\n\n
and observe any enlargement of the gland.<\/p>\n\n\n\n
D. \u201cTurn your head to the side against my hand.\u201d<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg42.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: To evaluate the strength of the neck muscles, the nurse should place a hand on the<\/p>\n\n\n\n
side of the client\u2019s head and ask her to turn her head against the resistance from the hand. The<\/p>\n\n\n\n
nurse should then repeat this step on the other side of the client\u2019s head.<\/p>\n\n\n\n
175. A nurse is providing discharge teaching for a client who has type 2 diabetes mellitus and<\/p>\n\n\n\n
will be caring for herself at home. The client expresses concerns about preparing an appropriate<\/p>\n\n\n\n
diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses<\/p>\n\n\n\n
should the nurse offer?<\/p>\n\n\n\n
A. \u201cThe home health dietitian will visit and help you learn to cook all over again.\u201d<\/p>\n\n\n\n
-incorrect: Telling the client she should learn to cook all over again does not show sensitivity to<\/p>\n\n\n\n
the client\u2019s cultural needs. It implies a judgment that the client\u2019s cooking is substandard or<\/p>\n\n\n\n
unacceptable.<\/p>\n\n\n\n
B. \u201cThe dietitian will give you a list of foods and dietary choices to keep your diabetes under<\/p>\n\n\n\n
control. \u201c<\/p>\n\n\n\n
-incorrect: Giving the client a standard list of foods and dietary choices does not show sensitivity<\/p>\n\n\n\n
to the client\u2019s cultural needs. It implies that replacing the client\u2019s cultural food preferences is the<\/p>\n\n\n\n
only therapeutic option.<\/p>\n\n\n\n
C. \u201cThe dietitian will help you choose foods you are used to that also meet your health<\/p>\n\n\n\n
needs.\u201d<\/p>\n\n\n\n
-This response shows respect for the client\u2019s food preferences and cultural needs by offering<\/p>\n\n\n\n
choices from among the client\u2019s usual foods.<\/p>\n\n\n\n
D. \u201cIt may be difficult, but I know you can change your eating and cooking habits with some<\/p>\n\n\n\n
help from the dietitian.\u201d<\/p>\n\n\n\n
-incorrect: Telling the client she will need to change her eating and cooking habits does not show<\/p>\n\n\n\n
sensitivity to the client\u2019s cultural needs. It implies a judgment that the client\u2019s eating and cooking<\/p>\n\n\n\n
habits are substandard or unacceptable.<\/p>\n\n\n\n
176. A nurse is talking with a client whose provider recently informed him of terminal pancreatic<\/p>\n\n\n\n
cancer. When the client reports that he understands the full impact of this diagnosis, the nurse<\/p>\n\n\n\n
should identify that the client is in which of the following stages of dying?<\/p>\n\n\n\n
A. Anger<\/p>\n\n\n\n
-incorrect: During the stage of anger, the client has realized the full impact of the loss and might<\/p>\n\n\n\n
express hopelessness and despair.<\/p>\n\n\n\n
B. Bargaining<\/p>\n\n\n\n
-incorrect: During the stage of bargaining, the client stalls awareness of the loss by trying to keep<\/p>\n\n\n\n
it from occurring.<\/p>\n\n\n\n
C. Depression<\/p>\n\n\n\n
-During the stage of depression, the client has realized the full impact of the loss and might<\/p>\n\n\n\n
express hopelessness and despair.<\/p>\n\n\n\n
D. Acceptance<\/p>\n\n\n\n
-incorrect: During the stage of acceptance, the client will integrate the loss (ex: by making final<\/p>\n\n\n\n
arrangements).<\/p>\n\n\n\n
177. A nurse is caring for an older adult client who becomes agitated when the nurse requests<\/p>\n\n\n\n
that the client\u2019s dentures be removed prior to surgery. Which of the following responses should<\/p>\n\n\n\n
the nurse provide?<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg43.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
A. \u201cIt\u2019s for your safety. Dentures can slip and block your airway during surgery.\u201d<\/p>\n\n\n\n
-incorrect: This represents the nontherapeutic communication technique of ignoring or<\/p>\n\n\n\n
dismissing the client\u2019s feelings and does not address the client\u2019s agitation.<\/p>\n\n\n\n
B. \u201cYou wouldn\u2019t want your teeth to be lost or broken during surgery, would you?\u201d<\/p>\n\n\n\n
-incorrect: This represents the nontherapeutic communication technique of disagreeing with the<\/p>\n\n\n\n
client and offering unsolicited advice. It does not address the client\u2019s agitation.<\/p>\n\n\n\n
C. \u201cThe anesthesiologist requires all clients to remove their dentures.\u201d<\/p>\n\n\n\n
-incorrect: This represents the nontherapeutic communication technique of focusing on<\/p>\n\n\n\n
inappropriate issues or individuals (the anesthesiologist). It does not address the client\u2019s<\/p>\n\n\n\n
agitation.<\/p>\n\n\n\n
D. \u201cWhat worries you about being without your teeth?\u201d<\/p>\n\n\n\n
-This response by the nurse is therapeutic because it validates the client\u2019s feelings of agitation<\/p>\n\n\n\n
and seeks a reason.<\/p>\n\n\n\n
178. A nurse is planning to insert a nasogastric tube for client after explaining the procedure. The<\/p>\n\n\n\n
client states, \u201cYou are not putting that hose down my throat.\u201d Which of the following statements<\/p>\n\n\n\n
should the nurse make?<\/p>\n\n\n\n
A. \u201cLet\u2019s get the process over with because you won\u2019t get better without this tube.\u201d<\/p>\n\n\n\n
-incorrect: This nontherapeutic response blocks communication by giving advice and threatening<\/p>\n\n\n\n
the client.<\/p>\n\n\n\n
B. \u201cYou should talk to your provider about your fears.\u201d<\/p>\n\n\n\n
-incorrect: This response blocks communication by rejecting the client\u2019s concerns and putting the<\/p>\n\n\n\n
client\u2019s feelings on hold, referring the client to another person at a later time.<\/p>\n\n\n\n
C. \u201cWhy don\u2019t you want the tube to be inserted?\u201d<\/p>\n\n\n\n
-incorrect: The nurse should avoid \u201cwhy\u201d questions. This response also passes judgment, which<\/p>\n\n\n\n
is a barrier to communication.<\/p>\n\n\n\n
D. \u201cI can see that this is upsetting you.\u201d<\/p>\n\n\n\n
-This response uses the therapeutic communication techniques of reflecting and restating, which<\/p>\n\n\n\n
encourages further communication by the client.<\/p>\n\n\n\n
179. A nurse is planning an in-service training session about various dietary practices. Which of<\/p>\n\n\n\n
the following pieces of information should the nurse include in the teaching?<\/p>\n\n\n\n
A. Ovo-vegetarian diets exclude eggs.<\/p>\n\n\n\n
-incorrect: Ovo-vegetarian diets are primarily vegetable-based diets that exclude meat and dairy<\/p>\n\n\n\n
except for eggs.<\/p>\n\n\n\n
B. Kosher diets have restrictions regarding how the food must be prepared.<\/p>\n\n\n\n
-Kosher diets are guided by a set of laws regarding the processing, preparation, and eating of<\/p>\n\n\n\n
food.<\/p>\n\n\n\n
C. Macrobiotic diets are plant-based and exclude all animals and seafood.<\/p>\n\n\n\n
-incorrect: Macrobiotic diets are primarily plant-based but do include fish and seafood.<\/p>\n\n\n\n
D. Flexitarian diets exclude the consumption of dairy products.<\/p>\n\n\n\n
-incorrect: Flexitarian diets are primarily plant-based with the occasional consumption of meat.<\/p>\n\n\n\n
fish, and dairy products.<\/p>\n\n\n\n
180. A nurse is planning care for a client who has anorexia and nausea due to cancer treatment.<\/p>\n\n\n\n
Which of the following interventions should the nurse include?<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg44.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
A. Serve foods at warm or hot temperatures<\/p>\n\n\n\n
-incorrect: The nurse should make sure the client receives cold or room-temperature foods.<\/p>\n\n\n\n
B. Offer the client low-density foods<\/p>\n\n\n\n
-incorrect: To increase the nutritional value of food and the client\u2019s caloric intake, the nurse<\/p>\n\n\n\n
should make sure that the client receives high-protein, high-calorie, nutrient-dense foods. The<\/p>\n\n\n\n
client should also eat nutrient-dense foods first during meals.<\/p>\n\n\n\n
C. Make sure the client lies supine after meals<\/p>\n\n\n\n
-incorrect: To reduce nausea, the client should sit upright for 1 hour after meals. The client<\/p>\n\n\n\n
should also rest before meals to conserve energy for eating and digesting food.<\/p>\n\n\n\n
D. Limit drinking liquids with food<\/p>\n\n\n\n
-Drinking beverages with food leads to early satiety and bloating, which results in the client<\/p>\n\n\n\n
consuming fewer calories.<\/p>\n\n\n\n
181. A nurse is calculating the protein needs of a young adult client who weighs 132lbs. The<\/p>\n\n\n\n
RDA for protein for an adult who has no medical conditions is 0.8g\/kg. How many grams of<\/p>\n\n\n\n
protein per day should the nurse recommend for this client?<\/p>\n\n\n\n
-48 g<\/p>\n\n\n\n
182. A nurse is caring for a client who has protein malnutrition. Which of the following foods<\/p>\n\n\n\n
should the nurse identify as a source of complete protein?<\/p>\n\n\n\n
A. Eggs<\/p>\n\n\n\n
-Complete proteins contain all the essential amino acids to support growth and homeostasis.<\/p>\n\n\n\n
Examples of complete proteins include eggs, meat, poultry, seafood, milk, yogurt, cheese,<\/p>\n\n\n\n
soybeans, and soybean products.<\/p>\n\n\n\n
B. Cereal<\/p>\n\n\n\n
-incorrect: Incomplete proteins are missing one or more of the essential amino acids necessary to<\/p>\n\n\n\n
support growth and maintain homeostasis. Cereal is an example of an incomplete protein.<\/p>\n\n\n\n
However, it can be combined with skim milk to make a complete protein.<\/p>\n\n\n\n
C. Peanut Butter<\/p>\n\n\n\n
-incorrect: Peanut butter is an example of an incomplete protein. However, it can be combined<\/p>\n\n\n\n
with whole-wheat bread to make a complete protein.<\/p>\n\n\n\n
D. Pasta<\/p>\n\n\n\n
-incorrect: Pasta is an example of an incomplete protein. However, it can be combined with<\/p>\n\n\n\n
cheese to make a complete protein.<\/p>\n\n\n\n
183. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the<\/p>\n\n\n\n
following actions should the nurse take?<\/p>\n\n\n\n
A. Administer 0.9% sodium chloride until TPN is available from the pharmacy.<\/p>\n\n\n\n
-incorrect: The nurse should administer 10% dextrose in water or 20% dextrose in water if TPN<\/p>\n\n\n\n
is temporarily unavailable from the pharmacy.<\/p>\n\n\n\n
B. Check the client\u2019s capillary blood glucose level every 4 hr<\/p>\n\n\n\n
-The nurse should check the client\u2019s capillary blood glucose level every 4 hours or according to<\/p>\n\n\n\n
facility policy due to the client\u2019s risk of hyperglycemia while receiving TPN. The dextrose<\/p>\n\n\n\n
concentration in TPN increases the risk of this complication.<\/p>\n\n\n\n
C. Obtain the client\u2019s weight each week<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg45.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: A client who is receiving TPN is at risk for fluid imbalance due to the fluid<\/p>\n\n\n\n
administration and hyperosmolarity of the TPN; therefore, the nurse should monitor the client\u2019s<\/p>\n\n\n\n
weight daily.<\/p>\n\n\n\n
D. Change the IV tubing every 3 days<\/p>\n\n\n\n
-incorrect: The nurse should change the IV tubing used for TPN every 24 hours to decrease the<\/p>\n\n\n\n
client\u2019s risk of infection.<\/p>\n\n\n\n
184. A nurse is supervising a newly licensed nurse who is suctioning a client\u2019s tracheostomy.<\/p>\n\n\n\n
Which of the following actions by the newly licensed nurse indicates an understanding of the<\/p>\n\n\n\n
procedure?<\/p>\n\n\n\n
A. Using clean technique to perform the procedure<\/p>\n\n\n\n
-incorrect: The nurse should instruct the newly licensed nurse to use sterile technique rather than<\/p>\n\n\n\n
clean technique to suction a tracheostomy to reduce the risk of infection.<\/p>\n\n\n\n
B. Applying suction while inserting the catheter<\/p>\n\n\n\n
-incorrect: The nurse should instruct the newly licensed nurse to insert the catheter gently<\/p>\n\n\n\n
without applying suction to reduce the risk of hypoxia and tissue damage.<\/p>\n\n\n\n
C. Lubricating the suction catheter with an oil-based lubricating jelly<\/p>\n\n\n\n
-incorrect: The nurse should instruct the newly licensed nurse to lubricate the suction catheter<\/p>\n\n\n\n
with sterile saline rather than oil-based lubricating jelly to reduce the risk of aspiration<\/p>\n\n\n\n
pneumonia.<\/p>\n\n\n\n
D. Administering high-flow oxygen prior to the procedure<\/p>\n\n\n\n
-The nurse should instruct the newly licensed nurse to administer 3 to 4 breaths of 100% oxygen<\/p>\n\n\n\n
via a resuscitation bag before suctioning to the client to reduce the risk of hypoxia.<\/p>\n\n\n\n
185. A nurse in a same-day procedure unit is caring for several clients who are undergoing<\/p>\n\n\n\n
different types of procedures. The nurse should anticipate that the client who has which of the<\/p>\n\n\n\n
following devices can safely undergo magnetic resonance imaging (MRI)?<\/p>\n\n\n\n
A. Coronary artery stents<\/p>\n\n\n\n
-incorrect: A coronary artery stent is a contraindication for undergoing MRI. The powerful<\/p>\n\n\n\n
magnetic field of the MRI system could pull on the metal stent and dislodge it.<\/p>\n\n\n\n
B. Aneurysm clip<\/p>\n\n\n\n
-incorrect: An aneurysm clip is contraindicated for undergoing MRI. The powerful magnetic<\/p>\n\n\n\n
field of the MRI system could pull on the metal clip and dislodge it.<\/p>\n\n\n\n
C. Hearing aids<\/p>\n\n\n\n
-A client who has hearing aids can undergo MRI because the hearing aids can be removed. The<\/p>\n\n\n\n
powerful magnetic field of the MRI system could damage the hearing aids, so they should be<\/p>\n\n\n\n
removed prior to the client undergoing MRI.<\/p>\n\n\n\n
D. Automated internal defibrillator<\/p>\n\n\n\n
-incorrect: An automated internal defibrillator is a contraindication for undergoing MRI. The<\/p>\n\n\n\n
powerful magnetic field of the MRI system could damage the defibrillator and cause it to<\/p>\n\n\n\n
malfunction.<\/p>\n\n\n\n
186. A nurse is caring for a client who is postoperative following a vaginal hysterectomy and<\/p>\n\n\n\n
asks for a drink. Her postoperative diet prescription states \u201cclear liquids; advance diet as<\/p>\n\n\n\n
tolerated.\u201d Which of the following responses should the nurse make?<\/p>\n\n\n\n
A. \u201cLunch trays should be here within the hour.\u201d<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg46.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: This response is the nontherapeutic and indicates that the client\u2019s immediate needs are<\/p>\n\n\n\n
not important.<\/p>\n\n\n\n
B. \u201cI am going to listen to your abdomen.\u201d<\/p>\n\n\n\n
-A common reason clients experience nausea and vomiting after surgery is delayed gastric<\/p>\n\n\n\n
emptying time or decreased peristalsis. The nurse should auscultate the client\u2019s abdomen to<\/p>\n\n\n\n
determine the presence of bowel sounds before clear liquids can be administered.<\/p>\n\n\n\n
C. \u201cI\u2019ll get you some water to drink.\u201d<\/p>\n\n\n\n
-incorrect: When a client is ready to resume a postsurgical diet, the nurse should offer clear<\/p>\n\n\n\n
liquids rather than water. Water provides hydration but no other nutrients.<\/p>\n\n\n\n
D. \u201cLet\u2019s wait a bit so you don\u2019t feel sick.\u201d<\/p>\n\n\n\n
-This response provides nontherapeutic communication by offering unsolicited advice to the<\/p>\n\n\n\n
client.<\/p>\n\n\n\n
187. A nurse is changing the dressings for a client recovering from an appendectomy following<\/p>\n\n\n\n
a ruptured appendix. The client\u2019s surgical would is healing by secondary intention. Which of the<\/p>\n\n\n\n
following observations should the nurse report to the provider?<\/p>\n\n\n\n
A. Tenderness when touched<\/p>\n\n\n\n
-incorrect: Tenderness when touched is an expected finding in a postoperative wound that is<\/p>\n\n\n\n
healing by secondary intention. Sever pain might indicate infection or underlying tissue<\/p>\n\n\n\n
destruction and should be reported.<\/p>\n\n\n\n
B. Pink, shiny tissue with a granular appearance<\/p>\n\n\n\n
-incorrect: Pink, shiny tissue with a grainy appearance is granulation tissue and indicates the<\/p>\n\n\n\n
proliferative stage of wound healing. This is an expected finding in a postoperative wound<\/p>\n\n\n\n
healing by secondary intention.<\/p>\n\n\n\n
C. Serosanguineous drainage<\/p>\n\n\n\n
-incorrect: Serosanguineous drainage, which is made up of RBCs and plasm, is an expected<\/p>\n\n\n\n
finding in a postoperative wound healing by secondary intention. Purulent drainage suggest<\/p>\n\n\n\n
infection and should be reported.<\/p>\n\n\n\n
D. Halo of erythema on the surrounding skin<\/p>\n\n\n\n
-The nurse should report to the provider when the client has a ring of erythema (redness) on the<\/p>\n\n\n\n
surrounding skin, which might indicate underlying infection. This and any other manifestation of<\/p>\n\n\n\n
infection (ex: purulent drainage, swelling, warmth, or a strong odor) should be reported to the<\/p>\n\n\n\n
provider.<\/p>\n\n\n\n
188. A nurse is caring for a client with dehydration who has developed hypovolemic shock.<\/p>\n\n\n\n
Which of the following laboratory values should the nurse expect for this client?<\/p>\n\n\n\n
A.BUN 18 mg\/dL<\/p>\n\n\n\n
-incorrect: This BUN falls within the expected reference range; therefore, it does not indicate<\/p>\n\n\n\n
hypovolemia.<\/p>\n\n\n\n
B. Capillary refill 1.5 sec<\/p>\n\n\n\n
-incorrect: This capillary refill time is within the expected reference range. With dehydration, it<\/p>\n\n\n\n
tends to be longer.<\/p>\n\n\n\n
C. Hct 55%<\/p>\n\n\n\n
-An elevated hematocrit indicates hypovolemia. Other indications of hypovolemia are a weak<\/p>\n\n\n\n
pulse, tachycardia, hypotension, tachypnea, slow capillary refill, elevated BUN, increased urine<\/p>\n\n\n\n
specific gravity, and decreased urine output.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg47.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
D. Urine specific gravity 1.001<\/p>\n\n\n\n
-incorrect: This low urine specific gravity indicates hypervolemia, not hypovolemia.<\/p>\n\n\n\n
189. A nurse is caring for a client who was transferred to the surgical unit by stretcher from the<\/p>\n\n\n\n
PACU. Which of the following actions should the nurse perform immediately following the<\/p>\n\n\n\n
transfer?<\/p>\n\n\n\n
A. Administer pain medication<\/p>\n\n\n\n
-incorrect: The nurse should assess the client\u2019s pain and administer medication to relieve pain<\/p>\n\n\n\n
and promote comfort as needed. However, the nurse should take another action first.<\/p>\n\n\n\n
B. Check the client\u2019s vital signs<\/p>\n\n\n\n
-The greatest risk to this client is an injury from unstable vital signs (ex: hypotension and<\/p>\n\n\n\n
respiratory depression) after receiving anesthesia and medication. Therefore, the first action the<\/p>\n\n\n\n
nurse should take is to check the client\u2019s vital signs and compare them with the readings during<\/p>\n\n\n\n
the PACU stay.<\/p>\n\n\n\n
C. Instruct the client to use the incentive spirometer every 1 hr<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client about using the incentive spirometer to prevent<\/p>\n\n\n\n
the development of atelectasis. However, the nurse should take another action first.<\/p>\n\n\n\n
D. Provide ice chips as per provider prescription<\/p>\n\n\n\n
-incorrect: The nurse should provide ice chips to the client as per provider prescription to<\/p>\n\n\n\n
promote comfort. However, the nurse should take another action first.<\/p>\n\n\n\n
190. A nurse is performing a focused assessment of a client\u2019s peripheral vascular system. In<\/p>\n\n\n\n
which of the following locations should the nurse palpate the posterior tibial pulse?<\/p>\n\n\n\n
A. Below the medial malleolus<\/p>\n\n\n\n
-The nurse should palpate tibial pulse by curving the fingers around the medial malleolus on the<\/p>\n\n\n\n
inner surface of the client\u2019s ankle.<\/p>\n\n\n\n
B. In the popliteal fossa<\/p>\n\n\n\n
-incorrect: The nurse should evaluate the client\u2019s popliteal pulse by palpating behind the knee in<\/p>\n\n\n\n
the area of the popliteal fossa.<\/p>\n\n\n\n
C. In the antecubital space<\/p>\n\n\n\n
-incorrect: The nurse should evaluate the client\u2019s brachial pulse by palpating in the groove<\/p>\n\n\n\n
between the biceps and triceps muscles in the area of the antecubital fossa.<\/p>\n\n\n\n
D. On the dorsum of the foot<\/p>\n\n\n\n
-incorrect: The nurse should evaluate the client\u2019s dorsalis pedis pulse by palpating on the dorsum<\/p>\n\n\n\n
of the foot.<\/p>\n\n\n\n
191. A nurse is measuring the blood pressure of several clients. Which of the following results is<\/p>\n\n\n\n
within the expected reference range for blood pressure?<\/p>\n\n\n\n
A. 142\/85 mmHg<\/p>\n\n\n\n
B. 116\/70 mmHg<\/p>\n\n\n\n
-This blood pressure is within the expected reference range, which is any value <120 mmHg<\/p>\n\n\n\n
systolic and <80 mmHg diastolic<\/p>\n\n\n\n
C. 130\/76 mmHg<\/p>\n\n\n\n
D. 124\/82 mmHg<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg48.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
192. A nurse is obtaining a capillary blood sample to determine a client\u2019s blood glucose level.<\/p>\n\n\n\n
The nurse prepares and punctures the client\u2019s finger for the procedure but does not obtain an<\/p>\n\n\n\n
adequate amount of blood. Which of the following actions should the nurse take next?<\/p>\n\n\n\n
A. Smear the small amount of blood onto the testing strip<\/p>\n\n\n\n
-incorrect: Smearing the blood on the reagent strip will lead to an inaccurate result.<\/p>\n\n\n\n
B. Hold the finger above heart level<\/p>\n\n\n\n
-incorrect: To improve blood flow, the nurse should keep the client\u2019s hand in a dependent<\/p>\n\n\n\n
position.<\/p>\n\n\n\n
C. Massage the client\u2019s fingertip<\/p>\n\n\n\n
-incorrect: Massaging can hemolyze the specimen, leading to an inaccurate result.<\/p>\n\n\n\n
D. Wrap the client\u2019s finger in a warm washcloth<\/p>\n\n\n\n
-Warmth helps increase the blood flow to the client\u2019s finger.<\/p>\n\n\n\n
193. A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should<\/p>\n\n\n\n
identify that the purpose of inflating the cuff includes which of the following? (SATA)<\/p>\n\n\n\n
A. Allowing the client to speak<\/p>\n\n\n\n
-incorrect: The client cannot speak when an endotracheal tube is in place.<\/p>\n\n\n\n
B. Stabilizing theposition ofthe tube<\/p>\n\n\n\n
C. Preventing aspiration of secretions<\/p>\n\n\n\n
D. Preventing air leaks<\/p>\n\n\n\n
-An inflated cuff helps prevent movement of the endotracheal tube, reduces the risk of aspiration<\/p>\n\n\n\n
of oropharyngeal secretions, and keeps air from leaking around the outer portion of the<\/p>\n\n\n\n
endotracheal tube.<\/p>\n\n\n\n
E. Preventing tracheal injury<\/p>\n\n\n\n
-incorrect: An inflated cuff does not prevent tracheal injury. If the cuff is overinflated and<\/p>\n\n\n\n
exerting a pressure that exceeds 25 mmHg, it can cause tracheal ischemia and necrosis.<\/p>\n\n\n\n
194. A nurse is reviewing the laboratory values of a client who has positive Chvostek\u2019s sign.<\/p>\n\n\n\n
Which of the following laboratory findings should the nurse expect?<\/p>\n\n\n\n
A. Decreased calcium<\/p>\n\n\n\n
-Calcium is necessary for nerve conduction and muscle contractions. When the client\u2019s total<\/p>\n\n\n\n
calcium level is <8.4 mg\/dL, tetany and muscle spasms may occur. The nurse should tap the<\/p>\n\n\n\n
facial nerve in front of the client\u2019s ear. If facial muscle twitching follows this stimulus, it if a<\/p>\n\n\n\n
positive Chvostek\u2019s sign and an indication of hypocalcemia.<\/p>\n\n\n\n
B. Decreased potassium<\/p>\n\n\n\n
-incorrect: Hypokalemia occurs when the client\u2019s potassium is <3.5 mEq\/L. The nurse should<\/p>\n\n\n\n
assess the client for muscle weakness and other clinical manifestations of hypokalemia, not a<\/p>\n\n\n\n
positive Chvostek\u2019s sign.<\/p>\n\n\n\n
C. Increased potassium<\/p>\n\n\n\n
-incorrect: Hyperkalemia occurs when the client\u2019s potassium is >5.0mEq\/L. The nurse should<\/p>\n\n\n\n
assess the client for muscle weakness, cardiac dysrhythmias, and other clinical manifestations of<\/p>\n\n\n\n
hyperkalemia but not a positive Chvostek\u2019s sign.<\/p>\n\n\n\n
D. Increased calcium<\/p>\n\n\n\n
-incorrect: Hypercalcemia occurs when the client\u2019s total calcium level is <10.5mg\/dL. The nurse<\/p>\n\n\n\n
should assess the client for lethargy, weakness, and other clinical manifestations of<\/p>\n\n\n\n
hypercalcemia but not a positive Chvostek\u2019s sign.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg49.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
195. A nurse is assessing a client who has fluid-volume excess. Which of the following findings<\/p>\n\n\n\n
should the nurse expect?<\/p>\n\n\n\n
A. Crackles in the lung fields<\/p>\n\n\n\n
-Manifestations of fluid-volume excess include crackles in the lungs, dependent edema, full neck<\/p>\n\n\n\n
veins when the client is upright, elevated blood pressure, and sudden weight gain.<\/p>\n\n\n\n
B. Flat neck veins<\/p>\n\n\n\n
-incorrect: Flat neck veins when the client is supine are a manifestation of fluid-volume deficit,<\/p>\n\n\n\n
not FVE.<\/p>\n\n\n\n
C. Postural hypotension<\/p>\n\n\n\n
-incorrect: Postural hypotension is a manifestation of FVD, not FVE.<\/p>\n\n\n\n
D. Dark yellow urine<\/p>\n\n\n\n
-incorrect: Dark yellow urine is a manifestation of FVD, not FVE.<\/p>\n\n\n\n
196. A nurse is admitting a client who is experiencing an exacerbation of heart failure. At which<\/p>\n\n\n\n
of the following times should the nurse initiate discharge planning?<\/p>\n\n\n\n
A. During the admission process<\/p>\n\n\n\n
-The nurse should initiate discharge planning as soon as the client is admitted to the facility. This<\/p>\n\n\n\n
is intended to ensure the continuity of care and meet the client\u2019s care needs. This process should<\/p>\n\n\n\n
include each member of the client\u2019s health care team.<\/p>\n\n\n\n
B. As soon as the client\u2019s condition is stable<\/p>\n\n\n\n
-incorrect: The nurse should initiate discharge planning as soon as the client is admitted to the<\/p>\n\n\n\n
facility. Continuity of care can require a transfer of the client to another facility that can meet the<\/p>\n\n\n\n
client\u2019s health-care needs, especially for a client whose condition is not stable.<\/p>\n\n\n\n
C. During the initial team conference<\/p>\n\n\n\n
-incorrect: Although this process should include each member of the client\u2019s health care team,<\/p>\n\n\n\n
the nurse should initiate discharge planning as soon as the client is admitted to the facility.<\/p>\n\n\n\n
D. On the day prior to discharge<\/p>\n\n\n\n
-incorrect: The nurse should initiate discharge planning as soon as the client is admitted to the<\/p>\n\n\n\n
facility. Waiting until the day prior to discharge might not allow enough time to meet the client\u2019s<\/p>\n\n\n\n
needs upon discharge.<\/p>\n\n\n\n
197. A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve<\/p>\n\n\n\n
stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps to<\/p>\n\n\n\n
relieve pain. Which of the following responses should the nurse take?<\/p>\n\n\n\n
A. \u201cIt provides a distraction from the pain.\u201d<\/p>\n\n\n\n
-incorrect: The nurse should inform the client that distraction is a method that can draw the<\/p>\n\n\n\n
client\u2019s attention away from the pain and help decrease the perception of pain. Methods can<\/p>\n\n\n\n
include visual, auditory, tactile, and intellectual distraction. However, this is not the way that a<\/p>\n\n\n\n
TENS unit helps relieve pain.<\/p>\n\n\n\n
B. \u201cIt modulates the transmission of the pain impulse.\u201d<\/p>\n\n\n\n
-The nurse should inform the client that a TENS unit applies low-voltage electrical stimulation<\/p>\n\n\n\n
directly over a location of pain at an acupressure point. It modulates the transmission of the pain<\/p>\n\n\n\n
impulse and can also cause a release of endorphins to assist with pain relief.<\/p>\n\n\n\n
C. \u201cIt promotes increased circulation to the painful area.\u201d<\/p>\n\n\n\n
D. \u201cIt elicits a relaxation response.\u201d<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg4a.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect C\/D: The nurse should inform the client that massage can be applied to facilitate<\/p>\n\n\n\n
relaxation, which decreases muscle tension. It can also decrease pain intensity by increasing<\/p>\n\n\n\n
superficial circulation to an area of the body experiencing pain. However, this is not the way that<\/p>\n\n\n\n
a TENS unit helps relieve pain.<\/p>\n\n\n\n
198. A nurse is evaluating a client\u2019s use of crutches. The nurse should identify that which of the<\/p>\n\n\n\n
following actions by the client indicates safe usage of this equipment?<\/p>\n\n\n\n
A. The client places a crutch on each side when assuming a sitting position.<\/p>\n\n\n\n
-incorrect: The client should place the crutches together in a hand and use the other hand to grasp<\/p>\n\n\n\n
the arm of the chair.<\/p>\n\n\n\n
B. The client moves the unaffected leg onto a step first when descending stairs.<\/p>\n\n\n\n
-incorrect: The client should move the crutches onto a step first when descending stairs, followed<\/p>\n\n\n\n
by the affected leg.<\/p>\n\n\n\n
C. The client places weight on the axillae when walking.<\/p>\n\n\n\n
-incorrect: The client should avoid placing weight on the axillae when walking. Continual<\/p>\n\n\n\n
pressure on the axillae can cause damage to the radial nerve, which can lead to crutch palsy or<\/p>\n\n\n\n
weakness of the muscles of the forearm, wrist, and hand.<\/p>\n\n\n\n
D. The client has slightly flexed elbows when ambulating with the crutches.<\/p>\n\n\n\n
-The client should have slightly flexed elbows when ambulating with crutches. This allows the<\/p>\n\n\n\n
client to bear weight on the hands and not on the axillae.<\/p>\n\n\n\n
199. A nurse is developing a plan of care for a client. Which of the following pieces of<\/p>\n\n\n\n
information should the nurse consider when planning care that is culturally congruent?<\/p>\n\n\n\n
A. Illness is not influenced by culture.<\/p>\n\n\n\n
-incorrect: A client\u2019s culture affects the social determinants of health and contributes to how an<\/p>\n\n\n\n
individual defines illness. Culture and life experiences play an important role in a client\u2019s view<\/p>\n\n\n\n
about health, illness and health care.<\/p>\n\n\n\n
B. The meaning of disease can vary widely across cultures.<\/p>\n\n\n\n
– A client may define and react to disease based on his or her unique cultural perspective. The<\/p>\n\n\n\n
nurse should seek to understand a client\u2019s culture and life experiences in order to provide care<\/p>\n\n\n\n
that is effective, evidence-based, and culturally congruent.<\/p>\n\n\n\n
C. Assigning clients to specific cultural categories facilitates communication.<\/p>\n\n\n\n
-incorrect: The nurse cannot make the assumption that all clients within a specific culture have<\/p>\n\n\n\n
the same beliefs. The nurse should consider each client as an individual and respect individual<\/p>\n\n\n\n
life patterns, values, and definitions of illness in order to provide culturally congruent care.<\/p>\n\n\n\n
D. Predetermined criteria should generate client care activities.<\/p>\n\n\n\n
-incorrect: The nurse should consider that patterns of daily life and meaning are generated by the<\/p>\n\n\n\n
client, not predetermined criteria. To provide culturally congruent care, the nurse should adjust<\/p>\n\n\n\n
client care activities such as medication administration or bath time to the client\u2019s daily patterns.<\/p>\n\n\n\n
200. A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger-stick blood<\/p>\n\n\n\n
sample. Which of the following actions by the AP requires the nurse to intervene?<\/p>\n\n\n\n
A. Elevating the finger above heart level<\/p>\n\n\n\n
-The nurse should intervene if the client elevates the finger about the level of the heart. Holding<\/p>\n\n\n\n
the finger below the level of the heart in a dependent position will help increase blood flow to the<\/p>\n\n\n\n
area and ensure an adequate specimen for collection.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg4b.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
B. Rubbing the fingertip with an alcohol pad<\/p>\n\n\n\n
-incorrect: The client should clean the finger with an antiseptic swab or with soap and water. The<\/p>\n\n\n\n
client should allow the finger to dry completely.<\/p>\n\n\n\n
C. Puncturing the side of the fingertip<\/p>\n\n\n\n
-incorrect: The client should puncture the side of the finger, avoiding sites beside bone.<\/p>\n\n\n\n
D. Wrapping the finger in a warm cloth<\/p>\n\n\n\n
-incorrect: The client should wrap the finger in a warm cloth to increase blood flow to the area.<\/p>\n\n\n\n
201. A nurse is leading an education session about disposing of biohazardous materials. Which<\/p>\n\n\n\n
of the following instructions should the nurse include in the teaching?<\/p>\n\n\n\n
A. Use isopropyl alcohol to clean blood spills<\/p>\n\n\n\n
-incorrect: Chlorine bleach should be used to clean blood spills to reduce the risk of transmission<\/p>\n\n\n\n
of microorganisms.<\/p>\n\n\n\n
B. Discard empty blood bags in a bedside trash can<\/p>\n\n\n\n
-incorrect: Empty blood bags should be returned to the blood bank in case transfusion reaction<\/p>\n\n\n\n
occurs and to reduce the risk of transmission of microorganisms.<\/p>\n\n\n\n
C. Break used needles before disposing<\/p>\n\n\n\n
-incorrect: To reduce the risk of injury, used needles should not be broken or bent.<\/p>\n\n\n\n
D. Place soiled linen in a single linen bag<\/p>\n\n\n\n
-Soiled linen should be placed in a single bag that is tightly secured to reduce the risk of<\/p>\n\n\n\n
transmission of microorganisms.<\/p>\n\n\n\n
202. A nurse is reviewing measures to prevent back injuries with assistive personnel (AP).<\/p>\n\n\n\n
Which of the following instructions should the nurse include?<\/p>\n\n\n\n
A. Stand 3 feet from the client when assisting with lifting<\/p>\n\n\n\n
-incorrect: The AP should stand as close as possible to the client to reduce back strain.<\/p>\n\n\n\n
B. Lock your knees when standing for long periods of time<\/p>\n\n\n\n
-incorrect: The AP should bend the knees and hips and rest the feet one at a time on a footrest<\/p>\n\n\n\n
when standing for long periods of time.<\/p>\n\n\n\n
C. Life up to 22.6 kg (50lb) without the use of assistive devices<\/p>\n\n\n\n
-The AP should use an assistive device or another person to lift an object weighing more than<\/p>\n\n\n\n
15.8 kg (35 lb)<\/p>\n\n\n\n
D. When lifting an object, spread your feet apart to provide a wide base of support<\/p>\n\n\n\n
-The AP should spread the feet apart because a wide base of support increases stability.<\/p>\n\n\n\n
203. A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved<\/p>\n\n\n\n
hand. The client has no documented bloodstream infection. Which of the following actions<\/p>\n\n\n\n
should the nurse take?<\/p>\n\n\n\n
A. Wash the gloved hands and then throw the gloves away<\/p>\n\n\n\n
-incorrect: Washing the hands while still gloved is not a recommended action.<\/p>\n\n\n\n
B. Prepare an incident report to document the event<\/p>\n\n\n\n
-incorrect: Unless there is a break in the nurse\u2019s skin, there is no need for an incident report.<\/p>\n\n\n\n
C. Carefully remove the gloves and proceed with hand hygiene<\/p>\n\n\n\n
-Standard precautions require the use of gloves and hand hygiene in the care of all clients.<\/p>\n\n\n\n
D. Ask the provider to order a blood culture to determine the risk of infection<\/p>\n\n\n\n
-incorrect: Unless there is a break in the nurse\u2019s skin, there is no need for further investigation.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg4c.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
204. A community health nurse is conducting a class about body mechanics for county office<\/p>\n\n\n\n
workers. Which of the following instructions should the nurse include? (SATA)<\/p>\n\n\n\n
A. \u201cSit with your back supported\u201d<\/p>\n\n\n\n
B. \u201cKeep your knees at hip level\u201d<\/p>\n\n\n\n
C. \u201cUse an ergonomically designed computer keyboard\u201d<\/p>\n\n\n\n
-Using lumbar support in a straight-back chair helps maintain posture and prevent back pain.<\/p>\n\n\n\n
Keeping the knees at the level of the hips or higher helps reduce the risk of lordosis, which is an<\/p>\n\n\n\n
exaggeration of the curve of the lumbar spine. Using a keyboard that maintains ergonomic<\/p>\n\n\n\n
positioning of the wrists can help prevent carpal tunnel syndrome.<\/p>\n\n\n\n
D. \u201cKeep your elbows away from your body.\u201d<\/p>\n\n\n\n
-incorrect: Keeping the upper arms and elbows close to the body limits straining of the shoulders<\/p>\n\n\n\n
and the upper back muscles.<\/p>\n\n\n\n
E. \u201cAdjust the monitor screen so that you have to tilt your head slightly to look at it\u201d<\/p>\n\n\n\n
-incorrect: Tilting the screen and tilting the head to look at it can strain the cervical spine.<\/p>\n\n\n\n
205. A nurse is caring for a client who requires wrist restraints. Which of the following actions<\/p>\n\n\n\n
should the nurse take?<\/p>\n\n\n\n
A. Tie a secure knot with the restraint straps<\/p>\n\n\n\n
-incorrect: The nurse must attach the restraint with a quick-release buckle or a knot that does not<\/p>\n\n\n\n
tighten when pulled.<\/p>\n\n\n\n
B. Attach the restraint\u2019s straps to the bedside rails<\/p>\n\n\n\n
-incorrect: Attaching the restraints straps to the bedside rails can lead to client injury.<\/p>\n\n\n\n
C. Make sure 3 fingers fir beneath the restraints<\/p>\n\n\n\n
-incorrect: The nurse should make sure 2 fingers fit under the restraints. If 3 fingers fit, the<\/p>\n\n\n\n
restraints are too loose. If only 1 finger fits, the restraints are too tight.<\/p>\n\n\n\n
D. Remove the restraints at least every 2 hours<\/p>\n\n\n\n
-The nurse should remove the restraints at least every 2 hours to reposition the client, provide<\/p>\n\n\n\n
fluids and nutrients, assist with ROM exercises, and evaluate the client\u2019s overall wellbeing.<\/p>\n\n\n\n
206. A nurse is admitting a client who has measles. Which of the following types of transmission<\/p>\n\n\n\n
precautions should the nurse initiate?<\/p>\n\n\n\n
A. Airborne<\/p>\n\n\n\n
-Airborne precautions are required for clients who have infections that spread via droplet nuclei<\/p>\n\n\n\n
that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles.<\/p>\n\n\n\n
B. Droplet<\/p>\n\n\n\n
-incorrect: Droplet precautions are required for clients who have infections that spread via<\/p>\n\n\n\n
droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal<\/p>\n\n\n\n
pneumonia, and streptococcal pharyngitis.<\/p>\n\n\n\n
C. Contact<\/p>\n\n\n\n
-incorrect: Contact precautions are required for clients who have infections that spread via direct<\/p>\n\n\n\n
contact or contact with the environment, including vancomycin-resistant Enterococci,<\/p>\n\n\n\n
methicillin-resistant staphylococcus aureus, and scabies.<\/p>\n\n\n\n
D. Protective environment<\/p>\n\n\n\n
-incorrect: Clients who have a compromised immune-system (ex: after an allogeneic<\/p>\n\n\n\n
hematopoietic stem cell transplant) require a protective environment.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg4d.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
207. A nurse rates a client\u2019s biceps reflex as 2+. Which of the following characteristics should<\/p>\n\n\n\n
the nurse document about the client\u2019s reflexes?<\/p>\n\n\n\n
A. Diminished<\/p>\n\n\n\n
-incorrect: diminished reflexes are 1+ or less.<\/p>\n\n\n\n
B. Average<\/p>\n\n\n\n
-Reflexes range on a scale of 0-4+. Active or expected reflexes are 2+.<\/p>\n\n\n\n
C. Brisk<\/p>\n\n\n\n
-incorrect: Brisk reflexes are 3+ or more<\/p>\n\n\n\n
D. Hyperactive<\/p>\n\n\n\n
-incorrect: Hyperactive reflexes are 4+.<\/p>\n\n\n\n
208. A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should<\/p>\n\n\n\n
place the client in which of the following positions for evaluation?<\/p>\n\n\n\n
A. Sims<\/p>\n\n\n\n
-incorrect: Sims position is used for rectal examinations and procedures.<\/p>\n\n\n\n
B. Supine<\/p>\n\n\n\n
-incorrect: Supine positioning is used for other types of assessment, such as thoracic and<\/p>\n\n\n\n
abdominal examinations.<\/p>\n\n\n\n
C. Sitting<\/p>\n\n\n\n
-The costovertebral angle is the area where the spine and the twelfth rib intersect. A sitting<\/p>\n\n\n\n
position promotes relaxation and allows access to the back for percussion of that region.<\/p>\n\n\n\n
D. Standing<\/p>\n\n\n\n
-incorrect: A standing position is used for observation of the client\u2019s posture.<\/p>\n\n\n\n
209. A nurse is employing a thorough, systematic method while obtaining objective data about a<\/p>\n\n\n\n
client. Through which of the following methods should the nurse collect this information?<\/p>\n\n\n\n
A. Health history<\/p>\n\n\n\n
-incorrect: A health history uses subjective data, which come verbally from the client or client\u2019s<\/p>\n\n\n\n
representative.<\/p>\n\n\n\n
B. Physical Examination<\/p>\n\n\n\n
-Physical findings are objective, and the nurse should collect this information in a systematic<\/p>\n\n\n\n
way.<\/p>\n\n\n\n
C. Review of systems<\/p>\n\n\n\n
-incorrect: A review of systems uses subjective data that the nurse collects during the interview<\/p>\n\n\n\n
about the client\u2019s body system and mental status. These subjective data come from the client or<\/p>\n\n\n\n
client\u2019s representative.<\/p>\n\n\n\n
D. Interview<\/p>\n\n\n\n
-incorrect: The interview is a process by which the nurse collects subjective data from the client.<\/p>\n\n\n\n
210. A nurse is assessing a client who is unconscious. Family members are present and answer<\/p>\n\n\n\n
the nurse\u2019s questions about the client\u2019s medical history. The nurse should document this<\/p>\n\n\n\n
information as which of the following types of data?<\/p>\n\n\n\n
A. Secondary-source data<\/p>\n\n\n\n
-Information provided by someone other than the client is secondary-source data.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg4e.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
B. Experimental data<\/p>\n\n\n\n
-incorrect: Experimental data are information that the nurse collects and processes while caring<\/p>\n\n\n\n
for clients.<\/p>\n\n\n\n
C. Primary-source data<\/p>\n\n\n\n
-incorrect: Primary source data come from the client, not another person or group.<\/p>\n\n\n\n
D. Quantitative data<\/p>\n\n\n\n
-incorrect: Quantitative data are information the nurse can measure and document in numerals<\/p>\n\n\n\n
(ex: vital signs).<\/p>\n\n\n\n
211. A nurse is conducting a health promotion class for a group of college students. Which of the<\/p>\n\n\n\n
following statements by a student should the nurse identify as a potential problem with achieving<\/p>\n\n\n\n
Erikson\u2019s developmental task for this age group?<\/p>\n\n\n\n
A. \u201cI am in no hurry to get married. I think I\u2019ll enjoy single life for a while.\u201d<\/p>\n\n\n\n
-incorrect: Making choices about finding a partner and raising a family is part of fulfilling<\/p>\n\n\n\n
Erikson\u2019s developmental task of intimacy vs. isolation for this age group.<\/p>\n\n\n\n
B. \u201cI go home on the weekends to be with my family because I do not have any good<\/p>\n\n\n\n
friends here on campus.\u201d<\/p>\n\n\n\n
-According to Erikson, the stage of psychosocial development for young adults is intimacy vs.<\/p>\n\n\n\n
isolation. This statement indicates that the student is having difficulty establishing relationships<\/p>\n\n\n\n
outside of the immediate family.<\/p>\n\n\n\n
C. \u201cI am interested in politics and may consider becoming an elected official.\u201d<\/p>\n\n\n\n
-incorrect: Making choices about civic responsibilities is part of fulfilling Erikson\u2019s<\/p>\n\n\n\n
developmental task of intimacy vs. isolation for this age group.<\/p>\n\n\n\n
D. \u201cI am looking forward to finishing school and going to work for my family\u2019s business.\u201d<\/p>\n\n\n\n
-incorrect: Making occupational choices is part of fulfilling Erikson\u2019s developmental task of<\/p>\n\n\n\n
intimacy vs. isolation for this age group.<\/p>\n\n\n\n
212. A nurse is teaching a newly licensed nurse about pain management in clients age 65 and<\/p>\n\n\n\n
older. Which of the following pieces of information should the nurse include in the teaching?<\/p>\n\n\n\n
A. Clients who are age 65 or older experience a decreased ability to perceive pain compared to<\/p>\n\n\n\n
young adult clients.<\/p>\n\n\n\n
-incorrect: Clients age 65 and older do not experience a decrease in pain perception.<\/p>\n\n\n\n
B. Clients who are age 65 or older are reluctant to report pain.<\/p>\n\n\n\n
-The nurse should instruct the newly licensed nurse that clients age 65 or older frequently can be<\/p>\n\n\n\n
reluctant to report pain because they might not want to bother or anger caregivers and might<\/p>\n\n\n\n
believe that pain is expected.<\/p>\n\n\n\n
C. Clients who are age 65 or older should not receive opioid narcotics.<\/p>\n\n\n\n
-incorrect: Clients age 65 and older can receive opioid narcotics for pain relief. However, these<\/p>\n\n\n\n
clients metabolize medications slowly and might require lower doses than younger adults.<\/p>\n\n\n\n
D. Clients who are age 65 or older experience a shorter duration of action with medications than<\/p>\n\n\n\n
young adult clients.<\/p>\n\n\n\n
-incorrect: Renal and liver function declines with age. Therefore, medications have a longer<\/p>\n\n\n\n
duration of action in clients who are age 65 and older. The nurse should frequently monitor these<\/p>\n\n\n\n
clients for adverse reactions and may need to administer a lower dosage of the medication at<\/p>\n\n\n\n
longer intervals compared to young adult clients.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg4f.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
213. A nurse at a screening clinic is assessing a client who reports a history of a heart murmur<\/p>\n\n\n\n
related to aortic valve stenosis. At which of the following anatomical areas should the nurse<\/p>\n\n\n\n
place the stethoscope to auscultate the aortic valve?<\/p>\n\n\n\n
A. Fifth intercostal space just medial to the midclavicular line<\/p>\n\n\n\n
-incorrect: The mitral valve is located in the fifth intercostal space just medial to the<\/p>\n\n\n\n
midclavicular line.<\/p>\n\n\n\n
B. Second intercostal space to the left of the sternum<\/p>\n\n\n\n
-incorrect: The pulmonic valve is located in the second intercostal space to the left of the<\/p>\n\n\n\n
sternum.<\/p>\n\n\n\n
C. Fifth intercostal space to the left of the sternum<\/p>\n\n\n\n
-incorrect: The tricuspid valve is located in the fifth intercostal space to the left of the sternum.<\/p>\n\n\n\n
D. Second intercostal space to the right of the sternum<\/p>\n\n\n\n
-The aortic valve is located in the second intercostal space to the right of the sternum. Aortic<\/p>\n\n\n\n
stenosis produces a mid-systolic ejection murmur that can be heard clearly at the aortic area with<\/p>\n\n\n\n
the client leaning forward.<\/p>\n\n\n\n
214. A nurse is caring for a group of clients in a long-term care facility. The nurse should<\/p>\n\n\n\n
understand that which of the following clients is eligible for hospice services at this time?<\/p>\n\n\n\n
A. A client who has multiple sclerosis and uses a wheelchair<\/p>\n\n\n\n
-incorrect: Although multiple sclerosis is a chronic debilitating disease, the client is not likely to<\/p>\n\n\n\n
be eligible for hospice services.<\/p>\n\n\n\n
B. A client who has end-stage cirrhosis<\/p>\n\n\n\n
-A client who has end stage cirrhosis likely has a life expectancy of <6 months. Therefore, this<\/p>\n\n\n\n
client is eligible for hospice services.<\/p>\n\n\n\n
C. A client who has hemiplegia due to a stroke<\/p>\n\n\n\n
-incorrect: A client who has hemiplegia due to a stroke might recover partially or fully.<\/p>\n\n\n\n
Therefore, this client is not likely to be eligible for hospice services.<\/p>\n\n\n\n
D. A client who has cancer and receives weekly radiation therapy<\/p>\n\n\n\n
-incorrect: This client is currently undergoing treatment for cancer. Therefore, this client is not<\/p>\n\n\n\n
likely to be eligible for hospice services.<\/p>\n\n\n\n
215. A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client<\/p>\n\n\n\n
states, \u201cAll this equipment is making me nervous.\u201d Which of the following responses should the<\/p>\n\n\n\n
nurse offer?<\/p>\n\n\n\n
A. \u201cYou won\u2019t need the equipment for very long.\u201d<\/p>\n\n\n\n
-incorrect: This statement illustrates the communication block of giving false reassurance. The<\/p>\n\n\n\n
nurse cannot accurately predict how long the client will need the equipment.<\/p>\n\n\n\n
B. \u201cAll of this equipment can be frightening.\u201d<\/p>\n\n\n\n
– This statement is therapeutic because the nurse is reflecting the client\u2019s statement. The client is<\/p>\n\n\n\n
feeling fearful, and this response shows the nurse understands those feelings, which will<\/p>\n\n\n\n
encourage the client to communicate more.<\/p>\n\n\n\n
C. \u201cWhy does the equipment bother you?\u201d<\/p>\n\n\n\n
-incorrect: This illustrates the communication block of requesting an explanation.<\/p>\n\n\n\n
D. \u201cLet me tell you about what each machine does.\u201d<\/p>\n\n\n\n
-incorrect: This response does not address the client\u2019s concerns about feeling nervous and<\/p>\n\n\n\n
changes the subject.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg50.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
216. A nurse is caring for a client who has terminal cancer. The client is proceeding with plans to<\/p>\n\n\n\n
build a new home. The nurse should identify that this behavior typically indicates which of the<\/p>\n\n\n\n
following stages of grief?<\/p>\n\n\n\n
A. Acceptance<\/p>\n\n\n\n
-incorrect: During the acceptance stage of grief, a client integrates the loss into his or her life (ex:<\/p>\n\n\n\n
by making final arrangements). Building a house does not usually reflect acceptance in a client<\/p>\n\n\n\n
who is dying.<\/p>\n\n\n\n
B. Bargaining<\/p>\n\n\n\n
-incorrect: During the bargaining stage of grief, a client stalls awareness of the loss by trying to<\/p>\n\n\n\n
keep it from occurring. Building a house does not usually reflect bargaining in a client who is<\/p>\n\n\n\n
dying.<\/p>\n\n\n\n
C. Anger<\/p>\n\n\n\n
-incorrect: During the anger stage of grief, a client shoes resistance or blames other people, a<\/p>\n\n\n\n
higher power, or the situation itself. Building a house does not usually reflect anger in a client<\/p>\n\n\n\n
who is dying.<\/p>\n\n\n\n
D. Denial<\/p>\n\n\n\n
-During the denial stage of grief, a client is unable to accept the reality of the loss. A client who<\/p>\n\n\n\n
has terminal disease has a limited amount of time, so building a house is unrealistic and denies<\/p>\n\n\n\n
reality.<\/p>\n\n\n\n
217. A nurse is caring for a client who is producing large amounts of urine. The nurse should<\/p>\n\n\n\n
document this finding as which of the following?<\/p>\n\n\n\n
A. Retention<\/p>\n\n\n\n
-incorrect: Retention is an accumulation of urine in the bladder as a result of incomplete<\/p>\n\n\n\n
emptying of the bladder or a cessation of the ability to urinate.<\/p>\n\n\n\n
B. Oliguria<\/p>\n\n\n\n
-incorrect: Oliguria is a diminishing urine output despite an acceptable fluid intake.<\/p>\n\n\n\n
C. Diuresis<\/p>\n\n\n\n
-Diuresis or polyuria is the excretion of a high volume of urine. This condition has many causes,<\/p>\n\n\n\n
including metabolic and hormonal imbalances and diuretic therapy for treating renal,<\/p>\n\n\n\n
cardiovascular, and pulmonary disorders.<\/p>\n\n\n\n
D. Dysuria<\/p>\n\n\n\n
-incorrect: Dysuria is painful or difficult urination, often as a result of a urinary tract infection or<\/p>\n\n\n\n
injury.<\/p>\n\n\n\n
218. A nurse is caring for a client who states that she does not want to get out of bed due to pain<\/p>\n\n\n\n
from arthritis. Which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Tell the client the provider does not want her to remain in bed<\/p>\n\n\n\n
-incorrect: This is a nontherapeutic response that implies the client should do what the provider<\/p>\n\n\n\n
wants and suggest the client has no input or control over her situation.<\/p>\n\n\n\n
B. Allow the client to remain in bed until her pain subsides<\/p>\n\n\n\n
-incorrect: Allowing the client to remain in bed could place the client at risk of complications of<\/p>\n\n\n\n
immobility, such as thrombus formation.<\/p>\n\n\n\n
C. Instruct the family to perform ADLs for the client<\/p>\n\n\n\n
-incorrect: Having the family perform ADLs for the client limits the client\u2019s independence.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg51.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
D. Advise the client to perform ROM exercises while in bed<\/p>\n\n\n\n
-Performing ROM exercises will help the client maintain mobility until her pain is under control<\/p>\n\n\n\n
and she is able to ambulate without excessive discomfort.<\/p>\n\n\n\n
219. A nurse is providing teaching about food choices to a client who has a prescription for a<\/p>\n\n\n\n
clear liquid diet. Which of the following selections by the client indicates an understanding of the<\/p>\n\n\n\n
teaching?<\/p>\n\n\n\n
A. Cream of rice<\/p>\n\n\n\n
-incorrect: cream of rice is allowed on a full liquid diet.<\/p>\n\n\n\n
B. Cottage cheese<\/p>\n\n\n\n
-incorrect: Cottage cheese is allowed on a soft diet.<\/p>\n\n\n\n
C. Gelatin<\/p>\n\n\n\n
-Foods allowed on a clear liquid diet are clear and liquid at room temperature.<\/p>\n\n\n\n
D. Ice cream<\/p>\n\n\n\n
-incorrect: Ice cream is allowed on a full liquid diet<\/p>\n\n\n\n
220. A nurse in a provider\u2019s office is talking with an older adult client who reports having<\/p>\n\n\n\n
trouble sleeping. Which of the following statements should the nurse identify as possible cause<\/p>\n\n\n\n
of the client\u2019s sleeping difficulties?<\/p>\n\n\n\n
A. \u201cI take a warm shower when getting ready for bed.\u201d<\/p>\n\n\n\n
-incorrect: A warm shower or bath can help the client relax and promotes sleep.<\/p>\n\n\n\n
B. \u201cI often have a cup of coffee with my dessert before going to bed.\u201d<\/p>\n\n\n\n
-The client should avoid beverages that contain caffeine in the late afternoon and evening<\/p>\n\n\n\n
because caffeine stimulates the CNS and can result in sleep disturbances. Caffeine is also a<\/p>\n\n\n\n
diuretic and can cause nighttime awakenings for urination.<\/p>\n\n\n\n
C. \u201cI usually read a chapter in a book before I go to bed.\u201d<\/p>\n\n\n\n
-incorrect: Reading before going to bed fosters relaxation in many individuals and might help<\/p>\n\n\n\n
promote sleep.<\/p>\n\n\n\n
D. \u201cI make sure I do my exercises in the morning.\u201d<\/p>\n\n\n\n
-incorrect: Exercising vigorously within 2 hours of bedtime can interfere with sleep.<\/p>\n\n\n\n
221. A nurse is caring for a client who is immobile. The nurse should recognize that immobility<\/p>\n\n\n\n
places the client at risk of which of the following health alterations?<\/p>\n\n\n\n
A. Increased intestinal motility<\/p>\n\n\n\n
-incorrect: Intestinal motility and peristalsis decrease with immobility.<\/p>\n\n\n\n
B. Respiratory alkalosis<\/p>\n\n\n\n
-incorrect: Immobility decreases respiratory movement, leading to poor oxygenation and carbon<\/p>\n\n\n\n
dioxide retention. If not corrected, the hypoventilation can eventually cause an immobile client<\/p>\n\n\n\n
to develop respiratory acidosis.<\/p>\n\n\n\n
C. Decreased cardiac output<\/p>\n\n\n\n
-During immobility, the client\u2019s heart rate increases to compensate for increased venous pooling.<\/p>\n\n\n\n
The reduction in circulating volume increases the workload of the heart, resulting in orthostatic<\/p>\n\n\n\n
hypotension and decreased cardiac output.<\/p>\n\n\n\n
D. Hypocalcemia<\/p>\n\n\n\n
-incorrect: Hypercalcemia occurs with immobility because bones demineralize from lack of<\/p>\n\n\n\n
weight-bearing. The excess calcium can deposit in joints, causing stiffness and pain.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg52.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
222. A nurse is assessing a client who is postoperative. Which of the following findings should<\/p>\n\n\n\n
the nurse identify as an indication that the client is experiencing pain?<\/p>\n\n\n\n
A. Diarrhea<\/p>\n\n\n\n
-incorrect: Diarrhea is not a common indication of pain. Initial responses to the stress that results<\/p>\n\n\n\n
from unrelieved or chronic pain can trigger gastrointestinal alterations, which can include<\/p>\n\n\n\n
constipation and flatus.<\/p>\n\n\n\n
B. Pupillary constriction<\/p>\n\n\n\n
-incorrect: Pupillary dilation is a more common indication of pain.<\/p>\n\n\n\n
C. Flushing<\/p>\n\n\n\n
-incorrect: Flushing is not a common indicator of pain. Initial responses to the stress resulting<\/p>\n\n\n\n
from unrelieved or chronic pain can cause pallor due to the release of norepinephrine, which<\/p>\n\n\n\n
constricts superficial blood vessels.<\/p>\n\n\n\n
D. Grimacing<\/p>\n\n\n\n
-Besides the client\u2019s self-report of pain, facial expressions such as grimacing, clenching the jaw,<\/p>\n\n\n\n
and lip biting can be indications of pain.<\/p>\n\n\n\n
223. During the completion of a health history with a nurse, a client reports intermittent chest<\/p>\n\n\n\n
pain for the past week. Which of the following questions is the nurse\u2019s priority?<\/p>\n\n\n\n
A. \u201cDid you report the chest pain episodes to your physician?\u201d<\/p>\n\n\n\n
-incorrect: Asking if the client notified the provider is important prior to the nurse reporting this<\/p>\n\n\n\n
finding to the provider. However, it is not the nurse\u2019s priority response. This question does not<\/p>\n\n\n\n
address the fact that the client is experiencing pain.<\/p>\n\n\n\n
B. \u201cIs there a history of heart disease in your family?\u201d<\/p>\n\n\n\n
-incorrect: Asking about a history of heart disease in the client\u2019s family is important for<\/p>\n\n\n\n
documenting the client\u2019s health history. However, it is not the nurse\u2019s priority response. This<\/p>\n\n\n\n
question does not address the fact that the client is currently experiencing pain.<\/p>\n\n\n\n
C. \u201cHave you had this pain before?\u201d<\/p>\n\n\n\n
-incorrect: Asking if the client had pain before these recent episodes is important for<\/p>\n\n\n\n
documenting the client\u2019s health history. However, it is not the nurse\u2019s priority response and does<\/p>\n\n\n\n
not address the fact that the client is currently having pain.<\/p>\n\n\n\n
D. \u201cCan you tell me what the pain felt like and show me exactly where it was?\u201d<\/p>\n\n\n\n
-Using the urgent vs. non-urgent approach to client care, the nurse should determine that the<\/p>\n\n\n\n
priority question for evaluating the client\u2019s pain is to quantify its characteristics, onset, duration,<\/p>\n\n\n\n
surrounding events, and location. This will help the nurse determine what action to take next.<\/p>\n\n\n\n
224. A client has 1 L of dextrose 5% in 0.45% sodium chloride infusing IV at 125 mL\/hr. How<\/p>\n\n\n\n
many hours will it take for the liter to infuse? (nearest whole number)<\/p>\n\n\n\n
-8 mL\/hr<\/p>\n\n\n\n
225. A nurse is preparing to administer 40 mL of 0.9% sodium chloride IV to infuse over 20<\/p>\n\n\n\n
mins. The drop factor of the manual IV tubing is 15 gtt\/mL. The nurse should set the manual IV<\/p>\n\n\n\n
infusion to deliver how many gtt\/min? (Nearest whole number)<\/p>\n\n\n\n
-30 gtt\/min<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg53.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
226. A nurse is preparing to administer eye drops to a client following surgery.Which of the<\/p>\n\n\n\n
following actions should the nurse take when instilling the eye drops?<\/p>\n\n\n\n
A. Drop the eye medication into the lower conjunctival sac<\/p>\n\n\n\n
-The nurse should drop the eye medication in the lower conjunctival sac to avoid placing the<\/p>\n\n\n\n
drops on the cornea and causing damage.<\/p>\n\n\n\n
B. Apply gentle pressure to the outer opening of the eye for 2 min<\/p>\n\n\n\n
-incorrect: The nurse should apply gentle pressure to the nasolacrimal duct after instilling the eye<\/p>\n\n\n\n
medication for 30-60 seconds to keep the medication from running down the duct or out of the<\/p>\n\n\n\n
eye.<\/p>\n\n\n\n
C. Hold the eyedropper 0.5 cm (0.2 in) from the cornea<\/p>\n\n\n\n
-incorrect: The nurse should hold the eyedropper 1 to 2 cm (0.4-0.8 in) from the lower<\/p>\n\n\n\n
conjunctival sac to protect the cornea of the eye from injury by preventing the tip of the dropper<\/p>\n\n\n\n
touching the eye.<\/p>\n\n\n\n
D. Instruct the client to close the eyes tightly after administration<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to close the eyes gently when applying ointment<\/p>\n\n\n\n
or liquid to distribute the medication and to avoid expelling the medication or injuring the eye.<\/p>\n\n\n\n
227. A nurse is preparing to administer a medication to a client. Which of the following<\/p>\n\n\n\n
administration schedules should the nurse identify as a prescription to administer the medication<\/p>\n\n\n\n
once and as soon as possible?<\/p>\n\n\n\n
A. Stat prescription<\/p>\n\n\n\n
-A stat medication prescription is carried out immediately or as soon as possible and for one time<\/p>\n\n\n\n
only.<\/p>\n\n\n\n
B. PRN prescription<\/p>\n\n\n\n
-incorrect: A PRN medication prescription refers to administering a medication as needed.<\/p>\n\n\n\n
C. Standing prescription<\/p>\n\n\n\n
-incorrect: A standing medication prescription indicates the frequency a prescribed medication is<\/p>\n\n\n\n
administered on a daily basis and might not have any specific date of cancelation.<\/p>\n\n\n\n
D. Single prescription<\/p>\n\n\n\n
-incorrect: A single medication prescription refers to administering a medication once and at a<\/p>\n\n\n\n
specified time.<\/p>\n\n\n\n
228. A nurse is performing a physical assessment of a client. The nurse should recognize that<\/p>\n\n\n\n
which of the following findings places the client at risk of impaired skin integrity?<\/p>\n\n\n\n
A. 3+ Achilles reflex<\/p>\n\n\n\n
-incorrect: A 3+ Achilles reflex does not indicate a risk of impaired skin integrity. Reflex testing<\/p>\n\n\n\n
provides information about the sensory and motor functions of the neurological system. A 3+<\/p>\n\n\n\n
reflex indicates a more active reflex than expected.<\/p>\n\n\n\n
B. Faint pedal pulses<\/p>\n\n\n\n
-Faint pedal pulses can indicate poo circulation and tissue perfusion, which puts the client at risk<\/p>\n\n\n\n
of impaired skin integrity.<\/p>\n\n\n\n
C. Feet warm to touch bilaterally<\/p>\n\n\n\n
-incorrect: Feet are warm to touch bilaterally do not indicate a risk of impaired skin integrity.<\/p>\n\n\n\n
This finding provides an indication of the adequacy of the client\u2019s peripheral circulation.<\/p>\n\n\n\n
D. Capillary refill of <2 sec<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg54.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: A capillary refill of <2 seconds does not indicate a risk of impaired skin integrity.<\/p>\n\n\n\n
This finding provides information about the adequacy of tissue perfusion.<\/p>\n\n\n\n
229. A nurse is performing a physical assessment of a client. Which of the following actions<\/p>\n\n\n\n
should the nurse take to assess the client\u2019s tissue perfusion?<\/p>\n\n\n\n
A. Perform a Romberg test<\/p>\n\n\n\n
-incorrect: A Romberg test is used to assess a client\u2019s balance and gross motor function. It is not<\/p>\n\n\n\n
used to assess tissue perfusion.<\/p>\n\n\n\n
B. Check nails for Beau\u2019s lines<\/p>\n\n\n\n
-incorrect: Beau\u2019s lines are depressions in the nail from temporary disturbance of nail growth.<\/p>\n\n\n\n
Beau\u2019s lines are caused by systemic illness or injury and are not indicators of tissue perfusion.<\/p>\n\n\n\n
C. Palpate for respiratory excursion<\/p>\n\n\n\n
-incorrect: Respiratory excursion is palpated to determine thoracic expansion and depth of<\/p>\n\n\n\n
breathing. It is not used to assess tissue perfusion.<\/p>\n\n\n\n
D. Perform a blanch test<\/p>\n\n\n\n
-The blanch test is used to check capillary refill, which is an indicator of peripheral circulation<\/p>\n\n\n\n
and tissue perfusion.<\/p>\n\n\n\n
230. A nurse is teaching a client who has low back pain about heat therapy.Which of the<\/p>\n\n\n\n
following statements by the client indicates an understanding of the teaching?<\/p>\n\n\n\n
A. \u201cI need to place a towel between the heating pad and my skin.\u201d<\/p>\n\n\n\n
-The nurse should instruct the client to place a towel between the heating pad and the skin to<\/p>\n\n\n\n
reduce the risk of burns.<\/p>\n\n\n\n
B. \u201cI\u2019ll need to turn up the temperature if I can\u2019t feel the heat.\u201d<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client not to increase the temperature because this can<\/p>\n\n\n\n
cause burns.<\/p>\n\n\n\n
C. \u201cI\u2019ll sleep on top of the heating pas to increase the heat penetration.\u201d<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client not to sleep on top of the heating pad because this<\/p>\n\n\n\n
can result in burns.<\/p>\n\n\n\n
D. \u201cKeeping the heat continuously on my back will help it heal.\u201d<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to apply heat for 30 mins at a time to reduce the<\/p>\n\n\n\n
risk of burns.<\/p>\n\n\n\n
231. A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a long-term<\/p>\n\n\n\n
care facility. Using this scale, which of the following parameters should the nurse evaluate?<\/p>\n\n\n\n
A. Incontinence<\/p>\n\n\n\n
-incorrect: Incontinence is a parameter on the Norton scale, not the Braden scale.<\/p>\n\n\n\n
B. Mental state<\/p>\n\n\n\n
-incorrect: Mental state is a parameter on the Norton scale, not the Baden scale.<\/p>\n\n\n\n
C. Nutrition<\/p>\n\n\n\n
-Nutrition, sensory perception, moisture, activity, mobility, and friction and shear are the<\/p>\n\n\n\n
parameters on the Braden scale for determining a client\u2019s risk of developing pressure ulcers.<\/p>\n\n\n\n
D. General physical condition<\/p>\n\n\n\n
-incorrect: General physical condition is a parameter on the Norton scale, not the Braden scale.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg55.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
232. A nurse is teaching a client how to self-administer insulin. Which of the following actions<\/p>\n\n\n\n
should the nurse take to evaluate the client\u2019s understanding of the process within the<\/p>\n\n\n\n
psychomotor domain of learning?<\/p>\n\n\n\n
A. Ask the client if he wants to self-administer his insulin<\/p>\n\n\n\n
-incorrect: Asking the client if he wants to self- administer his insulin evaluates the client\u2019s<\/p>\n\n\n\n
understanding within the affective domain of learning.<\/p>\n\n\n\n
B. Have the client list the steps of the procedure<\/p>\n\n\n\n
-incorrect: Having the client list the steps of the procedure evaluates the client\u2019s learning within<\/p>\n\n\n\n
the cognitive domain.<\/p>\n\n\n\n
C. Have the client demonstrate the procedure<\/p>\n\n\n\n
-Having the client demonstrate the procedure provides the nurse the ability to evaluate the<\/p>\n\n\n\n
client\u2019s understanding within the psychomotor domain of learning.<\/p>\n\n\n\n
D. Ask the client if he understands the purpose of insulin<\/p>\n\n\n\n
-incorrect: Asking the client if he understands the purpose of insulin evaluates the client\u2019s<\/p>\n\n\n\n
understanding within the cognitive domain of learning.<\/p>\n\n\n\n
233. A nurse is teaching a client who is postoperative how to use a flor-oriented incentive<\/p>\n\n\n\n
spirometer. Which of the following instructions should the nurse include?<\/p>\n\n\n\n
A. Blow into the spirometer to elevate the balls in the device<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to inhale deeply to elevate the balls in the device.<\/p>\n\n\n\n
B. Cough deeply after each use<\/p>\n\n\n\n
-Proper use of the incentive spirometer loosens secretions in the client\u2019s lungs. The client should<\/p>\n\n\n\n
cough deeply to facilitate the removal of secretions from his lungs.<\/p>\n\n\n\n
C. Clean the mouthpiece with an alcohol swab after each use<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to clean the mouthpiece with water and dry it after<\/p>\n\n\n\n
each use.<\/p>\n\n\n\n
D. Use the spirometer every 8 hr<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to use the spirometer several times every hour<\/p>\n\n\n\n
while awake.<\/p>\n\n\n\n
234. A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic<\/p>\n\n\n\n
procedure. Which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube<\/p>\n\n\n\n
-incorrect: The nurse should lubricate 5-8 cm (2-3 in) of the tip of the rectal tube before inserting<\/p>\n\n\n\n
it to decrease the risk of irritation or injury to the mucosa.<\/p>\n\n\n\n
B. Position the client on the right side<\/p>\n\n\n\n
-incorrect: The nurse should position the client on the left side and in the Sims position to allow<\/p>\n\n\n\n
the solution to flow downward into the sigmoid colon and rectum and promote retention of the<\/p>\n\n\n\n
enema<\/p>\n\n\n\n
C. Insert the tip of the tubing 8 cm (3.1 in)<\/p>\n\n\n\n
-The nurse should insert the tip of the tubing 7-10 cm (3-4 in) along the rectal wall to prevent<\/p>\n\n\n\n
dislodging of the tube during procedure and avoid injury to the rectal mucosa.<\/p>\n\n\n\n
D. Hold the enema container 61 cm (24in) above the rectum<\/p>\n\n\n\n
-incorrect: The nurse should hold the enema container a maximum of 45 cm (18 in) above the<\/p>\n\n\n\n
rectum to prevent painful distention of the colon.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg56.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
235. A nurse is caring for a client who is 48 hr postoperative following a small bowel resection.<\/p>\n\n\n\n
The client reports gas pains in the periumbilical area. The nurse should plan care based on which<\/p>\n\n\n\n
of the following factors contributing to this postoperative complication?<\/p>\n\n\n\n
A. Blood loss<\/p>\n\n\n\n
-incorrect: Blood loss can cause shock but does not contribute to the findings demonstrated by<\/p>\n\n\n\n
this client.<\/p>\n\n\n\n
B. NPO status after surgery<\/p>\n\n\n\n
-incorrect: NPO status after surgery can cause dehydration but does not contribute to the findings<\/p>\n\n\n\n
demonstrated by this client.<\/p>\n\n\n\n
C. Nasogastric tube suctioning<\/p>\n\n\n\n
-incorrect: Nasogastric tube suctioning keeps the stomach and intestines decompressed and can<\/p>\n\n\n\n
help prevent the findings demonstrated by this client.<\/p>\n\n\n\n
D. Impaired peristalsis of the intestines<\/p>\n\n\n\n
-Normal bowel function is delayed for up to several days following a bowel resection. When<\/p>\n\n\n\n
peristalsis is absent or sluggish, intestinal gas builds up, producing pain and abdominal<\/p>\n\n\n\n
distention. The nurse should plan to help the client ambulate to promote peristalsis.<\/p>\n\n\n\n
236. A nurse in the emergency department is assessing a client who has deep, rapid respirations.<\/p>\n\n\n\n
Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3- 18.<\/p>\n\n\n\n
Which of the following acid-base imbalances should the nurse identify and report to the<\/p>\n\n\n\n
provider?<\/p>\n\n\n\n
A. Respiratory alkalosis<\/p>\n\n\n\n
-incorrect: With respiratory alkalosis, the pH is elevated.<\/p>\n\n\n\n
B. Metabolic alkalosis<\/p>\n\n\n\n
-incorrect: With metabolic alkalosis, the pH is elevated.<\/p>\n\n\n\n
C. Respiratory acidosis<\/p>\n\n\n\n
-incorrect: With respiratory acidosis, the PaCO2 is elevated.<\/p>\n\n\n\n
D. Metabolic acidosis<\/p>\n\n\n\n
-A pH of 7.25 indicates acidosis. If the cause is respiratory, pH and PaCO2 values will deviate in<\/p>\n\n\n\n
opposite directions. Since PaCO2 is within the expected reference range, despite the low pH, the<\/p>\n\n\n\n
cause must be metabolic. Therefore, the nurse should report to the provider that the client has<\/p>\n\n\n\n
metabolic acidosis.<\/p>\n\n\n\n
237. A nurse is measuring a client\u2019s vital signs. The client\u2019s heart rate is 105\/min. The nurse<\/p>\n\n\n\n
should document this finding as which of the following alterations?<\/p>\n\n\n\n
A. Palpitation<\/p>\n\n\n\n
-incorrect: A palpitation is a subjective feeling of the heart \u201cskipping a beat\u201d or fluttering.<\/p>\n\n\n\n
B. Bradycardia<\/p>\n\n\n\n
-incorrect: Bradycardia is a heart rate under 60\/min in adults.<\/p>\n\n\n\n
C. Tachycardia<\/p>\n\n\n\n
-Tachycardia is a heart rate over 100\/min in adults.<\/p>\n\n\n\n
D. Dysrhythmia<\/p>\n\n\n\n
-incorrect: Dysrhythmia is an irregularly or erratic heart rhythm.<\/p>\n\n\n\n
238. A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a<\/p>\n\n\n\n
chair at the bedside. Which of the following actions should the nurse take first?<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg57.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
A. Provide oxygen<\/p>\n\n\n\n
-incorrect: The nurse might need to provide oxygen to the client during the postictal phase;<\/p>\n\n\n\n
however, there is another action the nurse should take first.<\/p>\n\n\n\n
B. Place the client in a side-lying position<\/p>\n\n\n\n
-incorrect: The nurse should place the client in a side-lying position if possible, to keep the<\/p>\n\n\n\n
airway clear; however, there is another action the nurse should take first.<\/p>\n\n\n\n
C. Provide privacy<\/p>\n\n\n\n
-incorrect: The nurse should provide pirvacy by closing the privacy curtain or the door to the<\/p>\n\n\n\n
client\u2019s room; however, there is another action the nurse should take first.<\/p>\n\n\n\n
D. Lower the client to the floor<\/p>\n\n\n\n
-The nurse should apply the safety and risk reduction priority-setting framework. Which assigns<\/p>\n\n\n\n
priority to the factor or situation posing the greatest safety risk to the client. When there are<\/p>\n\n\n\n
several risks to client safety, the one posing the greatest threat is the highest priority. The nurse<\/p>\n\n\n\n
should use Maslow\u2019s hierarchy of needs, the ABC priority setting-framework, and\/or nursing<\/p>\n\n\n\n
knowledge to identify which risk poses the greatest threat to the client. Therefore, if a client<\/p>\n\n\n\n
begins to have a seizure while sitting or standing, the nurse should first lower the client to the<\/p>\n\n\n\n
floor to protect the client from injury.<\/p>\n\n\n\n
239. A nurse is caring for a client who has peripheral edema. The nurse should identify that<\/p>\n\n\n\n
which of the following nutrients regulates extracellular fluid volume?<\/p>\n\n\n\n
A. Sodium<\/p>\n\n\n\n
-Sodium regulates extracellular fluid balance, nerve impulse transmission, acid-base balance, and<\/p>\n\n\n\n
various other cellular activities.<\/p>\n\n\n\n
B. Calcium<\/p>\n\n\n\n
-incorrect: Calcium supports bone and tooth formation and facilitates nerve impulse<\/p>\n\n\n\n
transmission. However, it does not affect extracellular fluid volume.<\/p>\n\n\n\n
C. Potassium<\/p>\n\n\n\n
-incorrect: Potassium affects storage of glycogen, nerve impulse transmission, cardiac<\/p>\n\n\n\n
conduction, and smooth muscle contraction. However, it does not affect extracellular fluid<\/p>\n\n\n\n
volume.<\/p>\n\n\n\n
D. Magnesium<\/p>\n\n\n\n
-incorrect: Magnesium affects enzyme and neurochemical activities and the excitability of<\/p>\n\n\n\n
cardiac and skeletal muscles. However, it does not affect extracellular fluid volume.<\/p>\n\n\n\n
240. A nurse is caring for a client who requires ventilatory assistance with breathing following a<\/p>\n\n\n\n
motor vehicle crash. The nurse should suspect an injury to which of the following parts of the<\/p>\n\n\n\n
brain?<\/p>\n\n\n\n
A. Hypothalamus<\/p>\n\n\n\n
-incorrect: The nurse should suspect an injury to the hypothalamus if a client is experiencing<\/p>\n\n\n\n
difficulty with sleeping. This area of the brain serves as the sleep center in the body by secreting<\/p>\n\n\n\n
hypocretins, which promote rapid eye movement (REM).<\/p>\n\n\n\n
B. Cerebral cortex<\/p>\n\n\n\n
-incorrect: The nurse should suspect an injury to the cerebral cortex if a client is experiencing<\/p>\n\n\n\n
difficulty with expression. This area of the brain contains the neural networks that facilitate<\/p>\n\n\n\n
complex behaviors like learning, memory, and language.<\/p>\n\n\n\n
C. Brainstem<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg58.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-The nurse should identify an injury to the medulla and pons of the brainstem for a client who is<\/p>\n\n\n\n
experiencing difficulty with breathing. The brainstem serves as the respiratory control center,<\/p>\n\n\n\n
and a neurological injury can impair this center and inhibit respiratory effort.<\/p>\n\n\n\n
D. Cerebellum<\/p>\n\n\n\n
-incorrect: The nurse should suspect an injury to the cerebellum if a client is experiencing<\/p>\n\n\n\n
difficulty controlling balance and coordination. A client\u2019s movements can become<\/p>\n\n\n\n
uncoordinated, unsure, and clumsy following an injury to this area of the brain.<\/p>\n\n\n\n
241. A nurse is caring for a client who has xerostomia with a lack of saliva. Which of the<\/p>\n\n\n\n
following nutrients will be affected by the lack of salivary amylase?<\/p>\n\n\n\n
A. Fat<\/p>\n\n\n\n
-incorrect: Lipase breaks down fat.<\/p>\n\n\n\n
B. Protein<\/p>\n\n\n\n
-incorrect: Pepsin breaks down proteins.<\/p>\n\n\n\n
C. Starch<\/p>\n\n\n\n
-Salivary amylase begins the process of digestion in the mouth with the initial breakdown of<\/p>\n\n\n\n
starches. The majority of starch breakdown occurs in the small intestine with pancreatic amylase.<\/p>\n\n\n\n
D. Fiber<\/p>\n\n\n\n
-incorrect: Fiber is not digestible, but fermentation occurs in the large intestine by intestinal<\/p>\n\n\n\n
microbes, which results in the release of methane, hydrogen, water, and fatty acids.<\/p>\n\n\n\n
242. A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client<\/p>\n\n\n\n
appears upset and refuses to take the medication before throwing the pill on the floor. Which of<\/p>\n\n\n\n
the following entries should the nurse enter into the client\u2019s medical record?<\/p>\n\n\n\n
A. The client refused to take medication today.<\/p>\n\n\n\n
-incorrect: The nurse should be specific when documenting information in the client\u2019s medical<\/p>\n\n\n\n
record. The nurse should document the name of the medication, the dose, and the time the client<\/p>\n\n\n\n
refused to take the medication.<\/p>\n\n\n\n
B. The client stated, \u201cI will not take this pill.\u201d<\/p>\n\n\n\n
-incorrect: The nurse should only document information that is factual. The nurse should not<\/p>\n\n\n\n
quote a client as having stated something that the client did not say. Even though the client<\/p>\n\n\n\n
implied a refusal of the medication, the nurse should document the occurrence accurately in the<\/p>\n\n\n\n
medical record.<\/p>\n\n\n\n
C. The client seemed angry and hostile.<\/p>\n\n\n\n
-incorrect: The nurse should avoid the use of vague terminology when documenting an<\/p>\n\n\n\n
occurrence in the client\u2019s medical record because this can indicate the nurse is stating an opinion.<\/p>\n\n\n\n
D. The client threw the medication on the floor.<\/p>\n\n\n\n
-The nurse should document exactly what took place to provide an accurate, factual account of<\/p>\n\n\n\n
the events. Thus, the nurse should document the client\u2019s actions in the medical record.<\/p>\n\n\n\n
243. A nurse is caring for a client who has breast cancer. The client has been receiving radiation<\/p>\n\n\n\n
therapy for several months and now refuses to undergo further treatment. Which of the following<\/p>\n\n\n\n
actions should the nurse take?<\/p>\n\n\n\n
A. Suggest the client talk with someone who has survived breast cancer<\/p>\n\n\n\n
-incorrect: By suggesting that the client talks with a cancer survivor, the nurse is challenging the<\/p>\n\n\n\n
client\u2019s decision, which indicates the nurse is not considering the client\u2019s feeling.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg59.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
B. Encourage the client not to give up<\/p>\n\n\n\n
-incorrect: By encouraging the client not to give up, the nurse is passing judgment on the client,<\/p>\n\n\n\n
which indicates that the nurse disapproves of the client\u2019s decision.<\/p>\n\n\n\n
C. Support the client\u2019s decision<\/p>\n\n\n\n
– The nurse has the responsibility to support the client\u2019s decision and respect the client\u2019s right of<\/p>\n\n\n\n
refusal. The nurse should notify the provider of the client\u2019s decision and document the refusal in<\/p>\n\n\n\n
the client\u2019s medical record.<\/p>\n\n\n\n
D. Refer the client to a counselor<\/p>\n\n\n\n
-incorrect: By referring the client to a counselor, the nurse is challenging the client\u2019s decision,<\/p>\n\n\n\n
which will make the client feel defensive.<\/p>\n\n\n\n
244. A nurse is assisting a client who has right-sided weakness while ambulating using a cane.<\/p>\n\n\n\n
Which of the following client actions should indicate to the nurse that the client understands the<\/p>\n\n\n\n
procedure of cane walking?<\/p>\n\n\n\n
A. The client holds the cane on the affected side<\/p>\n\n\n\n
-incorrect: When ambulating with a cane, the client should hold the cane on the unaffected or<\/p>\n\n\n\n
stronger side of the body.<\/p>\n\n\n\n
B. The client advances the unaffected leg followed by the cane<\/p>\n\n\n\n
-incorrect: When ambulating with a cane, the client should advance the cane and then follow it<\/p>\n\n\n\n
with the unaffected or stronger leg.<\/p>\n\n\n\n
C. The client supports this weight on the unaffected leg when moving the cane forward<\/p>\n\n\n\n
-incorrect: When ambulating with a cane, the client should support weight on both legs when<\/p>\n\n\n\n
moving the cane forward.<\/p>\n\n\n\n
D. The client keeps 2 points of support on the ground<\/p>\n\n\n\n
-When ambulating with a cane, the client should keep 2 points of support on the ground at all<\/p>\n\n\n\n
times, which can be either both feet or a foot and the cane.<\/p>\n\n\n\n
245. A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the<\/p>\n\n\n\n
following findings should indicate to the nurse that the client is experiencing fluid volume<\/p>\n\n\n\n
deficit?<\/p>\n\n\n\n
A. Decreased urine specific gravity<\/p>\n\n\n\n
-incorrect: An increase in urine gravity should indicate to the nurse that the client is experiencing<\/p>\n\n\n\n
fluid volume deficit.<\/p>\n\n\n\n
B. Increased heart rate<\/p>\n\n\n\n
-An increased heart rate should indicate to the nurse that the client is experiencing fluid volume<\/p>\n\n\n\n
deficit. Other findings can include an increased BUN level, dry mucous membranes, and dark<\/p>\n\n\n\n
yellow urine.<\/p>\n\n\n\n
C. Decreased hematocrit<\/p>\n\n\n\n
-incorrect: An increased hematocrit should indicate to the nurse that the client is experiencing<\/p>\n\n\n\n
fluid volume deficit.<\/p>\n\n\n\n
D. Increased skin turgor<\/p>\n\n\n\n
-Poor skin turgor should indicate to the nurse that the client is experiencing fluid volume deficit.<\/p>\n\n\n\n
246. A nurse is caring for a client who has a temperature of 38.7 C (101.7 F). Which of the<\/p>\n\n\n\n
following action should the nurse take?<\/p>\n\n\n\n
A. Apply an alcohol-water solution to the client\u2019s skin<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg5a.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: This therapy is no longer recommended as an intervention for a fever because it can<\/p>\n\n\n\n
lead to shivering, which is counterproductive and can cause an increase in energy expenditure.<\/p>\n\n\n\n
B. Keep the client\u2019s bed linens dry<\/p>\n\n\n\n
-The nurse should maximize the client\u2019s heat loss by keeping the client\u2019s clothes and bed linens<\/p>\n\n\n\n
dry. The nurse should also reduce external coverings on the client\u2019s bed without causing<\/p>\n\n\n\n
shivering.<\/p>\n\n\n\n
C. Apply ice packs to the groin<\/p>\n\n\n\n
-incorrect: This therapy is no longer recommended as an intervention for fever because it can<\/p>\n\n\n\n
lead to shivering, which is counterproductive and can cause an increase in energy expenditure.<\/p>\n\n\n\n
D. Limit the client\u2019s fluid intake to 1183 mL (40 0z) of fluid per day<\/p>\n\n\n\n
-incorrect: The nurse should satisfy the client\u2019s increased metabolic needs by providing the client<\/p>\n\n\n\n
with at least 1893 mL (64 oz) of fluid per day.<\/p>\n\n\n\n
247. A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger-stick blood<\/p>\n\n\n\n
sample. Which of the following actions by the AP requires the nurse to intervene?<\/p>\n\n\n\n
A. Elevating the finger above heart level<\/p>\n\n\n\n
-The nurse should intervene if the client elevates the finger above the level of the heart. Holding<\/p>\n\n\n\n
the finger below the level of the heart, in a dependent position; will help increase blood flow to<\/p>\n\n\n\n
the area and ensure an adequate specimen for collection.<\/p>\n\n\n\n
B. Rubbing the fingertip with an alcohol pad<\/p>\n\n\n\n
-incorrect: The client should clean the finger with an antiseptic swab or with soap and water. The<\/p>\n\n\n\n
client should allow the fingertip to dry completely.<\/p>\n\n\n\n
C. Puncturing the side of the fingertip<\/p>\n\n\n\n
-incorrect: The client should puncture the side of the finger, avoiding sites beside bone.<\/p>\n\n\n\n
D. Wrapping the finger in a warm cloth<\/p>\n\n\n\n
-incorrect: The client should wrap the finger in a warm cloth to increase blood flow to the area.<\/p>\n\n\n\n
248. A nurse is auscultating a client\u2019s lungs and identifies rhonchi over the trachea and bronchi.<\/p>\n\n\n\n
Which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Limit the client\u2019s fluid intake<\/p>\n\n\n\n
-incorrect: The nurse should not limit the client\u2019s fluid intake for rhonchi heard over the trachea<\/p>\n\n\n\n
and bronchi. The nurse should attempt to clear the adventitious sounds by asking the client to<\/p>\n\n\n\n
cough.<\/p>\n\n\n\n
B. Assist the client into a supine position<\/p>\n\n\n\n
-incorrect: The nurse should not assist the client into a supine position for rhonchi heard over the<\/p>\n\n\n\n
trachea and bronchi. The nurse should assist the client into an upright position to facilitate<\/p>\n\n\n\n
breathing.<\/p>\n\n\n\n
C. Administer oxygen at 2 L\/min<\/p>\n\n\n\n
-incorrect: The nurse should administer oxygen to a client who is experiencing shortness of<\/p>\n\n\n\n
breath or is displaying an oxygen saturation level below the expected reference range of 95% to<\/p>\n\n\n\n
100%.<\/p>\n\n\n\n
D. Encourage the client to cough<\/p>\n\n\n\n
-Rhonchi are loud, low-pitched, rumbling sounds primarily detected over the trachea and<\/p>\n\n\n\n
bronchi. The nurse should encourage the client to cough because doing so clears this adventitious<\/p>\n\n\n\n
sound.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg5b.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
249: A nurse is caring for a client who is postoperative following vascular surgery on the left<\/p>\n\n\n\n
femoral artery. The nurse should identify that the surgical wound should be cleansed in which of<\/p>\n\n\n\n
the following directions?<\/p>\n\n\n\n
A. From the middle of the thigh toward the wound<\/p>\n\n\n\n
B. From the left lower abdominal quadrant toward the wound<\/p>\n\n\n\n
C. From the left hip toward the wound<\/p>\n\n\n\n
D. From the wound toward the surrounding skin<\/p>\n\n\n\n
-The nurse should cleanse a surgical wound from the least contaminated location (the inside of<\/p>\n\n\n\n
the wound) toward the most contaminated location (the surrounding skin).<\/p>\n\n\n\n
250. A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve<\/p>\n\n\n\n
stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps<\/p>\n\n\n\n
relieve pain. Which of the following responses should the nurse make?<\/p>\n\n\n\n
A. \u201cIt provides a distraction from the pain.\u201d<\/p>\n\n\n\n
-incorrect: The nurse should inform the client that distraction is a method that can draw the<\/p>\n\n\n\n
client\u2019s attention away from the pain and help decrease the perception of pain. Methods can<\/p>\n\n\n\n
include visual, auditory, tactile, and intellectual distraction. However, this is not the way that a<\/p>\n\n\n\n
TENS unit helps relieve pain.<\/p>\n\n\n\n
B. \u201cIt modulates the transmission of the pain impulse.\u201d<\/p>\n\n\n\n
-The nurse should inform the client that a TENS unit applies low-voltage electrical stimulation<\/p>\n\n\n\n
directly over a location of pain at an acupressure point. It modulates the transmission of the pain<\/p>\n\n\n\n
impulse and can also cause a release of endorphins to assist with pain relief.<\/p>\n\n\n\n
C. \u201cIt promotes increased circulation to the painful area.\u201d<\/p>\n\n\n\n
D. \u201cIt elicits a relaxation response.\u201d<\/p>\n\n\n\n
-incorrect C\/D: The nurse should inform the client that massage can be applied to facilitate<\/p>\n\n\n\n
relaxation, which decreases muscle tension. It can also decrease pain intensity by increasing<\/p>\n\n\n\n
superficial circulation to an area of the body experiencing pain. However, this is not the way that<\/p>\n\n\n\n
a TENS unit helps to relieve pain.<\/p>\n\n\n\n
251. As part of a neurological examination, a nurse instructs a client to keep his eyes closed,<\/p>\n\n\n\n
places an object in his hand, and asks him to identify the object. Which of the following abilities<\/p>\n\n\n\n
is the nurse evaluating with this technique?<\/p>\n\n\n\n
A. Gustation<\/p>\n\n\n\n
-incorrect: Gustation is the ability to taste.<\/p>\n\n\n\n
B. Stereognosis<\/p>\n\n\n\n
-Stereognosis is the ability to identify an object\u2019s size, shape and texture via tactile sensation.<\/p>\n\n\n\n
C. Proprioception<\/p>\n\n\n\n
-incorrect: Proprioception is the awareness of the position of the body.<\/p>\n\n\n\n
D. Kinesthesia<\/p>\n\n\n\n
-incorrect: Kinesthesia is the ability to sense the position and movement of the body parts<\/p>\n\n\n\n
without visualizing them.<\/p>\n\n\n\n
252. A nurse is preparing to anchor the catheter tube with tape for a male client who has a newly<\/p>\n\n\n\n
inserted indwelling urinary catheter. At which of the following locations should the nurse tape<\/p>\n\n\n\n
the catheter?<\/p>\n\n\n\n
A. Lateral thigh<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg5c.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: Taping the indwelling urinary catheter to the client\u2019s lateral thigh or outside thigh can<\/p>\n\n\n\n
cause discomfort and tissue injury due to pressure on the urethra at the penoscrotal junction.<\/p>\n\n\n\n
B. Lower abdomen<\/p>\n\n\n\n
-The nurse should secure the client\u2019s indwelling urinary catheter with tape to the lower abdomen<\/p>\n\n\n\n
or the upper aspect of the thigh to eliminate the penoscrotal angle and prevent tissue injury.<\/p>\n\n\n\n
C. Mid-abdominal region<\/p>\n\n\n\n
-incorrect: Taping the indwelling urinary catheter to the client\u2019s mid-abdominal region can cause<\/p>\n\n\n\n
discomfort and does not allow the downward flow of urine via gravity into the drainage bag.<\/p>\n\n\n\n
D. Medial thigh<\/p>\n\n\n\n
-incorrect: Taping the indwelling urinary catheter to the client\u2019s medial or mid-thigh area can<\/p>\n\n\n\n
cause discomfort due to pressure on the urethra at the penoscrotal junction and can lead to tissue<\/p>\n\n\n\n
injury.<\/p>\n\n\n\n
253. A nurse is caring for a client who has emphysema. The client has not stopped smoking<\/p>\n\n\n\n
cigarettes and states, \u201cit\u2019s too late for me to quit.\u201d Which of the following actions should the<\/p>\n\n\n\n
nurse take?<\/p>\n\n\n\n
A. Assist the client in finding local smoking-cessation assistance programs<\/p>\n\n\n\n
-Smoking cessation slows the progression of chronic obstructive pulmonary disease (COPD). It<\/p>\n\n\n\n
is not \u201ctoo late\u201d for this client to stop smoking, and the nurse should encourage the client to do<\/p>\n\n\n\n
so.<\/p>\n\n\n\n
B. Tell the client that she will be all right receiving medical care<\/p>\n\n\n\n
-incorrect: This is an example of the nontherapeutic communication technique of giving false<\/p>\n\n\n\n
reassurance. Without smoking cessation, the client\u2019s condition will likely deteriorate further.<\/p>\n\n\n\n
C. Inform the client that she must stop smoking or the provider will not be able to care for her<\/p>\n\n\n\n
-incorrect: Threatening the client with potential harm due to lack of care is unethical and abusive.<\/p>\n\n\n\n
This action by the nurse will not help the client stop smoking. Also, in this context, the nurse\u2019s<\/p>\n\n\n\n
action violates the ethical principle of beneficence.<\/p>\n\n\n\n
D. Advocate for the client by supporting her statement about not quitting<\/p>\n\n\n\n
-incorrect: Advocacy aims to improve a client\u2019s health and safety. Rather than advocating for the<\/p>\n\n\n\n
client, the nurse is simply agreeing with the client, which is a nontherapeutic communication<\/p>\n\n\n\n
technique.<\/p>\n\n\n\n
254. A nurse is providing teaching about crutches to a client who has a fracture of the right foot.<\/p>\n\n\n\n
Which of the following instructions should the nurse include?<\/p>\n\n\n\n
A. \u201cWhen you go up a flight of stairs, place your right foot on the first step.\u201d<\/p>\n\n\n\n
-incorrect: The client should put his weight on the crutches, place his left foot on the first step,<\/p>\n\n\n\n
transfer his weight to the left foot, move the crutches to the step, and then bring up his right foot.<\/p>\n\n\n\n
B. \u201cKeep the rubber crutch tips securely in place.\u201d<\/p>\n\n\n\n
-The client should never use crutches without the rubber crutch tips. The client should inspect the<\/p>\n\n\n\n
tips regularly, replace them when they show signs of wear, and remove and dry them thoroughly<\/p>\n\n\n\n
with paper towels if they become wet.<\/p>\n\n\n\n
C. \u201cWhen standing, keep the crutches 12 inches in front of you and 12 inches to the side.\u201d<\/p>\n\n\n\n
-incorrect: The basic crutch stance should have the crutches 15 cm (6in) in front and 15 cm (6in)<\/p>\n\n\n\n
to the side of the client\u2019s feet, forming a tripod or triangular position.<\/p>\n\n\n\n
D. \u201cPlace your weight on the crutch pads at your armpits.\u201d<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg5d.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The client should have his arms bear the weight of his body. Pressure on the axillae<\/p>\n\n\n\n
can damage the radial nerve and cause weakness and partial paralysis below his elbows.<\/p>\n\n\n\n
255. A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal<\/p>\n\n\n\n
incision. Which of the following adhering devices is the best choice for the nurse to use to<\/p>\n\n\n\n
decrease skin irritation?<\/p>\n\n\n\n
A. Abdominal binder<\/p>\n\n\n\n
-incorrect: An abdominal binder can hold the dressings in place and decrease skin irritation while<\/p>\n\n\n\n
the client rests in bed; however, when the client ambulates, the dressings tend to slide out.<\/p>\n\n\n\n
Securing the dressings first is the preferred method when applying a binder. Therefore, the nurse<\/p>\n\n\n\n
should use a less-restrictive intervention first.<\/p>\n\n\n\n
B. Montgomery straps<\/p>\n\n\n\n
-The nurse should apply the least-restrictive priority-setting framework, which assigns priority to<\/p>\n\n\n\n
nursing interventions that are the least restrictive to the client, as long as those interventions do<\/p>\n\n\n\n
not jeopardize client safety. Least-restrictive interventions promote restraints when the safety of<\/p>\n\n\n\n
the client, staff members, or others is at risk. The nurse should plan to use Montgomery straps to<\/p>\n\n\n\n
minimize irritation of the skin near the incisional area. Montgomery straps are adhesive strips<\/p>\n\n\n\n
applied to the skin on either side of the surgical wound. The adhesive strips have holes for using<\/p>\n\n\n\n
gauze to tie the dressing securely.When the dressing is change, the ties are released, the dressing<\/p>\n\n\n\n
is replaced, and the ties are secured again without removing the adhesive strips.<\/p>\n\n\n\n
C. Hypoallergenic tape<\/p>\n\n\n\n
-incorrect: Hypoallergenic tape is used when a client is sensitive to adhesive material; however,<\/p>\n\n\n\n
hypoallergenic tape can cause skin sensitivity when frequently removed and reapplied. The nurse<\/p>\n\n\n\n
should use a less-restrictive intervention first.<\/p>\n\n\n\n
D. Plastic tape<\/p>\n\n\n\n
-incorrect: Plastic tape adheres well to skin and can cause skin sensitivity when frequently<\/p>\n\n\n\n
removed and reapplied. However, the nurse should use a less-restrictive intervention first.<\/p>\n\n\n\n
256. A nurse is reviewing a client\u2019s laboratory results. The client\u2019sABG levels are pH 7.5,<\/p>\n\n\n\n
PaCO2 32 mmHg and HCO3- 24 mEq\/L. The nurse should determine that the client has which<\/p>\n\n\n\n
of the following acid-base imbalances.<\/p>\n\n\n\n
A. Respiratory alkalosis<\/p>\n\n\n\n
-This client\u2019s pH is elevated above the expected reference range of 7.35 to 7.45, indicating<\/p>\n\n\n\n
alkalosis. Additionally, the client\u2019s PaCO2 is below the expected reference range of 35 to 45<\/p>\n\n\n\n
mmHg, which indicates a respiratory origin. Hence, the nurse should conclude that the client\u2019s<\/p>\n\n\n\n
elevated pH and decreased PaCO2 indicate respiratory alkalosis.<\/p>\n\n\n\n
B. Metabolic acidosis<\/p>\n\n\n\n
-incorrect: ABGs are drawn to determine the acid-base balance in the arterial blood. Acidosis is<\/p>\n\n\n\n
determined by measuring a pH lower than the expected reference range of 7.35-7.45. This client<\/p>\n\n\n\n
has a pH of 7.5 and therefore does not have acidosis.<\/p>\n\n\n\n
C. Respiratory acidosis<\/p>\n\n\n\n
-incorrect: This client\u2019s pH is elevated above the expected reference range of 7.35-7.45. Acidosis<\/p>\n\n\n\n
is presented by a lower pH, usually below 7.35.<\/p>\n\n\n\n
D. Metabolic alkalosis<\/p>\n\n\n\n
-incorrect: Metabolic origin is determined by examining the HCO3- levels. The client\u2019s<\/p>\n\n\n\n
bicarbonate is within the expected reference range of 22 to 26 mEq\/L.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg5e.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
257. A nurse is caring for a client who has a hearing impairment. Which of the following<\/p>\n\n\n\n
interventions should the nurse use when speaking with the client?<\/p>\n\n\n\n
A. Speak directly into the client\u2019s impaired ear<\/p>\n\n\n\n
-incorrect: The nurse should speak toward the client\u2019s better ear. Moving closer to the better ear<\/p>\n\n\n\n
facilitates communication.<\/p>\n\n\n\n
B. Exaggerate lip movements<\/p>\n\n\n\n
-incorrect: The nurse should accentuate words, especially consonants, so the information does<\/p>\n\n\n\n
not sound like mumbling. The client\u2019s ability to read lips is inhibited when using exaggerated lip<\/p>\n\n\n\n
movements.<\/p>\n\n\n\n
C. Speak loudly<\/p>\n\n\n\n
-incorrect: Speaking loudly or shouting can cause distortion because sounds are at a higher pitch.<\/p>\n\n\n\n
D. Face the client when speaking<\/p>\n\n\n\n
-The nurse should directly face the client who has a hearing impairment and stand or sit at the<\/p>\n\n\n\n
same level to maximize communication. Many clients who are hearing-impaired combine lip<\/p>\n\n\n\n
reading with their residual hearing when communicating.<\/p>\n\n\n\n
258. A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA).<\/p>\n\n\n\n
Which of the following precautions should the nurse implement?<\/p>\n\n\n\n
A. Place the client in a semi-private room<\/p>\n\n\n\n
-incorrect: The nurse should place the client in a private room when a wound is contaminated<\/p>\n\n\n\n
with a virulent or multi-drug resistant organism such as MRSA.<\/p>\n\n\n\n
B. Wear a mask when providing care<\/p>\n\n\n\n
-incorrect: The nurse should wear a mask when a client has an infection that can be transmitted<\/p>\n\n\n\n
via airborne or droplet routes. When splashing or spraying of body fluids is anticipated, the nurse<\/p>\n\n\n\n
will require full-face protection.<\/p>\n\n\n\n
C. Wear a gown when in the client\u2019s room<\/p>\n\n\n\n
-The nurse should apply a gown at all times when in the client\u2019s room to maintain contact<\/p>\n\n\n\n
precautions. This client who has MRSA should be placed in contact isolation, which includes the<\/p>\n\n\n\n
use of gloves and a gown when providing care.<\/p>\n\n\n\n
D. Dispose of all bed linens used by the client<\/p>\n\n\n\n
-incorrect: The nurse should use moisture-resistant single bags to collect linen. The nurse should<\/p>\n\n\n\n
not overfill and should tie the bag securely to prevent the transmission of microorganisms. The<\/p>\n\n\n\n
nurse should double bag the initial bag if the outside becomes contaminated. The linens should<\/p>\n\n\n\n
be properly sanitized and reused.<\/p>\n\n\n\n
259. A nurse is measuring a client\u2019s vital signs and notices an irregularity in the pulse. Which of<\/p>\n\n\n\n
the following actions should the nurse take?<\/p>\n\n\n\n
A. Measure the pulse using a Doppler ultrasound stethoscope<\/p>\n\n\n\n
-incorrect: The nurse should use Doppler ultrasound stethoscope for a pulse that is nonpalpable<\/p>\n\n\n\n
or difficult to palpate.<\/p>\n\n\n\n
B. Check the client\u2019s pedal pulses<\/p>\n\n\n\n
-incorrect: The nurse should assess pedal pulses to determine circulation in the client\u2019s lower<\/p>\n\n\n\n
extremities.<\/p>\n\n\n\n
C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg5f.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 60 seconds to<\/p>\n\n\n\n
obtain an accurate rate. Then, the nurse should document the irregularity in the client\u2019s medical<\/p>\n\n\n\n
record.<\/p>\n\n\n\n
D. Take the pulse at each peripheral site and count the rate for 30 sec<\/p>\n\n\n\n
-incorrect: The nurse should assess all peripheral pulses to determine the equality of blood<\/p>\n\n\n\n
perfusion to the extremities.<\/p>\n\n\n\n
260. A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room,<\/p>\n\n\n\n
the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and<\/p>\n\n\n\n
is pulseless. Which of the following actions should the nurse take first?<\/p>\n\n\n\n
A. Start chest compressions<\/p>\n\n\n\n
-The nurse should apply the safety and risk-reduction priority-setting framework, which assigns<\/p>\n\n\n\n
priority to the factor or situation posing the greatest safety risk to the client. When there are<\/p>\n\n\n\n
several risks to client safety, the one posing the greatest threat is the highest priority. The nurse<\/p>\n\n\n\n
should use Maslow\u2019s hierarchy of needs, the ABC priority-setting framework, and\/or nursing<\/p>\n\n\n\n
knowledge to identify which risk poses the greatest threat to the client. The nurse should perform<\/p>\n\n\n\n
cardiopulmonary resuscitation, which starts with chest compressions followed by opening the<\/p>\n\n\n\n
airway and breathing for adults and pediatric clients; evidence indicates a great survival rate<\/p>\n\n\n\n
when chest compressions are started before a breath is initiated.<\/p>\n\n\n\n
B. Provide breaths with a manual resuscitation bag<\/p>\n\n\n\n
-incorrect: The nurse should provide breaths with a manual resuscitation bag to oxygenate a<\/p>\n\n\n\n
client during cardiopulmonary resuscitation; however, there is another action the nurse should<\/p>\n\n\n\n
take first.<\/p>\n\n\n\n
C. Administer oxygen<\/p>\n\n\n\n
-incorrect: The nurse should administer oxygen to a client to ensure adequate oxygen is<\/p>\n\n\n\n
circulating during cardiopulmonary resuscitation; however, there is another action the nurse<\/p>\n\n\n\n
should take first.<\/p>\n\n\n\n
D. Establish an airway<\/p>\n\n\n\n
-incorrect: The nurse should establish an airway to perform ventilations and oxygenate the client<\/p>\n\n\n\n
during cardiopulmonary resuscitation; however, there is another action the nurse should perform<\/p>\n\n\n\n
first.<\/p>\n\n\n\n
261. A nurse is admitting a client who has a hearing aid. Which of the following actions should<\/p>\n\n\n\n
the nurse take before beginning the interview process?<\/p>\n\n\n\n
A. Sit beside the client during the interview<\/p>\n\n\n\n
B. Make sure the device is functioning<\/p>\n\n\n\n
-The nurse should ensure that all of the client\u2019s assistive devices are working before beginning<\/p>\n\n\n\n
the interview process<\/p>\n\n\n\n
C. Make sure lighting in the room is soft<\/p>\n\n\n\n
-incorrect: Room lighting should be bright enough to maximize the client\u2019s ability to see the<\/p>\n\n\n\n
nurse\u2019s mouth during the interview.<\/p>\n\n\n\n
D. Provide a lengthy interview process to allow adequate time to answer questions<\/p>\n\n\n\n
-incorrect: The interview process should be brief, so it does not tire the client. The nurse can<\/p>\n\n\n\n
gather additional data at a later time.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg60.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
262. A nurse is teaching a group of unit nurses about the experiences of clients who are having<\/p>\n\n\n\n
surgery. In which phase of care is the client transferred to the surgical suite table before being<\/p>\n\n\n\n
transferred to the PACU?<\/p>\n\n\n\n
A. Preoperative<\/p>\n\n\n\n
-incorrect: Preoperative care begins when the client agrees to have surgery and ends when the<\/p>\n\n\n\n
client is transferred to the surgical suite.<\/p>\n\n\n\n
B. Postoperative<\/p>\n\n\n\n
-incorrect: Postoperative care begins when the client is admitted to the PACU and ends when<\/p>\n\n\n\n
healing is complete.<\/p>\n\n\n\n
C. Intraoperative<\/p>\n\n\n\n
-Intraoperative care begins when the client is transferred to the surgical suite table and ends<\/p>\n\n\n\n
when the client is admitted to the PACU.<\/p>\n\n\n\n
D. Admission<\/p>\n\n\n\n
-incorrect: The client\u2019s admission to the facility where the surgery is to take place is part of the<\/p>\n\n\n\n
preoperative phase and typically occurs outside of the surgical suite.<\/p>\n\n\n\n
263. A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which<\/p>\n\n\n\n
of the following instructions should the nurse give the client before beginning the procedure?<\/p>\n\n\n\n
A. \u201cInhale forcefully during insertion.\u201d<\/p>\n\n\n\n
B. \u201cRaise your index finger if you need to pause during the insertion.\u201d<\/p>\n\n\n\n
-The nurse should instruct the client that the insertion of an NG tube is uncomfortable, and the<\/p>\n\n\n\n
gag reflex will be activated during the procedure. The nurse should establish a communication<\/p>\n\n\n\n
technique such as having the client raise a finger or hand to indicate distress and the need to<\/p>\n\n\n\n
pause the insertion process.<\/p>\n\n\n\n
C. \u201cBear down during insertion.\u201d<\/p>\n\n\n\n
-incorrect A\/C: The nurse should instruct the client to breathe through the mouth and swallow<\/p>\n\n\n\n
during the insertion of the tube.<\/p>\n\n\n\n
D. \u201cAvoid making any swallowing motions during the insertions.\u201d<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to swallow during the insertion of the tube to<\/p>\n\n\n\n
facilitate passage of the tube past the oropharynx.<\/p>\n\n\n\n
264. A nurse is caring for a client who has chronic kidney disease. The kidneys regulate body<\/p>\n\n\n\n
fluids as well as assisting with which of the following functions?<\/p>\n\n\n\n
A. Regulation of acid-base balance<\/p>\n\n\n\n
-The nurse should identify that the kidneys assist with regulation of acid-base balance in the<\/p>\n\n\n\n
body by retaining bicarbonate as they excrete hydrogen ions.<\/p>\n\n\n\n
B. Reabsorption of nutrients for cellular growth<\/p>\n\n\n\n
-incorrect: The small intestines absorb nutrients for cellular growth, not the kidneys.<\/p>\n\n\n\n
C. Regulation of body temperature<\/p>\n\n\n\n
-incorrect: The integumentary system, not the kidneys, helps regulate body temperature.<\/p>\n\n\n\n
D. Secretion of hormones needed for growth<\/p>\n\n\n\n
-incorrect: The anterior pituitary gland secretes somatotropin (growth hormone), which is<\/p>\n\n\n\n
necessary for the growth of tissues and organs.<\/p>\n\n\n\n
265. A nurse is teaching a client with lower extremity weakness how to use a 4-point crutch gait.<\/p>\n\n\n\n
Which of the following instructions should the nurse include in the teaching?<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg61.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
A. \u201cSupport the majority of your weight on the axillae.\u201d<\/p>\n\n\n\n
-incorrect: Pressure on the axillae increases the risk to underlying nerves, which could result in<\/p>\n\n\n\n
partial paralysis of the arms.<\/p>\n\n\n\n
B. \u201cKeep your elbows extended.\u201d<\/p>\n\n\n\n
-incorrect: The client should keep his elbows flexed about 30 degrees.<\/p>\n\n\n\n
C. \u201cBear weight on both of your legs.\u201d<\/p>\n\n\n\n
-The client should keep 3 points on the ground at all times. Therefore, he must be able to bear<\/p>\n\n\n\n
weight on both legs.<\/p>\n\n\n\n
D. \u201cMove both crutches forward at the same time.\u201d<\/p>\n\n\n\n
-incorrect: The client should move each leg alternately with each opposite crutch so that 3 points<\/p>\n\n\n\n
of support are on the floor at all times.<\/p>\n\n\n\n
266. A nurse is changing the dressings for a client who is 3 days postoperative following a<\/p>\n\n\n\n
cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should<\/p>\n\n\n\n
document this finding as which of the following types of drainage?<\/p>\n\n\n\n
A. Sanguineous exudate<\/p>\n\n\n\n
-incorrect: Sanguineous exudate drainage on the client\u2019s dressings indicates an accumulation of<\/p>\n\n\n\n
RBCs from the plasma that appears bright red on the dressings.<\/p>\n\n\n\n
B. Serous exudate<\/p>\n\n\n\n
-incorrect: Serous exudate drainage on the client\u2019s dressings indicates plasma from the blood and<\/p>\n\n\n\n
appears watery and clear to light yellow in color.<\/p>\n\n\n\n
C. Serosanguineous exudate<\/p>\n\n\n\n
-incorrect: Serosanguineous exudate drainage on the client\u2019s dressings indicates plasma mixed<\/p>\n\n\n\n
with light bloody drainage, which is typically pale yellow to blood-tinged. Watery drainage may<\/p>\n\n\n\n
also be evident.<\/p>\n\n\n\n
D. Purulent exudate<\/p>\n\n\n\n
-Purulent exudate on the client\u2019s dressings includes thick yellow, green, or brown drainage and<\/p>\n\n\n\n
usually indicates wound sloughing or infection.<\/p>\n\n\n\n
267. A nurse is caring for a client in a long-term care facility.Which of the following findings<\/p>\n\n\n\n
should alert the nurse to the possibility that the client has developed delirium?<\/p>\n\n\n\n
A. Gradual memory loss<\/p>\n\n\n\n
-incorrect: Gradual memory loss is a common finding in dementia, not delirium.<\/p>\n\n\n\n
B. Reduced level of consciousness<\/p>\n\n\n\n
-When a client has delirium, the nurse should expect a reduced level of consciousness, sudden<\/p>\n\n\n\n
memory impairment, illogical thinking, and sleep disturbances.<\/p>\n\n\n\n
C. Difficulty with abstract thought<\/p>\n\n\n\n
-incorrect: Difficulty with abstract thought is a common finding in dementia, not delirium.<\/p>\n\n\n\n
D. Verbalized feelings of hopelessness<\/p>\n\n\n\n
-incorrect: Verbalization of feelings of hopelessness is a common finding in depression, not<\/p>\n\n\n\n
delirium.<\/p>\n\n\n\n
268. A nurse is reviewing a client\u2019s laboratory results and notes a WBC count of 3,600\/ mm^3.<\/p>\n\n\n\n
The nurse should identify this result as which of the following conditions?<\/p>\n\n\n\n
A. Leukoplakia<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg62.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: Leukoplakia involves thick white patches in the mucosa of the mouth. These lesions<\/p>\n\n\n\n
can be precancerous and are often seen in clients who smoke heavily.<\/p>\n\n\n\n
B. Leukemia<\/p>\n\n\n\n
-incorrect: Leukemia involves the uncontrolled production of blast cells or immature white blood<\/p>\n\n\n\n
cells in the bone marrow.<\/p>\n\n\n\n
C. Leukocytosis<\/p>\n\n\n\n
-incorrect: Leukocytosis is an increase in circulating white blood cells in response to white blood<\/p>\n\n\n\n
cells exiting from the blood vessels in response to inflammation.<\/p>\n\n\n\n
D. Leukopenia<\/p>\n\n\n\n
-Leukopenia occurs when there is a decrease in the production of WBCs. This alteration places<\/p>\n\n\n\n
the client at an increased risk of infection.<\/p>\n\n\n\n
269. A nurse is preparing to perform mouth care for an unresponsive client. Which of the<\/p>\n\n\n\n
following actions should the nurse plan to take?<\/p>\n\n\n\n
A. Place the client supine<\/p>\n\n\n\n
-incorrect: To prevent the risk of aspiration, the nurse should raise the client\u2019s head to 30 degrees<\/p>\n\n\n\n
or turn the client to a side-lying position.<\/p>\n\n\n\n
B. Keep both side rails up<\/p>\n\n\n\n
-incorrect: To prevent straining reduce the risk of self-injury, the nurse should lower the near<\/p>\n\n\n\n
side rail before performing mouth care.<\/p>\n\n\n\n
C. Raise the level of the bed<\/p>\n\n\n\n
-The nurse should raise the bed to allow the use of proper body mechanics and reduce the risk of<\/p>\n\n\n\n
self-injury.<\/p>\n\n\n\n
D. Inspect the client\u2019s mouth using a finger sweep<\/p>\n\n\n\n
-incorrect: To reduce the risk of caregiver injury, the nurse should never insert fingers into the<\/p>\n\n\n\n
mouth of an unresponsive client.<\/p>\n\n\n\n
270. A nurse is talking with the parent of a preschool-aged child who tells the nurse, \u201cMy child<\/p>\n\n\n\n
has suddenly become disinterested in certain foods.\u201d Which of the following statements should<\/p>\n\n\n\n
the nurse make?<\/p>\n\n\n\n
A. \u201cDuring this phase, feed your child anything that she will eat.\u201d<\/p>\n\n\n\n
-incorrect: The nurse should inform the parent that children\u2019s dietary habits can change from day<\/p>\n\n\n\n
to day. It is important to feed the child healthy foods and focus on the quality of food rather than<\/p>\n\n\n\n
the quantity of food during this time.<\/p>\n\n\n\n
B. \u201cIncrease the amount of calories and water your child consumes.\u201d<\/p>\n\n\n\n
-incorrect: The nurse should inform the client that calorie and fluid requirements decrease<\/p>\n\n\n\n
slightly in preschool-aged children. The nurse should not promote an increase of calories and<\/p>\n\n\n\n
water in the child\u2019s diet.<\/p>\n\n\n\n
C. \u201cKeep a diary of the foods your child eats each day.\u201d<\/p>\n\n\n\n
-The nurse should encourage the parent to keep a diary of the foods the child eats throughout the<\/p>\n\n\n\n
day for 1 week. This can help the parent realize that the child may be eating better than expected.<\/p>\n\n\n\n
Evidence suggests that children can self-regulate their caloric intake. When they eat less at a<\/p>\n\n\n\n
meal, they can compensate by eating more at another meal or by having a snack.<\/p>\n\n\n\n
D. \u201cProvide a large variety of fruit juices for your child to choose from.\u201d<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg63.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The nurse should inform the parent that excessive consumption of sweetened<\/p>\n\n\n\n
beverages, including fruit juices, can be associated with adverse health effects such as dental<\/p>\n\n\n\n
caries, obesity, and metabolic syndrome.<\/p>\n\n\n\n
271. A nurse is performing a mental-status examination on a client who has manifestations of<\/p>\n\n\n\n
dementia. Which of the following directions should the nurse give the client when evaluating the<\/p>\n\n\n\n
client\u2019s ability to think abstractly?<\/p>\n\n\n\n
A. Subtract by 7 serially, starting at 100<\/p>\n\n\n\n
-incorrect: This part of the mental-status exam evaluates the client\u2019s attention span.<\/p>\n\n\n\n
B. Describe a previous illness<\/p>\n\n\n\n
-incorrect: This part of the mental-status exam evaluates the client\u2019s remote memory.<\/p>\n\n\n\n
C. Explain what to do if a fire happened in his bedroom<\/p>\n\n\n\n
-incorrect: This part of the mental-status exam evaluates the client\u2019s judgment.<\/p>\n\n\n\n
D. Discuss the meaning of a common proverb<\/p>\n\n\n\n
-This part of the mental-status exam evaluates the client\u2019s ability to think abstractly.<\/p>\n\n\n\n
272. A nurse is caring for a client who is receiving enteral feedings through an NG tube and<\/p>\n\n\n\n
develops diarrhea. Which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Change the tube feeding bag every 48 hours<\/p>\n\n\n\n
-incorrect: The nurse should change the bag and tubing every 4 hours to decrease bacterial<\/p>\n\n\n\n
growth within the feeding tube system. The nurse should also employ aseptic technique.<\/p>\n\n\n\n
B. Chill the formula prior to administration<\/p>\n\n\n\n
-incorrect: The nurse should ensure the formula is at room temperature prior to administration.<\/p>\n\n\n\n
Cold formula can result in abdominal cramping and discomfort.<\/p>\n\n\n\n
C. Increase the infusion rate<\/p>\n\n\n\n
-incorrect: The nurse should decrease the infusion rate for a client who develops diarrhea while<\/p>\n\n\n\n
receiving feedings via NG tube. This can assist in reducing diarrhea as well as gastric intolerance<\/p>\n\n\n\n
to the formula.<\/p>\n\n\n\n
D. Request a prescription for an isotonic enteral nutrition formula<\/p>\n\n\n\n
-The nurse should assist a client who develops diarrhea while receiving NG tube feedings by<\/p>\n\n\n\n
consulting with the provider and the dietitian regarding changing the client\u2019s formula to an<\/p>\n\n\n\n
isotonic formula. This formulation can be easier for the client to digest and can decrease<\/p>\n\n\n\n
diarrhea.<\/p>\n\n\n\n
273. A nurse is caring for a client who has a temperature of 38.7 C (101.7 F). Which of the<\/p>\n\n\n\n
following actions should the nurse take?<\/p>\n\n\n\n
A. Apply an alcohol-water solution to the client\u2019s skin<\/p>\n\n\n\n
-incorrect: This therapy is no longer recommended as an intervention for a fever because it can<\/p>\n\n\n\n
lead to shivering, which is counterproductive and can cause an increase in energy expenditure.<\/p>\n\n\n\n
B. Keep the client\u2019s bed linens dry<\/p>\n\n\n\n
-The nurse should maximize the client\u2019s heat loss by keeping the client\u2019s clothes and bed linens<\/p>\n\n\n\n
dry. The nurse should also reduce external coverings on the client\u2019s bed without causing<\/p>\n\n\n\n
shivering.<\/p>\n\n\n\n
C. Apply ice packs to the groin<\/p>\n\n\n\n
-incorrect: This therapy is no longer recommended as an intervention for a fever because it can<\/p>\n\n\n\n
lead to shivering, which is counterproductive and can cause an increase in energy expenditure.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg64.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
D. Limit the client\u2019s fluid intake to 1183 mL (40oz) of fluid per day<\/p>\n\n\n\n
-incorrect: The nurse should satisfy the client\u2019s increased metabolic needs by providing the client<\/p>\n\n\n\n
with at least 1893 mL (64 oz) of fluid per day.<\/p>\n\n\n\n
274. A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which<\/p>\n\n\n\n
of the following actions should the nurse take?<\/p>\n\n\n\n
A. Hold the irrigator 1.25 cm (0.5 in) above the eye<\/p>\n\n\n\n
-incorrect: The nurse should hold the irrigator 2.5 cm (1 in) above the eye to keep the irrigator<\/p>\n\n\n\n
from touching the eye and to prevent the solution from damaging the eye tissue.<\/p>\n\n\n\n
B. Direct the irrigation solution up toward the upper eyelid<\/p>\n\n\n\n
-incorrect: The nurse should direct the irrigation solution onto the lower conjunctival sac to avoid<\/p>\n\n\n\n
injuring the cornea and having contaminated fluid flow down the nasolacrimal duct.<\/p>\n\n\n\n
C. Exert pressure on the bony prominences when holding the eyelids open<\/p>\n\n\n\n
-The nurse should hold the upper lid against the eyebrow and the lower lid against the cheekbone<\/p>\n\n\n\n
when irrigating the eye.<\/p>\n\n\n\n
D. Direct the irrigation from the outer canthus to the inner canthus of the eye<\/p>\n\n\n\n
-incorrect: The nurse should direct the irrigation solution from the inner canthus to the outer<\/p>\n\n\n\n
canthus of the eye to avoid injuring the cornea and having contaminated fluid flow down the<\/p>\n\n\n\n
nasolacrimal duct.<\/p>\n\n\n\n
275. A nurse is planning to perform passive ROM exercises for a client. Which of the following<\/p>\n\n\n\n
actions should the nurse take?<\/p>\n\n\n\n
A. Repeat each joint motion 5 times during each session<\/p>\n\n\n\n
-To maintain the client\u2019s joint mobility, the nurse should repeat each motion 3 to 5 times.<\/p>\n\n\n\n
B. Move the joint to the point of considerable resistance<\/p>\n\n\n\n
-incorrect: The nurse should move the joint to the point of slight resistance.<\/p>\n\n\n\n
C. Sit approximately 2 ft from the side of the bed closest to the joint being exercised<\/p>\n\n\n\n
-incorrect: The nurse stand at the side of the bed closest to the joint being exercised<\/p>\n\n\n\n
D. Exercise the smaller joints first<\/p>\n\n\n\n
-incorrect: The nurse should exercise the large joints first<\/p>\n\n\n\n
276. A nurse is called away for an emergency while conversing with a client who is corrected<\/p>\n\n\n\n
about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the<\/p>\n\n\n\n
following ethical principles is the nurse demonstrating?<\/p>\n\n\n\n
A. Autonomy<\/p>\n\n\n\n
-incorrect: The ethical principle of autonomy involves ensuring the client has the right to make<\/p>\n\n\n\n
personal decisions.<\/p>\n\n\n\n
B. Fidelity<\/p>\n\n\n\n
-The nurse is demonstrating the ethical principle of fidelity by keeping a promise that was made.<\/p>\n\n\n\n
C. Nonmaleficence<\/p>\n\n\n\n
-The ethical principle of nonmaleficence involves doing no harm.<\/p>\n\n\n\n
D. Justice<\/p>\n\n\n\n
-The ethical principle of justice involves treating everyone fairly.<\/p>\n\n\n\n
277. A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported<\/p>\n\n\n\n
for the procedure, which of the following actions should the nurse take first?<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg65.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
A. Explain the x-ray procedure to the client<\/p>\n\n\n\n
-incorrect: The nurse should explain the x-ray procedure to the client. However, there is another<\/p>\n\n\n\n
action the nurse should take first.<\/p>\n\n\n\n
B. Help the client into a wheelchair before the transporter arrives<\/p>\n\n\n\n
-incorrect: The nurse should have the client ready for the procedure. However, there is another<\/p>\n\n\n\n
action the nurse should take first.<\/p>\n\n\n\n
C. Ask if the client has any questions<\/p>\n\n\n\n
-incorrect: The nurse should inquire if the client has any questions about the procedure.<\/p>\n\n\n\n
However, there is another action the nurse should take first.<\/p>\n\n\n\n
D. Identify the client using 2 identifiers<\/p>\n\n\n\n
-The nurse should apply the safety and risk-reduction-priority-setting framework, which assigns<\/p>\n\n\n\n
priority to the factor or situation posing the greatest safety risk to the client. When there are<\/p>\n\n\n\n
several risks to the client safety, the one posing the greatest threat is the highest priority.The<\/p>\n\n\n\n
nurse should use Maslow\u2019s Hierarchy of needs, the ABC priority-setting framework, and\/or<\/p>\n\n\n\n
nursing knowledge to identify which risk poses the greatest threat to the client.<\/p>\n\n\n\n
-Once the client\u2019s identity is determined, the nurse can proceed with other options. This action is<\/p>\n\n\n\n
the priority because it provides for the safety of the client. The nurse must be certain that each<\/p>\n\n\n\n
client receives only what has been prescribed. Hence, the nurse must assure that the correct client<\/p>\n\n\n\n
is being transported for a chest x-ray.<\/p>\n\n\n\n
278. A nurse is calculating a client\u2019s intake for a 12-hr shift. The client had dextrose 5% in<\/p>\n\n\n\n
0.45% sodium chloride infusing at 125 mL\/hr, gentamicin 150 mg in 100mL at 1400, ranitidine<\/p>\n\n\n\n
50 mg in 50mL at 1000 and 1600, 250 mL of blood over 2 hr and a nasogastric flush of 30mL<\/p>\n\n\n\n
every 2 hr. What is the total intake in milliliters that the nurse should document for this client for<\/p>\n\n\n\n
this 12-hr period? (nearest whole number)<\/p>\n\n\n\n
-2130 mL<\/p>\n\n\n\n
279. A nurse is performing a neurological assessment of a client. To promote safety during the<\/p>\n\n\n\n
examination, the nurse stands nearby as the client follows the instructions for which of the<\/p>\n\n\n\n
following tests?<\/p>\n\n\n\n
A. Romberg<\/p>\n\n\n\n
-A Romberg test evaluates standing balance, first with the client\u2019s eyes open and then with them<\/p>\n\n\n\n
closed. The nurse should remain nearby because the client could fall during this test.<\/p>\n\n\n\n
B. Kinesthetic sensation<\/p>\n\n\n\n
-incorrect: Kinesthetic sensation tests the client\u2019s ability to identify the position in which the<\/p>\n\n\n\n
examiner is holding the client\u2019s middle finger or great toe. It is not likely to endanger the client\u2019s<\/p>\n\n\n\n
safety.<\/p>\n\n\n\n
C. 2-point discrimination<\/p>\n\n\n\n
-incorrect: When performing 2-point discrimination, the nurse touches various areas on the<\/p>\n\n\n\n
client\u2019s body with 1 and 2 pointed objects to see if the client can discriminate between 1 and 2<\/p>\n\n\n\n
objects. It is unlikely to endanger the client\u2019s safety.<\/p>\n\n\n\n
D. Weber<\/p>\n\n\n\n
-incorrect: A Weber test is a hearing screening that uses a tuning fork. Following the instructions<\/p>\n\n\n\n
for this test is not likely to endanger the client\u2019s safety.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg66.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
280. A nurse is initiating seizure precautions for a client who has a seizure disorder. Which of<\/p>\n\n\n\n
the following pieces of equipment should the nurse have readily available at the client\u2019s bedside?<\/p>\n\n\n\n
A. Vest restraint<\/p>\n\n\n\n
-incorrect: The nurse does not need to have a vest restraint at the client\u2019s bedside for seizure<\/p>\n\n\n\n
precautions. The nurse should not restrain a client during a seizure but should hold the client\u2019s<\/p>\n\n\n\n
flailing limbs loosely and loosen the client\u2019s clothing.<\/p>\n\n\n\n
B. Tongue blade<\/p>\n\n\n\n
-incorrect: The nurse does not need to have a tongue blade at the client\u2019s bedside for seizure<\/p>\n\n\n\n
precautions. The nurse should not place any objects into the client\u2019s mouth during a seizure,<\/p>\n\n\n\n
including a tongue blade or airway.<\/p>\n\n\n\n
C. Oxygen equipment<\/p>\n\n\n\n
-The nurse should have oxygen equipment at the bedside of a client who is on seizure<\/p>\n\n\n\n
precautions. The nurse should be able to apply oxygen via mask or nasal cannula to a client who<\/p>\n\n\n\n
experiences a seizure.<\/p>\n\n\n\n
D. Neck brace<\/p>\n\n\n\n
-incorrect: The nurse does not need to have a neck brace at the client\u2019s bedside for seizure<\/p>\n\n\n\n
precautions. The nurse should protect the client\u2019s head by holding it in the lap, placing the head<\/p>\n\n\n\n
on a pillow, or placing a pad under the client\u2019s head.<\/p>\n\n\n\n
281. A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing<\/p>\n\n\n\n
diarrhea and may have a right ear infection. Which of the following routes should the nurse use<\/p>\n\n\n\n
to obtain the child\u2019s temperature?<\/p>\n\n\n\n
A. Rectal<\/p>\n\n\n\n
-incorrect: The rectal route is accurate for obtaining body temperature in young children;<\/p>\n\n\n\n
however, it should not be used for clients who have diarrhea.<\/p>\n\n\n\n
B. Tympanic<\/p>\n\n\n\n
-incorrect: The tympanic route can be used in young children but should be avoided in a child<\/p>\n\n\n\n
who has an active ear infection or who has tympanostomy tubes in place.<\/p>\n\n\n\n
C. Oral<\/p>\n\n\n\n
-incorrect: The oral route is not appropriate for use in children under the age of 3.<\/p>\n\n\n\n
D. Temporal<\/p>\n\n\n\n
-The temporal artery route, while not as accurate as the rectal route for obtaining a precise body<\/p>\n\n\n\n
temperature, is noninvasive and can be used to obtain a temperature in a toddler who might have<\/p>\n\n\n\n
an ear infection and who is having diarrhea. The nurse should place the probe behind the ear if<\/p>\n\n\n\n
the client is diaphoretic but should avoid placing it over an area covered with hair.<\/p>\n\n\n\n
282. A nurse is performing a neurological assessment for a client. Which of the following<\/p>\n\n\n\n
examinations should the nurse use to check the client\u2019s balance?<\/p>\n\n\n\n
A. 2-point discrimination test<\/p>\n\n\n\n
-incorrect: Two-point discrimination is tested by touching the skin with 2 sharp, pointed objects.<\/p>\n\n\n\n
The purpose of the test if to determine when the client can differentiate between the points.<\/p>\n\n\n\n
B. Glasgow coma scale<\/p>\n\n\n\n
-incorrect: The Glasgow coma scale is used to measure a client\u2019s level of consciousness.<\/p>\n\n\n\n
C. Babinski reflex<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg67.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The Babinski reflex is tested by using an object to strike the sole of the foot. When<\/p>\n\n\n\n
the test is negative, all of the toes bend. The test is positive if the toes spread outward.<\/p>\n\n\n\n
D. Romberg test<\/p>\n\n\n\n
-When using the Romberg test, the nurse instructs the client to stand with the feet together and<\/p>\n\n\n\n
arms at the sides, first with the eyes open and then with the eyes closed. The inability to maintain<\/p>\n\n\n\n
balance is a positive Romberg test.<\/p>\n\n\n\n
283. A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning<\/p>\n\n\n\n
how to self-inject insulin. Which of the following statements should the nurse make?<\/p>\n\n\n\n
A. \u201cTell me what I can do to help you overcome your fear of giving yourself injections.\u201d<\/p>\n\n\n\n
-This response illustrates the therapeutic communication technique of clarifying and offering<\/p>\n\n\n\n
self. The nurse should allow the client to express feelings and fears and support the client in<\/p>\n\n\n\n
learning how to give the injections.<\/p>\n\n\n\n
B. \u201cYour provider will not be pleased that you refuse to give yourself insulin injections.\u201d<\/p>\n\n\n\n
-incorrect: This response illustrates the nontherapeutic communication technique of challenging<\/p>\n\n\n\n
and ignores the client\u2019s concern.<\/p>\n\n\n\n
C. \u201cIt\u2019s okay. I\u2019m sure your partner will be able to learn how to give you the insulin injections.\u201d<\/p>\n\n\n\n
-incorrect: This response illustrates the nontherapeutic communication technique of unwarranted<\/p>\n\n\n\n
reassurance and does not address the client\u2019s fears.<\/p>\n\n\n\n
D. \u201cYou won\u2019t be able to go home unless you learn to give yourself insulin injections.\u201d<\/p>\n\n\n\n
-incorrect: This response illustrates the nontherapeutic communication technique of threatening<\/p>\n\n\n\n
the client. This response will not help the client overcome these fears.<\/p>\n\n\n\n
284. During a client care staff meeting, a nurse manager discusses potential problems with data<\/p>\n\n\n\n
security that affect confidential client information. Which of the following environments should<\/p>\n\n\n\n
the nurse manager identify as an acceptable place for discussing clients\u2019 information?<\/p>\n\n\n\n
A. Areas with no public access<\/p>\n\n\n\n
-Nurses should only discuss client\u2019s information in private arears where no one else can<\/p>\n\n\n\n
overhear. For example, a unit medication room is a non-public area where nurses can privately<\/p>\n\n\n\n
discuss information that pertains to the client\u2019s care.<\/p>\n\n\n\n
B. Outside the door of a client\u2019s room<\/p>\n\n\n\n
-incorrect: Discussing client information in a semi-public place risks other overhearing protected<\/p>\n\n\n\n
health information.<\/p>\n\n\n\n
C. In the cafeteria during break<\/p>\n\n\n\n
-incorrect: Discussing client information in a public place could allow others to overhear<\/p>\n\n\n\n
protected health information.<\/p>\n\n\n\n
D. In the hallway near the nurse\u2019s station<\/p>\n\n\n\n
-incorrect: Discussing client information in a semi-public place could allow others to overhear<\/p>\n\n\n\n
protected health information.<\/p>\n\n\n\n
285. A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who<\/p>\n\n\n\n
are postoperative. Which of the following clients should the nurse see first?<\/p>\n\n\n\n
A. A client who is 1 day postoperative following a lobectomy for a small-cell carcinoma and has<\/p>\n\n\n\n
a chest tube with 35 mL\/hr of bright red, bloody drainage.<\/p>\n\n\n\n
-incorrect: Following a lobectomy, the client may need chest tubes for both pneumothorax and<\/p>\n\n\n\n
hemothorax (collapse of the lung with blood in the pleural space). Fully reinflating and removing<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg68.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
the remaining blood can take several days or more, depending on the severity of the trauma.<\/p>\n\n\n\n
Chest tube drainage of 35 mL is within the expected parameters for an adult client, especially on<\/p>\n\n\n\n
the first postoperative day. A client who has a draining chest tube after a lobectomy is stable.<\/p>\n\n\n\n
B. A client who is 2 days postoperative following a colectomy due to colorectal cancer and<\/p>\n\n\n\n
has an ostomy bag full of bright red, bloody drainage.<\/p>\n\n\n\n
-The nurse should apply the unstable vs stable priority-setting framework when caring for<\/p>\n\n\n\n
clients. Using this framework, unstable clients are prioritized due to needs that threaten survival.<\/p>\n\n\n\n
The nurse should first address problems involving the airway, breathing, or circulatory status that<\/p>\n\n\n\n
are life-threatening. Clients whose vital signs or laboratory values indicate a risk of becoming<\/p>\n\n\n\n
unstable are also a higher priority than clients who are stable. The nurse may need to use nursing<\/p>\n\n\n\n
knowledge to determine which option describes the most unstable client.<\/p>\n\n\n\n
-An ostomy bag full of blood indicates that the client\u2019s bowel is hemorrhaging, and the nurse<\/p>\n\n\n\n
must report this finding to the surgeon immediately.The client may require fluid replacement,<\/p>\n\n\n\n
transfusion, and additionaly surgery to repair the bleeding vessel. This finding poses an<\/p>\n\n\n\n
immediate threat to the client\u2019s circulation.<\/p>\n\n\n\n
C. A client who is 2 days postoperative following the excision of an abdominal mass and has a<\/p>\n\n\n\n
portable wound suction device with 20 mL\/hr of serosanguineous drainage.<\/p>\n\n\n\n
-incorrect: A portable suction device drains a surgical wound by gentle, continuous self-suction.<\/p>\n\n\n\n
Over time, the drainage will change from sanguineous to serosanguineous to serous.<\/p>\n\n\n\n
Serosanguineous drainage of 20 mL\/hr on the second postoperative day is within the expected<\/p>\n\n\n\n
reference range for an adult client. A client who has a draining wound after abdominal surgery is<\/p>\n\n\n\n
stable.<\/p>\n\n\n\n
D. A client who is 1 day postoperative following the excision of a bladder wall tumor and<\/p>\n\n\n\n
prostate and has continuous bladder irrigation with 300 mL\/hr reddish-pink urine.<\/p>\n\n\n\n
-incorrect: Continuous bladder irrigation (CBI) prevents clots from forming in the bladder. To<\/p>\n\n\n\n
keep the client\u2019s urine free of clots and mucous plugs, the nurse should irrigate the bladder with<\/p>\n\n\n\n
0.9% sodium chloride. During the first few postoperative days, reddish-pink urine at an hourly<\/p>\n\n\n\n
output slightly greater than the amount of solution the nurse instills is expected. Consequently,<\/p>\n\n\n\n
drainage of 300 mL\/hr on the first postoperative day is within expected reference range for this<\/p>\n\n\n\n
client.<\/p>\n\n\n\n
286. A nurse in a provider\u2019s office is measuring a client and notes a loss in height from the<\/p>\n\n\n\n
previous year. The nurse should identify this finding as a manifestation of which of the following<\/p>\n\n\n\n
musculoskeletal system disorders?<\/p>\n\n\n\n
A. Osteoporosis<\/p>\n\n\n\n
-A loss of height is often and early indication of osteoporosis. This occurs due to loss of calcium<\/p>\n\n\n\n
in the vertebrae, which can cause them to fracture and collapse.<\/p>\n\n\n\n
B. Scoliosis<\/p>\n\n\n\n
-incorrect: Scoliosis does not precipitate a decrease in the height of a client. It is an abnormal<\/p>\n\n\n\n
lateral curve of the spine.<\/p>\n\n\n\n
C. Kyphosis<\/p>\n\n\n\n
-incorrect: Kyphosis does not precipitate a decrease in height of a client. It is an exaggerated<\/p>\n\n\n\n
posterior curvature of the thoracic spine. (ex: hunchback)<\/p>\n\n\n\n
D. Lordosis<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg69.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: Lordosis does not precipitate a decrease in the height of a client. It is an exaggerated<\/p>\n\n\n\n
lumbar curvature. (ex: swayback)<\/p>\n\n\n\n
287. A nurse is witnessing a client sign an informed consent form for surgery. What is the nurse<\/p>\n\n\n\n
affirming by this action?<\/p>\n\n\n\n
A. The client fully understands the provider\u2019s explanation of the procedure<\/p>\n\n\n\n
-incorrect: It is the responsibility of the provider who will perform the procedure to ensure that<\/p>\n\n\n\n
the client understands the explanation of the procedure.<\/p>\n\n\n\n
B. The client has been informed about the risks and benefits of the procedure<\/p>\n\n\n\n
-incorrect: It is the responsibility of the provider who will perform the procedure to inform the<\/p>\n\n\n\n
client about the risks and benefits and to obtain consent.<\/p>\n\n\n\n
C. The nurse witnessed the provider\u2019s explanation of the procedure<\/p>\n\n\n\n
-incorrect: It is not necessary for the nurse to witness the provider\u2019s explanation of the procedure.<\/p>\n\n\n\n
D. The signature on the preoperative consent form is the client\u2019s<\/p>\n\n\n\n
-The nurse acts as a witness to confirm that the client\u2019s signature is present on the preoperative<\/p>\n\n\n\n
consent form. It is the responsibility of the provider who will perform the procedure to obtain<\/p>\n\n\n\n
consent by explaining the procedure alone with the associated risks and benefits.<\/p>\n\n\n\n
288. A nurse is assisting a client who has dysphagia at mealtimes. Which of the following<\/p>\n\n\n\n
actions should the nurse take?<\/p>\n\n\n\n
A. Assist the client into a semi-sitting position<\/p>\n\n\n\n
-incorrect: The nurse should assist the client to sit in an upright position when eating.<\/p>\n\n\n\n
B. Have the client lean slightly backward<\/p>\n\n\n\n
-incorrect: The nurse should have the client lean slightly forward when eating<\/p>\n\n\n\n
C. Advise the client to tuck his chin downward<\/p>\n\n\n\n
-To help the client swallow safely, the nurse should have the client sit upright, lean slightly<\/p>\n\n\n\n
forward, tilt his head forward, and tuck his chin. This position helps moves the food downward<\/p>\n\n\n\n
without lodging in the throat, where the client could aspirate it.<\/p>\n\n\n\n
D. Instruct the client to tilt his head slightly backward<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to tilt his head slightly forward when eating.<\/p>\n\n\n\n
289. A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous<\/p>\n\n\n\n
humor in the eye. This manifestation is consistent with which of the following eye disorders?<\/p>\n\n\n\n
A. Retinopathy<\/p>\n\n\n\n
-incorrect: Manifestations of retinopathy include changes in the blood vessels of the retina that<\/p>\n\n\n\n
can lead to blindness.<\/p>\n\n\n\n
B. Glaucoma<\/p>\n\n\n\n
-The nurse should identify that an obstruction of the flow of the vitreous humor of the eye is a<\/p>\n\n\n\n
manifestation of glaucoma. This obstruction leads to an increase in intraocular pressure, resulting<\/p>\n\n\n\n
in damage to the eye.<\/p>\n\n\n\n
C. Cataracts<\/p>\n\n\n\n
-incorrect: Manifestations of cataracts include an increase in the opacity of the lens, blocking<\/p>\n\n\n\n
rays of light from entering the eye.<\/p>\n\n\n\n
D. Macular degeneration<\/p>\n\n\n\n
-incorrect: Manifestations of macular degeneration include changes in sharp and central vision<\/p>\n\n\n\n
and are often associated with aging.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg6a.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
290. A charge nurse is providing teaching to a newly licensed nurse about removing sutures from<\/p>\n\n\n\n
a client\u2019s laceration. Which of the following statements by the newly licensed nurse indicates an<\/p>\n\n\n\n
understanding of the teaching?<\/p>\n\n\n\n
A. \u201cI will use a staple remover and remove each suture individually.\u201d<\/p>\n\n\n\n
-incorrect: A staple remover is used to remove staples, not sutures.<\/p>\n\n\n\n
B. \u201cBandage scissors are used to cut the sutures.\u201d<\/p>\n\n\n\n
-incorrect: Bandage scissors are ineffective in removing sutures, as the tips of the scissors are too<\/p>\n\n\n\n
large and blunt to capture the suture material. Special suture scissors with a short, curved tip are<\/p>\n\n\n\n
used to remove sutures.<\/p>\n\n\n\n
C. \u201cTweezers are necessary only for removing retention sutures.\u201d<\/p>\n\n\n\n
-incorrect: Retention sutures are placed more deeply within the body than regular sutures.<\/p>\n\n\n\n
Agency policy will determine if nurses are allowed to remove them. Tweezers, however, can be<\/p>\n\n\n\n
used to remove all types of sutures, not just retention ones.<\/p>\n\n\n\n
D. \u201cI will clip each suture close to the skin and pull it through from the other side.\u201d<\/p>\n\n\n\n
-Clipping close to the skin and pulling the suture from the other side does not disrupt the wound-<\/p>\n\n\n\n
healing process.<\/p>\n\n\n\n
291. A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of<\/p>\n\n\n\n
the following actions should the nurse have the client perform just before inserting the catheter?<\/p>\n\n\n\n
A. Swallow water<\/p>\n\n\n\n
-incorrect: Swallowing eases the passage of a nasogastric tube past the client\u2019s oropharynx.<\/p>\n\n\n\n
B. Prepare for painful sensation<\/p>\n\n\n\n
-incorrect: The insertion of a catheter can feel uncomfortable but should not cause pain, and it<\/p>\n\n\n\n
can ease the discomfort of bladder distention.<\/p>\n\n\n\n
C. Hold her breath<\/p>\n\n\n\n
-incorrect: The nurse should ask the client to take a slow, deep breath just before insertion.<\/p>\n\n\n\n
D. Bear down gently<\/p>\n\n\n\n
-Bearing down helps the nurse visualize the urinary meatus and relaxes the external sphincter,<\/p>\n\n\n\n
which facilitates the insertion of the catheter.<\/p>\n\n\n\n
292. A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the<\/p>\n\n\n\n
following statements by the AP indicates that further teaching is required?<\/p>\n\n\n\n
A. \u201cI should not leave all 4 side rails up unless there is a prescription for restraints.\u201d<\/p>\n\n\n\n
-incorrect: Side rails are a form of restraint when all 4 rails are raised. This requires a<\/p>\n\n\n\n
prescription form the provider after less restrictive methods have been unsuccessful.<\/p>\n\n\n\n
B. \u201cAn alert client will be safest if I raise the 2 upper side rails at the head of the bed.\u201d<\/p>\n\n\n\n
-incorrect: Leaving the 2 upper side rails up improves the client\u2019s ability to turn and move<\/p>\n\n\n\n
around in bed. The client will also be able to use the rails when getting out of bed, which will<\/p>\n\n\n\n
help prevent falls.<\/p>\n\n\n\n
C. \u201cIf the client seems confused, I\u2019ll raise all 4 side rails so that he doesn\u2019t hurt himself.\u201d<\/p>\n\n\n\n
-Raising all 4 side rails can put the client at greater risk for injury. For example, the client might<\/p>\n\n\n\n
try to climb over the side rails, which could result in a fall.<\/p>\n\n\n\n
D. \u201cIf a client is sedated, I should raise all 4 side rails to prevent a fall out of bed.\u201d<\/p>\n\n\n\n
-incorrect: Raising all 4 side rails is not considered a restraint if the client is sedated. This action<\/p>\n\n\n\n
reduces the client\u2019s risk for injury due to falling out of bed.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg6b.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
293. A nurse is teaching a client how to use an albuterol metered-dose inhaler. After removing<\/p>\n\n\n\n
the cap form the inhaler and shaking the canister, what sequence of instructions should the nurse<\/p>\n\n\n\n
give the client?<\/p>\n\n\n\n
-\u201cHold the mouthpiece 1 to 2 inches in front of your mouth.\u201d<\/p>\n\n\n\n
-\u201cTilt your head slightly and open your mouth wide.\u201d<\/p>\n\n\n\n
-\u201cDepress the canister while taking a slow, deep breath.\u201d<\/p>\n\n\n\n
-\u201cHold your breath for 10 seconds.\u201d<\/p>\n\n\n\n
294. A nurse in an emergency department is caring for a client who reports developing severe<\/p>\n\n\n\n
right eye pain with a gritty sensation while sawing wood. Which of the following actions should<\/p>\n\n\n\n
the nurse take first?<\/p>\n\n\n\n
A. Instill proparacaine hydrochloride eye drops<\/p>\n\n\n\n
-incorrect: The nurse should instill proparacaine hydrochloride eyedrops, after assessing for<\/p>\n\n\n\n
client allergies, to promote relief of eye pain; however, there is another action the nurse should<\/p>\n\n\n\n
take first.<\/p>\n\n\n\n
B. Perform ocular irrigation of the right eye<\/p>\n\n\n\n
-incorrect: The nurse should prepare for and quickly perform ocular irrigation when a foreign<\/p>\n\n\n\n
body in the eye is suspected; however, there is another action the nurse should take first.<\/p>\n\n\n\n
C. Place the client in a supine position with the head turned toward the affected side<\/p>\n\n\n\n
-incorrect: The nurse should place the client in supine position with the head turned toward the<\/p>\n\n\n\n
affected eye to promote drainage of irrigation fluid during ocular irrigation; however, there is<\/p>\n\n\n\n
another action the nurse should take first.<\/p>\n\n\n\n
D. Ask the client about first aid performed at the scene<\/p>\n\n\n\n
-The nurse should apply the nursing process priority-setting framework to plan client care and<\/p>\n\n\n\n
prioritize nursing action. Each step of the nursing process builds on the previous step, beginning<\/p>\n\n\n\n
with an assessment or data collection. Before the nurse can formulate a plan of action, implement<\/p>\n\n\n\n
a nursing intervention, or notify the provider of a change in the client\u2019s status, the nurse must<\/p>\n\n\n\n
first collect adequate data from the client. Assessing or collecting additional data will provide the<\/p>\n\n\n\n
nurse with the knowledge to make an appropriate decision. Therefore, the first action the nurse<\/p>\n\n\n\n
should take is to assess the first aid that was performed at the scene to determine if eye irrigation<\/p>\n\n\n\n
was administered.<\/p>\n\n\n\n
295. A nurse is performing a neurological assessment for a client. By asking the client to stick<\/p>\n\n\n\n
out his tongue, which of the following cranial nerves if the nurse testing?<\/p>\n\n\n\n
A. Cranial nerve XII<\/p>\n\n\n\n
-The nurse is checking the function of cranial nerve XII (hypoglossal), which innervates the<\/p>\n\n\n\n
tongue, by observing a range of tongue movements.<\/p>\n\n\n\n
B. Cranial nerve X<\/p>\n\n\n\n
-incorrect: The nurse checks for functioning of cranial nerve X (vagus) by asking the client to<\/p>\n\n\n\n
vocalize.<\/p>\n\n\n\n
C. Cranial nerve VIII<\/p>\n\n\n\n
-incorrect: The nurse checks the functioning of cranial nerve VIII (vestibulocochlear) through<\/p>\n\n\n\n
using the Rinne and Weber tests and asking the client if he can hear a whisper.<\/p>\n\n\n\n
D. Cranial nerve V<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg6c.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-The nurse checks the functioning of cranial nerve V (trigeminal) by asking the client to clench<\/p>\n\n\n\n
his teeth and palpating the masseter muscles for contraction.<\/p>\n\n\n\n
296. A nurse in an acute care facility is planning care for a client who is alert but temporarily<\/p>\n\n\n\n
immobile due to a total hip arthroplasty.Which of the following interventions should the nurse<\/p>\n\n\n\n
plan to take to prevent a complication of immobility?<\/p>\n\n\n\n
A. Move the client from supine to a low Fowler\u2019s position every 2-3 hours to help prevent<\/p>\n\n\n\n
orthostatic hypotension.<\/p>\n\n\n\n
-incorrect: Moving the client from supine to a low Fowler\u2019s position every 2-3 hours is not<\/p>\n\n\n\n
sufficient to help prevent orthostatic hypotension. Changing positions slowly helps prevent or<\/p>\n\n\n\n
minimize the effects of orthostatic hypotension.<\/p>\n\n\n\n
B. Limit fluid intake to 1 L (33.8 oz) in 24 hr to help prevent dependent edema<\/p>\n\n\n\n
-incorrect: Clients who are immobile should ingest at least 1.1-1.4 L (37.2-47.3 oz) of fluid in 24<\/p>\n\n\n\n
hrs to help prevent bladder complications. Limiting fluid intake does not prevent dependent<\/p>\n\n\n\n
edema.<\/p>\n\n\n\n
C. Encourage the client to turn from side to side every 3-4 hr to help prevent<\/p>\n\n\n\n
respiratory complications<\/p>\n\n\n\n
-incorrect: The client should cough and breathe deeply every 1-2 hours to help prevent<\/p>\n\n\n\n
respiratory complications. Turning from side to side every 1-2 hours also helps prevent skin<\/p>\n\n\n\n
breakdown.<\/p>\n\n\n\n
D. Instruct the client to perform foot and leg exercises every 1-2 hr while awake to help<\/p>\n\n\n\n
prevent thrombophlebitis.<\/p>\n\n\n\n
-Antiembolic exercises (ex: flexion of the knees and rolls and pumps of the feet and ankles)<\/p>\n\n\n\n
every 1-2 hours help prevent thrombophlebitis, which is a complication of immobility.<\/p>\n\n\n\n
297. A nurse is planning care for an adult client who has fluid volume excess. Which of the<\/p>\n\n\n\n
following intervention should the nurse plan to include to monitor the client\u2019s weight?<\/p>\n\n\n\n
A. Calibrate the scales weekly<\/p>\n\n\n\n
-incorrect: The nurse should calibrate the scales to 0 each day or before each use to provide<\/p>\n\n\n\n
accurate information.<\/p>\n\n\n\n
B. Use a different scale each time<\/p>\n\n\n\n
-incorrect: The nurse should weigh the client using the same scale each time because there<\/p>\n\n\n\n
generally is a slight difference between readings from each scale.<\/p>\n\n\n\n
C. Weigh the client on arising<\/p>\n\n\n\n
-The nurse should weigh the client on arising each day, after voiding, and before breakfast. An<\/p>\n\n\n\n
accurate weight requires the client to be weighed wearing the same garments and on the same<\/p>\n\n\n\n
carefully calibrated scale (balanced to 0 before each use). Accurate daily weights provide the<\/p>\n\n\n\n
easiest measurement of volume status. An increase of 1 kg (2.2 lbs) is equal to 1,000mL (1L) of<\/p>\n\n\n\n
retained fluid.<\/p>\n\n\n\n
D. Weigh the client without clothing<\/p>\n\n\n\n
-incorrect: The nurse should plan to have the client\u2019s weight taken wearing the same type of<\/p>\n\n\n\n
clothing each day to provide an accurate reading and to avoid embarrassment.<\/p>\n\n\n\n
298. A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy<\/p>\n\n\n\n
tube and has a gastrostomy tube for enteral feedings. Which pieces of information are critical to<\/p>\n\n\n\n
communicate to the next nurse who will be caring for this client? (SATA)<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg6d.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
A. Room temperature<\/p>\n\n\n\n
-incorrect: Unless it is extreme, the room temperature should not affect the client\u2019s care and<\/p>\n\n\n\n
should not be included in a nursing handoff report.<\/p>\n\n\n\n
B. New prescriptions<\/p>\n\n\n\n
C. Number of visitors<\/p>\n\n\n\n
-incorrect: Unless there is a specific concern about visitors, it is not necessary to report the<\/p>\n\n\n\n
number of visitors that the client had in the handoff report.<\/p>\n\n\n\n
D. Arterial blood gas results<\/p>\n\n\n\n
E. Tracheal secretion characteristics<\/p>\n\n\n\n
-The nurse should report any changes in the client\u2019s treatment in the nursing handoff report. For<\/p>\n\n\n\n
a client who is receiving mechanical ventilation, the latest arterial blood gas results reflect the<\/p>\n\n\n\n
client\u2019s current respiratory and ventilatory status and are an essential part of the nursing handoff<\/p>\n\n\n\n
report. Additionally, tracheal secretion characteristics provide important information about the<\/p>\n\n\n\n
client\u2019s current respiratory and ventilatory status and are an essential part of the nursing handoff<\/p>\n\n\n\n
report.<\/p>\n\n\n\n
299. A nurse is assessing a client who has a total calcium level of 12.7 mg\/dL. Which of the<\/p>\n\n\n\n
following findings should the nurse expect?<\/p>\n\n\n\n
A. Muscle tremors<\/p>\n\n\n\n
-incorrect: Muscle tremors are manifestations of hypocalcemia, not hypercalcemia.<\/p>\n\n\n\n
B. Positive Chvostek\u2019s sign<\/p>\n\n\n\n
-incorrect: Positive Chvostek\u2019s sign and Trousseau\u2019s signs are manifestations of hypocalcemia,<\/p>\n\n\n\n
not hypercalcemia.<\/p>\n\n\n\n
C. Depressed deep-tendon reflexes<\/p>\n\n\n\n
-A total calcium level of 12.7 mg\/dL is above the expected reference range. Manifestations of<\/p>\n\n\n\n
hypercalcemia include depressed deep-tendon reflexes, nausea, vomiting, bone pain, lethargy,<\/p>\n\n\n\n
and weakness.<\/p>\n\n\n\n
D. Numbness around the mouth<\/p>\n\n\n\n
-incorrect: Numbness and tingling around the mouth and in the extremities are manifestations of<\/p>\n\n\n\n
hypocalcemia, not hypercalcemia.<\/p>\n\n\n\n
300. During the insertion of a urinary catheter for a client, the tip of the catheter brushes against<\/p>\n\n\n\n
the nurse\u2019s arm. Which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Wipe the catheter with povidone-iodine and continue the catheter insertion.<\/p>\n\n\n\n
-incorrect: Antibacterial solutions do not guarantee sterility. This action could increase the<\/p>\n\n\n\n
client\u2019s risk for a catheter-associated urinary tract infection.<\/p>\n\n\n\n
B. Soak the catheter in chlorhexidine for 15 mins and then reattempt insertion.<\/p>\n\n\n\n
-incorrect: Antibacterial solutions do not guarantee sterility. This action could increase the<\/p>\n\n\n\n
client\u2019s risk for a catheter-associated urinary tract infection.<\/p>\n\n\n\n
C. Continue with the catheter insertion.<\/p>\n\n\n\n
-incorrect: Once the tip of the catheter touches a nonsterile surface, it is contaminated and should<\/p>\n\n\n\n
not be inserted.<\/p>\n\n\n\n
D. Obtain a new catheter and reattempt insertion.<\/p>\n\n\n\n
-The instruction of a urinary catheter is a sterile procedure. The only way to ensure sterility of<\/p>\n\n\n\n
the catheter the nurse plans to insert is by obtaining a new sterile catheter and following surgical<\/p>\n\n\n\n
asepsis throughout the insertion procedure.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg6e.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
301. A nurse is assessing a client\u2019s peripheral pulses. Which of the following descriptions should<\/p>\n\n\n\n
the nurse use to document the findings?<\/p>\n\n\n\n
A. Peripheral pulses equal bilaterally at a rate of 60\/min<\/p>\n\n\n\n
-incorrect: The nurse measures the client\u2019s pulse rate at the apical and radial sites. Determination<\/p>\n\n\n\n
of rate is not a component of peripheral pulse evaluation.<\/p>\n\n\n\n
B. Radial, brachial, and pedal pulses bilaterally weak<\/p>\n\n\n\n
-incorrect: A full evaluation of peripheral pulses typically includes palpation of the radial,<\/p>\n\n\n\n
brachial, ulnae, femoral, popliteal, tibial, and dorsalis pedal pulses. It is not necessary to specify<\/p>\n\n\n\n
details about all pulse points, but the evaluation should indicate the upper portion of the lower<\/p>\n\n\n\n
extremities.<\/p>\n\n\n\n
C. Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities<\/p>\n\n\n\n
-The nurse does not evaluate the peripheral pulses routinely when measuring vital signs.<\/p>\n\n\n\n
Peripheral pulse evaluation is for specific clinical indications such as circulatory impairment to<\/p>\n\n\n\n
an extremity or during a comprehensive physical examination. A full evaluation of peripheral<\/p>\n\n\n\n
pulses typically includes palpation of the radial, brachial, ulnar, femoral, popliteal, tibial, and<\/p>\n\n\n\n
dorsalis pedal pulses. Documentation of peripheral pulse evaluation should include the strength<\/p>\n\n\n\n
of pulsations as well as their equality and symmetry in all 4 extremities.<\/p>\n\n\n\n
D. Brachial, radial, popliteal, and dorsalis pedis pulses regular, 58, and bilaterally palpable<\/p>\n\n\n\n
-incorrect: The nurse measures the client\u2019s pulse rate at the apical and radial sites. Determination<\/p>\n\n\n\n
of rate is not a component of peripheral pulse evaluation.<\/p>\n\n\n\n
302. A nurse is providing teaching to an older adult client who has constipation. Which of the<\/p>\n\n\n\n
following statements should the nurse include in the teaching?<\/p>\n\n\n\n
A. \u201cDrink a minimum of 1,000mL of fluid daily.\u201d<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to consume a minimum of 1,500 mL of fluid to<\/p>\n\n\n\n
prevent constipation.<\/p>\n\n\n\n
B. \u201cIncrease your intake of refined-fiber foods.\u201d<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to increase consumption of coarse fiber and whole<\/p>\n\n\n\n
grains, rather than refined-fiber foods.<\/p>\n\n\n\n
C. \u201cSit on the toilet 30 mins after eating a meal.\u201d<\/p>\n\n\n\n
-Increased peristalsis occurs after food enters the stomach. Siting on the toilet 30 mins after<\/p>\n\n\n\n
eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel<\/p>\n\n\n\n
retraining to treat constipation.<\/p>\n\n\n\n
D. \u201cTake a laxative every day to maintain regularity.\u201d<\/p>\n\n\n\n
-incorrect: The nurse should not recommend intake of daily laxatives because consistent use<\/p>\n\n\n\n
hinders natural defecation habits and can cause constipation.<\/p>\n\n\n\n
303. A nurse in the emergency department is caring for a client who has abdominal trauma.<\/p>\n\n\n\n
Which of the following assessment findings should the nurse identify as an indication of<\/p>\n\n\n\n
hypovolemic shock?<\/p>\n\n\n\n
A. Warm, dry skin<\/p>\n\n\n\n
-incorrect: Cool, clammy skin is an indication of hypovolemic shock.<\/p>\n\n\n\n
B. Increased urinary output<\/p>\n\n\n\n
-incorrect: Urine output of <30 mL\/hr is an indication of hypovolemic shock.<\/p>\n\n\n\n
C. Tachycardia<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg6f.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-Due to the decreased circulating blood volume that occurs with internal bleeding, the oxygen-<\/p>\n\n\n\n
carrying capacity of the blood is reduced. The body attempts to relieve the hypoxia by increasing<\/p>\n\n\n\n
the heart rate and cardiac output while increasing the respiratory rate.<\/p>\n\n\n\n
D. Bradypnea<\/p>\n\n\n\n
-incorrect: Tachypnea is an indication of hypovolemic shock.<\/p>\n\n\n\n
304. A nurse is caring for an adult client who is grieving following the death of a loved one.<\/p>\n\n\n\n
Which of the following factors increases the client\u2019s risk of developing complicated grief?<\/p>\n\n\n\n
A. The deceased was a close friend<\/p>\n\n\n\n
-incorrect: Loss of a close friend is only a risk factor for complicated grief if the grieving<\/p>\n\n\n\n
individual has had multiple recent losses, was strongly dependent on the friend, or is influenced<\/p>\n\n\n\n
by another compounding factor.<\/p>\n\n\n\n
B. The client lived far from the deceased<\/p>\n\n\n\n
-incorrect: Living far away from the deceased is only a risk factor for complicated grief if the<\/p>\n\n\n\n
grieving individual has had multiple recent losses, had unresolved issues with the deceased, or is<\/p>\n\n\n\n
influenced by another compounding factor.<\/p>\n\n\n\n
C. The death was sudden<\/p>\n\n\n\n
-Complicated grief can occur when the death of a loved one is sudden and unexpected.<\/p>\n\n\n\n
D. The client has not visited the deceased in a long time<\/p>\n\n\n\n
-incorrect: Not visiting the deceased in a long time is only a risk factor for complicated grief if<\/p>\n\n\n\n
the grieving individual has had multiple recent losses, had unresolved issues with the deceased,<\/p>\n\n\n\n
or is influenced by another compounding factor.<\/p>\n\n\n\n
305. A nurse is communicating with a group of clients about what to expect during the<\/p>\n\n\n\n
postoperative phase of a total hip arthroplasty.Which of the following elements of the<\/p>\n\n\n\n
communication process should the nurse identify as an evaluation of effective communication?<\/p>\n\n\n\n
A. The motivation for communication is evident<\/p>\n\n\n\n
-incorrect: The element of \u201creferent\u201d motivates communication between people (ex: a sound of<\/p>\n\n\n\n
perception). This will not assist in determining whether the communication is effective.<\/p>\n\n\n\n
B. Feedback is provided<\/p>\n\n\n\n
-Feedback in verbal and\/or nonverbal forms is evidence of successful communication. Feedback<\/p>\n\n\n\n
can indicate to the nurse whether the meaning of the message was understood by the recipient.<\/p>\n\n\n\n
C. A message is communicated to the group of clients<\/p>\n\n\n\n
-incorrect: The message is only the content of what the sender is trying to convey in the<\/p>\n\n\n\n
communication process. It can contain both verbal and nonverbal expression. Massages should<\/p>\n\n\n\n
be clear and concise. However, even though a message might be clearly delivered, this does not<\/p>\n\n\n\n
mean the communication if effective.<\/p>\n\n\n\n
D. Multiple channels are used by the sender<\/p>\n\n\n\n
-incorrect: Using multiple channels (ex: visual, auditory, and facial expressions) can improve the<\/p>\n\n\n\n
effectiveness of communication. However, this will not assist in determining if the<\/p>\n\n\n\n
communication is effective.<\/p>\n\n\n\n
306. A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of<\/p>\n\n\n\n
the following actions should the nurse take?<\/p>\n\n\n\n
A. Auscultate bowel sounds after each feeding<\/p>\n\n\n\n
-incorrect: The nurse should auscultate bowel sounds before each feeding to ensure the client has<\/p>\n\n\n\n
peristalsis bowel activity for the digestive system to digest or absorb the enteral nutrition.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg70.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
B. Ensure the formula is cold before administering<\/p>\n\n\n\n
-incorrect: The nurse should ensure the formula is at room temperature before administering<\/p>\n\n\n\n
because cold formula might cause intestinal cramping and discomfort.<\/p>\n\n\n\n
C. Elevate the head of the client\u2019s bed to 45 degrees before the feeding<\/p>\n\n\n\n
-The nurse should elevate the client\u2019s head of bed between 30-45 degrees to prevent aspiration.<\/p>\n\n\n\n
D. Flush the tubing with 15mL of water after the enteral feeding<\/p>\n\n\n\n
-incorrect: The nurse should flush the tubing with at least 30mL of water after the enteral feeding<\/p>\n\n\n\n
to maintain patency of the feeding tube.<\/p>\n\n\n\n
307. A nurse is caring for a client who has a prescription for a vest restraint. Which of the<\/p>\n\n\n\n
following actions should the nurse take?<\/p>\n\n\n\n
A. Fasten the ties on the restraints to the side rails of the bed<\/p>\n\n\n\n
-incorrect: The nurse should not fasten the ties on the restraint to the side rails. If the side rails<\/p>\n\n\n\n
are lowered, the client could be injured.<\/p>\n\n\n\n
B. Tie the restraint with a quick-release knot<\/p>\n\n\n\n
-The nurse should use a quick-release knot that can be untied easily in case the client\u2019s well-<\/p>\n\n\n\n
being requires quickly removing the restraints.<\/p>\n\n\n\n
C. Allow a fingerbreadth between the restraint and the client\u2019s chest<\/p>\n\n\n\n
-incorrect: The nurse should allow two fingerbreadths between the restraint and the client\u2019s<\/p>\n\n\n\n
chest.<\/p>\n\n\n\n
D. Place the restraint under the client\u2019s clothing<\/p>\n\n\n\n
-incorrect: The nurse should apply the restraint over the client\u2019s clothing.<\/p>\n\n\n\n
308. An assistive personnel (AP) is helping a nurse care for a female client who has an<\/p>\n\n\n\n
indwelling urinary catheter. Which of the following actions by the AP indicates a need for<\/p>\n\n\n\n
further teaching?<\/p>\n\n\n\n
A. The AP uses soap and water to clean the perineal area<\/p>\n\n\n\n
-incorrect: The AP should cleanse the client\u2019s perineal area with soap and water at least 3 times<\/p>\n\n\n\n
per day to reduce the risk of infection.<\/p>\n\n\n\n
B. The AP tapes the catheter to the client\u2019s inner thigh<\/p>\n\n\n\n
-incorrect: The AP should tape the catheter to the inner thigh of a female client to prevent pulling<\/p>\n\n\n\n
on the urethra as the client moves around. When the catheter tugs and pulls on the urethra, it<\/p>\n\n\n\n
increases the risk of infection and dislodging the catheter.<\/p>\n\n\n\n
C. The AP hangs the collection bag at the level of the bladder<\/p>\n\n\n\n
-The AP should place the drainage bag below the level of the bladder to ensure proper drainage<\/p>\n\n\n\n
by gravity.<\/p>\n\n\n\n
D. The AP ensures there are no kinks in the drainage tube<\/p>\n\n\n\n
-incorrect: The AP should make sure there are no kinks in the tubing to ensure proper drainage<\/p>\n\n\n\n
by gravity.<\/p>\n\n\n\n
309. A nurse in a provider\u2019s office is collecting information from an older adult client who<\/p>\n\n\n\n
reports taking acetaminophen 500 mg\/day for severe joint pain. The nurse should instruct the<\/p>\n\n\n\n
client that large doses of acetaminophen could cause which of the following adverse effects?<\/p>\n\n\n\n
A. Constipation<\/p>\n\n\n\n
-incorrect: Constipation is an adverse effect of opioid analgesics.<\/p>\n\n\n\n
B. Gastric Ulcers<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg71.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: Gastric ulcers are an adverse effect of aspiring and other nonselective NSAIDs.<\/p>\n\n\n\n
C. Respiratory depression<\/p>\n\n\n\n
-incorrect: Respiratory depression is an adverse effect of opioid analgesics.<\/p>\n\n\n\n
D. Liver damage<\/p>\n\n\n\n
-Acetaminophen in large doses can be toxic to the liver. Daily intake should be limited to less<\/p>\n\n\n\n
than 3 to 4 grams per day for healthy individuals and 2.4 grams per day for older adults and those<\/p>\n\n\n\n
with a history of liver impairment.<\/p>\n\n\n\n
310. A nurse is caring for a client who reports using several herbal medicines. Which of the<\/p>\n\n\n\n
following actions should the nurse take?<\/p>\n\n\n\n
A. Discourage the use of unregulated medications and supplements<\/p>\n\n\n\n
-incorrect: Although herbal products are not subject to the regulation and scrutiny of the U.S.<\/p>\n\n\n\n
Food and Drug Administration, many can be safe and effective for treating a variety of health<\/p>\n\n\n\n
concerns.<\/p>\n\n\n\n
B. Verify the herbal supplements do not interact with medications the provider has<\/p>\n\n\n\n
prescribed<\/p>\n\n\n\n
-Many herbal products interact with other prescription and nonprescription medications.<\/p>\n\n\n\n
Valerian, for example, interacts with antihistamines as well as barbiturates and other sleep-<\/p>\n\n\n\n
promoting medications. The nurse should report any potential interactions to the provider.<\/p>\n\n\n\n
C. Tell the client to limit the number of herbal supplements to no more than 2<\/p>\n\n\n\n
-incorrect: The nurse\u2019s responsibility is to obtain a list of all the medications and herbal products<\/p>\n\n\n\n
the client takes so that the provider can review them and make recommendations. The nurse<\/p>\n\n\n\n
should not set specific limits on how many herbals products the client uses.<\/p>\n\n\n\n
D. Describe the dangers of taking plant-derived medications and supplements<\/p>\n\n\n\n
-incorrect: Pharmaceutical companies make many prescription medications from plants (ex:<\/p>\n\n\n\n
digoxin, reserpine, aspirin, and morphine).<\/p>\n\n\n\n
311. A nurse asks a client to explain the statement, \u201cA bird in the hand is worth two in the bush.\u201d<\/p>\n\n\n\n
Through this question, the nurse is evaluating the client\u2019s ability in which of the following<\/p>\n\n\n\n
intellectual functions?<\/p>\n\n\n\n
A. Judgment<\/p>\n\n\n\n
-incorrect: To test judgment, the nurse could ask what decisions the client would make in<\/p>\n\n\n\n
response to a specific real-life challenge.<\/p>\n\n\n\n
B. Short-term memory<\/p>\n\n\n\n
-incorrect: To test short-term memory, the nurse could ask the client to recall something like a<\/p>\n\n\n\n
list of 3 words that was provided a few months earlier.<\/p>\n\n\n\n
C. Attention span<\/p>\n\n\n\n
-incorrect: To test attention span, the nurse could ask the client to count backward from 100 in<\/p>\n\n\n\n
intervals of 7.<\/p>\n\n\n\n
D. Abstract reasoning<\/p>\n\n\n\n
-This exercise evaluates higher- level thinking and the ability to understand and interpret abstract<\/p>\n\n\n\n
thoughts.<\/p>\n\n\n\n
312. A nurse is planning care for a client who reports abdominal pain. An assessment by the<\/p>\n\n\n\n
nurse reveals the client has a temperature of 39.2 C (102.6 F), a heart rate of 105\/min, a soft<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg72.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
nontender abdomen, and menses overdue by 2 days. Which of the following findings should be<\/p>\n\n\n\n
the nurse\u2019s priority?<\/p>\n\n\n\n
A. Heart rate of 105\/min<\/p>\n\n\n\n
-incorrect: This is an important assessment finding because the client\u2019s heart rate is elevated.<\/p>\n\n\n\n
However, a fever and pain can contribute to tachycardia. This is not the priority finding.<\/p>\n\n\n\n
B. Soft nontender abdomen<\/p>\n\n\n\n
-incorrect: This is an important assessment finding because of the client\u2019s report of pain.<\/p>\n\n\n\n
However, a soft non-tender abdomen is an expected finding and should not cause concern.<\/p>\n\n\n\n
C. Temperature<\/p>\n\n\n\n
-Elevated temperature is an emergent physiological need that requires priority intervention by the<\/p>\n\n\n\n
nurse. The nurse should consider Maslow\u2019s Hierarchy of Needs, which includes five levels of<\/p>\n\n\n\n
priority. The levels are as follows: physiological needs, safety, and security needs, love and<\/p>\n\n\n\n
belonging needs, personal achievement and self-esteem needs, and achievement of full potential<\/p>\n\n\n\n
and the ability to problem-solve and cope with life situations.<\/p>\n\n\n\n
-When applying Maslow\u2019s Hierarchy of Needs, the nurse should review physiological needs first<\/p>\n\n\n\n
before following the remaining four levels. However, it is important for the nurse to consider all<\/p>\n\n\n\n
contributing client factors, as higher levels of the pyramid can compete with those at the lower<\/p>\n\n\n\n
levels, depending on the situation.<\/p>\n\n\n\n
D. Overdue menses<\/p>\n\n\n\n
-incorrect: This is an important assessment finding because of the client\u2019s report of pain.<\/p>\n\n\n\n
However, an irregularity in the menstrual cycle is a common finding when a client is stressed.<\/p>\n\n\n\n
This is not the priority finding.<\/p>\n\n\n\n
313. A nurse is caring for a client who had a stroke and is at risk of falling. Which of the<\/p>\n\n\n\n
following actions should the nurse take?<\/p>\n\n\n\n
A. Assign the client to a private room<\/p>\n\n\n\n
-incorrect: The client does not need to have a private room sure to an increased risk of falls.<\/p>\n\n\n\n
Increased social interaction can decrease the client\u2019s fall risk. The nurse should place the client in<\/p>\n\n\n\n
a room near the nurse\u2019s station for improved visual contact of the client.<\/p>\n\n\n\n
B. Keep 4 side rails up while the client is in bed<\/p>\n\n\n\n
-incorrect: The use of 4 raised side rails on the client\u2019s bed is considered a physical restraint that<\/p>\n\n\n\n
the nurse cannot employ without a prescription from the provider. Bed rails can increase a<\/p>\n\n\n\n
client\u2019s fall risk if the client attempts to climb over the rails to get out of bed.<\/p>\n\n\n\n
C. Monitor the client at least once every hour<\/p>\n\n\n\n
-The nurse should monitor the client frequently as a means of reducing the client\u2019s fall risk.<\/p>\n\n\n\n
Other measures can include keeping the client\u2019s bed in a low position, creating elimination<\/p>\n\n\n\n
schedules, and using a gait belt when the client is ambulating.<\/p>\n\n\n\n
D. Request a PRN prescription for restraints<\/p>\n\n\n\n
-incorrect: The nurse should consider and attempt any potential alternatives prior to<\/p>\n\n\n\n
implementing restrains. The use of restraints can contribute to an increased risk of complications<\/p>\n\n\n\n
for a client such as incontinence and the development of pressure ulcers due to immobilization.<\/p>\n\n\n\n
314. A nurse is caring for a middle-aged adult client. The nurse should evaluate the client for<\/p>\n\n\n\n
progress toward which of the following developmental tasks?<\/p>\n\n\n\n
A. Managing a home<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg73.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: Young adults should focus on learning to manage a home.<\/p>\n\n\n\n
B. Establishing a sense of self in the adult world<\/p>\n\n\n\n
-incorrect: Young adults should focus on establishing themselves in the adult world.<\/p>\n\n\n\n
C. Forming new friendships<\/p>\n\n\n\n
-incorrect: Young adults should focus on forming new friendships.<\/p>\n\n\n\n
D. Ceasing to compare personal identity with others<\/p>\n\n\n\n
-Middle-aged adults usually feel more comfortable with themselves and cease to make<\/p>\n\n\n\n
comparisons with others.<\/p>\n\n\n\n
315. A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client<\/p>\n\n\n\n
states that the hearing aid is making a whistling sound. The nurse should identify which of the<\/p>\n\n\n\n
following factors as the source for this sound?<\/p>\n\n\n\n
A. Low battery power<\/p>\n\n\n\n
-incorrect: A hearing aid with low battery power will not work effectively, but it will not whistle.<\/p>\n\n\n\n
Removing the battery at night can help extend the life of the battery.<\/p>\n\n\n\n
B. Excessive wax in the ear canal<\/p>\n\n\n\n
-Factors that can make a hearing aid whistle include a poor seal with the ear mold, an ear<\/p>\n\n\n\n
infection, excessive wax in the ear canal, an improper fit, or a malfunction.<\/p>\n\n\n\n
C. A volume setting that is too low<\/p>\n\n\n\n
-incorrect: A hearing aid might whistle if the volume is too high, not too low.<\/p>\n\n\n\n
D. A crack in the ear tube<\/p>\n\n\n\n
-incorrect: A crack in the ear tube of an in-the-ear-canal hearing aid can impair the hearing aid\u2019s<\/p>\n\n\n\n
amplification of sound; however, it would not cause whistling.<\/p>\n\n\n\n
316. A client who reports shortness of breath requests the nurse\u2019s help in changing positions.<\/p>\n\n\n\n
After repositioning the client, which of the following actions should the nurse take next?<\/p>\n\n\n\n
A. Encourage the client to take deep breaths<\/p>\n\n\n\n
-incorrect: Encouraging the client to take deep breaths can increase the intake of oxygen.<\/p>\n\n\n\n
However, there is another action the nurse should take first.<\/p>\n\n\n\n
B. Observe the rate, depth, and character of the client\u2019s respirations<\/p>\n\n\n\n
-The nurse should apply the nursing process priority-setting framework when caring for this<\/p>\n\n\n\n
client in order to plan client care and prioritize nursing actions. Each step of the nursing process<\/p>\n\n\n\n
builds on the previous step, beginning with an assessment or data collection.<\/p>\n\n\n\n
-Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a<\/p>\n\n\n\n
provider of a change in the client\u2019s status, the nurse must first collect adequate data from the<\/p>\n\n\n\n
client. Assessing or collecting additional data will provide the nurse with the knowledge needed<\/p>\n\n\n\n
to make an appropriate decision; therefore, the nurse should first assess the client\u2019s respiratory<\/p>\n\n\n\n
status.<\/p>\n\n\n\n
C. Prepare to administer oxygen<\/p>\n\n\n\n
-incorrect: Preparing to administer oxygen is important because oxygen is frequently<\/p>\n\n\n\n
administered when a client is experiencing dyspnea. However, there is another action the nurse<\/p>\n\n\n\n
should take first.<\/p>\n\n\n\n
D. Give the client a back rub to promote relaxation<\/p>\n\n\n\n
-incorrect: Giving the client a back rub is a relaxation technique that can reduce dyspnea.<\/p>\n\n\n\n
However, there is another action the nurse should take first.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg74.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
317. A nurse in a provider\u2019s office is assessing a client who has heart failure. The client has<\/p>\n\n\n\n
gained weight since her last visit, and her ankles are edematous. Which of the following findings<\/p>\n\n\n\n
is another clinical manifestation of fluid volume excess?<\/p>\n\n\n\n
A. Sunken eyeballs<\/p>\n\n\n\n
-incorrect: Sunken eyeballs are a clinical manifestation of fluid volume deficit.<\/p>\n\n\n\n
B. Hypotension<\/p>\n\n\n\n
-incorrect: Hypotension is a clinical manifestation of fluid volume deficit.<\/p>\n\n\n\n
C. Poor skin turgor<\/p>\n\n\n\n
-incorrect: Poor skin turgor is a clinical manifestation of fluid volume deficit.<\/p>\n\n\n\n
D. Bounding pulse<\/p>\n\n\n\n
-A bounding pulse is an expected finding of fluid volume excess.<\/p>\n\n\n\n
318. A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an<\/p>\n\n\n\n
assistive personnel (AP). The nurse later observes the AP emptying the bag without wearing<\/p>\n\n\n\n
gloves. Which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Notify the charge nurse about the incident<\/p>\n\n\n\n
-incorrect: The nurse does not need to notify the charge nurse about the incident. The nurse who<\/p>\n\n\n\n
delegates a task transfers responsibility for the task but retains accountability for the task. The<\/p>\n\n\n\n
nurse should evaluate the AP\u2019s performance and provide feedback as needed.<\/p>\n\n\n\n
B. Insist that the AP attend an in-service training about standard precautions<\/p>\n\n\n\n
-incorrect: Although further training and education may be necessary, the nurse should discuss<\/p>\n\n\n\n
the situation with the AP and listen attentively to the reason for the AP\u2019s actions. If the cause of<\/p>\n\n\n\n
the error is a lack of understanding of the procedure, the nurse can conduct training for the AP<\/p>\n\n\n\n
and other staff who may need assistance. The nurse can also gain assistance from the education<\/p>\n\n\n\n
department.<\/p>\n\n\n\n
C. Talk with the AP about the technique used<\/p>\n\n\n\n
-The nurse who delegates a task is responsible for providing the right supervision and evaluation.<\/p>\n\n\n\n
The nurse is responsible for providing feedback to the AP and should reinforce the correct<\/p>\n\n\n\n
procedure for this task with the AP, which includes wearing gloves.<\/p>\n\n\n\n
D. Observe the AP a second time and intervene if the technique remains the same<\/p>\n\n\n\n
-incorrect: The nurse should not allow the AP an opportunity to make the same mistake twice.<\/p>\n\n\n\n
The nurse should discuss the situation with the AP to determine the cause of the incorrect<\/p>\n\n\n\n
procedure and intervene the first time it is observed.<\/p>\n\n\n\n
319. A nurse is preparing to administer an intramuscular injection to a young adult client. Which<\/p>\n\n\n\n
of the following injection sites is the safest for this client?<\/p>\n\n\n\n
A. Vastus lateralis<\/p>\n\n\n\n
-incorrect: The vastus lateralis is safe for adults because it is thick and away from major blood<\/p>\n\n\n\n
vessels and nerves. However, according to evidence-based practice, it is not the safest injection<\/p>\n\n\n\n
site.<\/p>\n\n\n\n
B. Dorsogluteal<\/p>\n\n\n\n
-incorrect: The dorsogluteal site is close to the sciatic nerve, as well as the superior gluteal nerve<\/p>\n\n\n\n
and artery. Therefore, according to evidence-based practice, it is not the safest injection site.<\/p>\n\n\n\n
C. Deltoid<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg75.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The deltoid site is easy to access. However, according to evidence-based practice, it is<\/p>\n\n\n\n
not the safest site because the muscle is small and sometimes poorly developed. Additionally, it<\/p>\n\n\n\n
is close to numerous arteries and nerves.<\/p>\n\n\n\n
D. Ventrogluteal<\/p>\n\n\n\n
-According to evidence-based practice, the ventrogluteal site is the safest injection site for all<\/p>\n\n\n\n
adults because it contains thick gluteal muscles and does not contain major nerves or blood<\/p>\n\n\n\n
vessels.<\/p>\n\n\n\n
320. A nurse is caring for a client who has a dysrhythmia. Which of the following techniques<\/p>\n\n\n\n
should the nurse use to assess for a pulse deficit?<\/p>\n\n\n\n
A. Obtain the apical and radial rates simultaneously<\/p>\n\n\n\n
-To assess for a pulse deficit, the nurse and a second person assess the client\u2019s radial and apical<\/p>\n\n\n\n
pulses simultaneously and then compare both rates. To calculate the pulse deficit, the nurse<\/p>\n\n\n\n
should subtract the difference between the apical and radial pulse rates.<\/p>\n\n\n\n
B. Check the blood pressure in the left and right arms<\/p>\n\n\n\n
-incorrect: It is important to check the blood pressure in both the left and right arms for a client<\/p>\n\n\n\n
who is experiencing a dysrhythmia. However, this is not the correct procedure for assessing a<\/p>\n\n\n\n
pulse deficit.<\/p>\n\n\n\n
C. Compare the pulse strength in the upper extremities<\/p>\n\n\n\n
-incorrect: Comparing the pulse strengths in the upper extremities will not assess a pulse deficit.<\/p>\n\n\n\n
The nurse must obtain pulse measurements in the upper extremities and subtract the difference.<\/p>\n\n\n\n
D. Palpate the pulses in the lower extremities<\/p>\n\n\n\n
-incorrect: The nurse does not need to palpate pulses in the lower extremities to assess a pulse<\/p>\n\n\n\n
deficit. The nurse must obtain pulse measurements in the upper extremities and subtract the<\/p>\n\n\n\n
difference.<\/p>\n\n\n\n
321. A nurse is admitting a client who has tuberculosis. In addition to standard precautions,<\/p>\n\n\n\n
which of the following transmission-based precautions should the nurse add to the client\u2019s plan<\/p>\n\n\n\n
of care?<\/p>\n\n\n\n
A. Protective<\/p>\n\n\n\n
-incorrect: Protective environment precautions are for clients who are immunocompromised and<\/p>\n\n\n\n
are at high-risk for infection (ex: clients who had chemotherapy).<\/p>\n\n\n\n
B. Airborne<\/p>\n\n\n\n
-Tuberculosis requires airborne precautions, which are protocols that prevent the spread of<\/p>\n\n\n\n
infections via very small droplets (ex: measles and varicella).<\/p>\n\n\n\n
C. Droplet<\/p>\n\n\n\n
-incorrect: Droplet precautions prevent the spread of infections via larger droplets (ex: rubella,<\/p>\n\n\n\n
pertussis, and meningococcal pneumonia).<\/p>\n\n\n\n
D. Contact<\/p>\n\n\n\n
-incorrect: Contact precautions prevent the spread of infections via direct or indirect contact with<\/p>\n\n\n\n
contaminated blood or other body fluids (ex: Shigella, herpes simplex, and E. coli).<\/p>\n\n\n\n
322. A nurse is planning to administer pain medication to a client following abdominal surgery.<\/p>\n\n\n\n
Which of the following actions should the nurse take first?<\/p>\n\n\n\n
A. Use the pain scale to determine the client\u2019s pain level<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg76.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-The nurse should consider Maslow\u2019s Hierarchy of Needs, which includes 5 levels of priority.<\/p>\n\n\n\n
The levels are as follows: physiological needs, safety and security needs, love and belonging<\/p>\n\n\n\n
needs, personal achievement and self-esteem needs, and achieving full potential and the ability to<\/p>\n\n\n\n
problem-solve and cope with life situations.<\/p>\n\n\n\n
– When applying Maslow\u2019s hierarchy of needs priority-setting framework, the nurse should<\/p>\n\n\n\n
review physiological needs first and then address the client\u2019s needs by following the remaining<\/p>\n\n\n\n
hierarchal levels. The nurse should also consider all contributing client factors, as higher levels<\/p>\n\n\n\n
of the pyramid can compete with those at the lower levels, depending on the specific client<\/p>\n\n\n\n
situation. To meet the client\u2019s physiological needs, the nurse should begin pain management by<\/p>\n\n\n\n
asking the client to describe her pain.<\/p>\n\n\n\n
B. Discuss the adverse effects of pain medication with the client<\/p>\n\n\n\n
-incorrect: The nurse should discuss the adverse effects of pain medication with the client and<\/p>\n\n\n\n
instruct the client to report any problems with the intervention chosen. However, there is another<\/p>\n\n\n\n
action the nurse should take first.<\/p>\n\n\n\n
C. Obtain the client\u2019s vital signs<\/p>\n\n\n\n
-incorrect: The nurse should obtain the client\u2019s vital signs before choosing an intervention to<\/p>\n\n\n\n
relieve the client\u2019s pain. Obtaining vital signs provides a baseline for the nurse to compare to<\/p>\n\n\n\n
when monitoring the client after treating the client\u2019s pain. Respiratory depression and decreased<\/p>\n\n\n\n
blood pressure are adverse effects of opioid pain medications. However, there is another action<\/p>\n\n\n\n
the nurse should take first.<\/p>\n\n\n\n
D. Check the client\u2019s allergies<\/p>\n\n\n\n
-incorrect: The nurse should check the client\u2019s allergies if a pain medication will be<\/p>\n\n\n\n
administered. However, there is another action the nurse should take first.<\/p>\n\n\n\n
323. A nurse is preparing to administer medication to a client who has gout. The nurse discovers<\/p>\n\n\n\n
that an error was made during the previous shift in which the client received atenolol instead of<\/p>\n\n\n\n
allopurinol. Which of the following interventions is the nurse\u2019s priority?<\/p>\n\n\n\n
A. Measure the client\u2019s apical pulse<\/p>\n\n\n\n
-The first action the nurse should take using the nursing process is to assess the client by<\/p>\n\n\n\n
measuring the client\u2019s apical pulse. Atenolol is a beta blocker and can decrease the client\u2019s heart<\/p>\n\n\n\n
rate.<\/p>\n\n\n\n
B. Administer the allopurinol to the client<\/p>\n\n\n\n
-incorrect: The nurse should administer allopurinol to the client to ensure timely administration<\/p>\n\n\n\n
of medication. However, there is another action the nurse should take first.<\/p>\n\n\n\n
C. Inform the nurse manager<\/p>\n\n\n\n
-incorrect: The nurse should inform the nurse manager and report the error. However, there is<\/p>\n\n\n\n
another action the nurse should take first.<\/p>\n\n\n\n
D. Complete an incident report<\/p>\n\n\n\n
-incorrect: The nurse should complete an incident report to inform the risk manager of the<\/p>\n\n\n\n
medication error. However, there is another action the nurse should take first.<\/p>\n\n\n\n
324. A nurse is assessing the pH of a client\u2019s gastric fluid to confirm the placement of an NG<\/p>\n\n\n\n
tube in the stomach. Which of the following pH values should the nurse expect?<\/p>\n\n\n\n
A. 6<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg77.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: A pH of 6 can indicate the tube is in the lung. The expected reference range for lung<\/p>\n\n\n\n
secretions is >6.<\/p>\n\n\n\n
B. 2<\/p>\n\n\n\n
-A pH of 2 is within the expected reference range of 0-4 for gastric secretions.<\/p>\n\n\n\n
C. 10<\/p>\n\n\n\n
-incorrect: A pH of 10 can indicate a false reading, as an alkaline value is too high for intestinal<\/p>\n\n\n\n
or lung secretions.<\/p>\n\n\n\n
D. 8<\/p>\n\n\n\n
-incorrect: A pH of 8 can indicate the tube has migrated down into the intestines where the<\/p>\n\n\n\n
expected reference range is between 7 and 8.<\/p>\n\n\n\n
325. A nurse is preparing to assist an older adult client with ambulation following bed rest for 3<\/p>\n\n\n\n
days. Which of the following actions should the nurse take to decrease the risk of a fall?<\/p>\n\n\n\n
A. Use a gait belt during ambulation<\/p>\n\n\n\n
-The nurse should use a gait belt to keep the client\u2019s center of gravity midline and decrease the<\/p>\n\n\n\n
risk of a fall.<\/p>\n\n\n\n
B. Ensure the client is wearing socks before ambulating<\/p>\n\n\n\n
-incorrect: The nurse should ensure the client is wearing non-skid shoes or slippers when<\/p>\n\n\n\n
ambulating to decrease the risk of a fall from slipping.<\/p>\n\n\n\n
C. Instruct the client to sit on the edge of the bed for 15 sec before ambulating<\/p>\n\n\n\n
-incorrect: The nurse should encourage the client to dangle the legs on the edge of the bed for 60<\/p>\n\n\n\n
seconds before attempting to ambulate to decrease the risk of a fall due to orthostatic<\/p>\n\n\n\n
hypotension.<\/p>\n\n\n\n
D. Walk 2 ft behind the client during ambulation<\/p>\n\n\n\n
-incorrect: The nurse should walk beside the client to provide physical support while ambulating<\/p>\n\n\n\n
and decrease the risk of a fall.<\/p>\n\n\n\n
326. A nurse is planning care for a young adult client who has a terminal illness. Which of the<\/p>\n\n\n\n
following concepts of death should the nurse consider for this client?<\/p>\n\n\n\n
A. Death is unacceptable under any circumstances<\/p>\n\n\n\n
-incorrect: Adolescents tend to reject the end of life, especially their own.<\/p>\n\n\n\n
B. Magical thinking helps avoid thoughts of death<\/p>\n\n\n\n
-incorrect: Preschoolers tend to avoid thoughts of death by employing magical thinking.<\/p>\n\n\n\n
C. Death is viewed as an interruption of what might have been<\/p>\n\n\n\n
-Young adults tend to see a whole life ahead of them, so death is often seen as interrupting that<\/p>\n\n\n\n
life. Young adults do not typically welcome death at this time.<\/p>\n\n\n\n
D. Death is a natural consequence of a deteriorating body<\/p>\n\n\n\n
-incorrect: Accepting the deterioration of the body is more likely among older adults, some of<\/p>\n\n\n\n
whom might consider death a relief from chronic or terminal illness.<\/p>\n\n\n\n
327. A nurse is caring for a client who has a prescription for acetaminophen 325 mg PO for an<\/p>\n\n\n\n
oral temperature above 38.4 C. Above what Fahrenheit temperature should the nurse administer<\/p>\n\n\n\n
acetaminophen to the client? (nearest tenth)<\/p>\n\n\n\n
-101.1 F<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg78.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
328. A nurse is preparing to administer oral phenytoin to a client who has a seizure disorder.<\/p>\n\n\n\n
Before administering the medication, which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Document the administration of the medication<\/p>\n\n\n\n
-incorrect: The nurse should document the administration of the medication after dispensing it to<\/p>\n\n\n\n
the client, not before.<\/p>\n\n\n\n
B. Count the amount of available medication on hand and sign for it<\/p>\n\n\n\n
-incorrect: Phenytoin is not a controlled substance, so narcotic counts do not apply.<\/p>\n\n\n\n
C. Measure the client\u2019s respiratory rate<\/p>\n\n\n\n
-incorrect: Phenytoin does not affect respiratory status, so it is not necessary for the nurse to<\/p>\n\n\n\n
measure the client\u2019s respiratory rate immediately prior to administering this medication.<\/p>\n\n\n\n
D. Check the medication dose and the client\u2019s identification<\/p>\n\n\n\n
-The \u201crights\u201d of medication administration include verifying the right client and the right dose.<\/p>\n\n\n\n
329. A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea.<\/p>\n\n\n\n
Which of the following results should the nurse report to the provider?<\/p>\n\n\n\n
A. Calcium 9.5 mg\/dL<\/p>\n\n\n\n
-incorrect: A calcium level of 9.5 mg\/dL is within the expected reference range of 9 to 10.5<\/p>\n\n\n\n
mg\/dL.<\/p>\n\n\n\n
B. Sodium 150 mEq\/L<\/p>\n\n\n\n
-A sodium level of 150 mEq\/L is greater than the expected reference range of 135 to 145 mEq\/L.<\/p>\n\n\n\n
This client is at risk for dehydration due to diarrhea. Hypernatremia is a manifestation of<\/p>\n\n\n\n
dehydration, and the nurse should report this finding to the provider.<\/p>\n\n\n\n
C. Potassium 4 mEq\/L<\/p>\n\n\n\n
-incorrect: A potassium level of 4 mEq\/L is within the expected reference range of 3.5-5 mEq\/L.<\/p>\n\n\n\n
However, this client is at risk for hypokalemia due to diarrhea, so the client\u2019s potassium level<\/p>\n\n\n\n
should be monitored.<\/p>\n\n\n\n
D. Magnesium 1.5 mEq\/L<\/p>\n\n\n\n
-incorrect: A magnesium level of 1.5 mEq\/L is within the expected reference range of 1.3 to 2.1<\/p>\n\n\n\n
mEq\/L.<\/p>\n\n\n\n
330. A nurse is providing teaching about proper care to a client who has a new colostomy.<\/p>\n\n\n\n
Which of the following pieces of information should the nurse include in the teaching?<\/p>\n\n\n\n
A. Change the colostomy bag following breakfast<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to change the colostomy bag before a meal<\/p>\n\n\n\n
because drainage from the ostomy is less likely to occur.<\/p>\n\n\n\n
B. Cleanse the skin around the stoma with warm water<\/p>\n\n\n\n
-The nurse should instruct the client to cleanse the skin around the stoma with warm water, as<\/p>\n\n\n\n
using soap can leave a residue on the skin and cause poor adherence of the pouch.<\/p>\n\n\n\n
C. Change the pouch every day<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to change the pouch every 3 to 7 days to avoid<\/p>\n\n\n\n
skin breakdown around the stoma.<\/p>\n\n\n\n
D. Place an aspirin in the ostomy pouch to decrease odor<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client not to place an aspirin in the ostomy pouch to<\/p>\n\n\n\n
decrease odor, as this can cause stoma bleeding.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg79.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
331. A nurse is caring for a client who is exhibiting confusion. The nurse should identify that<\/p>\n\n\n\n
which of the following laboratory values can cause confusion?<\/p>\n\n\n\n
A. Sodium 123 mEq\/L<\/p>\n\n\n\n
-A sodium level of 123 mEq\/L is below the expected reference range of 136 to 145 mEq\/L. Low<\/p>\n\n\n\n
sodium levels can cause confusion and lead to seizures, coma, and death.<\/p>\n\n\n\n
B. Blood glucose 100 mg\/dL<\/p>\n\n\n\n
-incorrect: A blood glucose level of 100 mg\/dL is within the expected reference range of 70-110<\/p>\n\n\n\n
mg\/dL for fasting and less than 200 mg\/dL for a casual blood draw.<\/p>\n\n\n\n
C. Potassium 3.5 mEq\/L<\/p>\n\n\n\n
-incorrect: A potassium level of 3.5 mEq\/L is within the expected reference range of 3.5 to 5<\/p>\n\n\n\n
mEq\/L.<\/p>\n\n\n\n
D. Hemoglobin 13 g\/dL<\/p>\n\n\n\n
-incorrect: A hemoglobin level of 13 g\/dL is within expected reference range of 12 to 18 g\/dL.<\/p>\n\n\n\n
332. A nurse is caring for a client who has a gastric ulcer. The nurse should explain that<\/p>\n\n\n\n
prolonged exposure of the body to stress can also cause which of the following to occur?<\/p>\n\n\n\n
A. Hyperglycemia<\/p>\n\n\n\n
-Stress causes an increased secretion of cortisol, which can lead to hypertension and<\/p>\n\n\n\n
hyperglycemia.<\/p>\n\n\n\n
B. Hypotension<\/p>\n\n\n\n
-incorrect: Prolonged stress can lead to essential hypertension.<\/p>\n\n\n\n
C. Heightened immune response<\/p>\n\n\n\n
-incorrect: Prolonged stress weakens the immune response, placing the client at risk of various<\/p>\n\n\n\n
infections and worsening the severity of those infections.<\/p>\n\n\n\n
D. Bleeding tendencies<\/p>\n\n\n\n
-incorrect: Prolonged stress can lead to platelet aggregation and can increase the client\u2019s risk of<\/p>\n\n\n\n
myocardial infarction and stroke.<\/p>\n\n\n\n
333. A nurse is assessing a client who is experiencing stress and anxiety regarding a recent<\/p>\n\n\n\n
diagnosis. Which of the following findings should the nurse expect?<\/p>\n\n\n\n
A. Increased blood pressure<\/p>\n\n\n\n
-The nurse should expect a client who is experiencing stress and anxiety to manifest an increase<\/p>\n\n\n\n
in blood pressure and heart rate as a result of sympathetic stimulation.<\/p>\n\n\n\n
B. Decreased blood glucose level<\/p>\n\n\n\n
-incorrect: The nurse should expect a client who is experiencing stress and anxiety to manifest an<\/p>\n\n\n\n
increase in blood glucose due to the release of glucocorticoids and gluconeogenesis.<\/p>\n\n\n\n
C. Decreased oxygen use<\/p>\n\n\n\n
-incorrect: The nurse should expect a client who is experiencing stress and anxiety to manifest an<\/p>\n\n\n\n
increase in oxygen use due to an increased metabolic rate and oxygen demands of the body.<\/p>\n\n\n\n
D. Increased gastrointestinal motility<\/p>\n\n\n\n
-incorrect: The nurse should expect a client who is experiencing stress and anxiety to manifest<\/p>\n\n\n\n
decreased gastrointestinal motility, which can result in constipation and flatus.<\/p>\n\n\n\n
334. A nurse is planning to assess the abdomen of a client who reports feeling bloated for several<\/p>\n\n\n\n
weeks. Which of the following methods of assessment should the nurse use first?<\/p>\n\n\n\n
A. Inspection<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg7a.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-According to evidence- based practice, the nurse should inspect the abdomen first by observing<\/p>\n\n\n\n
the contour of the abdomen, the condition of the skin, and the position of the umbilicus. Findings<\/p>\n\n\n\n
from the step of assessment are used by the nurse in the subsequent steps.<\/p>\n\n\n\n
B. Auscultation<\/p>\n\n\n\n
-incorrect: The nurse should auscultate the client\u2019s abdomen before percussion or palpation, both<\/p>\n\n\n\n
of which can stimulate peristalsis, yielding inaccurate results. This sequence is different from the<\/p>\n\n\n\n
assessment of other body systems.<\/p>\n\n\n\n
C. Percussion<\/p>\n\n\n\n
-incorrect: The nurse should not percuss the client\u2019s abdomen first because percussion can cause<\/p>\n\n\n\n
pain and stimulate peristalsis, yielding inaccurate results in auscultation.<\/p>\n\n\n\n
D. Palpation<\/p>\n\n\n\n
-incorrect: The nurse should not palpate the client\u2019s abdomen first because palpation can cause<\/p>\n\n\n\n
pain and stimulate peristalsis, yielding inaccurate results on auscultation.<\/p>\n\n\n\n
335. A nurse is teaching the parent of a child who is to take 30mL of a liquid medication. The<\/p>\n\n\n\n
parent has a hollow medication spoon that has marks to indicate teaspoons and tablespoons. How<\/p>\n\n\n\n
many tablespoons of medication should the nurse instruct the parent to give to the child? (nearest<\/p>\n\n\n\n
whole number).<\/p>\n\n\n\n
-2 tablespoons<\/p>\n\n\n\n
336. A nurse is explaining Piaget\u2019s theory of cognitive development to a group of daycare<\/p>\n\n\n\n
providers for employees\u2019 children at an acute care facility. Which of the following activities<\/p>\n\n\n\n
should the nurse include as an example of concrete operational thinking?<\/p>\n\n\n\n
A. Playing in the sand<\/p>\n\n\n\n
-incorrect: Playing in the sand is an example of Piaget\u2019s sensorimotor stage, which characterizes<\/p>\n\n\n\n
children from birth to 2 years of age.<\/p>\n\n\n\n
B. Playing dress-up with old clothes<\/p>\n\n\n\n
-incorrect: Playing dress-up involves pretending, which reflects Piaget\u2019s preoperational thinking<\/p>\n\n\n\n
stage for ages 2 to 7 years.<\/p>\n\n\n\n
C. Collecting and trading game cards<\/p>\n\n\n\n
-Collecting and trading game cards require seriation of the cards, involving what to collect, what<\/p>\n\n\n\n
to trade, and what has value. This is a characteristic of Piaget\u2019s concrete operational stages for<\/p>\n\n\n\n
ages 7 to 11 years.<\/p>\n\n\n\n
D. Describing interpersonal relationships<\/p>\n\n\n\n
-incorrect: Describing interpersonal relationships requires abstract thought, which is part of<\/p>\n\n\n\n
Piaget\u2019s formal operational reasoning stage for ages 11 years and beyond.<\/p>\n\n\n\n
337. A nurse is caring for a toddler at a well-child visit when the mother calls, \u201cHelp! My baby is<\/p>\n\n\n\n
choking on his food!\u201d Which of the following findings indicates the toddler has an airway<\/p>\n\n\n\n
obstruction?<\/p>\n\n\n\n
A. Flushing of the skin<\/p>\n\n\n\n
-incorrect: Cyanosis is a finding with poor oxygenation, which could indicate an airway<\/p>\n\n\n\n
obstruction. The nurse should check the skin, nailbeds, and mucous membranes to identify the<\/p>\n\n\n\n
presence of cyanosis.<\/p>\n\n\n\n
B. Inability to cry or speak<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg7b.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-When the client has no sound passing through the vocal cords, a complete airway obstruction is<\/p>\n\n\n\n
evident. The nurse should use the Heimlich maneuver to dislodge whatever is obstructing the<\/p>\n\n\n\n
trachea.<\/p>\n\n\n\n
C. Presence of nausea and mild emesis<\/p>\n\n\n\n
-incorrect: The presence of mild emesis does not indicate an airway obstruction. The nurse<\/p>\n\n\n\n
should monitor the client to ensure the client clears emesis from the oral cavity in order to<\/p>\n\n\n\n
prevent the airway from becoming obstructed.<\/p>\n\n\n\n
D. Capillary refill time of 1.5 sec<\/p>\n\n\n\n
-incorrect: The expected finding for capillary refill time or blanch testing of the nailbed is <2<\/p>\n\n\n\n
seconds; therefore, the nurse should not identify this finding as an indication of airway<\/p>\n\n\n\n
obstruction. Delayed capillary refill time can indicate circulatory impairment.<\/p>\n\n\n\n
338. A nurse is assessing the heart sounds of a client who has developed chest pain that worsens<\/p>\n\n\n\n
with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and<\/p>\n\n\n\n
diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the<\/p>\n\n\n\n
following heart sounds should the nurse document?<\/p>\n\n\n\n
A. Audible click<\/p>\n\n\n\n
-incorrect: An audible clicking sound occurs in clients who have undergone prosthetic valve<\/p>\n\n\n\n
replacement surgery.<\/p>\n\n\n\n
B. Murmur<\/p>\n\n\n\n
-incorrect: A heart murmur has a swishing or whistling sound. Heart murmurs are caused by<\/p>\n\n\n\n
turbulent blood flow through valves or ventricular outflow tracts. Low- and medium- frequency<\/p>\n\n\n\n
sounds are more easily heard with the bell of the stethoscope applied lightly to the skin; high-<\/p>\n\n\n\n
frequency sounds are more easily heard with a diaphragm. A murmur can be a manifestation of<\/p>\n\n\n\n
valvular disease.<\/p>\n\n\n\n
C. Third heart sound<\/p>\n\n\n\n
-incorrect: A third heart sound (S3) is a low-pitched noise after the second heart sound. An S3 is<\/p>\n\n\n\n
caused by rapid ventricular filling during diastole. It is best heard at the mitral area, with the<\/p>\n\n\n\n
client lying on the left side. An S3 is commonly heard in children and young adults. In older<\/p>\n\n\n\n
adults and clients who have heart disease, an S3 often indicates heart failure.<\/p>\n\n\n\n
D. Pericardial friction rub<\/p>\n\n\n\n
-A pericardial friction rub has a high-pitched scratching, grating, or squeaking leathery sound<\/p>\n\n\n\n
that is heard best with the diaphragm of the stethoscope at the left sternal border. A pericardial<\/p>\n\n\n\n
friction rub is a manifestation of pericardial inflammation and can be heard with infective<\/p>\n\n\n\n
pericarditis with myocardial infarction, following cardiac surgery or trauma, and with some<\/p>\n\n\n\n
autoimmune problems like rheumatic fever. A client who develops pericarditis typically has<\/p>\n\n\n\n
chest pain that becomes worse with inspiration or coughing and may be relieved by sitting up<\/p>\n\n\n\n
and leaning forward.<\/p>\n\n\n\n
339. A nurse is assessing a client who is experiencing stress following a near fall out of bed.<\/p>\n\n\n\n
Which of the following physiological responses should the nurse expect due to the fight or flight<\/p>\n\n\n\n
response?<\/p>\n\n\n\n
A. Decreased respiratory rate<\/p>\n\n\n\n
-incorrect: The nurse should expect an increased respiratory rate in a client who is experiencing<\/p>\n\n\n\n
the fight or flight response.<\/p>\n\n\n\n
B. Pinpoint pupils<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg7c.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The nurse should expect dilated pupils in a client who is experiencing the fight or<\/p>\n\n\n\n
flight response.<\/p>\n\n\n\n
C. Increased blood pressure<\/p>\n\n\n\n
-The nurse should expect a client who is experiencing the fight or flight response to manifest an<\/p>\n\n\n\n
increase in arterial blood pressure, heart rate, and cardiac output due to arousal of the central<\/p>\n\n\n\n
nervous system.<\/p>\n\n\n\n
D. Bronchiolar construction<\/p>\n\n\n\n
-incorrect: The nurse should expect bronchiolar dilation in a client who is experiencing the fight<\/p>\n\n\n\n
or flight response.<\/p>\n\n\n\n
340. A nurse is assessing a client\u2019s incision and observes the drainage to be blood tinged. Which<\/p>\n\n\n\n
of the following terms should the nurse use to document this finding?<\/p>\n\n\n\n
A. Sanguineous<\/p>\n\n\n\n
-The nurse should document blood tinged drainage as sanguineous. This type of drainage<\/p>\n\n\n\n
contains large amounts of RBCs, indicating that damaged capillaries are allowing the escape of<\/p>\n\n\n\n
RBCs from the plasma.<\/p>\n\n\n\n
B. Purulent<\/p>\n\n\n\n
-incorrect: The nurse should identify that purulent drainage is exudate that is thicker than other<\/p>\n\n\n\n
drainages, indicating the presence of pus. This pus consists of leukocytes, liquefied dead tissue<\/p>\n\n\n\n
debris, and dead and living bacteria.<\/p>\n\n\n\n
C. Serous<\/p>\n\n\n\n
-incorrect: The nurse should identify serous drainage as exudate that is mostly serum, which is<\/p>\n\n\n\n
the clear portion of the blood. It appears watery and contains few cells.<\/p>\n\n\n\n
D. Hyperemia<\/p>\n\n\n\n
-incorrect: The nurse should identify hyperemia as a red coloration of the skin in clients who<\/p>\n\n\n\n
have light skin or as a blue coloration of the skin in clients who have dark skin. Hyperemia is not<\/p>\n\n\n\n
a type of drainage.<\/p>\n\n\n\n
341. A nurse is providing discharge teaching to a client who has a prescription for daily wound<\/p>\n\n\n\n
care via home health services. Which of the following statements by the client indicates an<\/p>\n\n\n\n
understanding of the teaching?<\/p>\n\n\n\n
A. \u201cA nurse will show me how to care for my wound.\u201d<\/p>\n\n\n\n
-The home health nurse will provide wound care as prescribed and educate the client about<\/p>\n\n\n\n
wound care and illness management.\u201d<\/p>\n\n\n\n
B. \u201cA nurse will stay with me at home during the day.\u201d<\/p>\n\n\n\n
-incorrect: A client who will receive daily wound care will not require a nurse to stay throughout<\/p>\n\n\n\n
the day. The home health nurse can make a referral for a home health aide to stay with the client<\/p>\n\n\n\n
if needed.<\/p>\n\n\n\n
C. \u201cI will call the nurse to change my bed linens.\u201d<\/p>\n\n\n\n
-incorrect: If needed, the home health nurse can make a referral to a home health aide to provide<\/p>\n\n\n\n
personal care, such as changing bed linens.<\/p>\n\n\n\n
D. \u201cI will call the nurse to help me bathe in the morning.\u201d<\/p>\n\n\n\n
-incorrect: If needed, the home health nurse can make a referral to a home health aide to provide<\/p>\n\n\n\n
personal care, such as bathing.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg7d.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
342. A nurse is removing protective personal equipment (PPE) after performing a procedure for<\/p>\n\n\n\n
a client who requires isolation precautions. Which of the following items of PPE should the<\/p>\n\n\n\n
nurse remove first?<\/p>\n\n\n\n
A. Gloves<\/p>\n\n\n\n
-According to evidence-based practice, the nurse should first remove the gloves because they are<\/p>\n\n\n\n
the most contaminated piece of PPE. Next, the nurse should remove the goggles or face shield<\/p>\n\n\n\n
and then the gown. Finally, the nurse should remove the respirator or mask because it is the least<\/p>\n\n\n\n
contaminated piece of PPE.<\/p>\n\n\n\n
B. Gown<\/p>\n\n\n\n
C. Eyewear<\/p>\n\n\n\n
D. Mask<\/p>\n\n\n\n
-incorrect B\/C\/D: According to evidence-based practice, nurses should remove the most<\/p>\n\n\n\n
contaminated piece of PPE first and the least contaminated piece of PPE last. The most<\/p>\n\n\n\n
contaminated piece of PPE are the gloves, and the least contaminated piece of PPE is the mask.<\/p>\n\n\n\n
343. A nurse is measuring a client\u2019s vital signs. The client\u2019s resting radial pulse rate is 55\/min.<\/p>\n\n\n\n
Which of the following actions should the nurse take next?<\/p>\n\n\n\n
A. Document the finding<\/p>\n\n\n\n
-incorrect: The nurse should document all findings in the client\u2019s medical record to verify that<\/p>\n\n\n\n
this measurement was obtained. However, there is another action the nurse should take first.<\/p>\n\n\n\n
B. Measure the client\u2019s apical pulse rate<\/p>\n\n\n\n
-The first action the nurse should take using the nursing process is to assess or collect data from<\/p>\n\n\n\n
the client. This pulse rate is below the expected reference range for an adult. The nurse and<\/p>\n\n\n\n
coworker should measure the apical and radial pulse rates simultaneously to determine if there is<\/p>\n\n\n\n
a pulse deficit. If the client\u2019s radial pulse rate is lower than the apical rate, the client might have a<\/p>\n\n\n\n
cardiovascular disorder.<\/p>\n\n\n\n
C. Talk with the client about factors that can affect the pulse rate<\/p>\n\n\n\n
-incorrect: The nurse should inform the client about the low pulse rate and possible causes so that<\/p>\n\n\n\n
the client understands the reason for any additional actions the nurse might take. However, there<\/p>\n\n\n\n
is another action the nurse should take first.<\/p>\n\n\n\n
D. Notify the provider about the client\u2019s radial pulse rate<\/p>\n\n\n\n
–incorrect: The nurse should inform the provider of the client\u2019s low pulse rate to obtain<\/p>\n\n\n\n
additional diagnostic or treatment prescriptions. However, there is another action the nurse<\/p>\n\n\n\n
should take first.<\/p>\n\n\n\n
344. A nurse is caring for a client who is unconscious. Which of the following actions should the<\/p>\n\n\n\n
nurse take when providing oral care for the client?<\/p>\n\n\n\n
A. Test for the presence of the client\u2019s gag reflex<\/p>\n\n\n\n
-The nurse is responsible for checking for the presence of a gag reflex prior to performing oral<\/p>\n\n\n\n
care. This is done to determine the risk of aspiration and is especially important for clients who<\/p>\n\n\n\n
are unconscious because many clients who have decreased level of consciousness often do not<\/p>\n\n\n\n
have a gag reflex.<\/p>\n\n\n\n
B. Place the client in the supine position<\/p>\n\n\n\n
-incorrect: The nurse should raise the bed to a semi-Fowler\u2019s position and turn the client\u2019s head<\/p>\n\n\n\n
toward the person who will be performing oral care.<\/p>\n\n\n\n
C. Use a firm toothbrush for tooth and gum care<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg7e.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The nurse should use a soft-bristled toothbrush with nonabrasive fluoride toothpaste<\/p>\n\n\n\n
to perform oral care.<\/p>\n\n\n\n
D. Use 2 gauze-wrapped fingers to hold the mouth open<\/p>\n\n\n\n
-incorrect: The nurse should use a small oral airway or a padded tongue blade to hole the client\u2019s<\/p>\n\n\n\n
mouth open when cleansing the oral cavity.A bite from the client\u2019s mouth can contain multiple<\/p>\n\n\n\n
pathogenic microorganisms; therefore, the nurse should not place fingers inside the client\u2019s<\/p>\n\n\n\n
mouth.<\/p>\n\n\n\n
345. A nurse is preparing to administer a partial dose of a prefilled opioid analgesic parenterally<\/p>\n\n\n\n
to a client. Which of the following actions should the nurse plan to take?<\/p>\n\n\n\n
A. Return the unused portion of the medication to the pharmacy<\/p>\n\n\n\n
-incorrect: The nurse should not return the unused portion of medication to the pharmacy. The<\/p>\n\n\n\n
medication should be wasted, and the amount wasted should be recorded on the controlled<\/p>\n\n\n\n
substance inventory.<\/p>\n\n\n\n
B. Dispose of the wasted medication into a sharps container<\/p>\n\n\n\n
-incorrect: The nurse should dispose of a controlled substance into a sharps container. Both the<\/p>\n\n\n\n
amount of the medication given, and the amount of medication wasted should be signed for.<\/p>\n\n\n\n
C. Record the amount of medication wasted on the controlled substance inventory record<\/p>\n\n\n\n
-Two nurses should sign the controlled substance inventory record to document the amount of<\/p>\n\n\n\n
medication wasted.<\/p>\n\n\n\n
D. Ask an assistive personnel (AP) to witness the wasting of the controlled substance<\/p>\n\n\n\n
-incorrect: A second nurse, not an AP, must serve as the witness to the wasting of the remaining<\/p>\n\n\n\n
controlled substance.<\/p>\n\n\n\n
346. A nurse is monitoring a client\u2019s laboratory results. Which of the following results should the<\/p>\n\n\n\n
nurse report to the provider?<\/p>\n\n\n\n
A. Sodium 140 mEq\/L<\/p>\n\n\n\n
-incorrect: This sodium value is within the expected reference range.<\/p>\n\n\n\n
B. Potassium 3.0 mEq\/L<\/p>\n\n\n\n
-This potassium level is below the expected reference range, indicating hypokalemia. The nurse<\/p>\n\n\n\n
should report this finding to the provider for instructions about preventing muscle weakness that<\/p>\n\n\n\n
could affect respiration.<\/p>\n\n\n\n
C. Chloride 100 mEq\/L<\/p>\n\n\n\n
-incorrect: This chloride value is within the expected reference range.<\/p>\n\n\n\n
D. Magnesium 2.0 mEq\/L<\/p>\n\n\n\n
-incorrect: This magnesium value is within the expected reference range.<\/p>\n\n\n\n
347. A nurse is caring for a client who has the head of the bed elevated to a 45-degree angle with<\/p>\n\n\n\n
his knees slightly flexed. Which of the following positions should the nurse document for the<\/p>\n\n\n\n
client?<\/p>\n\n\n\n
A. Sims\u2019<\/p>\n\n\n\n
-incorrect: In this position, the client lies on a side with the leg on that side slightly flexed and<\/p>\n\n\n\n
the opposite leg more acutely flexed. The lower arm is behind, with the opposite arm flexed at<\/p>\n\n\n\n
the shoulder and the elbow.<\/p>\n\n\n\n
B. Prone<\/p>\n\n\n\n
-incorrect: In this position, the client is lying on the abdomen.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg7f.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
C. Supine<\/p>\n\n\n\n
-incorrect: In this position, the client is lying flat on the back.<\/p>\n\n\n\n
D.Fowler\u2019s<\/p>\n\n\n\n
-This describes Fowler\u2019s position. Although various definitions exist for Fowler\u2019s position,<\/p>\n\n\n\n
generally a low Fowler\u2019s position means 30 degrees of elevation, semi-Fowler\u2019s is 45-60<\/p>\n\n\n\n
degrees, and high Fowler\u2019s is 60-90 degrees of elevation.<\/p>\n\n\n\n
348. A nurse is teaching a client who has asthma about the proper use of an albuterol inhaler.<\/p>\n\n\n\n
Which of the following client statements indicates an understanding of the teaching?<\/p>\n\n\n\n
A. \u201cI should rinse my mouth out right before I use the inhaler.\u201d<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to rinse the mouth with water following the use of<\/p>\n\n\n\n
the inhaler to reduce irritation and infection, not before using the inhaler.<\/p>\n\n\n\n
B. \u201cAfter the first puff, I will wait 10 seconds before taking the second puff. \u201c<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to wait 20-30 seconds between inhalations of<\/p>\n\n\n\n
bronchodilator medications such as albuterol.<\/p>\n\n\n\n
C. \u201cI will shake the inhaler well right before I use it.\u201d<\/p>\n\n\n\n
-The nurse should instruct the client to shake the inhaler vigorously for 3-5 seconds, which will<\/p>\n\n\n\n
mix the medication within the inhaler evenly.<\/p>\n\n\n\n
D. \u201cI will tilt my head forward while inhaling the medication.\u201d<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to place the inhaler in the mouth and tightly close<\/p>\n\n\n\n
the lips around the mouthpiece to create a seal. The client should then depress the canister, take a<\/p>\n\n\n\n
deep breath, and hold it for at least 10 seconds.<\/p>\n\n\n\n
349. A nurse is caring for a client who had a stroke and is at risk for falling. Which of the<\/p>\n\n\n\n
following actions should the nurse take?<\/p>\n\n\n\n
A. Assign the client to a private room<\/p>\n\n\n\n
B. Keep 4 side rails up while the client is in bed<\/p>\n\n\n\n
C. Monitor the client at least once every hour<\/p>\n\n\n\n
D. Request a PRN prescription for restraints<\/p>\n\n\n\n
350. A nurse is caring for a group of clients. Which of the following tasks should the nurse<\/p>\n\n\n\n
assign to an assistive personnel (AP)?<\/p>\n\n\n\n
A. Provide oral care to a client who cannot take oral fluids<\/p>\n\n\n\n
-Providing oral care to a client who cannot take oral fluids is within the range of function for an<\/p>\n\n\n\n
AP. Therefore, the nurse can assign this task to the AP.<\/p>\n\n\n\n
B. Check the client\u2019s IV insertion site for manifestations of infiltration<\/p>\n\n\n\n
-incorrect: Checking the client\u2019s IV insertion site for manifestations of infiltration is not within<\/p>\n\n\n\n
the range of function for an AP. Therefore, the nurse should not assign this task to the AP.<\/p>\n\n\n\n
C. Assess a client\u2019s ability to ambulate<\/p>\n\n\n\n
-incorrect: Assessing a client\u2019s ability to ambulate is not within the range of function for an Ap.<\/p>\n\n\n\n
Therefore, the nurse should not assign the AP this task.<\/p>\n\n\n\n
D. Demonstrate the use of a glucometer to a client who has diabetes mellitus<\/p>\n\n\n\n
-incorrect: Demonstrating the use of a glucometer to a client who has DM is not within the range<\/p>\n\n\n\n
of function for an AP. Therefore, the nurse should not assign this task to the AP.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg80.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
351. A nurse is teaching a group of young adults. Which of the following should the nurse<\/p>\n\n\n\n
identify as an expected developmental task for this age group?<\/p>\n\n\n\n
A. Independent moral development<\/p>\n\n\n\n
-According to Kohlberg\u2019s theory of moral development, making individual decisions about<\/p>\n\n\n\n
moral issues is a function of the highest level of moral development, the post-conventional level.<\/p>\n\n\n\n
Young adults who have reached this level separate themselves from the rules and tenets of others<\/p>\n\n\n\n
and make their own decisions according to personal beliefs and principles.<\/p>\n\n\n\n
B. Acceptance of body changes<\/p>\n\n\n\n
-incorrect: Acceptance of body changes should take place during adolescence<\/p>\n\n\n\n
C. Strengthening ties with the family of origin<\/p>\n\n\n\n
-incorrect: Young adults need to develop intimacy outside of the family.<\/p>\n\n\n\n
D. Development of concrete reasoning<\/p>\n\n\n\n
-incorrect: Concrete thinking develops during middle childhood. Abstract reasoning develops<\/p>\n\n\n\n
during adolescence.<\/p>\n\n\n\n
352. A nurse in a provider\u2019s office is reviewing the laboratory findings of a client who reports<\/p>\n\n\n\n
chills and aching joints. The nurse should identify which of the following findings as an<\/p>\n\n\n\n
indication of an infection?<\/p>\n\n\n\n
A. WBC 15,000 mm^3<\/p>\n\n\n\n
-This finding is above the expected reference range and is an indication of infection.<\/p>\n\n\n\n
B. Erythrocyte sedimentation rate (ESR) 15 mm\/hr<\/p>\n\n\n\n
-incorrect: Although an elevated ESR can indicate an infection, this finding is within the<\/p>\n\n\n\n
expected reference range.<\/p>\n\n\n\n
C. Urine pH 7.2<\/p>\n\n\n\n
-incorrect: A urine pH of 7.2 is within the expected reference range.<\/p>\n\n\n\n
D. Urine specific gravity 1.0063<\/p>\n\n\n\n
-incorrect: A urine specific gravity of 1.0063 is within the expected reference range.<\/p>\n\n\n\n
353. A nurse is assessing a client\u2019s vascular system. Which of the following techniques should<\/p>\n\n\n\n
the nurse use when evaluating the carotid arteries?<\/p>\n\n\n\n
A. Palpation of both carotid arteries simultaneously<\/p>\n\n\n\n
-incorrect: Palpating the carotid arteries simultaneously can compromise the blood flow to the<\/p>\n\n\n\n
brain.<\/p>\n\n\n\n
B. Auscultation of the arteries for bruits with the bell of the stethoscope<\/p>\n\n\n\n
-The bell of the stethoscope is more effective than the diaphragm in transmitting blowing or<\/p>\n\n\n\n
swishing sounds, such as those from turbulence in blood vessels.<\/p>\n\n\n\n
C. Palpation of the arteries for murmurs bilaterally<\/p>\n\n\n\n
-incorrect: Murmurs are swishing or blowing sounds. Detecting them requires auscultation, not<\/p>\n\n\n\n
palpation.<\/p>\n\n\n\n
D. Auscultation of the arteries for thrills with the diaphragm of the stethoscope<\/p>\n\n\n\n
-incorrect: Thrills are palpable purring sensations. Detecting them requires palpation, not<\/p>\n\n\n\n
auscultation.<\/p>\n\n\n\n
354. A nurse on a surgical unit is receiving a client who had abdominal surgery from the post<\/p>\n\n\n\n
anesthesia care unit. Which of the following assessments should the nurse make first?<\/p>\n\n\n\n
A. Pain level<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg81.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The nurse should assess the pain level of a client who is postoperative; however,<\/p>\n\n\n\n
another assessment should be made first.<\/p>\n\n\n\n
B. Hydration status<\/p>\n\n\n\n
-incorrect: The nurse should assess the hydration status of a client who is postoperative;<\/p>\n\n\n\n
however, another assessment should be made first.<\/p>\n\n\n\n
C. Airway<\/p>\n\n\n\n
-The nurse should apply the ABC priority-setting framework when caring for this client. This<\/p>\n\n\n\n
framework emphasizes the basic core of human functioning and prioritizes having an open<\/p>\n\n\n\n
airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the<\/p>\n\n\n\n
body\u2019s organs via the blood. An alteration in any of these can indicate a threat to life. Therefore,<\/p>\n\n\n\n
this is the nurse\u2019s priority concern.<\/p>\n\n\n\n
-When applying the ABC priority-setting framework, airway is always the highest priority<\/p>\n\n\n\n
because the airway must be clear for oxygen exchange to occur. Breathing is the second highest<\/p>\n\n\n\n
priority in the ABC priority-setting framework because adequate ventilatory effort is essential for<\/p>\n\n\n\n
oxygen exchange to occur. Circulation is the third highest priority in the ABC priority-setting<\/p>\n\n\n\n
framework because the delivery of oxygen to critical organs only occurs if the heart and blood<\/p>\n\n\n\n
vessels are capable of efficiently carrying oxygen to them.<\/p>\n\n\n\n
D. Urinary output<\/p>\n\n\n\n
-incorrect: The nurse should assess the urinary output of a client who is postoperative; however,<\/p>\n\n\n\n
another assessment should be made first.<\/p>\n\n\n\n
355. A nurse is caring for a client who starts to experience a seizure while sitting in a chair.<\/p>\n\n\n\n
Which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Place a padded tongue blade in the client\u2019s mouth<\/p>\n\n\n\n
-incorrect: The nurse should avoid placing a padded tongue blade in the client\u2019s mouth because<\/p>\n\n\n\n
this can cause injury (ex: broken teeth).<\/p>\n\n\n\n
B. Lower the client to the floor and place a pad under the client\u2019s head<\/p>\n\n\n\n
-To reduce the risk of injury to the client, the nurse should lower the client to the floor and place<\/p>\n\n\n\n
a pillow or another soft object under the client\u2019s head.<\/p>\n\n\n\n
C. Seek the help of a coworker and lift the client back into bed<\/p>\n\n\n\n
-incorrect: The nurse should not attempt to lift a client who is experiencing a seizure.<\/p>\n\n\n\n
D. Use an oropharyngeal airway to keep the upper airway passages open<\/p>\n\n\n\n
-incorrect: The nurse should avoid inserting an oropharyngeal airway because this can cause<\/p>\n\n\n\n
injury.<\/p>\n\n\n\n
356. A nurse is preparing to change a dressing on a client who is receiving negative pressure<\/p>\n\n\n\n
wound therapy (NPWT). What sequence of actions should the nurse plan to take?<\/p>\n\n\n\n
-Turn off the vacuum on the NPWT device and administer the prescribed analgesic.<\/p>\n\n\n\n
-Remove the soiled dressing and perform hand hygiene<\/p>\n\n\n\n
-Apply sterile or clean gloves and irrigate the wound<\/p>\n\n\n\n
-Apply a skin protectant or barrier film to the skin around the wound<\/p>\n\n\n\n
-Place prepared foam into the wound bed and cover with a transparent dressing<\/p>\n\n\n\n
-Connect the tubing to transparent film and turn on the NPWT unit<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg82.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
357. A nurse is providing teaching to a client with heart failure about reducing his daily intake of<\/p>\n\n\n\n
sodium. Which of the following factors is the most important in determining the client\u2019s ability<\/p>\n\n\n\n
to learn new dietary habits?<\/p>\n\n\n\n
A. The involvement of the client in planning the change<\/p>\n\n\n\n
-According to evidence-based practice, client involvement in planning dietary changes is the<\/p>\n\n\n\n
most important factor in the client\u2019s ability to learn new habits.<\/p>\n\n\n\n
B. The emphasis the provider places on the dietary changes<\/p>\n\n\n\n
-incorrect: The emphasis the provider places on the dietary changes can influence the client\u2019s<\/p>\n\n\n\n
ability to learn new dietary habits; however, it is not the most important factor.<\/p>\n\n\n\n
C. The learning theory the nurse uses to teach the dietary changes<\/p>\n\n\n\n
-incorrect: The learning theory the nurse uses to teach dietary changes can influence the client\u2019s<\/p>\n\n\n\n
ability to learn new dietary habits; however, it is not the most important factor.<\/p>\n\n\n\n
D. The extent of the dietary changes planned for the client<\/p>\n\n\n\n
-incorrect: The extent of the changes planned can influence the client\u2019s ability to learn new<\/p>\n\n\n\n
dietary habits; however, it is not the most important factor.<\/p>\n\n\n\n
358. While admitting a client to the medical unit, the nurse asks him if he has advanced<\/p>\n\n\n\n
directives. This client states \u201cI have a document with me that names someone who can make<\/p>\n\n\n\n
health care decisions for me if I am not stable.\u201d The nurse should identify that the client is<\/p>\n\n\n\n
referring to which of the following documents?<\/p>\n\n\n\n
A. Informed consent form<\/p>\n\n\n\n
-incorrect: Prior to specific procedures, clients must sign an informed consent form to confirm<\/p>\n\n\n\n
that the provider has explained the risks and benefits and pertinent information about the<\/p>\n\n\n\n
procedure.<\/p>\n\n\n\n
B. Living will document<\/p>\n\n\n\n
-incorrect: A living will contain advance directives that inform medical personnel about the care<\/p>\n\n\n\n
to provide in case the individual is unable to make decisions.<\/p>\n\n\n\n
C. Do-not-resuscitate (DNR) directive<\/p>\n\n\n\n
-incorrect: A DNR directive is a prescription the provider writes on the client\u2019s request to<\/p>\n\n\n\n
instruct the staff to forego resuscitation efforts for the client.<\/p>\n\n\n\n
D. Durable power of attorney document<\/p>\n\n\n\n
-A durable power of attorney for health care document, or health care proxy, names a surrogate<\/p>\n\n\n\n
who can make health care decisions for the client if he is unable to do so.<\/p>\n\n\n\n
359. A nurse is caring for a client who has a terminal illness. Which of the following findings<\/p>\n\n\n\n
indicates that the client\u2019s death is imminent?<\/p>\n\n\n\n
A. Urinary retention<\/p>\n\n\n\n
-incorrect: Urinary incontinence is a physical change that occurs when a client\u2019s death is<\/p>\n\n\n\n
imminent.<\/p>\n\n\n\n
B. Cold extremities<\/p>\n\n\n\n
-The presence of cold extremities, first in the feet and then in the hands, is a physical change that<\/p>\n\n\n\n
occurs when a client\u2019s death is imminent.<\/p>\n\n\n\n
C. Hypertension<\/p>\n\n\n\n
-incorrect: Hypotension is physical change that occurs when a client\u2019s death is imminent.<\/p>\n\n\n\n
D. Tachycardia<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg83.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: A slow, weak pulse is a physical change that occurs when a client\u2019s death is<\/p>\n\n\n\n
imminent.<\/p>\n\n\n\n
360. A nurse is using the I-SBAR communication tool to give a client\u2019s provider information<\/p>\n\n\n\n
about the client. The nurse should convey this client\u2019s pain status in which portion of the report?<\/p>\n\n\n\n
A. Assessment<\/p>\n\n\n\n
-The nurse provides information about the assessment findings in this portion of the report,<\/p>\n\n\n\n
including vital signs, pain assessment, and changes in assessment findings.<\/p>\n\n\n\n
B. Background<\/p>\n\n\n\n
-incorrect: The nurse provides information about pertinent medical history, laboratory findings,<\/p>\n\n\n\n
allergies, and code status in this portion of the report.<\/p>\n\n\n\n
C. Situation<\/p>\n\n\n\n
-incorrect: The nurse provides information about problems the client is experiencing in this<\/p>\n\n\n\n
portion of the report.<\/p>\n\n\n\n
D. Recommendation<\/p>\n\n\n\n
-incorrect: The nurse makes recommendations about treatment and asks the provider about<\/p>\n\n\n\n
additional treatment in this portion of the report.<\/p>\n\n\n\n
361. A nurse is preparing to administer a tap water enema to a client. Which of the following<\/p>\n\n\n\n
actions should the nurse take?<\/p>\n\n\n\n
A. Raise the enema bag if the client experiences cramping<\/p>\n\n\n\n
-incorrect: The nurse should administer the fluids slowly and lower the container for a client who<\/p>\n\n\n\n
experiences fullness or pain during the administration of the enema.<\/p>\n\n\n\n
B. Lubricate 2.54 cm (1in) of the tip of the rectal tube prior to insertion<\/p>\n\n\n\n
-incorrect: The nurse should lubricate 5.08 cm (2in) of the tip rectal tube prior to insertion.<\/p>\n\n\n\n
C. Place the client in a left Sims\u2019 position<\/p>\n\n\n\n
-The nurse should place the client into a left Sims\u2019 position for the insertion of an enema. This<\/p>\n\n\n\n
left lateral position facilitates the flow of the enema solution into the sigmoid and descending<\/p>\n\n\n\n
colon. The anus is exposed by flexing the right leg.<\/p>\n\n\n\n
D. Don sterile gloves prior to the procedure<\/p>\n\n\n\n
-incorrect: The nurse should don clean gloves to perform an enema procedure for a client.<\/p>\n\n\n\n
362. A nurse enters a client\u2019s room and finds the client sitting on the floor and leaning against<\/p>\n\n\n\n
the side of the bed. The client states she slipped while getting out of bed. Which of the following<\/p>\n\n\n\n
actions should the nurse take first?<\/p>\n\n\n\n
A. Complete an incident report<\/p>\n\n\n\n
-incorrect: Any accident or unusual occurrence, such as a fall or a medication error, requires the<\/p>\n\n\n\n
nurse to complete an incident report to document the event for the facility and to help the risk<\/p>\n\n\n\n
managers create strategies to prevent future occurrences; however, there is another action the<\/p>\n\n\n\n
nurse should take first.<\/p>\n\n\n\n
B. Check the client for injuries<\/p>\n\n\n\n
– Using the nursing process, the nurse should first evaluate the client for any injuries or<\/p>\n\n\n\n
physiological changes. The nurse should also notify the provider to determine the need for any<\/p>\n\n\n\n
further examination or intervention.<\/p>\n\n\n\n
C. Make sure the client has skid-free footwear<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg84.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The nurse should ensure the client has skid-free footwear that fits well that the client<\/p>\n\n\n\n
knows to wear this footwear any time she gets out of bed; however, there is another action the<\/p>\n\n\n\n
nurse should take first.<\/p>\n\n\n\n
D. Remind the client to ask for help when getting out of bed<\/p>\n\n\n\n
-incorrect: The nurse should seek to prevent future injuries, such as reminding the client to use<\/p>\n\n\n\n
the call light to ask for help when getting out of bed; however, there is another action the nurse<\/p>\n\n\n\n
should take first.<\/p>\n\n\n\n
363. A nurse is preparing to administer a tuberculin skin test to a client. After performing hand<\/p>\n\n\n\n
hygiene, which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Select a 23-gauge needle<\/p>\n\n\n\n
-incorrect: A 25-27-gauge needle is used for intradermal injections.<\/p>\n\n\n\n
B. Insert the needle into the skin at a 25-degree angle<\/p>\n\n\n\n
Incorrect: The needle should be inserted at an angle of 10-15 degrees. This ensures the solution<\/p>\n\n\n\n
will be injected into the intradermal area.<\/p>\n\n\n\n
C. Massage the area of injection following removal of the needle<\/p>\n\n\n\n
-incorrect: The area of injection should not be massaged because this can spread the medication<\/p>\n\n\n\n
into the tissue or out through the insertion site.<\/p>\n\n\n\n
D. Circle the injection area with a pen<\/p>\n\n\n\n
-Circling the area with a pen ensures the nurse will examine the correct site when reading the test<\/p>\n\n\n\n
48-72 hours later.<\/p>\n\n\n\n
364. A nurse is planning to document care provided for a client. Which of the following<\/p>\n\n\n\n
abbreviations should the nurse use?<\/p>\n\n\n\n
A. BT for bedtime<\/p>\n\n\n\n
-incorrect: The nurse should avoid using this abbreviation because it can be mistaken for BID,<\/p>\n\n\n\n
which means twice daily. Instead, the. nurse should use the word \u201cbedtime\u201d.<\/p>\n\n\n\n
B. SC for subcutaneously<\/p>\n\n\n\n
-incorrect: The nurse should avoid using this abbreviation because it can be mistaken for<\/p>\n\n\n\n
sublingual. Instead, the nurse should use \u201csubtcut\u201d or \u201csubcutaneously\u201d.<\/p>\n\n\n\n
C. PC for after meals<\/p>\n\n\n\n
-The nurse can use this abbreviation because it is approved and not error-prone.<\/p>\n\n\n\n
D. HS for half-strength<\/p>\n\n\n\n
-incorrect: The nurse should avoid this abbreviation and use \u201cHalf-strength\u201d instead.<\/p>\n\n\n\n
365. A nurse is caring for a client who is having difficulty breathing. The nurse should assist the<\/p>\n\n\n\n
client into which of the following positions?<\/p>\n\n\n\n
A. Supine<\/p>\n\n\n\n
-incorrect: Although many clients find lying on their back comfortable, this position does not<\/p>\n\n\n\n
facilitate lung expansion for a client who has dyspnea.<\/p>\n\n\n\n
B. Lateral<\/p>\n\n\n\n
-incorrect: A side-lying position facilitates expansion of a single lung. However, a client who has<\/p>\n\n\n\n
dyspnea needs maximum expansion of both lungs.<\/p>\n\n\n\n
C. Fowler\u2019s<\/p>\n\n\n\n
-Sitting upright promotes full expansion of both lungs and facilitates ventilation and perfusion.<\/p>\n\n\n\n
D. Trendelenburg<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg85.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: Lowering the head of the bed with the foot of the bed raised in a straight incline can<\/p>\n\n\n\n
promote venous circulation and facilitate postural drainage. However, it will not improve lung<\/p>\n\n\n\n
expansion for a client who has dyspnea.<\/p>\n\n\n\n
366. A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the<\/p>\n\n\n\n
following actions should the nurse take when performing tracheostomy care for the client?<\/p>\n\n\n\n
A. Perform tracheostomy care using medical asepsis<\/p>\n\n\n\n
-incorrect: Tracheostomy care for a client with a new tracheostomy should be performed using<\/p>\n\n\n\n
surgical asepsis (sterile technique).<\/p>\n\n\n\n
B. Allow enough slack under the tracheostomy ties to insert three fingers<\/p>\n\n\n\n
-incorrect: The nurse should allow room to insert 1 to 2 fingers under the tracheostomy ties; this<\/p>\n\n\n\n
ensures they are not too restrictive.<\/p>\n\n\n\n
C. Soak the inner cannula of the tracheostomy tube in normal saline<\/p>\n\n\n\n
-The inner cannula of the tracheostomy tube should be soaked in normal saline or a mixture of<\/p>\n\n\n\n
normal saline and hydrogen peroxide to loosen secretions.<\/p>\n\n\n\n
D. Cut a sterile gauze pad to place between the neck and tracheostomy tube<\/p>\n\n\n\n
-incorrect: A cut gauze pad should not be used near a tracheostomy tube because the client can<\/p>\n\n\n\n
aspirate loose threads. The nurse should use a commercially prepared tracheostomy dressing<\/p>\n\n\n\n
under the tracheostomy tube.<\/p>\n\n\n\n
367. A nurse is preparing to administer a bolus feeding to a client through an NG tube and<\/p>\n\n\n\n
observes that the exit mark on the tube has moved since the last feeding. Which of the following<\/p>\n\n\n\n
actions should the nurse plan to take?<\/p>\n\n\n\n
A. Auscultate over the stomach while injecting air<\/p>\n\n\n\n
-incorrect: The nurse should not verify the NG tube placement by auscultating over the stomach<\/p>\n\n\n\n
while injecting air because it is difficult to distinguish whether the sound is coming from the<\/p>\n\n\n\n
stomach, lung, or intestine.<\/p>\n\n\n\n
B. Request an X-ray of the client\u2019s abdomen<\/p>\n\n\n\n
-The nurse should request an x-ray to verify the placement of the NG tube both after to initial<\/p>\n\n\n\n
insertion of the tube and if displacement of the tube is suspected. The nurse should verify NG<\/p>\n\n\n\n
tube placement prior to administering a bolus feeding.<\/p>\n\n\n\n
C. Place the head of the client\u2019s bed in a flat position<\/p>\n\n\n\n
-incorrect: The nurse should verify NG tube placement and elevate the head of the client\u2019s bed<\/p>\n\n\n\n
before administering a bolus tube feeding to reduce the risk of aspiration.<\/p>\n\n\n\n
D. Administer the feeding if the pH of the aspirated contents is >6<\/p>\n\n\n\n
-incorrect: The pH of gastric contents should be <5. Aspirated contents that have a pH of >6<\/p>\n\n\n\n
indicates that the NG tube is in the lungs or intestines. Therefore, the nurse should not administer<\/p>\n\n\n\n
the feeding.<\/p>\n\n\n\n
368. A nurse is caring for a client who is having difficulty with muscle coordination following a<\/p>\n\n\n\n
head injury. The nurse should suspect injury to which of the following areas of the brain?<\/p>\n\n\n\n
A. Hypothalamus<\/p>\n\n\n\n
-incorrect: The nurse should suspect an injury to the hypothalamus if a client is experiencing<\/p>\n\n\n\n
difficulty with sleeping. This area of the brain serves as the sleep center in the body by secreting<\/p>\n\n\n\n
hypocretins that promote rapid eye movement (REM) sleep.<\/p>\n\n\n\n
B. Cerebral cortex<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg86.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The nurse should suspect an injury to the cerebral cortex if a client is experiencing<\/p>\n\n\n\n
difficulty with expression. This area of the brain contains the neural networks that facilitate<\/p>\n\n\n\n
complex behaviors like learning, memory, and language.<\/p>\n\n\n\n
C. Pituitary<\/p>\n\n\n\n
-incorrect: The pituitary gland secretes several hormones such as adrenocorticotropic hormone<\/p>\n\n\n\n
that produces cortisol. These hormones are necessary for stress adaptation.<\/p>\n\n\n\n
D. Cerebellum<\/p>\n\n\n\n
-The nurse should suspect an injury to the cerebellum if the client is experiencing difficulty<\/p>\n\n\n\n
controlling balance and coordination. A client\u2019s movements can become uncoordinated, unsure,<\/p>\n\n\n\n
and clumsy following an injury to this area of the brain.<\/p>\n\n\n\n
369. A nurse is planning an in-service training session about nutrition. Which of the following<\/p>\n\n\n\n
pieces of information should the nurse take?<\/p>\n\n\n\n
A. Fat breaks down into amino acids<\/p>\n\n\n\n
-incorrect: Protein breaks down into amino acids.<\/p>\n\n\n\n
B. Protein serves as an energy source when other sources are inadequate<\/p>\n\n\n\n
-Protein is used as an energy source for the body when carbohydrates and fat stores are<\/p>\n\n\n\n
unavailable or depleted.<\/p>\n\n\n\n
C. Glucose breaks down into ammonia<\/p>\n\n\n\n
-incorrect: Protein breaks down into ammonia. Glucose does not produce any products of<\/p>\n\n\n\n
metabolism.<\/p>\n\n\n\n
D. Carbohydrates provide 9 cal\/g of energy<\/p>\n\n\n\n
-incorrect: Carbohydrates provide 4 cal\/g of energy. Fat provides 9 cal\/g of energy.<\/p>\n\n\n\n
370. A nurse is teaching a client who has urinary incontinence about bladder retraining. Which<\/p>\n\n\n\n
of the following instructions should the nurse include?<\/p>\n\n\n\n
A. \u201cWake up every 2 hr to urinate during the night.\u201d<\/p>\n\n\n\n
-incorrect: The client should wake up every 4 hours to urinate during the night; for most clients,<\/p>\n\n\n\n
this occurs just once during sleeping hours.<\/p>\n\n\n\n
B. \u201cDrink citrus juices throughout the day.\u201d<\/p>\n\n\n\n
-incorrect: Citrus juices can irritate the bladder, increasing the likelihood of incontinence<\/p>\n\n\n\n
episodes.<\/p>\n\n\n\n
C. \u201cTry to block the urge to urinate until the next scheduled time.\u201d<\/p>\n\n\n\n
-When the client is following a schedule of voiding intervals and feels the urge to urinate before<\/p>\n\n\n\n
the next scheduled time, she should try slow, deep breathing to help reduce the urge. She can<\/p>\n\n\n\n
also try 5 or 6 strong and quick pelvic muscle exercises.<\/p>\n\n\n\n
D. \u201cLimit fluids to no more than 1 L (34 oz) during waking hours.\u201d<\/p>\n\n\n\n
-incorrect: The client should reduce her fluid intake during the 4 hours before bedtime; however,<\/p>\n\n\n\n
she should drink plenty of fluids during the rest of her waking hours and avoid drinking large<\/p>\n\n\n\n
amount all at once.<\/p>\n\n\n\n
371. A nurse is collecting a specimen for culture from a client\u2019s infected wound. Which of the<\/p>\n\n\n\n
following actions should the nurse perform?<\/p>\n\n\n\n
A. Wear sterile gloves when collecting the specimen<\/p>\n\n\n\n
-incorrect: The nurse should wear clean gloves to collect a wound culture specimen. The nurse\u2019s<\/p>\n\n\n\n
hands will not touch the wound or the culture swab.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg87.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
B. Cleanse the wound with 0.9% sodium chloride irrigation<\/p>\n\n\n\n
-The nurse should cleanse the wound with sterile water or 0.9% sodium chloride irrigation to<\/p>\n\n\n\n
remove any surface debris or old exudate.<\/p>\n\n\n\n
C. Allow the collection swab to absorb old exudate<\/p>\n\n\n\n
–incorrect: Pooled drainage can collect microorganisms that are not the pathogens causing the<\/p>\n\n\n\n
wound infection.<\/p>\n\n\n\n
D. Rotate the collection swab over the edges of the wound<\/p>\n\n\n\n
-incorrect: The nurse should rotate the swab back and forth over the clean areas in the base of the<\/p>\n\n\n\n
wound to collect the pathogens causing the wound infection. The edges of the wound can harbor<\/p>\n\n\n\n
superficial microorganisms from the skin that are not infecting the wound.<\/p>\n\n\n\n
372. A nurse is teaching a middle-aged adult client about health promotion and disease<\/p>\n\n\n\n
prevention. The nurse should inform the client that which of the following changes could occur?<\/p>\n\n\n\n
A. Decreased estrogen and testosterone production<\/p>\n\n\n\n
-Both estrogen and testosterone levels start to decrease in middle age.<\/p>\n\n\n\n
B. Increased tone of the large intestines<\/p>\n\n\n\n
-incorrect: The tone of the large intestines decreases during middle age, placing clients at risk for<\/p>\n\n\n\n
constipation.<\/p>\n\n\n\n
C. Increased percentage of the body\u2019s muscle mass<\/p>\n\n\n\n
-incorrect: There is a decrease in the body\u2019s muscle mass as clients approach the latter portion of<\/p>\n\n\n\n
middle age.<\/p>\n\n\n\n
D. Decreased incidence of chronic illnesses<\/p>\n\n\n\n
-incorrect: The likelihood of developing a chronic illness increases during middle age.<\/p>\n\n\n\n
373. A nurse is performing a physical examination for a client. To evaluate the client\u2019s skin<\/p>\n\n\n\n
moisture, the nurse should use which of the following techniques?<\/p>\n\n\n\n
A. Percussion<\/p>\n\n\n\n
-incorrect: Percussion is not an effective way to evaluate skin moisture. Percussion helps the<\/p>\n\n\n\n
nurse locate organs or masses and determine their dimensions.<\/p>\n\n\n\n
B. Auscultation<\/p>\n\n\n\n
-incorrect: Auscultation is not an effective way to evaluate skin moisture. Auscultation helps the<\/p>\n\n\n\n
nurse listen to lung, heart, and bowel sounds.<\/p>\n\n\n\n
C. Inspection<\/p>\n\n\n\n
-incorrect: Inspection is not an effective way to evaluate skin moisture. With inspection, the<\/p>\n\n\n\n
nurse observes visual variations from expected observational findings.<\/p>\n\n\n\n
D. Palpation<\/p>\n\n\n\n
-With palpation, the nurse uses touch to help detect unusual or expected sensations including<\/p>\n\n\n\n
texture, temperature, masses, or moisture.<\/p>\n\n\n\n
374. A nurse is responding to a parent\u2019s question about his infant\u2019s expected physical<\/p>\n\n\n\n
development during the first year of life. Which of the following pieces of information should<\/p>\n\n\n\n
the nurse include?<\/p>\n\n\n\n
A. A 2-month old infant can turn from his abdomen to his back<\/p>\n\n\n\n
-incorrect: An infant cannot turn from his abdomen to his back until 5 months of age.<\/p>\n\n\n\n
B. A 10-month old infant can pull up to a standing position<\/p>\n\n\n\n
-An 8-10-month-old infant can pull up to a standing position.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg88.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
C. A 4-month old infant can sit up without support<\/p>\n\n\n\n
-incorrect: A 6 to 8-month old infant can sit up without support.<\/p>\n\n\n\n
D. A 6-month old infant can crawl on his hands and knees<\/p>\n\n\n\n
-incorrect: An 8 to 10-month old infant can crawl on hands and knees.<\/p>\n\n\n\n
375. A nurse is planning care for a client who is postoperative and has a history of poor<\/p>\n\n\n\n
nutritional intake. Which of the following actions should the nurse include in the plan of care to<\/p>\n\n\n\n
promote wound healing?<\/p>\n\n\n\n
A. Limit total caloric intake to 25 kcal\/kg of body weight<\/p>\n\n\n\n
-incorrect: A caloric intake of 35-40 kcal\/kg of body weight per day is necessary to maintain a<\/p>\n\n\n\n
positive nitrogen balance, which promotes wound healing.<\/p>\n\n\n\n
B. Provide an intake of 500 mg\/day of vitamin E<\/p>\n\n\n\n
-incorrect: Vitamin E is not essential for wound healing.<\/p>\n\n\n\n
C. Limit fluid intake to 20 mL\/kg of body weight per day<\/p>\n\n\n\n
-incorrect: The nurse should encourage a fluid intake of 30-35 mL\/kg of body weight per day, as<\/p>\n\n\n\n
water is essential to the wound- healing process.<\/p>\n\n\n\n
D. Provide a protein intake of 1.5 g\/kg of body weight per day<\/p>\n\n\n\n
-A protein intake of 1 to 1.5 g\/kg of body weight per day is necessary to maintain a positive<\/p>\n\n\n\n
nitrogen balance, which promotes wound healing.<\/p>\n\n\n\n
376. A nurse is caring for a client who has Clostridium difficile infection and is in contact<\/p>\n\n\n\n
isolation. Which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Wear gloves when changing the client\u2019s gown.<\/p>\n\n\n\n
-The nurse should wear gloves when handling articles that have the potential to contaminate the<\/p>\n\n\n\n
hands when caring for a client in contact isolation.<\/p>\n\n\n\n
B. Use alcohol-based sanitizer to cleanse the hands<\/p>\n\n\n\n
-incorrect: The nurse should use soap and water to cleanse the hands. Alcohol-based hand<\/p>\n\n\n\n
sanitizer is ineffective against the spores of C. difficile.<\/p>\n\n\n\n
C. Wear a mask when assisting the client with his meal tray<\/p>\n\n\n\n
-incorrect: The nurse should wear a mask when working within 3 feet of a client who has an<\/p>\n\n\n\n
infection, and droplet precautions are required.<\/p>\n\n\n\n
D. Place the client on complete bed rest<\/p>\n\n\n\n
-incorrect: The nurse should not place the client on complete bed rest because this places him at<\/p>\n\n\n\n
risk for the hazards of immobility, such as impaired skin integrity and retained respiratory<\/p>\n\n\n\n
secretions. The nurse should instruct the client to remain in his room but to move, cough, and<\/p>\n\n\n\n
deep breathe at least every 2 hours.<\/p>\n\n\n\n
377. A home health nurse enters a client\u2019s home and finds a used insulin syringe without a cap<\/p>\n\n\n\n
on the table. Which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Recap the needle on the syringe<\/p>\n\n\n\n
-incorrect: The nurse should not recap the needle because of the risk of a needlestick injury<\/p>\n\n\n\n
during this action.<\/p>\n\n\n\n
B. Schedule a nurse to administer future injection for this client<\/p>\n\n\n\n
-incorrect: The nurse should not schedule another nurse to administer future injections for this<\/p>\n\n\n\n
client. The nurse should teach the client about potential injuries and infections that can result<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg89.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
from a needlestick injury. After exploring the client\u2019s reasons for nonadherence to safety<\/p>\n\n\n\n
measures, the nurse should review appropriate methods of disposal for used syringes.<\/p>\n\n\n\n
C. Explain to the client that the syringe should be disposed of in the bathroom trash can<\/p>\n\n\n\n
-incorrect: The nurse should not instruct the client to dispose of used syringes in a bathroom<\/p>\n\n\n\n
trash can due to the risk of a needlestick injury when handling the trash.<\/p>\n\n\n\n
D. Place the syringe in a puncture-proof disposal container<\/p>\n\n\n\n
-The nurse should place the uncapped syringe in a puncture-proof sharps disposal or rigid plastic<\/p>\n\n\n\n
container to prevent a needlestick injury.The nurse should keep the syringe uncapped to prevent<\/p>\n\n\n\n
a needlestick injury while placing the cap on the needle. Then, the nurse should provide client<\/p>\n\n\n\n
education on safety and proper disposal of syringes.<\/p>\n\n\n\n
378. A nurse is performing an admission assessment for a client. Which of the following<\/p>\n\n\n\n
responses by the nurse reflects the communication technique of clarifying?<\/p>\n\n\n\n
A. \u201cNow that we have talked about your medications, let\u2019s talk about your pain.\u201d<\/p>\n\n\n\n
-incorrect: This is an example of the communication technique of focusing. The nurse can use<\/p>\n\n\n\n
this technique to keep the conversation moving in an organized direction.<\/p>\n\n\n\n
B. \u201cAre you having other symptoms?\u201d<\/p>\n\n\n\n
-incorrect: This is an example of the communication technique of asking a relevant question.<\/p>\n\n\n\n
These kinds of questions are open-ended and allow the client to offer more information to the<\/p>\n\n\n\n
nurse.<\/p>\n\n\n\n
C. \u201cIt sounds like your pain is intermittent.\u201d<\/p>\n\n\n\n
-This response by the nurse reflects communication technique of clarifying. The nurse should use<\/p>\n\n\n\n
this technique to ensure an understanding of the client\u2019s message.<\/p>\n\n\n\n
D. \u201cIt seems as though you have really had a rough time these past few weeks.\u201d<\/p>\n\n\n\n
-incorrect: This is an example of the communication technique of sharing empathy. With this<\/p>\n\n\n\n
technique, the nurse is able to convey understanding and acceptance of what the client is or has<\/p>\n\n\n\n
been experiencing.<\/p>\n\n\n\n
379. A nurse is preparing to assess the function of the client\u2019s trigeminal nerve (cranial nerve V).<\/p>\n\n\n\n
Which of the following items should the nurse gather for the test?<\/p>\n\n\n\n
A. Sugar<\/p>\n\n\n\n
-incorrect: The nurse should use sugar to test the function of the olfactory nerve (CN VII).<\/p>\n\n\n\n
B. Coffee<\/p>\n\n\n\n
-incorrect: The nurse should use coffee to test the function of the olfactory nerve (CN I).<\/p>\n\n\n\n
C. Cotton wisps<\/p>\n\n\n\n
-The trigeminal nerve has both sensory and motor capabilities. To assess its sensory function, the<\/p>\n\n\n\n
nurse uses a safety pin to assess for recognition of pain and a cotton wisp to evaluate recognition<\/p>\n\n\n\n
of touch sensations. To test motor abilities of cranial nerve (CN V), the nurse should ask the<\/p>\n\n\n\n
client to clench the teeth.<\/p>\n\n\n\n
D. Snellen Chart<\/p>\n\n\n\n
-incorrect: The nurse should use the Snellen chart to test the function of the optic nerve (CN II).<\/p>\n\n\n\n
380. A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any<\/p>\n\n\n\n
further treatment. The nurse should provide care that facilitates which of the following<\/p>\n\n\n\n
outcomes?<\/p>\n\n\n\n
A. Allows minimal treatment<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg8a.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The client has the right to refuse all treatment, and the nurse has a duty to honor that<\/p>\n\n\n\n
right.<\/p>\n\n\n\n
B. Benefits the client\u2019s family<\/p>\n\n\n\n
-incorrect: The nurse\u2019s priority is to provide care that benefits the client, not necessarily the<\/p>\n\n\n\n
family.<\/p>\n\n\n\n
C. Offers hope for a cure<\/p>\n\n\n\n
-incorrect: Offering hope for a cure when lung cancer is advanced is a nontherapeutic response<\/p>\n\n\n\n
and provides false reassurance to the client.<\/p>\n\n\n\n
D. Supports self-determination<\/p>\n\n\n\n
-The nurse must honor the client\u2019s autonomy and ability to make health care decisions. The<\/p>\n\n\n\n
client has the right to refuse treatment; as the client\u2019s advocate, the nurse must support that right.<\/p>\n\n\n\n
381. A nurse is preparing to administer medications to a client who is unconscious. The nurse<\/p>\n\n\n\n
should bring the medication administration record (MAR) to the client\u2019s bedside and perform<\/p>\n\n\n\n
which of the following verification procedures?<\/p>\n\n\n\n
A. Check the client\u2019s name and medical record number on the MAR against the room and bed<\/p>\n\n\n\n
number<\/p>\n\n\n\n
-incorrect: The client\u2019s room and bed numbers are not acceptable identifiers.<\/p>\n\n\n\n
B. Call the client by name and check the name on her identification band against the MAR<\/p>\n\n\n\n
-incorrect: This client cannot respond to her name.<\/p>\n\n\n\n
C. Compare the medical record number and name on the MAR with the client\u2019s<\/p>\n\n\n\n
identification band<\/p>\n\n\n\n
-The Joint Commission requires the use of 2 client identifiers when administering medications.<\/p>\n\n\n\n
The nurse should compare the medical record number and name on the MAR with the client\u2019s<\/p>\n\n\n\n
identification band.<\/p>\n\n\n\n
D. Ask the client\u2019s visitor to identify the client by name and to state the client\u2019s date of birth<\/p>\n\n\n\n
-incorrect: A visitor is not an acceptable source for identification.<\/p>\n\n\n\n
382. A nurse is preparing to administer an intramuscular injection to a client who is overweight.<\/p>\n\n\n\n
Which of the following sites should the nurse select for the injection?<\/p>\n\n\n\n
A. Lower medial quadrant of the buttock near the coccyx<\/p>\n\n\n\n
-incorrect: To administer an intramuscular medication using the dorsogluteal site, the nurse<\/p>\n\n\n\n
should select the upper lateral quadrant of the buttock. However; this site can increase the risk of<\/p>\n\n\n\n
injury to the client because the medication is more likely to be injected into subcutaneous tissue,<\/p>\n\n\n\n
and there is an increased risk of piercing the sciatic nerve.<\/p>\n\n\n\n
B. Side hip between the iliac crest and anterior iliac spine<\/p>\n\n\n\n
-The side hip between the iliac crest and anterior iliac spine forms the boundaries for a<\/p>\n\n\n\n
ventrogluteal injection; therefore, this is an appropriate site for the nurse to select. This site is<\/p>\n\n\n\n
preferred for intramuscular injections for an adult client. The nurse should prepare for injection<\/p>\n\n\n\n
by placing a hand on the client\u2019s greater trochanter (ex: right hand on left hip) with the first 2<\/p>\n\n\n\n
fingers touching the iliac crest and anterior superior iliac spine, forming a \u201cV\u201d shape.<\/p>\n\n\n\n
C. Tissue of the posterior upper arm<\/p>\n\n\n\n
-incorrect: The nurse should select the outer posterior tissue of the upper arm when preparing to<\/p>\n\n\n\n
administer a subcutaneous injection. For intramuscular injections that are <1 mL, the nurse may<\/p>\n\n\n\n
select the deltoid muscle by placing 4 fingers on the deltoid muscle with the top finger on the<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg8b.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
acromion process. The injection site then is three finger widths below the acromion process, or<\/p>\n\n\n\n
about 5 cm (2in).<\/p>\n\n\n\n
D. Lower inner thigh 4 finger-widths above the patella<\/p>\n\n\n\n
-incorrect: To administer intramuscular medication using the vastus lateralis site, the nurse<\/p>\n\n\n\n
should select the middle portion of the muscle from the midline of the thigh to the midline of the<\/p>\n\n\n\n
outer side of the thigh. The nurse can place a hand below the greater trochanter and the other<\/p>\n\n\n\n
hand just above the knee to locate the middle portion of the muscle for the injection site.<\/p>\n\n\n\n
383. A nurse is preparing to perform postural drainage for a client. Which of the following<\/p>\n\n\n\n
actions should the nurse take?<\/p>\n\n\n\n
A. Give the client a bronchodilator immediately after the procedure<\/p>\n\n\n\n
-incorrect: The nurse does not administer a bronchodilator to a client who is receiving postural<\/p>\n\n\n\n
drainage.<\/p>\n\n\n\n
B. Position the client for drainage of secretions by gravity<\/p>\n\n\n\n
-Postural drainage consists of providing drainage, positioning, and turning the client. The<\/p>\n\n\n\n
positioning can help to drain secretions from the affected lung segments and bronchi into the<\/p>\n\n\n\n
trachea.<\/p>\n\n\n\n
C. Schedule postural drainage following meals<\/p>\n\n\n\n
-incorrect: Procedures such as postural drainage, chest physiotherapy, or vibration should be<\/p>\n\n\n\n
scheduled prior to the client eating a meal to decrease the risk of gastrointestinal discomfort.<\/p>\n\n\n\n
D. Instruct the client regarding the importance of fluid restrictions<\/p>\n\n\n\n
384. A nurse is applying antiembolitic stockings for a client who has a history of deep vein<\/p>\n\n\n\n
thrombosis. Which of the following actions should the nurse take when applying the stockings?<\/p>\n\n\n\n
A. Roll the stocking partially down if too long<\/p>\n\n\n\n
-incorrect: The nurse should apply another size stocking if the stocking is too long. Rolling the<\/p>\n\n\n\n
stocking partially down can decrease venous return and cause skin irritation.<\/p>\n\n\n\n
B. Remove the stocking once per day<\/p>\n\n\n\n
-incorrect: The nurse should remove the stockings once every shift to inspect the skin and check<\/p>\n\n\n\n
circulation.<\/p>\n\n\n\n
C. Bunch and pull the stocking halfway up the calf<\/p>\n\n\n\n
-incorrect: The nurse should slide the top of the stocking up over the client\u2019s calf all at once to<\/p>\n\n\n\n
lessen constrictive wrinkles, which can decrease venous return.<\/p>\n\n\n\n
D. Turn the stocking inside out up to the heel before applying<\/p>\n\n\n\n
-The nurse should turn the stocking inside out up to the client\u2019s heel to make the application of<\/p>\n\n\n\n
the stocking easier and cause fewer constrictive wrinkles.<\/p>\n\n\n\n
385. A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client<\/p>\n\n\n\n
appears upset and refuses to take the medication before throwing the pill on the floor. Which of<\/p>\n\n\n\n
the following entries should the nurse enter into the client\u2019s medical record?<\/p>\n\n\n\n
A. The client refused to take medication today<\/p>\n\n\n\n
B. The client states, \u201cI will not take this pill. \u201c<\/p>\n\n\n\n
C. The client seemed angry and hostile<\/p>\n\n\n\n
D. The client threw the medication on the floor<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg8c.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
386. A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling<\/p>\n\n\n\n
the medication, which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Instruct the client to blink several times after instilling the medication<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to close the eyes gently and to avoid blinking after<\/p>\n\n\n\n
the instillation to prevent any loss of the medication out of the eye and promote absorption.<\/p>\n\n\n\n
B. Ask the client to look straight ahead during instillation of the medication<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to look upward toward the ceiling during<\/p>\n\n\n\n
instillation of the medication to allow proper placement of the medication and to suppress the<\/p>\n\n\n\n
client\u2019s blink reflex.<\/p>\n\n\n\n
C. Apply pressure to the puncta after instilling the medication<\/p>\n\n\n\n
-The nurse should instill the medication into the conjunctival sac and apply pressure to the<\/p>\n\n\n\n
puncta for 1-2 minutes afterward to prevent systemic absorption of the medication.<\/p>\n\n\n\n
D. Place each drop of the medication directly onto the client\u2019s cornea<\/p>\n\n\n\n
-incorrect: The nurse should instill the medication into the client\u2019s conjunctival sac and should<\/p>\n\n\n\n
take measures to protect the client\u2019s cornea during administration.<\/p>\n\n\n\n
387. A newly licensed nurse is preparing to administer medications to a client. The nurse notes<\/p>\n\n\n\n
that the provider has prescribed a medication that is unfamiliar to him. Which of the following<\/p>\n\n\n\n
actions should the nurse take?<\/p>\n\n\n\n
A. Consult the medication reference book available on the unit<\/p>\n\n\n\n
-A nurse must have knowledge about medications to administer them safely. The nurse should<\/p>\n\n\n\n
become familiar with the medication by looking it up in the medication reference on the unit.<\/p>\n\n\n\n
B. Ask a more experienced nurse for information about the medication<\/p>\n\n\n\n
-incorrect: Even if the more experienced nurse has knowledge of the medication, information<\/p>\n\n\n\n
from this source is not sufficient to allow the nurse to administer the medication safely.<\/p>\n\n\n\n
C. Call the client\u2019s provider and verify the prescription<\/p>\n\n\n\n
-incorrect: There is no reason to believe that the medication prescription is in error; therefore, it<\/p>\n\n\n\n
is unnecessary for the nurse to confirm it with the provider.<\/p>\n\n\n\n
D. Ask the client is she takes this medication at home<\/p>\n\n\n\n
-incorrect: Even if the client has knowledge of the medication, information from the client is not<\/p>\n\n\n\n
sufficient to allow the nurse to administer the medication safely.<\/p>\n\n\n\n
388. A nurse is changing the bed linens for a client who is on bed rest. Which of the following<\/p>\n\n\n\n
actions should the nurse perform?<\/p>\n\n\n\n
A. Place the soiled linens on the chair while making the bed<\/p>\n\n\n\n
-incorrect: The nurse should place the soiled linens in a linen bag immediately after removing the<\/p>\n\n\n\n
linen from the bed to prevent the spread of microorganisms on surfaces within the client\u2019s room<\/p>\n\n\n\n
and to minimize exposure to personnel.<\/p>\n\n\n\n
B. Hold the linens away from the body and clothing<\/p>\n\n\n\n
-The nurse should hold the linens away from the body and clothing to prevent soiling or the<\/p>\n\n\n\n
transfer of microorganisms. The microorganisms present on the nurse\u2019s clothing can expose<\/p>\n\n\n\n
other clients to microorganisms.<\/p>\n\n\n\n
C. Place the linens on the floor until a linen bag is available<\/p>\n\n\n\n
-incorrect: Soiled linen is contaminated with microorganisms and will further contaminate the<\/p>\n\n\n\n
floor and attract any microorganisms present on the floor, which places the nurse and the client<\/p>\n\n\n\n
at risk of infection.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg8d.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
D. Shake the clean linens to unfold<\/p>\n\n\n\n
-incorrect: Opening linens by shaking them causes movement of air. Air currents can carry dust<\/p>\n\n\n\n
and spread microorganisms throughout the room, which places the client and the nurse at risk of<\/p>\n\n\n\n
infection.<\/p>\n\n\n\n
389. A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV<\/p>\n\n\n\n
catheter.The nurse notes that the area of the arm immediately surrounding the insertion site is<\/p>\n\n\n\n
red and feels warm. Which of the following actions should the nurse take?<\/p>\n\n\n\n
A. Change the infusion tubing<\/p>\n\n\n\n
-incorrect: These manifestations do not suggest that the infusion tube is punctured, contaminated,<\/p>\n\n\n\n
occluded, or expired.<\/p>\n\n\n\n
B. Flush the IV catheter<\/p>\n\n\n\n
-incorrect: This action could worsen the complication suggested by the client\u2019s manifestations.<\/p>\n\n\n\n
C. Remove the IV catheter<\/p>\n\n\n\n
-This client\u2019s manifestations suggest phlebitis. The nurse should stop the infusion and remove<\/p>\n\n\n\n
the IV catheter immediately. The nurse should then apply warm compresses to the site.<\/p>\n\n\n\n
D. Apply a cool compress to the site<\/p>\n\n\n\n
-incorrect: Warm moist heat is part of the treatment protocol for the complication suggested by<\/p>\n\n\n\n
the client\u2019s manifestations.<\/p>\n\n\n\n
390. A nurse is caring for a client who is well-hydrated and has no visible evidence of nutritional<\/p>\n\n\n\n
deficiencies. Alaboratory results within the expected reference range for which of the following<\/p>\n\n\n\n
substances indicates adequate protein uptake and synthesis?<\/p>\n\n\n\n
A. Albumin<\/p>\n\n\n\n
-The nurse should identify that an albumin level within the expected reference range is an<\/p>\n\n\n\n
indication that the client has adequate protein uptake and synthesis. Albumin levels measure<\/p>\n\n\n\n
protein status. They are useful for identifying long-term protein depletion rather than short-term<\/p>\n\n\n\n
or acute changes in nutritional status.<\/p>\n\n\n\n
B. Calcium<\/p>\n\n\n\n
-incorrect: Calcium levels do not reflect protein status. Calcium levels reflect the adequacy of<\/p>\n\n\n\n
bone and tooth formation, blood clotting, nerve impulse transmission, muscle contraction and<\/p>\n\n\n\n
relaxation, and various other essential processes.<\/p>\n\n\n\n
C. Sodium<\/p>\n\n\n\n
-incorrect: Sodium levels do not reflect protein status. Sodium levels indicate fluid balance,<\/p>\n\n\n\n
nerve impulse transmission, acid-base balance, and various other cellular activities.<\/p>\n\n\n\n
D. Potassium<\/p>\n\n\n\n
-incorrect: Potassium levels do not reflect protein status. Potassium levels reflect the status of<\/p>\n\n\n\n
many metabolic activities, including nerve impulse transmission, cardiac conduction, and<\/p>\n\n\n\n
skeletal and smooth muscle contraction.<\/p>\n\n\n\n
391. A nurse is caring for a client who has a stage II pressure ulcer. Which of the following<\/p>\n\n\n\n
wound dressings should the nurse apply to the ulcer?<\/p>\n\n\n\n
A. Hydrocolloid<\/p>\n\n\n\n
-The nurse should apply a hydrocolloid dressing to a stage II pressure ulcer. This type of<\/p>\n\n\n\n
dressing is applied to absorb exudate and to produce a moist environment that will facilitate<\/p>\n\n\n\n
healing while preventing maceration of surrounding skin.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg8e.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
B. Collagen<\/p>\n\n\n\n
-incorrect: The nurse should apply collagen to a clean, moist wound to stop bleeding, bring cells<\/p>\n\n\n\n
into the wound, and stimulate their proliferation to facilitate healing.<\/p>\n\n\n\n
C. Calcium alginate<\/p>\n\n\n\n
-incorrect: The nurse should apply calcium alginate to a stage IV pressure ulcer. This type of<\/p>\n\n\n\n
dressing is used for wounds with significant exudate and must be covered with a secondary<\/p>\n\n\n\n
dressing.<\/p>\n\n\n\n
D. Proteolytic enzyme<\/p>\n\n\n\n
-incorrect: The nurse should apply a proteolytic enzyme to an unstageable pressure ulcer. This<\/p>\n\n\n\n
type of dressing is applied to facilitate debridement and to soften eschar.<\/p>\n\n\n\n
392. A nurse on a medical-surgical unit observes smoke billowing from a client\u2019s room. Which<\/p>\n\n\n\n
of the following actions should the nurse take first?<\/p>\n\n\n\n
A. Close the door to the client\u2019s room<\/p>\n\n\n\n
-incorrect: The nurse should close the doors and windows in the immediate vicinity to help<\/p>\n\n\n\n
contain the fire; however, this is not the first action the nurse should take.<\/p>\n\n\n\n
B. Evacuate the client from the room<\/p>\n\n\n\n
-The acronym RACE can help nurses remember the order of the actions to take in the event of a<\/p>\n\n\n\n
fire. The components of RACE are rescue, activate, confine, and extinguish. The first priority is<\/p>\n\n\n\n
rescuing or removing the client from immediate danger. The second action is activation of the<\/p>\n\n\n\n
fire alarm system. The third action is confining the fire by closing doors and windows. The final<\/p>\n\n\n\n
action is extinguishing the fire, if possible, using an available fire extinguisher. If attempts to<\/p>\n\n\n\n
extinguish a fire could compromise the safety of clients or staff members, the nurse should await<\/p>\n\n\n\n
the arrival of emergency fire personnel.<\/p>\n\n\n\n
C. Sound the fire alarm<\/p>\n\n\n\n
-incorrect: The nurse should sound the fire alarm to summon fire professionals to put out the fire<\/p>\n\n\n\n
and ensure safety in the facility; however, this is not the first action the nurse should take.<\/p>\n\n\n\n
D. Activate the fire extinguisher<\/p>\n\n\n\n
-incorrect: The nurse should attempt to extinguish the fire safely if possible; however, this is not<\/p>\n\n\n\n
the first action the nurse should take.<\/p>\n\n\n\n
393. A. nurse is teaching a client who is recovering from gallbladder surgery how to use an<\/p>\n\n\n\n
incentive spirometer. Which of the following pieces of information should the nurse include in<\/p>\n\n\n\n
the teaching?<\/p>\n\n\n\n
A. Exhale slowly to reach the goal volume<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to inhale slowly to reach the goal volume and to<\/p>\n\n\n\n
decrease the collapse of alveoli in the client\u2019s lungs.<\/p>\n\n\n\n
B. Hold the breath for 5 sec after goal volume is reached<\/p>\n\n\n\n
-The nurse should instruct the client to hold the breath for 3 to 5 seconds after reaching maximal<\/p>\n\n\n\n
inspiratory volume. This decreases the collapse of alveoli, which helps prevent the risk of<\/p>\n\n\n\n
atelectasis and pneumonia.<\/p>\n\n\n\n
C. Continue to breathe deeply between each cycle<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to breathe normally for short periods of time<\/p>\n\n\n\n
between each cycle of breaths to reduce hyperventilation and fatigue.<\/p>\n\n\n\n
D. Limit the repeat pattern of breathing to 5 breaths<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg8f.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: The nurse should instruct the client to repeat the patterns for 10 to 20 breathes every<\/p>\n\n\n\n
hour while awake to prevent atelectasis and pneumonia.<\/p>\n\n\n\n
394. A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the<\/p>\n\n\n\n
following abdominal assessments should the nurse expect?<\/p>\n\n\n\n
A. Frequent bowel sounds with flatus<\/p>\n\n\n\n
B. Absent bowel sounds with distention<\/p>\n\n\n\n
-Paralytic ileus is an immobile bowel. In this disorder, bowel sounds are absent, and the<\/p>\n\n\n\n
abdomen is distended.<\/p>\n\n\n\n
C. Hyperactive bowel sounds with diarrhea<\/p>\n\n\n\n
D. Normal bowel sounds with increased peristalsis<\/p>\n\n\n\n
-incorrect A\/C\/D: With paralytic ileus, bowel sounds are absent, the abdomen is distended and<\/p>\n\n\n\n
there is no flatus or stool.<\/p>\n\n\n\n
395. A nurse is caring for a client who has a fecal impaction. Before the digital removal of the<\/p>\n\n\n\n
mass, which of the following types of enemas should the nurse plan to administer to soften the<\/p>\n\n\n\n
feces?<\/p>\n\n\n\n
A. Carminative<\/p>\n\n\n\n
-incorrect: The nurse should administer a carminative enema to assist a client to expel flatus.<\/p>\n\n\n\n
B. Hypertonic<\/p>\n\n\n\n
-incorrect: The nurse should administer a hypertonic fluid solution to cleanse the client\u2019s bowels<\/p>\n\n\n\n
(ex: in preparation for surgery).<\/p>\n\n\n\n
C. Oil retention<\/p>\n\n\n\n
-The nurse should administer an oil retention enema prior to the removal of a fecal impaction to<\/p>\n\n\n\n
soften the stool. This makes the procedure less painful for the client.<\/p>\n\n\n\n
D. Sodium polystyrene sulfate<\/p>\n\n\n\n
-incorrect: The nurse should administer a sodium polystyrene sulfate enema to a client who has a<\/p>\n\n\n\n
high potassium level.<\/p>\n\n\n\n
396. A nurse is teaching a client about how to remove a soiled dressing. Which of the following<\/p>\n\n\n\n
statements by the client indicates an understanding of the teaching?<\/p>\n\n\n\n
A. \u2018I\u2019ll wear nonsterile gloves.\u201d<\/p>\n\n\n\n
-Wearing gloves prevents the spread of microorganisms outside of the dressings and onto the<\/p>\n\n\n\n
client\u2019s hands. The gloves the client uses can be clean and do not need to be sterile unless the<\/p>\n\n\n\n
provider specifically prescribes sterile gloves for dressing changes.<\/p>\n\n\n\n
B. \u201cI\u2019ll use adhesive remover each time.\u201d<\/p>\n\n\n\n
-incorrect: The client should use adhesive remover only if tape removal or residual adhesive<\/p>\n\n\n\n
creates significant problems on especially sensitive skin.<\/p>\n\n\n\n
C. \u201cI\u2019ll take my pain pill after I change the dressing.\u201d<\/p>\n\n\n\n
-incorrect: If the client expects the dressing removal to hurt, the client should take an analgesic<\/p>\n\n\n\n
long enough before the dressing change for the medication to take effect.<\/p>\n\n\n\n
D. \u201cI\u2019ll fold the dressing with the soiled surface facing outward.\u201d<\/p>\n\n\n\n
-incorrect: The client should remove the dressing by folding the soiled surfaces inward to prevent<\/p>\n\n\n\n
the transfer of microorganisms to the client\u2019s hands and other surfaces.<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg90.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
397. A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the<\/p>\n\n\n\n
following actions should the nurse take?<\/p>\n\n\n\n
A. Encourage the child to cough frequently to clear congestion from anesthesia<\/p>\n\n\n\n
-incorrect: The child should be discouraged from coughing or clearing the throat following a<\/p>\n\n\n\n
tonsillectomy because these actions can contribute to bleeding.<\/p>\n\n\n\n
B. Place a heating pad on the client\u2019s neck for comfort<\/p>\n\n\n\n
-incorrect: The nurse should offer an ice collar, not a heating pad, to ease the child\u2019s pain.<\/p>\n\n\n\n
C. Administer analgesics to the child on a routine schedule throughout the day and night<\/p>\n\n\n\n
-To soothe the client\u2019s throat following a tonsillectomy, the nurse should administer pain<\/p>\n\n\n\n
medication routinely. The nurse can provide the medication rectally or intravenously to avoid the<\/p>\n\n\n\n
oral route.<\/p>\n\n\n\n
D. Provide the child with ice cream when oral intake is initiated<\/p>\n\n\n\n
-incorrect: Milk products, such as ice cream and pudding, are usually avoided because they coat<\/p>\n\n\n\n
the mouth and throat, causing the child to clear the throat and potentially leading to bleeding. Ice<\/p>\n\n\n\n
chips and ice pops are usually the first items offered following a tonsillectomy.<\/p>\n\n\n\n
398. A nurse is collecting a urine specimen for culture and sensitivity for a client who has a<\/p>\n\n\n\n
urinary tract infection. The client has an indwelling urinary catheter in place. Which of the<\/p>\n\n\n\n
following actions should the nurse take?<\/p>\n\n\n\n
A. Withdraw the specimen from the drainage bag<\/p>\n\n\n\n
-incorrect: The nurse should use a fresh specimen obtained near the indwelling urinary catheter<\/p>\n\n\n\n
to prevent contamination.<\/p>\n\n\n\n
B. Cleanse the collection port with soap and water<\/p>\n\n\n\n
-incorrect: The nurse should cleanse the collection port with an antimicrobial swab to prevent<\/p>\n\n\n\n
contamination.<\/p>\n\n\n\n
C. Place the specimen in a clean specimen cup<\/p>\n\n\n\n
-incorrect: The nurse should place the specimen in a sterile specimen cup to prevent<\/p>\n\n\n\n
contamination.<\/p>\n\n\n\n
D. Clamp the tubing below the collection port<\/p>\n\n\n\n
-The nurse should clamp the tubing below the collection port to allow fresh, uncontaminated<\/p>\n\n\n\n
urine to collect before withdrawing the specimen through the port and placing it in a sterile cup.<\/p>\n\n\n\n
399. A nurse is caring for a client who is receiving a blood transfusion. The client reports flank<\/p>\n\n\n\n
pain, and the nurse notes reddish-brown urine in the client\u2019s urinary catheter bag. The nurse<\/p>\n\n\n\n
recognizes these manifestations as which of the following types of transfusion reactions?<\/p>\n\n\n\n
A. Hemolytic<\/p>\n\n\n\n
-A hemolytic reaction occurs when the client\u2019s blood is incompatible with the donor\u2019s blood.<\/p>\n\n\n\n
Chills, low back pain, hypotension, and tachycardia are indications of a hemolytic transfusion<\/p>\n\n\n\n
reaction.<\/p>\n\n\n\n
B. Febrile<\/p>\n\n\n\n
-incorrect: A febrile reaction occurs when the client\u2019s blood is sensitive to the WBCs and<\/p>\n\n\n\n
platelets in the donor\u2019s blood. Fevers, chills, headaches, and flushing are indications of a febrile<\/p>\n\n\n\n
reaction.<\/p>\n\n\n\n
C. Circulatory overload<\/p>\n\n\n\n
![\"\"](\"https:\/\/d3tvd1u91rr79.cloudfront.net\/50afdeea70d45df6555f6438197eec98\/html\/bg91.png?Policy=eyJTdGF0ZW1lbnQiOlt7IlJlc291cmNlIjoiaHR0cHM6Ly9kM3R2ZDF1OTFycjc5LmNsb3VkZnJvbnQubmV0LzUwYWZkZWVhNzBkNDVkZjY1NTVmNjQzODE5N2VlYzk4L2h0bWwvKiIsIkNvbmRpdGlvbiI6eyJEYXRlTGVzc1RoYW4iOnsiQVdTOkVwb2NoVGltZSI6MTY5MDQwOTM5OX19fV19&Signature=O95MTUkbDdwQC3~Iwyhg7uWv6BTM4aobRpHEsHvMp7B-yKd-CngjBidjSkLon0Klt2GXgO~wirIhpsk6BeKT-hEiUQXc2i83eTGPE~WOigC7pt5EjUmc4~VwtML38DjnPN9QvoEvhhstW4xAl~KfW~2qJWNMOZ~apWZgtr6R9GcW7fFC3-0Ar7yFIA5PSb7W2EnVUuJQFuB4QbXceR~93~993mMzAg2i~6JoclDdQYj50Fn7fGzECOwLdEbQ4GU36RiE-3ycahyT3jcW5lIosuWO~o2ApYct4bH0a0O99Aj3-gD8xTY-yDJsFdGjzm~GC8tqDRRmQm4XkfjAUDIRIQ__&Key-Pair-Id=APKAJ535ZH3ZAIIOADHQ\")
<\/p>\n\n\n\n
-incorrect: Circulatory overload occurs when blood is administered too quickly for the client\u2019s<\/p>\n\n\n\n
circulatory system to handle. Dyspnea, coughing, headaches, and hypertension are indications of<\/p>\n\n\n\n
circulatory overload.<\/p>\n\n\n\n
D. Sepsis<\/p>\n\n\n\n
-incorrect: Sepsis occurs when the blood is contaminated with bacteria. High fevers, vomiting,<\/p>\n\n\n\n
and diarrhea are indications of sepsis.<\/p>\n\n\n\n
400. A nurse is teaching the parent of a child who is to take 10 mLof a liquid medication. The<\/p>\n\n\n\n
parent has a hollow medication spoon with marks to indicateteaspoons andtablespoons. How<\/p>\n\n\n\n
many teaspoons should the nurse instruct the parent to give the child? (Nearest whole number).<\/p>\n\n\n\n
-2 teaspoons<\/p>\n\n\n\n
401. A nurse is implementing cold therapy for a client who has an ankle sprain. Which of the<\/p>\n\n\n\n
following actions should the nurse take?<\/p>\n\n\n\n
A. Apply a cold pack to the edematous area<\/p>\n\n\n\n
-incorrect: The nurse should avoid applying a cold pack to an area that displays edema because it<\/p>\n\n\n\n
can further decrease adequate circulation and prevent absorption of the edema.<\/p>\n\n\n\n
B. Check capillary refill before applying an ice pack to the affected area<\/p>\n\n\n\n
-The nurse should check the affected area for adequate circulation by assessing pulses and<\/p>\n\n\n\n
capillary refill because a cold pack applied to an area of impaired circulation can further decrease<\/p>\n\n\n\n
the blood supply to the area.<\/p>\n\n\n\n
C. Half-fill an ice pack with crushed ice<\/p>\n\n\n\n
-incorrect: The nurse should fill an ice pack two-thirds full of crushed ice to mold around the<\/p>\n\n\n\n
affected area.<\/p>\n\n\n\n
D. Apply an ice pack for 60 min intervals<\/p>\n\n\n\n
-incorrect: The nurse should apply an ice pack for 30-minute intervals to anesthetize and prevent<\/p>\n\n\n\n
further swelling of the affected area.<\/p>\n\n\n\n
402. A nurse is demonstrating postoperative deep breathing and coughing exercises to a client<\/p>\n\n\n\n
who is scheduled for emergency surgery for appendicitis. Which of the following statements<\/p>\n\n\n\n
indicates a lack of readiness to learn by the client?<\/p>\n\n\n\n
A. The client asks the nurse to repeat the instructions before attempting the exercises<\/p>\n\n\n\n
-incorrect: By asking the nurse to repeat the instructions, the client is demonstrating a readiness<\/p>\n\n\n\n
to learn the activity, even though he might not understand the mechanics of performing the<\/p>\n\n\n\n
exercises.<\/p>\n\n\n\n
B. The client reports severe pain<\/p>\n\n\n\n
-A client who is experiencing severe pain is not able to concentrate and is not ready to learn a<\/p>\n\n\n\n
new activity.<\/p>\n\n\n\n
C. The client asks the nurse how often deep breathing should be done after surgery<\/p>\n\n\n\n
-incorrect: Asking about the frequency of the activity indicates a readiness to learn, as the client<\/p>\n\n\n\n
is motivated to perform the exercises and wants to know how often to do them.<\/p>\n\n\n\n
D. The client tells the nurse that this exercise will probably be painful after surgery<\/p>\n\n\n\n
-incorrect: This indicates a readiness to learn because the client is able to think about the possible<\/p>\n\n\n\n
effects of the exercise following surgery.<\/p>\n","protected":false},"excerpt":{"rendered":"
ATI Fundamentals Proctored Exam | Questions and Answers Complete with Rationales LATEST 2021\/ 2022 1. 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 […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[],"tags":[],"class_list":["post-110067","post","type-post","status-publish","format-standard","hentry"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/110067","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=110067"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/110067\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=110067"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=110067"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=110067"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}