Fundamentals A

Question 1

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

Answer 1

C. I flushed what I urinated at 7am. I have saved all urine since
For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings.

Question 2

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

Answer 2

C. Calf swelling
Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility.

Question 3

A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines?
A. A nurse who is caring for a client reviews the client’s medical chart with the nursing student who is working with the nurse
B. A nurse asks a nurse from another unit to assist with her documentation
C. A nurse who is caring for a client returns a call to the client’s durable power of attorney for healthcare designee to discuss the client’s care
D. A nurse discusses the client’s status with the physical therapist that is caring for the client at the client’s bedside

Answer 3

B. A nurse asks a nurse from another unit to assist with her documentation
Only health care professionals directly caring for a client may access medical information; therefore, this is a violation of HIPAA guidelines

Question 4

A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take?
A. Apply the stockings so the creases are on the front side of the leg
B. Apply the stockings while the client’s legs are in a dependent position
C. Remove the stockings at least once per shift
D. Remove the stockings while the client is sitting in a reclining chair

Answer 4

C. Remove the stockings at least once per shift

The nurse should remove the stocking once per shift to check the client’s circulation and skin integrity.

Question 5

A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects?
A. Auscultate lung sounds
B. Measure urine output 
C. Monitor blood pressure readings 
D. Monitor serum electrolyte levels

Answer 5

A. Auscultate lung sounds
The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles heard in lung fields, dyspnea, and shortness of breath.

Question 6

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

Answer 6

A. I can concentrate best in the morning
Romberg’s test helps identify alterations in balance. The nurse should have the client stand with her arms at her sides and her feet together to observe her for swaying and a loss of balance.

Question 7

A nurse is performing a Romberg’s test during the physical assessment of a client. Which of the following techniques should the nurse use?
A. Touch the face with a cotton ball
B. Apply a vibrating tuning fork to the client’s forehead
C. Have the client stand with her arms at her side and her feet together
D. Perform direct percussion over the area of the kidneys

Answer 7

C. Have the client stand with her arms at her side and her feet together
Romberg’s test helps identify alterations in balance. The nurse should have the client stand with her arms at her sides and her feet together to observe her for swaying and a loss of balance.

Question 8

A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client?
A. Allow extra time for the client to respond to questions
B. Expect the client to have difficulty understanding the information
C. Avoid references to the client’s past experiences
D. Keep the learning session private and one-on-one

Answer 8

A. Allow extra time for the client to respond to questions

Older adult clients often process information at a slower rate than younger clients; therefore, the nurse should plan for extra time to allow the client to ask questions and absorb the information.

Question 9

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

Answer 9

A. Walking briskly

Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy.

Question 10

A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention?
A. Erythema on pressure points 
B. Lower-extremity pulse strength of 2+
C. Fluid intake of 3,000 mL per day
D. A bowel movement every other day

Answer 10

A. Erythema on pressure points

Erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from further breakdown

Question 11

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

Answer 11

A. Gently shake the container of medication prior to administration

The nurse should gently shake the liquid medication to ensure the medication is mixed

Question 12

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
A. Check the client for injuries
B. Move hazardous objects away from the client
C. Notify the provider
D. Ask the client to describe how she felt before the fall
The first action the nurse should take when using the nursing process is to assess the client for injuries

Answer 12

A. Check the client for injuries

The first action the nurse should take when using the nursing process is to assess the client for injuries

Question 13

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

Answer 13

D. Reassure the client that this is an expected response to grief

During the anger stage of the client’s psychosocial adaptation to illness, the nurse should support the client and ensure him that this is an expected reaction to a cancer diagnosis.

Question 14

A nurse in a clinic is caring for a middle adult client who states, “The doctor says that, since I am at average risk for colon cancer, I should have a routine screening. What does that involve?” Which of the following responses should the nurse make?
A. I’ll get a blood sample from you and send it for a screening test
B. Beginning at age 60, you should have a colonoscopy
C. You should have a fecal occult blood test every year
D. The recommendation is to have a sigmoidoscopy every 10 years

Answer 14

C. You should have a fecal occult blood test every year

Colorectal cancer screening for clients at average risk begins at age 50. One option for screening is a fecal occult blood test annually.
One option for screening is a flexible sigmoidoscopy every 5 years.
Colorectal cancer screening for clients at average risk begins at age 50. One option for screening is a colonoscopy every 10 years.
Blood tests do not detect colorectal cancer. One option for screening is a double-contrast barium enema every 5 years.

Question 15

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

Answer 15

A. Use the complete name of the medication magnesium sulfate

The Institute for Safe Medication Practices designates that nurses and providers write the complete medication name magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate

Question 16

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply)
A. Place the client in a room with negative-pressure airflow
B. Wear gloves when assisting the client with oral care
C. Limit each visitor to 2-hour increments
D. Wear a surgical mass when providing client care
E. Use antimicrobial sanitizer for hand hygiene

Answer 16

A. Place the client in a room with negative-pressure airflow
B. Wear gloves when assisting the client with oral care
E. Use antimicrobial sanitizer for hand hygiene
Place the client in a room with negative-pressure airflow is correct. The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions.

Wear gloves when assisting the client with oral care is correct. The nurse should wear gloves when assisting with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever her hands might come in contact with a client’s body fluids, such as saliva, and the mucous membranes in the mouth.

Limit each visitor to 2-hr increments is incorrect. The nurse does not need to limit the client’s visitors. However, the nurse should limit the client’s presence outside the room and have him wear a surgical mask when he does leave the room.

Wear a surgical mask when providing client care is incorrect. The nurse should wear an N95 respirator during client care to meet the requirements of airborne precautions.

Use antimicrobial sanitizer for hand hygiene is correct. The nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. The nurse should also wash her hands with soap and water when her hands have visible soiling.

Question 17

A charge nurse is discussing the responsibility of nurses caring for clients who have C.diff infection. Which of the following information should the nurse include in the teaching?
A. Assign the client to a room with a negative-airflow system
B. Use alcohol-based hand sanitizer when leaving the client’s room
C. Clean contaminated surfaces in the client’s room with a phenol solution
D. Have family members wear a gown and gloves when visiting

Answer 17

D. Have family members wear a gown and gloves when visiting

Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Caregivers must also wear gowns and gloves.

Question 18

A nurse in a surgical suite notes documentation on a client’s medical record that he has a latex allergy. In preparation for the client’s procedure, which of the following precautions should the nurse take?
A. Ensure sterilization of non-disposable items with ethylene oxide
B. Wrap monitoring cords with stockinette and tape them in place
C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication
D. Wear hypoallergenic latex gloves that contain powder

Answer 18

B. Wrap monitoring cords with stockinette and tape them in place

Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client’s skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them

Question 19

A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend?
A. Drink a cu of hot cocoa before bedtime
B. Exercise 1 hour before going to bed
C. Use progressive relaxation techniques at bedtime
D. Reflect on the day’s activities before going to bed

Answer 19

C. Use progressive relaxation techniques at bedtime

Progressive relaxation promotes sleep by decreasing stress and reducing muscle tension.

Question 20

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.
A. Withdraw the correct dose of regular insulin from the bottle
B. Inject 10 units of air into the bottle of NPH insulin
C. Withdraw the correct dose of NPH insulin from the bottle
D. Inject 5 units of air into the bottle of regular insulin

Answer 20

B. Inject 10 units of air into the bottle of NPH insulin
D. Inject 5 units of air into the bottle of regular insulin
A. Withdraw the correct dose of regular insulin from the bottle
C. Withdraw the correct dose of NPH insulin from the bottle
Just remember cloudy (NPH) to clear (regular) then clear (regular) to cloudy (NPH)!
The nurse should first inject air into the vial of NPH without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin, and then withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.

Question 21

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?
A. Insert an implanted port
B. Close a laceration with sutures
C. Place an endotracheal tube
D. Initiate an enteral feeding through a gastrostomy tube

Answer 21

D. Initiate an enteral feeding through a gastrostomy tube

It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes.

Question 22

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

Answer 22

D. Have the client take sips of water to promote insertion of the NG tube into the esophagus

Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube’s passage into the trachea.

Question 23

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

Answer 23

B. Pupil clarity
D. Visual fields
E. Visual acuity
Lacrimal apparatus is incorrect. If the client has an impairment in his ability to produce tears, it should not affect his fall risk. The nurse tests this by palpating the tear duct at the lower eyelid to see if any tears emerge.

Pupil clarity is correct. Cloudy pupils mean that the client has cataracts. This makes his vision cloudy and creates halos around lights, which can increase his risk for falls because he cannot see items in his path clearly.

Appearance of bulbar conjunctivae is incorrect. The nurse should examine the bulbar conjunctivae by gently retracting the lower and upper lids to evaluate color and texture and assess for the presence of infection. However, the condition of the conjunctivae will not impede the client’s safety.

Visual fields is correct. The nurse should use a finger to test the client’s peripheral vision by moving it out of range and then back into his visual field to determine when he sees the finger. If the client has a visual field impairment, he is at risk for falls because he might not see objects outside his central vision and trip over them or bump into them and fall.

Visual acuity is correct. The nurse should use a Snellen chart to assess distance vision and a handheld card to assess near vision. If the client wears glasses, he should wear them during the assessments. If the client has a vision impairment, he is at risk for falls because he might not see objects in his path and trip over them or bump into them and fall.

Question 24

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

Answer 24

C) The client holds the cane on the stronger side of her body.

The client should hold the cane on the stronger side of her body to increase support and maintain alignment.

Question 25

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client’s neck, she hears the following sound. This sound indicates which of the following? (Click on the audio button to listen to the clip.)
A) Narrowed arterial lumen
B) Distended jugular veins
C) Impaired ventricular contraction
D) Asynchronous closure of the aortic and pulmonic valves

Answer 25

A) Narrowed arterial lumen

A) Narrowed arterial lumen

Arterial bruits are blowing sounds resulting from blood flowing through occluded or narrowed arteries
Distended jugular veins
Blood flowing through distended jugular veins does not produce a sound.
Asynchronous closure of the aortic and pulmonic valves
MY ANSWER
Asynchronous closure of the aortic and pulmonic valves is known as “splitting” of S2, so the nurse should hear two “dub” sounds during auscultation.
Impaired ventricular contraction
Impaired ventricular function produces extra heart sounds, either S3 or S4.

Question 26

A nurse is admitting a client who has influenza. Which of the following types of transmission precautions should the nurse initiate?
A) Airborne/Varicella 
B) Droplet
C) Contact
D) Protective environment

Answer 26

B) Droplet

Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis.
Contact precautions are a requirement for clients who have infections that spread via direct contact or contact with the environment, including vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and scabies.
Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles.
Clients who have an immune-system compromise, such as those who have had an allogeneic hematopoietic stem cell transplant, require a protective environment.

Question 27

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?
A) Dissolve each medication in 5 mL of sterile water.
The nurse should dissolve each medication in at least 30 mL of warm, sterile water
B) Draw up medications together in the syringe.
The nurse should dissolve each medication in at least 30 mL of warm, sterile water
C) Push the syringe plunger gently when feeling resistance.
If the nurse encounters resistance when administering medications, he should stop and contact the provider.
D) Flush the tube with 15 mL of sterile water.

Answer 27

D) Flush the tube with 15 mL of sterile water.

The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication.

Question 28

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

Answer 28

C) Cleanse the wound from the center outward

The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface..

Question 29

A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report?
A) A nurse tied a client’s restraint straps to the moveable part of the bed frame.
B) An assistive personnel placed a surgical mask on a client who has tuberculosis before transporting her to radiology.
C) A nurse administers a medication to a client 30 min before the dose is due.
D) A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

Answer 29

D) A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

The nurse should complete an incident report if an IV infusion pump malfunctions to assist in compiling information for risk management to determine actions to take to prevent further similar incidents.

Question 30

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

Answer 30

C) Skin blanching

Skin blanching, edema, and coolness at the IV site indicate infiltration.

Question 31

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?
A) Critical pathway
B) Situation, background, assessment, and recommendation (SBAR)
C) Transfer report
D) Medication administration record (MAR)

Answer 31

B) Situation, background, assessment, and recommendation (SBAR)

Medication administration record (MAR)
The nurse should use the MAR to document medication administration.
Critical pathway
A critical pathway is an interprofessional approach to planning all phases of client care.
Situation, background, assessment, and recommendation (SBAR)
MY ANSWER
SBAR is a communication tool used to relate a client’s status during a change-of-shift report.
Transfer report
The nurse should use a transfer report when the client is moving from one health care area or facility to another.

Question 32

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

Answer 32

D) Contact precautions

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

Question 33

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first?
A) Suction the client’s airway.
B) Administer a bronchodilator.
C) Increase the humidity in the client’s room.
D) Assist the client to an upright position.

Answer 33

D) Assist the client to an upright position.
When providing client care, the nurse should first use the least invasive intervention. Therefore, the nurse should elevate the head of the client’s bed to the semi-Fowler’s or high Fowler’s position to facilitate maximal chest expansion. Sitting upright improves gas exchange and prevents pressure on the diaphragm from abdominal organs

Question 34

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

Answer 34

D) Potassium 5.4 mEq/L

The value is above the expected reference range and the nurse should report this finding. This client is at risk for dysrhythmias

Question 35

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

Answer 35

D) Stand close to the cabinet when lifting it.

This action keeps the cabinet close to the nurse’s center of gravity and decreases back strain from horizontal reaching.

Question 36

A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse question?
A) The medication
B) The route
C) The dose
D) The frequency

Answer 36

C) The dose

The dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer

Question 37

A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?
A) Tomato juice 
B) Bananas 
C) Pancakes
D) Eggs

Answer 37

D) Eggs

Evidence-based practice indicates the nurse should remove fried eggs from the client’s tray. Fried eggs are not a part of a mechanical soft diet. Eggs that are poached or scrambled are an acceptable replacement for this item

Question 38

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

Answer 38

A) “What could I have done to deserve this illness?”

Question 39

nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client’s partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?
A) Ask the client to consider a direct donation.
B) Withhold the blood transfusion.
C) Request a consultation with the ethics committee.
D) Ask the client’s family to intervene.

Answer 39

B) Withhold the blood transfusion.

The principle of autonomy ensures that a client who is competent has the right to refuse treatment.

Question 40

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

Answer 40

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

The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa

Question 41

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

Answer 41

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

By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-ulcer development.

Question 42

A nurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress?
A) Role ambiguity
B) Sick role
C) Role overload
D) Role conflict

Answer 42

C) Role overload

The partner’s expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can perform

Question 43

A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse’s priority before beginning this procedure?
A) “When do you usually bathe, in the morning or in the evening?”
B) “Do you prefer a bath or a shower?”
C) “At what temperature do you prefer your bath water?”
D) “Are you able to help with your hygiene care?”

Answer 43

D) “Are you able to help with your hygiene care?”

The greatest risk to the client’s safety is an injury resulting from an overestimation of the client’s ability to help with hygiene care; therefore, the nurse’s priority is to assess the client’s ability to assist with her hygiene care.

Question 44

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

Answer 44

D) Acupuncture
Aloe
Aloe is a complementary and alternative therapy used by clients for skin disorders and can have wound healing effects. This type of therapy is not known to be contraindicated for a client who has herpes zoster.
Biofeedback
Biofeedback is a complementary and alternative therapy used by clients for disease processes such as stroke recovery, smoking cessation, and headache disorders. The use of this mind-body technique is not known to be contraindicated for a client who has herpes zoster.
Acupuncture
MY ANSWER
The nurse should inform the client that the use of acupuncture is contraindicated for a client who has herpes zoster, or any skin infection, to prevent an open portal on the skin’s surface, which could increase the risk of further infection.
Feverfew
Feverfew is a complementary and alternative therapy used by clients for wound healing. It should not be taken by clients who are prescribed warfarin or other blood thinners, but this type of therapy is not known to be contraindicated for a client who has herpes zoster

Question 45

A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?
A) “I’ll make sure that, when my friend comes by, she smokes at least 6 feet away from my oxygen tank.”
B) “I’ll use a woolen blanket if I get chilly while I’m using my oxygen.”
C) “I’ll check the wires and cables on my TV to make sure they are in good working order.”
D) “I’ll lay my oxygen tank down on the floor when the grandchildren visit so they don’t knock it over.”

Answer 45

C) “I’ll check the wires and cables on my TV to make sure they are in good working order.”

Oxygen is a highly flammable gas. The client should make sure any electrical equipment in the room where she is using supplemental oxygen is functioning properly so it does not create any electrical sparks

Question 46

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

Answer 46

A) Ask another nurse to observe the medication wastage.

A second nurse must witness the disposal of any portion of a dose of a controlled substance.

Question 47

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

Answer 47

B) 0.3 mg

The use and placement of a decimal point can cause a medication error. A zero should precede a decimal point (0.3 mg), but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg.

Question 48

A nurse is caring for a client who is terminally ill. Which of the following statements should the nurse identify as an indication that the client’s family member is coping effectively with the situation?
A) “We are not worried. We still have hope that everything will be okay.”
B) “This is a difficult time, but we are helping each other through this.”
C) “After he comes home, we can plan our family reunion.”
D) “We don’t need to talk about funeral arrangements at this time.”

Answer 48

B) “This is a difficult time, but we are helping each other through this.”

An effective coping strategy is talking with others in the family and supporting each other. This statement displays effective coping skills because the family is using social supports to assist them throughout the grief process

Question 49

A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care?
A) Tell the client which food she should eat first.
B) Provide small-handle utensils for the client.
C) Thicken liquids on the client’s tray.
D) Use a clock pattern to describe food on the client’s plate.

Answer 49

D) Use a clock pattern to describe food on the client’s plate.

Describing the location of the food on the plate by using a clock pattern allows the client to have greater independence during meals.

Question 50

A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

1) Ask the client if he can bear weight
2) Use the stand-and-pivot technique to move the client to the chair
3) Position the chair on the left side of the bed
4) Have the client sit and dangle his feet at the bedside

Answer 50

1) Ask the client if he can bear weight
3) Position the chair on the left side of the bed
4) Have the client sit and dangle his feet at the bedside
2) Use the stand-and-pivot technique to move the client to the chair

The first action the nurse should take is to assess the client to determine if he can bear weight and assist with his transfer. Next, the nurse should position the chair on the side of the bed closest to the client’s stronger side for easy access. Next, the nurse should have the client sit and dangle his feet at the bedside to allow him to adjust to sitting up and prevent dizziness when transferring. Finally, the nurse should use the stand-and-pivot technique to move the client to the chair.

Question 51

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?
A) “They allow the court to overrule an adult client’s refusal of medical treatment.”
B) “They indicate the form of treatment a client is willing to accept in the event of a serious illness.”
C) “They permit a client to withhold medical information from health care personnel.”
D) “They allow health care personnel in the emergency department to stabilize a client’s condition.”

Answer 51

B) “They indicate the form of treatment a client is willing to accept in the event of a serious illness.”

Advance directives include a living will, which permits the client to direct treatment in the event of a terminal illness.

Question 52

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

Answer 52

C) Rapid heart rate

Tachycardia indicates fluid-volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.

Question 53

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

Answer 53

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

The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action is for the nurse to determine why the client is refusing the treatment

Question 54

A nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Answer 54

8.0mL/hr

Desired Over Have
STEP 1: What is the unit of measurement the nurse should calculate? mL/hr
STEP 2: What is the dose the nurse should administer? Dose to administer = Desired 800 units/hr
STEP 3: What is the dose available? Dose available = Have 25,000 units
STEP 4: Should the nurse convert the units of measurement? No
STEP 5: What is the quantity of the dose available? 250 mL
STEP 6: Set up an equation and solve for X.
Desired x Quantity/Have = X mL
800 units x 250 mL/25,000 units = X mL
X = 8
STEP 7: Round if necessary.
STEP 8: Reassess to determine whether the amount to administer makes sense. If there are 25,000 units/250 mL and the prescription reads 800 units/hr, it makes sense to administer 8 mL/hr. The nurse should set the infusion pump to administer 8 mL/hr.

Question 55

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

Answer 55

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

The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula backward into the esophagus.

Question 56

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

Answer 56

A) Press gently on the tragus of the client’s ear.

Pressing gently on the tragus of the ear will help the medication get into the inner ear.

Question 57

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

Answer 57

C) Subtract the amount of irrigant used from the client’s urine output.

The nurse should calculate the fluid used for irrigation and subtract it from the client’s total urinary output.

Question 58

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

Answer 58

B) Place the client’s arm in a dependent position.

The nurse should place the client’s arm in a dependent position because the veins will dilate due to gravity.

Question 59

The nurse should place the client’s arm in a dependent position because the veins will dilate due to gravity.

Answer 59

C) Semi-Fowler’s

Positioning the client in semi-Fowler’s or high-Fowler’s position allows for maximum expansion of the lungs.