NURSING PRACTICE I

1. The nurse is to administer 25 mg of promethazine (Phenergan) IM to a 150pound client. The nurse no!s that this medication should "e gi#en into a deep large muscle mass. The preferred site of in$ection for this client !ould "e !hich of the follo!ing% &. 'eltoid (. 'orsogluteal ). *astus lateralis '. *entrogluteal 2. To administer 1ml of a flu #accine intramuscularl+ (IM) to an o"ese adult in the deltoid area +ou !ould use !hat size needle% &. 5,- inch (. 1 inch ). 1 . inch '. 2 inch /. The nurse is caring for se#eral clients !ith central #enous catheters. 0hile changing the tu"ing on the central lines1 the nurse !ould not need to instruct the client to perform a *alsal#a2s maneu#er !hen the client has !hich of the follo!ing catheters% &. The 3roshong catheter (. 4ingle-lumen catheter ). Percutaneous catheter '. &ccessed su"cutaneous #enous port 5. 0hen communicating !ith a culturall+ di#erse client !ho spea s a different language1 the "est practice for the nurse is to6 &. 4pea loudl+ and slo!l+. (. 4tand dose to the client and spea loudl+. ). &rrange for an interpreter !hen communicating !ith the client. '. 4pea to the client and famil+ together to increase the chances that the topic !ill "e understood. 5. The client !ith m+asthenia gra#is is ha#ing difficult+ spea ing. The speech is d+sarthric and has a nasal tone. The nurse !ould a#oid using !hich of the follo!ing communication strategies !hen !or ing !ith this client% &. 7ncouraging the client to spea 8uic l+ (. &s ing +es and no 8uestions !hen a"le ). 9sing a communication "oard !hen necessar+ '. :epeating !hat the client said to #erif+ the message ;. & client admitted to the mental health unit is e<periencing distur"ed thought processes

and "elie#es that the food is "eing poisoned. 0hich communication techni8ue does the nurse plan to use to encourage the client to eat% &. 9sing open-ended 8uestions and silence (. =ocusing on self-disclosure regarding food preferences ). Identif+ing the reasons that the client ma+ not !ant to eat '. >ffering opinions a"out the necessit+ of ade8uate nutrition ?. The nurse is pro#iding care to a client admitted to the hospital !ith a diagnosis of acute an<iet+ disorder. 0hile con#ersing !ith the client1 the client sa+s to the nurse1 @I ha#e a secret that I !ant to tell +ou. Aou !onBt tell an+one a"out it1 !ill +ou%@ The appropriate nursing response is !hich of the follo!ing% &. @Co1 I !onD tell an+one.B (. @I cannot promise to eep a secret.@ ). BIf +ou tell me the secret1 I !ill tell it to +our doctor.@ '. @If +ou tell me the secret1 I !ill need to document it in +our record.@ -. The nurse is performing an admission assessment on a client and is attempting to o"tain su"$ecti#e data regarding the clientBs se<ual and reproducti#e status. The client states1 @I donBt !ant to discuss thisE itBs pri#ate and personal.@ 0hich statement1 if made "+ the nurse1 indicates that the nurse is therapeutic% &. @I hate "eing as ed these sorts of 8uestions too.@ (. @I am a professional nurse1 and as such IBll ha#e +ou no! that all information is ept confidential.@ ). This is difficult for +ou to spea a"out1 "ut I am tr+ing to perform a complete assessment and I need this information.F '. @I no! that some of these 8uestions are difficult for +ou1 "ut as a professional nurse1 I need to ha#e complete information so I can pro#ide the "est care.@ G. & nurse is monitoring a client !ith a diagnosis of schizophrenia. The nurse notes that the clientBs emotional responses to situations occurring throughout the da+ are incongruent !ith the tone of the situation. The nurse documents the findings using !hich description of the clientBs "eha#ioral response% &. Inappropriate affect (. =lat affect ). -lunled affect

'. (izarre affect 10. & +oung male client tentati#el+ diagnosed !ith a "orderline personalit+ disorder sa+s to the nurse1 @I donBt no! !h+ I got m+ tattoo1 it !as for me. >H% 4ometimes I do these things to get m+ parents mad and sometimes I do them "ecause IBm "ored. ThatBs !hat happened the night I crashed the famil+ car. I !asnBt drun or suicidal or an+thing li e the police thought. It !as $ust for ic sD@ 0hich of the follo!ing is the appropriate nursing response% &. @Ce<t time1 pic less dangerous and e<pensi#e !a+s to e<plode.@ (. @II is scar+ !hen +ou feel out of control !ith such feelings of emptiness and anger that +ou canBt stop +ourself.@ ). @ItBs a good thing that +ou donBt a"use su"stances or +ou might "e dead due to +our rec less disregard.@ '. B0hat can +ou do to stop +our "eha#ior !hen it gets to that point the ne<t time%F 11. & nurse is reading a ph+sicianBs progress notes in the clientBs record and reads that the ph+sician has documented @insensi"le fluid loss of appro<imatel+ -00 mlI dail+.@ The nurse understands that this t+pe of fluid loss can occur through6 &. The s in (. 9rinar+ output ). 0ound drainage '. The gastrointestinal tract 12. The nurse is assessing the I* dressing of a client !ith a peripheral intra#enous infusion running. The date on the dressing is ?,25 (Jul+ 25). The nurse documents on the clientBs record that the dressing should "e changed on !hich of the follo!ing dates% &. ?,2; (. ?,2). ?,/0 '. -,1 1/. & nurse is monitoring a client !ho is in the acti#e stage of la"or. The client has "een e<periencing contractions that are short1 irregular1 and !ea . The nurse documents that the client is e<periencing !hich t+pe of la"or d+stocia% &. K+potonic (. Precipitous ). K+pertonic '. Preterm la"or 15. & mother of a 5-+ear-old e<presses concern "ecause her hospitalized child has "egun thum" suc ing. The mother states that this "eha#ior "egan 2 da+s after hospital

admission. The appropriate nursing response is !hich of the follo!ing% &. @It is "est to ignore the "eha#ior.@ (. @Aour child is acting li e a "a"+.@ ). The doctor !ill need to "e notified.@ '. @& 5-+ear-old is too old for this t+pe of "eha#ior.@ 15. & clinic nurse re#ie!s the record of a child $ust seen "+ a ph+sician and diagnosed !ith suspected aortic stenosis. The nurse e<pects to note documentation of !hich clinical manifestation specificall+ found in this disorder% &. Pallor (. K+peracti#it+ ). 7<ercise intolerance '. 3astrointestinal distur"ances 1;. The nurse is documenting the assessment and care of a hospitalized client follo!ing an uncomplicated c+stoscop+. 0hich one of the follo!ing !ould "e an unli el+ notation postprocedure for this client% &. *oiding pin -Iinged urine (. &ssisted lo tu" room for sitz "ath ). Traction applied to =ole+ catheter '. Increasing fluid inta e !ithout nausea 1?. The nurse is caring for a client !ith a "urn in$ur+ to the lo!er legs. Citrofurazone (=uracin) is prescri"ed to "e applied to the sites of in$ur+. The nurse documents !hich of the follo!ing in the plan of care as the appropriate method for appl+ing this medication% &. &ppl+ saline-soa ed dressings o#er Ihe medication. (. &ppl+ 1-inch film directl+ to the "um sites. ). &ppl+ a 1,1;-inch film directl+ to the "urn sites. '. &ppl+ a 15-inch film directl+ to the "urn sites after cleansing the !ounds. 1-. & nurse is performing &pgar scoring for a ne!"orn immediatel+ after "irth. The nurse notes that the respirator+ rate is less than 1001 that respirator+ effort is irregular1 and that muscle tone sho!s some e<tremit+ fle<ion. The ne!"orn grimaces !hen suctioned !ith a "ul" s+ringe1 and the s in color indicates some c+anosis of the e<tremities. The nurse should appropriatel+ document !hich of the follo!ing &pgar scores for the ne!"orn% &. / (. 5 ). ? '. 10

1G. & left atrial catheter is inserted into a client during cardiac surger+. The nurse is monitoring the left atrial pressure (L&P) and documents that the pressure is normal if !hich of the follo!ing L&P #alues is noted% &. - mm Kg (. 15mmKg ). 25mmKg M '. /2mmKg 20. & nurse is performing an assessment on a child !ith a head in$ur+. The nurse notes an a"normal fle<ion of the upper e<tremities and an e<tension of the lo!er e<tremities. The nurse documents that the child is e<periencing6 &. 'ecorticate posturing (. 'ecere"rate posturing ). =le<ion of the arms and legs '. Cormal e<pected positioning after head In$ur+ 21. & client has a pressure ulcer on the sacrum. The nurse notes that the ulcer has partial thic ness s in loss and the formation of a "lister. The nurse documents that the ulcer is a6 &. 4tage I ulcer (. 4tage II ulcer ). 4tage III ulcer '. 4tage I* ulcer 22. & nurse is told that a client !ill ha#e an arterial "lood gas sample dra!n on room air. The nurse is as ed to complete the la"orator+ re8uisition. The nurse documents on the re8uisition that the client !as recei#ing ho! much o<+gen for the procedure% &. 1;N (. 21N ). /0N '. 50N 2/. & nurse is assessing a clientBs legs for the presence of edema. The nurse notes that the client has mild pitting !ith slight indentation and no percepti"le s!elling of the leg. The nurse documents this finding as defining6 &. 1O edema (. 2O edema ). /O edema '. 5O edema 25. & nurse is performing a ph+sical assessment of a clientBs musculos eletal s+stem and notes that the client is righthanded. The nurse !ould document !hich of the follo!ing as an a"normal finding% &. 1-cm h+pertroph+ of nghl upper arm (. 4+mmetrical mo#ements "ilaterall+

). Presence of fasciculalions '. Muscle strength graded 5?5 25. & ph+sician as s a nurse to discontinue tu"e feeding in a client !ho is in a chronic #egetati#e state. The ph+sician tells the nurse that thi re8uest !as made "+ the clientBs spouse and children. The nurse understands the legal "asis for carr+ing out the order and first chec s the clientBs record for documentation of6 &. )ourt appro#al to discontinue the treatment (. & !ritten order "+ the ph+sician to remo#e the tu"e ). &uthorization "+ the famil+ to discontinue the treatment '. &ppro#al "+ the institutional ethics committee 2;. The nurse understands that !hich of the follo!ing statements regarding her"al therapies is true% &. Pinc is used for insomnia. (. 3inger is used lo impro#e memor+. ). 7chinacea is used for erectile d+sfunction. '. (lac cohosh produces estrogen-li e effects. 2?. & client !ho ta es theoph+lline for chronic o"structi#e pulmonar+ disease is seen in the urgent care center for respirator+ distress. >nce the client is sta"ilized1 the nurse "egins discharge teaching. The nurse !ould "e especiall+ #igilant to include information a"out compl+ing !ith medication therap+ if the clientBs "aseline theoph+lline le#el !as6 &. 10 mcg,mL (. 12 mcg,mL ). 15 mcg,mL '. 1- mcg,mL 2-. The nurse is conducting a dietar+ assessment on a client !ho is on a #egan diet. The nurse plans to pro#ide dietar+ teaching focusing on foods high in !hich #itamin that ma+ "e lac ing in a #egan diet% &. *ilamin & (. *ilamin (12 ). *ilamin ) '. *ilamin 7 2G. & nurse is planning to teach a client !ith mala"sorption s+ndrome a"out the necessit+ of follo!ing a lo!-fat diet. The nurse de#elops a list of high-fat foods to a#oid and includes !hich food item on the list% &. >ranges (. (roccoli ). )ream cheese

'. (roiled haddoc /0. & nurse is preparing a 2-+ear-old child !ith suspected nephrotic s+ndrome for diagnostic tests to confirm the diagnosis. The mother as s the nurse if the child !ill e#er loo thin again. The nurse most appropriatel+ responds "+ telling the mother6 &. @>h +ou feel guilt+ "ecause +ou didnBt notice the !eight gain%@ (. @0hen children are little1 itBs e<pected the+Bll loo a little chu""+.@ ). @In most cases1 medication and diet !ill control the fluid retention.@ '. @0eanng loose-fitting clothing should help conceal the e<tra !eight.@ /1. The nurse is documenting the assessment and care of a hospitalized client follo!ing an uncomplicated c+stoscop+. 0hich one of the follo!ing !ould "e an unli el+ notation postprocedure for this client% &. *oiding pin -Iinged urine (. &ssisted lo tu" room for sitz "ath ). Traction applied to =ole+ catheter '. Increasing fluid inta e !ithout nausea /2. & home care nurse is #isiting a client to pro#ide follo!-up e#aluation and care of a leg ulcer. >n remo#ing the dressing from the leg ulcer1 the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to touch. The nurse should document that these findings identif+ !hich t+pe of ulcer% &. & #ascular ulcer (. & #enous stasis ulcer ). &n arterial ulcer '. & stage 1 ulcer //. The nurse is tr+ing to communicate !ith a client !ith "rain attac (stro e) and aphasia. 0hich of the follo!ing actions "+ the nurse !ould "e least helpful to the client% &. 4pea ing to Ihe client at a slo!er rate (. &llo!ing plent+ of time for the client to respond ). )ompleting the sentences that the client cannot finish '. Loo ing directl+ at the client during attempts at speech /5. & nurse o"tains an order from a ph+sician to restrain a client "+ using a $ac et restraint and instructs a nursing assistant to appl+ the restraint to the client. 0hich o"ser#ation "+ the nurse indicates inappropriate application of the restraint "+ the nursing assistant% &. & safel+ not in the restraint straps (. :estraint straps that are safel+ secured to the side rails

). Jac et restraint straps that do not tighten !hen force is applied against them '. Jac et restraint secured so that t!o fingers can slide easil+ "et!een the restraint and the clientBs s in /5. & nurse is gi#ing a report to a nursing assistant !ho !ill "e caring for a client !ho has hand restraints. The nurse instructs the nursing assistant to assess the s in integrit+ of the restrained hands e#er+6 &. 2 hours (. / hours ). 5 hours '. /0 minutes /;. The nurse is teaching the client !ho has had a lar+ngectom+ for lar+ngeal cancer ho! to use an artificial lar+n<. The nurse tells the client to6 &. Insert the de#ice into Ihe tracheostom+. (. Kold the de#ice alongside the nec . ). Kold the de#ice o#er the upper portion of the sternum. '. 4!allo! air into the esophagus to ma e speech. /?. The nurse is planning to pro#ide a list of instructions to a client "eing discharged to home !ith a peripherall+ inserted central cathete (PI))). The nurse !ould a#oid !riting !hich of the follo!ing incorrect items on the instruction sheet% &. 0ear a Medic-&lert lag or "racelet1 (. Ka#e a repair it a#aila"le in the home for use if needed. ). Heep the insertion site protected !hen in the sho!er or "ath. '. Heep acti#it+ le#el to a minimum !hile this catheter is in place. /-. & nurse is conducting preoperati#e teaching !ith a client a"out the use of an incenti#e spirometer. The nurse should include !hich piece of information in discussions !ith the client% &. Inhale as rapidl+ as possi"le. (. Heep a loose seal "et!een the lips and the mouthpiece. ). &fter ma<imum inspiration1 hold the "reath for 15 seconds and e<hale. '. The "est results are achie#ed !hen sitting up or !ith the head of the "ed is ele#ated 55 to G0 degrees. /G. & nurse e<plains the purpose of effleurage to a client in earl+ la"or. The nurse tells the client that effleurage is6 &. The application of pressure to the sacrum to relie#e a "ac ache

(. & form of "iofeed"ac to enhance "earing-do!n efforts during deli#er+ ). Light stro ing of the a"domen to facilitate rela<ation during la"or and pro#ide tactile stimulation to the fetus '. Performed to stimulate uterine acti#it+ "+ contracting a specific muscle group !hile other parts of the "od+ rest 50. & nurse on a postpartum unit is instructing a client regarding lochia and the amount of e<pected lochia drainage. The nurse instructs the client that the normal amount of lochia ma+ #ar+ "ut should ne#er e<ceed the need for6 &. >ne peripad a da+ (. T!o peripads a da+ ). 7ight peripads a da+ '. Three peripads a da+ 51. & nursing instructor as s a nursing student to descri"e the formal operations stage of PiagetBs cogniti#e de#elopmental theor+. The appropriate response "+ the nursing student is6 &. The child has the a"ilit+ to thin a"stractl+.@ (. The child de#elops logical thought patterns.B ). The child "egins to understand the en#ironment.@ '. The child has difficult+ separating fantas+ from realit+.@ 52. & maternit+ nurse is pro#iding instructions to a ne! mother regarding the ps+chosocial de#elopment of the ne!"orn infant. 9sing 7ri sonBs ps+chosocial de#elopment theor+1 the nurse instructs the mother to6 &. &llo! the ne!"orn infant to signal a need. (. &nticipate all the needs of the ne!"orn infant. ). &ttend to the ne!"orn infant immediatel+ !hen cr+ing. '. &#oid the ne!"orn infant during the first 10 minutes of cr+ing. 5/. & mother of a /-+ear-old child tells a clinic nurse that the child is re"elling constantl+ and ha#ing temper tantrums. 9sing 7ri sonBs ps+chosocial de#elopment theor+1 the nurse tells the mother to6 &. 4et limits on the childBs "eha#ior. (. Ignore the child !hen this "eha#ior occurs. ). &llo! the "eha#ior1 "ecause this is normal at this age period'. Punish the child e#er+ time the child sa+s @no@ to change the "eha#ior.

55. & mother of a /-+ear-old child as s a clinic nurse a"out appropriate and safe to+s. The nurse tells the mother that the most appropriate to+ is !hich of the follo!ing% &. & !agon (. & golf set ). & farm set '. & $ac sel !ilh mar"les 55. The mother of a /-+ear-old is concerned "ecause her child still is insisting on a "ottle at nap time and at "edtime. 0hich of the follo!ing is the appropriate suggestion to the mother% &. &llo! the "ottle If it contains $uice. (. &llo! the "ottle if it contains !ater. ). 'o not allo! the child to ha#e the "ottle. '. &llo! the "ottle during naps "ut not at "edtime. 5;. & clinic nurse pro#ides instructions to the mother of a child !ith impetigo regarding the application of anti"iotic ointment. The mother as s the nurse !hen the child can return to school. The appropriate response to the mother is6 &. 1 !ee after using anll"iolic ointment. (. 10 da+s after using anti"iotic ointment. ). 25 hours after using anti"iotic ointment. '. 5- hours after using anti"iotic ointment. 5?. The health education nurse pro#ides instructions to a group of clients regarding measures that !ill assist in pre#enting s in cancer. 0hich statement "+ a client indicates a need for further instructions% &. BI !ill a#oid sun e<posure after / PM.@ (. @I !ill use sunscreen !hen participating In outdoor acti#ities.@ ). @I !ill !ear a hat1 opa8ue clothing1 and sunglasses !hen In the sun.@ '. BI !ill e<amine m+ "od+ monthl+ for an+ lesions that ma+ "e suspicious.@ 5-. The nurse is re#ie!ing the discharge instructions for the client !ho had a s in "iops+. 0hich statement "+ the client indicates a need for further instruction% &. @I !ill use the anti"iotic ointment as prescri"ed.@ (. @I !ill return in ? da+s to ha#e the sutures remo#ed.B ). @I !ill call the ph+sician if I see an+ drainage from the !ound.@ '. @I !ill remo#e the dressing as soon as I get home and !ash it !ith tap !ater.@ 5G. The camp nurse as s the children preparing to s!im in the la e if the+ ha#e applied sunscreen. The nurse reminds the children that chemical sunscreens are most effecti#e !hen applied6

&. (. ). '.

Immediatel+ "efore s!imming 15 minutes "efore e<posure to the sun Immediatel+ "efore e<posure to the sun /0 to ;0 minutes "efore e<posure to the sun

50. The communit+ health nurse conducts a health promotion program regarding testicular cancer to communit+ mem"ers. The nurse determines that further information needs to "e pro#ided if a communit+ mem"er states that !hich of the follo!ing is a sign of testicular cancer% &. &lopecia (. (ac pain ). Painless testicular s!elling '. Kea#+ sensation In the scrotum 51. The nurse is teaching a client a"out the ris factors associated !ith colorectal cancer. The nurse determines that further teaching related to colorectal cancer is necessar+ if the client identifies !hich of the follo!ing as an associated ris factor% &. &ge +ounger than 50 +ears (. Kistor+ of colorectal pol+ps ). =amil+ histor+ of colorectal cancer '. )hronic inflammator+ "o!el disease 52. The nurse is caring for a client follo!ing a radical nec dissection and creation of a tracheostom+ performed for lar+ngeal cancer and is pro#iding discharge instructions to the client. 0hich statement "+ the client indicates a need for further instructions% &. @I !ill protect the stoma from !ater.B (. @I need to eep po!ders and spra+s a!a+ from the stoma site. ). @I need to use an air conditioner to pro#ide cool air to assist in "reathing.@ '. @I need to appl+ a thin la+er of petrolatum to the s in around the stoma to pre#ent crac ing.F 5/. & nurse manager is teaching the nursing staff a"out signs and s+mptoms related to h+percalcemia in a client !ith metastatic prostate cancer and tells the staff that !hich of the follo!ing is a serious late sign of this oncological emergenc+% &. Keadache (. '+sphagia ). )onstipation '. 7lectrocardiographic changes 55. &n e<ternal insulin pump is prescri"ed for a client !ith dia"etes mellitus and the client as s the nurse a"out the functioning of the pump. The nurse "ases the response on the information that the pump6

&. Is limed to release programmed doses of regular or CPK Insulin into the "loodstream at specific inter#als (. )ontinuousl+ infuses small amounts of CPK insulin into the "loodstream !hile regularl+ monitoring "lood glucose le#els ). Is surgicall+ attached to the pancreas and infuses regular insulin into the pancreas1 !hich in turn releases the insulin into the "loodstream '. 3i#es a small continuous dose of regular insulin su"cutaneousl+1 and the client can self-administer a "olus !ith an additional dose from the pump "efore each meal 55. & nurse pro#ides instructions to a client !ho is ta ing le#oth+ro<ine (4+nthroid). The nurse tells the client to ta e the medication6 &. 0ith food (. &I lunchtime ). >n an empl+ stomach '. &I "edlime !ilh a snac 5;. & nurse is teaching a client ho! to mi< regular insulin and CPK insulin in the same s+ringe. 0hich of the follo!ing actions1 if performed "+ the client1 indicates the need for further teaching% &. 0ithdra!s the CPK insulin first (. 0ithdra!s the regular insulin first ). In$ects air into CPK insulin #ial first '. In$ects an amount of air e8ual to the desired dose of insulin into the #ial 5?. The nurse has gi#en postprocedure instructions to a client !ho has undergone a colonoscop+. 0hich statement "+ the client indicates the need for further teaching% &. @It Is normal to feel gass+ or "loated after the procedure.@ (. The a"dominal muscles ma+ "e tender from the procedure.@ ). @It is all right to dri#e once IB#e "een home for an hour or so.@ '. @Inta e should "e light at first and then progress to regular inta e.@ 5-. The nurse is teaching a client ho! to perform a colostom+ irrigation. To enhance the effecti#eness of the irrigation and fecal returns1 !hat measure should the nurse instruct the client to do% &. Increase fluid inta e. (. Place heat on Ihe a"domen. ). Perform the irrigation in the e#ening. '. :educe the amount of irrigation solution. 5G. The client !ith peptic ulcer disease needs dietar+ modification to reduce episodes of epigastric pain. The nurse tells the client that

!hich item does not need to "e limited or eliminated !ith this disease% &. 0ine (. )offee ). =resh fruit '. (a ed chic en ;0. The nurse instructs the ileostom+ client to include !hich action as part of essential care of the stoma% &. Massage the area "elo! the stoma. (. Limit fluid inta e to pre#ent diarrhea. ). Ta e in high-fi"er foods such as nuts. '. )leanse the peristomal s in meticulousl+. ;1. The client !ith a ne! colostom+ is concerned a"out the odor from stool in the ostom+ drainage "ag. The nurse teaches the client to include !hich food in the diet to reduce odor% &. 7ggs (. Aogurt ). (roccoli '. )ucum"ers ;2. The nurse has gi#en instructions to the client !ith an ileostom+ a"out foods to eat to thic en the stool. The nurse determines that the client needs further instructions if the client states that !hich food ma es the stool less !ater+% &. (ran (. Pasta ). (oiled rice '. Lo!-fat cheese ;/. The client !ith chronic pancreatitis needs information on dietar+ modification to manage the health pro"lem. The nurse teaches the client to limit !hich item in the diet% &. =at (. Protein ). )ar"oh+drate '. 0ater-solu"le #itamins ;5. The nurse is participating in a health screening clinic and is preparing teaching materials a"out colorectal cancer. 0hich ris factor for colorectal cancer should the nurse include% &. &ge older lhan /0 +ears (. Kigh-fi"er1 lo!-fat diet ). 'istant relati#e !ith colorectal cancer '. Personal histor+ of ulcerati#e colitis or gastrointestinal pol+ps ;5. & nurse instructs a client to use the pursedlip method of "reathing and the client as s the nurse a"out the purpose of this t+pe of "reathing. The nurse responds1 no!ing that

the primar+ purpose of pursed-lip "reathing is to6 &. Promote o<+gen Inia e. (. 4trengthen the diaphragm. ). 4trengthen the intercostal muscles. '. Promote car"on dio<ide elimination. ;;. & nurse teaches a client a"out the use of a respirator+ inhaler. 0hich action "+ the client indicates a need for further teaching% &. Inhales the mist and 8uic l+ e<hales (. :emo#es the cap and sha es the inhaler !ell "efore use ). Presses the canister do!n !ith the finger as he "reathes in '. 0aits 1 to 2 minutes "et!een puffs if more than one puff has "een prescri"ed ;?. & nurse is teaching a client !ith chronic respirator+ failure ho! to use a metereddose inhaler correctl+. The nurse instructs the client to6 &. Inhale 8uic l+. (. Inhale through the nose. ). Kold the "reath after inhalation. '. Ta e t!o inhalations during one "reath. ;-. & home health nurse instructs a client a"out the use of a nitrate patch. The nurse tells the client that !hich of the follo!ing !ill pre#ent client tolerance to nitrates% &. @'o not remo#e Ihe patches.@ (. @Ka#e a 12-hour Bno-nitrateB time.@ ). @Ka#e a 25-hour Bno-nitrateB time.@ '. @Heep nitrates on 25 hours1 then off 25 hours.@ ;G. & nurse is instructing a client to administer epoetin alfa (7pogen1 Procrit) "+ the su"cutaneous route. The nurse tells the client to6 &. 4ha e the #ial "efore use. (. :efrigerate the medication. ). =reeze the medication "efore use. '. >"tain s+ringes !ith *,i-inch needles from the pharmac+. ?0. & client has a fi"erglass (nonplaster) cast applied to the lo!er leg. The client as s the nurse !hen the client !ill "e a"le to !al using the casted leg. The nurse replies that the client !ill "e a"le to "ear !eight on the casted leg6 &. In 5- hours (. In 25 hours ). In a"out - hours '. 0ithin 20 to /0 minutes of application ?1. & client !ith right-sided !ea ness needs to learn ho! to use a cane !hile am"ulating. The nurse plans to teach the client to position the cane "+ holding it !ith the6

&. Left hand and placing Ihe cane in front of the left foot (. :ight hand and placing the cane in front of the right foot ). Left hand and mo#ing it for!ard 12 inches. ; inches lateral to the left foot '. :ight hand and mo#ing it for!ard 12 inches. ; inches lateral to the right foot ?2. The ph+sician orders a 25-hour urine collection for *M& (#anill+lmandelic acid). The communit+ health nurse #isits the client at home and instructs the client in the procedure for the collection of the urine. 0hich statement1 if made "+ the client1 !ould indicate a need for further instruction% &. @I !ill start the collection in 2 da+s. 4tarting no!. I cannot eat or drin an+ tea1 chocolate1 #anilla1 or fruit until the test is completed.@ (. B0hen I start the collection1 I !ill urinate and discard that specimen.@ ). @I !ill pour the urine in the collection "ottle each time I urinate and refrigerate the urine.@ '. @I can ta e medication if I need to during the collection.B ?/. The maternit+ nurse is descri"ing the o#arian c+cle to a group of nursing students. The instructor as s a nursing student to identif+ the phases of the c+cle. 0hich of the follo!ing1 if identified as a phase of the c+cle "+ the nursing student1 indicates a need to further research this area% &. =ollicular phase (. >#ulator+ phase ). Luteal phase '. Proliferati#e phase ?5. & client is seen in the health care clinic and is diagnosed !ith mild anemia. The anemia is "elie#ed to "e a result of the menstrual period. The !oman as s the nurse ho! much "lood is lost during a menstrual period. The nurse plans to respond "+ stating !hich of the follo!ing amounts of "lood is lost during this time% &. 50mL (. ;0 mL ). -0 mL '. 100 mL ?5. & nursing assistant collects a urine specimen from a client and is planning to deli#er the specimen to the la"orator+ after completing morning care for other assigned clients. The registered nurse instructs the nursing assistant to place the collected specimen in the unit la"orator+ refrigerator. The nursing assistant as s the registered nurse a"out the reason that the urine needs

refrigeration. The registered nurse "ases the response on the fact that !hen urine is allo!ed to stand un refrigerated6 &. The urine "ecomes more acidic. (. (acteria and !hite "lood cells (0()s) decompose. ). The urine clumps. '. The pK decreases. ?;. & registered nurse is instructing a ne! nursing graduate a"out hemodial+sis. 0hich statement if made "+ the ne! nursing graduate !ould indicate an inaccurate understanding of the procedure for hemodial+sis% &. @4terile dlal+sate must "e used.@ (. B0arming the dial+sale increases the efficienc+ of diffusion.@ ). @Keparin sodium is administered during dial+sis.@ '. @'ial+sis cleanses the 0ood from accumulated !aste products.@ ??. & client "eing discharged to home after renal transplantation has a nursing diagnosis of ris for infection related to immunosuppressi#e medication therap+. The nurse determines that the client needs further instruction on measures to pre#ent and control infection if the client states to6 &. Ta e an oral temperature dail+. (. 9se good hand-!ashing techni8ue. ). Ta e all scheduled medications e<actl+ as prescri"ed. '. Monitor urine character and output at least 1 da+ each !ee . ?-. & nurse is e<plaining an upper gastrointestinal series to a client and pro#ides the client !ith the pre-procedure and post-procedure instructions. The nurse informs the client that after this procedure1 the stools can "e e<pected to remain !hite for6 &. 1 !ee (. ; hours ). - hours '. 1 to 2 da+s ?G. & nursing student is performing an otoscopic e<amination in an adult client. The nursing instructor o"ser#es the student perform this procedure. 0hich o"ser#ation "+ the instructor indicates that the student is using correct techni8ue for the procedure% &. Pulling the pinna do!n and "ac "efore inserting the speculum (. Pulling the earlo"e do!n and "ac "efore inserting the speculum ). 9sing the smallest speculum a#aila"le

'. Tilting the clientBs head slightl+ a!a+ and holding the otoscope upside do!n "efore inserting the speculum -0. & clinic nurse conducting a health screening clinic is performing hearing assessments on clients !ho attend the clinic. 4enior nursing students are assisting the nurse !ith the assessments. The clinic nurse instructs the students to perform a #oice test and teaches the students to6 &. 4tand 1 to 2 feet a!a+ from the client and as the client to "loc one e<ternal ear canal. (. Quietl+ !hisper a statement and test "oth ears at the same time. ). 0hisper a statement !ith the e<aminerBs "ac to the client. '. 0hisper a statement !hile the client "loc s "oth ears. -1. & registered nurse (:C) is pro#iding instructions to a nursing assistant assigned to gi#e a "ed "ath to a client !ho is on contact precautions. The :C instructs the nursing assistant to use !hich of the follo!ing protecti#e items !hen gi#ing the "ed "ath% &. 3lo#es and goggles (. 3lo#es and shoe protectors ). & go!n and glo#es '. & go!n and goggles -2. & nurse is planning a teaching session !ith a client !ith chronic renal failure ():=) a"out managing the condition "et!een dial+sis treatments- The nurse plans to include that !eight gain "et!een dial+sis treatments should "e ideall+ no more than6 &. 0.5 to 1.0 g (. 1to 1.5 g ). 2 to 5 g '. 5 to ; g -/. & nurse is planning to teach a client !ith a left arm cast a"out measures to eep the left shoulder from "ecoming stiff and immo#a"le. 0hich suggestion !ould the nurse include in the teaching plan% &. 9se a sling on the left arm. (. Lift the left arm up o#er the head. ). Lift the right arm up o#er the head. '. Ma e a fisl !ith the hand of the casted arm. -5. & nursing instructor is e#aluating a nursing student for no!ledge of anti"od+ classes. The instructor as s the student !hich anti"od+ is the first that is produced in response to an antigen. The student responds correctl+ "+ naming !hich of the follo!ing anti"odies%

&. (. ). '.

lg3 lg& IgM lg>

-5. & nursing student !ho is enrolled in an anatom+ and ph+siolog+ course is stud+ing the immune s+stem. The student understands that a nonspecific immune response can include ph+sical "arriers and chemical "arriers. The student identifies !hich of the follo!ing as an e<ample of a chemical "arrier% &. The s in (. The mucous mem"ranes ). The cilia lining the respirator+ Iracl '. &cids and enz+mes found in "od+ fluids -;. & nursing student is conducting a clinical conference on immunit+. In discussing acti#e #ersus passi#e immunit+1 the student emphasizes that acti#e immunit+6 &. Lasts much longer then passi#e immunit+ (. Is less effecti#e at pre#enting su"se8uent infections ). Pro#ides protection immediatel+ '. Kas a half-life of a"out /0 da+s -?. & nursing student is re#ie!ing information related to the inflammator+ reaction. The student understands that the primar+ purpose of neutrophils in the inflammator+ response is to6 &. 'ilale the "lood #essels (. Increase fluids at Ihe site of in$ur+ ). Phagoc+tize an+ potentiall+ harmful agents '. Produce permea"ilit+ of the "lood #essels --. & nursing student is descri"ing the differences "et!een specific and nonspecific immunit+. The student correctl+ identifies specific immunit+ "+ stating that this t+pe of immunit+ is6 &. The first line of defense against Infection (. The t+pe of immunit+ that reacts the same to all antigens ). The second tine of defense against infection '. Present and functioning at "irth -G. & nurse is reinforcing instructions to a hospitalized client !ith heart "loc a"out the fundamental concepts regarding the cardiac rh+thm. The nurse e<plains to the client that the normal site in the heart responsi"le for initiating electrical impulses is the6 &. &trio#entricular (&*) node (. -undle of Kis ). Pur in$e fi"ers

'. 4inoatrial (4&) node G0. & male client !ho is "eginning an e<ercise program as s the nurse !f his heart @feels li e itBs pounding@ !hen he is e<ercising #igorousl+. In formulating a response1 the nurse understands that this is due lo Ihc clientBs need for an increased6 &. Pulse rale (. 4tro e #olume ). )ardiac output '. )ardiac inde< G1. & nurse is reinforcing instructions to a client a"out diaphragmatic "reathing. The nurse tells the client that this techni8ue is helpful "ecause1 in normal respiration1 as the diaphragm contracts1 it6 &. Mo#es do!n!ard and out (. Mo#es up and in!ard ). Ma es the thoracic cage smaller '. &ids in e<halation G2. & nurse is teaching a client !ith pulmonar+ disease a"out fundamental concepts of gas e<change. 0hen re8uested for further details "+ the client1 the nurse e<plains that gas e<change occurs through a process called6 &. 'iffusion (. >smosis ). &cti#e transport '. Ionization G/. client a"out an upcoming colonoscop+ procedure. The nurse !ould include in the instructions that the client !ill "e placed in !hich of the follo!ing positions for the procedure% &. Left 4ims (. :ight 4ims ). Hnee-chest '. Lithotom+ G5. The nurse is caring for a client !ho suffered an inhalation in$ur+ from a !ood sto#e. The car"on mono<ide "lood report re#eals a le#el of 12N. (ased on this le#el1 the nurse !ould anticipate !hich of the follo!ing signs in the client% &. )oma (. =lushing ). 'izziness '. Tach+cardia G5. The client is recei#ing e<ternal radiation to the nec for cancer of the lar+n<. The most li el+ side effect to "e e<pected is6 &. '+spnea (. 'iarrhea ). 4ore throat '. )onstipation

G;. 0hen assessing the la"orator+ results of the client !ith "ladder cancer and "one metastasis1 the nurse notes a calcium le#el of 12 mg,dL. The nurse recognizes that this is consistent !ith !hich oncological emergenc+% &. K+per alemia (. K+percalcemia ). 4pinal cord compression '. 4uperior #ena ca#a s+ndrome G?. The hospice nurse #isits a client d+ing of o#arian cancer. 'uring the #isit1 the client e<presses that @If I can $ust li#e long enough to attend m+ daughterBs graduation1 Til "e read+ to die.@ 0hich phase of coping is this client e<periencing% &. &nger (. 'enial ). (argaining '. 'epression G-. The nurse is assessing the colostom+ of a client !ho has had an a"dominal perineal resection for a "o!el tumor. 0hich of the follo!ing assessment findings indicates that the colostom+ is "eginning to function% &. &"sent "o!el sounds (. The passage of flalus ). The clientBs a"ilit+ to tolerate food '. (lood+ drainage from the colostom+ GG. The nurse is assessing the stoma of a client follo!ing a ureterostom+. 0hich of the follo!ing should the nurse e<pect to note% &. & dr+ stoma (. & pale stoma ). & dar -colored stoma '. & red and moist stoma 100. The client has $ust had surger+ to create an ileostom+. The nurse assesses the client in the immediate postoperati#e period for !hich most fre8uent complication of this t+pe of surger+% &. =olate deficienc+ (. Mala"sorplion offal ). Intestinal o"struction '. =luid and electrol+te im"alance