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Funda With Answers

Funda With Answers

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1. A home care nurse is assessing a geriatric client.

What is the most common cause of medication errors in noninstitutionalized geriatric clients? a. Knowledge deficit b. Poor vision c. Dementia d. Confusion Answer: A Rationale: Knowledge deficit is the most common cause of medication errors among noninstitutionalized geriatric clients. Poor vision, dementia, and confusion can contribute to medication errors in this group, but they occur less frequently.

2. Which drug delivery system relieves the nurse of the responsibility for transcribing the medication order? a. Floor stock b. Unit-dose c. Individual prescription d. Automated Answer: D Rationale: An automated drug delivery system relieves the nurse of the responsibility for transcribing the medication order. The floor stock and unit-dose drug delivery systems require a transcription of the medication order. An individual prescription isn't dispensed by the nurse in a hospital setting.

4. Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the client's medication drawer. What should the nurse do?

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a. Discard the syringe to avoid a medication error. b. Obtain a label for the syringe from the pharmacy c. Use the syringe because it looks like it contains the same medication the nurse was prepared to give. d. Call the day nurse to verify the contents of the syringe Answer: A Rationale: As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe because they promote error.

5. The nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation rapidly drops. He complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include: a. diminished or absent breath sounds on the affected

sidepneomothorax b. paradoxical conditions c. tracheal deviation to the unaffected side.  Tension pneumothorax d. muffled or distant heart sounds. pericardial tamponade Answer: A Rationale: In the case of a pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled or distant heart sounds occur in pericardial tamponade. chest wall movement with respirationschest

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6. When monitoring a client's central venous pressure (CVP), the nurse knows that a normal CVP measurement is: a. 2 cm water. b. 1 mm Hg. c. 10 mm Hg. d. 5 cm water. Answer: D Rationale: Normally, CVP ranges from 4 to 10 cm water, or 3 to 7 mm Hg. The other options are outside this range. 7. During an admission assessment, the nurse asks a client why he's being admitted to the facility. The client responds, "The physician found a lump in my prostate gland. I guess I have cancer." Which response by the nurse would be most therapeutic? a. "There is no way to know whether you have cancer until a biopsy is done." b. "It isn't unusual for a man your age to have an enlarged prostate. Try not to worry." c. "It's important to keep a positive attitude. There is a good chance it isn't cancer." d. "You think you have cancer?" Answer: D Rationale: This response acknowledges the client's concern and shows a willingness to listen. Although a biopsy is needed to confirm cancer, telling the client this wouldn't permit him to discuss his concerns. Urging the client not to worry or advising him to maintain a positive attitude is a clichéd response. Offering advice about how he should handle the problem also wouldn't be therapeutic.

8. Which action would be contraindicated for a client who develops a temperature of 102° F (38.9° C). 3

maintain a cool room temperature. Increasing fluid intake c. the nurse should: a. A client hospitalized with pneumonia has thick. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing but wouldn't liquefy secretions. c. Answer: C Rationale: Increasing the client's intake of oral or I. and covering him with a light blanket — are therapeutic interventions for a fever 9. The nurse is giving nutritional counseling to the mother of a child with celiac disease. d. encourage increased fluid intake. Maintaining a cool room temperature would increase the client's comfort but wouldn't liquefy secretions. Monitoring temperature every 4 hours b. Which statement by the mother would indicate understanding? 4 . tenacious secretions and ensures adequate hydration. fluids helps liquefy thick. Turning the client every 2 hours would decrease pooling of secretions but wouldn't liquefy them. 10. Therefore.V.a. turn the client every 2 hours. tenacious secretions. Providing a low-calorie diet Answer: D Rationale: A client with a fever has an increased basal metabolism rate. All the other responses — monitoring the client's temperature. elevate the head of the bed 30 degrees. Covering the client with a light blanket d. he needs additional calories in his diet. increasing his fluid intake. To help liquefy these secretions. b.

Such foods as potatoes. therefore. a NG tube isn't necessary because the client can drink the activated charcoal. If foods containing gluten are eaten. After intentionally taking an overdose of hydrocodone (Vicodin). Activated charcoal is prescribed. flour. is able to follow commands. Therefore. and barley must be eliminated from the diet. b. Being able to follow commands isn't required. 5 . Frozen and packaged foods may contain gluten fillers." b." Answer: A Rationale: A child with celiac disease must eat a gluten-free diet." c.a. changes occur in the intestinal mucosa that prevent the absorption of foods. especially fats. "My son needs a diet rich in gluten. has audible bowel sounds. rice. Advance directives aren't required for treatment. 11. "My son can safely eat frozen and packaged foods. rye. flour. rye. Before administering the drug. or barley. oats. d. in some instances. the nurse should ensure that the client: a. c. "My son must avoid potatoes." d. the client should have audible bowel sounds before the drug is given. the client may not be fully responsive. they should be avoided. "My son can't eat wheat. and cornstarch are allowed in a gluten-free diet. has an advance directive on file. Answer: D Rationale: Activated charcoal binds to the ingested drug and is eliminated in the stool. a NG tube should be in place. oats. all foods containing wheat. a client is admitted to the emergency department. Therefore. has a nasogastric (NG) tube in place. and cornstarch. Ideally. however. rice.

However. the nurse performs deep palpation.O.12." The order is correctly transcribed on the Kardex. The facility's policy does provide for a system of checks and balances. The purpose of deep palpation is to assess which of the following? a. a nurse administers prednisone 5 mg P. daily for 3 days. the facility isn't responsible for the error.8 cm). On the 4th day after the order was instituted. A physician writes the following order for a client: "Prednisone 5 mg P. A facility has a system for transcribing medication orders to a Kardex as well as a computerized medication administration record (MAR). pharmacist who filled the order and provided the erroneous dose. Answer: B Rationale: The nurse administering the dose should have compared the MAR with the Kardex and noted the discrepancy. 13. however. Organs d. Skin turgor b. The person most responsible for the error is the: a. d. During an audit of the chart. the nurse who transcribes the order onto the MAR neglects to place the limitation of 3 days on the prescription. The transcribing nurse and pharmacist aren't void of responsibility.O. To evaluate a client's chief complaint. the error is identified. nurse who transcribed the order incorrectly on the MAR b. facility because of its policy on transcription of medications. Temperature Answer: C Rationale: The purpose of deep palpation. in which the nurse indents the client's skin approximately 1½" (3. Hydration c. Therefore. is to assess underlying 6 . nurse who administered the erroneous dose. c. the nurse administering the dose is most responsible.

A 30-degree angle isn't used for any type of injection. When giving an I. When prioritizing a client's plan of care based on Maslow's hierarchy of needs. 15 degrees.organs and structures. b. dartlike motion.or 90-degree angle can be used when giving a subcutaneous injection 15. A client.M. hydration. d. age 43. such as the kidneys and spleen. After age 50. to establish a baseline b. Every 2 years d.M. 90 degrees. the nurse should insert the needle into the muscle at an angle of: a. injection. and temperature can be assessed by using light touch or light palpation 14. Once. injection. has no family history of breast cancer or other risk factors for this disease. the client should have a mammogram every year 16. the nurse's first priority would be: 7 . Once per year c. c. Skin turgor. the nurse inserts the needle into the muscle at a 90-degree angle. Answer: D Rationale: When giving an I. Twice per year Answer: C Rationale: A client age 40 to 49 with no family history of breast cancer or other risk factors for this disease should have a mammogram every 2 years. A 15-degree angle is appropriate when administering an intradermal injection. The nurse should instruct her to have a mammogram how often a. using a quick. 45 degrees. 30 degrees. A 45.

a. An isotonic solution has no effect on the cell. or hypotonic. the nurse should consider which challenges faced by clients in this age-group? a. A sodium chloride solution can be isotonic. love b. Developing leisure activities. would cause a shift of fluid from body tissues to the bloodstream? a. Sodium chloride d. pain relief is on the first layer. and managing a home b. allowing the family to see a newly admitted client. Selecting vocation. activity2nd c. and resolving empty-nest crisis 8 . Which of the following types of solutions. Hypertonicout Answer: D Rationale: A hypertonic solution causes fluids to be absorbed into the bloodstream until equal pressure is established on both sides of the blood vessel. when administered I. Love and belonging (option A) are on the fourth layer. depending on the concentration of sodium. becoming financially independent. 17.V. Activity (option B) is on the second layer. When developing a plan of care for an older adult. Hypotonicinto cell b. Isotonicno effect c. safety Answer: C Rationale: In Maslow's hierarchy of needs. placing wrist restraints on the client. ambulating the client in the hallway. Safety (option D) is on the third layer. hypertonic. preparing for retirement.. administering pain medication comfortfirst d. 18. A hypotonic solution causes fluids to move from the bloodstream into the tissues.

and decreased physical strength Answer: D Rationale: Challenges faced in older adulthood include adjusting to retirement. The nurse also shouldn't omit doses of medication without an order from the physician. which nursing diagnosis takes highest priority for this client? 9 . A client who received general anesthesia returns from surgery.m. and preparing for retirement d. The client is away from his room for a diagnostic study.c. Ask the client's roommate to keep the medications for the client until he returns. Challenges faced in middle adulthood include developing leisure activities. c. Answer: C Rationale: Whenever a client isn't immediately available to take medication. Leave the medications on the client's bedside table. Challenges faced in young adulthood include selecting a vocation. d. Adjusting to retirement. becoming financially independent. 19. developing leisure activities. Managing a home. and decreased physical strength. the nurse must put the medicine in a secured area. Which action is most appropriate for the nurse to take? a. The nurse is delivering the client's 10 a. medications. 20. deaths of family members. deaths of family members. Postoperatively. The nurse should never leave drugs unattended in a client's room or in the care of a roommate. Lock the medications in the medicine preparation area until the client returns. and resolving empty-nest crisis. b. preparing for retirement. Have the client skip that dose of medication. and managing a home.

warm. The physician's assistant Answer: B 10 . Red. which of the following would the nurse expect to find? a. When assessing a client with cellulitis of the right leg. are secondary. or necrotic. The skin becomes reddened. although important. Which member of the health care team is responsible for obtaining informed consent from a client? a. swollen. Painful skin that is swollen and pale in color b. The other options. Pain related to surgery b. possibly leading to aspiration. Small. pale. The physician c. and sometimes painful. swollen skin with inflammation spreading to surrounding tissues Answer: D Rationale: Cellulitis is an inflammation of soft tissues that can extend to surrounding tissues.a. Cold. localized blackened area of skin d. Risk for aspiration related to anesthesia Answer: D Rationale: Risk for aspiration related to surgery takes priority for this client because general anesthesia may impair the gag and swallowing reflexes. The nurse working with the physician d. red skin c. 21. The primary nurse b. 22. Impaired physical mobility related to surgery d. The skin wouldn't be cold. Deficient fluid volume related to blood and fluid loss from surgery c.

23." 11 . In some health care facilities. The nurse discovers that the client isn't taking all of his medications. 24. "Why aren't you taking your medications? Don't you want to get better?" d. The nurse is caring for a client on a regimen of four medications to treat tuberculosis. What is appropriate for the nurse to say to the client? a. a physician must act as cosigner. Tell me about the difficulties you're having. "Taking many medications can be difficult. By indenting the skin 1". How is light palpation performed? a. By indenting the skin 1" and then releasing the pressure quickly Answer: A Rationale: To perform light palpation. Do you need supervision?" c.3 to 1. however. The nurse indents the skin approximately 1½" (3. using both hands d. "Don't you realize that resistance can develop if you don't take your medications properly?" b. "You need to take your medication as you were instructed. The nurse prepares to perform light palpation. By indenting the skin 1" to 2" (2.Rationale: The physician involved with the procedure is responsible for obtaining the client's informed consent. a physician's assistant may obtain informed consent. in this case.8 cm) when performing deep palpation. The primary nurse or the nurse working with the physician may serve as a witness to the client's signature.9 cm) b. By indenting the skin ½" to ¾" (1. using the tips and pads of the fingers.5 to 5 cm) c. The nurse indents the skin 1" and then releases the pressure quickly when eliciting rebound tenderness. the nurse indents the client's skin ½" to ¾".

c. the bed must first be in the lowest position. Answer: B Rationale: Keeping the bed at the lowest possible position is the first priority for clients at risk for falling.Answer: D Rationale: Acknowledging that a multidrug regimen can be difficult conveys empathy. keeping the bedpan available so that the client doesn't have to get out of bed. Even when assistance is required. A client who speaks little English has emergency gallbladder surgery. d. which nursing action would best help this client understand wound care instructions? a. Keeping the call light easily accessible is important but isn't a top priority. The nurse is caring for a client with a history of falls. 26. Asking the client to discuss difficulties promotes active participation. The client may not require a bedpan. During discharge preparation. They also have an adversarial tone and are judgmental. Instructing the client not to get out of bed may not effectively prevent falls — for example. The other responses are closed questions that require only a yes or no answer. making the client defensive 25. The first priority when caring for a client at risk for falls is: a. if the client is confused. The nurse can then provide more education and help remove potential obstacles to compliance such as lack of finances. blocking further therapeutic communication. Asking frequently whether the client understands the instructions 12 . keeping the bed in the lowest possible position. b. instructing the client not to get out of bed without assistance. "Why" questions should be avoided because they can be interpreted as accusations. placing the call light for easy access.

A 49-year-old client with acute respiratory distress watches everything the staff does and demands full explanations for all procedures and medications.b. Joking about the present condition d. asking to see family. Decreasing eye contact. 27. Clients may claim to understand discharge instructions when they don't. A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. and trusting and is less anxious. and joking may also indicate that the client is more relaxed. During a bolus feeding. 26. Asking an interpreter to relay the instructions to the client c. However. the client vomits and 13 . these also could be diversions. Sleeping undisturbed for 3 hours Answer: D Rationale: Sleeping undisturbed for a period of time would indicate that the client feels more relaxed. An interpreter or family member may communicate verbal or written instructions inaccurately. Writing out the instructions and having a family member read them to the client d. Which of the following actions would best indicate that the client has achieved an increased level of psychological comfort? a. comfortable. Asking to see family members c. Making decreased eye contact b. Demonstrating the procedure and having the client return the demonstration Answer: D Rationale: Demonstration by the nurse with a return demonstration by the client ensures that the client can perform wound care correctly.

The nurse is caring for a geriatric client with a pressure ulcer on the sacrum. Legumes provide incomplete protein. There is no indication that the client is terminally ill. Making the client comfortable ignores the lifethreatening event.begins choking. which promotes healing. The nurse should clear the client's airway. 14 . d. which should be limited to 30% or less of caloric intake. which foods should the nurse plan to emphasize? a. Fruits and vegetables provide mainly carbohydrates. Cardiopulmonary resuscitation isn't indicated. Furthermore. Make the client comfortable. Start cardiopulmonary resuscitation. Fruits and vegetables d. the diet should emphasize foods that supply complete protein. such as lean meats and low-fat milk. and removing the NG tube would exacerbate the situation 28. but also fat. Stop the feeding and remove the NG tube. Clear the client's airway. because protein helps build and repair body tissue. c. Whole grain products c. Which of the following actions is most appropriate for the nurse to take? a. b. When teaching the client about dietary intake. Lean meats and low-fat milk Answer: D Rationale: Although the client should eat a balanced diet with foods from all food groups. a living will doesn't apply to nonterminal events such as choking on an enteral feeding device. Legumes and cheese b. Whole grain products supply incomplete proteins and carbohydrates. Cheese contains complete protein. Answer: A Rationale: A living will states that no life-saving measures are to be used in terminal conditions.

000/μl. hemoglobin (Hb) level. 30.29. Self-care deficient: Toileting Answer: C Rationale: A client with renal failure can't eliminate sufficient fluid. a respiratory rate of 32 breaths/minute. Answer: B Rationale: The client is at risk for infection because the WBC count is dangerously low. Promote fluid balance b. Urinary retention c. Urinary retention may cause renal failure but is a less urgent concern than fluid imbalance. and prevention of injury are inappropriate. a blood pressure of 190/110 mm Hg. c. 42%. Promote rest. d. 15 . Fear b. A client with chronic renal failure is admitted with a heart rate of 122 beats/minute. 14 g/dl. fluid balance. Excessive fluid volume d. but they take lower priority because they aren't life-threatening. A client's blood test results are as follows: white blood cell (WBC) count is 1. increasing the risk of fluid overload and consequent respiratory and electrolyte problems. rest. Fear and a toileting self-care deficit may be problems. Prevent infection. hematocrit (HCT). and bibasilar crackles. This client has signs of excessive fluid volume and is acutely ill. therefore. Which nursing diagnosis takes highest priority for this client? a. Prevent injury. neck vein distention. Which of the following goals would be most important for this client? a. Hb level and HCT are within normal limits.

Find the number of milliliters per minute as follows: 125/60 minutes = X/1 minute 60X = 125 = 2. Retrospective c. or 32 drops/minute 32.1 ml/X gtt = 1 ml/15 gtt X = 32 gtt/minute. Answer: C Rationale: Giving 1. Formative b. infusion at a rate of: a.31. tubing delivers 15 drops/ml. or retrospective. 125 drops/minute. 16 . Informative isn't a type of evaluation. The nurse should run the I. 32 drops/minute.000 ml over 8 hours is the same as giving 125 ml over 1 hour (60 minutes). Summative. InformativeX Answer: A Rationale: Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. 15 drops/minute.V. d. Summative d. Which type of evaluation occurs continuously throughout the teaching and learning process? a. The physician orders dextrose 5% in water. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning. 21 drops/minute.000 ml to be infused over 8 hours. 1.1 ml/minute To find the number of drops per minute: 2. b. The I.V. c. evaluation occurs at the conclusion of the teaching and learning session.

family history. c. including a description of any reactions. the nurse should review the client's pertinent medical history. the history of the present problem. medications. route of excretion. d. and recent major operations. When a nurse enters the room. When doing this. review of systems. Answer: A Rationale: When developing a drug therapy regimen that won't interfere with a client's lifestyle. the history of the present problem. the history of the present problem. d. the history of the present problem. any illness requiring treatment. medications. the nurse must consider the drug's adverse effects because these 34. b. allergies. psychosocial history. steady-state duration of action. b. The nurse takes a quick health history that includes: a. and recent major operations. major surgeries performed. medications. the nurse must consider the drug's: a. This 17 . The nurse is developing a drug therapy regimen that won't interfere with the client's lifestyle. and current medications (both prescription and over-the-counter) and their purposes. review of systems. medications. including why and when. and recent major operations. and review of systems. the client complains that she's spitting up blood when she coughs.33. Answer: B Rationale: After assessing the client's chief complaint. c. peak concentration time. allergies. allergies. adverse effects.

What good will they do?" Which action by the nurse would be most appropriate? a. and other needs and. participate fully in the therapeutic regimen. Insisting that the client take the medication b. As a result of a serious motorcycle accident. esteem. Explaining the consequences of not taking the medication d. D Rationale: After helping the client explore feelings about the change in health status. the nurse can determine how these feelings affect the decision to refuse medication. Then the nurse can help the client develop new ways to satisfy self-care. When the nurse tries to administer medication. I'll ask the physician for something to help you sleep. "You seem worried about something. 36. a client suffers paraplegia. ultimately. "It isn't unusual to worry about surgery. "Would you like me to call a chaplain to talk with you about any concerns you may have about surgery?" c. Exploring how the client's feelings affect the decision to refuse medication Answer. Reporting the client's comments to the physician c. The other options are inappropriate because they fail to explore the client's feelings. "Are you worried about your surgery tomorrow?" b. 35. A client who has been admitted for surgery seems preoccupied and anxious the night before the operation. the client refuses it. "I don't have to take those pills if I don't want to. saying." 18 . Would it help to talk about it?" d. Which comment by the nurse would promote therapeutic communication? a. If you'd like.information allows the nurse to establish a baseline and determine the cause and urgency of the client's problem.

PaCO2 d. which doesn't promote therapeutic communication as effectively. Which pulse should the nurse palpate during rapid assessment of an unconscious adult? a. Carotidcirculatory Answer: D 19 . PaO2 c. Femoral d. Radial b. The partial pressure of arterial oxygen (PaO2) value indicates the amount of oxygen dissolved in the blood. Option A is a closed-ended question (one requiring only a "yes" or "no" answer).Answer: C Rationale: Sharing the observation that the client seems anxious and then offering to discuss the client's concerns promotes therapeutic communication. the partial pressure of arterial carbon dioxide (PaCO2) value represents the amount of carbon dioxide dissolved in the blood. The nurse is reviewing a client's arterial blood gas (ABG) report. The bicarbonate (HCO3–) value indicates the amount of bicarbonate. Asking whether 37. 38. Which ABG value reflects the acid concentration in the blood? a. in the blood. Brachialinfant c. pH b. or base. HCO3– Answer: A Rationale: The pH value in an ABG report reflects the acid concentration in the blood.

Edema Answer: C 20 . the radial pulse may not be palpable. 39.Rationale: During a rapid assessment.500 X = 7. Which of the following is the most common source of airway obstruction in an unconscious victim? a. The vial reads 10. and circulation. The physician orders heparin. breathing. ½ ml c. To check a client's circulation.000 or ¾ ml 40.500 units = 1 ml/X 10. the nurse must assess his heart and vascular network function.500/10. 7. to be administered subcutaneously every 6 hours. ¾ ml d. The nurse should anticipate giving how much heparin for each dose? a. Saliva or mucus c.000 units/7. In a client with a circulatory problem or a history of compromised circulation. most importantly. The tongue d. temperature.000 units per milliliter. mental status and. This is done by checking his skin color. The nurse should use the carotid artery to check a client's circulation.000X = 7.500 units. 1¼ ml Answer: C Rationale: The nurse solves the problem as follows: 10. the nurse's first priority is to check the client's vital functions by assessing his airway. The brachial pulse is palpated during rapid assessment of an infant. ¼ ml b. A foreign object b. his pulse.

Rationale: In many cases. b. 42. be unable to palpate the bladder." b. the nurse should use the head-tilt. When this occurs." d. feel that the bladder is smooth. 41. "I will administer the enema while sitting on the toilet." Answer: B Rationale: Lying on the left side allows the enema solution to flow downward by gravity into the rectum and sigmoid colon. When preparing a client for a diagnostic study of the colon. which took place 8 hours ago. palpate the bladder at the umbilicus. When assessing the client. "I will administer the enema while lying on my back with both knees flexed. the nurse will: a. causing the tongue to obstruct the airway. palpate the bladder above the symphysis pubis. the jaw-thrust maneuver must be performed. "I will administer the enema while lying on my left side with my right knee flexed. chin-lift maneuver to cause the tongue to fall back in place. A client hasn't voided since before surgery. the nurse teaches the client how to self-administer a prepackaged enema. The other options don't accomplish this goal and therefore are less effective in evacuating the lower bowel. "I will administer the enema while lying on my right side with my left knee flexed. d." c. Which statement by the client indicates effective teaching? a. c. the muscles controlling the tongue relax. Answer: C 21 . If a neck injury is suspected.

b. Typically. Limit salt intake to 2 g per day. Which of the following is a complete nursing diagnosis statement? a. Tachycardia. 43. c. Ineffective airway clearance related to mucus plugs and nonproductive cough b. 44. d. the nurse formulates relevant nursing diagnoses. the kidneys produce 35 to 55 ml of urine in 1 hour. Ineffective airway clearance related to mucus plugs and nonproductive cough meets these requirements. Which of the following instructions should the nurse include? a. high-protein diet. and signs and symptoms essential to the diagnosis.Rationale: Eight hours is a long time not to have voided. The nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Encourage a high-calorie. Restrict fluids to 1. and Shortness of breath related to anxiety don't use the NANDA taxonomy. the etiology. After assessing a client. Tachycardia d.500 ml per day. the bladder would be full of urine and palpable above the symphysis pubis. After 8 hours of not voiding. Answer: A 22 . Encourage foods high in vitamin B. Hyperventilation related to anxiety c. Hyperventilation related to anxiety. Shortness of breath related to anxiety Answer: A Rationale: A complete nursing diagnosis has three parts: the actual or potential health problem using the taxonomy of the North American Nursing Diagnosis Association (NANDA).

once daily.125 mg P. The nurse should then rapidly inflate the cuff until she can no longer palpate or auscultate the pulse and continue inflating until the pressure rises another 30 mm Hg. Water-soluble forms of the fat-soluble vitamins (A. once daily" c. In cystic fibrosis.125 mg P. D. once daily" (exactly as written by the physician) b. and K) are necessary. 45. inflate the cuff to at least 200 mm Hg. the duodenum isn't able to digest fat. how should the nurse transcribe this order onto the medication administration record? a. the child can become malnourished. E. c.Rationale: The child should eat a high-calorie. "Digoxin . "Digoxin 0. Because fats aren't easily tolerated. take blood pressure readings in both arms. the nurse should: a.O. they may need to be restricted. To avoid recording an erroneously low systolic blood pressure because of failure to recognize an auscultatory gap. the enzymes from the pancreas (lipase. especially on warm days or when exercising. 46. Without these enzymes.125 mg P. protein." To prevent a dosage error. The physician writes the following order for a client: "Digoxin . and some sugars.O. The other options aren't appropriate measures. therefore. and amylase) become so thick that the ducts become plugged. have the client lie down while taking his blood pressure. high-protein diet. inflate the cuff at least another 30 mm Hg after the radial pulse becomes unpalpable.O. The child with cystic fibrosis needs to drink plenty of fluid and take salt supplements.1250 mg P. d. trypsin.O. Answer: D Rationale: The nurse should wrap an appropriately sized cuff around the client's upper arm and then place the diaphragm of the stethoscope over the brachial artery. once daily" 23 . b. "Digoxin 0.

d." b. "Digoxin . "Do I have cancer?" Which response by the nurse would be best? a." d.1250 mg P. take aspirin for pain relief. The client may 24 . age 68. report incidents of diarrhea. c. The nurse is caring for a client who is taking an anticoagulant. "Most people your age develop some type of colon problem. communication by failing to address the client's concerns and feelings. "You sound concerned about what is happening." c. The nurse should never insert a zero at the end of a dosage that includes a decimal point because this could be misread.O. asks the nurse. 47. b. use a straight razor when shaving. possibly leading to a tenfold increase in the dosage. which could result in a dosage error. Answer: B Rationale: The client should avoid consuming large amounts of vitamin K because vitamin K can interfere with anticoagulation. admitted for treatment of a colon tumor. 48. A client. d. The nurse should teach the client to: a. "You'll have to have some tests before cancer can be ruled out. once daily" Answer: B Rationale: The nurse should always place a zero before a decimal point so that no one misreads the figure. avoid foods high in vitamin K. "Your physician can discuss this in more detail." Answer: C Rationale: This discussion of response the conveys empathy The and other invites options further block client's concerns.

need to report diarrhea, but diarrhea isn't an effect of taking an anticoagulant. An electric razor — not a straight razor — should be used to prevent cuts that cause bleeding. Aspirin may increase the risk of bleeding; acetaminophen should be used for pain relief. 49. The nurse administers racemic epinephrine to an 8-year-old boy. Ten minutes after administration, the nurse should be alert for: a. respiratory distress. b. respiratory distress. c. signs of improved oxygenation. d. diminished cyanosis. Answer: A Rationale: A rebound effect from racemic epinephrine can occur up to 4 hours after treatment with signs of respiratory distress (tachypnea, restlessness, and cyanosis). Tachycardia may initially follow treatment with racemic epinephrine as well as improvement in client status (improved oxygenation and improved color). 50. missing 51. A client twists the right ankle while playing basketball and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which statement by the client suggests that ice application has been effective? a. "I need something stronger for pain relief." b. "My ankle looks less swollen now." c. "My ankle appears redder now." d. "My ankle feels very warm." Answer: B Rationale: Ice application decreases pain and swelling. Continued or increased pain, redness, and increased warmth are signs of inflammation that shouldn't occur after ice application. 25

52. The physician prescribes meperidine (Demerol), 75 mg I.M. every 4 hours as needed, to control a client's postoperative pain. The package insert reads: "Meperidine, 100 mg/ml." How many milliliters of meperidine should the client receive? a. 0.25 b. 0.5 c. 0.6 d. 0.75 Answer: D Rationale: To determine the number of milliliters the client should receive, the nurse uses the fraction method in the following equation: 75 mg/X ml = 100 mg/1 ml To solve for X, cross-multiply: 75 mg × 1 ml = X ml × 100 mg 75 = 100X 75/100 = X 0.75 ml (or ¾ ml) = X

53. Which of the following planes divides the body longitudinally into anterior and posterior regions? a. Frontal plane b. Sagittal plane c. Midsagittal plane d. Transverse plane Answer: A Rationale: A frontal or coronal plane runs longitudinally at a right angle to a sagittal plane, dividing the body into anterior and posterior regions. A sagittal plane runs longitudinally, dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse 26

plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions.

54. The nurse is preparing to help a client with weakness in his right leg get out of bed to a chair. Where should the nurse place the chair? a. Parallel to the bed on the right side b. Perpendicular to the bed on the right side c. Parallel to the bed on the left side d. Parallel to the bed on either side Answer: A Rationale: The client can maintain his weight and pivot with his left foot if the chair is placed on his right side parallel to the bed. The nurse shouldn't place the chair on his left side or perpendicular to the bed because the client won't be able to support his weight on his right leg.

55. A client who recently immigrated to the United States from Korea is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after his admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action would be most appropriate at this time? a. Documenting that the client is resting quietly and denies pain b. Calling a family member to obtain information about the client c. Giving the client the prescribed d. Checking vital signs and assessing for nonverbal indications of pain Answer: D Rationale: The nurse should consider the possibility that the client didn't understand the question or has been conditioned culturally not to complain openly of pain. Checking vital signs and assessing for 27

Drug knowledge b. Would you like to talk about it?" Answer: D Rationale: This response validates the client's feelings and promotes further discussion. Option B invalidates the client's feelings. "I don't blame you for being nervous. Disease duration and severity Answer: C Rationale: Two major clinical characteristics affect client compliance: the nurse-client relationship and the therapeutic regimen. Calling the family or giving pain medication isn't warranted because the client denies pain. also. Which response by the nurse would be best? a. "You sound really upset. 57. Which clinical characteristic affects client compliance? a. The client's drug knowledge. "Don't worry.nonverbal indications of pain helps the nurse determine whether the client is in pain. 56. and disease duration and severity are client characteristics. The nurse-client relationship d. A client scheduled for cardiac catheterization tells the nurse she is nervous because she has heard of people dying during this procedure. the nurse shouldn't suggest that a client deserves — or doesn't deserve — blame for feeling a certain way. not clinical ones. Option A doesn't address the client's feelings. Psychosocial factors c. We all worry b. Option C demands an explanation for the client's feelings. "Why do you feel this way? Do you know someone who had a problem?" d." c. Accepting the client's response without question or further assessment may lead to inadequate intervention. psychosocial factors. You're in excellent hands. 28 .

1 ml c. The label of a drug package reads "meperidine hydrochloride (Demerol). and snacks." How many milliliters would the nurse give a client for a 30-mg dose? a. Provide the client with normal sleep aids. such as pillows. 0. Teach the client relaxation techniques. The ratio to determine this answer is 30 mg : X ml :: 50 mg : 1 ml.6 ml equals 30 mg when the ratio is 50 mg/ml. Administer sleeping medication before bedtime. b. c. d. 0. Which intervention should the nurse try first for a client who exhibits signs of sleep disturbance? a. back rubs. such as guided imagery. 50 mg/ml. Answer: D Rationale: The nurse should begin with the simplest interventions. meditation. 29 .58.6 ml d. before interventions that require greater skill such as relaxation techniques. especially if common sense interventions fail.6 ml b. 1. the nurse should do a thorough sleep assessment. At some point. 59. Ask the client each morning to describe the quality of sleep during the previous night.5 ml Answer: C Rationale: A measure of 0. such as pillows or snacks. Sleep medication should be avoided whenever possible. and progressive muscle relaxation.

c. Crush the tablets and wash the powder down the NG tube. using a syringe filled with saline solution. Electrocardiographic (ECG) waveforms Answer: C Rationale: Subjective data come directly from the client and usually are recorded as direct quotations that reflect the client's opinions or feelings about a situation. A client has a nasogastric (NG) tube. the nurse must reproduce the disintegration and dissolution processes by crushing the tablets and preparing a liquid form. Vital signs. 30 . Vital signs b. Heating the tablets may destroy or alter the drug's action. The nurse is assessing a postoperative client. Laboratory test results c. using a syringe filled with water. possibly providing inaccurate dosing and causing the tube to clog. Answer: C Rationale: To administer oral medication through an NG tube. How should the nurse administer oral medication to this client? a. The nurse then inserts the liquid into the NG tube. Client's description of pain d. and then insert d. Crush the tablets and prepare a liquid form. laboratory test results. and ECG waveforms are examples of objective data. Washing cut tablets or crushed powder down the tube may cause the medication to stick to the sides of the tube. b. Which of the following should the nurse document as subjective data? a. Heat the tablets until they liquefy. and then pour the liquid down the NG tube. 61. Cut the tablets in half and wash them down the NG tube.60.

is indicated by a verbal response to an actual change in physical appearance or structure. This indicates that the disease is controlled and the child is utilizing nutrients effectively. which nursing diagnosis is most appropriate? a. She doesn't report an existing difficulty with sexual behavior. a client tells the nurse. which would indicate an ineffective sexuality pattern.62. measuring blood urea nitrogen and serum creatinine levels. Monitor vital signs every 4 hours. How should the nurse evaluate the effectiveness of nutritional therapy? a. size. "Now I won't be sexually attractive to my husband. The client may be experiencing anxiety. b. Taking vital signs. Measure intake and output. Ineffective sexuality patterns d." Based on this statement. fat. a disruption in the way one perceives one's body. 63. nor has she expressed an inability to cope. Disturbed body image c. Answer: B Rationale: When a child with celiac disease is placed on a gluten-free diet. and number of stools. bulky. c. and measuring intake and output don't provide an indication of the effectiveness of diet therapy. 31 . Measure blood urea nitrogen and serum creatinine levels d. but her statement doesn't reflect this specifically. foul-smelling stools should be eliminated. Two days after undergoing a modified radical mastectomy. The nurse is caring for a child with celiac disease. Anxiety b. Ineffective individual coping Answer: B Rationale: Disturbed body image. Monitor the appearance.

64. percussion. and palpation b. including bathing clients and administering medication and prescribed treatments. auscultation. Managerscheduling and assignments b. the nurse asks the client to repeat the instructions. auscultation. The nurse is caring for a 3-year-old child admitted to the pediatric unit with acetaminophen poisoning. percussion. and auscultation d. and percussion c. Educator c. and auscultation Answer: A Rationale: The inspection. Inspection. The nurse administers syrup of 32 . A client is being discharged after cataract surgery. and auscultation 65. Client advocatecx wishes Answer: B Rationale: When teaching a client about medications before discharge. Inspection. palpation. percussion. palpation. the nurse should follow which examination sequence? a. Caregiverdirect care d. The nurse acts as a manager when performing such activities as scheduling and making client care assignments. percussion. the nurse is acting as an educator. After providing medication teaching. The nurse acts as a client advocate when making the client's wishes known to the physician 66. When performing an abdominal assessment. Inspection. The nurse is performing which professional role? a. The correct sequence for all other assessments is inspection. The nurse acts as a caregiver when providing direct care. percussion. palpation. correct sequence for abdominal palpation assessment because is this auscultation. and sequence prevents altering bowel sounds with palpation before auscultation. Inspection. palpation.

Alanine aminotransferase and aspartate aminotransferase b. Her nurse. raising the liver enzymes alanine aminotransferase and aspartate aminotransferase. c. self-disclosurerevealing personal info d. Self-disclosure involves the nurse revealing personal information. Blood urea nitrogen and serum creatinine levels provide information on renal function and aren't indicators of effectiveness of drug therapy in acetaminophen poisoning. Which laboratory findings confirm the effectiveness of the drug therapy? a. A complete blood count won't give the nurse information on the effectiveness of therapy. clarification. 67. reviewing cx idea. ask more questions b.ipecac followed by acetylcysteine every 4 hours for 72 hours. Blood urea nitrogen and serum creatinine d. Complete blood count Answer: A Rationale: Acetaminophen poisoning causes liver damage. A client in her first postpartum month has developed mastitis secondary to breast-feeding. Clarification involves the nurse asking the client 33 . reflection. "I remember the discomfort I had and how quickly it resolved when I began getting treatment. Creatine kinase-MB levels are elevated with heart muscle damage and aren't associated with acetaminophen poisoning. Creatine kinase-MB c. restating repetition Answer: D Rationale: Using self-disclosure as a therapeutic communication technique encourages an open and authentic relationship between the nurse and her client. says. a mother who developed and recovered from mastitis after her third child." The therapeutic communication being used by the nurse is: a.

Restating is the nurse's repetition of the client's main message 68. the nurse performs interventions to meet the client's needs such as administering medication. the nurse labels or describes the client's health problems or needs such as pain. 69. Assessment b. 50 mg I.M. this action is considered part of evaluation.for more information. the nurse asks the client whether the pain is relieved. Which step of the nursing process is the nurse using? a. During implementation. because the nurse performed an intervention and is evaluating whether the goal has been met. Analysis c. the nurse determines whether the goals established in the plan of care have been achieved and evaluates the success of the plan. During the nursing analysis (or diagnosis) step of the nursing process. The nurse is revising a client's plan of care. If a goal is unmet or 34 . D Rationale: During the evaluation step of the nursing process. Planning c. Assessment b. Implementation d. Evaluation Answer. not assessment. During which step of the nursing process does such revision take place? a. Reflection is reviewing the client's ideas. Thirty minutes later. Implementation d. for relief of surgical pain. A client receives meperidine (Demerol).. Evaluation Answer: D Rationale: Although the nurse is assessing pain relief.

Planning involves setting priorities. Serum potassium levelfluid and e b.partially met. Albumin levelproteinrepair d. Lymphocyte count and differential count help assess for infection. and selecting appropriate interventions. Potassium levels indicate fluid and electrolyte status. Differential countinfection Answer: C Rationale: Protein and vitamin C help build and repair injured tissue. therefore. Assessment involves data collection. "Is the pain stabbing like a knife?" Answer: B Rationale: Asking such an open-ended question as "Can you describe the pain?" encourages the client to describe any and all aspects of the pain in the client's own words. The other options are likely to elicit less 35 . A client complains of severe abdominal pain. "Where does it hurt the most?" d. the nurse reexamines the data and revises the plan. To elicit as much information as possible about the pain. Implementation involves providing actual nursing care 70. "Do you have the pain all the time?" b. "Can you describe the pain?" c. Which of the following laboratory test results is the most important indicator of malnutrition in a client with a wound? a. Albumin is a major plasma protein. a client's albumin level helps gauge his nutritional status. establishing goals. the nurse should ask: a. 71. Lymphocyte countinfection c.

b. Repeat the order to the nursing supervisor. Answer: A Rationale: When taking a telephone order. c. 73. the nurse should repeat the order to the prescriber to ensure that it is clearly understood. warm. Red. Wait for the physician to sign the order before administering the drug.000/μlNormal Answer: C Rationale: Redness. White blood cell (WBC) count of 8. Which sign or symptom would be most indicative of infection? a. The presence of an invasive device predisposes a client to infection but alone doesn't indicate infection. 72.000/μl. and tenderness in the incision area would lead the nurse to suspect a postoperative infection. The drug may be administered before the physician signs the order. it isn't necessary to repeat the order to a nursing supervisor. Repeat the order to the prescriber. Which safeguard should the nurse take to ensure accuracy with a telephone order? a. A normal WBC count ranges from 4. warmth. The presence of an indwelling urinary catheter b. Although 36 . tender incision d.8° C) c. Rectal temperature of 100° F (37. A rectal temperature of 100° F would be a normal expectation in a postoperative client because of the inflammatory process. d.000 to 10.information because they're more specific and would limit the client's response. but the order must be cosigned within the time period established by facility policy. The nurse is evaluating a postoperative client for infection. Insist that the nursing supervisor monitor the call.

assists with gowning and gloving. Which assessment finding by the nurse contraindicates the application of a heating pad? a. an edematous lower leg. Edematous lower leg d. Positioning the clientcircu b. The circulating nurse assists the surgeon and scrub nurse. applies appropriate equipment and surgical drapes. A scrub nurse in the operating room has which responsibility? a. Handing surgical instruments to the surgeon scrub d.it's a good idea to have a second nurse monitor the call. and instruments. and provides the surgeon and scrub nurse with supplies. 37 . or a wound with purulent drainage promotes healing. applying heat to a reddened abscess. Applying surgical drapes circu Answer: C Rationale: The scrub nurse assists the surgeon by providing appropriate surgical instruments and supplies. Reddened abscess c. however. Assisting with gowning and gloving circu c. with the circulating nurse. For the same reason. Active bleeding b. accounting for all gauze sponges. needles. positions the client. 74. Purulent wound drainage Answer: A Rationale: Heat application increases blood flow and therefore is contraindicated in active bleeding. 75. maintaining strict surgical asepsis and. it doesn't have to be the nursing supervisor.

Standard precautions include which of the following measures? 38 . Answer: C Rationale: When measuring blood pressure. Ventrogluteal area1 y/owalking c. Wrapping the cuff around the limb. with the uninflated bladder covering about one-fourth of the limb circumference b. injection site is appropriate for a 6-month-old infant? a. Gluteus maximus muscleX Answer: A Rationale: The nurse should administer an I.76.M. Which I. Using a bladder that is 6" (15 cm) long. The ventrogluteal area should be used only after the child has been walking for about a year. with the uninflated bladder covering about three-quarters of the limb circumference d. injection to a 6-monthold infant in the vastus lateralis muscle. Bladder size is chosen according to the size of the extremity. What is the correct procedure for measuring blood pressure? a. The nurse prepares to measure a client's blood pressure.M. Measuring the arm about 2" (5 cm) above the antecubital space c. the nurse should wrap the cuff around the client's arm or leg with the bladder uninflated. the bladder should cover approximately three-quarters (not one-fourth) of the limb circumference. 78. The deltoid and gluteus maximus muscles aren't appropriate injection sites in children. Deltoid muscleX d. Wrapping the cuff around the limb. Vastus lateralis muscle b. 77.

Rinne test air and bone Answer: D Rationale: The Rinne test compares air conduction to bone conduction in both ears. the client may experience: a. throbbing headache or dizziness. nervousness or paresthesia. Weber's testbone conduction c. 39 . Whispered voice testlow ptched b. Wearing eye protection during tracheal suctioning d. Wearing gloves when changing a dressing b. To compare air conduction to bone conduction. d. c. the nurse should conduct which test? a. drowsiness or blurred vision. The whispered voice test evaluates low-pitched sounds. and wear goggles during procedures that are likely to generate splashes of blood or body fluids.a. place used. Immediately afterward. 79. Watch tick testhigh ptched d. Both tests assess gross hearing. All of the above Answer: D Rationale: To follow standard precautions. b. The nurse is evaluating a client's auditory function. The nurse is administering sublingual nitroglycerin to the client. The Weber test evaluates bone conduction. 80. uncapped needles and syringes in a puncture-resistant container. Disposing of needles in a puncture-resistant container c. tinnitus or diplopia. and the watch tick test assesses high-pitched sounds. caregivers must wear gloves when there is the potential for contact with a client's body fluids.

Lying down and crying can cause the fontanels to bulge.V. Why should an infant be quiet and seated upright when the nurse assesses his fontanels? a.Answer: B Rationale: Headache and dizziness often occur when nitroglycerin is taken at the beginning of therapy. d. the client usually develops a tolerance. 40 . blurred vision. The fontanels should feel soft and either flat or slightly indented. and diplopia don't occur as a result of nitroglycerin therapy. upright infant. b. The fontanels should look almost flush with the scalp and surface. Nervousness. paresthesia. These drugs should be administered at the same time via I. The mother will have less trouble holding a quiet. infusion to promote bacterial cell penetration. These drugs should be mixed and given together via continuous I. tinnitus. c. Answer: D Rationale: Lying down and crying can cause the fontanels to bulge. 82. giving the nurse an inaccurate assessment. The doses should be separated by at least 1 hour to prevent inactivation of gentamicin. The nurse should sit the child upright and try to keep him calm and quiet. The infant can breathe more easily when sitting up. 81. Lying down can cause the fontanels to recede. However. b.V. Which statement about concurrent administration of piperacillintazobactam and gentamicin is correct? a. making assessment more difficult. and slight pulsation should be visible. c. drowsiness. bolus for maximum effectiveness.

Bar soap shouldn't be used because it's a potential carrier of bacteria. Policy and procedure dictate that hand washing is a requirement when caring for clients. Which statement about hand washing is true? a. which is generally available. This interaction is clinically relevant in clients with poor renal function because elevated blood concentrations of both agents may exist simultaneously. Waterless products shouldn't be used in situations where running water is unavailable. When water is unavailable. Frequent hand washing reduces transmission of pathogens from one client to another. should be used for hand washing.d. Which of the following clients would qualify for hospice care? a. A client with late-stage acquired immunodeficiency syndrome (AIDS) 41 . Bar soap. Answer. c. the nurse should wash using a liquid hand sanitizer. Answer: A Rationale: Whether gloves are worn or not. Doses of both agents should be 83. d. hand washing is required before and after client contact because thorough hand washing reduces the risk of cross-contamination. B Rationale: High doses of penicillin G and extended-spectrum penicillins such as piperacillin/tazobactam inactivate aminoglycosides. Wearing gloves is a substitute for hand washing. These drugs should be separated by at least 15 minutes to prevent inactivation of piperacillin. Soap dispensers are preferable but they must also be checked for bacteria. b. 84.

specilized d. what should the nurse do first? a. and send the tip for culture. as well as their families. Answer: D Rationale: When maintaining a central venous catheter. such as those with late-stage AIDS. Remove the catheter. according to facility policy. The nurse should draw a circle around the moist spot and note the date and time if drainage is noted on a wound dressing. Draw a circle around the moist spot and note the date and time. Notify the physician.b. and apply a new dressing. the nurse should cover the site with a transparent semipermeable dressing. moist. A client with left-sided paralysis resulting from a cerebrovascular accident (CVA) c. the dressing should be changed every 72 hours or when it becomes soiled. or one who had coronary artery bypass surgery 2 weeks before because these health problems aren't necessarily terminal. The physician should be notified if there are any complications observed related to the catheter. A client who had coronary artery bypass surgery 2 weeks before Answer: A Rationale: Hospices provide supportive. A client who's undergoing treatment for heroin addiction d. check for catheter integrity. a client who's undergoing treatment for heroin addiction. the nurse should clean around the site using sterile technique. After removing the soiled dressing. c. wound b. Hospice services wouldn't be appropriate for a client with left-sided paralysis resulting from a CVA. or loose. When a central venous catheter dressing becomes moist or loose. 85. Remove the dressing. Only nurses with the 42 . After the cleaning solution has dried. clean the site. palliative care to terminally ill clients.

HCO3–. Palpation. Additional assessment should proceed in which order? a. and percussion Answer: A 43 . not nursing. a nurse inspects the client's abdomen and notices that it's slightly concave. On admission. 7. Based on these values. Deficient fluid volume c. percussion. and a moist or loose dressing wouldn't be an indication for its removal. 70 mm Hg. the nurse should formulate which nursing diagnosis for this client? a. 28 mEq/L.20. PaCO2. supporting the nursing diagnosis of Impaired gas exchange. Palpation. ABG values can't indicate a diagnosis of Fluid volume deficit (or excess) or Risk for deficient fluid volume. and palpation b. diagnosis. these ABG values indicate respiratory. Impaired gas exchange d. A client with fever. in any event. weight loss. pH. and auscultation c.appropriate qualifications can remove a central venous catheter. Metabolic acidosis is a medical. 50 mm Hg. acidosis. not metabolic. Auscultation. Metabolic acidosis Answer: C Rationale: The client has a below-normal value for the partial pressure of arterial oxygen (PaO2) and an above-normal value for the partial pressure of arterial carbon dioxide (PaCO2). and auscultation d. a client has the following arterial blood gas (ABG) values: PaO2. While assessing the client. 86. 87. Risk for deficient fluid volume b. palpation. auscultation. and watery diarrhea is being admitted to the facility. percussion. Percussion.

The reason for this approach is that the less intrusive techniques should be performed before the more intrusive techniques. Disturbed body image related to immobility Answer: A Rationale: The information documented in the client's chart reflects the potential for impaired skin integrity. Percussion and palpation can alter natural findings during auscultation. 88. auscultation. making the nursing diagnosis of Impaired skin integrity inappropriate. While examining a client's leg." "Improved skin turgor noted." "Client up in chair three times today. While caring for a client who's immobile. interventions would focus on the client's feelings about self and the disease. Constipation related to immobility d. Povidone-iodine–soaked gauze 44 . Moist sterile saline gauze d. Until a wound specialist can be contacted. interventions would focus on diet and activity.Rationale: The correct order of assessment for examining the abdomen is inspection. Because the client's skin is intact. the nurse documents the following information in the client's chart: "Turned client from side to back every 2 hours." "Skin intact. If constipation were a problem." Which nursing diagnosis accurately reflects this information? a. the problem is only a potential one. no redness noted. Risk for impaired skin integrity related to immobility b. Sterile petroleum gauze c. If body image disturbance were a problem. percussion. Dry sterile dressing b. which of the following types of dressings is most appropriate for the nurse to apply? a. and palpation. not an actual one. 89. Impaired skin integrity related to immobility c. the nurse notes an open ulceration with visible granulation tissue in the wound.

or status epilepticus. Povidone-iodine is used as an antiseptic cleaning agent. 6" (15 cm) c. the nurse should advance an indwelling urinary catheter 2" to 3" (5 to 7. Lethal arrhythmias b. the nurse should advance the catheter 6" to 8". Malignant hypertension c. it can irritate epithelial cells. In a male client. however. Petroleum supports healing but is expensive. ½" (1 cm) Answer: A Rationale: In a female client. Chloramphenicol isn't known to cause lethal arrhythmias. 90. Status epilepticus d. 91. What is the most toxic reaction to chloramphenicol? a. malignant hypertension. 8" (20 cm) d. Dry sterile dressings adhere to the wound and debride the tissue when removed. the nurse should advance the catheter how far into the urethra? a. 2" (5 cm) b. The nurse must monitor a client receiving chloramphenicol for adverse drug reactions. 45 . Bone marrow suppression Answer: D Rationale: The most toxic reaction to chloramphenicol is bone marrow suppression.5 cm) into the urethra.Answer: C Rationale: Sterile saline dressings support wound healing and are costeffective. so it shouldn't be left on an open wound. When placing an indwelling urinary catheter in a female client.

V. During the planning step. site in a client's hand has infiltrated. Elevating the hand and wrapping it in a warm towel b. Evaluation d. 93. measures vital signs. the nurse designs methods to help resolve client problems and meet client needs. the nurse determines the effectiveness of nursing interventions in achieving 46 . Assessment c. The nurse obtains a health history. During evaluation. applying warmth increases circulation and eases pain and edema. The nurse discovers that an I. A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. Ice application would relieve pain but not edema. and auscultates for bowel sounds. and performs a physical examination to gather data for use in formulating the nursing diagnoses. Wrapping the arm in an elastic bandage from wrist to elbow Answer: A Rationale: Elevating the arm promotes venous drainage and reduces edema. measures vital signs.92. Planning b. Wrapping the arm above the hand would slow venous return and is contraindicated. causing localized pain and swelling. the nurse obtains the client's health history. Which step of the nursing process is the nurse performing? a. An analgesic wouldn't correct the primary cause of the discomfort. Which intervention would relieve the client's discomfort most effectively? a. Administering an as-needed analgesic d. Placing an ice pack on the hand c. Implementation Answer: B Rationale: During the assessment step of the nursing process.

Scabs indicate which phase of wound healing? a. Contractionsloughing b. the nurse does which of the following? a. During implementation. The nurse performs palpation and 47 . 94. the nurse observes scabs around the lacerations.client goals. Palpates the client's abdomen c. Inflammationedema Answer: C Rationale: At the end of the lag phase. the nurse takes actions to meet the client's needs. Auscultates for the client's breath sounds d. and nutritional history. the fibrin network dries out and forms a scab. When obtaining a client's history. Documents medication administered Answer: A Rationale: When obtaining a client's history. 95. the nurse gathers subjective data by asking questions about the client's chief complaint. The fibrinoplastic phase concludes with a scar. and drawing of leukocytes to the wound area. Asks questions about the client's chief complaint b. family. and other factors. Lag scab d. such as past medical. Inflammation is the first stage of wound healing and includes hemostasis. edema. When assessing the facial lacerations of a middle-aged client admitted to the facility 1 week ago. and the contraction phase is demonstrated by sloughing and shrinking of the scar. psychosocial. Fibrinoplasticscar c. current health status.

97. A soft. If it is palpable. the nurse should include which intervention? a.5 to 5 cm) above the symphysis pubis. A nonpalpable bladder d. rough bladder c. Increasing fluids may improve the client's condition but doesn't address poor coughing. Increasing fluids to 2.auscultation during the physical examination and documents medications administered when implementing the plan of care. A palpable bladder located 3" to 5" (7. Suctioning the client every 2 hours Answer: B Rationale: Interventions should address the etiology of the client's problem — poor coughing.5 to 12. smooth bladder b. the nurse should identify which finding as normal? a. Improving airway clearance d. A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing. Teaching deep breathing and coughing addresses this etiology. smooth. When palpating the bladder of an adult client.7 cm) above the symphysis pubis Answer: C Rationale: An adult's bladder may not be palpable. Suctioning isn't indicated unless other measures fail to clear the airway. it usually is firm. 48 . Improving airway clearance is too vague. A hard. and located 1" to 2" (2.500 ml/day b. 96. When planning this client's care. Teaching the client how to deep-breathe and cough c.

1 L d. only the physician can change the route of an ordered drug.75 L c. What would this amount be in liters? a. 500 ml. Answer: B Rationale: Because the client has diarrhea. c.98. withhold the suppository and notify the client's physician. The physician orders a soap suds enema. 2 L Answer: A Rationale: 500 ml equals 0. substitute 325-mg aspirin by mouth. Milk of magnesia doesn't relieve the client's constipation. d. Waiting 15 minutes or until the client is finished is inappropriate because the client will most likely have another urge to defecate and will expel the suppository. 49 . A suppository should never be given to a client with diarrhea because the suppository would be expelled.5 L. 0. 0. tell the client you'll give him the suppository when he's finished in the bathroom. The nurse is to give a client a 325-mg aspirin suppository. the nurse needs to hold the medication and talk with the physician. wait 15 minutes after the diarrhea stops and then administer the suppository. The client has diarrhea and is in the bathroom.5 L b. 99. The best nursing approach at this time would be to: a. Substituting the oral form is inappropriate. b.

the nurse focuses on the client's basic needs. Option C may be warranted but is secondary to ineffective tissue perfusion. Impaired gas exchange related to increased blood flow b. Option B is inappropriate because no evidence suggests that this client has a excessive fluid volume. Dorothy Johnson behavioral b. Dorothea Orem self care deficit d. In Martha Rogers' peripheral tissue perfusion related to venous 50 . Martha Rogers unitary human being Answer: C Rationale: Dorothea Orem's general theory of nursing addresses selfcare deficits as the basis for nursing care.100. According to Virginia Henderson's theory of nursing. which have been disrupted by stress. A client is diagnosed with deep vein thrombosis. Which nursing theorist addressed self-care deficits in her nursing theory? a. 101. not increased. Virginia Henderson needs c. blood flow. Ineffective congestion Answer: D Rationale: Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with deep vein thrombosis. Which nursing diagnosis should receive highest priority at this time? a. Excessive fluid volume related to peripheral vascular disease c. Dorothy Johnson's behavioral systems theory views nursing as a means to reestablish balance in the client's behavioral subsystems. Risk for injury related to edema d. This theory posits that the nurse intervenes to reestablish the client's self-care capacity. Option A is incorrect because impaired gas exchange is related to decreased.

Watch tick test d. Answer: D Rationale: The client most likely has a wound evisceration or dehiscence. The whispered voice test evaluates low-pitched sounds. the nurse should conduct which test? a. then the nurse can implement appropriate measures. Splint the abdomen with a pillow and call the surgeon. Whispered voice test b. or reinforcing the existing dressing would delay treatment. Reinforce the existing dressing with another dressing. the dressing was dry and intact. applying an abdominal binder. the nurse helps the client balance the changes that occur as the client constantly evolves 102. and the watch tick test assesses high-pitched sounds. malnourished client has undergone abdominal surgery. 103. While ambulating on the 4th postoperative day. Rinne test Answer: D Rationale: The Rinne test compares air conduction to bone conduction in both ears. Which of the following is the best initial action for the nurse to take? a. she complains to the nurse that her dressing is saturated with drainage. Weber's test c. d. Splinting the abdomen. To compare air conduction to bone conduction. c. b. The first step is to assess the wound. The nurse is evaluating a client's auditory function. Both tests assess gross hearing. The Weber test evaluates bone conduction. Apply an abdominal binder. An obese. 51 . Reinforce the existing dressing with another dressing.unitary human beings theory. Before this activity.

the nurse should ask: a. The nurse should sign the preoperative checklist after notifying the physician of the client's condition and learning the physician's decision on whether to proceed with surgery. "What does the pain feel like?" Answer: D Rationale: An open-ended question (one that can't be answered with a simple "yes" or "no") provides more information than a closed-ended 52 . Answer: C Rationale: The nurse should notify the physician immediately because dyspnea.m. A client complains of abdominal pain. To elicit as much information about the pain as possible. b. 106. "Is the pain constant?" c. What should the nurse do next? a. and back pain may signal a change in the client's respiratory status. Notify the physician immediately of these findings d. Check to see that the chest X-ray was done yesterday as ordered. serum electrolyte levels. and back pain.. At 8 a. the nurse assesses a client who's scheduled for surgery at 10 a.m. Missing 105. During the assessment. and CBC) after notifying the physician because they may help explain the change in the client's condition. "Are you having pain?" b. The nurse should check any ordered tests (such as a chest X-ray. the nurse detects dyspnea. a nonproductive cough. "Is the pain sharp?" d. c.104. a nonproductive cough. Sign the preoperative checklist for this client. Check the serum electrolyte levels and complete blood count (CBC).

b. the nurse should insert it approximately how far into the client's rectum? a. 1" (2. it isn't necessary to repeat the order to a nursing supervisor. 107.5 cm) d. the nurse should repeat the order to the prescriber to ensure that it is clearly understood. When administering the suppository. 3" (7. 4" (10 cm) Answer: C 53 . Wait for the physician to sign the order before administering the drug. c. Which safeguard should the nurse take to ensure accuracy with a telephone order? a. which limits the client's response. The other options are closed-ended questions. A client is to receive a glycerin suppository. Repeat the order to the nursing supervisor. Repeat the order to the prescriber. but the order must be cosigned within the time period established by facility policy.5 cm) b. The drug may be administered before the physician signs the order. Insist that the nursing supervisor monitor the call. it doesn't have to be the nursing supervisor.question. Although it's a good idea to have a second nurse monitor the call. Answer: A Rationale: When taking a telephone order. 2" (5 cm) c. Missing 109. 108. d.

In an adult. the fibrin network dries out and forms a scab. and develops the plan of care. When assessing the facial lacerations of a middle-aged client admitted to the facility 1 week ago. and the 54 . Evaluation b. Planning c. 110. the nurse delivers nursing care. Contraction b. Implementation d. the nurse identifies expected client outcomes. Lag d. the nurse collects and analyzes data 111. During implementation. During the planning step. this distance is approximately 3".Rationale: The nurse should advance a rectal suppository far enough into the rectum to pass the internal anal sphincter. When caring for a client. During assessment. Nflammation Answer: C Rationale: At the end of the lag phase. Fibrinoplastic c. if needed. The nurse determines goal achievement during which step of the nursing process? a. establishes priorities. The fibrinoplastic phase concludes with a scar. the nurse assesses the client's goal achievement by comparing the actual outcome with the outcome identified during the planning step of the nursing process. Scabs indicate which phase of wound healing? a. Assessment Answer: A Rationale: During evaluation. the nurse observes scabs around the lacerations. the nurse then revises the plan of care. the nurse must determine whether the client has achieved the goals established in the plan of care.

prevents atelectasis. Inflammation is the first stage of wound healing and includes hemostasis. the nurse sees that the surgical consent form hasn't been signed. While completing the preoperative checklist. 113. Teaching the client about incentive spirometry won't alleviate his discomfort. cough. Notifying the surgeon that the consent form hasn't been signed d. A client is scheduled for surgery at 8 a. Answer: A Rationale: Administering pain medication and waiting for its effect before any activity will increase client compliance. arrange a care schedule to provide rest periods. A client is unable to take a deep breath and doesn't want to get out of bed because his chest tube is causing discomfort. teach the client how to use an incentive spirometer.contraction phase is demonstrated by sloughing and shrinking of the scar. An incentive spirometer measures deepbreathing ability. tell the client the importance of lung expansion. Canceling the surgery Answer: C 55 . and is a visual progress chart for the client. the nurse should: a. Providing rest periods is essential but won't relieve the client's discomfort. Giving the preoperative analgesic at the scheduled time b. Which nursing action takes the highest priority in this situation? a. It's time to administer the preoperative analgesic. edema. To increase client compliance with ambulation and deep breathing. or get out of bed.m. c. administer pain medication before having the client deep breathe. d. b. Explaining the purpose of the intended treatment is important but won't decrease the discomfort of the chest tube. Asking the client to sign the consent form c. and drawing of leukocytes to the wound area. 112.

"You probably should have had surgery sooner so the tumor could have been caught earlier. although the nurse may confirm or witness consent. "I thought the chemotherapy would help. Would it help you to talk about it?" c. but now I feel worse. Canceling surgery also isn't within the scope of nursing practice." d. A client has a blood pressure of 152/86 mm Hg. "Don't worry. 86 mm Hg d. 115." Which response by the nurse would be most therapeutic? a. Giving the preoperative analgesic at the scheduled time would alter the client's ability to give informed consent." 56 . the client is sobbing and states. 114. The nurse should document the client's pulse pressure as which of the following? a. Obtaining consent to surgery isn't within the scope of nursing practice. Six months after undergoing a radical modified mastectomy to treat breast cancer. 152 mm Hg Answer: A Rationale: Pulse pressure is the difference between the systolic and diastolic pressures — in this case.Rationale: Notifying the surgeon takes priority because informed consent must be obtained before the client receives drugs that can alter cognition. a client is admitted for chemotherapy. 66 mm Hg b. 66 mm Hg. 238 mm Hg c. When the nurse enters the client's room." b. I'm sure everything will be OK if you just give it time. "I'll sit here with you for a while. "I'll bring you a sedative to calm you down.

a therapeutic communication technique that promotes interactions focused on the client's feelings and concerns. the nurse should hang only the amount of formula that can be infused in 3 hours. Oral c. 116. the nurse should avoid which route? a. When such elevation is contraindicated. Elevating the head of the bed b. Rectal b. Hanging a full day's worth of formula at one time Answer: A Rationale: Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow into the client's intestines. Addressing the client's feelings validates the client as a person and helps establish trust. Tympanic 57 . Options C and D are nontherapeutic responses that would prevent the nurse from helping the client recognize and deal with feelings. The nurse is assigned to a client with a cardiac disorder. Positioning the client on the left side c. Sedating the client (option A) would delay dealing with feelings. The nurse should give enteral feedings at room temperature to minimize GI distress. the nurse is engaging in active listening. To limit microbial growth. Warming the formula before administering it d. Axillary d.Answer: B Rationale: In this response. Which nursing action is essential when providing continuous enteral feeding? a. When monitoring body temperature for this client. the client should be positioned on the right side. 117.

V. 58 . When assessing a client's I. Elevate the I. However. increased drug doses at longer intervals. no blood returns to the tubing. tubing with 1 ml of normal saline solution.V. Discontinue the I. infusion only if other measures fail to solve the problem. such as kinks in the tubing and poor positioning of the affected arm. Elevating the I. c. c. Check the tubing for kinks and reposition the client's wrist and elbow.V. 118.V. fluid bag. 119. Answer: C Rationale: The nurse should check for common causes of a decreased I. The other options are appropriate routes for measuring the temperature of a client with a cardiac disorder. nursing home placement. Irrigating I. if present. tubing may dislodge clots. b. What should the nurse do first? a. the nurse should avoid using the rectal route to take temperature because it may stimulate the vagus nerve. d.V. fluid bag. the flow rate is slow even with the roller clamp wide open. the nurse notes normal color and temperature at the site and no swelling. reduced drug dosages. infusion at that site and restart it in the other arm.V.V. Irrigate the I. solutions haven't infused at the ordered rate. possibly leading to vasodilation and bradycardia.V. fluid bag may help if no kinks are found and if repositioning doesn't resolve the problem.V. When the nurse lowers the I. the I. The nurse should discontinue the I.Answer: A Rationale: When caring for a client with a cardiac disorder. b. A geriatric client who experiences several adverse drug reactions may benefit from: a. insertion site.V. flow rate.

pleural friction rub b. They're high-pitched. or coarse. medium.200 ml. Answer: A Rationale: Older clients frequently have diminished hepatic and renal function that reduces drug metabolism and excretion. The physician prescribes an infusion of 2. 240 ml/hour Answer: C Rationale: First. 100 ml/hour c. They're grating sounds. c. During the first 10 hours. frequent visits to the physician. 0 ml/hour b. with half this amount to be infused over the first 10 hours. They may be fine. musical squeaks. the nurse determines how many milliliters (half of the total) to administer over the first 10 hours: 2. Which of the following is true about crackles? a. the client should receive how many milliliters of I.V. d. Increased drug doses at longer intervals may increase adverse reactions rather than decrease them.d.400 ml ÷ 2 = 1. 59 .V. therefore the client may benefit from reduced drug dosages. Although frequent visits to the physician may benefit the client. fluid over 24 hours. Adverse drug reactions aren't a cause for nursing home placement. the visits themselves won't alter how the drug reacts in the client's body 120. Adverse reactions frequently are related to blood level. Then the nurse determines how many of these milliliters to deliver per hour: 1. 120 ml/hour d. fluid per hour? a. They're low-pitched noises that sound like snoring.400 ml of I.200 ml ÷ 10 hours = 120 ml/hour 121.

coarse. Asks questions about the client's chief complaint b. Sutures in place d. Wheezes are continuous. purulent drainage suggests infection. Yellow. As the name indicates. Wheezes occur on expiration and sometimes on inspiration. Pink granulation tissue Answer: B Rationale: Yellow. these breath sounds result when inflamed visceral and parietal pleurae rub together. crackles are discrete sounds that vary in pitch and intensity. Loud. When obtaining a client's history. the nurse does which of the following? a. 122. Pleural friction rubs have a distinctive grating sound. the nurse must report this finding to the physician immediately and obtain a culture as ordered. purulent drainage c. 123. Auscultates for the client's breath sounds d. They're classified as fine. musical squeaks that result when air moves rapidly through airways narrowed by asthma or infection — or when an airway is partially obstructed by a tumor or foreign body.Answer: D Rationale: Crackles result from air moving through airways that contain fluid. The nurse is changing a client's dressing. Approximated wound edges b. Documents medication administered 60 . high-pitched. Which observation of the wound warrants immediate physician notification? a. or coarse. and low-pitched. The other options represent normal findings for a wound. medium. Audible during both inspiration and expiration. Palpates the client's abdomen c. they resemble snoring. Gurgles develop when thick secretions partially obstruct airflow through the large upper airways.

current health status. Dysfunctional grieving c. tenacious secretions and ensures adequate hydration. maintain a cool room temperature. family. d. A client hospitalized with pneumonia has thick. A client is admitted with fatigue. 125. Ineffective role performance d. Turning the client every 2 hours would decrease pooling of secretions but wouldn't liquefy them. the nurse should: a. Impaired physical mobility Answer: B 61 . Answer: C Rationale: Increasing the client's intake of oral or I. the nurse gathers subjective data by asking questions about the client's chief complaint. Which nursing diagnosis is most appropriate for this client? a. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing but wouldn't liquefy secretions. c. and nutritional history. turn the client every 2 hours. psychosocial. The nurse performs palpation and auscultation during the physical examination and documents medications administered when implementing the plan of care.Answer: A Rationale: When obtaining a client's history.V. To help liquefy these secretions. elevate the head of the bed 30 degrees. b. such as past medical. fluids helps liquefy thick. Activity intolerance b. weight loss. and other factors. encourage increased fluid intake. anorexia. tenacious secretions. and inability to sleep. Maintaining a cool room temperature would increase the client's comfort but wouldn't liquefy secretions. 124. which started 1 month after the death of the client's spouse.

sleep patterns. The nurse prepares to administer a buccal medication. Radial b. Chest compressions performed during CPR preclude accurate assessment of the apical 127. Ineffective role performance. To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR). Under the client's tongue d. and Impaired physical mobility don't include these defining characteristics. Carotid d. Apical c. In the client's conjunctival sac Answer: B Rationale: The nurse should place a buccal medication in the client's upper or lower buccal pouch. Where should the nurse place this medication? a. between the cheek and gum. 126. Between the client's cheek and gum c.Rationale: Behavioral manifestations of Dysfunctional grieving include changes in eating habits. and activity levels. A topical 62 . On the client's skin b. the nurse should palpate which pulse site? a. the carotid artery pulse is the most accessible and may persist when the peripheral pulses (radial and brachial) no longer are palpable because of decreases in cardiac output and peripheral perfusion. Diagnoses of Activity intolerance. Brachial Answer: C Rationale: During CPR.

Opening a closed urine-drainage system. the nurse should aspirate it from a port. sterile gloves aren't necessary for this procedure. would increase the risk of urinary tract infection (UTI). Documenting observed client behaviors or conversations is appropriate. Which statement reflects appropriate documentation in the medical record of a hospitalized client? a. Answer: A Rationale: To obtain urine properly. d. To prevent infection. "Client seems to be mad at the physician. open the drainage bag and pour out some urine. "Client had a good day. 128. c. b. Documentation of a leg ulcer should include its exact size and location. or felt. as in options B and C." c. "Client's skin is moist and cool. and an eye (ocular) medication. disconnect the catheter from the tubing and obtain urine. wear sterile gloves when obtaining urine." b. 129. under the tongue." d. aspirate urine from the tubing port. The nurse should record findings or observations precisely and accurately. Although standard precautions specify wearing gloves during contact with body fluids. using a sterile syringe and needle. a sublingual medication. The nurse is obtaining a sterile urine specimen from a client's indwelling urinary catheter. smelled. seen. the nurse should: a. in the conjunctival sac. Stating that the 63 .medication is applied on the client's skin." Answer: D Rationale: Documentation should include data that the nurse obtains using only observations that are heard. but drawing conclusions about a client's feelings is not. "Small pressure ulcer noted on left leg. using a sterile syringe and needle after cleaning the port.

the nurse grasps the helix of the ear and pulls it up and back to straighten the ear canal. laboratory test results. c. The nurse prepares to perform an otoscopic examination on an adult. For proper visualization. 130.client had a good day doesn't provide precise enough information to be useful. For a child. Physical findings. Radiologic findings Answer: A Rationale: Only the health history provides subjective data. b. 64 . helix up and forward. Which one is the major source of subjective data about the client's health status? a. lobule down and forward. All of the following components may be part of a client's medical record. lobule down and back. the nurse grasps the helix and pulls it down to straighten the ear canal. 131. helix up and back. and radiologic findings are examples of objective data. Physical findings c. Laboratory test results d. d. Pulling the lobule in any direction wouldn't straighten the ear canal for visualization. Answer: B Rationale: To perform an otoscopic examination on an adult. the nurse should position the client's ear by pulling the: a. Health history b.

the nurse leaves the bed in the high position when finished. the nurse fanfolds these linens to the side opposite from where the client will enter and places the pillow on the bedside chair. Sengstaken-Blakemore tubeesophageal b. the nurse rolls the client to the far side of the bed. 134. Rolls the client to the far side of the bed d. Places the pillow at the head of the bed c. A SengstakenBlakemore tube is an esophageal tube. When making an occupied or unoccupied bed. The nurse obtains a health 65 . Leaves the bed in the high position when finished b. Salem sump tubeNG Answer: B Rationale: A Miller-Abbott tube is an intestinal tube. When making an occupied bed. the nurse identifies which of the following as an intestinal tube a. A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. All of these actions promote transfer of the postoperative client from the stretcher to the bed. What does the nurse do when making a surgical bed? a. When gathering equipment for this procedure. The physician orders an intestinal tube to decompress a client's GI tract.132. the nurse places the pillow at the head of the bed and tucks the top sheet and blanket under the bottom of the bed. Tucks the top sheet and blanket under the bottom of the bed Answer: A Rationale: When making a surgical bed. 133. After placing the top linens on the bed without touching them. Miller-Abbott tube intestinal c. Levin's tube NG d. A Levin's tube and a Salem sump tube are nasogastric tubes.

the nurse 135. Which of the following factors would have the most influence on the outcome of a crisis situation? a. Therefore. Although sometimes useful. the nurse obtains the client's health history. may prevent the person from learning 66 . Evaluation d. Planning b. Self-esteem d. Age could have either a positive or negative effect during crisis. option A is the best answer. Perception of the problem Answer: B Rationale: Coping is the process by which a person deals with problems using cognitive and noncognitive components. the nurse determines the effectiveness of nursing interventions in achieving client goals. noncognitive measures. Previous coping skills c. measures vital signs. noncognitive responses are automatic and focus on relieving discomfort. Age b. During implementation.history. such as self-esteem. Assessment c. During the planning step. depending on previous experiences. and auscultates for bowel sounds. Implementation Answer: B Rationale: During the assessment step of the nursing process. the nurse designs methods to help resolve client problems and meet client needs. During evaluation. Previous coping skills are cognitive and include the thought and learning necessary to identify the source of stress in a crisis situation. and performs a physical examination to gather data for use in formulating the nursing diagnoses. Which step of the nursing process is the nurse performing? a. Cognitive responses come from learned skills. measures vital signs.

"Read this manual and then ask me any questions you may have. and profuse perspiration are definite signs of activity intolerance. 70100/min b. The client took small steps at a rate of 40 to 50 per minute." b. c. Dizziness. The person involved could have correct or incorrect perception of the problem that could have either a positive or negative outcome." 67 . The nurse is helping a client ambulate for the first time after 3 days of bed rest. "Let's talk about what is bothering you. "Everything will be fine. gazes straight ahead. Don't worry. The client reported feeling dizzy and weak and perspired profusely. especially if it's the first ambulation after 3 days of bed rest. a much slower pace may indicate distress.more about the crisis as well as a better solution to the problem. Which observation by the nurse suggests that the client tolerated the activity without distress? a. Which response by the nurse is most likely to reduce the client's anxiety? a. The client's pulse and respiratory rates increased moderately during ambulation Answer: D Rationale: The pulse and respiratory rates normally increase during and for a short time after ambulation. and keeps the toes pointed forward. and toes were pointed outward. option C describes a client with activity intolerance. A client who tolerates ambulation well holds the head erect. "Why don't you listen to the radio?" d. A normal walking pace is 70 to 100 steps/minute. 136. weakness. The client's head was down. 137. A client exhibits signs of heightened anxiety. gaze was cast down." c. d.

Obtaining a Papanicolaou (PAP) test to screen for cervical cancerscreening2nd d. which promotes early detection and treatment of disease. Which intervention is an example of primary prevention? a. Which of the following strategies should the nurse use to help assess a client's orientation? 68 . which aims to help a client deal with the residual consequences of a problem or to prevent the problem from recurring.Answer: D Rationale: Anxiety may result from feelings of helplessness. they wouldn't reduce anxiety. The nurse should be supportive and develop goals together with the client to give the client some control over an anxietyinducing situation. isolation. or insecurity. which aims to prevent health problems. Administering a measles. Administering digoxin to treat heart failure and obtaining a PAP test for screening are examples of secondary prevention. 138. Because the other options ignore the client's feelings and block communication. This response helps reduce anxiety by encouraging the client to express feelings. Using occupational therapy to help a client cope with digoxin (Lanoxicaps) to a client with heart arthritistherapy3rd Answer: B Rationale: Immunizing an infant is an example of primary prevention. 139. Using occupational therapy to help a client cope with arthritis is an example of tertiary prevention. and rubella immunization to an infant c. Administering failure2nd b. mumps.

5 cm) into the urethra. place. Asking the client to repeat a series of digits assesses memory. When a nurse brings prescribed medication to a client. 8" (20 cm) d.a. What should the nurse do first? 69 . Use the Glasgow Coma Scale and compute the score. 2" (5 cm) b. LOC Answer: A Rationale: To help assess orientation. ½" (1 cm) Answer: A Rationale: In a female client. such as the client's name and city of residence and the time of day or day of the week. the nurse should advance the catheter 6" to 8". Ask the client's name and city of residence and the time of day. When placing an indwelling urinary catheter in a female client. b. In a male client. the client says she usually takes a white tablet.->memory c. not the yellow tablet that the nurse has brought. 141. The Glasgow Coma Scale assesses level of consciousness. the nurse asks the client direct questions about person. language d. 140. and time. Point to common objects and ask the client to name them. Ask the client to repeat a series of three digits spoken slowly. 6" (15 cm) c. the nurse should advance an indwelling urinary catheter 2" to 3" (5 to 7. Pointing to common objects and asking the client to name them assesses for language deficits. the nurse should advance the catheter how far into the urethra? a.

Withholding the medication and notifying the physician would be appropriate if the nurse detects an error when rechecking the medication name and strength. and along the top of the foot. over the instepposterior tibial Answer: C Rationale: To evaluate the posterior tibial pulse. Withhold the medication and notify the physician. Reassure the client that the white tablet is the correct medication. Along the top of the foot. where should the nurse palpate? a. To evaluate a client's posterior tibial pulse. The nurse palpates medially in the antecubital space to evaluate the brachial pulse. c. the nurse should check the medication name and strength again. 142. 70 . below the medial malleolus. Check the name and strength of the medication again. to evaluate the dorsalis pedis pulse. On the inner aspect of the ankle. over the instep. Medially in the antecubital spacebrachial b. b.a. Tell the client that the white tablet must be from a different manufacturer. Telling the client that the white tablet must be from a different manufacturer or reassuring the client that it's the correct medication would be inappropriate because the client may be correct. midway between the superior iliac spine and symphysis pubis to assess the femoral pulse. Answer: D Rationale: If a client says a medication seems unusual or different. d. the nurse palpates the inner aspect of the ankle. Midway between the superior iliac spine and symphysis pubisfemoral c. below the medial malleolusdorsalis pedis d.

the nurse should wipe in which direction? a. the kidneys produce 35 to 55 ml of urine in 1 hour. To determine the I. Answer: C Rationale: Eight hours is a long time not to have voided. feel that the bladder is smooth. be unable to palpate the bladder. from the center to the opposite side. 145. When cleaning around the drain. The nurse wipes laterally. A client hasn't voided since before surgery. c. A client has a wound with a drain. infusion at 125 ml/hour for a client. In a circle. The physician orders an I. which took place 8 hours ago. Laterally. which is: a. the number of milliliters in one drop. the nurse must know the drip factor. when cleaning a large horizontal wound and wipes from top to bottom when cleaning a vertical incision. d. From top to bottom c. the nurse should wipe in a circle around the drain. Typically. from the center to the opposite side b. 71 .V. palpate the bladder at the umbilicus. the bladder would be full of urine and palpable above the symphysis pubis 144. b. the nurse will: a. palpate the bladder above the symphysis pubis. After 8 hours of not voiding. None of the above Answer: C Rationale: When cleaning the area around the drain.143. When assessing the client.V. working from the center outward. from the center outward d. drip rate.

Eupnea is a respiratory rate of 12 to 20 breaths/minute with a regular rhythm. A client is receiving furosemide (Lasix). The drip rate refers to the number of drops infused per minute. potassium c. the number of drops in one milliliter. 147. not the number of milliliters in one drop. Bradypnea refers to a respiratory rate below 12 breaths/minute with a regular rhythm. low-fat milk. the nurse should use which term? a. 146. b. Answer: B Rationale: The drip factor is the number of drops in one milliliter. the nurse measures a client's respiratory rate at 32 breaths/minute with a regular rhythm. drip factor c. not the number of drops. Eupnea b. 72 . infused per hour.b. 40 mg by mouth twice a day. During assessment. the number of drops per minute to be infused. Apnea d. Apnea refers to absence of breathing. The flow rate is the number of milliliters. Tachypnea Answer: D Rationale: A respiratory rate of 32 breaths/minute with a regular rhythm is faster than normal and should be documented as tachypnea. the nurse should emphasize teaching the client about the importance of consuming: a. the number of drops per hour to be infused. green vegetables. In the plan of care. fresh. bananas and oranges.-->drp rate d. When documenting this pattern. Bradypnea c.

"It's your responsibility as I have already stated to you. green vegetables. the family must provide an around-the-clock attendant for the client. "You find the attendant. The charge nurse informs the family that to avoid restraints. The primary nurse for the client calls the physician and receives an order for soft wrist restraints. 149. access. An elderly client becomes confused. Such statements don't increase rapport with the family or enhance problem-solving. It can also help the problemsolving process. the nurse should plan to teach the client to increase intake of potassium-rich foods. and creamed corn aren't good sources of potassium." c. "I recommend family members arrange to stay with the client." b. The staff can't dismiss responsibility to the client if the family won't allow restraints." It would be a." d. creamed corn. and attempts to remove his indwelling urinary catheter. which involves the client. The family spokesman replies. dislodges his I.d. Answer: B Rationale: Because furosemide is a potassium-wasting diuretic. 148. Restating that it's the family's responsibility and saying that they're making the situation more difficult are confrontational approaches. However. such as bananas and oranges. After the nurse applies ice to the ankle 73 . Fresh. A client twists the right ankle while playing basketball and seeks care for ankle pain and swelling. milk. family. "I think you're making the situation more difficult than it really is. that is your responsibility. the client's family insists that he not be restrained. "We can't be responsible if you won't let us restrain the client.V." Answer: D Rationale: Offering the family a solution to the situation is therapeutic and can advance rapport with the family. and staff.

150. apical-radial c. in which the interval between beats is consistent. dias-systo b. 151. which statement by the client suggests that ice application has been effective? a. "I need something stronger for pain relief. redness. the pulse deficit. pulsus regularis." Answer: B Rationale: Ice application decreases pain and swelling." c. and increased warmth are signs of inflammation that shouldn't occur after ice application.for 30 minutes. the pulse pressure. The differential between these two pulses is called: a. "My ankle looks less swollen now. the pulse rhythm. Multiple questionslack knowledge 74 ." b. Pulse rhythm is the interval pattern between heartbeats. "My ankle appears redder now. d. Answer: B Rationale: The differential between the apical and radial pulse rates is called the pulse deficit." d. Which client characteristic would be an example of noncompliance? a. Pulsus regularis is the normal pulse pattern. Pulse pressure refers to the differential between systolic and diastolic blood pressures. "My ankle feels very warm. The nurse measures a client's apical pulse rate and compares it with the radial pulse rate. Undesired drug actionadversereaction b. Continued or increased pain.

Resolved symptomssuccess Answer: C Rationale: Failure to progress is an example of noncompliance. Resolved symptoms indicate that drug therapy was successful. every 4 hours as needed. 0. 0. 0.75 ml (or ¾ ml) = X 153. 75 mg I.25 b. the nurse uses the fraction method in the following equation: 75 mg/X ml = 100 mg/1 ml To solve for X. A client asks to be discharged from the health care facility against medical advice (AMA). What should the nurse do? a. Multiple questions show a client's lack of knowledge about the drug." How many milliliters of meperidine should the client receive? a. Failure to progressnon compliance d.75 Answer: D Rationale: To determine the number of milliliters the client should receive. The package insert reads: "Meperidine. 0. The physician prescribes meperidine (Demerol).M. Prevent the client from leaving. Undesired drug action indicates adverse drug reaction. cross-multiply: 75 mg × 1 ml = X ml × 100 mg 75 = 100X 75/100 = X 0.6 d. to control a client's postoperative pain. 75 .5 c. 152.c. 100 mg/ml.

Call a security guard to help detain the client. If the physician can't convince the client to stay. A scrub nurse in the operating room has which responsibility? a. The circulating nurse assists the surgeon and scrub nurse. which releases the facility from legal responsibility for any medical problems the client may experience after discharge.b. needles. 154. the physician will ask the client to sign an AMA form. Applying surgical drapescircu Answer. and instruments. c. accounting for all gauze sponges. the nurse should discuss the AMA form with the client and obtain the client's signature. assists with gowning and gloving. maintaining strict surgical asepsis and. with the circulating nurse. If the physician isn't available. positions the client. Assisting with gowning and glovingcircu c. 76 . Positioning the clientcircu b. Answer: B Rationale: If a client requests a discharge AMA. and provides the surgeon and scrub nurse with supplies. A client who refuses to sign the form shouldn't be detained because this would violate the client's rights. Handing surgical instruments to the surgeonscrub d. After the client leaves. the nurse should document the incident thoroughly and notify the physician that the client has left. applies appropriate equipment and surgical drapes. the nurse should notify the physician immediately. Notify the physician. d. C Rationale: The scrub nurse assists the surgeon by providing appropriate surgical instruments and supplies. Have the client sign an AMA form.

155. A client who's scheduled for open heart surgery in 2 days has been having circulation problems in the feet and legs, so the physician orders antiembolism stockings. Now, the nurse is teaching the client about this treatment. What is the purpose of antiembolism stockings? a. To decrease arterial blood circulation to the legs and feet b. To decrease venous blood circulation from the legs and feet c. To reduce or prevent edema in the legs and feet d. To maintain warmth in the legs Answer: C Rationale: Made of elastic material, antiembolism stockings are designed to reduce or prevent edema of the legs or feet by promoting venous return. They do this by increasing — not decreasing — arterial and venous blood circulation to the legs and feet. They don't maintain warmth in the legs; however, blankets can be used for this purpose.

156. A client with heart failure hasn't slept for the past 3 nights because of dyspnea. Arterial blood gas (ABG) analysis reveals pH, 7.32; PaO2, 79 mm Hg; PaCO2, 50 mm Hg; and HCO3–, 29 mEq/L. Which nursing diagnosis takes highest priority for this client? a. Fatigue b. Risk for injury c. Activity intolerance d. Disturbed sleep pattern Answer: B Rationale: These ABG values indicate hypoxia (insufficient oxygen in the blood), which causes altered thought processes and so is associated with a Risk for injury. Although the diagnoses of Fatigue, Activity intolerance, and Disturbed sleep pattern also may apply to this client, safety is the first concern.

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157. The nurse is teaching a client how to administer subcutaneous (S.C.) insulin injections. Which injection site would be appropriate for the client to use? a. DeltoidIM b. Rectus femoris c. Vastus lateralisIM d. Anterior aspect of the thighsubQ Answer: D Rationale: S.C. injection sites, which are relatively distant from bones and major blood vessels, include the lateral aspects of the upper arm, the anterior aspects of the thigh, and the abdomen. The deltoid, rectus femoris, and vastus lateralis are I.M. injection sites.

158. A client with shock brought on by hemorrhage has a temperature of 97.6° F (36.4° C), a heart rate of 140 beats/minute, a respiratory rate of 28 breaths/minute, and a blood pressure of 60/30 mm Hg. For this client, the nurse should question which physician order? a. "Monitor urine output every hour." b. "Infuse I.V. fluids at 83 ml/hour. rapid dapat c. "Administer oxygen by nasal cannula at 3 L/minute." d. "Draw samples for hemoglobin and hematocrit every 6 hours." Answer: B Rationale: Because shock signals a severe fluid volume loss (750 to 1,300 ml), its treatment includes rapid I.V. fluid replacement to sustain homeostasis and prevent death. The nurse should expect to administer three times the estimated fluid loss to increase the circulating volume. An I.V. infusion rate of 83 ml/hour wouldn't begin to replace the necessary fluids and reverse the problem. The other options are appropriate orders for this client

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159. A nurse implements a teaching plan for a client who's scheduled for discharge. Which client behavior best demonstrates effective teaching? a. Exhibiting a positive change in behavior b. Verbally repeating the instruction c. Making statements indicating that the client understands d. Exhibiting nonverbal signs such as nodding the head to indicate "yes" Answer: A Rationale: Exhibiting a positive change in behavior best demonstrates that the client understands and is complying with discharge teaching. Merely repeating what has been said, telling the nurse that the client understands, or nodding the head to indicate "yes" wouldn't demonstrate that the client has learned anything.

160. A blind client is admitted for treatment of gastroenteritis. Which nursing diagnosis takes highest priority for this client? a. Anxiety b. Risk for injury c. Activity intolerance d. Impaired physical mobility Answer: B Rationale: A sensory deficit such as blindness puts the client at risk for injury from the environment. To prevent an injury that could further complicate the client's stay, the nurse should assign highest priority to this nursing diagnosis. Although Anxiety, Activity intolerance, or Impaired physical mobility also may be relevant, these nursing diagnoses don't take precedence over client safety.

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Answer: A Rationale: An elastic bandage should be applied from the distal area to the proximal area.000X = 7.500 units. Which client action indicates an accurate understanding of the technique? 80 . lower thigh.500/10. The vial reads 10. The nurse has been teaching a client how to use an incentive spirometer that must be used at home for several days after discharge. The nurse must apply an elastic bandage to a client's ankle and calf. 1¼ ml Answer: C Rationale: The nurse solves the problem as follows: 10. She should apply the bandage beginning at the client's: a. or knee doesn't promote venous return. b.000 units per milliliter. 7. ¾ ml d.161. ½ ml c. c. 163. This method promotes venous return. ankle. ¼ ml b. foot.000 units/7. The physician orders heparin. Beginning at the ankle. d. knee.500 X = 7. lower thigh. to be administered subcutaneously every 6 hours. In this case.500 units = 1 ml/X 10. The nurse should anticipate giving how much heparin for each dose? a. the nurse should begin applying the bandage at the client's foot.000 or ¾ ml 162.

164. Rapid. but they don't help the nurse formulate nursing diagnoses. Which source of information helps the nurse formulate nursing diagnoses for a specific client? a. Admission criteria may help formulate the diagnoses but not without essential assessment data. 81 . deep breaths to elevate the spirometer ball. deep breaths to ensure maximum ventilation. the client should sit upright — rather than lie supine — to promote maximum ventilation.a. c. d. Essential assessment data c. The client uses the device while lying supine Answer: A Rationale: When using an incentive spirometer. a spirometer requires less effort to raise the ball. The client tilts the spirometer down when using it. Outcome criteria d. The client should hold the spirometer upright. Research articles b. The client takes rapid. b. shallow breathing doesn't allow maximum ventilation and lung expansion. Admission criteria Answer: B Rationale: Formulating a nursing diagnosis occurs after the assessment or data collection step in the nursing process. shallow breaths to elevate the ball. when tilted. The client takes slow. the client should take slow. which elevates the ball (or disc) inside the spirometer. Outcome criteria are formulated after (not before) nursing diagnoses. Analysis of essential assessment data and identification of the specific signs or symptoms and probable cause help the nurse to diagnose the client. Research articles provide information related to developing current interventions. During spirometry.

Which step of the nursing process is the nurse using? a. or ball. thrills. Analysis c. The nurse is assessing tactile fremitus in a client with pneumonia. the nurse labels or describes the client's health problems or needs such as pain. The fingertips and finger pads best distinguish texture and shape. Assessment b. For this examination. During the nursing analysis (or diagnosis) step of the nursing process.M. because the nurse performed an intervention and is evaluating whether the goal has been met. the nurse should use the: a. the nurse asks the client whether the pain is relieved. this action is considered part of evaluation. The dorsal surface best feels warmth. During implementation. 166. 82 . A client receives meperidine (Demerol). Mplementation d.165. c. the nurse performs interventions to meet the client's needs such as administering medication. 50 mg I. ulnar surface of the hand. d. Answer: B Rationale: The nurse uses the ulnar surface. Thirty minutes later. not assessment. dorsal surface of the hand. fingertips. and vocal vibrations through the chest wall. b.. finger pads. Evaluation Answer: D Rationale: Although the nurse is assessing pain relief. of the hand to assess tactile fremitus. for relief of surgical pain.

so it shouldn't be left on an open wound. however. 83 . a physician must act as cosigner. Petroleum supports healing but is expensive. The primary nurse b. The primary nurse or the nurse working with the physician may serve as a witness to the client's signature. Dry sterile dressings adhere to the wound and debride the tissue when removed. the nurse notes an open ulceration with visible granulation tissue in the wound. The nurse working with the physician d. which of the following types of dressings is most appropriate for the nurse to apply? a. a physician's assistant may obtain informed consent. Moist sterile saline gauze d. it can irritate epithelial cells. Povidone-iodine–soaked gauze Answer: C Rationale: Sterile saline dressings support wound healing and are costeffective. 168. Until a wound specialist can be contacted. The physician's assistant Answer: B Rationale: The physician involved with the procedure is responsible for obtaining the client's informed consent. Which member of the health care team is responsible for obtaining informed consent from a client? a. The physician c. Sterile petroleum gauze c. in this case. Dry sterile dressing b. however. Povidone-iodine is used as an antiseptic cleaning agent.167. While examining a client's leg. In some health care facilities.

position the client in the shock position with his legs elevated. turn the client on his left side and place the bed in Trendelenburg's position. What is an appropriate nursing intervention for a client with an arm restraint? a. lie the client supine and prepare for cardiopulmonary resuscitation. d. The other positions are therapeutic for other situations but not for air embolism. disoriented.169. This allows the air to collect in the right atrium rather than enter the pulmonary system. Applying the restraint loosely to prevent pressure on the skin b. A nurse is assisting a physician with the insertion of a subclavian central line. b. After the physician has gained access to the subclavian vein. The appropriate response from the nurse should be to: a. place the client on his left side and in Trendelenburg's position. Positioning the restrained arm in full extension d. Suddenly. the nurse should leave approximately one fingerbreadth between the restraint and the extremity. Tying the restraint to the side rail c. the client becomes confused. Tying a restraint to the side rail or an 84 . c. Answer: C Rationale: When an air embolism is suspected. place the client in high-Fowler's position and give supplemental oxygen. To make sure the restraint is secure without compromising the circulation. The nurse suspects an air embolus. and pale. Monitoring circulatory status every 2 hours Answer: D Rationale: The nurse must assess the circulatory status of a restrained extremity every 2 hours to prevent circulatory impairment. 170. he connects a 10-ml syringe to the catheter and withdraws a sample of blood. He then disconnects the syringe from the port.

Answer: D Rationale: Early signs and symptoms of dehydration include thirst. Used needles are never recapped. and increased heart rate with hypotension are all later signs. thirst or confusion. Goggles approved by the Occupational Safety and Health Organization are used 85 . wearing gloves only for sterile procedures. sunken eyeballs and poor skin turgor. d. increased heart rate with hypotension. Early manifestations of dehydration include: a. regardless of their diagnosis or infection status. coma or seizures. sunken eyeballs.immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. seizures. c. confusion. and dizziness. The restrained arm or leg should be flexed slightly to allow slight joint movement without reducing the effectiveness of the restraint. irritability. disposing of sharp instruments in an impervious container. d. b. 172. immediately recapping used needles. Coma. Gloves are used if contact with body fluids is anticipated. poor skin turgor. substituting regular eyeglasses for eye protection Answer: B Rationale: Disposing of sharp instruments in an impervious container is included in the guidelines for standard precautions. c. Guidelines for standard precautions include: a. The nurse is assessing a client who may be in the early stages of dehydration. 171. Standard precautions were designed for the care of all clients in hospitals. they should be disposed of in a sharps container. b.

How should the nurse respond to this order? a. and louder there than S1.for eye protection. c. d. in four divided doses over the next 24 hours. b. lower. S1 and S2 sound equally loud over the entire cardiac area. Refuse to carry out the order. the nurse should write and sign a verbal order as dictated by the prescriber and then repeat the order aloud for the prescriber's verification. and then repeat it aloud for the physician's verification. 173. higher. After examining the client. Write and sign the order as dictated. It sounds shorter. the physician gives a verbal order for digoxin (Lanoxin). Although verbally repeating the order for verification is appropriate. b. S1 and S2 sound fainter at the base. Answer: D Rationale: The S1 sound — the "lub" sound — is loudest at the apex of the heart. and S2 is loudest at the base. and louder there than the S2 sounds. and then repeat it aloud for the physician's verification. S1 and S2 sound fainter at the apex. c. d. Write and sign the order as dictated. asking the prescriber to spell the drug name if necessary. Insist that the physician write the order. It sounds longer. such as the one described here. The S2 — the "dub" sound — is loudest at the base. 1 mg I. sharper. Eyeglasses aren't an acceptable form of protection because they're open at the sides. Answer: A Rationale: In urgent situations. S1 is loudest at the apex.V. Which statement regarding heart sounds is correct? a. starting with the first dose stat. 174. the nurse must write 86 . then administer the drug. A client comes to the emergency department complaining of a fast and irregular heartbeat.

176. Sims' left lateral b. the dorsal recumbent or right lateral position may be used. 0. Dorsal recumbent c. If the client can't assume this position or has poor sphincter control. 175. In an urgent situation. insisting that the physician write the order would take valuable time away from crucial interventions and client evaluation.6 ml equals 30 mg when the ratio is 50 mg/ml. Prone Answer: A Rationale: The Sims' left lateral position is the most common position used to administer a cleansing enema because it allows gravity to aid the flow of fluid along the curve of the sigmoid colon. The supine and prone positions are inappropriate and uncomfortable for the client.6 ml d.5 ml Answer: C Rationale: A measure of 0. 1 ml c. The ratio to determine this answer is 30 mg : X ml :: 50 mg : 1 ml. 0. Refusing to carry out the order would be appropriate only if the nurse felt the order was unsafe. What is the most common client position used for this procedure? a. The label of a drug package reads "meperidine hydrochloride (Demerol). 87 . 50 mg/ml.6 ml b. 1. The nurse prepares to administer a cleansing enema.the order to prevent errors. Supine d." How many milliliters would the nurse give a client for a 30-mg dose? a.

Sodium chloride d. Which of the following types of solutions. interdependent. whereas consulting with the physician and pharmacist to change a client's medication because of adverse reactions represents an interdependent intervention. Interdependent c. when administered I. A sodium chloride solution can be isotonic. Independent Answer: D Rationale: Nursing interventions are classified as independent. Hypertonic Answer: D Rationale: A hypertonic solution causes fluids to be absorbed into the bloodstream until equal pressure is established on both sides of the blood vessel. An isotonic solution has no effect on the cell. depending on the concentration of sodium.177. would cause a shift of fluid from body tissues to the bloodstream? a. 178. A client requests his medication at 9 p. or dependent. Hypotonic b. Isotonic c. 88 .m.V. instead of 10 p.. A hypotonic solution causes fluids to move from the bloodstream into the tissues. Which type of nursing intervention is required? a. so that he can go to sleep earlier. An intradependent nursing intervention doesn't exist. or hypotonic. Altering the drug schedule to coincide with the client's daily routine represents an independent intervention. Intradependent b. hypertonic. Dependent d. Administering an already-prescribed drug on time is a dependent intervention.m.

179. Which strategy can help make the nurse a more effective teacher? a. Including the client in the discussion b. Using technical terms c. Providing detailed explanations d. Using loosely structured teaching sessions Answer: A Rationale: An effective teacher always involves the student in the discussion. Using technical terms and providing detailed explanations usually confuse the student and act as barriers to learning. Using loosely structured teaching sessions permits distractions and deviations from the teaching goals.

180. Policy and procedure dictate that hand washing is a requirement when caring for clients. Which statement about hand washing is true? a. Frequent hand washing reduces transmission of pathogens from one client to another. b. Wearing gloves is a substitute for hand washing. c. Bar soap, which is generally available, should be used for hand washing. d. Waterless products shouldn't be used in situations where running water is unavailable. Answer: A Rationale: Whether gloves are worn or not, hand washing is required before and after client contact because thorough hand washing reduces the risk of cross-contamination. Bar soap shouldn't be used because it's a potential carrier of bacteria. Soap dispensers are preferable but they must also be checked for bacteria. When water is unavailable, the nurse should wash using a liquid hand sanitizer.

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181. The nurse prepares to assess a client who has just been admitted to the health care facility. During assessment, the nurse performs which activity? a. Collects data b. Formulates nursing diagnoses c. Develops a plan of care d. Writes client outcomes Answer: A Rationale: During the assessment step of the nursing process, the nurse collects relevant data from various sources. The nurse formulates nursing diagnoses during the nursing diagnosis step and develops a plan of care and writes appropriate client outcomes during the planning step. The nurse evaluates the success of client outcomes during the evaluation step.

182. After receiving a visit from the spouse, a client begins crying and saying that the spouse is a mean person. When the client starts pounding on the overbed table and using incomprehensible language, the nurse feels unable to handle the situation. What should the nurse do at this time? a. Tell the client that the spouse is probably under a lot of stress. b. Instruct the client to stop pounding on the overbed table. c. Call facility security to control the situation. d. Request assistance by using the call system. Answer: D Rationale: Whenever a nurse feels unable to handle a problem, the nurse should seek assistance by using the call system. Options A and B are inappropriate because they're nontherapeutic responses; they don't address the client's feelings or needs. Informing facility security is an overreaction to the situation at this point.

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183. A client is scheduled for surgery under general anesthesia. The night before surgery, the client tells the nurse, "I can't wait to have breakfast tomorrow." Based on this statement, the nurse should formulate which nursing diagnosis? a. Deficient knowledge related to food restrictions associated with anesthesia b. Fear related to surgery c. Risk for impaired skin integrity related to upcoming surgery d. Ineffective individual coping related to the stress of surgery Answer: A Rationale: The client's statement reveals a Deficient knowledge related to food restrictions associated with general anesthesia. The other options may be applicable but aren't related to the client's statement.

184. The nurse prepares to palpate a client's maxillary sinuses. For this procedure, where should the nurse place the hands? a. On the bridge of the nose b. Below the eyebrows c. Below the cheekbonesmaxillary d. Over the temporal area Answer: C Rationale: To palpate the maxillary sinuses, the nurse places the hands on either side of the client's nose below the cheekbone (zygomatic bone). To palpate the frontal sinuses, the nurse places the thumb just above the client's eye under the bony ridge of the orbit. No sinuses are located on the bridge of the nose or in the temporal area.

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and the twin sister says to the nurse. 100 U of regular insulin in normal saline solution b. abide by the wishes of the sister who is the durable power of attorney agent. inform the sister that she doesn't have the power to assign a different physician. Further along in the therapy." In response. The client has identified her twin sister as the agent in her durable power of attorney. politely ignore the sister's statement and continue to call the dismissed physician for orders. Which solution is the most appropriate at the beginning of therapy? a. a dextrose solution is administered to prevent hypoglycemia. ask the dismissed physician if the client ever stated she wanted a different physician. Answer: C Rationale: A durable power of attorney transfers all rights that the individual normally has regarding health care decisions to the 92 . 100 U of regular insulin in dextrose 5% in water d. I've dismissed her friend. The nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of 800 mg/dl. 100 U of NPH insulin in dextrose 5% in water Answer: A Rationale: Only short-acting regular insulin is used in continuous insulin infusions. the nurse should: a. b. 186. "There will be a different physician caring for my sister now. A client with terminal breast cancer is being cared for by a longtime friend who's a physician. The client loses decisionmaking capacity. d. Insulin is added to normal saline solution and administered until blood glucose levels fall. 100 U of neutral protamine Hagedorn (NPH) insulin in normal saline solution c. c.185.

The order is correct and valid. It's within the power of the twin sister to change the physician caring for her terminally ill twin. When determining appropriate nursing interventions for a client with a medical diagnosis. The ordered route is inappropriate for this drug. Regional anatomy d.designated agent. Developmental 93 . The order should be clarified with the physician. the nurse shouldn't consider this order correct and valid." The nurse responsible for administering the drug should base the next action on which understanding? a. d. 188. Because the order specifies the drug volume but not the dosage. Answer: C Rationale: The nurse must clarify this order with the physician because meperidine is available in several dosage strengths. Descriptive anatomy Answer: B Rationale: The nurse uses applied anatomy to base nursing interventions on the knowledge of anatomic findings for nursing care and diagnosis and treatment of medical disorders. Developmental anatomy b. A medication order reads "Meperidine 1 ml I. The order should specify the exact time to give the drug. It would be inappropriate and unprofessional of the nurse to ignore the wishes of the client's agent.M. Applied anatomy c. b. 187. Meperidine commonly is given I. The dismissed physician has no power to interfere with the wishes of the durable power of attorney. the nurse is using which of the following? a.M. Stat orders need not specify an exact administration time. stat. and 1 ml may contain varying amounts of the drug. c.

the nurse should monitor a client's: a. Pressing on release Answer: A Rationale: The nurse elicits rebound tenderness by pressing the affected area firmly with one hand. 189. The drug isn't known to affect serum potassium or glucose levels or PTT. releasing pressure while maintaining fingertip contact with the skin. Pressing the affected area firmly with one hand. serum creatine level. releasing pressure quickly. serum glucose level. How does the nurse elicit rebound tenderness? a. c. Descriptive anatomy studies individual body parts in an orderly fashion. 190. partial thromboplastin time (PTT). d. the nurse should monitor a client's serum creatine level because the most notable adverse reactions to aminoglycoside therapy are nephrotoxicity and ototoxicity. and noting any tenderness on release. During gentamicin therapy. and noting tenderness 94 . serum potassium level. Regional anatomy refers to the study of limited portions of the body.anatomy is used to study the structural changes occurring from conception through old age. b. releasing pressure quickly. The other options aren't used to elicit rebound tenderness. firmly with one hand. The nurse is examining a client with suspected peritonitis. Using light palpation. Answer: D Rationale: During gentamicin therapy. Using deep ballottement. noting any tenderness over an area c. and noting any tenderness on release b. noting any tenderness over an area d.

alternate warm compresses with cold compresses. either should be applied only for a limited time. Warm compresses increase circulation and promote absorption of fluid in the infiltrated area. Questions about muscle strength help evaluate the motor system. The physician orders warm soaks for the area. c. Keeping the 95 . Questions about eyesight help evaluate the cranial nerves associated with vision 192. keep the area covered with the warm soaks continuously. cause vasoconstriction. Removing the compresses every 20 minutes for at least 15 minutes prevents injury to the skin and subsequent rebound vasoconstriction. The nurse has just removed an I. and mental status. Questions about coordination help assess cerebellar function. "Have you noticed a change in your memory?" b. d. Cold compresses.V. Based on the principles of heat and cold application. although helping to reduce edema. the nurse should ask: a. the nurse should ask about the client's level of consciousness. "Have you had any coordination problems?"cerebellar d. "Have you noticed a change in your muscle strength?"motor c. b. orientation. question the order because heat increases edema.191. remove the warm compress after 20 minutes for at least 15 minutes. including memory. "Have you had any problems with your eyes?"cranial nerves Answer: A Rationale: To assess cerebral function. Answer: B Rationale: Because heat and cold can injure the skin. the nurse would: a. catheter from a client's arm because fluid has infiltrated the arm. To help assess a client's cerebral function.

upcoding. 194. c. such illegal behavior is known as: a. and sensory deficits. 193. Under the False Claims Act. A client in a behavioral-health facility receives a 30-minute psychotherapy session and the provider bills for a 50-minute session. misrepresentation. Answer: C Rationale: Upcoding is the practice of using a current procedure terminology code that is reimbursed at a higher rate than the code for the service actually provided. Bowel habits and allergies Answer: A Rationale: General background data consist of such components as allergies. overbilling. Urine output and allergies c. Allergies and socioeconomic status b. and bowel habits are significant only if a disease affecting these functions is present. gastric reflex. unbundling. Gastric reflex and age d. Unbundling. Which of the following factors are major components of a client's general background drug history? a. and misrepresentation aren't the terms used for this illegal practice. d. overbilling. beliefs. lifestyle. Urine output. socioeconomic status. medical history. b. 96 . habits.area covered continuously isn't appropriate because this can lead to skin breakdown.

195. The nurse is caring for a client receiving lidocaine I. Decrease in arterial oxygen saturation (SaO2) when measured with a pulse oximeter b. SaO2. Which factor is most relevant to administration of this medication? a. Altered nutrition: Less than body requirements d. carinii pneumonia. Increase in systemic blood pressure c. Impaired gas exchange is the nursing diagnosis with priority for a client with P.V. A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Airway. Which nursing diagnosis has the highest priority? a. Impaired gas exchange b. Increase in intracranial pressure (ICP) Answer: C Rationale: Lidocaine drips are commonly used to treat clients whose arrhythmias haven't been controlled with oral medication and who are having PVCs that are visible on the cardiac monitor. blood pressure. Activity intolerance Answer: A Rationale: Although all of the nursing diagnoses are appropriate for a client with AIDS. Presence of premature ventricular contractions (PVCs) on a cardiac monitor d. Altered oral mucous membranes c. breathing. and ICP are important factors but aren't as significant as PVCs in this situation 97 . and circulation take top priority for any client 196.

Before meals c. Marital status information may be important for discharge planning but isn't as significant for addressing the immediate medical problem. The physician orders chest physiotherapy for a client with respiratory congestion. 70 mm Hg. After meals b. and HCO3–. PaCO2. 24 mEq/L. PaO2. General health for the past 10 years b. however. Which information will be most useful to the nurse for planning care? a. General health in the previous 10 years is important. What do these values indicate? 98 . When the nurse has time Answer: B Rationale: Chest physiotherapy is best performed before meals to avoid tiring the client or inducing vomiting. When the client has time d. 7. Family history of diseases for a client in later years is of minor significance. Current health promotion activities c. the current activities of an 85-year-old client are most significant in planning care.51. The nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH. Family history of diseases d. Marital status Answer: B Rationale: Recognizing an individual's positive health measures is very useful. 28 mm Hg. Scheduling chest physiotherapy around client or nurse convenience is inappropriate. When should the nurse plan to perform chest physiotherapy? a.197. 199. 198. The nurse is taking the health history of an 85-year-old client.

shallow breaths with an increased respiratory rate. During routine assessment. the client is experiencing respiratory alkalosis. rapid. Hyperventilation leads to excess carbon dioxide (CO2) loss. Metabolic acidosis b. Respiratory acidosis d. Respiratory alkalosis Answer: D Rationale: A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Cheyne-Stokes respirations are: a. Because the HCO3– level is normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. rapid. progressively deeper breaths followed by shallower breaths with apneic periods. deep breaths with abrupt pauses between each breath. and equal depth between each breath. Therefore. 99 . kussmauls d. cheyne b. The kidneys' bicarbonate (HCO3–) response is delayed. deep breaths with abrupt pauses between each breath. so the client's HCO3– level remains normal. the nurse notices Cheyne-Stokes respirations. which causes alkalosis — indicated by this client's elevated pH value. deep breaths and irregular breathing without pauses. this imbalance has no metabolic component. Biot's respirations are rapid. Metabolic alkalosis c. biots c. The nurse is caring for a client who has suffered a severe cerebrovascular accident (CVA).a. 200. tachypnea Answer: A Rationale: Cheyne-Stokes respirations are breaths that become progressively deeper followed by shallower respirations with apneic periods.

Urine specific gravity c. Subcutaneous (S. indicating overhydration or dehydration. A client with heart failure must be monitored closely after starting diuretic therapy.V. Fluid intake and output and vital signs are less accurate than weight. Drugs that are administered I. resulting in weight gain. Intradermal d. 202.M. requiring no absorption? a. Answer: D Rationale: The I. A drug must enter the bloodstream before it can act within the body.) c. Therefore. deep breaths without pauses. weight is the most accurate indicator of this client's status.V.Kussmaul's respirations are rapid. Weight Answer: D Rationale: Heart failure typically causes fluid overload. although helpful. it isn't the most accurate indicator because it can be influenced by numerous factors. 100 .M.C.. Which parenteral administration route places a drug directly into the circulation. I. b. Tachypnea is abnormally rapid respirations. Urine specific gravity reflects urine concentration. I. S. Vital signs d. Fluid intake and output b. or intradermally must be absorbed.. route bypasses the absorption barriers and provides an immediate systemic response. 201.C. One pound gained or lost is equivalent to 500 ml. What is the most accurate indicator of this client's status? a.

Circumscribed. The American Cancer Society often sponsors support groups. Asking an occupational therapist to evaluate the client at home Answer: C Rationale: Many clients are discharged from acute care settings so quickly that they don't receive complete instructions. elevated. Solid.203. the nurse finds a vesicle on the client's arm. elevated. and circumscribedpapule c. Referring the client to a home health nurse for follow-up visits to provide colostomy care d. which are helpful when the person is ready. pus-filled. Requesting Meals On Wheels to provide adequate nutritional intake c. A client is being discharged after undergoing abdominal surgery and colostomy formation to treat colon cancer. A flat. Therefore. and circumscribedpustule Answer: C Rationale: A vesicle is a circumscribed skin elevation filled with serous fluid. Which description applies to a vesicle? a. nonpalpable. Elevated. and colored macule b. 101 . elevated. the first priority is to arrange for colostomy care. When inspecting a client's skin. nonpalpable. but contacting this organization doesn't take precedence over ensuring proper colostomy care. colored spot is a macule. and filled with serous fluidvesicle d. Notifying the American Cancer Society of the client's diagnosis b. Which nursing action is most likely to promote continuity of care? a. Flat. 204. A solid. Requesting Meals On Wheels and asking for an occupational therapy evaluation are important but can occur later in rehabilitation.

circumscribed lesion is a papule. Providing a low-calorie diet Answer: D Rationale: A client with a fever has an increased basal metabolism rate. All the other responses — monitoring the client's temperature. magnesium. he needs additional calories in his diet. Increasing fluid intake c. 205. Answer: A Rationale: Propofol causes urinary zinc losses. b. and covering him with a light blanket — are therapeutic interventions for a fever. 206. 102 . including elevated or depressed sodium and potassium levels. increasing his fluid intake. c. and burn clients are particularly susceptible to zinc deficiency. As a result. He becomes delusional and attempts to extubate himself. Therefore.9° C). Monitoring temperature every 4 hours b. He's given propofol (Diprivan). pus-filled. circumscribed lesion is a pustule. a. sodium. a sedative. potassium. Covering the client with a light blanket d. it's most important that the client receive a supplementation of: a. d. A client with severe thermal burns is on mechanical ventilation. Which action would be contraindicated for a client who develops a temperature of 102° F (38. however. Burn clients are prone to electrolyte imbalances. these aren't specifically related to propofol therapy. Therefore. An elevated. zinc. zinc supplementation may be necessary.

Dullness Answer: C Rationale: Resonance is a normal finding on percussion of healthy lung tissue. A client with a fluid volume deficit is receiving an I. Temperature of 99.6° C) is only slightly elevated and doesn't indicate a fluid volume deficit. but it isn't a result of propofol therapy. Hyperresonance may occur on percussion of hyperinflated lungs such as in emphysema.The need for magnesium supplementation may exist. When percussing a client's chest. urine appears light yellow. Tympany c. The nurse may assess tympany when percussing over the abdomen. Hyperresonance b. Resonance d. Which assessment finding indicates the need for additional I. The serum sodium level normally ranges from 135 to 145 mEq/L. fluids? a. such as with a gastric air bubble or 103 . 207. 208. Dark amber urine Answer: D Rationale: Normally. Neck vein distention d.6° C) c.V. the nurse should identify which sound as a normal finding? a.6° F (37.V. infusion of dextrose 5% in water and lactated Ringer's solution at 125 ml/hour. dark amber urine is concentrated and suggests decreased fluid intake. Serum sodium level of 135 mEq/L b.6° F (37. A temperature of 99. Neck vein distention is a sign of fluid volume overload.

The client's words are strong. For example. small air bubbles can change the dose of medication actually administered. I'm sick of this place and the staff. duration. and absorption won't be affected." The nurse's best response would be: a. "I've had my damn light on for 20 minutes. Altered onset of action b. the client frowns and states. and it's obvious that 104 . "You've had your light on for 20 minutes?" Answer: C Rationale: To be therapeutic. "My name is Mary and I'm your nurse for today. and a pregnant uterus. The drug's onset of action. 210. Altered drug absorption d." c. "You seem upset this morning. the nurse should always comment on the client's statements. the nurse should remove the air bubbles. Air bubbles may actually be helpful in some situations but should be added only after the dose of the drug has been withdrawn accurately.intestinal air. Altered drug dose Answer: D Rationale: Although not harmful to the client when injected. an air bubble and the Z-track method of injection help prevent permanent staining of the client's skin if the solution leaks into the subcutaneous tissue. therefore. Dullness occurs over the liver. It's about time you got here. Small air bubbles adhering to the interior surface of the syringe might have which effect with parenteral administration? a. "I'm sorry. with iron dextran. Altered duration c. a full bladder. 209. I was busy with another client." d. Upon entering a client's room." b.

d." d. 211." b. Answer: C Rationale: Inelastic skin turgor is a normal part of aging. the nurse should remember that: a. "I hate talking about this because it may upset you. normal skin turgor is moist and boggy. Overhydration — not dehydration — causes the skin to appear edematous and spongy. When evaluating skin turgor. her husband asks the nurse why she must sign a statement confirming that she has been told of her rights to communicate her wishes about life support and resuscitation. b. "Everyone has to sign this. dehydration causes the skin to appear edematous and spongy. Saying I'm sorry and introducing yourself ignores the client's problem. 212. Dehydration — not overhydration — causes inelastic skin with tenting. How should the nurse respond? a. overhydration causes the skin to tent. Normal skin turgor is dry and firm. As a client is being admitted to the facility. inelastic skin turgor is a normal part of aging. c. "We make sure our clients know they have the right to specify advance directives and appoint someone to speak for them.the client is angry." c. It doesn't mean we think anything will go wrong. Repeating the client's statement would only add to the client's anger. The nurse must assess skin turgor of an elderly client. We need to know what we should do in case something unexpected happens. "Hospital policy requires us to have your wife sign this." Answer: C 105 . but federal law requires her to sign this and there is nothing we can do.

Clients who ambulate after the first postoperative day d. and any signs or symptoms that help define the diagnostic label. Clients who require frequent pain medication b.8 kg) overweight c. 213. This list should include: a. Expected outcomes are measurable behavioral goals that the nurse develops during the evaluation step of the nursing process. factors influencing the client's problem. b. possibly 106 . Answer: C Rationale: A nursing diagnosis is a written statement of the client's actual or potential health problem. Frequent pain medication allows the client to be more comfortable. The nurse obtains a nursing history during the assessment step of the nursing process. It includes a specified diagnostic label. The nurse is developing a list of nursing diagnoses for a client. c. Vitamins and protein are essential for wound healing.Rationale: This response provides factual information. Clients who are 15 lb (6. therefore. 214. a malnourished client is at an increased risk for developing a wound infection. factors that influence the client's problem. nursing history. d. Actions to achieve goals are nursing interventions. The other options don't answer the husband's question or provide the information he requested. expected outcomes. Which of the following groups of clients is at an increased risk for developing a wound infection? a. actions to achieve goals. Clients who are undernourished Answer: D Rationale: Nutrition plays an important role in wound healing.

the change isn't unplanned. Within 6 months d. Ambulation improves circulation and thus promotes better healing. Situational c. an outpatient must fill a prescription for a controlled substance within 6 months of the date on which the prescription was written 216. Unplanned b. Within 3 months c.enabling the client to move about more easily. During discharge teaching. 215. Within 1 month b. Physiologic Rationale: Adjustment to the birth of a child is an example of a situational change. 107 . Which of the following changes is demonstrated when a nurse helps a young mother adjust to the birth of her child? a. Physiologic change refers to the events associated with aging and menopause. the nurse should explain that the client must fill this prescription how soon after the date on which it was written? a. which arises from the interaction between individuals and the environment. Adjustment to maturational change refers to that associated with puberty. Maturational d. A client is to be discharged with a prescription for an analgesic that is a controlled substance. Because pregnancy is a 9-month process. Within 12 months Answer: C Rationale: In most cases. A client who is 15 lb overweight isn't at increased risk.

Shortly after being admitted to the coronary care unit with an acute myocardial infarction (MI). The nurse notes that the client is restless and slightly diaphoretic.6° C). It would be inappropriate become for the nurse-manager and counsel to remind the charge staff of a responsibility that they may be fulfilling. and measures a temperature of 99. slightly labored respirations at 26 breaths/minute. Therefore. and a blood pressure of 150/90 mm Hg. a heart rate of 102 beats/minute. Risk for imbalanced body temperature b. c.6° F (37. arrange a meeting of the day-shift and night-shift nurses. It would be most prudent for the nurse-manager to: a. the nurse-manager should review the calibration documentation. Decreased cardiac output c. b. Which nursing diagnosis takes highest priority? a. then address the findings. Pain Answer: D 108 . arrange a meeting that could confrontational.217. a client reports midsternal chest pain radiating down the left arm. Anxiety d. A nurse-manager receives several complaints from day-shift nurses that the night-shift nurses aren't performing the daily calibration of the capillary glucose monitoring apparatus. counsel the night charge nurse about the discrepancy. review the capillary glucose monitoring calibration log book d. immediately remind the night-shift nurses of the daily calibrations. regular. 218. which is their responsibility. a manager should always gather data first. the nurse before investigating and gathering data about the complaint. Answer: C Rationale: When dealing with complaints.

The client's blood pressure and heart rate don't suggest a nursing diagnosis of Decreased cardiac output. cloudy vision. The client restricts fluid intake to prevent overhydration. Fluid intake should thin secretions. The client should be able to cough effectively and should be encouraged to increase activity. During the acute phase of an MI. d. low-grade fever is an expected result of the body's response to myocardial tissue necrosis. 220. Answer: D Rationale: If the interventions are effective. Answer: C 109 . A nurse is caring for a client with a diagnosis of Impaired gas exchange. 219. the nurse should consider that one normal aging change is: a. The client has normal breath sounds in all lung fields. diminished reflexes. Anxiety could be an appropriate nursing diagnosis. tremors. The client maintains a reduced cough effort to lessen fatigue. The client reduces daily activities to a minimum. When performing the assessment. d. incontinence. The nurse is assessing an elderly client.Rationale: The nursing diagnosis of Pain takes highest priority because it increases the client's pulse and blood pressure. but it may be corrected by addressing the priority concern: Pain. c. breath sounds should return to normal. b. as tolerated. Which outcome is most appropriate based upon this nursing diagnosis? a. b. c. This makes Risk for imbalanced body temperature an incorrect answer.

and tremors may be signs and symptoms of underlying pathology. incontinence. continued use of and need for oxygen. and a respiratory rate of 24 breaths/minute indicate that the client is still experiencing airway problems." Answer: A Rationale: A transdermal disk should be applied to a different site each time." c. Respiratory rate of 24 breaths/minute Answer: B Rationale: The expected outcome for a client with Ineffective airway clearance is for the lungs to be clear of secretions (or congestion) on auscultation. A client is to be discharged on daily medication delivered by a transdermal disk. "I'll wash my hands after applying the disk. The client should avoid placing it on uneven. The other options indicate an understanding of transdermal disk use." b. which is a normal result of aging. 110 ." d. "I'll change the disk at the same time every day. "I'll avoid touching the gel in the disk. Breath sounds clear on auscultation c. Presence of congestion on X-ray b. Which statement indicates the need for further medication teaching? a. Which of the following outcome criteria would be most appropriate for the client with a nursing diagnosis of Ineffective airway clearance? a. Cloudy vision. or irritated skin or on areas below the knee or elbow. Congestion on X-ray. 221. damaged. Continued use of oxygen when necessary d.Rationale: Degenerative changes can lead to decreased reflexes. 222. "I'll place the disk on the same spot each day.

d. Encourage the client to hire a visiting nurse. geriatric clients tend to use more than one medication concurrently. not the nurse. giving all instructions at least three times doesn't necessarily ensure compliance. Moreover. Give all instructions at least three times. Devise the simplest medication schedule possible. nurses should simplify the medication schedule. b. It's too costly and impractical to hire a visiting nurse in most instances.223. Adding air prevents the solution from entering a blood vessel. Although instructions may need to be repeated. must decide how often a medication should be given. the nurse measures the correct medication dose and then draws a small amount of air into the syringe. which could cause skin staining. Adding air ensures that the client receives the entire dose. Adding air prevents the drug from flowing back into the needle track. Adding air doesn't decrease pain (which results from the drug's chemical composition). b. What is the best way for the nurse to improve client compliance with the prescribed medication schedule? a. Change the administration schedule to longer intervals. preventing it from flowing back into the needle track. To give a Z-track injection. Answer: B Rationale: The added air pushes the drug into muscle tissue. Compliance drops sharply when more than three medications are prescribed. Answer: D Rationale: To improve client compliance. 224. What is the rationale for this action? a. a physician. d. c. c. Adding air decreases pain caused by the injection. and it has no bearing on whether the drug enters 111 .

9° C d.1° C Answer: C Rationale: To convert Fahrenheit degrees to Centigrade. 47° C c. use this formula: °C = (°F – 32) ÷ 1. The nurse should teach the client to: a.a blood vessel. but diarrhea isn't an effect of taking an anticoagulant. d. Answer: B Rationale: The client should avoid consuming large amounts of vitamin K because vitamin K can interfere with anticoagulation. 226. c. The client may need to report diarrhea. avoid foods high in vitamin K.8 °C = 38. An electric razor — not a straight razor — should be used to prevent cuts that cause bleeding. use a straight razor when shaving. Adding air isn't necessary to ensure that the client receives the entire dose 225. take aspirin for pain relief. The nurse is caring for a client who is taking an anticoagulant. What is the equivalent Centigrade temperature? a.8 °C = (102 – 32) ÷ 1. 39° C b. Aspirin may increase the risk of bleeding. report incidents of diarrhea. acetaminophen should be used for pain relief. b. The nurse measures a client's temperature at 102° F.9 112 . 40. 38.8 °C = 70 ÷ 1.

The wound drainage is serous. although the nurse may make referrals to the appropriate department for financial assistance. The other options — red or edematous surrounding tissue and serous drainage — are insufficient evidence that the wound is healing 228. This action aids the transition to a new setting and is designed to shorten facility stays. c. Preventing the need for medical follow-up care Answer: B Rationale: A common goal of discharge planning in all settings is teaching the client how to perform self-care activities. For healing by second intention. Teaching the client how to perform self-care activities c. Providing financial assistance isn't a goal of discharge planning. the nurse should encourage the client to return for these visits. When evaluating the wound. a client's wound has been packed with medicated dressings. The surrounding tissue is red in color. The granulation tissue is at the wound edges. Providing the financial resources needed to ensure proper care d.227. What is a common goal of discharge planning in all care settings? a. Prolonging hospitalization until the client can function independently b. d. which of the following findings indicates that healing is taking place? a. evidence of granulation tissue indicates wound healing. Answer: D Rationale: Connective tissue develops and fills in (or approximates) the wound edges from granulation tissue. Rather than preventing the need for follow-up visits. Thus. The skin around the wound is edematous. b. 113 .

Warm the I. b. The client is retired and looks back on his life with satisfaction. generativity.V. the nurse should aspirate the syringe gently for a small amount of blood to ensure correct placement of the I. bolus injection of lidocaine (Xylocaine) for a client with a ventricular arrhythmia. Then the nurse may inject the medication over the recommended time interval. Inserting another I. 114 . What should the nurse do before administering a direct I. b. The physician orders an I. Warming the medication may alter the drug's action. Ego integrity. Placing a tourniquet on the arm would close off the venous system and prevent drug injection. bolus? a. solution. the nurse assesses that the client is in a stage of: a. and industry all apply to earlier stages of development 230. Answer: A Rationale: Before administering a direct I.V. d. Gently aspirate the syringe for a blood return. ego identity. c.V. c.V. industry. bolus.V. Answer: A Rationale: An adult at age 74 is in the stage of generativity versus stagnation. line into the opposite arm. According to Erickson.V. Insert an I.V. needle. line isn't necessary unless the ordered medication is incompatible with that in the I. ego identity. d.V. medication to room temperature. A 74-year-old client has three grown children who each have families of their own. Place a tourniquet on the arm to be used for injection. ego integrity.229.

Discontinue the infusion. fluids (at a decreased rate) or additional I. Administer a prescribed diuretic. Administering a diuretic without changing the I. Keeping the call light easily accessible is important but isn't a top priority. medications.V. placing the call light for easy access. if the 115 . c. and tachycardia. b. Answer: D Rationale: Because this client has fluid overload. neck vein distention. infusion rate wouldn't prevent fluid overload from recurring. Slow the infusion and notify the physician.231.V. infusion at 125 ml/hour. keeping the bed in the lowest possible position. the nurse first should slow the infusion to prevent additional fluid overload. and then notify the physician and obtain further orders. 232.V. Answer: B Rationale: Keeping the bed at the lowest possible position is the first priority for clients at risk for falling.V. Notify the physician. instructing the client not to get out of bed without assistance. Now the client is short of breath and the nurse notes bilateral crackles. The nurse is caring for a client with a history of falls. A client with heart failure has been receiving an I. Notifying the physician without slowing the infusion would put the client at risk for pulmonary complications or respiratory failure. instructing the client not to get out of bed without assistance. The first priority when caring for a client at risk for falls is: a. d. b. d. What should the nurse do first? a. Discontinuing the infusion is inappropriate because vascular access still may be needed to administer I. Instructing the client not to get out of bed may not effectively prevent falls — for example. c.

Educator c. Even when assistance is required. Manager b. Enhanced blood flow to the GI tract Answer: B Rationale: Aging-related physiologic changes account for the increased frequency of adverse drug reactions in geriatric clients. the bed must first be in the lowest position. 234. Client advocate Answer: B Rationale: When teaching a client about medications before discharge. The nurse acts as a client advocate when making the client's wishes known to the physician. the nurse asks the client to repeat the instructions. A client is being discharged after cataract surgery. The client may not require a bedpan. The nurse acts as a caregiver when providing direct care. the nurse must stay especially alert for adverse effects. Renal and hepatic changes cause drugs to clear more slowly in these clients. Which factor makes geriatric clients more vulnerable than younger clients to adverse drug effects? a. Caregiver d. The nurse is performing which professional role? a. The nurse acts as a manager when performing such activities as scheduling and making client care assignments. the nurse is acting as an educator. When administering drug therapy to a geriatric client. 235. Faster drug clearance b. With 116 . Aging-related physiologic changes c. Increased amount of neurons d. After providing medication teaching.client is confused. including bathing clients and administering medication and prescribed treatments.

Timing in the cycle b. Which pulse feature should the nurse document? a. Pitch d. The client refuses to look at the stump. but the signs and symptoms described in the case most closely match the defining characteristics for Disturbed body image. he tells her that he doesn't wish to discuss it. and responding verbally or nonverbally to the actual or perceived change in structure or function. not looking at a body part. hiding or overexposing a body part.increasing age. The defining characteristics for this nursing diagnosis include undergoing a change in body structure or function. Answer: C Rationale: Disturbed body image is a negative perception of self that makes healthful functioning difficult. This client may have any of the other diagnoses. d. The nursing diagnosis that best describes the client's problem is: a. The nurse is assessing a client's pulse. Fear. 237. The nurse is caring for a client who has had an above-the-knee amputation. When the nurse attempts to speak with the client about his surgery. 236. neurons are lost and blood flow to the GI tract decreases. Disturbed body image. The client also refuses to have his family visit. Hopelessness. c. b. Amplitude c. Intensity Answer: B 117 . Powerlessness.

c. rhythm. percussion. The reason for this approach is that the less intrusive techniques should be performed before the more intrusive techniques. Which statement about a stethoscope with a bell and diaphragm is true? a. percussion. auscultation. palpation. Percussion and palpation can alter natural findings during auscultation. A client with fever. percussion. The diaphragm detects low-pitched sounds best Answer: B Rationale: The diaphragm of a stethoscope detects high-pitched sounds best. and auscultation c. and intensity aren't associated with pulse assessment 238. auscultation. The bell detects thrills best. While assessing the client. b. The diaphragm detects high-pitched sounds best. Palpation detects thrills best 118 . Pitch. and percussion Answer: A Rationale: The correct order of assessment for examining the abdomen is inspection. a nurse inspects the client's abdomen and notices that it's slightly concave. weight loss. and auscultation d. Auscultation. d.Rationale: The nurse should document the rate. Additional assessment should proceed in which order? a. timing. Palpation. Palpation. Percussion. and amplitude of a client's pulse. The nurse uses a stethoscope to auscultate a client's chest. the bell detects low-pitched sounds best. The bell detects high-pitched sounds best. and palpation b. and palpation. and watery diarrhea is being admitted to the facility. 239.

d. Apply a cold compress to decrease swelling.M. injection. which. the client should have a mammogram every year. Instruct the client to tighten his gluteal muscles to promote better absorption. Answer: B Rationale: Applying heat increases blood flow to the area. age 43. Twice per year Answer: C Rationale: A client age 40 to 49 with no family history of breast cancer or other risk factors for this disease should have a mammogram every 2 years. Massage is a good intervention. 119 . Once per year c. Tightening the gluteal muscles may cause additional burning if the drug irritates muscular tissues. Which nursing action would be the best to take at this time? a. has no family history of breast cancer or other risk factors for this disease.240. The nurse should instruct her to have a mammogram how often? a. Apply a warm compress to dilate the blood vessels. increases the absorption of the medication. Massage the area to promote absorption of the drug. in turn. to establish a baseline b. b. but applying a warm compress is better. Every 2 years d. After age 50. 241. he complains of burning pain in the injection site. After a client receives an I. Once. Cold decreases the pain but allows the medication to stay in the muscle longer. c. A client.

242. When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching? a. "I will administer the enema while sitting on the toilet." b. "I will administer the enema while lying on my left side with my right knee flexed." c. "I will administer the enema while lying on my right side with my left knee flexed." d. "I will administer the enema while lying on my back with both knees flexed." Answer: B Rationale: Lying on the left side allows the enema solution to flow downward by gravity into the rectum and sigmoid colon. The other options don't accomplish this goal and therefore are less effective in evacuating the lower bowel.

243. The nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation rapidly drops. He complains of shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. Further assessment findings supporting the presence of a pneumothorax include: a. diminished or absent breath sounds on the affected side. b. paradoxical chest wall movement with respirations. c. tracheal deviation to the unaffected side. d. muffled or distant heart sounds. Answer: A Rationale: In the case of a pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffled or distant heart sounds occur in pericardial tamponade. 120

244. The nurse writes the following note in the client's chart: "The physician is incompetent because he ordered the wrong drug dosage." This statement may lead to a charge of: a. assault. b. slander. c. battery. d. libel. Answer: D Rationale: Libel refers to written communication that injures a person's reputation. Assault is an unjustifiable attempt or threat to touch or injure another person. Slander is oral communication that injures a person's reputation. Battery refers to touching another person unlawfully or carrying out threatened physical harm.

245. Which of the following options serves as a framework for nursing education and clinical practice? a. Scientific breakthroughs b. Technological advances c. Theoretical models d. Medical practices Answer: C Rationale: Theoretical models of nursing provide the foundation for all nursing knowledge. They also direct nursing practice based on the concepts of health, person, environment, and nursing. Scientific breakthroughs, technological advances, and medical practices may affect nursing but aren't frameworks for nursing education and practice.

246. A client who speaks little English has emergency gallbladder surgery. During discharge preparation, which nursing action would best help this client understand wound care instructions? 121

a. Asking frequently whether the client understands the instructions b. Asking an interpreter to relay the instructions to the client c. Writing out the instructions and having a family member read them to the client d. Demonstrating the procedure and having the client return the demonstration Answer: D Rationale: Demonstration by the nurse with a return demonstration by the client ensures that the client can perform wound care correctly. Clients may claim to understand discharge instructions when they don't. An interpreter or family member may communicate verbal or written instructions inaccurately.

247. To avoid recording an erroneously low systolic blood pressure because of failure to recognize an auscultatory gap, the nurse should: a. have the client lie down while taking his blood pressure. b. inflate the cuff to at least 200 mm Hg. c. take blood pressure readings in both arms. d. inflate the cuff at least another 30 mm Hg after the radial pulse becomes unpalpable. Answer: D Rationale: The nurse should wrap an appropriately sized cuff around the client's upper arm and then place the diaphragm of the stethoscope over the brachial artery. The nurse should then rapidly inflate the cuff until she can no longer palpate or auscultate the pulse and continue inflating until the pressure rises another 30 mm Hg. The other options aren't appropriate measures.

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in which the nurse indents the client's skin approximately 1½" (3. The purpose of deep palpation is to assess which of the following? a. To evaluate a client's chief complaint. 249. "I can still eat a ham-and-cheese sandwich with potato chips for lunch. Temperature Answer: C Rationale: The purpose of deep palpation. Skin turgor b.248. and temperature can be 123 ." c. "I'm glad I can still have chicken bouillon soup. Organs d. Ham. A client is placed on a low-sodium (500 mg/day) diet." Answer: B Rationale: The client's choice of a baked potato with broiled chicken indicates effective nutrition teaching because potatoes and chicken are relatively low in sodium. Which client statement indicates that the nurse's nutrition teaching plan has been effective? a. sardines. hydration. the nurse performs deep palpation. such as the kidneys and spleen. "I chose broiled chicken with a baked potato for dinner.8 cm)." b. is to assess underlying organs and structures. Hydration c. "I chose a tossed salad with sardines and oil and vinegar dressing for lunch. and bouillon are extremely high in sodium and shouldn't be included in a low-sodium diet." d. Skin turgor.

Wearing eye protection during tracheal suctioning d. The nurse is to give a client a 325-mg aspirin suppository. The client has diarrhea and is in the bathroom. Waiting 15 minutes or until the client is finished is inappropriate because the client will most likely have another urge to defecate and will expel the suppository. and wear goggles during procedures that are likely to generate splashes of blood or body fluids. d. uncapped needles and syringes in a puncture-resistant container. Substituting the oral form is inappropriate. the nurse needs to hold the medication and talk with the physician. 124 . Answer: B Rationale: Because the client has diarrhea. caregivers must wear gloves when there is the potential for contact with a client's body fluids.250. only the physician can change the route of an ordered drug. The best nursing approach at this time would be to: a. Wearing gloves when changing a dressing b. c. 251. b. Disposing of needles in a puncture-resistant container c. All of the above Answer: D Rationale: To follow standard precautions. substitute 325-mg aspirin by mouth. wait 15 minutes after the diarrhea stops and then administer the suppository. Standard precautions include which of the following measures? a. tell the client you'll give him the suppository when he's finished in the bathroom. place used. withhold the suppository and notify the client's physician. A suppository should never be given to a client with diarrhea because the suppository would be expelled.

disease. environment. health (optimal functioning). families. environment. Illness. and treatment are concepts addressed by specific theorists. Health. Health. Fidelity d. Paternalism c. 125 .252. Which moral principle is the nurse applying by deciding what is best for a client and acting without consulting the individual? a. health. health restoration. and nursing. and employers. and nursing d. and health care b. health. health care. caring. illness. clients. Man. disease. What are the four key concepts of most nursing theories? a. The nurse's belief in autonomy leads to a respect for the client's decisions 253. Man. illness. the environment (external conditions affecting life and development). coworkers. Fidelity requires the nurse to be faithful and truthful and to keep promises made to self. Autonomy Answer: B Rationale: Paternalism is the moral principle applied by nurses and other health care workers when circumstances (for example. The nurse may use one of many nursing theories to guide client care. the client's loss of consciousness) compel them to decide what is best for a client and to act without consulting the individual. and treatment Answer: C Rationale: Most nursing theories deal with the key concepts of man (or person — the individual). health restoration. Autonomy refers to the right of every person to make rational decisions about one's life. and caring c. Beneficence b. Beneficence means that nursing actions always should be beneficial.

or physiologic. Tachycardia can result from: a. b. vagal stimulation. Gown 126 . or suctioning. anger. suctioning (causing vagal nerve stimulation). Safety d. the nurse should remove which protective equipment first? a. or pain. Cap b. c.254. need and therefore takes priority over all other needs. pain. Decreases in heart rate (bradycardia) can stem from vomiting. or anger. stress. Security b. Using Abraham Maslow's hierarchy of human needs. the nurse assigns highest priority to which client need? a. Security and safety are second-level needs. or certain medications. elimination is a first-level. d. or vomiting. 256. When leaving the room of a client in strict isolation. fear. vomiting. Mask c. Belonging Answer: B Rationale: According to Maslow. anger. Answer: C Rationale: Increases in heart rate (tachycardia) can stem from fear. belonging is a third-level need. pain. Elimination c. Second.and third-level needs can be met only after the client's first-level needs have been satisfied 255.

Assess for responsiveness. signs of improved oxygenation. Tachycardia may initially follow treatment with racemic epinephrine as well as improvement in client status (improved oxygenation and improved color). d. the nurse should remove the gloves first because they're considered the most contaminated. b. c. b. 258. The nurse administers racemic epinephrine to an 8-year-old boy. restlessness. c. and cyanosis). Answer: A Rationale: A rebound effect from racemic epinephrine can occur up to 4 hours after treatment with signs of respiratory distress (tachypnea. Gloves Answer: D Rationale: When leaving a strict-isolation room. A client suddenly loses consciousness. Ten minutes after administration. Call for assistance.d. 257. the nurse should be alert for: a. respiratory distress. Palpate for a carotid pulse. Assess for pupillary response. diminished cyanosis. d. Answer: B 127 . Removing other protective equipment before removing the gloves and washing hands could cause contamination of the hair and uniform and promote pathogen transmission. What should the nurse do first? a. profound tachycardia.

The young-old geriatric population ranges in age from 65 to 74. A 76-year-old client with no debilitating conditions belongs to which geriatric population? a. restores the inflammatory response. Assessing for pupillary response would waste valuable time and is inappropriate. Frail elderly Answer: B Rationale: A 76-year-old client with no debilitating conditions belongs to the middle-old geriatric population. Answer: D Rationale: The client should be encouraged to consume foods high in vitamin C because it's essential for protein synthesis. an important part 128 . d. b. enhances oxygen transport to tissues. the frail elderly. which includes all individuals over age 65 who have one or more debilitating conditions. reduces edema. Old-old d. the nurse should call for assistance.Rationale: The nurse always should assess for responsiveness first to prevent injuries to a client who isn't in cardiac or respiratory arrest. and palpate for a carotid pulse. Middle-old c. 259. check for breathing. 260. After assessing the client. The nurse should encourage a client with a wound to consume foods high in vitamin C because this vitamin: a. open the client's airway. and the oldold from 85 and older. c. Within each of these three subgroups is another group. Young-old b. the middle-old from 75 to 84. enhances protein synthesis.

It binds with ammonia in the GI tract. Hemostasis is responsible for the inflammatory response and reducing edema. Answer: C 129 . The drug also exerts its antibacterial activity directly on the ribosomes of susceptible organisms. portal of entry. coli. Neomycin is bactericidal in high concentrations and bacteriostatic in low concentrations. Answer: A Rationale: Neomycin lowers the blood ammonia level by reducing the number of ammonia-producing bacteria in the GI tract. they convert urea to ammonia. d. by inhibiting protein synthesis via direct action on ribosomal subunits. It acidifies the colon and traps ammonia in the GI tract. d. 261. 4 g by mouth daily in four divided doses. Client isolation techniques attempt to break the chain of infection by interfering with the: a. Her husband asks how neomycin decreases his wife's serum ammonia concentration. susceptible host. Thus. How should the nurse respond? a. It decreases the number of ammonia-producing bacteria in the GI tract b. c. transmission mode. Her physician prescribes neomycin (Mycifradin). 262. agent. b. A client is placed in isolation. It increases the growth of such bacteria as Escherchia coli. A client develops hepatic encephalopathy 1 week after portal caval shunt surgery. it doesn't trap or bind with ammonia in the GI tract. When these bacteria are present. Hemoglobin is responsible for oxygen transport. among them E.of wound healing. c.

decreased bowel motility. host. or portal of entry. increased bowel motility causes hyperactive bowel sounds. c. These techniques don't affect the agent. an as-needed order. Abdominal cramping causes 130 . Answer: C Rationale: High-pitched gurgles are a normal finding. A single order allows for a one-time dose only. 500 mg by mouth every 6 hours. b. nothing abnormal. When auscultating a client's abdomen. abdominal cramping. The physician orders ampicillin. a standard written order. 263. b. An asneeded order allows for drug administration when the client needs it. immediately.Rationale: Client isolation techniques attempt to break the chain of infection by interfering with the transmission mode. the nurse detects highpitched gurgles over the lower right quadrant. Answer: A Rationale: A standard written order is an order that applies until the prescriber writes another order to alter or discontinue the first one. are to remain valid. Many health care facilities have established policies dictating how long orders for certain classes of drugs. a stat order. c. Decreased bowel motility causes two or three bowel sounds per minute. such as narcotics or antibiotics. This medication order is an example of: a. A stat order includes such words as now. the nurse suspects: a. or stat 264. d. d. increased bowel motility. a single order. Based on this finding.

265. Checking the lungs for crackles every shift Answer: B Rationale: Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and with the client wearing similar clothing provides more objective data than measuring fluid intake and output. Which finding best indicates that suctioning has been effective? a. Clear breath sounds Answer: D Rationale: Clear breath sounds. Weighing the client daily at the same time each day c. may indicate other health concerns. Brisk capillary refill indicates adequate cardiovascular function. high-pitched tinkling bowel sounds and may indicate a bowel obstruction. 266. Heart rate of 104 beats/minute c. Brisk capillary refill d. may indicate that the airway isn't clear of secretions and the client's respiratory rate has increased to compensate. not suctioning effectiveness. which may be inaccurate 131 . as in option A. Respiratory rate of 24 breaths/minute b.hyperactive. A client is at risk for fluid volume excess. An abovenormal respiratory rate. Assessing vital signs every 4 hours d. A slightly increased heart rate. Which nursing intervention would ensure the most accurate monitoring of the client's fluid status? a. Measuring and recording fluid intake and output b. are the best indicator of effective suctioning. as in option B. which indicate that secretions have been removed.

268. wear gloves when anticipating contact with the blood.because of omitted measurements such as insensible losses. Although crackles indicate fluid accumulation in the lungs. swelling. Documenting blood administration in the client care record d. injection).M. 267. or dyspnea b. weight gain is an earlier sign than crackles. Wearing gloves for all client contact Answer: C Rationale: To follow standard precautions. medication d. To follow standard precautions. caregivers must place used. Which nursing intervention takes highest priority when caring for a client who's receiving a blood transfusion? a. mucous membranes. and wear a gown during procedures that are likely to generate splashes of blood or body fluids. the nurse should carry out which of the following measures? a.M. Changes in vital signs are less reliable because they usually are subtle during early stages of fluid retention. Wearing gloves when administering I. Standard precautions don't call for caregivers to wear a gown or gloves when bathing a client because this activity isn't likely to cause contact with blood or body fluids. Recapping needles after use b. Wearing a gown when bathing a client c. The nurse should plan to detect fluid accumulation before pulmonary edema occurs. body fluid. Instructing the client to report any itching. which represent pulmonary edema. Informing the client that the transfusion usually takes 1½ to 2 hours c. or nonintact skin of any client (such as when administering an I. uncapped needles and syringes in a puncture-resistant container. Assessing the client's vital signs when the transfusion ends 132 .

269. Determines the client's goal achievement b. Signs and symptoms of lifethreatening allergic reactions include itching. is admitted for treatment of a breast tumor. it doesn't focus on the client's feelings and concerns. "We won't know for sure until you undergo some tests. Writes a statement about the client's health problem c. "Your physician can tell you more about it. Generalizing about most women shifts the focus away from the client. The nurse should assess vital signs at least hourly during the transfusion.and long-term goals d. She asks the nurse. A client. age 40. "Do you think I have cancer?" Which response by the nurse would be most therapeutic? a. swelling. During the planning step of the nursing process. and dyspnea. "You sound concerned about what the physicians will tell you. 270." Answer: D Rationale: This response allows the client to express feelings and promotes further discussion. Establishes short." d. Although the statement about the need for tests is true.Answer: A Rationale: Because administration of blood or blood products may cause serious adverse effects such as allergic reactions." c. the nurse must monitor the client for these effects. "Most women your age have some kind of breast problem. these actions are less critical to the client's immediate health. the nurse does which of the following? a. Although the nurse should inform the client of the duration of the transfusion and should document its administration. Gathers objective data 133 ." b. Referring the client to the physician ends the discussion and prevents exploration of the client's feelings.

the nurse establishes priorities and shortand long-term goals. moistening it promotes microorganism growth and skin irritation. b. writes statements about the client's health problem during the nursing diagnosis step. The nurse must irrigate a gaping abdominal incision with sterile normal saline. Back (dorsal surface) 134 . projects measurable outcomes. the nurse should apply a sterile dressing. d. rapid or forceful instillation can damage tissues. When the area is dry. Rapidly instill a stream of irrigating solution into the wound. 271. the nurse should dry the area around the wound. After the irrigation. Irrigate continuously until the solution becomes clear or all of the solution has been used. When palpating a client's body to detect warmth. and develops a plan of care. Answer: A Rationale: To wash away tissue debris and drainage effectively. and gathers objective data during the assessment step. using a piston syringe. The nurse determines the client's goal achievement during the evaluation step. Apply a wet-to-dry dressing to the wound after the irrigation. 272. the nurse should use which part of the hand? a. the nurse should irrigate the wound until the solution becomes clear or all of the solution has been used. Fingertips b. How should the nurse proceed? a.Answer: C Rationale: During the planning step of the nursing process. Moisten the area around the wound with normal saline after the irrigation. rather than a wet-to-dry dressing. c. The nurse always should instill the irrigating solution gently. Finger pads c.

This thing may get me anyway. 273." b. and the ulnar surface. "Colon cancer can now be cured in many cases. the nurse should use the back. Let's hope you'll be one of the lucky ones. grasping tissues." Which response by the nurse would be most therapeutic? a. for feeling thrills and fremitus. The nurse is preparing a client for chemotherapy to treat colon cancer. "I don't know about this treatment. You need to keep a positive attitude. "You're wondering whether you've made the right decision about the treatment. The Client Self-Determination Act of 1990 requires all hospitals to inform clients of advance directives. 274." c. What should the nurse tell the 135 . or dorsal surface. Ulnar surface Answer: C Rationale: To feel for warmth. "Many people beat cancer. it may not do a bit of good. for assessing hair texture." d." Answer: A Rationale: By rephrasing the client's statement and focusing on the client's concerns. the nurse encourages further discussion of feelings. Mentioning that everyone with cancer worries overlooks the uniqueness of the client's feelings and implies that these feelings aren't acceptable. After everything is said and done. the finger pads. and feeling lymph node enlargement. The client says. Telling the client to keep a positive attitude incorrectly implies that the nurse knows how to deal with the situation best. The fingertips are best for distinguishing texture and shape. but you have every reason to be hopeful.d. Saying that cancer of the colon may be cured ignores the client's feelings. of the hand. "Everyone with cancer worries.

Subcutaneous (S.) Answer: C Rationale: A drug dissolved in the mouth enters the client's bloodstream more quickly. administration. c. They can't provide do-not-resuscitate (DNR) orders for clients with terminal illnesses..M. Oral b. I. witnessed documents that provide specific instructions for treatment if a client can't give those instructions personally when required. or S. The nurse knows that many drugs can be administered by more than one route.M.C. thereby avoiding the barriers of food and the destructive effects of stomach acid. not the physician. to make decisions about treatment.C. they may or may not include DNR orders. They allow physicians to make decisions about treatment.client about such advance directives as living wills and health care power of attorney? a. I. d. They permit physicians to give verbal DNR orders. Which administration route provides the most rapid response in a client? a. Advance directives allow the client. 136 . all physician's orders must be written and signed to be legal. Answer: A Rationale: Advance directives are signed. b. 275. With oral. Sublingual d. Depending on the client's wishes. c. They don't permit verbal orders. the response to the drug is slower. They guide the client's treatment in certain health care situations.

the nurse should: a. d. cannula insertion d. erase any errors. 277. Colostomy irrigation Answer: C Rationale: Caregivers must use surgical asepsis when performing wound care or any procedure in which a sterile body cavity is entered or skin integrity is broken. Nasogastric tube irrigation c. end each entry with the nurse's signature and title. use a #2 pencil. leave one line blank before each new entry. Answer: D Rationale: The end of each entry should include the nurse's signature and title. To achieve surgical asepsis. c. 137 . Which procedure or practice requires surgical asepsis? a.276. I. Inserting an I. objects must be rendered or kept free of all pathogens. Hand washing b.V. Erasing errors in documentation on a legal document such as a client's chart isn't permitted by law. The nurse is accountable for the information recorded and therefore shouldn't leave any blank lines in which another health care worker could make additions. therefore. When documenting information in a client's medical record.V. cannula requires surgical asepsis because it disrupts skin integrity and involves entry into a sterile cavity (a vein). Because a client's medical record is considered a legal document. irrigating a nasogastric tube or a colostomy requires only clean technique. the nurse should make all entries in ink. The other options are used to ensure medical asepsis or clean technique to prevent the spread of infection. b. The GI tract isn't sterile. the signature holds the nurse accountable for the recorded information.

Health-seeking behavior b. Impaired mobility c. Annual physical examinations and monthly breast self-examinations are examples of secondary preventive measures. and reluctance to move. Health-seeking 138 . these measures include lifestyle changes such as avoiding overexposure to the sun to prevent skin cancer. Participating in a cardiac rehabilitation program b. which promote early detection and treatment of disease. These signs and symptoms indicate which nursing diagnosis? a. Obtaining an annual physical examination c. decreased muscle strength. Disturbed sensory perception d. Which of the following is an example of a primary preventive measure? a. Practicing monthly breast self-examination d. 279. Primary preventive measures are designed to prevent or delay the onset of specific illnesses. limited range of motion. Participating in a cardiac rehabilitation program is an example of a tertiary preventive measure. which attempts to prevent complications of an existing disease. the nurse identifies the following signs and symptoms: impaired coordination.278. Deficient knowledge Answer: B Rationale: Impaired mobility is a limitation of physical movement that is identified by the characteristics found in this client. typically. When performing an assessment. Avoiding overexposure to the sun Answer: D Rationale: Primary prevention involves promoting health and helping clients achieve maximum wellness.

the nurse should instruct the client not to eat or drink anything for approximately 6 hours before the procedure. Subjective data are 139 . When preparing a client for bronchoscopy. eat. walk. Answer: B Rationale: A client outcome is a short. talking. 280." This statement is an example of: a. b. or coughing. Disturbed sensory perception are changes in the characteristics of incoming stimuli. It's not necessary for the client to avoid walking. A nursing diagnosis is a statement about a client's actual or potential problem. the nurse should instruct the client not to: a. b. d. a nursing diagnosis. cough. To prevent aspiration of stomach contents into the lungs. a nursing intervention. c.behavior is a state in which a client in stable health actively seeks ways to alter personal health habits or the environment in order to move toward optimal health. a client outcome. d. subjective data.Deficient knowledge exists when the client requires further teaching. talk. c. Answer: D Rationale: Bronchoscopy involves visualization of the trachea and bronchial tree. 281.or long-term goal based on projected nursing interventions. The following statement appears on a client's plan of care: "Client will ambulate in the hall without assistance within 4 days.

such as auscultation. offer dairy products at frequent intervals. Answer: B Rationale: Calcium absorption diminishes with reduced physical activity. Therefore. A nursing intervention is an action the nurse takes in response to a client's problem.information relayed to the nurse by the client. To help minimize calcium loss from the bones of a hospitalized client. the nurse should: reposition the client every 2 hours. The family and members of the health care team provide secondary source information. Subjective data are reported to the nurse by the client and family. Objective c. Providing dairy products and supplemental feedings wouldn't lessen calcium loss. provide supplemental feedings between meals. 282. such as by walking in the hall. During assessment. 283. Medical Answer: B Rationale: Physical examination techniques. which reflect findings without interpretation. Auscultation produces which type of data? a. Subjective b. Turning or repositioning the client every 2 hours wouldn't increase activity sufficiently to minimize bone loss. encouraging the client to increase physical activity. encourage the client to walk in the hall. 140 . Medical data are obtained from the physician and medical record. provide objective data. helps minimize calcium loss. even if the dairy products and feedings contained extra calcium. the nurse auscultates for a client's breath sounds. Secondary source d.

which commonly occurs after a few days of treatment with haloperidol. b. and tongue. stooped posture. which commonly occurs after a few days of treatment with haloperidol. tremors. and drooling. shuffling gait. The symptoms may be confused with psychotic symptoms and misdiagnosed. The nurse should recognize this as: a. pacing. flat-faced affect. After a few days. Signs and symptoms of akathisia are restlessness. Signs and symptoms of akathisia are restlessness. The symptoms may be confused with psychotic symptoms and misdiagnosed. A client begins taking haloperidol (Haldol). Parkinsonism results in muscle rigidity. tremors. dystonia d. psychotic symptoms. Answer: D Rationale: These symptoms describe dystonia. he experiences severe tonic contractures of muscles in the neck. Parkinsonism results in muscle rigidity. and inability to sit still. he experiences severe tonic contractures of muscles in the neck. akathisia. akathisia. 141 . dystonia. and drooling. mouth. and inability to sit still. The nurse should recognize this as: a. shuffling gait. and tongue. mouth. flat-faced affect. 285. pacing. After a few days. parkinsonism. A client begins taking haloperidol (Haldol). Answer: D Rationale: These symptoms describe dystonia.284. d. parkinsonism. c. psychotic symptoms b. c. stooped posture.

M. Standard written order Answer: D Rationale: This is a standard written order. and provide reassurance. Tell the client that family members and significant others can't visit but may telephone at any time. 287. A client with an infected abdominal wound must be placed in strict isolation for 10 days. d. Gently explain that the client's movements must be limited while in the isolation room. Tell the client to bring whatever personal items are desired into the isolation unit. A standing order. Standing order d. A stat order is written for medications given immediately for an urgent client problem. Facilities also may institute medication protocols that specifically designate drugs that a nurse may not give. also known as a protocol. Prescribers write a single order for medications given only once. Describe the reasons for isolation and how it's carried out. Answer: C Rationale: To meet the client's need for information and help reduce anxiety. Single order b. Visitors 142 . To help meet the client's emotional needs. Stat order c.286. daily × 3 days?" a. the nurse should describe the reasons for isolation and how it's carried out and also should provide reassurance and empathy. b. c. what should the nurse do? a. Which type of medication order might read "Vitamin K 10 mg I. establishes guidelines for treating a particular disease or set of symptoms in special care areas such as the coronary care unit.

6° F (38. drug's chemical name. In a client who had major surgery 5 days ago. Answer: D Rationale: A drug label must state the active ingredients and their quantities and proportions. they aren't as specific as the drainage and could be related to other problems. presence. c. Oral temperature of 100. the nurse examines the drug label. When preparing to administer a drug dose to a client. and uneven wound edges may accompany an infected wound. b. Evidence of uneven wound edges c. and Cosmetic Act requires that drug labels state the: a. d. date the drug was approved for use by the Food and Drug Administration. Drug.1° C) Answer: C Rationale: Thick. a description of 143 . Although an elevated temperature. 289. pain at the incision site. sharp incisional pain b. The nurse understands that the Food. 288. The client doesn't have to limit movements while in the isolation room. cost per dose. Complaints of deep. yellow wound drainage d. as well as directions for use. quantities. they usually aren't permitted in the isolation room. Thick. Drainage is typically serosanguineous. and proportions of certain ingredients. Unless personal items are needed.should be allowed to reduce the client's feelings of isolation. yellow drainage is most indicative of a wound infection. which of the following assessment findings would be the best indication of a wound infection? a.

144 . c. facing forward with arms at the sides and palms turned forward. such as guided imagery. Ask the client each morning to describe the quality of sleep during the previous night. Sleep medication should be avoided whenever possible. The law doesn't require any other information on the label. b. At some point. Teach the client relaxation techniques. Provide the client with normal sleep aids. especially if common sense interventions fail. meditation. Administer sleeping medication before bedtime. Palms are turned forward. c. The body is facing backward. d.the package contents. Answer: D Rationale: The nurse should begin with the simplest interventions. Answer: C Rationale: In the anatomic position. 290. such as pillows or snacks. b. and progressive muscle relaxation. d. the nurse should do a thorough sleep assessment. The body is supine. before interventions that require greater skill such as relaxation techniques. 291. the body is erect. and snacks. Arms are elevated at shoulder level. such as pillows. and certain other information. Which intervention should the nurse try first for a client who exhibits signs of sleep disturbance? a. back rubs. Which of the following correctly describes the anatomic position? a.

With the buccal route. The other options are inaccurate descriptions of the effects of ice application. c. The nurse should explain that ice application has which effect? a. Answer: C Rationale: The nurse should instruct the client to touch the tip of the tongue to the roof of the mouth and then place the sublingual tablet on the floor of the mouth. the nurse should instruct the client to place the tablet on the: a. Maintains proper bone alignment b.292. When teaching a client how to take a sublingual tablet. bypassing the GI and hepatic systems. the tablet 294. No drug is administered on top of the tongue or on the roof of the mouth. top of the tongue. Sublingual medications are absorbed directly into the bloodstream from the oral mucosa. d. floor of the mouth. Reduces pain by promoting vasodilation at the injury site Answer: B Rationale: Applying ice to the injury site soon after an injury causes vasoconstriction. Helps prevent skin maceration at the injury site d. When teaching a client how to take a sublingual tablet. Relieves swelling by reducing blood flow to the injury site c. inside of the cheek. During discharge teaching. a client with a fractured toe asks the nurse why ice should be applied to the fracture site. the nurse should instruct the client to place the tablet on the: 145 . helping to relieve or prevent swelling and bleeding. b. roof of the mouth. 293.

146 . c. A client complains of abdominal discomfort and nausea while receiving tube feedings. With the buccal route. 2 hours. 4 hours. inside of the cheek. Decrease the rate of feedings and the concentration of the formula. Sublingual medications are absorbed directly into the bloodstream from the oral mucosa. roof of the mouth. b. floor of the mouth. It shouldn't infuse for longer than 4 hours because the risk of contamination and sepsis increases after that time. Which intervention is most appropriate for this problem? a. b. bypassing the GI and hepatic systems. 295.a. according to facility policy 296. No drug is administered on top of the tongue or on the roof of the mouth. Answer: B Rationale: A unit of packed RBCs may be given over a period of between 1 and 4 hours. d. c. b. 1 hour. top of the tongue. d. Give the feedings at room temperature. the tablet is placed between the gum and the cheek. 6 hours. Discard or return to the blood bank any blood not given within this time. The maximum transfusion time for a unit of packed red blood cells (RBCs) is: a. Answer: C Rationale: The nurse should instruct the client to touch the tip of the tongue to the roof of the mouth and then place the sublingual tablet on the floor of the mouth.

Place the client in semi-Fowler's position while feeding. d.c. reactive to light and accommodation c. Change the feeding container every 12 hours. To prevent aspiration during feeding. to prevent bacterial growth. "I had trouble sleeping last night. Gathering more information about the sleep problem c. such as worries or medication use." The nurse lacks sufficient information to recommend warm milk or a warm shower or to make inferences about the cause of the sleep problem. the client says. Administer a sedative at bedtime b. Decreasing the rate of the feeding and the concentration of the formula should decrease the client's discomfort. Pupils round. As the nurse helps a client ambulate. 297. Which of the following is an approved nursing diagnosis? a. the head of the client's bed should be elevated at least 30 degrees. Feedings are normally given at room temperature to minimize abdominal cramping. Finding out whether the client is taking medication that may impede sleep Answer: B Rationale: The nurse first should determine what the client means by "trouble sleeping. Client will demonstrate subcutaneous injection independently d. Answer: B Rationale: Complaints of abdominal discomfort and nausea are common in clients receiving tube feedings." Which action should the nurse take first? a. 298. Also. feeding containers should be routinely changed every 8 to 12 hours. Recommending warm milk or a warm shower at bedtime b. Impaired gas exchange 147 . Determining whether the client is worried about something d.

The nurse must also remember to avoid massaging the carotid sinus. b. whether the drugs are generic.Answer: D Rationale: Impaired gas exchange is an approved nursing diagnosis — a statement about the client's health problem. Answer: C Rationale: The carotid arteries must be palpated one at a time to prevent severe bradycardia and impairment of cerebral circulation. whether the drugs are expensive. Why shouldn't the nurse palpate both carotid arteries at one time a. It may cause severe tachycardia. d. Answer: C Rationale: The nurse should determine whether the client knows dosages and administration schedules for any over-the-counter drugs 148 . whether the client knows the drug dosages and administration schedules. c. c. The pulse can't be assessed accurately unless the arteries are palpated one at a time. 300. It may cause transient hypertension. b. an assessment finding. option B. whether the client knows that these drugs are available in the hospital. a client outcome statement. the resulting bradycardia could lead to cardiac arrest. Option A is a nursing order. and option C. It may cause severe bradycardia. For a client who takes over-the-counter drugs regularly. located at the bifurcation of the carotid arteries. the nurse should ascertain: a. d. 299.

texture. temperature. the nurse taps the fingers or hands sharply to elicit sounds. Percussion Answer: C Rationale: During palpation. and body systems. to locate body structures. Individual prescription d. During auscultation. Automated Answer: D 149 . Unit-dose c. Availability of drugs in the hospital isn't a high-priority item unless the client wants to purchase them from an outpatient pharmacy to save time. During the physical examination. Inspection c. and to assess such characteristics as size. Neither the drug's cost nor its generic classification are as important unless a problem arises with either of these two factors. the nurse uses critical observation skills. Which drug delivery system relieves the nurse of the responsibility for transcribing the medication order? a. tenderness. the nurse uses a stethoscope to listen for sounds. Floor stock b. Palpation d. The nurse also should determine whether the client knows the correct reason for using the drug and its proper route of administration. 301. During percussion. During inspection.taken regularly. Which technique allows the nurse to feel for vibration and locate body structures? a. 302. the nurse uses various techniques to assess structures. Auscultation b. the nurse touches the client's body to feel for vibrations and pulsations. organs. and mobility.

Using a bladder that is 6" (15 cm) long. with the uninflated bladder covering about three-quarters of the limb circumference d. c. 20 hours. An individual prescription isn't dispensed by the nurse in a hospital setting. 50 hours.000 ml. Answer: C 150 . divided by the hourly rate. If the solution runs continuously at this rate. with the uninflated bladder covering about one-fourth of the limb circumference b. Measuring the arm about 2" (5 cm) above the antecubital space c. The nurse prepares to measure a client's blood pressure. What is the correct procedure for measuring blood pressure? a. 303.000 ml of dextrose and normal saline solution over 24 hours. 304. 12 hours. 150 ml/hour. 24 hours. d. The client is to receive an I. in this case. b.V. the infusion will be completed in: a. The nurse observes that the rate is 150 ml/hour. 3. The floor stock and unit-dose drug delivery systems require a transcription of the medication order.Rationale: An automated drug delivery system relieves the nurse of the responsibility for transcribing the medication order. Answer: B Rationale: The total amount to be given. Wrapping the cuff around the limb. Wrapping the cuff around the limb. equals the length of the infusion or. infusion of 3. 20 hours.

b. pH b. HCO3– Answer: A Rationale: The pH value in an ABG report reflects the acid concentration in the blood. administering antibiotics. assigning private rooms for clients. Answer: C Rationale: Hand washing is the first line of intervention for preventing the spread of infection. the nurse should wrap the cuff around the client's arm or leg with the bladder uninflated. The nurse tells the group that the first line of intervention for preventing the spread of infection is: a. PaO2 c. The bicarbonate (HCO3–) value indicates the amount of bicarbonate. washing hands. Bladder size is chosen according to the size of the extremity. d. Which ABG value reflects the acid concentration in the blood? a. 305. wearing gloves. 306.Rationale: When measuring blood pressure. Antibiotics should be initiated when an organism 151 . The partial pressure of arterial oxygen (PaO2) value indicates the amount of oxygen dissolved in the blood. the bladder should cover approximately three-quarters (not one-fourth) of the limb circumference. or base. The nurse is teaching a group of patient-care attendants about infection-control measures. The nurse is reviewing a client's arterial blood gas (ABG) report. the partial pressure of arterial carbon dioxide (PaCO2) value represents the amount of carbon dioxide dissolved in the blood. in the blood. c. PaCO2 d.

When preparing a client with a draining vertical incision for ambulation. Over the total wound Answer: C Rationale: When a client is ambulating. which nursing diagnosis is most appropriate? a. Anxiety b. At the base of the wound d. is indicated by a verbal response to an actual change in physical appearance or structure." Based on this statement. which would indicate an ineffective sexuality pattern.is identified. "Now I won't be sexually attractive to my husband. gravity causes the drainage to flow downward. where should the nurse apply the thickest portion of a dressing? a. a disruption in the way one perceives one's body. Ineffective individual coping Answer: B Rationale: Disturbed body image. Disturbed body image c. In the middle of the wound c. Covering the base of the wound with extra dressing will 152 . Two days after undergoing a modified radical mastectomy. 307. Wearing gloves and assigning private rooms for clients can also decrease the spread of infection and should be implemented according to standard precautions. a client tells the nurse. At the top of the wound b. 308. The client may be experiencing anxiety. Ineffective sexuality patterns d. She doesn't report an existing difficulty with sexual behavior. but her statement doesn't reflect this specifically. nor has she expressed an inability to cope.

310. achy. Because this maneuver can be painful. "Does the pain worsen in the morning upon rising?" b. When should the nurse check a client for rebound tenderness? a. the nurse should check for rebound tenderness. Before doing anything else c. The time of the day doesn't influence the pain associated with DVT. A dependent position will increase venous stasis and the pain associated with DVT. Anytime during the examination d. warm. For the past few days. in the middle. "Does the pain increase with activity and lessen with rest?" c.contain the drainage. and tender to touch. At the end of the examination Answer: D Rationale: If a client complains of abdominal pain. "Is the pain relieved by position changes?" d. "Is the pain worse with the toes pointed toward the knee?" Answer: D Rationale: The client's symptoms indicate deep vein thrombosis (DVT). or over the total wound won't contain the drainage 309. the nurse should perform it at the end of the abdominal assessment. A client with intermittent claudication experiences pain that increases during activity and decreases with rest. a client has been having calf pain and notices that the painful calf is larger than the other one. The right calf is red. Pointing toes toward the knee will elicit discomfort. Which of the following questions about the pain should the nurse include in the assessment? a. 153 . Near the beginning of the examination b. Applying the thickest portion of the dressing at the top.

Refer the client to a psychiatrist. The client is coping normally and doesn't need professional help. Invite a client with a similar experience to speak with the client. the client may feel that the nurse violated confidentiality. Discussing the concerns with the client's husband doesn't address the client's needs. d. A female client who recently had a colostomy expresses concerns about her sexual relationship with her husband. Answer: C Rationale: Having someone who has had a similar surgery and concerns speak to the client would be beneficial. Discuss the client's concern with the husband. Refer the client to a sex therapist. In fact. b.311. 154 . Which of the following interventions should the nurse implement? a. c.

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