The nurse is providing perineal care to an uncircumcised client who

is in a coma. Which of the following is CORRECT regarding the

perineal care?
Retract the foreskin all the way back.
Use another washcloth for the anus.
Wash the scrotum before the penis.
Clean the penis with sterile saline solution.

Answer: a

When providing perineal care for an uncircumcised client, pull the foreskin of the penis all the way back to
the head. Go around the urinary opening in a circular fashion, down to the shaft of the penis. This ensures
that all bacteria, sweat, and other debris are fully removed from their perineal area. Return the foreskin to its
natural position. The penis is washed before the scrotum, then the anal area, so additional washcloths are
not usually needed. Sterile solutions are not used.

Avoid pooling of blood in the lower legs.

The nurse is demonstrating to a new unlicensed assistive personnel
(UAP) how to apply antiembolism stockings. When is the CORRECT
time to apply the stockings?
before getting out of bed in the morning
After ambulating for several minutes
before going to bed at night
After performing PROM leg exercises
Anti-embolic stockings should be applied before blood can pool in the lower extremities, at the ankle and calf
areas. The best time is before the client gets out of bed in the morning. If this isn't possible, the client should
lie down with their legs propped on pillows for at least 15 minutes before applying the stockings. The
stockings are usually worn during the day, although the healthcare provider may order them to be worn at all
times.
Contraindications for administering an enema include all of the
following EXCEPT
suspected appendicitis.
recent colon surgery.
acute myocardial infarction.
hypercalcemia treatment.
An enema may be used to administer sodium polystyrene sulfonate (Kayexalate) for the treatment of
hyperkalemia. Kayexalate can be administered either orally or as an enema. Sodium polystyrene sulfonate is
not absorbed from the gastrointestinal tract. As the resin passes through the gastrointestinal tract, the resin
removes the potassium ions by exchanging them for sodium ions. Recent colon surgery, acute myocardial
infarction, and suspected appendicitis are contraindications for administering an enema. With elderly clients,
enemas should be used with caution because of their higher risk of hyperphosphatemia, perforation, and
sepsis.
After emptying a Jackson-Pratt drainage bulb, how does the nurse
reestablish negative pressure in the system?
Place the bulb lower than the client's body.
Open the valve and fill the bulb with air.
Fill the bulb with sterile saline solution.
Compress the bulb and close the valve.

A Jackson-Pratt drain creates negative pressure when the bulb is compressed and the valve is closed. This
causes fluid around the surgical site to flow into the drain.

A plaster cast can take up to 48 hours to dry completely.

After a high school athlete sustains a fractured femur during a
competition, a full leg plaster cast is applied. When the nurse
provides discharge instructions to the athlete and their parents six
hours later, which statement by the athlete indicates a need for
further education?
"I'll put an ice pack over the cast to relieve itching."
"I should walk around on my cast as soon as I get home."
"I will prop my cast on two pillows when I lie down."
"I should call my doctor if my toes turn blue or become numb."

Plaster casts are made up of a bandage and a hard covering, usually plaster of Paris. Client instructions
include: 1 Keep the limb raised on a soft surface, such as a pillow, for as long as possible in the first few days.
This will help any swelling to go down. 2. Keep the cast dry. If the plaster gets wet, it weakens and is unable
to support the bone. 3. Do not put anything into the cast to relieve itching. This can damage the skin and
cause an infection. A hair dryer set on cool or an ice pack over the itchy area can help. 4. Immediately report
any pain, tingling, or numbness, or if the toes turn blue or white.

Allow older children to become comfortable.

A father brings his 6-month-old son and 3-year-old daughter for
their routine check-ups. What is the nurse's best strategy?
Examine the 3-year-old first so she can show her brother.
Let the 3-year-old play during the baby's examination.
Examine the 6-month-old first while his sister watches.
Ask the father to step out with one child while the other child is examined.

Start with the least anxious and most cooperative sibling. Allow the older sibling to play; this reduces anxiety
and allows them to become familiar with the examination. Children are more comfortable and cooperative
when a parent is present.

7/57ProgressHintNext
The smaller the number, the larger the bore.
What is the smallest gauge intravenous catheter that can be used to
administer blood?
22-gauge
20-gauge
26-gauge
24-gauge
An 18-gauge needle or catheter is generally used to administer blood or push fluids, or for testing protocols
that require large IV bores. However, a 20-gauge is acceptable if the facility's policy allows it. This size is
better for clients with small veins. A 22-gauge is used for IVs of short duration or for clients who are not
critically ill. Usually, blood cannot be administered because of hemolysis of the RBCs. A 24-gauge is used for
pediatrics and adults who cannot tolerate a larger gauge. A 16-gauge is mostly used in intensive care and
surgery units because most fluids and blood products can be quickly administered. 26-gauge needles are
used for injections.
Use the client's unaffected side to perform the transfer.
The nurse is preparing to transfer a client with a recent
cerebrovascular accident (CVA) from their bed to a wheelchair. The
client has left-sided hemiplegia. What is the proper position for the
wheelchair to ensure a safe transfer?
Perpendicular to the bed on the client's right side.
Parallel to the bed on the client's right side.
Parallel to the bed on the client's left side.
Perpendicular to the bed on the client's left side.
The wheelchair should be placed parallel to the bed on the client's unaffected side. (In this case, on the
client's right side.) Once the client is standing, they can easily pivot until their back is toward the wheelchair
and they can reach for the armrest of the wheelchair with their unaffected arm. A perpendicular position
requires the client to reach farther for the armrest. Until the client has mastered the skill, two people should
assist. The wheelchair should be locked for stability. The client should wear non-slip socks or footwear.

Avoid any actions that could damage skin integrity.

The parent of a child with a short leg fiberglass cast phones the
clinic because the child complains of constant itching inside the
cast. Which intervention is appropriate for the nurse to suggest?
Use a blunt-ended object to scratch the itchy spot.
Trickle ice water into the cast.
Tap on the cast at the itchy spot.
Apply powder or a mild lotion.
The most common complaint about wearing a cast is the itching sensation. Clients should never use an object
(pencil, ruler, chopstick, etc.) to reach into the cast; this could break the skin and cause an infection. Powders
and lotions are not recommended either. Appropriate interventions include locating the itch and tapping on
it from outside the cast, blowing cool air from a blow dryer into the cast, and wrapping a watertight ice pack
or a sealed bag of frozen vegetables on the outside of the cast to cool the itchy area.

First, prepare for stability with both crutches.

An adult client with a fractured right tibia is placed in a leg cast. The
health care provider (HCP) prescribes axilla crutches for use at
home. The client tells the nurse there are stairs at home and wants
to learn how to go down the stairs using the crutches. When
reinforcing instructions about proper technique to descend stairs,
what is the client's FIRST step?
Place the right foot on the first step.
Place the right foot and left crutch on the first step.
Place both crutches on the first step.
Place the left foot and right crutch on the first step.

When descending stairs with crutches, both crutches are placed on the first step. Next, place the affected
lower extremity and then the unaffected lower extremity. Crutches are medical devices designed to aid in
ambulation, by transferring body weight from the legs to the torso and arms. Axilla crutches are the most
common type.
The cane supports the weaker side.

A client with a diagnosis of multiple sclerosis is learning to walk

with a cane. Which of the following instructions regarding safety is
CORRECT?
Position the cane one foot forward with each step.
Move the cane at the same time as the weak side.
Hold the cane on the weaker side of the body.
Place the cane near the feet to ensure stability.
A standard cane is generally appropriate for people with mild sensory, coordination, or balance problems. To
safely use a cane: 1. Hold the cane on the stronger side of body, or the stronger leg. 2. Position the cane
slightly to the side and a few inches forward. 3. Be sure the cane is not close to the feet to avoid tripping. 4.
Move the cane forward simultaneously with the weaker side of the body or weaker leg. 5. Plant the cane
firmly on the ground before stepping forward with the stronger leg.

12/57ProgressHintNext
Addison's disease can cause fluid loss and dehydration.

When instructing a patient with Addison’s disease about nutrition,

the healthcare provider should NOT recommend which of the
following dietary modifications?
A high-protein diet
A diet with adequate caloric intake
A restricted-sodium diet
A diet high in grains
A patient with Addison’s disease (adrenal insufficiency) requires normal dietary sodium to maintain
electrolyte balance and prevent excess fluid loss. The patient should be instructed to maintain adequate
caloric intake with a diet high in protein and complex carbohydrates, including grains.

A new client at the long-term care facility has experienced a recent

loss of vision tells the nurse that they are bored. Which activity is
BEST for the nurse to suggest?
Learning to weave baskets.
Listening to audio books.
Reading books in Braille.
Joining a discussion group.

The client with a new loss of vision can use their sense of hearing to enjoy listening to audio books or the
radio. Joining a group can be overwhelming or intimidating for someone with new loss of vision. Many crafts,
such as basket weaving, knitting, or working with clay can be therapeutic for the client after they have
adapted to their condition. Learning to read in Braille requires special instruction and practice.

"If it's dry, let it lie."

A nurse is caring for a client whose heel has a pressure ulcer
covered with intact hard, dry, black tissue. Which is the appropriate
dressing for this client?
Do a wet-to-dry dressing change.
Cover with sterile gauze.
No dressing is necessary.
Apply a hydrocolloid dressing.
Current standard of care guidelines recommend that stable, intact (dry, adherent, intact without erythema)
eschar on the heels should not be removed. Eschar works as a natural barrier or biological dressing by
protecting the wound bed from bacteria. Unless it is wet, draining, or loose, it should remain in place. Unless
the nurse is a certified wound specialist, removal or debridement of eschar is performed by a health care
provider (HCP). The other dressings are not indicated.

Allowing for edema can prevent other complications.

The purpose of a splint is to
provide permanent support for a fracture.
immobilize and allow for tissue swelling.
wrap around an injury for full protection.
manage complex or unstable fractures.

The primary purposes of splinting for limb fractures are to protect soft tissue from further damage, allow for
tissue swelling, reduce the client's pain, reduce the possibility of a fat embolism, and minimize painful
muscular spasms. A splint is easily applied and removed and involves fewer complications than a cast. A cast
is indicated for total immobilzation, to wrap completely around the fracture or injury, and to manage
complex or unstable fractures.

"I Am a People Person."

A client comes to the clinic, complaining of severe gastrointestinal
distress. Which abdominal physical assessment step does the nurse
do first?
Palpation
Percussion
Auscultation
Inspection

The correct sequence for physical assessment of the abdomen is as follows: 1. Inspect. 2. Auscultate. 3.
Percuss. 4. Palpate. Remember this sequence with the phrase "I Am a People Person." The order is different
from the physical assessment of the body systems, for which you inspect, then palpate, percuss, and
auscultate.

When a patient's nasogastric (NG) tube stops draining, what is the

nurse's first action?
Check tube placement.
Retract 2 inches.
Clamp for 1 hour.
Instill 50 mL of water.
ALWAYS verify tube placement before taking other measures. NEVER put anything in an NG tube unless you
know that its tip is in the stomach. Clamping has no effect on NG tube placement. Retracting without
knowing where the tip is would be unsafe for the patient.

Prepare, but don't scare.

The nurse prepares a 5-year-old girl for a pre-operative IV insertion.
Which statement is most appropriate to reduce the child's anxiety?
"Just look at the TV while I do this."
"Hold on to your doll. This is going to hurt."
"Tell me if this feels more like a pinch or a bug bite."
"It's going to hurt a little, but I know you're a brave girl."
Like all clients, children should be prepared for procedures. Educate them, but don't suggest that there will
be pain. Allow them to decide if there is discomfort. Ignoring an explanation or trying to distract the child is
rude and interferes with the child's sense of trust.
Vagal nerve stimulation can cause cardiac dysrhythmias.

During assessment, the home health nurse learns that the client has
a fecal impaction. Before proceeding to manually remove the stool,
what is the nurse's PRIORITY?
Recall that cardiac dysrhythmias are a possibility.
Give an analgesic or sedative to make the client comfortable.
Advise the family to increase the client's fluid and fiber intake.
Teach family members to perform the disimpaction process.
A fecal impaction is a large lump of dry, hard stool that stays stuck in the rectum. It is most often seen in
people who are constipated for a long time. Treatment of a fecal impaction includes administrating an enema
to soften the stool to produce a bowel movement, or manually removing the impaction. With a lubricated
glove, insert the index finger into the rectum to break up the hardened stool with a circular motion. Cardiac
dysrhythmias and reflex bradycardia can occur from vagal nerve stimulation.

Dehydration is the #1 culprit.

During their annual physical examination, a client tells the nurse
that they have dry, hard stools every 3 days. Which of the following
will be MOST helpful in improving the client's bowel movements?
Develop and follow a moderate exercise plan.
Drink at least four glasses of liquids a day.
Include fortified cereal and skim milk for breakfasts.
Eat 4-6 fresh fruits and vegetables every day.
The most common cause of hard stools is lack of adequate water to combine with the waste products and
undigested food in the large intestine. There can be other causes, including medication side effects, intestinal
disorders, and slow motility through the large intestine. Clients should drink at least four 8 oz glasses of water
a day. Fiber will also be helpful, but is not the first remedy. Too much fiber can cause bloating and abdominal
pain. Exercise is also important in stimulating the bowel. All the other options are helpful in avoiding
constipation.

Use the same precautions as for a living client.

The nurse is providing postmortem care for a client who was being
treated for Staphylococcus aureus. Which transmission-based
precautions are indicated?
Airborne precautions
Droplet precautions
Standard precautions
Contact precautions
MRSA is transmitted by contact, and MRSA bacteria remain alive for up to 3 days after the host dies.
Therefore, contact precautions must still be used after the client dies, including the use of a gown and gloves.
The body and bag should also be labeled as MRSA contaminated so other hospital, transportation, and
funeral home employees can protect themselves as well.
The goal is to provide patient comfort and avoid irritation or infection.
A patient receiving chemotherapy is experiencing stomatitis. Which
of the following should the healthcare provider offer the patient?
Vigorous oral care with a commercial mouthwash
Warm saline rinses four times each day
Hot soup for lunch and dinner
Plenty of ice chips between meals
Stomatitis is irritation of the lips, mouth, tongue, and oropharynx, which occurs when chemotherapy kills
healthy cells that are rapidly dividing. It can impair nutrition, speech, sleep, and the quality of life. Warm
saline rinses are non-irritating and help eliminate bacteria that can cause infection. Other nursing
interventions include gentle oral hygiene and administration of a topical analgesic as ordered by the
physician.
Start with the least restrictive choice.

The home health nurse notices that a client with a diagnosis of

multiple sclerosis is recently having difficulty chewing and
swallowing. What is the appropriate diet for this client?
Mechanical soft
Clear liquid
Full liquid
Pureed
A mechanical soft diet has a consistency that the client may be able to handle; this diet should be tried first. A
full liquid diet can be challenging for a client with poor swallowing. Pureed foods can cause the client to
regress or feel embarrassed. A clear liquid diet is not indicated and does not supply sufficient calories.
The nurse is an advocate for patient and family.
After your patient dies, the patient's family gathers at the bedside
and asks you to step out while their clergy performs a religious rite
for the deceased. As the patient's nurse, what is your most
appropriate course of action?
Inform the family that religious rites are not allowed.
Allow the ceremony but remain as a witness.
Educate the family about custody of care and stay in the room.
Allow the ceremony and step out of the room.
The nurse should honor the family's wishes and culture and leave the room. Most hospitals do not have a
policy that prohibits religious rites or ceremonies at the time of death. Remaining in the room shows
disrespect and lack of trust at a time of grieving.

It's "clear" that after surgery, it can take awhile for digestion to start again.
Following surgery, a client is placed on a "diet as tolerated" food
plan. Which of the following is BEST for the client's first post-
operative meal?
Soft
Bland
Clear liquid
Full liquid
The first meal after surgery should be clear liquids, only fluids and foods that can be seen through. It is the
least likely to induce nausea and vomiting. It also provides some liquids and calories, while stimulating
peristalsis. A soft diet has a soft texture that is easy to chew and digest; foods are low fiber. A bland diet has
soft foods that are not spicy, fried, or raw. A full liquid diet is made up only of fluids and foods that are
normally liquid and foods that turn to liquid when they are at room temperature, like ice cream. If the client
can tolerate the clear liquids, the diet can be advanced.

Can you "C" the foods that "PRO-mote" healing?

Which meal best promotes healing for a patient recovering from a
burn injury?
Pasta marinara, garlic bread, ginger ale
Peanut butter and jelly sandwich, banana, tea
Chicken breast, strawberries, milk
Pork chop, fried potatoes, coffee
The meal with the best nutrition for wound-healing includes protein and vitamin C. Foods that have low
nutritional value, such as sugar or those with low or no calories, are not beneficial.

This brace is worn 23 hours a day during the active growth years.

The nurse teaching a 14-year-old client about her cervico-

thoracolumbosacral orthosis (CTLSO) brace. Which statement by
the client would indicate a lack of understanding about the brace?
"I can take it off in hot weather."
"I should wear loose clothing underneath it."
"I can remove it when I take a shower."
"I must wear it all day and night."
The Milwaukee brace, also known as a cervico-thoracolumbosacral orthosis or CTLSO, is a back brace used in
the treatment of spinal curvatures such as scoliosis or kyphosis in children. It is a full-torso brace that extends
from the pelvis to the base of the skull. Its aim is to keep the body upright and prevent progression of the
curve while the patient is growing and awaiting possible need for operative intervention. The brace must be
worn long term, during periods of growth, usually for 1 to 2 years. The client's statement about not wearing
the brace in hot weather is incorrect and indicates a need for additional teaching. The other statements
indicate correct understanding.

Eating more often can reduce nausea.

A patient with a diagnosis of lung cancer is receiving chemotherapy.
The patient reports nausea and loss of appetite, resulting in
decreased food intake. What should the healthcare provider
recommend to the patient to promote adequate nutrition?
Eat only favorite foods to increase appetite.
Eat small meals throughout the day.
Eat large meals but less frequently throughout the day.
Eat only when feeling hungry.
Because of chemotherapy-induced nausea, the patient may not feel hungry, but they should be encouraged
to eat even if not hungry. Encouraging the patient to eat small meals frequently throughout the day can help
avoid nutritional deficiencies and improve the patient's quality of life. Chemotherapy can cause changes in
smell or taste; aversion to favorite foods can result.

Which one changes blood circulation?

When taking the blood pressure of a client who is seated, which
position must the client change so that the nurse can get an
accurate measurement?
Lean the head back.
Sit up straight.
Put down the phone.
Uncross the legs.
The nurse should ask the client to uncross their legs because the position can compress blood vessels and
affect the accuracy of the reading. The other positions do not affect circulation or the measurement.

Fat-soluble vitamins are not absorbed well in cystic fibrosis.

The nurse is educating the parents of a young child with a recent
diagnosis of cystic fibrosis. The nurse tells the parents that the child
will be at risk for which vitamin deficiencies?
A, D, and K
B12, C, and E
B1 and pantothenic acid
Folic acid and biotin
People with cystic fibrosis have trouble absorbing fats, which means they also have trouble absorbing
vitamins that need fat to be absorbed — A, D, E, and K. These fat-soluble vitamins are critical to normal
growth and good nutrition. B-complex, C, folic acid, biotin, and pantothenic acid are water soluble and easily
absorbed.
"In TWO months, dialysis can be done THREE times a week."
A client with end-stage renal disease has opted for an arteriovenous
(AV) fistula for long-term treatment with hemodialysis. Following
the surgical creation of the AV fistula, when will the client be able
to use it for hemodialysis?
2–3 weeks
2–3 months
4–6 months
4–6 weeks
An AV fistula is a connection of an artery to a vein, created by a vascular surgeon. An AV fistula frequently
requires 2 to 3 months to develop or mature before the patient can use it for long-term hemodialysis.
Consider which surfaces are appropriate for incontinent clients.
Despite frequent turning and skin assessment, occasional urinary
incontinence has caused a bedridden resident to develop a
reddened and tender area on the coccyx. The resident weighs 192
pounds. Which pressure-relieving device should be used for the
client?
Low air loss bed
Natural sheepskin
Alternating overlay
Egg crate foam
For clients who weigh less than 250 pounds, an alternating pressure overlay is the best choice because it is
liquid resistant. It has compartments that alternately inflate and deflate to relieve pressure. Foam and
sheepskin surfaces are not appropriate for clients with urinary incontinence. A low air loss bed is ideal but
expensive, and it can cause hypothermia if not carefully monitored.
The first stage without intact skin.
A client has a pressure ulcer on the sacrum. While assessing it, the
nurse observes that it has partial thickness, loss of dermis, and a
red-pink wound bed. Which stage will the nurse assign this pressure
ulcer?
Stage I
Stage II
Stage III
Stage IV
Stage I pressure ulcers have intact skin with a reddened area that may be firm and painful. Stage II pressure
ulcers are indicated by partial thickness, loss of dermis, and a red-pink wound bed. Stage III pressure ulcers
have full-thickness skin loss and may contain slough, visible subcutaneous tissue, and tunneling. Stage IV
pressure ulcers have full-thickness skin loss and exposed muscle, bone, or tendons.
Remember "FILM."
To measure an adult client's apical heart rate, where does the nurse
place the stethoscope?
Fifth left intercostal space at midclavicular line
Second left intercostal space at midclavicular line
Third left intercostal space at midclavicular line
Fourth left intercostal space at midclavicular line
FILM = Fifth Intercostal Midclavicular Line. The apical pulse is auscultated with a stethoscope over the chest
where the heart's mitral valve is best heard. For adults, the point of maximum pulse is the fifth left intercostal
space at the midclavicular line. In infants and young children, the apical pulse is located at the fourth
intercostal space at the left midclavicular line.
Cold constricts, warm dilates.
A client with chronic renal failure (CRF) is learning to perform
peritoneal dialysis at home. The nurse instructs the client to warm
the dialyzing solution to 37 degrees Celsius so that it will
remove toxins from the body's cells.
maintain a constant body temperature.
relax the abdominal muscles.
dilate the peritoneal blood vessels.
The rationale for warming the peritoneal dialysis solution is that the warm solution helps dilate peritoneal
vessels, which increases urea clearance. Warmed dialyzing solution also contributes to client comfort by
preventing cold sensations, but this is a secondary reason for warming the solution. The other options are
incorrect.
A client returns to the unit after abdominal surgery. While
monitoring the client, the nurse observes a moderate amount of red
blood on the dressing. The nurse will document this type of wound
drainage as
Sanguineous
Purulent
Serosanguineous
Serous
The nurse will document this drainage as Sanguineous. The word comes from the Latin, meaning "blood."
Wound drainage is described by type, color, amount, and odor. Types of drainage are: 1. Serous: clear and
thin; may be present in a healthy, healing wound. 2. Serosanguineous: containing blood; may also be present
in a healthy, healing wound. 3. Sanguineous: primarily blood. 4. Purulent: thick, white, and pus-like; may be
indicative of infection and should be cultured. The amount of drainage is generally documented as absent,
scant, minimal, moderate, large, or copious. The presence and degree of odor can be documented as absent,
mild, or foul. Foul odors can be indicative of an infection.
The gastrointestinal output will occur via the terminal end of the ileum.

The healthcare provider is preparing a patient for a total colectomy

and the placement of an ileostomy. The patient asks where the
stoma will be located. The healthcare provider identifies which of
the following areas as the correct stoma site?
A
B
D
C
A total colectomy involves the removal of the large intestine. The gastrointestinal output will occur at the
terminal end of the ileum. The stoma will be located in the right lower quadrant of the abdomen. A total
colectomy is performed for intestinal inflammatory conditions such as Crohn's disease or ulcerative colitis. It
may also be done for severe chronic constipation.
37/57Progress
Multiple myeloma can cause pathological fractures.
The palliative care nurse is caring for a client with advanced
multiple myeloma. Which intervention is MOST appropriate?
Limit administration of opioid medications.
Monitor blood work for hypocalcemia.
Use gentle repositioning techniques.
Maintain fluid intake at 1 liter per day.
Multiple myeloma occurs when abnormal plasma cells (myeloma cells) collect in several bones. In 70% of
multiple myeloma cases, the bones develop multiple holes, called osteolytic lesions. Multiple myeloma may
also affect other tissues and organs, especially the kidneys. This type of cancer causes hypercalcemia, renal
failure, anemia, and bone damage. Multiple myeloma can cause erosion of bone mass and fractures. Extra
care should be taken when moving or positioning a client because of the risk of pathological fractures. Pain is
intense from the bones and nerves and should be treated. Fluid hydration of 3 L daily is recommended
throughout the disease course and improves overall survival.
Dentures are fragile – and expensive.
Which of the following is the proper procedure for cleaning and
storing dentures as part of a client's HS oral care?
Remove dentures, clean with cool water, wrap them in a clean washcloth, leave next to the sink.
Remove dentures, clean with cool water, place in denture cup with cool water, leave within reach at client's
bedside.
Remove dentures, rinse quickly with hot water, place on a paper towel next to the sink.
Remove dentures, clean with hot water, place in empty denture cup, leave within reach at client's bedside.

Proper denture care is crucial to maintaining the life of the appliance and sustaining oral health. If dentures
aren't properly cared for, plaque can build up, causing additional tooth loss, bad breath, and even gum
disease. Dentures are fragile and easily damaged; they're also expensive, costing several thousand dollars.
After removing them, the proper procedure for denture care is as follows: 1. Take the dentures to the sink,
line the basin with a washcloth, and fill the basin partway with cool or tepid water, but do not place the
dentures in the sink. 2. Using a toothbrush, clean the surface of the dentures as if you were brushing your
own teeth. Work with one denture at a time. Using a small amount of toothpaste or denture cleaner is
appropriate. Be sure to clean the areas where the denture comes in contact with the gums or roof of the
mouth. 3. Rinse the denture thoroughly and place it into a clean denture cup filled with cool water. Repeat
this process with the other denture. 4. Place the cup within the client's reach. 5. Assist the patient with
proper oral care using sponge swabs and mouthwash. Look in the client's mouth for signs of infection such as
lesions. NEVER store dentures in a washcloth or paper towel; they could accidentally be thrown away.

The stoma should protrude above the abdominal wall.

A patient diagnosed with Crohn's disease has a new colostomy.
When assessing the patient's stoma, which of these would alert the
healthcare provider that the stoma has retracted?
Narrowed and flattened
Dry and reddish purple
Concave and bowl shaped
Pinkish red and moist
A colostomy is created when the bowel is pulled through an opening in the abdominal wall, creating a stoma
through which intestinal contents will pass. A healthy stoma will protrude about 2.5 cm with an open lumen
at the top. The stoma should appear pinkish red and moist. A dry, dusky, or reddish-purple stoma indicates
ischemia. A narrowed, flattened, or constricted stoma indicates stenosis. A concave and bowl-shaped stoma
has retracted. A retracted stoma can be difficult to care for. Complications include problems maintaining
appliance placement, leading to leakage and sore skin.
When cleaning the perineal area around the site of an indwelling
catheter, the nurse should
wipe the catheter away from the urinary meatus.
vigorously wash the periurethral area.
scrub the tubing toward the urinary meatus.
apply powder after giving perineal care.
The catheter should be wiped away from the meatus, to decrease the risk of introducing pathogens into the
urinary tract. The perineum should be washed gently with soap and water. Powder can retain moisture,
leading to an infection.
Reduce bright lights first.
A 10-year-old boy is admitted to the pediatric unit with a diagnosis
of viral meningitis. He is experiencing a severe headache, a stiff
neck, vomiting, photophobia, and drowsiness. The nurse can make
him more comfortable by
providing him with a large, soft pillow.
closing the shades and dimming the lights.
teaching him deep breathing.
encouraging him to drink fluids.
The first action should be to alleviate the photophobia by darkening the room. This may alleviate the child's
headache also. Deep breathing can be useful but will not eliminate the discomfort of meningitis symptoms.
Fluid balance is important but not the first priority. A large, soft pillow may place the neck in an awkward
position and exacerbate the child's discomfort by stretching the meninges.

Allow time for the gas to advance.

The health care provider (HCP) prescribed a rectal tube for a post-
operative client to relieve abdominal distention due to flatus.
Following insertion, the nurse notes that the client's abdomen
remains distended after 30 minutes. What should the nurse do
NEXT?
Remove the tube and reinsert it in 2-3 hours.
Advance the tube farther into the rectum.
Flush the tube with 100 mL of sterile water.
Withdraw 5 cm and rotate the tube several times.
The nurse should remove the tube and wait several hours to give the gas a chance to advance through the
gut. The use of a rectal tube to help remove flatus from the digestive tract is needed primarily in patients
who have had a recent surgery on the bowel or anus, or who have another condition which causes the
sphincter muscles not to work appropriately enough for gas to pass on its own. It helps to open the rectum
and is inserted into the colon to allow gas to move downward and out of the body. All the other options are
incorrect.

44/57ProgressHintNext
The tip of the rectal tube must extend past the anal sphincter.

As part of a pre-operative prep, the nurse is administering a

cleansing enema to an adult client. After positioning the client on
their left side and lubricating the tip of the rectal tube, how far
should the nurse insert the rectal tube?
4-5 inches (10-12.5 cm)
3-4 inches (7.5-10 cm)
1-2 inches (2.5-5 cm)
2-3 inches (5-7.5 cm)
In an adult, the anal sphincter is 1-2 inches (2.5-5 cm) past the anal orifice. The tip of the rectal tube should
be inserted 2-3 inches (5-7.5 cm) to ensure that the enema fluid enters the rectum, for a total of 3-4 inches
(7.5-10 cm). The purpose of a cleansing enema is to gently flush the colon. It can be used prior to a surgical
procedure, medical examination, or colonoscopy. It can also relieve constipation, fatigue, and some
backaches.

Treatments are not lengthy.

The nurse is providing education for a client who has just been
prescribed a transcutaneous electrical nerve stimulation (TENS) unit
for relief of chronic back pain. Which of the following instructions to
the client is correct?
"Muscle twitching means the TENS is working."
"Each TENS unit session lasts about 3 hours."
"It will take several days to build up tolerance."
"Don't go to sleep with the TENS unit on."
TENS relieves acute and chronic pain by using a mild electrical current that stimulates nerve fibers to block
the transmission of pain impulses to the brain. The current is delivered through electrodes placed on the skin
at points determined to be related to the pain. Clients should not go to sleep with the TENS unit on. Clients
are typically instructed to use the TENS unit for 30–60 minutes at a time, depending on the type of pain. TENS
may result in instant and possibly prolonged pain relief. Muscle twitching may indicate overstimulation.
Normal K range is 3.5–5.0 mEq/L.
Which lab value indicates hypokalemia?
5.6 mEq/L
3.6 mEq/L
4.2 mEq/L
3.2 mEq/L
The normal serum potassium (K) range is 3.5–5.0 mEq/L. For this question, the only correct option is 3.2
mEq/L. Hypokalemia is associated with an increased risk of cardiac arrhythmias. The nurse should report this
result immediately and be prepared to administer a potassium supplement.
A nurse working at a community health fair is administering
intramuscular injections of influenza vaccine. Which injection
technique will avoid leakage into subcutaneous tissue?
Injection at a 45-degree angle
Injection by the Z-track method
Massaging the injection site
Aspiration prior to injection
The Z-track injection method avoids leakage into subcutaneous tissue. Pull the client's skin downward or
upward, and inject the vaccination (or medication) at a 90-degree angle before releasing the skin. Aspiration
is done to assure that the injection is not going into a vein or artery. Massaging the injection site can
introduce the material into subcutaneous tissue. A 45-degree angle is incorrect.
Administer the drops with the least amount of resistance.
The nurse is teaching parents to instill eye drops for their 4-month-
old daughter. The parents tell the nurse that she shuts her eyes
tightly to avoid the drops. Which instruction by the nurse is most
appropriate?
The parents should open her eyes with a thumb and forefinger.
The parents should instill the drops into the conjunctival sac.
The parents should put the drops into the inner canthus.
The parents should wait until their daughter is relaxed.
Infants instinctively resist anything regarding their eyes by tightly closing them. The best way to instill eye
drops is to gently restrain the baby's head while the baby is in a supine position and put the drops at the
inner canthus of the eyes. When the baby opens its eyes and blinks, the medication will flow into the eyes.
The nurse should encourage the parents to be gentle and speak to the baby during the procedure.

A female patient complains of abdominal discomfort. Watery stool

has been leaking from her rectum. This could be a sign of
fecal impaction.
bowel incontinence.
diarrhea.
constipation.
Fecal impaction can be serious. When constipation is not resolved, stool becomes hardened and unable to
pass. Liquid stool may pass around the impaction. Patients may complain of feeling bloated; having the urge
to push; nausea or vomiting; or not wanting to eat. The impaction may need to be manually removed. Patient
education should include increasing liquids and fiber, as well as regular physical activity.
Of the following positions, which one facilitates maximum air
exchange?
Orthopneic
Lithotomy
Trendelenburg
High Fowler's
Orthopneic (sitting in a leaning position) allows for the most lung expansion. High Fowler's can help, but it
isn't as effective as the orthopneic position. Trendelenburg is used for hypotension or low cardiac output.
Lithotomy is used for vaginal examinations and childbirth.
ADL refers to self-care activities.
A patient with a total hip replacement requires certain equipment
for recovery. Which of the following will assist the patient with
activities of daily living (ADL)?
Abduction pillow
High-seat commode
Recliner
TENS unit
A high-seat commode keeps the hip higher than the knee. A recliner is helpful because it prevents 90° flexion,
but it is not necessary for activities of daily living (ADL). A TENS (Transcutaneous Electrical Nerve Stimulation)
unit helps with pain management, and an abduction pillow is used to prevent hip adduction and possibly
dislocation of the prosthesis, but neither are part of ADL.
Before administering a scheduled 300 mL enteral feeding bolus to a
comatose adult client, the nurse aspirates 100 mL of gastric residual
volume. Which nursing action is MOST appropriate?
Administer the bolus as prescribed.
Request a different enteral formula.
Flush the tubing with warm water.
Hold the feeding bolus for two hours.
Standard practice includes measuring gastric residual volume prior to administering an enteral feeding.
According to current American Society for Parenteral and Enteral Nutrition, enteral feedings can be
administered with a residual up to 500 mL; however, individual HCP orders should be followed. signs of
feeding intolerance include abdominal distention and/or pain, constipation, nausea, vomiting, and sense of
fullness.
Because the patient is diagnosed with pneumonia, the lung sounds will likely reflect fluid
accumulation.
A pediatric patient has been diagnosed with right lower lobe
pneumonia. Upon auscultation of this lung field, the healthcare
provider should expect to hear which breath sounds?
Wheezes
Stridor
Rhonchi
Crackles
Crackles would most likely be heard because they indicate fluid in the airspace. Fluid in the airspace is
consistent with pneumonia. Wheezes indicate a narrowing of the airways. Stridor is an emergency lung sound
that is seen in airway constriction that can lead to complete closure. Rhonchi are heard in mixed-issue airway
constriction and secretions.
Walking interferes with healing.
The nurse is caring for a pediatric client in a spica cast. All of the
following are true EXCEPT
Reposition often with pillows and blanket rolls.
Assist the client to ambulate several times a day.
Use a flashlight to check inside the cast for sore areas.
Offer small, frequent meals instead of three meals a day.
Spica (body) casts are used to immobilize the femur and pelvis. The cast holds the joint above the hip (the
spine) and the joint below the hip (the knee) still, so that the femur and pelvic bones are unable to move.
Skin should be checked for sores, around the edges and inside the cast. Large meals can cause an
uncomfortable feeling, so meals should be small. Repositioning is crucial. Use pillows, blankets, and cushions.
Do not allow the heels to rest on surfaces, to avoid pressure sores. Ambulation is not permitted when
wearing a spica cast.

A nurse working at a long-term care facility is observing a new

client. Which of the following signs indicates that the client may
have a vitamin B2 (riboflavin) deficiency?
Night blindness
Muscle cramps
Mouth sores
Frequent bruising
Vitamin B2, also called riboflavin, is one of 8 B vitamins. Signs of deficiency include cracks and sores at the
corner of the mouth; fatigue; digestive problems; swollen, magenta-colored tongue; itchy and burning eyes;
and sensitivity to light. B2 deficiency has been linked to cataracts and migraine headaches. All B vitamins help
the body to convert food (carbohydrates) into glucose) used to produce energy. They also help the nervous
system function properly. The B vitamins, often referred to as B-complex vitamins, also help the body
metabolize fats and proteins. B vitamins are water soluble, so the body does not store them. Bruising is a sign
of Vitamin C deficiency (scurvy). Night blindness indicates Vitamin A deficiency. Muscle cramps, aches, or
weakness indicate a Vitamin D deficiency.
It is a SELF-assessment tool.
The Wong-Baker FACES® Pain Rating Scale can be used by all of the
following EXCEPT
Non-English speakers
Parents and caregivers
Children ages 3 and older
Mentally disabled adults
The Wong-Baker FACES® Pain Scale is a self-assessment tool that is understood by the patient, so they can
choose the face that best matches their physical pain. It is NOT to be used by a third person, parents,
caregivers, or healthcare professionals to assess the patient's pain. It was originally created for use with
children, so they could communicate about their pain. It is now used around the world for people ages 3 and
older. (Wong-Baker FACES® Pain Scale used with permission.)
Allow time to rest.
The nurse is planning care for a client with status-post CVA and
limited mobility. The client is scheduled for occupational therapy at
10:00 a.m. and physical therapy at 2:00 p.m. What times are most
appropriate for nursing care?
AM care at 0900, PM care at 1500
AM care at 0900, PM care at 1600
AM care at 0800, PM care at 1600
AM care at 0800, PM care at 1500
Clients who are recovering from a serious condition and have limited mobility require extra time. Not only do
they need more time to prepare and to move but they also need more time to rest before and after therapy
sessions. The only correct option is to provide AM care at 0800 and PM care at 1600.