Unit : - Fundamentals of NursingChepter :- Basic Physical
Care
1001As a nurse helps a client ambulate, the client says, "I had
trouble sleeping last night." Which action should the nurse take
first?1. Recommending warm milk or a warm shower at bedtime2.
Gathering more information about the client's sleep problem3.
Determining whether the client is worried about something4. Finding
out whether the client is taking medication that may impede
sleepCorrect answer: 2RATIONALE: The nurse first should determine
what the client means by "trouble sleeping." The nurse lacks
sufficient information to recommend warm milk or a warm shower or
to make inferences about the cause of the sleep problem, such as
worries or medication use. CLIENT NEEDS CATEGORY: Physiological
integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application REFERENCE: Weber, J., and Kelley, J.
Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott
Williams & Wilkins, 2007, p. 32.
1002A 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 the client's 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 is most
appropriate at this time?1. Documenting that the client is resting
quietly and denies pain2. Calling a family member to obtain
information about the client3. Giving the client the ordered
as-needed pain medication4. Checking vital signs and assessing for
nonverbal indications of painCorrect answer: 4RATIONALE: 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 nonverbal
indications of pain help the nurse determine whether the client is
in pain. Accepting the client's response without question or
further assessment may result in inadequate intervention. Calling
the family or giving pain medication isn't warranted at this time
because the client denies pain and the nurse needs to obtain more
information. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT
NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL:
Application REFERENCE: Taylor, C., et al. Fundamentals of Nursing:
The Art and Science of Nursing Care, 6th ed. Philadelphia:
Lippincott Williams & Wilkins, 2008, p. 1375.
1003When 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?1. "I will administer the enema while sitting on the
toilet."2. "I will administer the enema while lying on my left side
with my right knee flexed."3. "I will administer the enema while
lying on my right side with my left knee flexed."4. "I will
administer the enema while lying on my back with both knees
flexed."Correct answer: 2RATIONALE: 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. CLIENT
NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS
SUBCATEGORY: Safety and infection control COGNITIVE LEVEL:
Comprehension REFERENCE: Taylor, C., et al. Fundamentals of
Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia:
Lippincott Williams & Wilkins, 2008, p. 1588.
1004A physician orders hourly urine output measurement for a
postoperative client with an indwelling catheter. The nurse records
the following amounts of output for 2 consecutive hours: 8 a.m.: 50
ml; 9 a.m.: 60 ml. Based on these amounts, which action should the
nurse take?1. Continue to monitor and record hourly urine output.2.
Notify the physician.3. Irrigate the indwelling urinary catheter.4.
Increase the I.V. fluid infusion rate.Correct answer: 1RATIONALE:
Normal urine output for an adult with an indwelling catheter is at
least 30 ml/hour. Therefore, this client's output is normal. Beyond
continued evaluation, no nursing action is warranted. CLIENT NEEDS
CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic
care and comfort COGNITIVE LEVEL: Analysis REFERENCE: Craven, R.F.,
and Hirnle, C.J. Fundamentals of Nursing: Human Health and
Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins,
2007, p.1079.
1005Nursing licensure and practice are regulated by:1. Nurse
practice acts.2. Standards of care.3. Civil law.4. The American
Nurses Association.Correct answer: 1RATIONALE: Nurse Practice acts
regulate nursing licensure and practice. Each state has its own
nurse practice act. Standards of care offer guidelines for
providing care and criteria for evaluating care. Civil law protects
an individual's rights and isn't associated with regulation of
nursing licensure or practice. The American Nurses Association, the
professional organization for registered nurses in the United
States, helps make policy and establish nursing care standards.
CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT
NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Knowledge
REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and
Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams
& Wilkins, 2008, p.20.
1006Which action should a nurse take when making a surgical
bed?1. Leave the bed in the high position when finished.2. Place
the pillow at the head of the bed.3. Tuck the top sheet and blanket
under the bottom of the bed.4. Roll the client to the far side of
the bed.Correct answer: 1RATIONALE: When making a surgical bed, the
nurse should leave the bed in the high position when finished.
After placing the top linens on the bed without touching them, the
nurse should fanfold these linens to the side opposite the side
from which the client will enter and place the pillow on the
bedside chair. All of these actions promote transfer of the
postoperative client from the stretcher to the bed. When making an
occupied or unoccupied bed, the nurse should place the pillow at
the head of the bed and tuck the top sheet and blanket under the
bottom of the bed. When making an occupied bed, the nurse should
roll the client to the far side of the bed. CLIENT NEEDS CATEGORY:
Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety
and infection control COGNITIVE LEVEL: Application REFERENCE:
Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th
ed. Philadelphia: Lippincott Williams & Wilkins, 2007,
p.159.
1007When moving a client in bed, the nurse can ensure proper
body mechanics by:1. Standing with her feet apart.2. Lifting the
client to the proper position.3. Straightening her knees and
back.4. Standing several feet from the client.Correct answer:
1RATIONALE: When moving a client in bed, the nurse should stand
with her feet apart to establish a wide base of support. To reduce
the amount of energy needed to move the client's weight against
gravity, the nurse should slide, roll, push, or pull rather than
lift the client. The nurse should flex her knees and use her arm
and leg muscles instead of her back. To minimize stress, the nurse
should stand as close to the client as possible. CLIENT NEEDS
CATEGORY: Safe, effective care environment CLIENT NEEDS
SUBCATEGORY: Safety and infection control COGNITIVE LEVEL:
Knowledge REFERENCE: Taylor, C., et al. Fundamentals of Nursing:
The Art and Science of Nursing Care, 6th ed. Philadelphia:
Lippincott Williams & Wilkins, 2008, p.1267.
1008A client with heart failure must be monitored closely after
starting diuretic therapy. The best indicator for the nurse to
monitor is:1. Fluid intake and output.2. Urine specific gravity.3.
Vital signs.4. Weight.Correct answer: 4RATIONALE: Heart failure
typically causes fluid overload, resulting in weight gain.
Therefore, weight is the best indicator of this client's status.
One pound gained or lost is equivalent to 500 ml. Fluid intakes and
output and vital signs are less accurate indicators than weight.
Urine specific gravity reflects urine concentration, indicating
over hydration or dehydration. Numerous factors can influence urine
specific gravity, so it isn't the most accurate indicator of the
client's status. CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
COGNITIVE LEVEL: Application REFERENCE: Smeltzer, S.C., and Bare,
B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing,
11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p.
953.
1009A nurse will use surgical asepsis for which procedure?1.
Hand washing2. Nasogastric tube irrigation3. I.V. catheter
insertion4. Colostomy irrigationCorrect answer: 3RATIONALE:
Caregivers must use surgical asepsis when performing wound care or
any procedure that involves entering a sterile body cavity or
breaking skin integrity. To achieve surgical asepsis, objects must
be sterilized or kept free of all pathogens. Because inserting an
I.V. catheter disrupts skin integrity and involves entry into a
sterile cavity (a vein), surgical asepsis is required. Hand washing
ensures medical asepsis or clean technique to prevent the spread of
infection. The GI tract isn't sterile; therefore, irrigating a
nasogastric tube or a colostomy requires only clean technique.
CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT
NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL:
Comprehension REFERENCE: Craven, R.F., and Hirnle, C.J.
Fundamentals of Nursing: Human Health and Function, 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 533.
1010A nurse is transferring a client from the bed to a chair.
Which action should the nurse take during this client transfer?1.
Position the head of the bed flat.2. Help the client dangle his
legs.3. Stand behind the client.4. Place the chair facing away from
the bed.Correct answer: 2RATIONALE: After placing the client in
high Fowlers position and moving the client to the side of the bed,
the nurse should help him sit on the edge of the bed and dangle his
legs. The nurse should then face the client and place the chair
next to and facing the head of the bed. CLIENT NEEDS CATEGORY:
Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety
and infection control COGNITIVE LEVEL: Knowledge REFERENCE: Craven,
R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and
Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins,
2007, p. 812.
1011A physician orders supplemental oxygen for a client with a
respiratory problem. Which oxygen delivery device should the nurse
use to provide the highest possible oxygen concentration?1. Nasal
cannula2. Venturi mask3. Simple mask4. Nonrebreather maskCorrect
answer: 4RATIONALE: A nonrebreather mask provides the highest
possible oxygen concentration up to 95%. A nasal cannula doesnt
deliver concentrations above 40%. A Venturi mask delivers precise
concentrations of 24% to 44%, regardless of the client's
respiratory pattern; because the same amount of room air always
enters the mask opening. A simple mask delivers 2 to 10 L/minute of
oxygen in uncontrollable concentrations. CLIENT NEEDS CATEGORY:
Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological
and parenteral therapies COGNITIVE LEVEL: Knowledge REFERENCE:
Taylor, C., et al. Fundamentals of Nursing: The Art and Science of
Nursing Care, 6th ed. Philadelphia: Lippincott Williams &
Wilkins, 2008, p. 1630.
1012A client has a nursing diagnosis of Ineffective airway
clearance related to poor coughing. When planning this client's
care, the nurse should include which intervention?1. Increasing
fluids to 2,500 ml/day2. Teaching the client how to deep-breathe
and cough3. Improving airway clearance4. Suctioning the client
every 2 hoursCorrect answer: 2RATIONALE: Interventions should
address the etiology of the client's problem poor coughing.
Teaching deep breathing and coughing addresses this etiology.
Increasing fluids may improve the client's condition, but this
intervention doesn't address poor coughing. Improving airway
clearance is too vague to be considered an appropriate
intervention. Suctioning isn't indicated unless other measures fail
to clear the airway. CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE
LEVEL: Application REFERENCE: Craven, R.F., and Hirnle, C.J.
Fundamentals of Nursing: Human Health and Function, 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 873.
1013A client is at risk for excess fluid volume. Which nursing
intervention ensures the most accurate monitoring of the client's
fluid status?1. Measuring and recording fluid intake and output2.
Weighing the client daily at the same time each day3. Assessing the
client's vital signs every 4 hours4. Checking the client's lungs
for crackles during every shiftCorrect answer: 2RATIONALE:
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 in similar clothing provides more objective data than
measuring fluid intake and output, which may be inaccurate because
of omitted measurements such as insensible losses. Changes in vital
signs are less reliable than daily weight because these changes
usually are subtle during early stages of fluid retention. Weight
gain is an earlier sign of excess fluid volume than crackles ,
which represent pulmonary edema . The nurse should plan to detect
fluid accumulation before pulmonary edema occurs. CLIENT NEEDS
CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY:
Reduction of risk potential COGNITIVE LEVEL: Application REFERENCE:
Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of
Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott
Williams & Wilkins, 2008, p. 957.
1014A client has a wound with a drain. When cleaning around the
drain, the nurse should wipe in which direction?1. Laterally, from
the center to the opposite side2. From top to bottom3. In a circle
around the drain, outward from the center4. In a circle around the
drain, from the outer border to the centerCorrect answer:
3RATIONALE: When cleaning the area around the drain, the nurse
should wipe in a circle around the drain, working from the center
outward. The nurse wipes laterally, from the center to the opposite
side, when cleaning a large horizontal wound and wipes from top to
bottom when cleaning a vertical incision. CLIENT NEEDS CATEGORY:
Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety
and infection control COGNITIVE LEVEL: Knowledge REFERENCE: Ellis,
J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 159.
1015To follow standard precautions , the nurse should carry out
which measure?1. Recapping needles after use2. Wearing a gown when
bathing a client3. Wearing gloves when administering I.M.
medication4. Wearing gloves for all client contactCorrect answer:
3RATIONALE: To follow standard precautions , caregivers must place
used, uncapped needles and syringes in a puncture-resistant
container; wear gloves when anticipating contact with a client's
blood, body fluid, mucous membranes, or nonintact skin (such as
when administering an I.M. injection); and wear a gown during
procedures that are likely to generate splashes of blood or body
fluids. 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. CLIENT NEEDS
CATEGORY: Safe, effective care environment CLIENT NEEDS
SUBCATEGORY: Safety and infection control COGNITIVE LEVEL:
Knowledge REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of
Nursing: Human Health and Function, 5th ed. Philadelphia:
Lippincott Williams & Wilkins, 2007, p. 531.
1016A nurse is performing a sterile dressing change. Which
action contaminates the sterile field?1. Holding sterile objects
above the waist2. Pouring solution onto a sterile field cloth3.
Leaving a 1 (2.5-cm) edge around the sterile field4. Opening the
outermost flap of a sterile package away from the bodyCorrect
answer: 2RATIONALE: Pouring solution onto a sterile field cloth
contaminates the sterile field because moisture penetrating the
cloth can carry microorganisms to the sterile field via capillary
action. Holding sterile objects above the waist, leaving a 1 edge
around the sterile field, and opening the outermost flap of a
sterile package away from the body maintain the sterile field.
CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT
NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL:
Knowledge REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic
Nursing Skills, 7th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 475.
1017A client is placed in isolation. Client isolation techniques
attempt to break the chain of infection by interfering with the:1.
agent.2. susceptible host.3. transmission mode.4. portal of
entry.Correct answer: 3RATIONALE: Client isolation techniques
attempt to break the chain of infection by interfering with the
transmission mode. These techniques don't affect the agent, host,
or portal of entry. CLIENT NEEDS CATEGORY: Safe, effective care
environment CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Knowledge REFERENCE: Craven, R.F., and Hirnle,
C.J. Fundamentals of Nursing: Human Health and Function, 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p.530.
1018A client is admitted to the health care facility with active
tuberculosis (TB). The nurse should include which intervention in
the care plan?1. Putting on an individually fitted mask when
entering the client's room2. Instructing the client to wear a mask
at all times3. Wearing a gown and gloves when providing direct
care4. Keeping the door to the client's room open to observe the
clientCorrect answer: 1RATIONALE: Because TB is transmitted by
droplet nuclei from the respiratory tract, the nurse should put on
a mask when entering the client's room. Occupation Safety and
Health Administration standards require an individually fitted
mask. Having the client wear a mask at all times would hinder
sputum expectoration and respirations would make the mask moist. A
nurse who doesn't anticipate contact with the client's blood or
body fluids need not wear a gown or gloves when providing direct
care. A client with TB should be in a room with laminar airflow,
and the room's door should be shut at all times. CLIENT NEEDS
CATEGORY: Safe, effective care environment CLIENT NEEDS
SUBCATEGORY: Safety and infection control COGNITIVE LEVEL:
Comprehension REFERENCE: Smeltzer, S.C., and Bare, B. Brunner &
Suddarth's Textbook of Medical Surgical-Nursing, 11th ed.
Philadelphia: Lippincott Williams & Wilkins, 2008, p. 645.
1019To help minimize calcium loss from a hospitalized client's
bones, the nurse should:1. reposition the client every 2 hours.2.
encourage the client to walk in the hall.3. provide the client
dairy products at frequent intervals.4. provide supplemental
feedings between meals.Correct answer: 2RATIONALE: Calcium
absorption diminishes with reduced physical activity because of
decreased bone stimulation. Therefore, encouraging the client to
increase physical activity, such as by walking in the hall, helps
minimize calcium loss. Turning or repositioning the client every 2
hours wouldn't increase activity sufficiently to minimize bone
loss. Providing dairy products and supplemental feedings wouldn't
lessen calcium loss even if the dairy products and feedings
contained extra calcium because the additional calcium doesn't
increase bone stimulation or osteoblast activity. CLIENT NEEDS
CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY:
Reduction of risk potential COGNITIVE LEVEL: Application REFERENCE:
Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of
Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott
Williams & Wilkins, 2008, p. 645.
1020When providing oral hygiene for an unconscious client , the
nurse must perform which action?1. Swab the client's lips, teeth,
and gums with lemon glycerin.2. Clean the client's tongue with
gloved fingers.3. Place the client in semi-Fowler's position.4.
Place the client in a side-lying position.Correct answer:
4RATIONALE: An unconscious client is at risk for aspiration. To
decrease this risk, the nurse should place the client in a
side-lying position when performing oral hygiene. Swabbing the
client's lips, teeth, and gums with lemon glycerin would promote
tooth decay. Cleaning an unconscious client's tongue with gloved
fingers wouldn't be effective in removing oral secretions or
debris. Placing the client in semi- Fowler's position would
increase the risk of aspiration. CLIENT NEEDS CATEGORY:
Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk
potential COGNITIVE LEVEL: Application REFERENCE: Taylor, C., et
al. Fundamentals of Nursing: The Art and Science of Nursing Care,
6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p.
1165.
1021A client hospitalized with pneumonia has thick, tenacious
secretions. Which intervention should the nurse include when
planning this client's care?1. Turning the client every 2 hours2.
Elevating the head of the bed 30 degrees3. Encouraging increased
fluid intake4. Maintaining a cool room temperatureCorrect answer:
3RATIONALE: Increasing the client's intake of oral or I.V. fluids
helps liquefy thick, tenacious secretions and ensures adequate
hydration. Turning the client every 2 hours would help prevent
pressure ulcers but wouldn't help with the secretions. Elevating
the head of the bed would reduce pressure on the diaphragm and ease
breathing but wouldn't help the client with secretions. Maintaining
a cool room temperature wouldn't help the client with secretions.
CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS
SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL:
Application REFERENCE: Smeltzer, S.C., and Bare, B. Brunner &
Suddarth's Textbook of Medical Surgical-Nursing, 11th ed.
Philadelphia: Lippincott Williams & Wilkins, 2008, p. 640.
1022Which option is an example of a primary preventive
measure?1. Participating in a cardiac rehabilitation program2.
Having an annual physical examination3. Practicing monthly breast
self-examination4. Avoiding overexposure to the sunCorrect answer:
4RATIONALE: Primary prevention involves promoting health and
helping clients achieve maximum wellness. Primary preventive
measures are designed to prevent or delay the onset of specific
illnesses; these measures typically include lifestyle changes such
as avoiding overexposure to the sun to prevent skin cancer.
Participating in a cardiac rehabilitation program is an example of
a tertiary preventive measure, which attempts to prevent
complications of an existing disease. Annual physical examinations
and monthly breast self-examinations are examples of secondary
preventive measures, which promote early detection and treatment of
disease. CLIENT NEEDS CATEGORY: Health promotion and maintenance
CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Comprehension
REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and
Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams
& Wilkins, 2008, p. 73.
1023A nurse is assigned to a client with a cardiac disorder. The
nurse should question an order to monitor the client's body
temperature by which route?1. Rectal2. Oral3. Axillary4.
TympanicCorrect answer: 1RATIONALE: When caring for a client with a
cardiac disorder, the nurse should avoid using the rectal route to
take temperature. Using this route could stimulate the vagus nerve,
possibly leading to vasodilation and bradycardia . The other
options are appropriate routes for measuring the temperature of a
client with a cardiac disorder. CLIENT NEEDS CATEGORY:
Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk
potential COGNITIVE LEVEL: Comprehension REFERENCE: Craven, R.F.,
and Hirnle, C.J. Fundamentals of Nursing: Human Health and
Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins,
2007, p. 487.
1024To evaluate a client for hypoxia , the physician is most
likely to order which laboratory test?1. Red blood cell count2.
Sputum culture3. Total hemoglobin4. Arterial blood gas (ABG)
analysisCorrect answer: 4RATIONALE: Red blood cell count, sputum
culture, total hemoglobin, and ABG analysis all help evaluate a
client with respiratory problems. However, ABG analysis is the only
test that evaluates gas exchange in the lungs, providing
information about the client's oxygenation status. CLIENT NEEDS
CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY:
Reduction of risk potential COGNITIVE LEVEL: Comprehension
REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's
Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia:
Lippincott Williams & Wilkins, 2008, p. 334.
1025A client, age 43, has no family history of breast cancer or
other risk factors for this disease . The nurse should instruct her
to have a mammogram how often?1. Once, to establish a baseline2.
Once per year3. Every 2 years4. Twice per yearCorrect answer:
2RATIONALE: Yearly mammograms should begin at age 40 and continue
for as long as the woman is in good health. If health risks exist,
such as family history, genetic tendency, or past breast cancer,
more frequent examinations may be necessary. CLIENT NEEDS CATEGORY:
Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
COGNITIVE LEVEL: Knowledge REFERENCE: American Cancer Society.
"American Cancer Society Guidelines for Early Detection of Cancer,
2006." [Online]. Available:
http://caonline.amcancersoc.org/cgi/content/full/56/1/11. [2007,
January 8].
1026A client asks to be discharged from the health care facility
against medical advice (AMA). What should the nurse do first?1.
Prevent the client from leaving.2. Notify the physician.3. Have the
client sign an AMA form.4. Call a security guard to help detain the
client.Correct answer: 2RATIONALE: If a client requests a discharge
AMA, the nurse should notify the physician immediately. If the
physician can't convince the client to stay, the physician will ask
the client to sign an AMA form, which releases the facility from
legal responsibility for any medical problems the client may
experience after discharge. If the physician isn't available, the
nurse should discuss the AMA form with the client and obtain the
client's signature. A client who refuses to sign the form shouldn't
be detained because this would violate the client's rights. After
the client leaves, the nurse should document the incident
thoroughly and notify the physician that the client has left.
CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT
NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Knowledge
REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and
Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams
& Wilkins, 2008, p. 182.
1027When bandaging a client's ankle , the nurse should use which
technique?1. Figure-eight2. Circular3. Recurrent4. Spiral
reverseCorrect answer: 1RATIONALE: The nurse uses a figure-eight
technique to bandage a joint, such as an ankle, elbow, wrist, or
knee. The nurse uses the circular bandaging technique to anchor a
bandage; the recurrent technique to bandage a stump, hand, or
scalp; and the spiral reverse bandaging technique to accommodate
the increasing circumference of a body part such as when in a cast.
CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS
SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Knowledge
REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and
Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams
& Wilkins, 2008, p. 1215.
1028When placing an indwelling urinary catheter in a female
client, the nurse should advance the catheter how far into the
urethra?1. (1 cm)2. 2 (5 cm)3. 6 (15 cm)4. 8 (20 cm)Correct answer:
2RATIONALE: In a female client, the nurse should advance an
indwelling urinary catheter 2 to 3 (5 to 7.5 cm) into the urethra.
In a male client, the nurse should advance the catheter 6 to 8.
CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT
NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL:
Knowledge REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of
Nursing: Human Health and Function, 5th ed. Philadelphia:
Lippincott Williams & Wilkins, 2007, p. 1105.
1029A scrub nurse in the operating room has which
responsibility?1. Positioning the client2. Assisting with gowning
and gloving3. Handing surgical instruments to the surgeon4.
Applying surgical drapesCorrect answer: 3RATIONALE: The scrub nurse
assists the surgeon by providing appropriate surgical instruments
and supplies, maintaining strict surgical asepsis and, with the
circulating nurse, accounting for all gauze sponges, needles, and
instruments. The circulating nurse assists the surgeon and scrub
nurse, positions the client, assists with gowning and gloving,
applies appropriate equipment and surgical drapes, and provides the
surgeon and scrub nurse with supplies. CLIENT NEEDS CATEGORY: Safe,
effective care environment CLIENT NEEDS SUBCATEGORY: Management of
care COGNITIVE LEVEL: Knowledge REFERENCE: Craven, R.F., and
Hirnle, C.J. Fundamentals of Nursing: Human Health and Function,
5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.
656.
1030A nurse is recording a client's complaint of painful
urination . When documenting this symptom, the nurse should use
which term?1. Oliguria2. Anuria3. Pyuria4. DysuriaCorrect answer:
4RATIONALE: The nurse should document painful urination as dysuria.
Oliguria refers to a decrease in the amount of urine excreted;
anuria , to a urine output below 50 ml/day; and pyuria , to pus in
the urine. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT
NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL:
Knowledge REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of
Nursing: Human Health and Function, 5th ed.Philadelphia: Lippincott
Williams & Wilkins, 2007, p. 1084.
1031A client has left-sided paralysis . The nurse should
document this condition as left-sided:1. monoplegia.2.
hemiplegia.3. paraplegia.4. quadriplegia.Correct answer:
2RATIONALE: Hemiplegia refers to paralysis of one side of the body;
therefore, the nurse should document that the client has left-sided
hemiplegia. Monoplegia refers to paralysis of one extremity;
paraplegia , to paralysis of both lower limbs; and quadriplegia ,
to paralysis of all four extremities and usually also the trunk.
CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS
SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Comprehension
REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and
Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams
& Wilkins, 2008, p. 1284.
1032Which member of the health care team is responsible for
obtaining informed consent from a client?1. The primary nurse2. The
physician involved with the procedure3. The nurse working with the
physician4. The social workerCorrect answer: 2RATIONALE: The
physician involved with the procedure is responsible for obtaining
the client's informed consent. The primary nurse or the nurse
working with the physician may witness the client's signature. The
social worker may not obtain informed consent. CLIENT NEEDS
CATEGORY: Safe, effective care environment CLIENT NEEDS
SUBCATEGORY: Management of care COGNITIVE LEVEL: Knowledge
REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing:
Human Health and Function, 5th ed. Philadelphia: Lippincott
Williams & Wilkins, 2007, p. 100.
1033A nurse implements a teaching plan for a client who's
scheduled for discharge. Which client behavior best demonstrates
effective teaching?1. Exhibiting a positive change in behavior2.
Verbally repeating the instruction3. Making statements indicating
understanding4. Exhibiting nonverbal signs such as nodding the head
to indicate "yes"Correct answer: 1RATIONALE: 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. CLIENT NEEDS CATEGORY: Psychosocial
integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL:
Application REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals
of Nursing: Human Health and Function, 5th ed. Philadelphia:
Lippincott Williams & Wilkins, 2007, p. 414.
1034Which strategy can help make the nurse a more effective
teacher?1. Including the client in the discussion2. Using technical
terms3. Providing detailed explanations4. Using loosely structured
teaching sessionsCorrect answer: 1RATIONALE: An effective teacher
always involves the client in the discussion. Using technical terms
and providing detailed explanations usually confuse the client and
act as barriers to learning. Using loosely structured teaching
sessions permits distractions and deviations from teaching goals.
CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT
NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Application
REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing:
Human Health and Function, 5th ed. Philadelphia: Lippincott
Williams & Wilkins, 2007, p. 413.
1035A client complains of dyspnea . Which action by the nurse is
most appropriate?1. Placing the client in Trendelenburg position2.
Placing the client in Sims' position3. Placing the client in
Fowler's position4. Placing the client in the supine
positionCorrect answer: 3RATIONALE: Fowler's position the posture
assumed by the client when the head of the bed is elevated 40 to 60
degrees promotes breathing by allowing the thoracic cavity to
expand. The Trendelenburg, Sims', and supine positions wouldn't
facilitate breathing. CLIENT NEEDS CATEGORY: Physiological
integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application REFERENCE: Craven, R.F., and Hirnle,
C.J. Fundamentals of Nursing: Human Health and Function, 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 870.
1036A client has a blood pressure of 152/86 mm Hg. The nurse
should document the client's pulse pressure as:1. 66 mm Hg.2. 238
mm Hg.3. 86 mm Hg.4. 152 mm Hg.Correct answer: 1RATIONALE: Pulse
pressure is the difference between the systolic and diastolic
pressures in this case, 66 mm Hg. CLIENT NEEDS CATEGORY:
Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and
comfort COGNITIVE LEVEL: Comprehension REFERENCE: Weber, J., and
Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia:
Lippincott Williams & Wilkins, 2007, p. 102.
1037A physician orders chest physiotherapy for a client with
pulmonary congestion. When should the nurse plan to perform chest
physiotherapy?1. After meals2. Before meals3. When the client has
time4. When the nurse has timeCorrect answer: 2RATIONALE: To avoid
tiring the client or inducing vomiting, chest physiotherapy is best
performed before meals. Scheduling chest physiotherapy around
client or nurse convenience is inappropriate. CLIENT NEEDS
CATEGORY: Safe, effective care environment CLIENT NEEDS
SUBCATEGORY: Safety and infection control COGNITIVE LEVEL:
Comprehension REFERENCE: Taylor, C., et al. Fundamentals of
Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia:
Lippincott Williams & Wilkins, 2008, p. 1626.
1038A physician orders a bland, full-liquid diet for a client.
The nurse tells the client that his diet may include:1. orange
juice, farina, and coffee.2. apple juice, cream of chicken soup,
and vanilla ice cream.3. pineapple juice, a bran muffin, and
milk.4. orange juice, custard, and tea.Correct answer: 2RATIONALE:
A bland, full-liquid diet may include fruit juices and foods from
all of the food groups. On this diet, the client should avoid
gastric irritants, such as coffee, tea, colas, cocoa, breads, bran
(fiber), and highly seasoned foods. CLIENT NEEDS CATEGORY:
Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and
comfort COGNITIVE LEVEL: Comprehension REFERENCE: Craven, R.F., and
Hirnle, C.J. Fundamentals of Nursing: Human Health and Function,
5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.
989.
1039A nurse is preparing a client for bronchoscopy . Which
instruction should the nurse give to the client?1. Don't walk.2.
Don't cough.3. Don't talk.4. Don't eat.Correct answer: 4RATIONALE:
Bronchoscopy involves visualization of the trachea and bronchial
tree. To prevent aspiration of stomach contents into the lungs, the
nurse should instruct the client not to eat or drink anything for
approximately 6 hours before the procedure. It isn't necessary for
the client to avoid walking, talking, or coughing. CLIENT NEEDS
CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY:
Reduction of risk potential COGNITIVE LEVEL: Knowledge REFERENCE:
Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of
Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott
Williams & Wilkins, 2008, p. 581.
1040When providing discharge teaching to a client with a
fractured toe , the nurse should include which instruction?1. Apply
heat to the fracture site.2. Apply ice to the fracture site.3.
Perform ankle dorsiflexion three times per day.4. Use crutches for
1 week.Correct answer: 2RATIONALE: Applying ice to the injury site
soon after an injury causes vasoconstriction , helping to relieve
or prevent swelling and bleeding. Applying heat to the fracture
site may increase swelling and bleeding. Ankle dorsiflexion has no
therapeutic use after a toe fracture. It's unlikely the client
would need crutches after a toe fracture. CLIENT NEEDS CATEGORY:
Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological
adaptation COGNITIVE LEVEL: Analysis REFERENCE: Smeltzer, S.C., and
Bare, B. Brunner & Suddarth's Textbook of Medical
Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams &
Wilkins, 2008, p. 2426.
1041A nurse is to collect a sputum specimen from a client. The
best time to collect this specimen is:1. early in the evening.2.
any time during the day.3. in the morning, as soon as the client
awakens.4. before bedtime.Correct answer: 3RATIONALE: Because
sputum accumulates in the lungs during sleep, the nurse should
collect a sputum specimen in the morning, as soon as the client
awakens. This specimen will be concentrated, increasing the
likelihood of an accurate culture. Sputum specimens collected at
other times during the day aren't concentrated and may not provide
an accurate culture. CLIENT NEEDS CATEGORY: Safe, effective care
environment CLIENT NEEDS SUBCATEGORY: Safety and infection control
COGNITIVE LEVEL: Knowledge REFERENCE: Ellis, J.R., and Bentz, P.M.
Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott
Williams & Wilkins, 2007, p. 288.
1042A nurse-manager notes that a staff nurse isn't working to
full potential. Which strategy by the nurse-manager would best
benefit the staff nurse?1. Assigning the staff nurse several
clients with multiple physical problems2. Allowing the staff nurse
to select her own assignments3. Discussing the staff nurse's
performance and ways she can improve4. Assigning the staff nurse
fewer patients than her coworkersCorrect answer: 3RATIONALE: The
nurse-manager should meet with the staff nurse to discuss her
performance and ways she can improve. Assigning the staff nurse
several clients with multiple physical problems would be
overwhelming, counterproductive, and unsafe because she has yet to
demonstrate the priority-setting and decision-making leadership
skills that this client load would require. Letting her select her
own assignments or giving her fewer patients could impair the
morale of other staff nurses. CLIENT NEEDS CATEGORY: Safe,
effective care environment CLIENT NEEDS SUBCATEGORY: Management of
care COGNITIVE LEVEL: Application REFERENCE: Craven, R.F., and
Hirnle, C.J. Fundamentals of Nursing: Human Health and Function,
5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.
115.
1043Which client would qualify for hospice care?1. A client with
late-stage acquired immunodeficiency syndrome (AIDS)2. A client
with left-sided paralysis resulting from a stroke3. A client who's
undergoing treatment for heroin addiction4. A client who had
coronary artery bypass surgery 2 weeks earlierCorrect answer:
1RATIONALE: Hospices provide supportive, palliative care to
terminally ill clients, such as those with late-stage AIDS , as
well as their families. Hospice services wouldn't be appropriate
for a client with left-sided paralysis resulting from a stroke, a
client who's undergoing treatment for heroin addiction, or one who
recently had coronary artery bypass surgery because these health
problems aren't necessarily terminal. CLIENT NEEDS CATEGORY: Health
promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE
LEVEL: Comprehension REFERENCE: Taylor, C., et al. Fundamentals of
Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia:
Lippincott Williams & Wilkins, 2008, p. 159.
1044A nurse should question an order for a heating pad for a
client who has:1. active bleeding.2. a reddened abscess.3. an
edematous lower leg.4. purulent wound drainage.Correct answer:
1RATIONALE: Heat application increases blood flow and therefore is
contraindicated in active bleeding. For the same reason, however,
applying heat to a reddened abscess, an edematous lower leg, or a
wound with purulent drainage promotes healing. CLIENT NEEDS
CATEGORY: Safe, effective care environment CLIENT NEEDS
SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Analysis
REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and
Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams
& Wilkins, 2008, p. 1223.
1045Which action must a nurse perform when cleaning the area
around a Jackson-Pratt wound drain?1. Clean from the center outward
in a circular motion.2. Remove the drain before cleaning the
skin.3. Clean briskly around the site with alcohol.4. Wear sterile
gloves and a mask.Correct answer: 1RATIONALE: The nurse should move
from the center outward in ever-larger circles when cleaning around
a wound drain because the skin near the drain site is more
contaminated than the site itself. The nurse should never remove
the drain before cleaning the skin. Alcohol should never be used to
clean around a drain; it may irritate the skin and, because it
evaporates, has no lasting effect on bacteria. The nurse should
wear sterile gloves to prevent contamination, but need not wear a
mask. CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE
LEVEL: Comprehension REFERENCE: Ellis, J.R., and Bentz, P.M.
Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott
Williams & Wilkins, 2007, p. 159.
1046A client who suffered a stroke has a nursing diagnosis of
Ineffective airway clearance. The goal of care for this client is
to mobilize pulmonary secretions . Which intervention helps meet
this goal?1. Repositioning the client every 2 hours2. Restricting
fluids to 1,000 ml/24 hours3. Administering oxygen by nasal cannula
as ordered4. Keeping the head of the bed at a 30-degree
angleCorrect answer: 1RATIONALE: Repositioning the client every 2
hours helps prevent secretions from pooling in dependent lung
areas. Restricting fluids would make secretions thicker and more
tenacious, thereby hindering their removal. Administering oxygen
and keeping the head of the bed at a 30-degree angle might ease
respirations and make them more effective but wouldn't help
mobilize secretions. CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE
LEVEL: Application REFERENCE: Craven, R.F., and Hirnle, C.J.
Fundamentals of Nursing: Human Health and Function, 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 873.
1047A nurse caring for a client with a fecal impaction should
watch for:1. liquid or semiliquid stools.2. hard, brown, formed
stools.3. loss of urge to defecate.4. increased appetite.Correct
answer: 1RATIONALE: Passage of liquid or semiliquid stools results
from seepage of unformed bowel contents around the impacted stool
in the rectum. Clients with fecal impaction don't pass hard, brown,
formed stools because the feces can't move past the impaction.
These clients typically report the urge to defecate (although they
can't pass stool) and decreased appetite. CLIENT NEEDS CATEGORY:
Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological
adaptation COGNITIVE LEVEL: Comprehension REFERENCE: Taylor, C., et
al. Fundamentals of Nursing: The Art and Science of Nursing Care,
6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p.
1575.
1048A nurse is obtaining a sterile urine specimen from a
client's indwelling urinary catheter. During the procedure, the
nurse should:1. aspirate urine from the tubing port, using a
sterile syringe and needle.2. disconnect the catheter from the
tubing and collect urine.3. open the drainage bag and pour out some
urine.4. wear sterile gloves when collecting urine.Correct answer:
1RATIONALE: To collect urine properly, the nurse should aspirate it
from a port, using a sterile syringe and needle after cleaning the
port. Opening a closed urine-drainage system, which would occur if
the nurse disconnected the catheter from the tubing or opened the
drainage bag, would increase the risk of urinary tract infection .
Although standard precautions specify wearing gloves during contact
with body fluids, the nurse need not wear sterile gloves for this
procedure. CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE
LEVEL: Comprehension REFERENCE: Taylor, C., et al. Fundamentals of
Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia:
Lippincott Williams & Wilkins, 2008, p. 1495.
1049Which nursing action is essential when providing continuous
enteral feeding?1. Elevating the head of the bed2. Positioning the
client on his left side3. Warming the formula before administering
it4. Adding methylene blue to the enteral feeding to detect
aspirationCorrect answer: 1RATIONALE: 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. When such
elevation is contraindicated, the client should be positioned on
his right side. The nurse should give enteral feedings at room
temperature to minimize GI distress. Because methylene blue can
cause adverse effects, it isn't a recommended enteral feeding
additive. CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE
LEVEL: Application REFERENCE: Taylor, C., et al. Fundamentals of
Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia:
Lippincott Williams & Wilkins, 2008, p. 1452.
1050A client is admitted with multiple pressure ulcers . When
developing the client's diet plan, the nurse should include:1.
fresh orange slices.2. ground beef patties.3. steamed broccoli.4.
ice cream.Correct answer: 2RATIONALE: Meat is an excellent source
of complete protein, which this client needs to repair the tissue
breakdown caused by pressure ulcers. Oranges and broccoli supply
vitamin C but not protein. Ice cream supplies only some incomplete
protein, making it less helpful in tissue repair. CLIENT NEEDS
CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic
care and comfort COGNITIVE LEVEL: Analysis REFERENCE: Craven, R.F.,
and Hirnle, C.J. Fundamentals of Nursing: Human Health and
Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins,
2007, p. 1014.
1051A client is admitted to the facility with a productive cough
, night sweats, and a fever. Which action is most important in the
initial care plan?1. Assessing the client's temperature every 8
hours2. Placing the client in respiratory isolation3. Monitoring
the client's fluid intake and output4. Wearing gloves during all
client contactCorrect answer: 2RATIONALE: Because the client's
signs and symptoms suggest a respiratory infection (possibly
tuberculosis ), respiratory isolation is indicated. Every 8 hours
isn't frequent enough to assess the temperature of a client with a
fever. Monitoring fluid intake and output may be required, but the
client should first be placed in isolation. The nurse should wear
gloves only for contact with mucous membranes, broken skin, blood,
and other body fluids and substances. CLIENT NEEDS CATEGORY: Safe,
effective care environment CLIENT NEEDS SUBCATEGORY: Safety and
infection control COGNITIVE LEVEL: Analysis REFERENCE: Smeltzer,
S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical
Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams &
Wilkins, 2008, p. 644.
1052A client is being discharged after abdominal surgery and
colostomy formation to treat colon cancer. Which nursing action is
most likely to promote continuity of care?1. Notifying the American
Cancer Society of the client's diagnosis2. Requesting Meals On
Wheels to provide adequate nutritional intake3. Referring the
client to a home health nurse for follow-up visits to provide
colostomy care4. Asking an occupational therapist to evaluate the
client at homeCorrect answer: 3RATIONALE: Many clients are
discharged from acute care settings so quickly that they don't
receive complete instructions. Therefore, the first priority is to
arrange for colostomy care. The American Cancer Society often
sponsors support groups, which are helpful when the person is
ready, but contacting this organization doesn't take precedence
over ensuring proper colostomy care. Requesting Meals On Wheels and
asking for an occupational therapy evaluation are important, but
these actions can occur later in rehabilitation. CLIENT NEEDS
CATEGORY: Safe, effective care environment CLIENT NEEDS
SUBCATEGORY: Management of care COGNITIVE LEVEL: Analysis
REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and
Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams
& Wilkins, 2008, p. 179.
1053A client's rights to information, informed consent , and
treatment refusal are addressed in the:1. standards of nursing
practice.2. Patient Care Partnership.3. nurse practice act.4. code
for nurses.Correct answer: 2RATIONALE: The Patient Care Partnership
addresses the client's rights to information, informed consent,
timely responses to requests for services, and treatment refusal.
It's a legal document and serves as a guideline for decision making
by the nurse. Standards of nursing practice, the nurse practice
act, and the code for nurses contain nursing practice parameters
and primarily describe use of the nursing process in providing
care. CLIENT NEEDS CATEGORY: Safe, effective care environment
CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL:
Knowledge REFERENCE: American Hospital Association. "What to expect
during your hospital stay." [Online]. Available:
http://www.aha.org/aha/content/2003/pdf/pcp_english_030730.pdf.
[2007, January 8].
1054An employer establishes a physical exercise area in the
workplace and encourages all employees to use it. This is an
example of which level of health promotion?1. Primary prevention2.
Secondary prevention3. Tertiary prevention4. Passive
preventionCorrect answer: 1RATIONALE: Primary prevention precedes
disease and applies to healthy clients. Secondary prevention
focuses on clients who have health problems and are at risk for
developing complications. Tertiary prevention focuses on
rehabilitating clients who already have a disease or disability.
Passive prevention enables clients to gain health as a result of
others' activities without doing anything themselves. CLIENT NEEDS
CATEGORY: Health promotion and maintenance CLIENT NEEDS
SUBCATEGORY: None COGNITIVE LEVEL: Comprehension REFERENCE: Taylor,
C., et al. Fundamentals of Nursing: The Art and Science of Nursing
Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins,
2008, p. 73.
1055When following standard precautions , a nurse's primary
responsibility is to:1. wear gloves for all client contact.2.
consider all body substances potentially infectious.3. place a body
substance isolation sign on the client's door.4. wear gloves and a
gown if the client is in respiratory isolation.Correct answer:
2RATIONALE: Standard precautions are based on the concept that all
body substances are potentially infectious and that direct contact
with them must be avoided. The nurse should wear gloves when
contact with body substances not unsoiled articles or intact skin
is anticipated. Because all body substances from all clients are
considered potentially infectious, signs on doors are unnecessary.
Gloves and gowns are inappropriate when caring for a client in
respiratory isolation because they don't prevent transmission of
airborne respiratory infections. The nurse should wear a mask as a
barrier to such infections. CLIENT NEEDS CATEGORY: Safe, effective
care environment CLIENT NEEDS SUBCATEGORY: Safety and infection
control COGNITIVE LEVEL: Knowledge REFERENCE: Craven, R.F., and
Hirnle, C.J. Fundamentals of Nursing: Human Health and Function,
5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.
531.
1056When changing a sterile surgical dressing, a nurse first
must:1. wash her hands.2. put on sterile gloves.3. remove the old
dressing while wearing clean gloves.4. open sterile packages and
moisten the dressings with sterile saline solution.Correct answer:
1RATIONALE: To prevent the spread of microorganisms, the nurse
should always wash her hands before providing client care. When
changing a sterile surgical dressing, the nurse also must put on
sterile gloves, remove the old dressing while wearing clean gloves,
open sterile packages, and moisten the dressings with sterile
saline. However, these actions follow hand washing. CLIENT NEEDS
CATEGORY: Safe, effective care environment CLIENT NEEDS
SUBCATEGORY: Safety and infection control COGNITIVE LEVEL:
Knowledge REFERENCE: Taylor, C., et al. Fundamentals of Nursing:
The Art and Science of Nursing Care, 6th ed. Philadelphia:
Lippincott Williams & Wilkins, 2008, p. 1210.
1057After suctioning a client, a nurse should expect to find:1.
a respiratory rate of 28 breaths/minute.2. a heart rate of 104
beats/minute.3. brisk capillary refill.4. clear breath
sounds.Correct answer: 4RATIONALE: Clear breath sounds, which
indicate that secretions have been removed, indicate effective
suctioning. An above-normal respiratory rate, such as a rate of 28
breaths/minute, may indicate that the airway isn't clear of
secretions and the client's respiratory rate has increased to
compensate. A slightly increased heart rate, such as a rate of 104
beats/minute, may indicate health concerns unrelated to suctioning.
Brisk capillary refill indicates adequate cardiovascular function
and is unrelated to suctioning. CLIENT NEEDS CATEGORY:
Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological
adaptation COGNITIVE LEVEL: Comprehension REFERENCE: Taylor, C., et
al. Fundamentals of Nursing: The Art and Science of Nursing Care,
6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p.
1649.
1058A client twists his 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 client statement suggests that
ice application has been effective ?1. "I need something stronger
for pain relief."2. "My ankle looks less swollen now."3. "My ankle
appears redder now."4. "My ankle feels very warm."Correct answer:
2RATIONALE: 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. CLIENT
NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY:
Physiological adaptation COGNITIVE LEVEL: Application REFERENCE:
Taylor, C., et al. Fundamentals of Nursing: The Art and Science of
Nursing Care, 6th ed. Philadelphia: Lippincott Williams &
Wilkins, 2008, p. 1222.
1059A client suddenly loses consciousness. What should the nurse
do first ?1. Call for assistance.2. Assess for responsiveness.3.
Palpate for a carotid pulse.4. Assess for pupillary
response.Correct answer: 2RATIONALE: A nurse always should assess
for responsiveness first to prevent injuries to a client who isn't
in cardiac or respiratory arrest. After assessing the client, the
nurse should call for assistance, open the client's airway, check
for breathing, and palpate for a carotid pulse. Assessing for
pupillary response would waste valuable time and is inappropriate.
CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS
SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Analysis
REFERENCE: ECC Committee, Subcommittees and Task Force of the
American Heart Association. "2005 American Heart Association
Guidelines for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care, Part 4: Adult Basic Life Support. Circulation
112(24 Suppl IV):IV19-IV34, December 13, 2005.
1060When leaving the room of a client in strict isolation, the
nurse should remove which protective equipment first ?1. Cap2.
Mask3. Gown4. GlovesCorrect answer: 4RATIONALE: When leaving a
strict-isolation room, the nurse should remove her gloves first
because they're considered the most contaminated protective
equipment. Removing other protective equipment before removing her
gloves and washing her hands could contaminate her hair and uniform
and promote pathogen transmission. CLIENT NEEDS CATEGORY: Safe,
effective care environment CLIENT NEEDS SUBCATEGORY: Safety and
infection control COGNITIVE LEVEL: Knowledge REFERENCE: Craven,
R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and
Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins,
2007, p. 531.
1061A client has a soft wrist-safety device. Which assessment
finding should the nurse investigate further?1. A palpable radial
pulse2. A palpable ulnar pulse3. Cool, pale fingers4. Pink nail
bedsCorrect answer: 3RATIONALE: A wrist-safety device on the wrist
may impair circulation and restrict blood supply to body tissues.
Therefore, the nurse should assess the client for signs of impaired
circulation such as cool, pale fingers. A palpable radial or ulnar
pulse and pink nail beds are normal findings. CLIENT NEEDS
CATEGORY: Safe, effective care environment CLIENT NEEDS
SUBCATEGORY: Safety and infection control COGNITIVE LEVEL:
Comprehension REFERENCE: Taylor, C., et al. Fundamentals of
Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia:
Lippincott Williams & Wilkins, 2008, p. 693.
1062Which nursing theorist addressed self-care deficits in her
nursing theory?1. Dorothy Johnson2. Virginia Henderson3. Dorothea
Orem4. Martha RogersCorrect answer: 3RATIONALE: Dorothea Orem's
general theory of nursing addresses self-care deficits as the basis
for nursing care. This theory posits that the nurse intervenes to
reestablish the client's self-care capacity. Dorothy Johnson's
behavioral systems theory views nursing as a means to reestablish
balance in the client's behavioral subsystems, which have been
disrupted by stress. According to Virginia Henderson's theory of
nursing, the nurse focuses on the client's basic needs. In Martha
Rogers' unitary human beings theory, the nurse helps the client
balance the changes that occur as he constantly evolves. CLIENT
NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS
SUBCATEGORY: Management of care COGNITIVE LEVEL: Knowledge
REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing:
Human Health and Function, 5th ed. Philadelphia: Lippincott
Williams & Wilkins, 2007, p. 59.
1063A physician orders an intestinal tube to decompress a
client's GI tract. When gathering equipment for this procedure, a
nurse should obtain a:1. Sengstaken-Blakemore tube.2. Miller-Abbott
tube.3. Levin tube.4. Salem sump tube.Correct answer: 2RATIONALE: A
Miller-Abbott tube is an intestinal tube. A Sengstaken-Blakemore
tube is an esophageal tube. Levin tubes and Salem sump tubes are
nasogastric tubes. CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL:
Knowledge REFERENCE: Smeltzer, S.C., and Bare, B. Brunner &
Suddarth's Textbook of Medical Surgical-Nursing, 11th ed.
Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1175.
1064During assessment, a nurse measures a client's respiratory
rate at 32 breaths/minute with a regular rhythm. When documenting
this pattern, the nurse should use which term?1. Eupnea2.
Bradypnea3. Apnea4. TachypneaCorrect answer: 4RATIONALE: A
respiratory rate of 32 breaths/minute with a regular rhythm is
faster than normal and should be documented as tachypnea . Eupnea
is a respiratory rate of 12 to 20 breaths/minute with a regular
rhythm. Bradypnea refers to a respiratory rate below 12
breaths/minute with a regular rhythm. Apnea refers to absence of
breathing. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT
NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL:
Comprehension REFERENCE: Taylor, C., et al. Fundamentals of
Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia:
Lippincott Williams & Wilkins, 2008, p. 571.
1065Which nursing intervention is appropriate for a client with
an arm restraint?1. Applying the restraint loosely to prevent
pressure on the skin2. Tying the restraint to the side rail3.
Positioning the restrained arm in full extension4. Monitoring
circulatory status every 2 hoursCorrect answer: 4RATIONALE: A nurse
must assess the circulatory status of a restrained extremity every
2 hours to prevent circulatory impairment. To make sure the
restraint is secure without compromising the circulation, the nurse
should leave approximately one fingerbreadth between the restraint
and the extremity. Tying a restraint to the side rail or an
immovable bed part may cause client injury if the rail or bed is
moved before the restraint is released. The restrained arm or leg
should be flexed slightly to allow joint movement without reducing
the effectiveness of the restraint. CLIENT NEEDS CATEGORY: Safe,
effective care environment CLIENT NEEDS SUBCATEGORY: Safety and
infection control COGNITIVE LEVEL: Application REFERENCE: Taylor,
C., et al. Fundamentals of Nursing: The Art and Science of Nursing
Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins,
2008, p. 692.
1066A nurse is reviewing a client's laboratory test results.
Which electrolyte is the major cation controlling a client's
extracellular fluid (ECF) osmolality ?1. Potassium2. Sodium3.
Chloride4. CalciumCorrect answer: 2RATIONALE: Sodium, the major ECF
cation, maintains ECF osmolality. Potassium is the major cation in
intracellular fluid. Chloride is the major anion in the ECF.
Calcium, found primarily in the intravascular fluid compartment of
ECF, is the major cation involved in the structure and function of
the teeth and bones. CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL:
Knowledge REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of
Nursing: Human Health and Function, 5th ed. Philadelphia:
Lippincott Williams & Wilkins, 2007, p. 920.
1067 Standard precautions include which measure?1. Wearing
gloves when changing a dressing2. Disposing of needles in a
puncture-resistant container3. Wearing eye protection during
tracheal suctioning4. All of the aboveCorrect answer: 4RATIONALE:
To follow standard precautions, caregivers must wear gloves when
there is the potential for contact with a client's body fluids;
place used, uncapped needles and syringes in a puncture-resistant
container; and wear goggles during procedures that are likely to
generate splashes of blood or body fluids. CLIENT NEEDS CATEGORY:
Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety
and infection control COGNITIVE LEVEL: Comprehension REFERENCE:
Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human
Health and Function, 5th ed. Philadelphia: Lippincott Williams
& Wilkins, 2007, p. 531.
1068A nurse has been teaching a client how to use an incentive
spirometer that he must use at home for several days after
discharge. Which client action indicates an accurate understanding
of the technique?1. The client takes slow, deep breaths to elevate
the spirometer ball.2. The client takes rapid, shallow breaths to
elevate the ball.3. The client tilts the spirometer down when using
it.4. The client uses the device while lying supine.Correct answer:
1RATIONALE: When using an incentive spirometer, the client should
take slow, deep breaths. This action ensures maximum ventilation,
which elevates the ball (or disk) inside the spirometer. Rapid,
shallow breathing doesn't allow maximum ventilation and lung
expansion. The client should hold the spirometer upright; when
tilted, a spirometer requires less effort to raise the ball. During
spirometry, the client should sit upright rather than lie supine to
promote maximum ventilation. CLIENT NEEDS CATEGORY: Health
promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE
LEVEL: Comprehension REFERENCE: Craven, R.F., and Hirnle, C.J.
Fundamentals of Nursing: Human Health and Function, 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 846.
1069A nurse is caring for an elderly client with a pressure
ulcer on the sacrum. When teaching the client about dietary intake,
which foods should the nurse emphasize ?1. Legumes and cheese2.
Whole grain products3. Fruits and vegetables4. Lean meats and
low-fat milkCorrect answer: 4RATIONALE: Although the client should
eat a balanced diet, including foods from all food groups, the diet
should emphasize foods that supply complete protein, such as lean
meats and low-fat milk. Protein helps build and repair body tissue,
which promotes healing. Legumes provide incomplete protein. Cheese
contains complete protein, but it also includes fat, which should
be limited to 30% or less of caloric intake. Whole grain products
supply incomplete proteins and carbohydrates. Fruits and vegetables
provide mainly carbohydrates. CLIENT NEEDS CATEGORY: Physiological
integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application REFERENCE: Craven, R.F., and Hirnle,
C.J. Fundamentals of Nursing: Human Health and Function, 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1014.
1070To collect a clean-catch midstream urine specimen from a
female client, the nurse instructs her to clean the area at the
external urinary meatus with an antiseptic. How should the client
clean the area?1. By swabbing the labia minora from front to back2.
By cleaning the labia minora from back to front3. By cleaning the
labia majora from back to front4. By swabbing the entire perineal
areaCorrect answer: 1RATIONALE: The client should swab the labia
minora from front to back, using one swab for each wipe. This
technique cleans from the area of least contamination to the area
of greatest contamination. The labia minora shouldn't be cleaned
from back to front because doing so increases the risk of
contamination. The labia majora should be cleaned with soap and
water from front to back not back to front. Before swabbing the
labia minora with an antiseptic, the client should wash the
perineal area with soap and water. CLIENT NEEDS CATEGORY: Safe,
effective care environment CLIENT NEEDS SUBCATEGORY: Safety and
infection control COGNITIVE LEVEL: Comprehension REFERENCE: Ellis,
J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 286.
1071A nurse is assigned to care for a client with a tracheostomy
tube. How can the nurse communicate with this client?1. By
providing a tracheostomy plug to use for verbal communication2. By
placing the call button under the client's pillow3. By supplying a
magic slate or similar device4. By suctioning the client
frequentlyCorrect answer: 3RATIONALE: The nurse should use a
nonverbal communication method, such as a magic slate, note pad and
pencil, and picture boards (if the client can't write or speak
English). The physician orders a tracheostomy plug when a client is
being weaned off a tracheostomy; it doesn't enable the client to
communicate. The call button, which should be within reach at all
times for all clients, can summon attention but doesn't communicate
additional information. Suctioning clears the airway but doesn't
enable the client to communicate. CLIENT NEEDS CATEGORY:
Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and
comfort COGNITIVE LEVEL: Application REFERENCE: Smeltzer, S.C., and
Bare, B. Brunner & Suddarth's Textbook of Medical
Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams &
Wilkins, 2008, p. 750.
1072A nurse must apply a wet-to-damp dressing over an ulcer on a
client's left ankle. How should the nurse proceed?1. Apply the
saturated fine-mesh gauze dressings over the wound.2. Apply an
occlusive dressing over the saturated fine-mesh gauze dressings.3.
Cover the saturated fine-mesh gauze dressings with an elastic
bandage.4. Pack the moistened fine-mesh gauze dressings into all
depressions and grooves of the wound.Correct answer: 4RATIONALE:
The nurse should pack the moistened fine-mesh gauze dressings into
all depressions and grooves of the wound because necrotic tissue is
usually more prevalent in those areas. The nurse should wring out
excess moisture from saturated fine-mesh gauze dressings because
saturated dressings won't dry properly. The nurse shouldn't apply
an occlusive dressing or elastic bandage because these products can
prevent air circulation and hinder drying of the fine-mesh gauze.
CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS
SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application
REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing
Skills, 7th ed. Philadelphia: Lippincott Williams & Wilkins,
2007, p. 753.
1073A nurse must irrigate a gaping abdominal incision with
sterile normal saline, using a piston syringe. How should she
proceed?1. Irrigate continuously until the solution becomes
clear.2. After the irrigation, moisten the area around the wound
with normal saline.3. After the irrigation, apply a wet-to-damp
dressing to the wound.4. Rapidly instill a stream of irrigating
solution into the wound.Correct answer: 1RATIONALE: To wash away
tissue debris and drainage effectively, the nurse should irrigate
the wound until the solution becomes clear. After irrigation, the
nurse should dry the area around the wound; moistening this area
promotes microorganism growth and skin irritation. When the area is
dry, the nurse should apply a dry, sterile dressing rather than a
wet-to-damp dressing . The nurse should always instill the
irrigating solution gently. Rapid or forceful instillation can
damage tissues. CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL:
Application REFERENCE: Taylor, C., et al. Fundamentals of Nursing:
The Art and Science of Nursing Care, 6th ed. Philadelphia:
Lippincott Williams & Wilkins, 2008, p. 1237.
1074Which intervention should a nurse use when administering
oxygen by face mask to a client?1. Secure the elastic band tightly
around the client's head.2. Assist the client to the semi-Fowler's
position if possible.3. Apply the face mask from the client's chin
up over the nose.4. Loosen the connectors between the oxygen
equipment and humidifier.Correct answer: 2RATIONALE: By assisting
the client to the semi- Fowler's position , the nurse promotes
easier chest expansion, breathing, and oxygen intake. The nurse
should secure the elastic band so that the face mask fits
comfortably and snugly rather than tightly, which could cause
irritation. The nurse should apply the face mask from the client's
nose down to the chin not vice versa. The nurse should ensure that
the connectors between the oxygen equipment and humidifier are
airtight; loosened connectors can cause loss of oxygen. CLIENT
NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY:
Pharmacological and parenteral therapies COGNITIVE LEVEL:
Application REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals
of Nursing: Human Health and Function, 5th ed. Philadelphia:
Lippincott Williams & Wilkins, 2007, p. 852.
1075During a teaching session, a nurse demonstrates to a client
how to change a tracheostomy dressing. Then the nurse watches as
the client returns the demonstration. Which client action indicates
an accurate understanding of the procedure?1. The client cleans
around the incision site, using gauze squares and full-strength
hydrogen peroxide.2. The client rinses around the clean incision
site, using gauze squares moistened with normal saline.3. The
client rinses around the clean incision site, using gauze squares
moistened with tap water.4. After cleaning around the incision
site, the client applies cotton-filled gauze squares as the sterile
dressing.Correct answer: 2RATIONALE: To change a tracheostomy
dressing effectively, the client should rinse around the clean
incision site, using gauze squares moistened with normal saline. If
crusts are difficult to remove, the client may use a solution of
50% hydrogen peroxide and 50% sterile saline not full-strength
hydrogen peroxide. The client shouldn't use tap water, which may
contain chemicals and other harmful substances. To prevent lint or
fiber aspiration and subsequent tracheal abscess, the client should
use sterile dressings made of nonraveling material instead of
cotton-filled gauze squares. CLIENT NEEDS CATEGORY: Physiological
integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application REFERENCE: Craven, R.F., and Hirnle,
C.J. Fundamentals of Nursing: Human Health and Function, 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 862.
1076A client who's scheduled for open-heart surgery in 2 days
has been having circulation problems in the feet and legs. The
physician orders antiembolism stockings . The nurse is teaching the
client about this treatment. What is the purpose of antiembolism
stockings?1. To decrease arterial blood circulation to the legs and
feet2. To decrease venous blood circulation from the legs and
feet3. To reduce or prevent edema of the legs and feet4. To
maintain warmth in the legsCorrect answer: 3RATIONALE: 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. Blankets can be used for this purpose. CLIENT NEEDS CATEGORY:
Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological
adaptation COGNITIVE LEVEL: Knowledge REFERENCE: Craven, R.F., and
Hirnle, C.J. Fundamentals of Nursing: Human Health and Function,
5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.
897.
1077A nurse is assisting with a subclavian vein central line
insertion when the client's oxygen saturation drops rapidly. He
complains of shortness of breath and becomes tachypneic . The nurse
suspects the client has developed a pneumothorax . Further
assessment findings supporting the presence of a pneumothorax
include:1. diminished or absent breath sounds on the affected
side.2. paradoxical chest wall movement with respirations.3.
tracheal deviation to the unaffected side.4. muffled or distant
heart sounds.Correct answer: 1RATIONALE: In the case of a
pneumothorax, auscultating for 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 cardiac tamponade. CLIENT NEEDS CATEGORY: Physiological
integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Analysis REFERENCE: Smeltzer, S.C., and Bare, B.
Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th
ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p.
696.
1078A physician inserts a chest tube into a client to treat a
pneumothorax . The tube is connected to a water-seal drainage
system. The nurse can prevent chest tube air leaks by:1. keeping
the chest drainage system below chest level.2. keeping the head of
the bed slightly elevated.3. checking and taping all connections.4.
checking patency of the chest tube.Correct answer: 3RATIONALE: Air
leaks commonly occur if the system isn't secure. Checking and
taping all connections will prevent air leaks. The chest drainage
system is kept below chest level, and the head of the bed may be
elevated to promote drainage not to prevent air leaks. Chest tubes
that aren't patent may lead to tension pneumothorax but wouldn't
cause an air leak. CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE
LEVEL: Analysis REFERENCE: Taylor, C., et al. Fundamentals of
Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia:
Lippincott Williams & Wilkins, 2008, p. 1633.
1079A client is unable to take a deep breath and doesn't want to
get out of bed because his chest tube is causing discomfort. To
increase client adherence to the treatment plan, the nurse
should:1. administer pain medication and delay client activity.2.
tell the client why lung expansion is important.3. arrange a care
schedule that includes rest periods.4. teach the client how to use
an incentive spirometer.Correct answer: 1RATIONALE: Administering
pain medication and delaying any activity until the medication
takes effect will increase client adherence to the treatment plan.
Explaining the purpose of the intended treatment is important but
won't decrease the discomfort of the chest tube. Providing rest
periods is essential but won't relieve the client's discomfort. An
incentive spirometer measures deep-breathing ability, prevents
atelectasis , and acts as a visual progress chart for the client.
Teaching the client about incentive spirometry won't alleviate his
discomfort. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT
NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL:
Analysis REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of
Nursing: Human Health and Function, 5th ed. Philadelphia:
Lippincott Williams & Wilkins, 2007, p. 1191.
1080To assess effectiveness of incentive spirometry, a nurse can
use a pulse oximeter to monitor a client's:1. oxygen saturation.2.
hemoglobin level.3. partial pressure of carbon dioxide (PaCO2).4.
partial pressure of oxygen (PaO2).Correct answer: 1RATIONALE: A
pulse oximeter is a noninvasive method of monitoring oxygen
saturation. It doesn't measure hemoglobin, PaCO2, or PaO2 levels.
Hemoglobin, the main component of the red blood cell that carries
oxygen from the lungs, is measured by a simple laboratory test.
Arterial blood gas analysis evaluates gas exchange in the lungs by
measuring PaCO2 and PaO2. CLIENT NEEDS CATEGORY: Physiological
integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
COGNITIVE LEVEL: Analysis REFERENCE: Taylor, C., et al.
Fundamentals of Nursing: The Art and Science of Nursing Care, 6th
ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p.
1615.
1081A nurse is caring for a client who required chest tube
insertion for a pneumothorax . To assess for pneumothorax
resolution , the nurse can anticipate that the client will
require:1. monitoring of arterial oxygen saturation (SaO2).2.
arterial blood gas (ABG) studies.3. chest auscultation.4. a chest
X-ray.Correct answer: 4RATIONALE: Chest X-ray confirms diagnosis by
revealing air or fluid in the pleural space. SaO2 values may
initially decrease with a pneumothorax but typically return to
normal within 24 hours. ABG studies may show hypoxemia , possibly
with respiratory acidosis and hypercapnia not related to a
pneumothorax. Chest auscultation will determine overall lung
status, but it's difficult to determine if the chest has reexpanded
sufficiently. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT
NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL:
Analysis REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The
Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott
Williams & Wilkins, 2008, p. 1633.
1082A nurse is teaching the parents of a child with cystic
fibrosis about proper nutrition. Which instruction should the nurse
include?1. Encourage a high-calorie, high-protein diet.2. Restrict
fluids to 1,500 ml per day.3. Limit salt intake to 2 g per day.4.
Encourage foods high in vitamin B.Correct answer: 1RATIONALE: The
child should be encouraged to eat a high-calorie, high-protein
diet. In cystic fibrosis, the pancreatic enzymes (lipase, trypsin,
and amylase) become so thick that they plug the ducts. In the
absence of these enzymes, the duodenum can't digest fat, protein,
and some sugars; therefore, the child can become malnourished. A
child with cystic fibrosis needs to drink plenty of fluid and take
salt supplements, especially on warm days or when exercising, to
help maintain hydration and adequate sodium levels. Water-soluble
forms of the fat-soluble vitamins (A, D, E, and K) are essential.
CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS
SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care
of the Childbearing and Childrearing Family, 5th ed. Philadelphia:
Lippincott Williams & Wilkins, 2007, p. 1271.
1083A child with rheumatic fever complains of painful joints.
Which nonpharmacologic measures should the nurse use to reduce the
child's pain?1. Perform gentle passive range-of-motion exercises.2.
Gently massage the painful joints.3. Use a bed cradle to keep
linens from pressing on the child's joints.4. Encourage the child
to change position in bed every 2 hours.Correct answer: 3RATIONALE:
In rheumatic fever, the joints may be so sensitive that even the
weight of the bed linens can cause pain. A bed cradle reduces pain
by lifting the linens off the child. Moving the affected joint may
increase pain; therefore, passive range-of-motion exercises aren't
recommended. Massaging the joints isn't likely to relieve pain. The
nurse should encourage the child to change positions at least every
2 hours to reduce the risk of skin breakdown, but this is unlikely
to relieve joint pain. CLIENT NEEDS CATEGORY: Physiological
integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
COGNITIVE LEVEL: Application REFERENCE: Hatfield, N. Broadribb's
Introductory Pediatric Nursing, 6th ed. Philadelphia: Lippincott
Williams & Wilkins, 2004, p. 383.
1084A nurse is giving nutritional counseling to the mother of a
child with celiac disease . Which statement by the mother indicates
understanding ?1. "My son can't eat wheat, rye, oats, or barley."2.
"My son needs a gluten-rich diet."3. "My son must avoid potatoes,
rice, and cornstarch."4. "My son can safely eat frozen and packaged
foods."Correct answer: 1RATIONALE: A child with celiac disease must
follow a gluten-free diet. If the child eats foods containing
gluten, changes in the intestinal mucosa will prevent the
absorption of fats and other foods. Therefore, all foods containing
wheat, rye, oats, and barley must be eliminated from the diet. Such
foods as potatoes, rice, and cornstarch may be included in a
gluten-free diet. Frozen and packaged foods, which may contain
gluten fillers, should be avoided. CLIENT NEEDS CATEGORY:
Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and
comfort COGNITIVE LEVEL: Comprehension REFERENCE: Hatfield, N.
Broadribb's Introductory Pediatric Nursing, 6th ed. Philadelphia:
Lippincott Williams & Wilkins, 2003, p. 261.
1085A nurse is caring for a child with celiac disease . How
should the nurse evaluate the effectiveness of nutritional
therapy?1. Monitor vital signs every 4 hours.2. Monitor the
appearance, size, and number of stools.3. Measure blood urea
nitrogen and serum creatinine levels.4. Measure intake and
output.Correct answer: 2RATIONALE: A gluten-free diet should
eliminate fat, bulky, foul-smelling stools in a child with celiac
disease. This finding indicates that the disease is controlled and
the child is using nutrients effectively. Taking vital signs,
measuring blood urea nitrogen and serum creatinine levels, and
measuring intake and output don't indicate the effectiveness of
nutritional therapy. CLIENT NEEDS CATEGORY: Physiological integrity
CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL:
Analysis REFERENCE: Hatfield, N. Broadribb's Introductory Pediatric
Nursing, 6th ed. Philadelphia: Lippincott Williams & Wilkins,
2003, p. 261.
1086Policy and procedure require hand washing when caring for
clients. Which statement about hand washing is true?1. Frequent
hand washing reduces transmission of pathogens from one client to
another.2. Wearing gloves is a substitute for hand washing.3. Bar
soap, which is generally available, should be used for hand
washing.4. Waterless products shouldn't be used in situations in
which running water is unavailable.Correct answer: 1RATIONALE: Even
if the nurse wears gloves, she must wash her hands before and after
client contact because thorough hand washing reduces the risk of
cross-contamination. She shouldn't use bar soap because it's a
potential carrier of bacteria. Soap dispensers are preferable, but
they must be checked for bacteria. When water is unavailable, the
nurse should use a liquid hand sanitizer to wash her hands. CLIENT
NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS
SUBCATEGORY: Safety and infection control COGNITIVE LEVEL:
Comprehension REFERENCE: Taylor, C., et al. Fundamentals of
Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia:
Lippincott Williams & Wilkins, 2008, p. 708.
1087A nurse is evaluating a postoperative client for infection .
Which sign or symptom is most indicative of infection?1. The
presence of an indwelling urinary catheter2. Rectal temperature of
100 F (37.8 C)3. Red, warm, tender incision4. White blood cell
(WBC) count of 8,000/lCorrect answer: 3RATIONALE: Redness, warmth,
and tenderness in the incision area indicate a postoperative
infection. The presence of an invasive device predisposes a client
to infection, but that alone doesn't indicate infection. A rectal
temperature of 100 F would be a normal expectation in a
postoperative client because of the inflammatory process. A normal
WBC count ranges from 4,000 to 10,000/l. This client's WBC count
falls within this normal range. CLIENT NEEDS CATEGORY: Safe,
effective care environment CLIENT NEEDS SUBCATEGORY: Safety and
infection control COGNITIVE LEVEL: Analysis REFERENCE: Taylor, C.,
et al. Fundamentals of Nursing: The Art and Science of Nursing
Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins,
2008, p. 1192.
1088A nurse is caring for a client with a fractured hip. The
client is combative, confused, and trying to pull out necessary
I.V. lines and an indwelling urinary catheter. The nurse should:1.
leave the client and get help.2. obtain a physician's order to
restrain the client.3. read the facility's policy on restraints.4.
order soft restraints from the storeroom.Correct answer:
2RATIONALE: In most settings, the nurse must have a physician's
order before restraining a client. A client should never be left
alone while the nurse summons assistance. All staff members must
receive annual instruction on the use of restraints, and the nurse
should be familiar with the facility's policy. CLIENT NEEDS
CATEGORY: Safe, effective care environment CLIENT NEEDS
SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Analysis
REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and
Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams
& Wilkins, 2008, p. 680.
1089A nurse is assessing a client for the risk of falls. The
nurse should obtain:1. gait and balance information.2. the
facility's restraint policy.3. the family's psychosocia