1. A mother calls a neighbor who is a nurse and tells the nurse
that her 3-year-old child has just ingested liquid furniture
polish. The nurse would direct the mother to take which immediate
action?Call the Poison Control Center.Rational: If a poisoning
occurs, the Poison Control Center should be contacted immediately.
Vomiting should not be induced if the victim is unconscious or if
the substance ingested is a strong corrosive or petroleum product.
Bringing the child to the emergency department or calling an
ambulance would not be the initial action because this would delay
treatment. The Poison Control Center may advise the mother to bring
the child to the emergency department and, if this is the case, the
mother should call an ambulance.
2. The nurse is caring for a client with a nasogastric (NG) tube
connected to continuous suction. During assessment the nurse
observes that the client is mouth-breathing, has dry mucous
membranes, and has a foul breath odor. In planning care, which
intervention would be most appropriate to maintain the integrity of
this client's oral mucosa?Brush the teeth frequently; use mouthwash
and water.Rational: After an NG tube is in place, mouth care is
extremely important. With one naris occluded, the client tends to
mouth-breathe, drying the mucous membranes. Small sips of water are
contraindicated when the client is on gastric suction. Hard candy
would increase the salivation, but would not be useful in cleaning
the oral cavity. Lemon glycerin swabs have a drying and irritating
effect on the mucous membranes.
3. A clinic nurse is preparing to evaluate the peripheral vision
of a client by the confrontational method. Which statement
demonstrates that the client correctly understands the instructions
for the test?"I will tell you when the small object is in my visual
field."Rational: The confrontational method assumes that the
examiner has normal peripheral vision. The client sits facing the
examiner approximately 2 feet away. The eyes of the client and the
examiner should be at the same level. Both the examiner and the
client cover the eyes directly opposite to one another and stare at
each other's uncovered eye. A small object is brought in from the
peripheral visual field, and the superior, temporal, inferior, and
nasal fields are evaluated. The client states when he or she sees
the object.
4. The nurse is performing a respiratory assessment and is
auscultating the client's breath sounds. On auscultation, the nurse
hears a grating and creaking type of sound. The nurse interprets
this to mean that client has which type of sounds?Pleural friction
rubRational: A pleural friction rub is characterized by sounds that
are described as creaking, groaning, or grating. The sounds are
localized over an area of inflammation on the pleura and may be
heard in both the inspiratory and expiratory phases of the
respiratory cycle. Wheezes are musical noises heard on inspiration,
expiration, or both and are the result of narrowed airway passages.
Rhonchi are usually heard on expiration when there is an excessive
production of mucus that accumulates in the air passages. Crackles
have the sound that is heard when a few strands of hair are rubbed
together and indicate fluid in the alveoli.
5. A health care provider has written a prescription for wrist
restraints to be applied on a client from 10:00 PM to 7:00 AM
because the client becomes disoriented during the night and is at
risk for pulling out the nasogastric tube and the intravenous
catheter. At 11:00 PM, the charge nurse makes rounds on all of the
clients in the unit. When assessing the client with the restraints,
which observation by the charge nurse indicates that the nurse who
applied the restraints performed an unsafe action?The restraints
were applied tightly.Rational: Restraints should never be applied
tightly because that could impair circulation. The restraint should
be applied securely (not tightly) to prevent the client from
slipping through the restraint and endangering himself or herself.
A safety knot should be used because it can be released easily in
an emergency. The call light must always be within the client's
reach in case the client needs assistance. Restraints, especially
limb restraints, must be released every 2 hours (or per agency
policy) to inspect the skin for abnormalities.
6. An unlicensed assistive personnel (UAP) is caring for a
client who has an indwelling urinary catheter. Which action by the
UAP would indicate the need for instruction in the care of the
client?Allowed the drainage tubing to rest under the legRational:
Proper care of an indwelling urinary catheter is especially
important to prevent infection in the client. The drainage tubing
is not placed under the client's leg; for the same reason, the
drainage bag is kept below the level of the bladder to prevent
urine from being trapped in the bladder. The tubing must drain
freely at all times. The perineal area is cleansed thoroughly,
using mild soap and water at least twice a day and following a
bowel movement. The nurse and all caregivers must use strict
aseptic technique when emptying the drainage bag or obtaining urine
specimens.
7. A client in ventricular fibrillation is about to be
defibrillated. A nurse knows that to convert this rhythm
effectively, the monophasic defibrillator machine should be set at
which energy level (in joules, J) for the first delivery?360
JRational: The energy level used for all defibrillation attempts
with a monophasic defibrillator is 360 joules.
8. A client is to undergo weekly intravesical chemotherapy for
bladder cancer for the next 8 weeks. What instruction should the
nurse provide to the client regarding management of the urine as a
biohazard?Disinfect the toilet with bleach after voiding for 6
hours after a treatment.Rational: After intravesical chemotherapy,
the client treats the urine as a biohazard. This involves
disinfecting the urine and the toilet with household bleach for 6
hours after the treatment. Using a bedpan for voiding is of no
value in this situation. Scented disinfectants are of no particular
use. The client does not need to have a separate bathroom for
personal use.
9. A client has returned to the nursing unit after an abdominal
hysterectomy. The client is lying supine. To thoroughly assess the
client for postoperative bleeding what is the primary nursing
action?Roll the client to one side and check her perineal
pad.Rational: The nurse should roll the client to one side after
checking the perineal pad and the abdominal dressing. This client
position allows the nurse to check the rectal area, where blood may
pool by gravity if the client is lying supine. Asking the client
about a sensation of moistness is not a complete assessment. Vital
signs will change with hemorrhage however; they are a compensatory
mechanism of change. Assess for external or most likely signs of
bleeding first.
10. The nurse develops a plan of care for a client with a
cervical-uterine radiation implant. Which intervention would be
appropriate for the nurse to include in the plan?Place a lead
shield at the bedside.Rational: The external radiation level
associated with an implant necessitates that exposure to staff,
other clients, and visitors be minimized. A lead shield is kept at
the bedside for use when providing direct care to prevent exposure
to radiation. Visitors are limited, and women who are pregnant or
who may be pregnant should not enter the room. Visitation is
allowed for clients older than 16 years of age. A client with a
radiation implant must have a warning sign posted on a closed door
and on the chart (per agency policy) to alert staff and visitors
that radiation therapy is in process. The client undergoing
internal radiation should be in a private room.
11. The nurse provides instructions to the parents of an infant
regarding car travel and safety seats. Which is the most
appropriate information related to the safety of the
infant?Restrain in a car seat in the back seat in a semireclined,
rear-facing positionRational: Infants should be restrained in a car
seat (convertible seat) or infant-only seat in a semireclined,
rear-facing position in the back seat of the car. The infant is not
placed in the front seat or in the forward-facing position;
therefore options 2, 3, and 4 are incorrect. Additionally, parents
should be instructed to always follow the guidelines from the
manufacturer of the safety seat.
12. A registered nurse (RN) is providing instructions to an
unlicensed assistive personnel (UAP) assigned to give a bed bath to
a client who is on contact precautions. The RN instructs the UAP to
use which protective item when giving the bed bath?A gown and
glovesRational: Contact precautions require the use of gloves and a
gown if direct client contact is anticipated. Goggles are not
necessary unless it is anticipated that splashes of blood, bodily
fluids, secretions, or excretions may occur. Shoe protectors are
not necessary.
13. A female client seen in the ambulatory care clinic has a
history of syphilis infection. The nurse assessing the client for
reinfection would expect to observe a lesion on the labia that has
which characteristic?Is painless and induratedRational: The
characteristic lesion of syphilis is painless and indurated. The
lesion is referred to as a chancre. Genital warts are characterized
by cauliflower-like growths or growths that are soft and fleshy.
Scabies is characterized by erythematous, papular eruptions.
Genital herpes is accompanied by the presence of one or more
vesicles that then rupture and heal.
14. A nurse is caring for a client who is scheduled for
abdominal surgery and administers the preoperative medications as
prescribed. The nurse then raises the side rails on the stretcher,
places the safety strap across the client, places the call bell
near the client, and instructs the client to call for assistance as
needed. Shortly thereafter the client calls the nurse and reports
the need to urinate. Which action should the nurse take to meet
this client's need?Assist the client onto a bedpan.Rational:
Because preoperative medications cause sedation, the client should
not be allowed to leave the bed or stretcher after the medications
are administered. To ensure safety, the nurse should assist the
client in using a bedpan. There is no need for a Foley catheter; in
addition, a Foley catheter places the client at risk for infection.
Option 4 is inappropriate; if the client verbalizes a need to void,
the nurse should assist in meeting this need.
15. The nurse receives a telephone call from the postanesthesia
care unit stating that a client is being transferred to the
surgical unit. The nurse plans to take which action first on
arrival of the client?Assess the patency of the airway.Rational:
The first action of the nurse is to assess the patency of the
airway and respiratory function. If the airway is not patent, the
nurse must take immediate measures for the survival of the client.
The nurse then takes vital signs followed by checking the dressing
and the tubes or drains. The other nursing actions should be
performed after a patent airway has been established.
16. A client is being transferred from the intensive care unit
to a step-down unit. The nurse is performing a final assessment of
the client before moving the client to the new unit. The priority
components of this final assessment should include which
parameters? Select all that apply.The client's vital signsThe
client's level of consciousnessThe patency of intravenous (IV)
linesRational: Assessment of the client's vital signs, level of
consciousness, and patency of IV lines are priority parameters when
transferring a client to another unit or area. Assessing these can
help reduce the risk of complications during the transfer. Client's
weight and dietary orders, although important in the client's care,
are not an immediate priority.
17. The nurse is giving a bed bath to a client and discovers
that an additional washcloth and towel are needed. Which is the
most appropriate action to take to obtain the needed items?Wash
hands, leave the client's room, and obtain the needed
items.Rational: To avoid spreading the client's germs, the nurse's
hands must be washed before leaving. By going to the linen room
without washing the hands first, the nurse will spread those germs
into the clean linen. It is not appropriate to ask the unit
secretary or a family member to obtain the supplies. It is never
appropriate to borrow other clients' supplies because this action
may spread germs.
18. The nurse is preparing the morning medications to be
administered to her assigned clients and is reviewing the health
care provider's prescriptions. Which medication prescription should
the nurse question?Hydrochlorothiazide (HCTZ) orally twice
dailyRational: The prescription for the HCTZ is incomplete because
the dosage is missing. The prescriptions in the other options are
complete prescriptions.
19. A client with pulmonary tuberculosis (TB) is on airborne
isolation precautions. Which item(s) is essential for the nurse to
wear?High-efficiency particulate air (HEPA) filter maskRational:
The hospitalized client with TB is placed on airborne isolation. A
HEPA filter mask must be worn whenever the nurse enters the
client's room, because these masks can remove almost 100% of the
small TB particles. This mask must fit snugly around the nose and
mouth. Option 1 is an incorrect option; although gloves may be
needed, the nurse must wear a HEPA mask. Option 2 is incorrect. The
mask must be a HEPA mask. Option 3 is an incorrect choice. The mask
must be a HEPA mask, and there is no need for gown and gloves
unless a wound, body fluid, or blood is involved.
20. The nurse is performing cardiopulmonary resuscitation (CPR)
on an infant. When performing chest compressions, the nurse
compresses at least how many times?100 times per minuteRational: In
an infant, the rate of chest compressions is at least 100 times per
minute.
21. While giving care to a client with an internal cervical
radiation implant, the nurse finds the implant in the bed. The
nurse should take which initial action?Pick up the implant with
long-handled forceps and place it in a lead container.Rational: In
the event that a radiation source becomes dislodged, the nurse
would first encourage the client to lie still until the radioactive
source has been placed in a safe closed container. The nurse would
use a long-handled forceps to place the source in the lead
container that should be in the client's room. The nurse should
then call the radiation oncologist and then document the event and
the actions taken. It is not within the scope of nursing practice
to insert a radiation implant.
22. The community health nurse has instructed a group of parents
of preschoolers about home safety measures for children. Which
statement by one of the parents should the nurse identify as
something that requires the need for reinforcement of the
instructions?Refers to medication as "candy for when you are
sick"Rational: Medicine should not be referred to as candy. Home
safety measures are simple but important. Medications should be
stored in child-proof containers. The number of tablets in a
container should be limited. The Poison Control Center telephone
number should be visible near all telephones. Toxic substances
should be labeled with poison stickers and placed in a locked area
out of reach of children.
23. An unconscious client has an impaired corneal reflex on one
side. The nurse should demonstrate the best understanding of how to
protect the client's eye by performing which action?Using sterile
saline drops every few hours to keep the eye moistRational: With
loss of the corneal (blink) reflex, the client is at risk for eye
dryness and also for corneal abrasions if foreign matter comes in
contact with the eye. Use of sterile saline drops is indicated to
keep the eyes lubricated. An eye patch would have to be used
carefully because corneal abrasion could result if the cornea comes
in contact with the patch. Taping the eye shut is inappropriate and
could impair the conscious client's vision, putting the client at
risk for other injury, such as from falls. Introduction of a
cotton-tipped applicator (foreign object) inside the lower eyelid
also risks corneal abrasion.
24. The nurse plans to administer a medication by intravenous
(IV) bolus through the primary IV line. The nurse notes that the
medication is incompatible with the primary IV solution. Which is
the appropriate nursing action to safely administer the
medication?Flush the tubing before and after the medication with
normal saline.Rational: When giving a medication by IV bolus, if
the medication is incompatible with the IV solution, the tubing is
flushed before and after the medication with infusions of normal
saline. Option 1 is premature and not necessary. Sterile water is
not used for an IV flush. Option 4 is inappropriate.
25. Contact precautions are initiated for a client with a health
careassociated (nosocomial) infection caused by
methicillin-resistant Staphylococcus aureus. The nurse prepares to
provide colostomy care and should obtain which protective items to
perform this procedure?Gloves, gown, goggles, and face
shieldRational: Splashes of body secretions can occur when
providing colostomy care. Goggles and a face shield are worn to
protect the face and mucous membranes of the eyes during
interventions that may produce splashes of blood, body fluids,
secretions, or excretions. In addition, contact precautions require
the use of gloves, and a gown should be worn if direct client
contact is anticipated. Shoe protectors are not necessary.
26. The nursing student is following standard precautions to
prevent a hospital-acquired infection in a client. The student
understands that which applies to the use of standard precautions?
Select all that apply.Used when working with all clientsApplies to
blood, all body fluids, secretions, and excretionsIs designed to
prevent the risk of spreading microorganismsRational: Standard
precautions are to be used on all clients and are designed to
prevent the risk of spreading microorganisms. It applies to contact
with blood, body fluids, secretions, and excretions.
27. The home care nurse is performing an environmental
assessment in the home of an older client. Which observation by the
nurse requires intervention?Unsecured scatter rugsRational: Trauma
to the older client in the home may be caused by a variety of
factors. These include an unsteady gait, the presence of unsecured
scatter rugs, cluttered passageways, inoperable smoke detectors,
and a history of previous falls. Any assessment findings that could
lead to injury or trauma in the home should be addressed
immediately.
28. The nurse is preparing to apply a mitten restraint to the
client's hand. The nurse should take which action to ensure that
the restraint is applied correctly? Click on the Question Video
button to view a video showing preparation procedures.Makes sure
that two fingers can be inserted under the restraintRational: Click
on the Rationale Video button. When applying a restraint, the nurse
applies the restraint snugly and makes sure that two fingers can be
inserted under the restraint. This ensures that the restraint is
not applied too tightly, causing constriction and injury to the
client. The sheepskin or soft part of the restraint needs to be
against the client's skin. Although a quick-release tie is used,
the restraint is never attached to the side rail because of
possible injury to the client if the side rail is lowered. Rather,
it is secured to the bed frame.
29. A nurse is conducting a health screening clinic and is
preparing to test the visual acuity of a client using a Snellen
chart. Which statement by the nurse includes the correct client
instructions?"Stand 20 feet from the chart and cover the one
eye."Rational: Visual acuity is assessed in one eye at a time and
then in both eyes together, with the client comfortably standing or
seated. Visual acuity is measured with or without corrective
lenses, and the client stands at a distance of 20 feet from the
chart. The right eye is tested first with the left eye covered;
then the left eye is tested with the right eye covered; and then
both are tested together.
30. In preparation for ambulation, the nurse is planning to
assist a postoperative client to progress from a lying position to
a sitting position. Which nursing action is most appropriate to
maintain the safety of the client?Assess the client for signs of
dizziness and hypotension.Rational: Early ambulation should not
exceed the client's tolerance. The client should be assessed before
sitting. The client is assisted to rise from the lying position to
the sitting position gradually until any evidence of dizziness, if
present, has subsided. This position can be achieved by raising the
head of the bed slowly. After sitting, the client may be assisted
to a standing position. The nurse should be at the client's side to
provide physical support and encouragement.
31. The clinic nurse is performing an assessment for a client
who is complaining of shortness of breath. The client tells the
nurse that he is a cigarette smoker and admits to smoking one pack
of cigarettes per day for the past 10 years. The nurse determines
that the client has a smoking history of how many pack years? Fill
in the blank.10 pack yearsRational: The standard method for
quantifying the smoking history is to multiply the number of packs
smoked per day by the number of years of smoking. The result is
then recorded as the number of pack years. The calculation for the
number of pack years for the client in this question who smokes 1
pack per day for 10 years is 1 pack 10 years = 10 pack years.
32. The nurse is conducting a neurological assessment, including
a health history, on a client with a neurological disorder. The
nurse observes that the client is having difficulty in answering
the questions and should perform which action?Ask the client to
give permission for a family member to stay during the
interview.Rational: The health history and physical assessment for
a client with a neurological problem are very similar to those for
any other client, with perhaps a more intense neurological
examination. If the client is confused or agitated or has
difficulty hearing or speaking, the nurse should ask the client to
give permission for a family member or significant other to stay
with him or her during the history taking to ensure accurate data.
Options 2 and 3 will not obtain the assessment data. Option 1 is of
no benefit.
33. The preoperative client expresses anxiety to the nurse about
the upcoming surgery. Which statement by the nurse is most likely
to stimulate further discussion between the client and the
nurse?"Can you share with me what you've been told about your
surgery?"Rational: Explanations should begin with the information
that the client knows. By providing the client with an
individualized explanation of care and procedures, the nurse can
assist the client in handling fears and providing a smooth
preoperative experience. Clients who are calm and emotionally
prepared for surgery withstand anesthesia better and experience
fewer postoperative complications. Option 1 is a stereotypical
response. Options 2 and 3 can increase the client's anxiety
34. The nurse notes documentation that a client is exhibiting
Cheyne-Stokes respirations. On assessment of the client, the nurse
should expect to note which finding?Rhythmic respirations with
periods of apneaRational: Cheyne-Stokes respirations are rhythmic
respirations with periods of apnea and can indicate a metabolic
dysfunction in the cerebral hemisphere or basal ganglia. Neurogenic
hyperventilation is a regular, rapid and deep, sustained
respiration that can indicate a dysfunction in the low midbrain and
middle pons. Ataxic respirations are totally irregular in rhythm
and depth and indicate a dysfunction in the medulla. Apneustic
respirations are irregular respirations with pauses at the end of
inspiration and expiration and can indicate a dysfunction in the
middle or caudal pons.
35. The nurse is obtaining a pulse oximetry reading from a
postoperative client who appears short of breath. The client has
dark fingernail polish on top of artificial nails. What is the most
appropriate action?Obtain a pulse oximetry reading from another
appropriate area, such as an earlobe.Rational: A pulse oximetry
reading may not provide an accurate measurement if it is measured
on a finger that has dark polish and an artificial nail; therefore
option 1 is not the most appropriate action. It is not appropriate
to remove an artificial nail so therefore elimination option 2.
Removing the polish and taking the reading with the artificial nail
may provide a better reading than taking the reading with the
polish; however, this is not the most appropriate action from those
provided so therefore elimination option 4.
36. The registered nurse is observing a newly hired nurse
perform a dressing change on a client with a leg ulcer. Sutilains
is being used to treat the ulcer. Which observation, if made by the
registered nurse, would indicate a need for further teaching with
the newly hired nurse?The nurse washes and dries the wound and
covers the sutilains application with a dry sterile
dressing.Rational: The wound should be cleansed with a sterile
solution before treatment. The nurse then thoroughly moistens the
wound with normal saline or sterile water, applies a thin film of
sutilains extending to inch beyond the area to be dbrided, and then
applies a loose, thin dressing. The ointment should be
refrigerated.
37. A man is admitted to the hospital with the diagnosis of
urethritis secondary to chlamydial infection. What precaution
should the nurse implement for this client?StandardRational:
Chlamydial infection is a sexually transmitted infection and
frequently is called nongonococcal urethritis in the male client.
It requires no special precautions other than standard precautions.
Caregivers cannot acquire the disease during administration of
care, and using standard precautions is the only necessary
measure.
38. The nurse enters a client's room and finds that the
wastebasket is on fire. The nurse immediately assists the client
out of the room. What is the next nursing action?Activate the fire
alarm.Rational: The order of priority in the event of a fire is to
rescue the clients who are in immediate danger. The next step is to
activate the fire alarm. The fire then is confined by closing all
doors and, finally, the fire is extinguished.
39. A nurse is developing a plan of care for a client with a
diagnosis of early-stage Alzheimer's disease. The plan of care
should include nursing interventions that address which early
characteristic of Alzheimer's disease?Forgetfulness interferes with
the daily routine.Rational: In early Alzheimer's disease,
forgetfulness begins to interfere with daily routines. The client
has difficulty concentrating and difficulty learning new material.
Options 1, 2, and 3 are characteristics of this disorder but occur
later as the disease progresses.
40. The nurse walking in a downtown business area witnesses a
worker fall from a ladder. The nurse rushes to the victim, who is
unresponsive. How should the nurse open the victim's airway?Jaw
thrust maneuverRational: Whenever a neck injury is suspected, the
jaw thrust maneuver should be used during basic life support (BLS)
to open the airway. The head tiltchin lift produces hyperextension
of the neck and could cause complications if a neck injury is
present. There is no such position as head tiltjaw thrust or
chin-lift.
41. The nurse is instructing a client in breast self-examination
(BSE). The nurse tells the client to lie down and examine the left
breast. The nurse should instruct the client that while examining
the left breast she should place a pillow under which area?Left
shoulderRational: The nurse should instruct the client to lie down
and place a towel or pillow under the shoulder on the side of the
breast to be examined. If the left breast is to be examined, the
pillow would be placed under the left shoulder; therefore all other
options are incorrect.
42. A confrontation test is prescribed for a client seen in the
eye and ear clinic. How should the nurse perform this test? Arrange
the actions in the order that they should be performed. All options
must be used.a. Stands 2 to 3 feet in front of and faces the
clientb. Asks the client to cover one eyec. Examiner covers eye
opposite to the eye covered by the clientd. Asks the client to
report when object is first notede. The examiner brings in an
object gradually from periphery Rational: The confrontation test is
a gross measure of peripheral vision. It compares the person's
peripheral vision with the examiner's, whose vision is assumed to
be normal. If the client does not see the object at the same time
as the nurse, peripheral field loss is expected. The client should
be referred to an eye care specialist. The procedure is conducted
in the following order: (1) Stand 2 to 3 feet in front of the
client and face him or her; (2) client covers one eye upon request;
(3) nurse covers the eye opposite the one covered by the client;
(4) an object is gradually brought inward from the periphery; and
(5) the client reports when the object is first noted.
43. When performing a surgical dressing change on a client's
abdominal dressing, the nurse notes an increased amount of drainage
and separation of the incision line. The underlying tissue is
visible to the nurse. The nurse should take which action in the
initial care of this wound?Apply a sterile dressing soaked with
normal saline.Rational: Wound dehiscence is the separation of wound
edges at the suture line. Signs and symptoms include increased
drainage and the visible appearance of underlying tissues.
Dehiscence usually occurs 6 to 8 days after surgery. The client
should be instructed to remain quiet and to avoid coughing or
straining. The client should be positioned to prevent further
stress on the wound (semi-Fowler's position). Sterile dressings
soaked with sterile normal saline should be used to cover the
wound. The nurse must notify the health care provider after
applying this initial dressing to the wound. Options 1, 2, and 4
are incorrect.
44. The nurse in a surgical unit receives a postoperative client
from the postanesthesia care unit. After the initial assessment of
the client, the nurse should plan to continue with postoperative
assessment activities how often?Every 15 minutes for the first
hour, every 30 minutes for 2 hours, every hour for 4 hours, and
then every 4 hours as neededRational: When the postoperative client
arrives from the postanesthesia care unit, the nurse performs an
initial assessment. Common time frames for continuing postoperative
assessment activities are every 15 minutes the first hour, every 30
minutes for 2 hours, every hour for 4 hours, and then every 4 hours
as needed. However, agency policies should always be followed.
Options 1 and 2 identify time frames that are too infrequent and
that will not provide adequate assessment of the postoperative
client. Option 4 identifies close time frames that are
unnecessary.
45. The nurse is working in an illness prevention clinic. An
important component of the nurse's practice is to advise high-risk
clients to receive an influenza vaccination. Which clients are at
high risk for influenza and would benefit from vaccination? Select
all that apply.a. A 47-year-old mother of a child with cystic
fibrosisb. A 54-year-old man scheduled for a routine diabetes
checkc. A 35-year-old registered nurse scheduled for an annual
pelvic examd. An 87-year-old woman from a nursing home scheduled
for a surgical follow-upRational: Influenza vaccinations are
recommended yearly and developed according to predicted strain for
clients at high risk. Influenza immunization is recommended for
high-risk clients. Anyone in close contact with clients with a
chronic respiratory or other chronic disorder should receive the
vaccine. Adults with chronic metabolic disease such as diabetes
mellitus are in the high-risk population. Residents of chronic care
facilities are at risk for influenza. Health care workers are in
the high-risk population. The influenza vaccine does not treat an
active infection with the virus.
46. The nurse is preparing to administer an intramuscular (IM)
injection to a client receiving a continuous heparin infusion.
Which action should the nurse prepare to do?Apply prolonged
pressure to the IM site after the injection.Rational: Heparin is an
anticoagulant that increases the risk of bleeding. Prolonged
pressure over the site of an IM injection will lessen the chance of
having an increase of bleeding into the tissue. It is not necessary
to apply a pressure dressing to the IM site of injection. A -inch
needle is not an appropriate size needle for an IM injection. The
heparin infusion is not decreased before an injection, and the rate
is not adjusted unless specifically prescribed by a health care
provider.
47. The nurse has administered diazepam (Valium) 5 mg by the
intravenous (IV) route to a client. The nurse should plan to
maintain the client on bed rest for at least how long?3
hoursRational: The client should remain in bed for at least 3 hours
after a parenteral dose of diazepam. The medication is a centrally
acting skeletal muscle relaxant and has antianxiety,
sedative-hypnotic, and anticonvulsant properties. Cardiopulmonary
adverse effects of the medication include apnea, hypotension,
bradycardia, and cardiac arrest. For this reason, resuscitative
equipment also is kept nearby.
48. The ambulatory care nurse is working with a 22-year-old
female client who has been diagnosed with pelvic inflammatory
disease (PID). The nurse incorporates which item in a teaching plan
for this client?Avoid frequent douching.Rational: The client who
has been diagnosed with PID should avoid frequent douching because
it decreases the natural flora that controls the growth of
infectious organisms. Intrauterine devices increase the client's
susceptibility to infection. The client should wear cotton
undergarments, and clothes should not fit tightly. Sanitary pads
should be changed at least every 4 hours. Tampons should not be
used during the acute infection, and some health care providers may
recommend avoiding them indefinitely. The client also should avoid
strong soaps, sprays, powders, and similar products that will
irritate the perineum.
49. A nurse discovers a fire in the trash basket in a client's
bathroom. The nurse assists the client out of the hospital room to
a safe place and takes which action next?Activates the fire
alarmRational: In the event of a fire, the first priority is to
rescue the client and protect the client from injury. The next
priority is to activate the fire alarm and report the exact
location of the fire to emergency personnel to aid in the rescue
process. Next, the nurse would contain the fire by closing doors
and placing towels under the doorways to prevent the spread of
smoke. The nurse then would obtain the fire extinguisher, pull the
pin, and extinguish the fire.
50. The home care nurse visits a client at home who has been
experiencing increased weakness. The client tells the nurse that he
is using a cane that was purchased at a local pharmacy. The home
care nurse assesses the client's use of the cane and determines
that the cane is sized correctly if which observation is made?The
client's elbow is flexed at a 15- to 30-degree angle when
ambulating with the cane.Rational: The height of a cane should be
even with the greater trochanter. This allows the elbow to be held
at approximately 15 to 30 degrees of flexion. The flexion is
necessary to allow the client to push off without bending over when
ambulating. Options 1, 2, and 4 are incorrect and present an unsafe
situation.
51. The community health nurse is providing a teaching session
about terrorism to members of the community and is discussing
information regarding anthrax. The nurse tells those attending that
anthrax can be transmitted by which route(s)? Select all that
apply.Inhalation of bacterial sporesThrough a cut or abrasion in
the skinIngestion of contaminated undercooked meatRational: Anthrax
is caused by Bacillus anthracis and can be contracted through the
digestive system or abrasions in the skin, or inhaled through the
lungs. It cannot be spread from person to person or from animal to
person, and it is not contracted via bites from ticks or deer
flies.
52. A client is brought into the emergency department in
ventricular fibrillation (VF). The advanced cardiac life support
(ACLS) nurse prepares to defibrillate by placing conductive gel
pads on which part of the chest?The right of the sternum just below
the clavicle and to the left of the precordiumRational: The ACLS
nurse would place one gel pad to the right of the sternum just
below the clavicle and the other gel pad to the left of the
precordium. The nurse would then place the electrode paddles over
the pads. Options 1, 2, and 3 identify incorrect positions.
53. A client has a risk for infection following radical
vulvectomy. Therefore, the nurse should avoid which action when
giving perineal care to this client?Cleansing with warm tap
waterRational: A sterile solution such as normal saline should be
used for perineal care using an aseptic syringe. This should be
done regularly at least twice a day and after each voiding and BM.
The wound is intermittently exposed to air to permit drying and
prevent maceration. Once sutures are removed, sitz baths may be
prescribed to stimulate healing and for the soothing effect.
54. The community health nurse who is conducting a teaching
session about the risks of testicular cancer has reviewed a list of
instructions regarding testicular self-examination (TSE) with the
clients attending the session. Which statement by a client
indicates a need for further instruction?"It is best to do TSE
first thing in the morning before a bath or shower."Rational: TSE
is performed once a month and should be done on the same day of
each month, as an aid to help the client remember to perform the
exam. The scrotum is held in one hand and the testicle is rolled
between the thumb and forefinger of the other hand. It is best to
perform the exam during or after a warm shower or bath when the
scrotum is most relaxed.
55. A client is being weaned from parenteral nutrition (PN),
also known as total parenteral nutrition, and is expected to begin
taking solid food today. The ongoing solution rate has been 100
mL/hour. The nurse anticipates that which prescription regarding
the PN solution will accompany the diet prescription?Decrease PN
rate to 50 mL/hour.Rational: When a client begins eating a regular
diet after a period of receiving PN, the PN is decreased gradually.
PN that is discontinued abruptly can cause hypoglycemia. Clients
often have anorexia after being without food for some time, and the
digestive tract also is not used to producing the digestive enzymes
that will be needed. Gradually decreasing the infusion rate allows
the client to remain adequately nourished during the transition to
a normal diet and prevents the occurrence of hypoglycemia. Even
before clients are started on a solid diet, they are given clear
liquids followed by full liquids to further ease the transition. A
solution of normal saline does not provide the glucose needed
during the transition of discontinuing the PN and could cause the
client to experience hypoglycemia.
56. The nurse is preparing to administer an oral medication to
an infant. Which position should the nurse place the
infant?Semi-Fowler'sRational: The nurse should administer oral
medications with the infant sitting in an upright position to
prevent aspiration if the infant cries or resists. Semi-Fowler's is
an upright position. Trendelenburg's position is on the back with
the head lowered, and prone is on the abdomen. Oral medications
could not be administered to an infant in either of these
positions. Dorsal recumbent means on the back and flat, so there
would be a risk of aspiration with this position.
57. A nurse is instructing a postpartum client with endometritis
about preventing the spread of infection to the newborn infant.
Which statement should the nurse make to the client?Hands should be
washed thoroughly before holding the infant.Rational: Transmission
of infectious diseases can occur through contaminated items such as
hands and bed linens of clients with endometritis. An important
method of preventing infection is to break the chain of infection.
Handwashing is one of the most effective methods of preventing the
transmission of infectious diseases. The newborn infant is allowed
in the mother's room and visitors are allowed to hold the newborn
infant as long as handwashing and other protective measures are
instituted.
58. When caring for a client with an internal radiation implant,
the nurse should observe which principles? Select all that
apply.Keeping pregnant women out of the client's room.Placing the
client in a private room with a private bath.Wearing a lead shield
when providing direct client care.Rational: The time that the nurse
spends in a room of a client with an internal radiation implant is
30 minutes per 8-hour shift. The client must be placed in a private
room with a private bath. The nurse should wear a lead shield to
reduce the transmission of radiation. The dosimeter film badge must
be worn when in the client's room. Children younger than 16 years
of age and pregnant women are not allowed in the client's room.
59. A client is seen in the health care clinic, and a diagnosis
of acute sinusitis is made. The nurse provides home care
instructions to the client regarding measures that will promote
sinus drainage and comfort. Which statement by the client indicates
a need for further instruction?"I should use a hot mist vaporizer
to liquefy secretions."Rational: The nurse provides instructions to
the client regarding measures to promote sinus drainage, comfort,
and resolution of the infection. The client should be instructed to
use a humidifier to help liquefy secretions and promote drainage.
Consumption of large amounts of fluids is important to help liquefy
secretions. Sleeping with the head of the bed elevated to a
45-degree angle will assist in promoting drainage. The nurse
instructs the client to apply heat in the form of wet packs over
the affected sinuses to promote comfort and help resolve the
infection.
60. A nursing student is performing a respiratory assessment on
a female adult client and is assessing for tactile fremitus. Which
action by the nursing student indicates a need for further
teaching?Palpating over the breast tissue to assess and compare
vibrations from one side to the otherRational: When assessing for
tactile fremitus, the nurse should begin palpating over the lung
apices in the supraclavicular area. The nurse should compare
vibrations from one side to the other as the client repeats the
word ninety-nine. The nurse should avoid palpating over female
breast tissue because breast tissue usually blocks the sound.
61. The nurse is assessing the colostomy of a client who has had
an abdominal perineal resection for a bowel tumor. Which assessment
finding indicates that the colostomy is beginning to function?The
passage of flatusRational: Following abdominal perineal resection,
the nurse would expect the colostomy to begin to function within 72
hours after surgery, although it may take up to 5 days. The nurse
should assess for a return of peristalsis, listen for bowel sounds,
and check for the passage of flatus. Absent bowel sounds would not
indicate the return of peristalsis. The client would remain NPO
until bowel sounds return and the colostomy is functioning. Bloody
drainage is not expected from a colostomy.
62. The nurse has instructed a client with a continuous passive
motion (CPM) device applied to the leg about the device and its
use. The nurse determines that the client has misunderstood one of
the teaching points if the client asks which question?How to reset
the degrees of flexion or extension according to comfortRational:
The client should not adjust the flexion and extension settings.
These settings are determined by the orthopedic surgeon and are
maintained as prescribed. The client is instructed about how to
stop and start the machine and to notify the nurse about knee
discomfort. The client also should be aware of proper positioning
so that the nurse can be notified if the leg slips. Other important
actions by the nurse with use of this device are to assess the
neurovascular status of the extremity and to ensure that the device
is padded with manufactured disposable padding before the client's
leg is placed in the device.
63. A postoperative client with a large abdominal wound
requiring frequent dressing changes is starting to develop skin
irritation in the area where the dressing tape is applied to the
skin. The nurse determines that the client would benefit most from
which measure?The use of Montgomery strapsRational: The use of
Montgomery straps is recommended to prevent skin breakdown with
frequent dressing changes. They limit the friction and shear that
could irritate skin with frequent removal and reapplication of
tape. Hypoallergenic tape is used on clients with thin, fragile
skin; clients whose skin is sensitive to standard tape; and clients
who require less frequent dressing changes. Cleansing with
povidone-iodine and obtaining a wound culture are not
indicated.
64. The nurse should plan to implement which intervention in the
care of a client experiencing neutropenia as a result of
chemotherapy?Teach the client and family about the need for hand
hygiene.Rational: In the neutropenic client, meticulous hand
hygiene education is implemented for the client, family, visitors,
and staff. Not all visitors are restricted, but the client is
protected from persons with known infections. Fluids should be
encouraged. Invasive measures such as an indwelling urinary
catheter should be avoided to prevent infections.
65. The nurse is instructing a client who had a stroke and has
weakness on one side how to ambulate with the use of a cane. Which
instruction should the nurse provide to the client?Hold the cane on
the unaffected (strong) side.Rational: The cane is kept on the
strong side of the body. It would be hard to hold the cane on the
weak side. The cane is assisting the weakened leg, so the weakened
leg moves with the cane, or right after it, in ambulating or in
going down stairs.
66. A clinic nurse is performing a cardiovascular assessment on
a client and auscultates the chest over the apex of the heartFirst
heart sound, S1Rational: The sound that the nurse hears is the
first heart sound, S1. The first heart sound (S1) is created by
closure of the mitral and tricuspid valves (atrioventricular [AV]
valves). It marks the onset of systole (ventricular contraction).
When auscultated, S1 is softer and longer than the second heart
sound (S2). S1 is low in pitch and is best heard at the left lower
sternal border or the apex of the heart. Disease and stiffened AV
valves (as in rheumatic heart disease) may augment S1; rhythms of
asynchrony between the atria and ventricles (as in atrial
fibrillation and with AV block) cause variable intensity of S1.
Phonetically, if a typical heartbeat, composed of the heart sounds
S1 and S2, is auscultated as lub-dup, S1 is the lub. To assess S1,
the nurse should assist the client to a supine position (the head
of the bed may be elevated slightly if necessary). The second heart
sound (S2) is related to closure of the pulmonic and aortic
(semilunar) valves and is heard best with the diaphragm of the
stethoscope at the aortic area. Phonetically, it is the dup of the
lub-dup of a typical heartbeat. It signifies the end of systole and
the onset of diastole (ventricular filling). S2 is
characteristically shorter and higher pitched than S1. Diastolic
filling sounds, or gallops (S3, the third heart sound, and S4, the
fourth heart sound) are produced when compliance of either or both
ventricles is decreased. S3 is termed ventricular gallop, and S4 is
referred to as atrial gallop. The S3 heart sound (a gallop sound)
occurs in early diastole, during passive, rapid filling of the
ventricles. The S4 sound occurs in the later stage of diastole,
during atrial contraction and active filling of the ventricles. It
is a soft, low-pitched sound and is heard immediately before S1
67. The nurse is providing home care instructions to the parents
of an infant who had a surgical repair of an inguinal hernia. What
instruction should the nurse include to prevent infection at the
surgical site?Change the diapers as soon as they become
damp.Rational: Changing diapers as soon as they become damp helps
prevent infection at the surgical site. Parents are instructed to
change diapers more frequently than usual during the day and once
or twice during the night. A fever may indicate the presence of an
infection but measuring the temperature does not prevent an
infection. No restrictions on the infant's activity are needed.
Parents are instructed to give the infant sponge baths instead of
tub baths for 2 to 5 days.
68. The nurse is preparing to perform a Weber test on a client.
The nurse should obtain which item needed to perform this test?A
tuning forkRational: A tuning fork is needed to perform the Weber
test, during which the nurse places the vibrating tuning fork at
the midline of the client's forehead or above the upper lip over
the teeth. Normally the sound is heard equally in both ears by bone
conduction. If the client has a sensorineural hearing loss in one
ear, the sound is heard in the other ear. If the client has a
conductive hearing loss in one ear, the sound is heard in that ear.
The items identified in options 2, 3, and 4 are not needed to
perform the Weber test.
69. The nurse performing a neurological examination is assessing
eye movement to evaluate cranial nerves III, IV, and VI. Using a
flashlight, the nurse would perform which action to obtain the
assessment data?Ask the client to follow the flashlight through the
six cardinal positions of gaze.Rational: The nurse asks the client
to follow the flashlight through the six cardinal positions of gaze
to assess for eye movement related to cranial nerves III, IV, and
VI. Options 1 and 3 relate to pupillary response to light. Also,
shining the light directly into the client's eye without asking the
client to focus on a distant object is not an appropriate
technique. Option 4 assesses accommodation of the eye.
70. A home care nurse performs a home safety assessment and
discovers that a client is using a space heater in the apartment.
Which instruction should the nurse provide to the client regarding
the use of the space heater?The space heater needs to be placed at
least 3 feet from anything that can burn.Rational: Space heaters
need to be used appropriately because they present a great risk of
fire. A space heater needs to be placed at least 3 feet from
anything that can burn. A space heater can be used in an apartment
if there is ample space and safety precautions are followed.
Placing a heater in a hallway does not guarantee that it will be 3
feet from anything that can burn. A low setting does not reduce the
risk of fire.
71. The nurse is preparing to nasotracheally suction a client
with acquired immunodeficiency syndrome who has had blood-tinged
sputum with previous suctioning. The nurse plans to use which item
as part of standard precautions for this client?Gloves, mask, and
protective eyewearRational: Standard precautions include the use of
gloves whenever there is actual or potential contact with blood or
body fluids. During procedures that aerosolize blood, the nurse
wears a mask and protective eyewear or a face shield. Impervious
gowns are worn in those instances when it is anticipated that there
will be contact with splashes of secretions or blood. No data in
the question is indicative that splashes are a concern.
72. A client who has undergone radical neck dissection is
experiencing problems with verbal communication related to
postoperative hoarseness. The nurse should formulate which outcome
as the most appropriate goal for this client problem?Incorporates
nonverbal forms of communication as neededRational: The client may
experience temporary hoarseness after neck dissection. Goals for
the client include using nonverbal forms of communication as
needed, expressing willingness to ring the call bell for
assistance, and using the services of a speech pathologist if
prescribed. Options 1, 2, and 3 are incorrect.
73. A nurse is assigned to change the surgical dressing on a
client who has undergone abdominal surgery. After removing the old
dressing, the nurse assesses the surgical site. Which should be the
nurse's initial action if the appearance shown in the figure is
observed? Refer to the figure.Apply a sterile nonadherent
dressing.Rational: Wound dehiscence is partial or complete
separation of the outer layers of the wound, sometimes described as
splitting open of the wound. If this is noted, the nurse applies a
sterile nonadherent dressing, such as a Telfa dressing or a saline
dressing, to the wound and notifies the health care provider. The
nurse would document the findings, but this would not be the
initial action. A dry dressing could disrupt the integrity of the
underlying tissues. Asking the client to cough could cause an
extension of the separation of the outer layers of the wound.
74. An emergency department nurse is performing an assessment on
a child suspected of being sexually abused. Which assessment data
obtained by the nurse most likely supports this
suspicion?Difficulty walkingRational: Abuse is the nonaccidental
physical injury or the nonaccidental act of omission of care by a
parent or person responsible for a child. It includes neglect and
physical, sexual, or emotional maltreatment. Sexual abuse can
involve incest, molestation, exhibitionism, pornography,
prostitution, or pedophilia. Many times the findings associated
with sexual abuse may not be easily apparent in the child. The most
likely assessment findings in sexual abuse include difficulty
walking or sitting; torn, stained, or bloody underclothing; pain,
swelling, or itching of the genitals; and bruises, bleeding, or
lacerations in the genital or anal area. Poor hygiene may indicate
physical neglect. Bald spots on the scalp and fear of the parents
most likely are associated with physical abuse.
75. The nurse educator is providing an information session to
unlicensed assistive personnel (UAP) regarding caring for the older
adult. The nurse educator should tell the UAPs that which situation
portrays ageism?Advising older adults to forgo aggressive
treatmentRational: Ageism is a form of prejudice in which older
adults are stereotyped by characteristics found in only a few
members of their group. Fundamental to ageism is the view that
older persons are different from "me" and will remain different
from "me." Therefore they are portrayed as not experiencing the
same desires, needs, and concerns as other age groups. Informing
older adults of their rights, allowing older adults to make
decisions, and accepting differences among older adults identify
supportive roles that the nurse engages in when dealing with the
older adult. The correct option suggests that the older adult is
not worthy of aggressive treatment and demonstrates ageism.
76. A client has a prescription for an injection to be
administered by the intradermal route. The nurse should avoid which
action when administering this medication?Massaging the area after
removing the needleRational: An intradermal injection is
administered with the needle bevel facing upward at a 10- to
15-degree angle. The medication is injected slowly, and a bleb
should form under the skin with injection. After withdrawal of the
needle, the area may be patted dry with a 2 2 sterile gauze. The
area should not be rubbed, to prevent the spread of the medication
beyond the area of injection. All equipment is then disposed of,
and the area of injection is outlined (circled) for later
reference.
77. The nurse is preparing to change the parenteral nutrition
(PN) solution bag and tubing. The client's central venous line is
located in the right subclavian vein. The nurse asks the client to
take which essential action during the tubing change?Take a deep
breath, hold it, and bear down.Rational: The client should be asked
to perform the Valsalva maneuver during tubing changes. This helps
avoid air embolism during tubing changes. The nurse asks the client
to take a deep breath, hold it, and bear down. If the intravenous
line is on the right, the client turns his or her head to the left.
This position increases intrathoracic pressure. Breathing normally
and exhaling slowly and evenly are inappropriate and could enhance
the potential for an air embolism during the tubing change.
78. Which action by the parent of an infant with respiratory
syncytial virus infection who is receiving ribavirin (Virazole)
would indicate a need for further instruction regarding the
management of the disease process?Telling the infant's aunt who is
pregnant that it is acceptable to visit the infantRational: When an
infant is receiving ribavirin, exposure precautions need to be
observed. Anyone entering the infant's room should wear a gown,
mask, gloves, and hair covering. Anyone who is pregnant or
considering pregnancy and anyone with a history of respiratory
problems or airway disease should not care for or visit the infant
who is receiving ribavirin. Hand washing is absolutely necessary
before leaving the room to prevent the spread of germs.
79. The health care provider prescribes 2000 mL of 5% dextrose
and half-normal saline to infuse over 24 hours. The drop factor is
15 drops (gtt) per mL. The nurse sets the flow rate at how many
drops per minute? Fill in the blank. Record your answer to the
nearest whole number.21 gtt/minRational: Focus on the subject, a
medication calculation. Use the intravenous (IV) flow rate
formula.
Total volume Drop factor = gtt/minTime in minutes
2000 mL 15 gtt30000 = 1440 minutes1440
= 20.83, or 21 gtt/min
80. The community health nurse is performing a safety assessment
in the home of a mother with two children, ages 1 and 3 years.
Which, if noted during the assessment, presents the greatest hazard
to the children?Toys with small loose parts in the
playroomRational: Toys with small loose parts would be the priority
concern. Children at this age are likely to place the small toy
parts in their mouths, which could lead to aspiration and choking.
A small dog as a house pet is not necessarily a hazard. The water
temperature of the hot water heater is a concern but is not the
greatest hazard. The mother should be aware of and taught safety
measures related to safe water temperatures for bathing the
children. A gate placed at the stairs of the second floor is a
safety measure.
81. The nurse is performing a voice test to assess the hearing
of a client. Which describes the accurate procedure for performing
this test?Whisper a statement while the client blocks one
ear.Rational: In the voice test, the examiner stands 1 to 2 feet
away from the client and asks the client to block one external ear
canal. The nurse whispers a statement and asks the client to repeat
it. Each ear is tested separately. Therefore options 2, 3, and 4
are incorrect.
82. The nurse is assessing the intravenous (IV) dressing of a
client with a peripheral IV infusion running. The date on the
dressing is 7/25 (July 25). The nurse documents on the client's
record that the dressing should be changed on which
date?7/28Rational: IV site dressings should be changed every 48 to
72 hours, which is every 2 to 3 days. With an insertion date of
7/25, the due date for change, depending on agency policy, would be
7/27 or 7/28. It would be unnecessary, uncomfortable, and not cost
effective to change the site dressing daily (option 1). Changing
the site dressing every 5 or 7 days (options 3 and 4) would place
the client at greater risk for infection or other catheter
complications.
83. A client has been taught to use a walker to aid in mobility
after internal fixation of a hip fracture. The nurse determines
that further teaching is required if the client performs which
action?Advances the walker with reciprocal motionRational: A
disadvantage of the walker is that it does not allow for reciprocal
walking motion. If the client were to try to use reciprocal motion
with a walker, the walker would advance forward one side at a time
as the client walks; thus the client would not be supporting the
weaker leg with the walker during ambulation. The client should use
the walker by placing the hands on the hand grips for stability.
The client lifts the walker to advance it and leans forward
slightly while moving it. The client walks into the walker,
supporting the body weight on the hands while moving the weaker
leg.
84. In what area of the chest would the nurse expect to
auscultate these breath sounds?Anteriorly and posteriorly over the
major bronchiRational: Breath sounds are noises resulting from
transmission of vibrations produced by the movement of air in the
respiratory passages. Normal breath sounds include bronchovesicular
sounds, vesicular breath sounds, and bronchial breath sounds. The
sounds that the nurse hears are bronchovesicular breath sounds.
Bronchovesicular breath sounds are normally heard over the first
and second intercostal spaces at the sternal border anteriorly and
at the T4 level medial to the scapula posteriorly (over major
bronchi). These sounds are a mixture of bronchial and vesicular
breath sounds and are moderately pitched with a medium intensity.
The inspiration and expiration phases are equal. Bronchial breath
sounds are loud, high-pitched sounds that resemble air blowing
through a hollow pipe. The expiration phase is louder and longer
than the inspiration phase, and there is a distinct pause between
the inspiration and expiration phases. Bronchial breath sounds are
normally heard over the manubrium. Vesicular breath sounds are
normally heard over the lesser bronchi, bronchioles, and lobes
(peripheral lung fields). These sounds are soft and low-pitched and
resemble a sighing or gentle rustling, and the inspiration phase is
longer than the expiration phase.
85. The nurse is preparing a plan of care for a client who will
be hospitalized for insertion of an internal cervical radiation
implant. Which nursing intervention should the nurse implement in
preparation for arrival of the client?Prepare a private room at the
end of the hallway.Rational: The client with an internal cervical
radiation implant should be placed in a private room at the end of
the hall because this location provides less chance of radiation
exposure to others. Nurses assigned to this client should be
rotated so that one nurse is not consistently caring for the client
and being exposed to excess amounts of radiation. The client's room
should be marked with appropriate signs (per agency policy) that
indicate the presence of radiation. Visitors should be limited to
30-minute visits. All linens should be kept in the client's room
until the implant is removed, in case the implant has dislodged and
needs to be located.
86. A client arrives at the surgical unit after nasal surgery.
The client has nasal packing in place. The nurse reviews the health
care provider's prescriptions and understands that it is essential
that the client be placed in which position to reduce
swelling?Semi-Fowler's positionRational: To reduce swelling the
client would be placed in the semi-Fowler's position. This position
should be maintained for at least 24 to 48 hours to minimize
postoperative edema. The Sims, prone, and supine positions would
not decrease swelling
87. The nurse is preparing to interview a client to collect data
about the client's health history. The nurse should take which
actions to make sure that the physical environment is ready? Select
all that apply.Provide sufficient lighting.Set the room temperature
at a comfortable level.Make sure that the client will be seated
comfortably at eye level with the nurse.Rational: When preparing
the physical environment for an interview, the nurse should provide
sufficient lighting for the client and nurse to see each other. The
nurse should avoid having the client face a strong light because
the client would have to squint into the full light. The nurse
should set the room temperature at a comfortable level. The nurse
should arrange seating so that both the nurse and the client are
seated comfortably at eye level. The distance between the nurse and
the client should be set by the nurse at 4 to 5 feet. If the nurse
places the client any closer, the nurse will be invading the
client's private space and may create anxiety in the client. If the
nurse places the client farther away, the nurse may be seen by the
client as distant and aloof. The nurse avoids facing the client
across a desk or table because this creates a barrier. Distracting
objects and equipment should be removed from the interview
area.
88. The nurse is providing care to a client admitted for
coronary artery disease (CAD) and a history of tobacco use. What is
the most important element of the nurse's focused assessment
regarding the client's smoking history?Number of
pack-yearsRational: The number of cigarettes smoked daily and the
duration of the habit are used to calculate the number of
pack-years, which is the standard method of documenting smoking
history. The brand of cigarettes may give a general indication of
tar and nicotine levels, but the information is of no immediate
clinical use. Desire to quit and number of past attempts to quit
smoking may be useful when the nurse develops a smoking cessation
plan with the client.
89. A nursing student is asked to describe the correct steps for
performing abdominal thrusts on an unconscious adult. In order of
priority, how should the nurse perform this technique? Arrange the
actions in the order that they should be performed. All options
must be used. (right)a. Assess unconsciousness.b. Open the
airway.c. Look in the mouth and remove the object blocking the
airway if seen.d. Attempt ventilation.e. Perform abdominal
thrusts.Rational: For health care providers (HCP), the sequence for
removing a foreign body airway obstruction in an adult is as
follows. After determining unconsciousness, the airway is opened
and the rescuer looks into the mouth of the victim and removes the
object blocking the airway if it is seen. Next, the HCP attempts to
ventilate the victim. If unsuccessful, the victim's head is
repositioned and ventilation is reattempted. Five abdominal thrusts
are then delivered. The sequence is repeated until successful.
90. A nursing student is performing an otoscopic examination in
an adult client. The nursing instructor observes the student
perform this procedure. Which observation by the instructor
indicates that the student is using correct technique for the
procedure?Tilting the client's head slightly away and holding the
otoscope upside down before inserting the speculumRational: In the
otoscopic examination, the nurse tilts the client's head slightly
away and holds the otoscope upside down as if it were a large pen.
The pinna is pulled up and back, and the nurse visualizes the
external canal while slowly inserting the speculum. A small
speculum is used in pediatric clients. The nurse may not be able to
adequately visualize the ear canal if a small speculum is used in
the adult client.
91. The nurse is providing instructions to the unlicensed
assistive personnel (UAP) who will be caring for a client with hand
restraints. The nurse asks the UAP to repeat the instructions to
ensure that the UAP understands the care. Which statement, if made
by the UAP, indicates an understanding of the care for this
client?"I need to remove the restraints at least every 2 hours to
perform range-of-motion exercises."Rational: The nurse should
instruct the UAP to check restraints, circulatory status, and skin
integrity every 30 minutes. Additionally, restraints need to be
removed at least every 2 hours to permit muscle exercise and
promote circulation. Restraints are not to be secured to the
bedrails because this could cause injury to the client if the rails
are lowered. The responsibility of the client should not be placed
on the family members. Agency guidelines regarding the use of
restraints should always be followed.
92. The nurse is conducting preoperative teaching with a client
about the use of an incentive spirometer. The nurse should include
which piece of information in discussions with the client?The best
results are achieved when sitting up or with the head of the bed
elevated 45 to 90 degrees.Rational: For optimal lung expansion with
the incentive spirometer, the client should assume the
semi-Fowler's or high Fowler's position. The mouthpiece should be
covered completely and tightly while the client inhales slowly,
with a constant flow through the unit. The breath should be held
for 5 seconds before exhaling slowly.
93. The home care nurse visits a client who has been started on
oxygen therapy. The nurse provides instructions to the client
regarding safety measures for the use of oxygen in the home. Which
statement, if made by the client, indicates a need for further
instruction?"It is all right to use an electric razor for shaving
only if I leave it plugged in for a short time."Rational: The use
of small electric items, tools, or other equipment could emit
sparks and should be avoided while oxygen is in use. The use of
this equipment could result in fire and injury to the client. The
client also should be instructed not to allow smoking in the home
and to stay at least 10 feet away from any type of flame. The
oxygen concentrator is kept away from walls and corners to permit
adequate airflow.
94. The ambulatory care nurse is seeing a client for a follow-up
visit after treatment for toxic shock syndrome (TSS). To assess the
client's recovery from TSS, the nurse should ask whether which
signs and symptoms have resolved?High fever, abdominal pain,
vomiting, and diarrheaRational: The classic symptoms of TSS are
high fever (temperature of 101 F or higher), vomiting, and severe
diarrhea. Other typical symptoms include headache, myalgia, chills,
abdominal pain, dizziness, lethargy, possible confusion, and
agitation. Vaginal bleeding or discharge is not part of the
clinical picture. TSS typically is caused by Staphylococcus aureus
infection associated with tampon use during menses.
95. The nurse is caring for a restless client who is beginning
nutritional therapy with parenteral nutrition (PN). The nurse
should plan to ensure that which action is taken to prevent the
client from sustaining injury?Secure all connections in the PN
system.Rational: The nurse should plan to secure all connections in
the tubing (tape is used per agency protocol). This helps prevent
the restless client from pulling the connections apart
accidentally. The nurse should also monitor intake and output, but
this does not relate specifically to a risk for injury as presented
in the question. Also, monitoring the temperature and blood glucose
levels does not relate to a risk for injury as presented in the
question. In addition, the client's temperature and blood glucose
levels are monitored more frequently than the time frames
identified in the options to detect signs of infection and
hyperglycemia, respectively.
96. A chest x-ray report states that the client has a left
apical pneumothorax. The nurse caring for the client monitors the
status of breath sounds in that area by placing the stethoscope at
which location?Just under the left clavicleRational: The apex of
the lung is the rounded, uppermost part of the lung. The nurse
would place the stethoscope just under the left clavicle. The other
options are incorrect locations
97. A client with tuberculosis (TB) asks the nurse about
precautions to take after discharge to prevent infection of others.
The nurse develops a response to the client's question based on
which correct understanding of TB transmission?The disease is
transmitted by droplet nuclei.Rational: TB is spread by droplet
nuclei or via the airborne route. The disease is not carried on
objects such as clothing, eating utensils, linens, or furniture. It
is unnecessary to remove carpeting from the home. Bleaching of
clothing and linens is unnecessary, although the client and family
members should use good hand washing technique.
98. The nurse has just reassessed the condition of a
postoperative client who was admitted 1 hour ago to the surgical
unit. The nurse plans to monitor which parameter most carefully
during the next hour?Urinary output of 20 mL/hourRational: Urine
output should be maintained at a minimum of 30 mL/hour for an
adult. An output of less than 30 mL for each of 2 consecutive hours
should be reported to the health care provider. A temperature
higher than 37.7 C (100 F) or lower than 36.1 C (97 F) and a
falling systolic blood pressure, lower than 90 mm Hg, are usually
considered reportable immediately. The client's preoperative or
baseline blood pressure is used to make informed postoperative
comparisons. Moderate or light serous drainage from the surgical
site is considered normal.
99. A male client who is admitted for an unrelated medical
problem is diagnosed with urethritis caused by chlamydial
infection. The unlicensed assistive personnel (UAP) assigned to the
client asks the nurse what measures are necessary to prevent
contraction of the infection during care. What should the nurse
tell the UAP?Standard precautions are quite sufficient because the
disease is transmitted sexually.Rational: Chlamydial infection is a
sexually transmitted infection and frequently is called
nongonococcal urethritis in the male client. It requires no special
precautions in delivery of nursing care. Caregivers cannot acquire
the disease during administration of care, and use of standard
precautions is the only necessary measure.
100. The nurse teaches the mother of a child diagnosed with
bacterial conjunctivitis about measures to prevent transmission of
the infection. Which statement by the mother indicates a need for
further teaching?"It is all right to share towels and washcloths as
long as they are bleached after use."Rational: Bacterial
conjunctivitis is highly contagious, and infection-control measures
should be taught. These measures include frequent hand washing and
not sharing towels and washcloths, regardless of the bleaching
process. Options 2 and 4 are also correct treatment measures.
1. Which assessment finding indicates that a client who had a
mastectomy is experiencing a complication related to the
surgery?Arm edema on the operative sideRational: Arm edema on the
operative side (lymphedema) is a complication after mastectomy. It
can occur immediately postoperatively or months to even years after
surgery. The remaining options are expected occurrences after
mastectomy and do not indicate a complication.
2. The nurse is preparing to care for a client with esophageal
varices who needs a Sengstaken-Blakemore tube inserted because
other treatments were unsuccessful. The nurse gathers supplies,
knowing that which item must be kept at the bedside at all times?A
pair of scissorsRational: The Sengstaken-Blakemore tube is a
triple-lumen gastric tube that may be used to treat bleeding
esophageal varices if other interventions are contraindicated or
are ineffective. The tube has an inflatable esophageal balloon, an
inflatable gastric balloon, and a gastric aspiration lumen. The
gastric balloon applies pressure at the cardioesophageal junction
to compress gastric varices directly and decrease blood flow to
esophageal varices. Traction is applied to maintain the gastric
balloon in place. When the client has a Sengstaken-Blakemore tube,
a pair of scissors must be kept at the client's bedside at all
times. The client must be observed for sudden respiratory distress,
which occurs if the gastric balloon ruptures and the entire tube
moves upward. If this occurs, the nurse immediately cuts all
balloon lumens and removes the tube. An obturator and a Kelly clamp
are kept at the bedside of a client with a tracheostomy. An
irrigation set may be kept at the bedside, but it is not the
priority item.
3. The nurse is instructing a client to perform a two-point gait
for crutch walking. The nurse should tell the client to perform
which action? Advance the right crutch and the left foot forward,
followed by advancing the right foot and the left crutch
forward.Rational: The two-point gait is used when weight bearing is
allowed on both feet. Only two points are in contact with the
floor. The two-point gait closely resembles normal walking. Options
1 and 2 describe three points of contact. Option 3 describes four
points of contact.
4. Treatment for a client with bleeding esophageal varices has
been unsuccessful and the health care provider decides to insert a
Sengstaken-Blakemore tube. What is the priority nursing
action?Place a pair of scissors at client's bedside.Rational: When
the client has a Sengstaken-Blakemore tube inserted, a pair of
scissors must be kept at the client's bedside at all times. The
client must be observed for sudden respiratory distress, which
occurs if the gastric balloon ruptures, moving the entire tube
upward. If this occurs, all balloon lumens are cut and the tube is
removed. An obturator and Kelly clamp would be kept at the bedside
of a client with a tracheostomy. An irrigation set may be kept at
the bedside but is not the priority item.
5. The nurse is preparing a group of Cub Scouts for an overnight
camping trip and instructs the scouts about the methods to prevent
Lyme disease. Which statement by one of the Cub Scouts indicates a
need for further instructions?"I should not use insect repellents
because it will attract the ticks."Rational: In the prevention of
Lyme disease, individuals need to be instructed to use an insect
repellent on the skin and clothes when in an area where ticks are
likely to be found. Long-sleeved tops and long pants, closed shoes,
and a hat or cap should be worn. If possible, heavily wooded areas
or areas with thick underbrush should be avoided. Socks can be
pulled up and over the pant legs to prevent ticks from entering
under clothing.
6. A client with tuberculosis whose status is being monitored in
an ambulatory care clinic asks the nurse when it is permissible to
return to work. What factor should the nurse include when
responding to the client?Three sputum cultures are
negative.Rational: The client with tuberculosis must have sputum
cultures performed every 2 to 4 weeks after initiation of
antituberculosis drug therapy. The client may return to work when
the results of three sputum cultures are negative because the
client is considered noninfectious at that point. Options 1, 3, and
4 are not reliable determinants of a noninfectious status.
7. The nurse is preparing to perform a Weber test on a client
who reports a loss of hearing in one ear. To perform the test, the
nurse places the tuning fork in which area? Refer to
Figure.ARational: The Weber test is valuable assessment test when a
client reports hearing that is better with one ear than the other.
In this test, a vibrating tuning fork is placed on the client's
head over the midline of the client's skull. The client is then
asked whether the tone sounds the same in both ears or better in
one. The client should hear the tone by bone conduction through the
skull, and it should sound equally loud in both ears.
8. A nurse assesses an older client. The nurse recognizes which
as an abnormal assessment finding in this client?Evidence of
abdominal ascitesRational: Evidence of abdominal ascites is an
abnormal finding and can be associated with conditions such as
cirrhosis of the liver or cancer. Gingival retraction, decreased
ability to taste, and diminished sense of smell are all normal
assessment findings in an older adult.
9. A nurse assigned to the pediatric unit finds an infant
unresponsive and without respirations or a pulse. The nurse should
begin chest compressions at which rate?100 times/minRational: In an
infant, the rate of chest compressions is at least 100 times/min.
The other options are incorrect.
10. In preparation for ambulation, the nurse is planning to
assist a postoperative client to progress from a lying position to
a sitting position. Which nursing action is most appropriate to
maintain the safety of the client?Assess the client for signs of
dizziness and hypotension.Rational: Early ambulation should not
exceed the client's tolerance. The client should be assessed before
sitting. The client is assisted to rise from the lying position to
the sitting position gradually until any evidence of dizziness, if
present, has subsided. This position can be achieved by raising the
head of the bed slowly. After sitting, the client may be assisted
to a standing position. The nurse should be at the client's side to
provide physical support and encouragement.
11. The nurse is assessing a client's muscle strength. The nurse
asks the client to hold the arms up and supinated, as if holding a
tray, and then asks the client to close the eyes. The client's left
hand turns and moves downward slightly. The nurse interprets this
to mean that the client has which condition?Pronator driftRational:
Pronator drift occurs when a client cannot maintain the hands in a
supinated position with the arms extended and the eyes closed. This
assessment may be done to detect small changes in muscle strength
that might not otherwise be noted. Ataxia is a disturbance in gait.
Nystagmus is characterized by fine, involuntary eye movements.
Hyperreflexia is an excessive reflex action.
12. The nurse is preparing to interview a client to collect data
about the client's health history. The nurse should take which
actions to make sure that the physical environment is ready? Select
all that apply.Provide sufficient lighting.Set the room temperature
at a comfortable level.Make sure that the client will be seated
comfortably at eye level with the nurse.Rational: When preparing
the physical environment for an interview, the nurse should provide
sufficient lighting for the client and nurse to see each other. The
nurse should avoid having the client face a strong light because
the client would have to squint into the full light. The nurse
should set the room temperature at a comfortable level. The nurse
should arrange seating so that both the nurse and the client are
seated comfortably at eye level. The distance between the nurse and
the client should be set by the nurse at 4 to 5 feet. If the nurse
places the client any closer, the nurse will be invading the
client's private space and may create anxiety in the client. If the
nurse places the client farther away, the nurse may be seen by the
client as distant and aloof. The nurse avoids facing the client
across a desk or table because this creates a barrier. Distracting
objects and equipment should be removed from the interview
area.
13. The nurse has administered an injection to a client. After
the injection, the nurse accidentally drops the syringe on the
floor. What is the most appropriate nursing action in this
situation?Carefully pick up the syringe from the floor and dispose
of it in a sharps container.Rational: Used syringes should always
be placed in a sharps container immediately after use to avoid
injury to anyone. A syringe should not be swept up because this
action poses an additional risk of needle stick. It is not the
responsibility of the housekeeping department to pick up the
syringe. Syringes should not be recapped because of the risk of
getting pricked with a contaminated needle.
14. The nurse is caring for a client with acute viral hepatitis
A who resides in a group home. Which outcome indicates that the
most important goal has been achieved for this client?Avoids
transmitting the virus to others in the group homeRational: All the
options are expected outcomes of care for this client. However,
because the disease can be communicable to others, one of the most
important goals in management of acute viral hepatitis is
preventing the spread of infection.
15. The nurse is preparing to perform an abdominal examination
on a client. The nurse should place the client in which position
for this examination?Supine with the head raised slightly and the
knees slightly flexedRational: During the abdominal examination,
the client lies supine (flat on the back) with the head raised
slightly and the knees slightly flexed. This position relaxes the
abdominal muscles. Sims position is a side-lying position and would
not adequately expose the abdomen for examination. Placing the head
and feet flat would result in the abdominal muscles' being taut.
The abdomen cannot be accurately assessed if the head is raised 45
degrees.
16. A preoperative client expresses anxiety to the nurse about
upcoming surgery. Which response by the nurse is most likely to
stimulate further discussion between the client and the nurse?"Can
you share with me what you've been told about your
surgery?"Rational: Explanations should begin with the information
that the client knows. By providing the client with individualized
explanations of care and procedures, the nurse can assist the
client in handling anxiety and fear for a smooth preoperative
experience. Clients who are calm and emotionally prepared for
surgery withstand anesthesia better and experience fewer
postoperative complications. Option 1 does not focus on the
client's anxiety. Explaining the entire surgical procedure may
increase the client's anxiety. Option 4 avoids the client's anxiety
and is focused on postoperative care.
17. The nurse is preparing the morning medications to be
administered to her assigned clients and is reviewing the health
care provider's prescriptions. Which medication prescription should
the nurse question?Hydrochlorothiazide (HCTZ) orally twice
dailyRational: Hydrochlorothiazide (HCTZ) orally twice daily
18. A client with right leg hemiplegia has a problem with
mobility. The nurse determines a need for reinforcement of teaching
the client and the client's family if the nurse observes which
action being done by the family?Encouraging the client to stand
unassisted on the legRational: Depending on the client's functional
ability, either passive or active range of motion is indicated to
keep the joint moving freely. Application of a premolded splint
also would keep the limb aligned and in good position. The client
should not attempt to stand unsupported on a weak or paralyzed
limb. The inability to bear weight will cause the client to
fall.
19. The nurse has conducted preoperative teaching for a client
scheduled for surgery in 1 week. The client has a history of
arthritis and has been taking acetylsalicylic acid (aspirin). The
nurse determines that the client needs additional teaching if the
client makes which statement?"I need to continue to take the
aspirin until the day of surgery."Rational: Anticoagulants alter
normal clotting factors and increase the risk of bleeding after
surgery. Aspirin has properties that can alter the clotting
mechanism and should be discontinued at least 48 hours before
surgery. However, the client should always check with his or her
health care provider regarding when to stop taking the aspirin when
a surgical procedure is scheduled. Options 1, 2, and 4 are accurate
client statements.
20. A nurse is initiating one-rescuer cardiopulmonary
resuscitation (CPR) on an adult client. The nurse should place the
hands in which position to begin chest compressions?On the lower
half of the sternumRational: Chest locations are found by placing
the hands on the lower half of the sternum. To locate this area,
find the notch where the rib margin meets the sternum, and place
the middle finger on this notch and the index finger next to it.
Next, place the heel of the opposite hand on the lower half of the
sternum, close to the index finger. Remove the first hand, place it
on top of the hand on the sternum, and begin chest compressions.
Chest compressions will not be as effective with hand placements
described in options 2, 3, and 4.
21. The nurse is preparing to administer an intradermal
medication. Which action should the nurse take before administering
the medication?Cleanse the site of injection with an alcohol swab
and wait for the alcohol to dry.Ratinal: Before administering an
intradermal medication, the site of injection is cleaned with an
alcohol swab and patted dry with tissue. Alcohol needs to dry to
appropriately. The actions in the remaining options are incorrect
because they contaminate the site before the administration of the
medication.