TEST BANK FOR RN ATI FUNDAMENTALS (ALL CHAPTERS 1- 58 WITH QUESTIONS AND ANSWERS)/FUNDAM | Exams Nursing | Docsity (2024)

Download TEST BANK FOR RN ATI FUNDAMENTALS (ALL CHAPTERS 1- 58 WITH QUESTIONS AND ANSWERS)/FUNDAM and more Exams Nursing in PDF only on Docsity! TEST BANK FOR RN ATI FUNDAMENTALS (ALL CHAPTERS 1- 58 WITH QUESTIONS AND ANSWERS)/FUNDAMENTALS OF NURSING 10TH EDITION (10.0) ATI, CONTENT MASTERY SERIES REVIEW MODULE For more @ manukeyah@gmail.com Ch. 1) A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply.) A. Home health care B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology centers - ANSWER- A, B, D Rationale: A. Restorative health care involves immediate follow up care for restoring health and prolonged self-care home healthcare is a type of restorative healthcare B. Rehabilitation facilities are a type of restorative health care D. Skilled nursing facilities are a type of restorative healthcare Ch. 1) A nurse is explaining the various types of health clients might have to a group care coverage of nurses. Which of the following health care financing mechanisms should the nurse include as federally funded? (Select all that apply.) A. Preferred provider organization (PPO) B. Medicare C. Long-term care insurance D. Exclusive provider organization (EPO) E. Medicaid - ANSWER- B, E Rationale: Medicare and Medicaid are federally funded. PPOs, Long-term care insurance and EPOs are privately funded Ch. 1) A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? A. Collaborating with providers to perform obesity screenings during routine office visits B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity C. Providing specialized intraoperative training in surgical treatments for obesity D. Educating acute care nurses about postoperative complications related to obesity - ANSWER- A Rationale: identify obesity screenings at office visit as an example of primary healthcare. primary healthcare emphasizes health promotion and disease control, is often delivered during office visit, and includes screenings. Ch. 1) A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? A. Monitoring evidence-based practice for clients who have a specific diagnosis B. Ensuring that health care providers comply with regulations C. Setting quality standards for accreditation of health care facilities D. Determining whether medications are safe for administration to clients - ANSWER- B A pharmacist must be knowledgeable about any medication dispensed for the client, including its actions, effects, and interactions. D. A registered nurse must be knowledgeable about any medication administered, including its actions, effects, and interactions. Ch. 2) A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Occupational therapist D. Speech-language pathologist - ANSWER- D Rationale: A speech language pathologist can initiate specific therapy for clients who have difficulty with feeding due to swallowing difficulties Ch. 2) A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a medical-surgical unit. When providing examples of the types of tasks certified nursing assistants (CNAS) can perform, which of the following client activities should the nurse include? (Select all that apply.) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs - ANSWER- A, B, C, E Rationale: it is within the range of function for a CNA to provide basic care to patients (bathing, assisting with ambulation, assisting with toileting, measuring and recording vital signs) Ch. 4) A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells the client that diapers will be used next time the urinal is used improperly. Which of the following torts is the AP committing? A. Assaul t B. Battery C. False imprisonment D. Invasion of privacy - ANSWER- A Rationale: by threatening the client, the AP is committing a salt. The AP's threats could make the client become fearful and apprehensive. Ch. 4) A nurse is caring for a competent adult client who tells the nurse, "I am leaving the hospital this morning whether the doctor discharges me or not." The nurse believes that this is not in the client's best interest, and prepares to administer a PRN sedative medication the client has not requested along with the scheduled morning medication. Which of the following types of tort is the nurse about to commit? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality - ANSWER- B Rationale: administering a medication as a chemical restraint to keep the client from leaving the facility against medical advice is false imprisonment, because the client neither requested nor consented to receiving the sedative. Ch. 4) A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that "I plan to prepare my advance directives before I come to the hospital." Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? A. "I'd rather have my brother make decisions for me, but I know it has to be my wife." B. "I know they won't go ahead with the surgery unless I prepare these forms." C. "I plan to write that I don't want them to keep me on a breathing machine." D. "I will get my regular doctor to approve my plan before I hand it in at the hospital." - ANSWER- C Rationale: The patient has the right to decide and specify which medical procedures he wants when a life-threatening situation arises. Ch. 4) A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select all that apply.) Ch. 5) A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (Select all that apply.) A. Cover errors with correction fluid, and write in the correct information. B. Put the date and time on all entries. C. Document objective data, leaving out opinions. D. Use as many abbreviations as possible. E. Wait until the end of the shift to document. - ANSWER- B, C Rationale: B. The date and time confirm the recording of the correct sequence of events C. Documentation must be factual, descriptive, and objective, without opinions or criticism Ch. 3) A nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence - ANSWER- B Rationale: in this situation the client is exercising their right to make their own personal decision about surgery, regardless of others opinions of what is best for them. This is an example of autonomy Ch. 3) A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficence - ANSWER- D Rationale: Beneficence is an action that promotes good for others without self interest. By administering pain medication before the client attempts a potentially painful exercise like ambulation, The nurse is taking a specific and positive action to help the client Ch. 3) A nurse is instructing a group of newly licensed nurses about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurses should understand that this aspect of cared delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence - ANSWER- C Rationale: justice is fairness in care delivery and in the use of resources. By applying the same qualifications to all potential kidney transplant recipients, organ procurement organizations demonstrate this ethical principle in determining the allocation of these scarce resources Ch. 3) A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Nonmaleficence - ANSWER- D Rationale: Non-malfeasance is a commitment to do no harm. In this situation, administering the medication could harm the patient. By questioning it, the nurse is demonstrating the ethical principle Ch. 3) A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurses identify as an ethical dilemma? A. A nurse on a medical-surgical unit demonstrates signs of chemical impairment B. A nurse overhears another nurse telling an older adult client that if he does not stay in bed, she will have to apply restraints C. A family has conflicting feelings about the initiation of enteral tube feedings for their father who is terminally ill D. A client who is terminally ill hesitates to name their partner on their durable power of attorney form - ANSWER- C Rationale: making the decision about initiating enteral tube feedings is an example of an ethical dilemma. A review of scientific data cannot resolve the issue, and it is not easy to resolve. The decision will have a profound effect on the situation and on the client. Ch. 5) A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching (SATA) A. Medication error B. Needlesticks C. Conflict with provider and nursing staff D. Omission of prescription Ch. 6) A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assign to a PN? A. Creating a plan of care for a client who is recovering following a stroke B. Assessing a pressure injury on a client who is on bed rest C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Teaching a client who has asthma to use a metered-dose inhaler - ANSWER- C Rationale: providing nasopharyngeal suctioning is within the scope of a practical nurse Ch. 6) A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation (SATA)? A. Right place B. Right supervision and evaluation C. Right direction and communication D. Right documentation E. Right circ*mstances - ANSWER- B, C, E (rights not in question- person and task) Ch. 7) By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. C. Change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing his pain. - ANSWER- A Rationale: collect further data from the client to determine why they have not achieved satisfactory pain relief, because various factors might be interfering with their comfort. The nursing process repeats in an ongoing manner across the span of client care Ch. 7) A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hours ago. The prescription reads every 4 hours PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps in the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation - ANSWER- A Rationale: A newly licensed nurse should have used the assessment step of the nursing process by asking the client to evaluate the severity of pain on a 0 to 10 scale. The nurse should have asked about the characteristics of the pain and assess for any changes that might have contributed to worsening of the pain Ch 31) A nurse in a provider's office is preparing to assess a young adult client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (SATA) A. Concave thoracic spine posteriorly B. Exaggerated lumbar curvature C. Concave lumbar spine posteriorly D. Exaggerated thoracic curvature E. Muscles slightly larger on the dominant side - ANSWER- C, E Ch 46 (#1): A nurse is caring for a client who is 1 day postoperative and reports a pain level of 10 on a scale of 0 to 10. After reviewing the client's medication administration record, which of the following medications should the nurse administer? A. Meperidine 75 mg IM B. Fentanyl 50 mcg/hr transdermal patch C. Morphine 2 mg IV D. Oxycodone 10 mg PO - ANSWER- C. Morphine 2 mg IV Rationale: administer IV morphine bc the onset is rapid, and absorption of the medication into the blood is immediate, which provides the optimal response for a client who is reporting pain at a level of 10. Ch 46 (#2): A nurse is teaching a client about medications at discharge. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I can open the time-release capsule with the beads in it and sprinkle them on my oatmeal." B. "If I am having difficulty swallowing, I will add the liquid medication to prepared package of pudding." C. "I can crush the enteric coated pill, if needed." D. "I will eat two crackers with the pain pills." - ANSWER- D. Ch. 53: A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply.) A. Restlessness B. Tachypnea C. Bradycardia D. Confusion E. Hypertension - ANSWER- A, B, D, E Ch. 53: A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.) A. Apply petroleum jelly around and inside the nares B. Remove the nasal cannula during mealtimes C. Check the position of the cannula frequently D. Report any nausea or difficulty breathing E. Post "No Smoking" signs in prominent locations - ANSWER- C, D, E Ch. 53: A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority. A. Increase the oxygen flow B. Assist the client to Fowler's position C. Promote removal of pulmonary secretions D. Obtain a specimen for arterial blood gases - ANSWER- B Ch 48 (#1): A nurse is preparing to administer methylprednisolone 10 mg by IV bolus. The amount available is methylprednisolone injection 40mg/mL. How many mL should the nurse administer? (Round answer to the nearest tenth. Do not use a trailing zero.) - ANSWER- Answer: 0.3 mL Ch 48 (#2): A nurse is preparing to administer LR IV 100 mL over 15 min. The nurse should set the IV infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Do nose use a trailing zero.) - ANSWER- Answer: 400 mL/hr Ch 48 (#3): A nurse is preparing to administer 0.9% NaCl 250 mL IV to infuse over 30 min. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should adjust the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Do nose use a trailing zero.) - ANSWER- Answer: 83 gtt/min Ch. 54: A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? A. Auscultate breath sounds B. Stop the feeding C. Obtain a chest x-ray D. Initiate oxygen therapy - ANSWER- B Ch. 54: A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure? A. Check how long the feeding container has been open B. Verify the placement of the NG tube C. Confirm that the client does not have diarrhea D. Make sure the client is alert and oriented - ANSWER- B Ch. 54: A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (Select all that apply.) A. Auscultate bowel sounds B. Assist the client to an upright position C. Test the pH of gastric aspirate D. Warm the formula to body temperature E. Discard any residual gastric contents - ANSWER- A, B, C Ch. 54: A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (Select all that apply.) A. Review a signal the client can use if feeling any distress B. Lay a towel across the client's chest C. Administer oral pain medication D. Obtain a Dobhoff tube for insertion E. Have a petroleum-based lubricant available - ANSWER- A, B Ch. 55: A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (Select all that apply.) A. Increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst - ANSWER- A, B, C Ch. 55: A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply.) A. Stage 3 pressure ulcer B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area - ANSWER- A, E Ch 50 (#2) A nurse is teaching a client who has a new prescription for oxybutynin about managing the medication's anticholinergic effects. Which of the following instructions should the nurse include? A. Take sips of water frequently. B. Wear sunglasses when outdoors in sunlight. C. Use a soft toothbrush when brushing teeth. D. Take the medication with an antacid. E. Urinate prior to taking the medication. - ANSWER- A, B, E Ch 50 (#3) A nurse is reviewing a client's medications. They include cimetidine and imipramine. Knowing that cimetidine decreases the metabolism of imipramine, the nurse should identify that this combination is likely to result in which of the following effects? A. Decreases therapeutic effects of cimetidine. B. Increased risk of imipramine toxicity. C. Decreased risk of adverse effects of cimetidine. D. Increased therapeutic effects of imipramine - ANSWER- Answer: B Ch 50 (#4): A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give to the client? A. "Get up and change positions slowly." B. "Avoid eating aged cheese and smoked meat" C. "Report any unusual bruising and bleeding to the doctor immediately." D. "Eat the same amount of foods that contain vitamin K every day." - ANSWER- A Ch 50 (#5): A nurse in an outpatient medical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering this medication, which of the following actions is the nurse's priority? A. Teaching the client about the purpose of this medication. B. Giving the medication at the administration time the provider prescribed. C. Identifying the clients medication allergies. D. Documenting the clients anxiety level. - ANSWER- C Ch 51 (#1): To promote adherence to medication self-administration, a nurse is making recommendations for an older adult client. Which of the following instructions should the nurse include? (Select all that apply) A. Adjust dosages according to daily weight. B. Place pills in daily pill holders. C. Ask for liquid form of the client has difficulty swallowing pills. D. Ask a relative to assist periodically. E. Request child-resistant caps on medication containers. - ANSWER- B, C, D Ch 51 (#2): A client in a providers office tells the nurse that "I fast for several days each week to control my weight." The client takes several medications for various chronic issues. The nurse should explain to the client that which of the following mechanisms that results from fasting puts her at risk for medication toxicity? A. Increasing the metabolism of the medication over time. B. Increasing the protein-binding response. C. Increasing the medications' transit time through the intestines. D. Decreasing the excretion of the medications. - ANSWER- B Ch 51 (#3): A nurse is preparing medications for a preschooler. Which of the following factors should the nurse identify as altering how a medication affects children? (Select all that apply) A. Increased gastric acid production B. Immature liver C. Higher body water content D. Increased absorption of topical medications E. Increased gastric emptying time - ANSWER- B, C, D Ch 51 (#4): A nurse is teaching a client who is lactating about taking medications. Which of the following actions should the nurse recommend to minimize in the entry of medication into breast milk? A. Drink 8 oz of milk with each dose of medication. Which of the following statements should the charge nurse identify as an indication that the newly licensed nurse understands the teaching? A. "I should obtain a specimen for culture and sensitivity after the first dose of an antimicrobial." B. "MRSA is usually resistant to vancomycin, so another antimicrobial will be prescribed." C. "I will protect others from exposure when I transport the client outside the room." D. "To decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile." - ANSWER- C Ch. 57: A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (Select all that apply.) A. Distended neck veins B. Hyperthermia C. Tachycardia D. Syncope E. Decreased skin turgor - ANSWER- C, D, E Ch. 57: A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? A. A client who has nasogastric suctioning B. A client who has chronic constipation C. A client who has syndrome of inappropriate antidiuretic hormone D. A client who took a toxic dose of sodium bicarbonate antacids - ANSWER- A Ch. 21 #4 A nurse is talking with the caregivers of a 10-year-old who is concerned that their child is becoming secretive, including closing the door when showering and dressing. Which of the following responses should the nurse make? A. "Perhaps you should try to find out what is happening behind those closed doors." B. "Suggest that the door be left ajar for safety reasons." C. "At this age, children tend to become modest and value their privacy." D. "You should establish a disciplinary plan to stop this behavior." - ANSWER- C School-age children develop a need for privacy. It is important for the caregivers to show trust in the child and respect the child's need for privacy. Ch. 56: A nurse in a primary care clinic is assessing a client who has a history of herpes zoster. Which of the following findings suggests that the client has postherpetic neuralgia. A. Linear clusters of vesicles on the right shoulder B. Purulent drainage from both eyes C. Decreased white blood cell count D. Report of continued pain following resolution of the rash - ANSWER- D Ch. 55: A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply.) A. Keep the head of the bed elevated 30 degrees B. Massage the client's bony prominences frequently C. Apply cornstarch liberally to the skin after bathing D. Have the client sit on a gel cushion when in a chair E. Reposition the client at least every 3 hr while in bed - ANSWER- A, D Ch. 21 #3 A nurse is evaluating teaching about nutrition with the guardians of an 11-year-old child. Which of the following statements should indicate to the nurse an understanding of the teaching? A. "Our child want to eat as much as we do, but we're afraid it will lead to becoming overweight." B. "Our child skips lunch sometimes, but we figure it's okay as long as we eat a healthy breakfast and dinner." C. "We limit fast-food restaurants meals to three times a week now." D. "We reward school achievements with a point system instead of pizza or ice cream." - ANSWER- D Guardians should avoid rewarding children with food for good behavior or achievements. Associations between food and feeling good can lead to weight problems. Ch 48 (#4): A nurse is preparing to administer metoprolol 200 mg PO daily. The amount available is metoprolol 100 mg/tablet. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Do nose use a trailing zero.) - ANSWER- Answer: 2 tablets prescription. Which of the following interventions should the charge nurse include? (SATA) A. Writing a prescription for morphine sulfate as needed for pain B. Inserting an NG tube to relieve gastric distention C. Showing a patient how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning a client every 2 hours to reduce pressure injury risk - ANSWER- C, D, E Rationale: C. Showing a client how to use progressive muscle relaxation is an appropriate nurse-initiated intervention for stress relief. Unless there is a contraindication for a specific client, use this technique with clients without a providers prescription D. Performing a bath is a routine nursing care procedure. Unless there is a contraindication for a specific client, determine when bathing is optimal for a client without a provider's prescription E. Repositioning a client every 2 hours is in appropriate nursing intervention for clients. Unless there is a contraindication for a specific client, use this strategy without a providers prescription Ch. 53: A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (Select all that apply.) A. Apply the oxygen source loosely if the SpO2 decreases during the procedure B. Use surgical asepsis to remove and clean the inner cannula C. Clean the outer cannula surfaces in a circular motion from the stoma site outward D. Replace the tracheostomy ties with new ties E. Cut a slit in gauze squares to place beneath the tube holder - ANSWER- A, B, C Ch. 7) A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (SATA) A. Respiratory rate is 22/bpm with even, unlabored respirations B. The client's partner states, "they said they hurt after walking about 10 minutes. C. The client's pain rating is 3 on a scale of 0 to 10 D. The client's skin is pink, warm, and dry E. The assistive personnel reports that the client walked with a limp - ANSWER- A, D, E Rationale: Objective data includes information the nurse measures (vital signs), the nurse observes (skin appearance), and observations of others (family and staff) Ch.21 #1 A nurse is talking with caregiver of a 12-year-old child. Which of the following issues verbalized by the caregivers should the nurse identify as the priority? A. "We just don't understand why our child can't keep up with the other kids in simple activities like running and jumping." B. "Our child keeps trying to find ways around our household rules. They always want to make deals with us." C. "We think our child is trying too hard to excel in math just to get the top grades in the class." D. "Our child likes to sing and worries it will make the other kids want to laugh." - ANSWER- A When using the urgent vs. nonurgent approach to client care, the priority issue is the delay in motor skills, which could indicate an illness and requires further investigation. Ch. 53: A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? (Select all that apply.) A. Apply suction while withdrawing the catheter B. Perform suctioning on a routine basis every 2 to 3 hr C. Maintain medical asepsis during suctioning D. Use a new catheter for each suctioning attempt E. Apply suction for 10 to 15 seconds - ANSWER- A, D, E Ch 47 (#5): A nurse reviewing a client's health record notes a new prescription for lisinopril 10 mg PO once every day. The nurse should identify this as which of the following types of prescriptions? A. Single B. Stat C. Routine D. Now - ANSWER- C. Routine Rationale: A routine or standing prescription identifies medications to give on a regular schedule with or without a termination date or a specific number of doses. Administer this medication every day until the provider discontinues it. Ch 47 (#4): A nurse educator is teaching newly licensed nurses about safe medication administration. Which of the following statements indicates understanding? (Select all that apply) A. "I will observe for adverse effects." B. "I will monitor for therapeutic effects." C. "I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in." D. "After the drops are in, I will place a cotton ball all the way into my ear canal." - ANSWER- B. (Also saw this exact question on the practice exam but the answers were worded a little differently) Ch 49 (#5): A nurse is caring for a client receiving dextrose 5% in 0.9% NaCl IV at 120 mL/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? (Select all that apply.) A. "I feel lightheaded" B. "I feel as though my heart is racing" C. "I feel a little short of breath" D. "The nurse technician told me that my blood pressure was 150/90" E. "I think my ankles are less swollen" - ANSWER- B, C, D Ch 50 (#1) A nurse is collecting data from a client who takes haloperidol to treat schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms (EPSs)? (Select all that apply) A. Orthostatic hypotension B. Tremors C. Acute dystonia D. Decreased level of consciousness E. Restlessness - ANSWER- B, C, E Ch. 57: A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction? A. A client who has a new diagnosis of adrenal insufficiency B. A client who has heart failure C. A client who is receiving treatment for diabetic ketoacidosis D. A client who has abdominal ascites - ANSWER- B Ch. 57: A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? A. Administer antihypertensive on schedule B. Check the client's weight each morning C. Notify the provider of a urine output greater than 20 mL/hr D. Encourage independent ambulation four times a day - ANSWER- B Ch. 58: A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care? A. Infuse hypotonic IV fluids B. Implement a fluid restriction C. Increase sodium intake D. Administer sodium polystyrene sulfonate - ANSWER- A Ch. 58: A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as a risk factor for the development of this electrolyte imbalance? A. Crohn's disease B. Postoperative following appendectomy C. History of bone cancer D. Hyperthyroidism - ANSWER- A Ch. 58: A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/L. When notifying the provider, the nurse should expect which of the following actions? A. Starting an IV infusion of 0.9% sodium chloride B. Consulting with dietitian to increase intake of potassium C. Initiating continuous cardiac monitoring D. Preparing the client for gastric lavage - ANSWER- C Ch. 58: A nurse is collecting data from a client who has hypercalcemia as a result of long-term use of glucocorticoids. Which of the following findings should the nurse expect? (Select all that apply.) A. Hyperreflexia B. Confusion C. Positive Chvostek's sign D. Bone pain E. Nausea and vomiting - ANSWER- B, D, E Ch. 58: A nurse is providing education for a client who has severe hypomagnesemia and is prescribed oral magnesium sulfate. Which of the following information should the nurse include in the teaching? A. "Avoid green, leafy vegetables while taking this medication." a. Fever b. malaise c. edema d. pain or tenderness e. increase in pulse and respiratory rate - ANSWER- a, b, e ch11)A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include? Select all that apply. a. Place the client in a room that has negative air pressure of at least six exchanges per hour b. wear a mask when providing care within 3 foot of the client c. place a surgical mask on the client if transportation to another department is unavoidable d. use sterile gloves when handling soiled linens e. wear a gun when performing care that might result in contamination from secretions - ANSWER- B, C, E ch10.) When entering the client room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? a. Keep the sterile field at least 6 foot away from the clients bedside b. instruct the client to refrain from coughing and sneezing during the dressing change c. place a mask on the client to limit the spread of microorganisms into the surgical wound d. keep a box of facial tissues nearby for the client to use during the dressing change - ANSWER- c ch10.) a nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flops should the nurse unfold first? a. The flap closest to the body b. the right side flap c. the left side flap d. the flap farthest from the body - ANSWER- d ch10.) A nurse is reviewing hand hygiene techniques with a group of assistive personnel. Which of the following instructions should the nurse include when discussing handwashing? Select all that apply. a. Apply 3 to 5 milliliters of liquid soap to dry hands b. wash the hands with soap and water for at least 15 seconds c. rinse the hands with hot water d. use a clean paper towel to turn off hand faucets e. allow the hands to air dry after washing - ANSWER- b, d ch10.) A nurse has prepared a sterile field for assisting a provider with chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? Select all that apply. a. The provider drops a sterile instrument onto the near side of the sterile field b. the nurse poisons a cotton ball with sterile Saline and places it on the sterile field c. the procedure is delayed one hour because the provider receives an emergency call d. the nurse turns to speak to someone who enters through the door behind the nurse e. the clients hand brushes against the outer edge of the sterile field - ANSWER- b, c, d ch10.) A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? Select all that apply. a. A bottle containing a sterile solution b. the edge of the sterile drip at the base of the field c. the inner wrapping of an item on the sterile field d. an irrigation syringe on the sterile field e. one gloved hand with the other gloved hand - ANSWER- c, d, e CH12.)a nurse discovers a small paper fire in a trash can in a client bathroom. The client has been taken to safety on the alarm has been activated. Which of the following actions should the nurse take? a. Open the windows in the clients room to allow smoke to escape b. obtain a Class C fire extinguisher to extinguish the fire c. remove all electrical equipment from the client room d. place wet towels along the base of the door to the clients room - ANSWER- d CH12.)a nurse is caring for a client who has a history of falls which of the following actions is the nurses priority? a. Complete a fall risk assessment b. educate the client and family about fall risks c. eliminate safety hazards from the clients environment d. make sure the client uses assistive aids in their possession - ANSWER- A CH12.)a nurse observes smoke coming from under the door of the staff lounge. Which of the following actions is the nurses priority? D. Echinacea - ANSWER- A Rationale: tea can contain chamomile, which can produce a calming effect, or valerian, which reduces anxiety. Attempt to gain further information to confirm the ingredients of any herbal or natural products the client can use Ch. 42) A nurse is reviewing complementary and alternative therapies with a group of newly licensed nurses. Which of the following interventions are mind-body therapies (SATA) - ANSWER- A, C, E Rationale: A. art therapy is a mind-body therapy because it allows the client to express unconscious emotions or concerns about their health C. Yoga is mind-body therapy because it focuses on achieving wellbeing through exercises E. Biofeedback is a mind-body therapy because it increases mental awareness of the body responses to stress A nurse is teaching a group of newly licensed nurses on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage them to use? (SATA) A. Guided imagery B. Massage therapy C. Meditation D. Music therapy E. Therapeutic touch - ANSWER- A, C, D Rationale: A. Nurses can use guided imagery with clients once they understand the general principles of this therapy C. Nurses can use meditation with clients once they understand the general principles of this therapy D. Nurses can uses music therapy with clients once they understand the general principles Ch. 42) A nurse is planning to use healing intention with a client who is recovering from a lengthy illness. Which of the following is the priority action to take before attempting this particular mind-body interventions? A. Tell the client the goal of the therapy is to promote healing B. Ask whether the client is comfortable with using prayer C. Encourage the client participate actively for best results D. Instruct the client to relax during the therapy - ANSWER- B. Rationale: The first action to take using the nursing process is to assess or collect data from the client. Because people can have personal, cultural or religious sensitivities or aversions to religious practices (prayer), the nurse must first determine that the client is comfortable with a therapy that involved prayer CH12.)A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place comma and time and can follow directions. Which of the following action should the nurse take to decrease the risk of another fall? Select all that apply. a. Place a belt restraint on the client when they were sitting on the bedside commode b. keep the bed in its lowest position with all side rails up c. make sure that the clients' call light is within reach d. provide the client with non skid footwear e. complete a fall risk assessment - ANSWER- C, D, E ch13.) a home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include? Select all that apply. a. Most food poisoning is caused by a virus b. immuno compromised individuals are at increased risk for complications from food poisoning c. clients who are at high risk should eat or drink only pasteurized dairy products d. healthy individuals usually recover from the illness in a few weeks e. handling raw and fresh food separately can prevent food poisoning - ANSWER- b, c, e ch13)a home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include? a. Carbon monoxide has a distinct color b. water heaters should be inspected every five years c. the lungs are damaged from carbon monoxide inhalation d. carbon monoxide binds with hemoglobin in the body - ANSWER- d ch13)A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements by a participant indicates understanding? a. I will set my water heater at 130 degrees Fahrenheit b. once my baby can set up there should be safe in the bathtub c. I will place my baby on their stomach to sleep d. once my infants start to push up I will remove the mobile from over the crib - ANSWER- d #4 A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority? A. "I kind of like this boy in my class, but he doesn't like me back." B. "I want to hang out with the kids in the science club, but the jocks pick on them." C. "I am so fat, I skip meals to try to lose weight." D. "My dad wants me to be a lawyer like him, but I just want to dance." - ANSWER- C The greatest risk to the client is injury due to an eating disorder. The priority issue is to provide counseling to promote body image and ensure proper nutrition. Ch.22 #5 A nurse is preparing a wellness presentation for families about health screening for adolescents. Which of the following information should the nurse include? (Select all that apply.) A. Obtain a periodic mental status evaluation. B. Discuss prevention of sexually transmitted infections. C. Regularly screen for tuberculosis. D. Provide education about drug and alcohol use. E. Teach monthly breast examinations. - ANSWER- A, B, C, D Ch. 22 #3 A nurse is reviewing the CDC's immunization recommendations with the guardians of an adolescent. Which of the following recommendations should the nurse include in this discussion? (Select all that apply.) A. Rotavirus B. Varicella C. Herpes zoster D. Human papilloma virus E. Seasonal influenza - ANSWER- B, D, E Ch. 41) A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client if there has been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine? A. Presence of associated manifestations B. Location of the pain C. Pain quality D. Aggravating and relieving factors - ANSWER- A Rationale: Attempt to identify manifestations that occur along with the client's pain (Nausea, fatigue or anxiety) ch14)A nurse educator is reviewing proper body mechanics during employee orientation period which of the following statements should the nurse identify as an indication that an attendee understands the teaching? Select all that apply. a. My line of gravity should fall outside my base of support b. the lower my center of gravity the more stability I have c. to broaden my base of support i should spread my feet apart d. when I left an object i should hold it as close to my body as possible e. when pulling an object i should move my front foot forward - ANSWER- b, c, d Ch. 22 #1 A nurse is teaching the guardian of a 12-year-old male client about manifestations of puberty. The nurse should explain that which of the following physical changes occurs first? A. Appearance of downy hair on the upper lip B. Hair growth in the axillae C. Enlargement of the testes and scrotum D. Deepening of the voice - ANSWER- C Using evidence-based practice, the first prepubescent change in boys is an increase in the size of the testicl*s and scrotum, and growth of pubic hair. ch14)A nurse manager is reviewing guidelines for preventing an injury with a staff nurse. Which of the following instructions should the nurse monitor include? Select all that apply. a. Request assistance when repositioning the client b. avoid twisting your spine or bending at the waist c. use smooth movements when lifting and moving clients d. take a break from repetitive movements every two to three hours to flex and stretch your joints and muscles - ANSWER- a, b, d ch14)A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make? a. Lie on your back with your head and shoulders supported by a pillow b. have your head turned to the side while you lie on your stomach c. have a table beside your bed so that you can sit on the bad side and B. I'll never be able to care for this at home, can't you just send a nurse to the house? C. I met my neighbor who also has a colostomy and they taught me a few things. D. It can take me a while to get the hang of this, I have to admit I am pretty nervous. - ANSWER- B; this client is displaying a lack of interest in learning how to care for the colostomy and preferring dependence on others to perform the care Ch 35) The nurse is using an interpreter to communicate with the client. Which of the following actions should the nurse use when communicating with the client and family members? (SATA) A. Talk to the interpreter about the family while the family is in the room B. Determine clients understanding several times during the conversation C. Look at that interpreter when asking the family questions D. Use lay terms is possible E. Do not interrupt the interpreter and the family as they talk - ANSWER- B, D, E Ch 35) Nurse enters The room of the client who is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take? A. Contact the hospital spiritual services B. Ask what is making the client cry C. Ensure no visitors or staff enters the room for a short time period D. Turn on the television for a distraction - ANSWER- C Ch 35) A nurse is caring for a client who tells the nurse that based on religious values and mandates a blood transfusion is not an acceptable treatment option. Which of the following responses should the nurse make? A. I believe in this case you should really make an exception and except the blood transfusion B. I know your family would approve of your decision to have a blood transfusion C. Why does your religion mandate that you cannot receive any blood transfusions? D. Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution. - ANSWER- D Ch 36) A nurse is caring for a client who has a terminal lung cancer. The nurse observed the client family and assisting with all activities of daily living. Which of the following rationales for self-care should the nurse communicate to the family? A. Allowing the client to function independently will strengthen muscles and promote healing B. The client needs privacy and times for self reflecting and organizing life C. The client's sense of loss can be lessened if they're retaining control of some areas of life D. Performing activities of daily living is a requirement prior to discharge from acute care facility - ANSWER- C; Allowing the client as much control as possible maintains dignity and self-esteem Ch 36) A nurses caring for a client who has a stage four lung cancer and is three days post operative following a wedge resection. The client states, "I told myself that I would go through with the surgery and quit smoking if I could just live long enough to attend my child's wedding." Based on the Kubler Ross model which stage of grief is the client experiencing? A. anger B. denial C. bargaining D. acceptance - ANSWER- C Ch 36) A nurse is about to perform postmortem care of the client. The family wishes to view the body. Which of the following actions should the nurse take? (SATA) A. Remove the dentures from the body B. Make sure the body is lying completely flat C. Supply fresh linens and place clean gown on the body D. Remove all equipment from the bedside E. Dim the lights in the room - ANSWER- C, D, E Ch 37) A nurse is performing mouth care for client who is unconscious. Which of the following actions should the nurse take? A. Turn the clients head to the side B. Place two fingers in the client's mouth to open C. Brush the client's teeth once per day D. Inject a mouth rinse into the center of the clients mouth - ANSWER- A Ch 37) A nurse is instructing a client who has diabetes mellitus about footcare. Which of the following guidelines should the nurse include? (SATA) B. I will ask the client if they want to schedule some times to pray during the day C. I will avoid discussing care when the clients family is around D. I will make sure daily communion is available for this client - ANSWER- B Ch 35) A nurse is caring for two clients who report following the same religion. Which of the following information should the nurse consider when planning care for these clients? A. Members of the same religions share similar feelings about their religion B. I Shared religious background generates mutual regard for one another C. The same religious beliefs can influence individuals differently D. The nurse and client should discuss the differences and commonalities in their beliefs - ANSWER- C Ch 34) A nurse is caring for a client who is three days post operative following a below-the-knee amputation as a result of a motor vehicle crash. Which of the following statements indicates the client has a distorted body image? A. I'll be able to function exactly as I did before the accident B. I just can't stop crying C. I am so mad at the guy who hit us I wish he lost his leg D. I don't even want to look at my leg. You can check the dressing. - ANSWER- D Ch 34) A nurse in an ambulatory care clinic is caring for a client who had a mastectomy six months ago. The client tells the nurse that there has been a decreased desire for sexual relations since the surgery, stating, "my body is so different now." Which of the following responses should the nurse make? A. Really you look just fine to me there's no need to feel undesirable B. I'm interested in finding out more about how your body feels to you C: Consider an afternoon at a spa, a facial will make you feel more attractive D. It's still too soon to expect to feel normal, give it a little more time - ANSWER- B; Showing interest in the client is applying a therapeutic communication technique of offering self. Asking more about how the client feels is applying a therapeutic communication technique of encouraging description of perception. Ch 33) The nurses caring for a client who has a new diagnosis of type II diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to treatment plan should the nurse initiate at this time? (SATA) A. Suggest coping skills for the client to use in this situation B. Allow the client to provide input in the treatment plan C. Assist the client with time management and address the client's priorities D. Provide extensive instructions on the client's treatment regimen E. Encourage the client in the expression of feelings and concerns - ANSWER- B, C, E Ch 32) A nurse is caring for a client who is concerned about being discharged home with the new colostomy because of being an avid swimmer. Which of the following statements should the nurse make? (SATA) A. You will do great you just have to get used to it! B. Why are you worried about going home? C. Your daily routines will be different when you get home. D. Tell me about the support system you'll have after you leave the hospital. E. It sounds like you're not sure how having a colostomy will affect swimming. - ANSWER- C, D, E Ch 33) A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident. The client works as a carpenter and is now experiencing situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following describes the client's role problem? A. role conflict B. role overlad C. role abiguity D. role strain - ANSWER- A; The client is experiencing role conflicts because their career is extremely physical and they can no longer perform the job duties Ch 33) Nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transfer team arrives, the nurses take the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)? A. exhaustion stage B. resistance stage C. alarm stage D. restating - ANSWER- B; Reflecting directs the focus of the conversation back to the client so that they can further explore their own feelings Ch 31) The nurse is collecting data from an older adult client as part of neurologic examination. Which of the following findings should the nurse expect as changes associated with aging? (SATA) A. Slower light touch sensation B. Some vision and hearing decline C. Slower fine finger movement D. Some short-term memory decline E. Decreased risk of depression - ANSWER- A, B, C, D Ch 31) A nurse is performing an neurologic examination for client. Which of the following assessments should the nurse perform to test the client's balance? (SATA) A. Romberg test B. Heel-to-toe walk C. Snellen test D. Spinal accessory function E. Rosenbaum test - ANSWER- A, B ch14)A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for CF care of this client? a. Supine b. semi fowlers c. semi prone d. trendelenburg - ANSWER- b Ch 31) A nurse who is assessing a client's neurologic system, should ask the client to close their eyes and identify which of the following items? A. A word the nurse whispers 30 cm from the ear B. A number the nurse traces on the palm of the hand C. The vibration of a tuning fork the nurse places on the foot D. A familiar object the nurse places in the hand - ANSWER- D ch15)A nurse educator is teaching staff members about facility protocol in the event of a tornado. Which of the following should the nurse include? Select all that apply. a. Open doors to client rooms b. place blankets over clients who are confined to beds c. move beds away from the windows d. draw shades and close drapes e. instruct ambulatory clients in the hallways to return to their rooms - ANSWER- b, c, d ch15)A nurse on a medical surgical unit is informed that a mass casualty event occurred in the community and that it is necessary to discharge stable clients to make beds available for injury victims. Which of the following clients should the nurse recommend for discharge? Select all that apply. a. A client who is dehydrated on receiving IV fluid and electrolytes b. a client who has a nasal gastric tube to treat a small bowel obstruction c. a client who is scheduled for elective surgery d. a client who has chronic hypertension and blood pressure of 135/85 e. a client who has acute appendicitis under scheduled for an appendectomy - ANSWER- c, d, ch15)an occupational health nurse is caring for an employee who is exposed to an unknown dry chemical, resulting in a chemical burn. Which of the following interventions should the nurse include in the plan of care? a. Irrigate the affected area with running water b. wash the affected area with antibacterial soap c. brush the chemical off the skin and clothing d. leave the clothing in place until emergency personnel arrive - ANSWER- c ch16)a nurse at the providers office is talking about routine screenings with a 45 year old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands hard to proceed? A. So I don't need the colon cancer procedure for another two to three years B. for now i should continue to have a mammogram each year C. because the doctor just did a papsmear I will come back next year for another one D. i had my blood glucose test next year so I won't need it for another four years - ANSWER- b ch16)a nurse at the health Department is planning strategies related to heart disease . Which of the following activities should the nurse include as part of primary prevention? a. Providing cholesterol screenings b. teaching about healthy diet c. providing information about anti hypertensive medications A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include to address common health risks for this age group? (Select all that apply.) A. Install bath rails and grab bars in bathrooms. B. Wear a helmet while skiing. C. Install a carbon monoxide detector. D. Secure firearms in a safe location. E. Remove throw rugs from the home. - ANSWER- B, C, D ch17)a nurse is evaluating how well a client learned the information presented in an instructional session following a heart healthy diet. Which of the following actions should the nurse take to evaluate the clients learning? a. Encourage the client to ask questions b. ask the client to explain how to select or prepare meals c. encourage the client to fill out an evaluation form about how the nurse presented the information d. ask whether the client has resources for further instructions on the topic - ANSWER- b ch17)a nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn? a. I don't want my spouse to see my incision b. will you give me pain medicine after the surgery c. can you tell me about how long the surgery will take d. my roommate listens to everything I say - ANSWER- c ch17) A nurse is preparing an instructional session for a client about managing stress incontinence. Which of the following actions should the nurse take first when meeting with the client? a. Encourage the client to participate actively in learning b. select instructional materials c. identify goals the nurse and the client agree or reasonable d. determine what the client knows about stress incontinence - ANSWER- d ch17)A nurse is observing a client drawing upon mixing insulin. Which of the following findings should the nurse identify as an indication that cycle motor learning has taken place? a. The client is able to discuss the appropriate technique b. the client is able to demonstrate the appropriate technique c. the client states an understanding of the process d. the client is able to write the steps on a piece of paper - ANSWER- b ch18)a nurse is assessing a two week old newborn during a routine checkup. Which of the following findings should the nurse expect? a. Sleeps 14 to 16 hours each day b. posterior fontanelle closed c. Hans remain in a closed position d. current weight is the same as birth weight - ANSWER- a Ch. 23 #4 A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following statements should the nurse identify as a priority to assess further? A. "I have my own apartment now, but it's not easy living away from my guardians." B. "It's been so stressful for me to even think about having my own family." C. "I don't even know who I am yet, and now I'm supposed to know what to do." D. "My partner is pregnant, and I don't think I have what it takes to be a good parent." - ANSWER- C When using the urgent vs. nonurgent approach to client care, determine that the counseling priority is the problem that reflects a lack of completion of the previous stage of development and progression to the current stage. According to Erikson, it is a task of adolescence to develop identity vs. role confusion. Recognize this young is still struggling with this task and needs assistance in working through that dilemma. Ch. 23 #3 A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the charge nurse include as a developmental task for a young adult? A. Becoming actively involved in providing guidance to the next generation. B. Adjusting to major changes in roles and relationships due to losses. C. Devoting time to establishing an occupation. ch18)the mother of a 7 month old infant tells the nurse at the pediatric clinic that her baby has been fussy with occasional loose stools since she started feeding him fruit and vegetables. Which of the following responses should the nurse make? Select all that apply. a. It might be good to add bananas as they can help with loose stools b. let's make a list of the foods your baby is eating so we can spot any problems c. did the changes begin after you started one particular food d. has your baby been vomiting since starting these new foods e. most babies react with a little indigestion when you start new foods - ANSWER- b, c, d ch19)A nurse is giving a presentation about accident prevention to a group of parents of toddlers. Which of the following accident prevention strategies should the nurse include? Select all that apply. a. Store toxic agents in locked cabinets b. keep toilet seats up c. turn pot handles toward the back of the stove d. place safety gates across stairways e. make sure balloons are fully inflated - ANSWER- a, c, d ch19)a nurse is planning diversionary activities for toddlers on an inpatient unit which of the following activities should the nurse include? Select all that apply. a. Building models b. working with clay c. filling and emptying containers d. playing with blocks e. looking at books - ANSWER- c, d, e ch19)A nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest? a. establish consistent boundaries for the toddler b. place the toddler in a room with the doors closed c. inform the toddler how you feel when he misbehaves d. users favorite snacks to reward the toddler - ANSWER- a ch19)a mother tells the nurse that her two year old toddler has temper tantrums and says no every time the mother tries to help them get dressed. The nurse should recognize the toddler is manifesting which of the following stages of development: a. trying to increase independence b. developing a sense of trust c. establishing a new identity d. attempting to master a skill - ANSWER- a ch19)a nurse is reviewing nutritional guidelines with the parents of a 2 year old toddler. Which of the following parent statements should indicate to the nurse that an understanding of the teaching has happened? a. i should keep feeding my son whole milk until he is 3 years old b. it is OK for me to give my son a cup of Apple juice with each meal c. I will give my son 2 tablespoons of food at mealtimes d. my son loves popcorn and I know it is better for him than sweets - ANSWER- c ch20)A nurse is talking with guardians about several issues with their preschooler. Which of the following issues should the nurse identify as a priority? a. My child mimics the way my partner and I dress b. my child has temper tantrums every time we tell him to do something they don't want to do c. I think my child believes that toys have personalities and can talk d. I feel bad when I see my child trying so hard to put in their shirt - ANSWER- b ch20)A nurse is preparing to administer medication to a preschooler. Which of the following strategies should the nurse implement to increase the child's cooperation and taking medications? Select all that apply. a. Reassure the child that the injection will not hurt b. mix oral medications in a large glass of milk c. offer the child choices where possible d. have the guardians bring a favorite toy from home e. engage the child and pretend play with a toy medical kit - ANSWER- d, e ch20)A nurse is talking with the Guardian of a four year old child who reports that the child is waking up at night with nightmares. Which of the following interventions should the nurse suggest? a. offer the child a large snack before bedtime b. allow the child to watch 30 minutes extra of television c. have the child go to bed at a consistent time each day d. increase physical activity before bedtime - ANSWER- c ch20)a nurse is planning diversionary activities for preschoolers on an inpatient pediatric unit. Which of the following activities should the nurse include? Select all that apply. a. assembling puzzles E. Screening for depressive disorders - ANSWER- A, C, D, E Ch. 23 #5 A nurse is counseling a middle adult client who describes having difficulty dealing with several issues. Which of the following client statements should the nurse identify as the priority to assess further? A. "I am struggling to accept that my parents are aging and need so much help." B. "It's been so stressful for me to think about having intimate relationships." C. "I know I should volunteer my time for a good cause, but maybe I'm just selfish." D. "I love my grandchildren, but my child expects me to relive my parenting days." - ANSWER- B When using the urgent vs. nonurgent approach to client care, the counseling priority is the problem that reflects a lack of completion of the previous stage and progression to the current stage of development. According to Erikson, developing intimacy vs. isolation is a task of young adulthood. This middle adult is still struggling with the tasks and needs assistance in working through searching for and developing intimate relationships with others. Ch. 43) While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? A. have the client hold their breath briefly and bear down B. Clamp the enema tubing C. Remind the client that cramping is common at this time D. Raise the level of the enema fluid container - ANSWER- B Rationale: Clamp the enema tubing for 30 seconds to reduce intestinal spasms Ch. 44) A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? (SATA) A. Limit total daily fluid intake B. Decrease or avoid caffeine C. Take calcium supplements D. Avoid drinking alcohol E. Use the Crede maneuver - ANSWER- B, D Rationale: Caffeine and Alcohol are bladder irritants and can worsen stress incontinence Ch. 44) A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? A. Check to see wether the catheter is patent B. Reassure the client that is is not possible for them to urinate C. Recatheterize the bladder with a larger-gauge catheter D. Collect a urine specimen for analysis - ANSWER- A Rationale: A clogged or kinked catheter causes the bladder to fill and stimulates the ned to urinate Ch. 44) A nurse is caring for a client who has a prescription for a 24 hour urine collection. Which of the following actions should the nurse take? A. Discard the first voiding B. Keep the urine in a single container at room temperature C. Dispose of the last voiding D. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container - ANSWER- A Rationale: Discard the first voiding of the 24 hour urine specimen and note the time Ch. 44) A nurse is reviewing factors that increase the risk of UTIs with a client who has recurrent UTIs. Which of the following factors should the nurse include? (SATA) A. Frequent sexual intercourse B. Lowering of testosterone levels C. Wiping from front to back to clean the perineum D. Location of the urethra closer to the anus E. Frequent catheterization - ANSWER- A, D, E Rationale: A. Having frequent sexual intercourse increases the risk of UTIs in all clients B. NOT CORRECT- decrease in estrogen levels increases UTI risk C. NOT CORRECT- wiping from front to back decreases the risk D. The close proximity of the urethra to the anus is a factor that increases the risk of UTIs E. Frequent catheterization and the use of indwelling catheters are risk factors for UTIs Ch. 44) A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (SATA) A. restrict the client intake of fluids during the daytime B. have the client record urination times C. Gradually increase the urination intervals #2 A nurse is collecting data to evaluate a middle adults psychosocial development. The nurse should expect muddle adults to demonstrate which of the following developmental tasks? (Select all that apply.) A. Develop an acceptance of diminished strength and increased dependence on others. B. Spend time focusing on improving job performance. C. Welcome opportunities to be creative and productive. D. Commit to finding friendships and companionship. E. Become involved with community issues and activities. - ANSWER- B, C, E Ch. 25 #2 A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) since the last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. "Eat three large meals a day." B. "Eat your meals in front of the television." C. "Eat foods that are easy to eat, such as finger foods." D. "Invite family members to eat meals with you." E. "Exercise every day to increase appetite." - ANSWER- C, D, E Ch. 25 #5 A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? (Select all that apply.) A. Skin thickening B. Decreased height C. Increased saliva production D. Nail thickening E. Decreased bladder capacity - ANSWER- B, D, E Ch. 25 #4 A nurse is talking with an older adult client about improving nutritional status. Which of the following interventions should the nurse recommend? (Select all that apply.) A. Increase protein intake to increase muscle mass. B. Decrease fluid intake to prevent urinary incontinence. C. Increase calcium intake to prevent osteoporosis. D. Limit sodium intake to prevent edema. E. Increase fiber intake to prevent constipation. - ANSWER- A, C, D, E Ch. 25 #3 A nurse is planning a presentation for a group of older adults about health promotion and disease prevention. Which of the following interventions should the nurse plan to recommend? (Select all that apply.) A. Human papilloma virus (HPV) immunization B. Pneumococcal immunization C. Yearly eye examination D. Periodic mental health screening E. Annual fecal occult blood test - ANSWER- B, C, D, E Ch. 25 #1 A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? A. " I spent my whole life dreaming about retirement, and now I wish I had my job back." B. "It's been so stressful for me to have to depend on my child to help around the house." C. "I just heard my friend Al died. That's the third one in 3 months." D. "I keep forgetting which medications I have taken during the day." - ANSWER- D The greatest risk to this client is injury from overdosing or underdosing medications due to loss of short-term memory. The priority issue is to assist the client to implement safe medication strategies. Assist the client to use a pill organizer to help them remember to take their medications and to keep a list of all current medications. Ch.26 #1 A nurse provides an introduction to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (Select all that apply.) A. Address the client with the appropriate title and their last name. B. Use a mix of open- and closed-ended questions. C. Reduce environmental noise. D. Have the client complete a printed history form. E. Perform the general survey before the examination. - ANSWER- B, C, E D. Allow plenty of time for the client to respond. E. Use brief sentences with simple words. - ANSWER- B. CORRECT: Make sure only one person speaks at a time because trying to understand more than one voice at a time is challenging D. CORRECT: Allowing ample time for the client to respond helps enhance communication. Rushing ahead to the next question would be demeaning and could cause frustration. E. CORRECT: Use brief sentences with simple words because these are easier for the client to understand. Ch. 27 #1 A nurse is caring for a client in the emergency department who has an oral body temperature of 38.3 C (101 F), pulse rate 114/min, and RR 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take? (Select all that apply.) A. Obtain culture specimens before initiating antimicrobials. B. Restrict the client's oral fluid intake. C. Encourage the client to rest and limit activity. D. Allow the client to shiver to dispel excess heat. E. Assist the client with oral hygiene frequently. - ANSWER- A, C, E Ch. 45) A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (Select all that apply.) A. Weber test showing lateralization to the right ear B. Light reflex at 10 o'clock in the left ear C. Indications of obstruction in the left ear canal D. Rinne test showing less time for air and bone conduction E. Rinne test showing air conduction less than bone conduction in the left ear - ANSWER- 3. A, D A. CORRECT: With sensorineural hearing loss, the Weber test demonstrates lateralization to the unaffected ear. D. CORRECT: With sensorineural hearing loss in the left ear, length of time is decreased for both air and bone conduction. Ch. 45) A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications the client currently takes should alert the nurse to a further risk for ototoxicity? (Select all that apply.) A. Furosemide B. Ibuprofen C. Cimetidine D. Simvastatin E. Amiodarone - ANSWER- A, B Rationale: A. CORRECT: Furosemide, a loop diuretic, can cause hearing loss as well as blurred vision. B. CORRECT: Ibuprofen, a nonsteroidal anti-inflammatory agent, can cause hearing loss as well as vision loss. Ch. 45) A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I use a damp cloth to clean the outside part of my hearing aids." B. "I clean the ear molds of my hearing aids with rubbing alcohol." C. "I keep the volume of my hearing aids turned dn so I can hear better." D. "I take the batteries out of my hearing aids when I take them off at night." - ANSWER- D Rationale: D. CORRECT: to conserve battery power, the client should turn off the hearing aids and removie batteries when not in use Ch. 27 #2 A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring vital signs for this client? A. "Do not measure the clients temperature rectally." B. " Count the client's radial pulse for 30 seconds and multiply by 2." C. "Do not let the client know you are counting their respirations." D. "Let the client rest for 5 minutes before you measure their blood pressure." - ANSWER- A The greatest risk to a client who has a low platelet count is an injury that results in bleeding. Using a thermometer rectally poses a risk of injury to the rectal mucosa. The low platelet count contraindicates the use of the rectal route for this client. Ch. 27 #3 A nurse is instructing a group of assistive personnel in measuring a client's RR. Which of the following guidelines should the nurse include? (Select all that apply.) A. Place the client in semi-fowlers position B. Have the client rest an arm across the abdomen. C. Observe one full respiratory cycle before counting the rate. D. Count the rate for 30 seconds if it is irregular.