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.