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 rub Rational: 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 leg

Rational: 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 J Rational: 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 position Rational: 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 gloves Rational: 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 indurated Rational: 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 signs The client's level of consciousness The patency of intravenous (IV) lines Rational: 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 daily Rational: 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 mask Rational: 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 minute Rational: 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 moist Rational: 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 methicillinresistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure? Gloves, gown, goggles, and face shield Rational: 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 clients Applies to blood, all body fluids, secretions, and excretions Is designed to prevent the risk of spreading microorganisms Rational: 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 rugs Rational: 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 restraint Rational: 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 quickrelease 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 years Rational: 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 apnea Rational: 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? Standard Rational: 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 maneuver Rational: 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 shoulder Rational: 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 client
b. Asks the client to cover one eye c. Examiner covers eye opposite to the eye covered by the client d. Asks the client to report when object is first noted e. 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 needed Rational: 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 fibrosis b. A 54-year-old man scheduled for a routine diabetes check c. A 35-year-old registered nurse scheduled for an annual pelvic exam d. An 87-year-old woman from a nursing home scheduled for a surgical follow-up Rational: 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 hours

Rational: 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, sedativehypnotic, 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 alarm Rational: 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 spores Through a cut or abrasion in the skin Ingestion of contaminated undercooked meat Rational: 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 precordium Rational: 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 water

Rational: 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's Rational: 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 other Rational: 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 flatus Rational: 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 comfort Rational: 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 straps Rational: 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 heart First heart sound, S1 Rational: 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, lowpitched 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 fork Rational: 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 eyewear Rational: 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 needed

Rational: 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 walking Rational: 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 treatment Rational: 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 needle Rational: 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 infant Rational: 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/min Rational: Focus on the subject, a medication calculation. Use the intravenous (IV) flow rate formula.
Total volume Drop factor = gtt/min Time in minutes 2000 mL 15 gtt 30000 = 1440 minutes 1440

= 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 playroom Rational: 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? 7/28 Rational: 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 motion Rational: 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 bronchi Rational: 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 position Rational: 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-years Rational: The number of cigarettes smoked daily and the duration of the habit are used to calculate the number of packyears, 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 speculum Rational: 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 diarrhea Rational: 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 clavicle Rational: 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/hour Rational: 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 side Rational: 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 scissors Rational: 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. A Rational: 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 ascites Rational: 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/min Rational: 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 drift Rational: 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 home Rational: 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 flexed

Rational: 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 daily Rational: 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 leg Rational: 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 sternum Rational: 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.
22. A client with a perforated gastric ulcer is scheduled for

surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? Obtain a telephone consent from a family member, following agency policy. Rational: Every effort should be made to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. A telephone consent must be witnessed by two persons who hear the family member's oral consent. The two witnesses then sign the consent with the name of the family member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency, a client may be unable to sign and family members may not be available. In this situation, a health care provider is permitted legally to perform surgery without consent, but in this case it is not an emergency. Options 1 and 3 are not appropriate in this situation. Also, agency policies regarding informed consent should always be followed.
23. The nurse is working in an illness prevention clinic. An

important component of the nurse's practice is to advise highrisk clients to receive an influenza vaccination. Which clients are at high risk for influenza and would benefit from vaccination? Select all that apply. A 47-year-old mother of a child with cystic fibrosis A 54-year-old man scheduled for a routine diabetes check A 35-year-old registered nurse scheduled for an annual pelvic exam An 87-year-old woman from a nursing home scheduled for a surgical follow-up Rational: 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.
24. A filled blood specimen tube was dropped and broken in the

client's room. Which action performed by the unlicensed assistive personnel (UAP) to clean up the blood spill is incorrect? Blots up the spill with a face cloth or cloth towel Rational: The unlicensed assistive personnel should blot the spill with an absorbent disposable material, such as paper towels or terry wipes, but not with a face cloth or cloth towel. Gloves are worn for the procedure, and tongs are used to pick up any broken glass. The area is disinfected with a dilute bleach solution or an agency-approved product.
25. 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 other Rational: 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.
26. 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 mask Rational: 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.
27. The nurse is preparing to instill medication into a client's

nasogastric tube. Which actions should the nurse take before instilling the medication? Select all that apply. Check the residual volume. Aspirate the stomach contents. Turn off the suction to the nasogastric tube. Check the stomach contents for a pH of less than 3.5. Rational: By aspirating stomach contents the residual volume can be determined and the pH checked. A pH less than 3.5 verifies gastric placement. The suction should be turned off before the tubing is disconnected to check for residual volume; in addition, suction should remain off for 30 to 60 minutes following medication administration to allow for medication absorption. There is no need to remove the tube and place it in the other nostril in order to administer a feeding; in fact, this is an invasive procedure and is unnecessary.
28. A nurse is reviewing the health care provider's prescription

sheet for a preoperative client, which states that the client must be NPO after midnight. Which medication should the nurse clarify to be given and not withheld? Atenolol (Tenormin) Rational: Atenolol is a beta blocker. Beta blockers should not be stopped abruptly, and the health care provider (HCP) should be contacted about the administration of this medication before surgery. If a beta blocker is stopped abruptly, the myocardial need for oxygen is increased. Atorvastatin (Lipitor) is a cholesterol lowering medication used to treat high cholesterol. Cyclobenzaprine (Flexeril) is a skeletal muscle relaxant. Conjugated estrogen (Premarin) is an estrogen used for hormone replacement therapy in postmenopausal women. The other three medications may be withheld before surgery without undue effects on the client.

29. A client who has had abdominal surgery complains of feeling

as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions should the nurse take? Select all that apply. Contact the surgeon. Instruct the client to remain quiet. Prepare the client for wound closure. Document the findings and actions taken Rational: Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client. The nurse places the client in a low Fowler's position, and the client is kept quiet, and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken.
30. 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 rugs Rational: 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.
31. The nurse is preparing to feed a client who is at risk for

aspiration. The nurse assesses the client and uses a penlight and tongue blade to check the mouth and cheeks for pockets of food. Which action does the nurse take next? Click on the Question Video button to view a video showing preparation procedures Places the client in a semi-Fowler's position Rational: Click on the Rationale Video button. When preparing a client who is at risk for aspiration for feeding, the nurse first

performs an assessment of the client. The nurse next checks the client's mouth and cheeks for pockets of food or other substances. The nurse next elevates the head of the client's bed (hips should be bent at a 90-degree angle with the head slightly forward) because this position will assist in swallowing and preventing aspiration. The nurse then performs mouth care, adds thickening to the food, and starts feeding the client.
32. The nurse notes that a 5-year-old child is choking but is awake

and alert at this time. The nurse rushes to perform the abdominal thrust maneuver. At which landmark should the nurse place the hands between? The umbilicus and xiphoid process Rational: To perform the abdominal thrust maneuver, the rescuer stands behind the victim and places the arms directly under the victim's axillae and then around the victim. The thumb side of one fist is placed against the victim's abdomen in the midline slightly above the umbilicus and well below the tip of the xiphoid process. The xiphoid process and ribs are avoided to prevent damage to internal organs. The fist is grasped with the other hand, and upward thrusts are delivered.
33. 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.

34. 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 treatment Rational: 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.
35. A client with a diagnosis of asthma is admitted to the hospital

with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? Wheezes Rational: Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring.
36. The nurse is reviewing a health care provider's (HCP's)

prescription sheet for a preoperative client that states that the client must be NPO after midnight. The nurse would telephone the HCP to clarify that which medication should be given to the client and not withheld? Prednisone Rational: Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability

of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine (Flexeril) is a skeletal muscle relaxant. Conjugated estrogen (Premarin) is an estrogen used for hormone replacement therapy in postmenopausal women. These last three medications may be withheld before surgery without undue effects on the client.
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? Standard Rational: 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. A client has a prescription to receive purified protein derivative

(PPD), 0.1 mL, intradermally. The nurse should administer the medication by using a tuberculin syringe according to which guidelines? 26-gauge, 5/8-inch needle inserted almost parallel to the skin, with the bevel side up Rational: A tuberculin skin test is administered by giving 0.1 mL of PPD intradermally. Administration involves drawing the medication into a tuberculin syringe with a 25- to 27-gauge, 5/8inch needle. The injection is given by inserting the needle as close as possible to a parallel position with the skin and with the needle bevel facing up. This results in formation of a wheal when the PPD is administered correctly.
39. The nurse is performing a neurological assessment on a client

with a head injury. The nurse should use which technique to assess the plantar reflex? Stroking the foot from the heel to the toe Rational: The plantar reflex is assessed by stroking the outer plantar surface of the foot from the heel to the toe. The anal

reflex is assessed by stimulating the perianal area or gently inserting a gloved finger in the rectum. Pupillary response is tested using a flashlight. The pharyngeal (gag) reflex is tested by touching the back of the throat with an object such as a tongue depressor. A positive response to each of these reflexes is considered normal.
40. The nurse witnesses a neighbor's husband sustain a fall from

the roof of his house. The nurse rushes to the victim and determines the need to open the airway. The nurse opens the airway in this victim by using which method? Jaw thrust maneuver Rational: If a neck injury is suspected, the jaw thrust maneuver is used to open the airway. The head tiltchin lift maneuver produces hyperextension of the neck and could cause complications if a neck injury is present. A flexed position is an inappropriate position for opening the airway.
41. The community health nurse is conducting an education

session for community members regarding measures to prevent skin cancer and is providing instructions for use of sunscreen protection. The nurse determines that teaching was effective if a community member states that chemical sunscreens are most effective when applied at what time? One hour before exposure to the sun Rational: Sunscreens are most effective when applied about 30 minutes to 1 hour before exposure to the sun, so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating.
42. The nurse provides home care instructions to a client with

sickle cell anemia. Which statement by the client indicates a need for further instruction? "When I'm feeling better, I'm returning to the soccer team." Rational: Clients with sickle cell anemia are advised to avoid strenuous activities. Quiet activities as tolerated are recommended when the client is feeling well. Increasing fluid intake is encouraged to assist in preventing sickle cell crisis.

43. 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/hour Rational: 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.
44. A nursing student is caring for a client with a stroke (brain

attack) who is experiencing unilateral neglect. The nurse would intervene if the student plans to use which strategy to help the client adapt to this deficit? Approaching the client from the unaffected side Rational: Unilateral neglect is an unawareness of the paralyzed side of the body, which increases a client's risk for injury. The nurse's role is to refocus the client's attention to the affected side. The nurse moves personal care items and belongings to the affected side, as well as the bedside chair and commode. The nurse teaches the client to scan the environment so as to become aware of the affected half of the body. The nurse approaches the client from the affected side to increase awareness further.
45. A client is in extreme pain from scrotal swelling that is caused

by epididymitis. The nurse providing care for the client administers an opioid analgesic to relieve the pain, as prescribed. What is the next nursing action for this client? Ensure the call bell is within the client's reach. Rational: The nurse should ensure that the call bell is within reach for the client who receives an opioid analgesic. The nurse also instructs the client to call for assistance if it is necessary to get out of bed to prevent injury once the medication has taken effect. Dimming the light in the room is the next most helpful action. The name bracelet should have been checked before

administering the medication. It is unnecessary to do ROM at the site of injection.

use of a walker. Which statement by the client would indicate the need for further instruction? "The walker height should allow for about 45 degrees of flexion at my elbow so that the height of the walker will be safe." Rational: In a standing position, there should be 25 to 30 degrees of flexion at the client's elbow. A walker of incorrect height will not allow the client's line of gravity to go through his or her base of support. The other options regarding the use of a walker are correct statements.
47. A nurse has completed four cycles of compressions after

beginning cardiopulmonary resuscitation (CPR) on a hospitalized adult client. What should the nurse do next? Continue CPR. Rational: After completing four cycles of compressions and ventilations, the nurse should continue CPR unless directed by the health care provider to take a different intervention. The nurse defibrillates only with special training and when ventricular fibrillation is the documented rhythm. There are no data in the question that indicate the need for defibrillation. The nurse would prepare for the administration of bicarbonate only when it is prescribed by a health care provider. CPR is stopped only when a health care provider (HCP) terminates the code.
48. The nurse is performing a physical examination on a

hospitalized client. On abdominal assessment, the nurse listens to the bowel sounds and hears these sounds. Normal bowel sounds Rational: Normal bowel sounds are high-pitched, gurgling, cascading sounds occurring irregularly between 5 to 30 times a minute. A bruit is a pulsatile blowing sound and occurs with stenosis or occlusion of an artery. Hyperactive bowel sounds are loud, high-pitched, rushing, tinkling sounds that signal increased motility. Hypoactive bowel sounds are either diminished or absent, signal decreased motility, and occur after surgery or with inflammation of the peritoneum.

49. 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 client b. Asks the client to cover one eye c. Examiner covers eye opposite to the eye covered by the client d. The examiner brings in an object gradually from periphery e. Asks the client to report when object is first noted 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.
50. A client is being discharged to home after application of a

plaster leg cast. Which statement indicates to the nurse that the teaching has been effective? "I will avoid getting the cast wet." Rational: A plaster cast must remain dry to keep its strength. The cast should be handled using the palms of the hands, not the fingertips, until fully dry. The client should never scratch under the cast. A hair dryer set at a cool setting may be used to relieve an itch. Air should circulate freely around the cast to help it dry. Also, the cast gives off heat as it dries.
51. The home health nurse is visiting a client for the first time.

While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first? Determine whether there are medication duplications.

Rational: Polypharmacy is a concern in the older client. Duplication of medications needs to be identified before medication interactions can be determined because the nurse needs to know what the client is taking. Asking about medication administration supervision may be part of the assessment but is not a first action. The phone call to the HCP is the intervention after all other information has been collected.
52. When a client is transferred from the post-anesthesia care unit

(PACU) and arrives on the surgical unit, which should be the first action taken by the nurse? Obtain the client's vital signs. Rational: When a client arrives on the nursing unit from the PACU, the nurse receives the client and immediately checks the client's airway status. The nurse next performs an initial assessment consisting of vital signs. The results must be compared with the vital signs last obtained in the PACU. Once this has been done, the intravenous infusion is checked and a pain, respiratory, neurological, wound, urinary, and safety assessment is performed. Oxygen is not needed for every postoperative client but may be administered to those who may have a compromised respiratory status. The nurse documents the findings including the time that the client arrived from the PACU.
53. A client is in the bathroom when the nurse arrives at his room

with his scheduled medications. The client calls to the nurse, "Just leave my medication on the bedside table like the rest of the nurses, and I will take it when I get finished." What is the nurse's best action? Tell the client you will be back when he is finished. Rational: The best action is to tell the client that you will return with his medication once he is finished. It is inappropriate to leave a medication in a client's room. Another nurse should not administer a medication that he or she did not prepare. It is not within a UAP's scope of practice to administer medications.

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. The nurse has given a client with a leg cast instructions on

cast care at home. The nurse determines that the client needs further instruction if the client makes which statement? "If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting." Rational: Client instructions should include avoiding walking on wet slippery floors to prevent falls. The client should never scratch under a cast because of the risk of skin breakdown and ulcer formation. Surface soil on a cast can be removed with a damp cloth. If the cast gets wet, it can be dried with a hair dryer set to a cool setting to prevent skin breakdown. If the skin under the cast itches, cool air from a hair dryer may be used to relieve it.
56. The nurse is providing mouth care to an unconscious client.

The nurse should avoid which action during this procedure? Rinsing with a large volume of fluid Rational: The client who is unconscious is at great risk of aspiration. The nurse assesses the client for the presence of a gag reflex. The nurse turns the client's head to the side and places an emesis basin underneath the mouth. A bite stick or padded tongue blade is used to open the mouth; use of the nurse's gloved fingers is avoided to prevent injury to the nurse. Small volumes of fluid are used in rinsing the mouth, and oral suctioning is used to prevent aspiration.

57. The nurse on the day shift walks into a client's room and finds

the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. Which is the next nursing action? Start chest compressions. Rational: The next nursing action would be to start chest compressions. Chest compressions are used to keep blood moving through the body and to the vital areas, such as the brain. After 2 minutes of compressions the rescuer opens the victim's airway.
58. A nurse is testing a client for graphesthesia and asks the client

to close his eyes. The nurse should next ask the client to take which action? Identify three numbers or letters traced in the client's palm. Rational: Graphesthesia is the ability to recognize the form of written symbols. The nurse can assess for this by tracing symbols, such as numbers, in the client's palm. Option 1 tests for stereognosis, which is the ability to identify the form of common objects using the sense of touch. Options 3 and 4 test for extinction phenomenon and two-point stimulation, respectively.
59. A nurse has a prescription to administer phenytoin (Dilantin)

by intravenous push (IVP) through an IV line infusing 1000 mL of 0.9% sodium chloride. Arrange the actions in the order that they should be performed. All options much be used. a. Check the client's identification (ID) bracelet. b. Draw up the medication in a 3-mL syringe. c. Check the compatibility of phenytoin with the IV solution. d. Pinch off the IV tubing above the injection port. e. Inject the medication f. Document that the medication was administered. Rational: The nurse should first check the compatibility of the medication with the ingredients in the IV solution. The nurse then draws up the medication, checks the ID bracelet to verify client identity, pinches off the tubing above the injection port, and injects the medication at the recommended rate through the port nearest to the IV insertion site. The nurse then documents that the medication was administered.

60. 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 signs The client's level of consciousness The patency of intravenous (IV) lines Rational: 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.
61. A nurse is preparing to check the breath sounds of a client.

When auscultating for bronchovesicular breath sounds, the nurse should place the stethoscope over which area? The major bronchi Rational: Bronchovesicular breath sounds are heard over major bronchi. The upper sternum area is where major bronchi are located. Bronchial (tracheal) breath sounds are heard over the trachea and larynx. Vesicular breath sounds are heard over the peripheral lung fields.
62. The nurse assesses a client for the presence of Homans' sign.

Which could be an indication that this sign is positive? Pain with dorsiflexion of the foot Rational: To elicit Homans' sign, the nurse would dorsiflex the client's foot and assess for pain in the calf area. The presence of pain may indicate a positive Homans' sign. Wound pain and absent bowel sounds are unrelated findings. Crackles on auscultation of the lungs may indicate a respiratory complication
63. 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.
64. 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 packs Rational: 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.
65. The mother of a 2-year-old child arrives at the hospital

emergency department and reports to the nurse that the child has been complaining of a "tummy ache." The mother also reports that the child has been irritable and that it has been difficult to awaken the child. On further assessment, the nurse suspects lead poisoning. Which assessment question would elicit specific data related to this condition? "Do you live in a house that is more than 25 years old?" Rational: Homes that are older than 25 years may have lead paint and will most likely have lead pipes, which can contribute to lead poisoning. Pencil lead is made of graphite, so it does not present a hazard to the child. Crayons are not toxic. A sweet and fruity odor to the breath is a symptom of ketoacidosis. Breathing rapidly and diaphoresis are signs of salicylate poisoning.

66. The nurse would evaluate that defibrillation of a client was

most successful if which observation was made? Arousable, sinus rhythm, BP 116/72 mm Hg Rational: After defibrillation, the client requires continuous monitoring of electrocardiographic rhythm, hemodynamic status, and neurological status. Respiratory and metabolic acidosis develop during ventricular fibrillation because of lack of respiration and cardiac output. These can cause cerebral and cardiopulmonary complications. Arousable status, adequate blood pressure, and a sinus rhythm indicate successful response to defibrillation.
67. A client has been receiving a series of medications as part of

intravenous antineoplastic therapy. The nurse should implement neutropenic precautions after noting which laboratory result for this client? White blood cell (WBC) count of 2000 cells/mm 3 Rational: The normal WBC is 5000 to 10,000 cells/mm 3. When the WBC count drops, neutropenic precautions should be implemented to protect the client from infection. Bleeding precautions should be initiated when the platelet count drops; bleeding precautions include avoiding trauma such as from rectal temperatures or injections. The normal platelet count is 150,000 to 450,000 cells/mm3. The normal clotting time is 8 to 15 minutes. The normal ammonia value is 10 to 80 mcg/dL.
68. A nurse places a hospitalized client with active tuberculosis in

a private, well-ventilated isolation room. In addition, which action should the nurse take before entering the client's room? Wash hands and place a high-efficiency particulate air (HEPA) respirator mask over the nose and mouth. Rational: The nurse wears a HEPA respirator mask when caring for a client with active tuberculosis. Hands are always thoroughly washed before and after caring for the client. Options 1, 2, and 4 offer inadequate protection. Option 1, a surgical mask, will not protect against Mycobacterium tuberculosis.

69. A nurse is preparing to infuse (piggyback) a 50-mL dose of a

compatible medication through the primary intravenous (IV) line. How should the nurse correctly attach the medication bag? Hanging the medication bag higher than the primary IV bag Rational: For an intermittent IV infusion that is piggybacked to the primary IV line, the bag for the intermittent infusion is placed higher than the primary solution bag. This allows gravity to assist in infusing the medication. Once the intermittent infusion is complete, the primary IV infusion will resume at the drip rate set for the intermittent infusion. For this reason, it also is important to remember to check the infusion frequently and reset the primary IV drip rate correctly once the intermittent infusion is complete.
70. 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 infant Rational: 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.
71. The nurse is examining a dark-skinned client for the presence

of petechiae. The nurse will best observe these lesions in which body area? Oral mucosa Rational: In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa. Jaundice would best be noted in the sclerae of the eye. Cyanosis would be best noted in the palms of the hands and soles of the feet.

72. A nurse is providing preoperative teaching to a client

scheduled for a cholecystectomy. Which intervention would be of highest priority in the preoperative teaching plan? Teaching coughing and deep breathing exercises Rational: After cholecystectomy, respirations tend to be shallow because deep breathing is painful as a result of the location for the surgical procedure. Although all the options are correct, teaching coughing and deep breathing exercises is the highest priority.
73. The nurse is providing instructions to an unlicensed assistive

personnel (UAP) who is assigned to care for a client with hemiparesis of the right arm and leg. Where should the nurse instruct the UAP to place personal articles for morning care? Within the client's reach on the left side Rational: Hemiparesis is weakness of the face, arm, and leg on one side. The nurse would instruct the unlicensed assistive personnel to place objects on the unaffected side and within reach of the client. Options 2, 3, and 4 are incorrect and would not be helpful or safe for the client.
74. The nurse is developing a plan of care for a client scheduled

for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? Have the client void immediately before going into surgery. Rational: The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 6 to 8 hours before surgery instead of 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period and is usually the result of anxiety.
75. The nurse is preparing to insert a nasogastric tube (NG) into a

client. What nursing measure will best facilitate easy insertion of the tube? Asking the client to swallow as the tube is being advanced Rational: To facilitate insertion best, when the tube reaches the pharynx, the client is encouraged to lower the head slightly,

swallow and, if allowed, take sips of water. The NG tube would be iced to stiffen it, which eases insertion. If resistance is met, the tube is withdrawn and repassed. The correct option is the only one that would facilitate insertion.
76. The nurse is caring for an 18-month-old child who has been

vomiting. Which is the most appropriate position for this child while sleeping? Side-lying position Rational: The vomiting child should be placed in an upright or side-lying position to prevent aspiration. Placing the child supine or prone will place the child at risk for aspiration if vomiting occurs.
77. A nursing instructor asks a nursing student to describe the

route of transmission of tuberculosis (TB). The instructor concludes that the student understands this information if the student states that which is the route of transmission for TB? The airborne route Rational: Tuberculosis (TB) is an infectious disease caused by the bacillus Mycobacterium tuberculosis and is spread primarily by the airborne route. The remaining options are incorrect.
78. The nurse is assessing a client who had abdominal surgery

earlier in the day. Which preexisting medical condition would place the client at most risk for postoperative complications? Alcohol abuse Rational: A client with a history of alcohol abuse is at risk for liver disease, including altered metabolism and elimination of medications, impaired wound healing, and clotting and bleeding abnormalities. A client with this risk factor also would be at risk for experiencing alcohol withdrawal during the postoperative period. Clients with a pacemaker, osteoporosis, and peptic ulcer disease need to be monitored closely but are not at risk for major complications, as is the client with alcohol abuse and liver disease.

79. A nurse is preparing an intravenous (IV) set before starting

the infusion. After removing the cap from the IV tubing port on the IV bag, the nurse removes the cover from the tubing insertion spike, but then touches the spike with a finger. What should the nurse do next? Discard the IV tubing and use a new set for the infusion. Rational: The IV tubing's insertion spike must remain sterile. If it is touched during the preparation of the infusion, the tubing must be discarded and replaced with a sterile set. Otherwise the infusion set is contaminated, which could cause infection in the client. Therefore, the remaining actions are incorrect.
80. 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 shoulder Rational: 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.
81. The school nurse has conducted a class on testicular self-

examination (TSE) at the local high school. The nurse determines that the information was correctly interpreted if one of the students states that which action should be performed? Roll the testicle between the thumb and forefinger. Rational: TSE is an excellent self-screening examination for testicular cancer, which predominantly affects men in their late teens and 20s. The examination is performed once a month, as is breast self-examination. As an aid to remember to do it, the examination should be done on the same day each month. The scrotum is held in one hand, and the testicle is rolled between the thumb and forefinger of the other hand. The examination should not be painful. It is easiest to do either during or after a warm shower (or bath), when the scrotum is relaxed.

82. 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.
83. A client is receiving outpatient radiation treatments for

carcinoma of the oropharynx and is experiencing dysphagia. The nurse should include which intervention in the plan of care? Encourage the client to use artificial saliva to manage dryness. Rational: Epithelial cells are destroyed by radiation involving the head and neck. Inflammation and ulceration occur because of the rapid cell destruction and impair normal saliva excretion and distribution. Artificial saliva aids in preventing further damage by lubricating the affected area. A client with difficulty swallowing should avoid drinking thin liquids because of the increased risk of aspiration resulting from epiglottis dysfunction related to radiation therapy. Examining the oral mucosa is a preventive maintenance intervention to alert the client to changes in the mucosa, but this should be done daily, not monthly. The client with dysphagia has difficulty swallowing, not difficulty speaking; therefore teaching the client to speak slowly and enunciate clearly would provide no health benefit for the impairment in swallowing.
84. The nurse is performing cardiopulmonary resuscitation (CPR)

on an adult client. When performing chest compressions, the nurse should depress the sternum by how many inch(es)? 2 inches

Rational: When performing CPR on an adult client, the sternum is depressed 2 inches. The depth for the adult and the child is 2 inches whereas for the infant it is 1 inches.
85. The home health nurse is watching the caregiver change the

sternotomy dressing on the postoperative client. Which action by the caregiver identifies correct principles of infection control? The caregiver washes hands before removal of the soiled dressing and again before applying the clean dressing. Rational: The single most effective technique to prevent the spread of germs and bacteria is hand washing. The initial step with all aseptic procedures is hand washing. Using previously opened gauze, not washing hands after sneezing, and not applying new gloves after removing the old dressing increase the risk of wound contamination as a result of poor aseptic technique.
86. 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 flatus Rational: 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.
87. The nurse is assisting to defibrillate a client in ventricular

fibrillation. After placing the paddles on the client's chest and before discharging them, which intervention should be done? Confirm that the rhythm is actually ventricular fibrillation. Rational: Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless

ventricular tachycardia. Leads also are checked for any loose connections. A nitroglycerin patch, if present, is removed. The client does not have to be intubated to be defibrillated. The machine is not set to the synchronous mode because there is no underlying rhythm with which to synchronize. Amiodarone may be given subsequently but is not required before defibrillation.
88. The nurse is performing rescue breathing on a 7-year-old

child. The nurse delivers one breath per how many seconds to the child? 6-8 Rational: In a child between the ages of 1 and 8 years, one breath every 6-8 seconds is delivered.
89. A nursing student is asked about the procedure used to elicit

Homans' sign. Which response by the student indicates an understanding of this assessment technique? "I will ask the client to extend her legs flat on the bed, and I will gently dorsiflex her foot forward." Rational: To elicit Homans' sign, the nurse asks the client to extend her legs flat on the bed. The nurse then grasps the foot and dorsiflexes it forward. If this causes any discomfort or resistance, the nurse should notify the health care provider that Homans' sign may be present. Options 1, 2, and 4 are incorrect descriptions of this assessment technique.
90. The nurse is monitoring a wound in a dark-skinned client for

signs of erythema. How should the nurse best determine the presence of erythema? Palpate for increased skin temperature around the wound edges. Rational: Erythema is a form of macula characterized by diffuse redness of the skin. In a dark-skinned client, erythema is best determined by palpating for increased skin temperature. Redness around the wound edges may be difficult to note in the darkskinned client. Swelling and drainage from the wound are not specific indicators of erythema.

91. A postoperative client asks the nurse why it is so important to

deep-breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to which condition? Pneumonia Rational: Postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Hypoxemia is an inadequate concentration of oxygen in arterial blood. Fluid imbalance can be a deficit or excess related to fluid loss or overload. Pulmonary embolus occurs as a result of a blockage of the pulmonary artery that disrupts blood flow to one or more lobes of the lung; this is usually due to clot formation.
92. A client has a prescription for continuous monitoring of oxygen

saturation by pulse oximetry for a preoperative client. The nurse should perform which best action to ensure accurate readings on the oximeter? Ask the client to limit motion in the hand attached to the pulse oximeter. Rational: Several factors can interfere with the reading of accurate oxygen saturation levels on a pulse oximeter. To ensure accurate readings, the nurse should ask the client to limit motion of the area attached to the sensor. The nurse should apply the device to a warm area because hypotension, hypothermia, and vasoconstriction interfere with blood flow to the area. The nurse needs to know that very dark nail polish (black, brown-red, blue, green) interferes with accurate measurement. The nurse also should avoid placing the sensor distal to any invasive arterial or venous catheters, pressure dressings, or blood pressure cuffs.
93. 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 moist Rational: 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.
94. The nurse is preparing to initiate an intravenous line

containing a high dose of potassium chloride and plans to use an intravenous infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action? Contact the electrical maintenance department for assistance. Rational: Electrical equipment must be maintained in good working order and should be grounded; otherwise it presents a physical hazard. An intravenous line that contains a dose of potassium chloride should be administered by an infusion pump. The nurse needs to use hospital resources for assistance. A regular extension cord should not be used because it poses a risk for fire. Use of electrical appliances near a sink also presents a hazard.
95. The nurse is inserting a nasogastric tube in an adult client.

During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate nursing action? Pull back on the tube and wait until the respiratory distress subsides. Rational: During the insertion of a nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. It is not necessary to notify the health care provider immediately or remove the tube completely. Quickly inserting the tube is not an appropriate action because, in this situation, it may be likely that the tube has entered the bronchus.

96. A nurse notes that the site of a client's peripheral intravenous

(IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse should document in the medical record that which occurred? Phlebitis of the vein Rational: Phlebitis at an IV site can be distinguished by client discomfort at the site, as well as redness, warmth, and swelling proximal to the catheter. The IV line should be discontinued, and a new line should be inserted at a different site. The remaining options are incorrect occurrences.
97. A client with active tuberculosis demonstrates less-than-

expected interest in learning about the prescribed medication therapy. The nurse assesses that this client may ultimately need which intervention as a last resort? Directly observed therapy Rational: Tuberculosis is a highly communicable disease that is reportable to the local public health department. This agency has regulations that may be enforced to ensure compliance with tuberculosis therapy. Ultimately the client may be required to have directly observed therapy to reduce the risk to the public. This involves having a responsible person actually observe the client taking the medication each day.
98. The nurse is planning to instruct a client with chronic vertigo

about safety measures to prevent exacerbation of symptoms or injury. Which instruction should the nurse plan to include in the client's teaching plan? Remove throw rugs and clutter in the home. Rational: The client with chronic vertigo should maintain the home without throw rugs and in a state that is free of clutter because the effort of trying to regain balance after slipping could trigger the onset of vertigo. To further prevent vertigo attacks, the client should change positions slowly and should turn the entire body, not just the head, when spoken to. If vertigo does occur, the client should immediately sit down or grasp the nearest piece of furniture. The client should avoid driving and using public transportation. The sudden movements involved in each could precipitate an attack.

99. To perform cardiopulmonary resuscitation (CPR), the nurse

should use this method to open the airway in which situation? Refer to figure. If neck trauma is suspected Rational: The jaw thrust without the head tilt maneuver is used when head or neck trauma is suspected. This maneuver opens the airway while maintaining proper head and neck alignment, reducing the risk of further damage to the neck. Options 2, 3, and 4 are incorrect. In addition, it is unlikely that the nurse would be able to obtain data about the client's history.
100. A registered nurse (RN) asks a licensed practical nurse (LPN)

to set up a hospital room for a client who is being admitted with a diagnosis of tonic-clonic seizures and asks the LPN to institute seizure precautions. The RN checks the client's room before the arrival of the client and determines that which item placed in the room by the LPN is unsafe? Restraints Rational: Seizure precautions include keeping side rails up and padded if the client has tonic-clonic seizures, ensuring that suction and oxygen equipment is available, and disabling the locks on the bathroom and room doors. Restraints are not used and can result in client injury.