MED-SURG ATI part A

MED-SURG ATI part A 1. A nurse is reinforcing discharge teaching about wound care with a family member of a client who is postoperative. Which of the following should the nurse include in the teaching? a) Administer an ...

MED-SURG ATI part A 1. A nurse is reinforcing discharge teaching about wound care with a family member of a client who is postoperative. Which of the following should the nurse include in the teaching? a) Administer an analgesic following wound care. (The nurse should remind the family member to administer an analgesic prior to wound care to prevent discomfort.) b) Irrigate the wound with povidone iodine. (The nurse should remind the family member to irrigate the wound with 0.9% sodium chloride.) c) Cleanse the wound with a cotton-tipped applicator. (The nurse should remind the family member to avoid using a cotton-tipped applicator to cleanse the wound because the fibers can become embedded in the wound, cause infection, and delay wound healing.) d) Report purulent drainage to the provider. (The nurse should remind the family member to report signs of infection, including purulent drainage.) 2. A nurse is caring for a client who has bacterial meningitis. Upon monitoring the client, which of the following findings should the nurse expect? a) Flaccid neck (The nurse should recognize that nuchal rigidity, rather than a flaccid neck, is a manifestation of meningitis.) b) Stooped posture with shuffling gait (The nurse should recognize that a stooped posture with shuffling gait is a manifestation of Parkinson's disease, not a manifestation of meningitis.) c) Red macular rash (The nurse should expect to find a red macular rash, sometimes called a petechial rash, which is a manifestation of meningococcal meningitis.) d) Masklike facial expression (The nurse should recognize that a masklike expression is a manifestation of Parkinson's disease, not a manifestation of meningitis.) 3. A nurse is contributing to the plan of care for an older adult client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss? a) Increase fluid intake. (Fluid intake is beneficial for general health and wellness, and it helps to treat some disorders. Caffeine and alcohol intake can increase the client's risk of developing osteoporosis. However, fluid intake does not prevent bone loss.) b) Encourage range-of-motion exercises. (Range-of-motion exercises are beneficial for general health and wellness, and they help to maintain flexibility and prevent contractures. However, range-of-motion exercises do not prevent bone loss.) c) Massage bony prominences. (Massaging bony prominences should be avoided because it can traumatize deep tissues.) d) Encourage weight-bearing exercises. (Weight-bearing exercises, such as walking, can maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis.) 4. A nurse is collecting data from a client and notices several skin lesion. Which of the following findings should the nurse report as possible melanoma? a) Scaly patches (The nurse should report scaly patches as possible basal or squamous cell carcinoma. b) Silvery white plaques (The nurse should report silvery white plaques as possible psoriasis.) c) Irregular borders (The nurse should report irregular borders of a skin lesion to the provider because it can indicate malignant melanoma.) d) Raised edges (The nurse should report raised edges of a skin lesion as possible basal cell carcinoma.) 5. A nurse is reinforcing discharge teaching to prevent dumping syndrome for a client following a partial gastrectomy for ulcers. Which of the following information should the nurse include in the teaching? a) Avoid liquids at mealtimes. (The nurse should remind the client to avoid drinking liquids at mealtimes to prevent the food from emptying into the small bowel too quickly.) b) Exclude eating starchy vegetables. (The nurse should remind the client to include starchy vegetables in the meal plan to slow gastric emptying.) c) Avoid eating high-protein meals. (The nurse should remind the client to eat high-protein meals to help slow gastric emptying.) d) Plan to increase intake of sweetened fruits. (The nurse should remind the client to exclude sweetened fruits from the diet to help slow gastric emptying.) 6. A nurse is collecting data on a client who is scheduled for a cardiac catheterization. Which of the following laboratory levels should the nurse review prior to the procedure? a) Albumin (Albumin levels determine the amount of protein the liver produces in the body and is an indication of hepatic function and nutritional status. However, it is not impacted by contrast media used for cardiac catheterization. Therefore, the nurse does not need to review this laboratory level prior to a cardiac catheterization.) b) Phosphorus (Phosphorus is an electrolyte that combines with calcium to maintain bone health and is involved as an energy source in metabolism. However, it is not impacted by contrast media used for cardiac catheterization. Therefore, the nurse does not need to review this laboratory level prior to a cardiac catheterization.) c) TSH (TSH levels determine thyroid function. However, it is not impacted by contrast media used for cardiac catheterization. Therefore, the nurse does not need to review this laboratory level prior to a cardiac catheterization.) d) BUN (BUN levels indicate kidney function. Contrast media used during cardiac catheterization can cause renal failure. The nurse should review this laboratory level to determine if the client can tolerate the IV contrast dye during the procedure.) 7. A nurse is reinforcing glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching? a) "The HbA1c test should be performed 2 hr after I eat a meal that is high in carbohydrates." (The nurse should remind the client that carbohydrate consumption is not required for HbA1c testing.) b) "The HbA1c test can help detect the presence of ketones in my body." (The nurse should remind the client that urine testing can detect ketone bodies.) c) "I will have my HbA1c checked twice per year." (An HbA1c test provides the client's average glucose level for the preceding 3 months. The nurse should instruct the client to have her HbA1c tested twice yearly to manage her glucose.) d) "I will plan to fast before I have my HbA1c tested." (The nurse should remind the client that fasting is not required for HbA1C testing.) 8. A nurse is examining a client’s IV site and notes a red line up his arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client’s manifestations indicate which of the following complications of IV therapy? a) Thrombophlebitis (The nurse should identify pain, warmth, and a red streak up the arm as indications of thrombophlebitis.) b) Infiltration (The nurse should identify swelling and cool skin at the IV site as indications of infiltration.) c) Hematoma (The nurse should identify swelling and bruising as indications of a hematoma that can develop by not holding enough pressure after discontinuing the IV.) d) Venous spasms (The nurse should identify cramping at or above the insertion site and numbness as indications of venous spasms.) 9. A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. Which of the following should the nurse include in the teaching? a) Increase intake of fiber-rich foods. (The nurse should instruct the client to increase the amount of fiber-rich foods in his diet. Dried beans and brown rice are examples of fiber-rich foods.) b) Take a laxative every morning. (The nurse should instruct the client to initially take a laxative in the evening to stimulate the evacuation of stool. However, the nurse should instruct the client to use laxatives sparingly.) c) Maintain a fluid intake of 1200 mL per day. (The nurse should instruct the client to increase his fluid intake to 2,000 mL per day to maintain soft stools.) d) Limit activity to preserve energy. (The nurse should instruct the client to increase activity to stimulate the evacuation of stool.) 10. A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following actions should the nurse take? a) Position pillows between the bony prominences. (The nurse should use positioning devices to keep bony prominences from being in direct contact with each other, which will prevent skin breakdown and pressure ulcer development.) b) Check for incontinence every 3 hr. (The nurse should check the client for incontinence at least every 2 hr to prevent skin breakdown.) c) Massage reddened areas of the skin. (The nurse should avoid massaging reddened areas of the skin, which can lead to the formation of a pressure ulcer by damaging underlying tissue.) d) Elevate the head of the bed to 45°. (The nurse should avoid elevating the head of the bed to an angle greater than 30°. An angle greater than 30° can cause shearing of the skin, which leads to tissue injury and pressure ulcer development.) 11. A nurse is contributing to the plan of care for a client who has peripheral arterial disease (PAD) of the lower extremities. Which of the following interventions should the nurse include? a) Place moist heat pads on the extremities. (The nurse should avoid applying heat to the client's extremities to prevent injury due to decreased sensation.) b) Perform manual massage of the affected extremities. (The nurse should avoid massaging the client's lower extremities if the client is having pain from ischemia. A warm environment and keeping the client warm will help with circulation to the extremities and decrease pain through vasodilation.) c) Dangle the extremities off the side of the bed. (The nurse should include in the plan of care to have the client dangle the lower extremities off the side of the bed to aid in reducing pain by increasing arterial blood flow. The client should not raise the lower extremities above the level of the heart when resting in bed because it impairs arterial blood flow.) d) Apply support stockings before getting out of bed. (The nurse should avoid applying support stockings to the lower extremities because support stockings interfere with the arterial blood flow to the lower extremities.) 12. A nurse is caring for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use? a) Gown (The nurse should wear a gown when caring for a client who requires contact precautions.) b) Mask (The nurse should identify that a client who has Meningococcal pneumonia requires droplet precautions, which include wearing a mask when providing care within 3 feet of the client.) c) Sterile gloves (The performance of sterile dressing changes or tracheostomy care requires the nurse to wear sterile gloves. However, clean gloves are used to provide medical aseptic care.) d) Protective eyewear A nurse should wear protective eyewear when there is a risk for splashing, such as during the irrigation of a wound.) 13. A nurse is assisting with the care of a client who has a cardiac catheterization via the right femoral artery. Which of the following actions should the nurse take to prevent postprocedure complications (Select all that apply?) a) Should wait at least 2 hours after eating before going to bed." (The client should wait to lie down or go to bed at least 2 hr after eating to minimize reflux.) b) "I should eat three meals a day without eating snacks between meals." (The client should eat four to six small meals per day rather than three large meals to minimize bloating and abdominal distention.) c) "I should season my food with garlic." (The client should avoid spicy foods, including garlic, to minimize reflux.) d) "I should drink my liquids through a straw." (The client should avoid drinking through a straw, which can promote belching and reflux.) 14. A nurse is caring for a client who is postoperative and has an epidural infusion. Which of the following findings should the nurse recognize as the priority? a) Pruritus (The nurse should identify pruritus as an adverse effect of an epidural infusion. However, another finding is the priority.) b) Nausea (The nurse should identify nausea as an adverse effect of an epidural infusion. However, another finding is the priority.) c) Urinary retention (The nurse should identify urinary retention as an adverse effect of an epidural infusion. However, another finding is the priority. d) Dyspnea (When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is dyspnea, which is a complication of the epidural infusion.) 15. A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with a client. Which of the understanding of the teaching? a) I should wait at least 2 hours after eating before going to bed." (The client should wait to lie down or go to bed at least 2 hr after eating to minimize reflux.) b) "I should eat three meals a day without eating snacks between meals." (The client should eat four to six small meals per day rather than three large meals to minimize bloating and abdominal distention.) c) "I should season my food with garlic." (The client should avoid spicy foods, including garlic, to minimize reflux.) d) "I should drink my liquids through a straw." (The client should avoid drinking through a straw, which can promote belching and reflux.) 16. A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the following information should the nurse include in the teaching? a) This type of insulin should be given at the same time every day." (Insulin glargine is released in the body over a 24 hr period. The nurse should instruct the client to administer the insulin at the same time each day to maintain consistent serum levels for optimal therapeutic effect.) b) "This insulin can be mixed with short-acting insulin in a single syringe." (The nurse should remind the client that insulin glargine should not be mixed with any other insulin.) c) "This type of insulin can be used in a pump." (The nurse should inform the client insulin glargine is a long-acting insulin that is administered once daily at the same time and is not to be administered intravenously.) d) "This insulin has an increased risk for hypoglycemia." (The nurse should inform the client that insulin glargine has a low risk for hypoglycemia because serum levels of the insulin do not peak and remain consistent over time.) 17. A nurse is preparingto administer phytonadione 7 mg subcutaneously to a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) Ratio and Proportion Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 7 mg Step 3: What is the dose available? Dose available = Have 10 mg Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 1 mL Step 6: Set up an equation and solve for X. Have/Quantity = Desired/X 10 mg/1 mL = 7 mg/X mL X = 0.7 Step 7: Round if necessary. Step 8: Reassess to determine whether the amount to administer makes sense. If there are 10 mg/mL and the provider prescribed 7 mg, it makes sense to administer 0.7 mL. The nurse should administer phytonadione 0.7 mL subcutaneously. Desired Over Have Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the dose the nurse should administer? Dose to administer = Desired 7 mg Step 3: What is the dose available? Dose available = Have 10 mg Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 1 mL Step 6: Set up an equation and solve for X. Desired x Quantity/Have = X 7 mg x 1 mL/10 mg = X mL 0.7 = X Step 7: Round if necessary. Step 8: Reassess to determine whether the amount to administer makes sense. If there are 10 mg/mL and the provider prescribed 7 mg, it makes sense to administer 0.7 mL. The nurse should administer phytonadione 0.7 mL subcutaneously. Dimensional Analysis Step 1: What is the unit of measurement the nurse should calculate? mL Step 2: What is the quantity of the dose available? 1 mL Step 3: What is the dose available? Dose available = Have 10 mg Step 4: What is the dose the nurse should administer? Dose to administer = Desired 7 mg Step 5: Should the nurse convert the units of measurement? No Step 6: Set up an equation and solve for X. X = Quantity/Have x Conversion (Have)/Conversion (Desired) x Desired/ X mL = 1 mL/10 mg x 7 mg/ X = 0.7 Step 7: Round if necessary. Step 8: Reassess to determine whether the amount to administer makes sense. If there are 10 mg/mL and the provider prescribed 7 mg, it makes sense to administer 0.7 mL. The nurse should administer phytonadione 0.7 mL subcutaneously. 18. A nurse is reinforcing teaching with an adolescent client regarding testicular self-examination. Which of the following statements by the client demonstrates an understanding of the teaching? a) “I will perform the exam before I shower.” (Clients should perform a testicular self-examination after a warm shower.) b) “I will check my testicles every 6 months.” (Clients should perform a testicular self-examination monthly.) c) "I understand that testicular cancer is painless." (Clients should report a lump that is not painful because testicular cancer is typically painless.) d) "I understand that pea-sized lumps are normal." (Clients should report pea-sized lumps in the testes to a provider.) 19. A nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as the priority? a) Determine the client's understanding of the procedure. (Using the nursing process, the first action the nurse should take is to collect data from the client. Therefore, the nurse should determine the client's understanding of the procedure to provide necessary teaching, which can help manage his anxiety.) b) Encourage the client to express his feelings. (Encouraging the client to express his feelings can reduce anxiety. However, this is not the first action the nurse should take.) c) Allow the client's family to stay with him. (Allowing the client's family to stay with him can reduce anxiety. However, this is not the first action the nurse should take.) d) Provide music as a distraction. (Providing music as a distraction can reduce anxiety. However, this is not the first action the nurse should take.) 20. A nurse is reinforcing teaching about home care with a client who had a knee arthroplasty. Which of the following factors should the nurse identify as an indication that a barrier to learning might be present? a) The client asks questions each time the nurse stops talking. (The nurse should identify that asking questions indicates active listening by the client and enhances learning.) b) The client stops the nurse and asks for pain medication. (The nurse should identify that a client who is in pain will not be able to concentrate, which can interfere with his ability to learn.) c) While the nurse is speaking, the client refers to the written materials. (The nurse should identify that clients learn in different ways. Using multiple methods of teaching, including hands-on practice and providing written materials, enhances learning.) d) A family member who is present asks the client to repeat important points. (The nurse should identify that family member who are actively engaged in the teaching session and ask questions can enhance learning.) 21. A nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. Which of the following statements should the nurse make? a) You may cross your legs in 60 days." (The nurse should instruct the client to wait 90 days before crossing her legs. Crossing her legs early in the postoperative period can result in dislocation of the replacement hip.) b) "Avoid lying on your operative side." (The nurse should inform the client that she may lie on her operative side with a pillow between her legs. This will not injure the suture site or cause dislocation of the replacement hip.) c) "Avoid bending your hips more than 90 degrees." (The nurse should instruct the client to avoid bending her hips more than 90° to prevent dislocation of the replacement hip.) d) "You may sleep on a soft mattress." (The nurse should instruct the client to sleep on a firm mattress to avoid potential dislocation of the replacement hip.) 22. A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take? a) Perform pin site care daily. (The nurse should perform pin site care daily with chlorhexidine solution or use a solution according to facility protocol. The nurse should also monitor the pin sites for manifestations of infection.) b) Remove the overbed trapeze.(The nurse should ensure the client has an overbed trapeze to aid in lifting the upper body off the bed when necessary and to help prevent skin breakdown of the heels and elbows with client repositioning.) c) Remove the boot every 2 hr. (The nurse should identify that balanced suspension skeletal traction is managed through the use of pins, pulleys, weights, and frames and that the client does not wear a boot.) d) Keep the weights on a stable, flat surface. (The nurse should ensure the weights hang freely at all times.) 23. A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include? a) Restrict the time pregnant women are allowed in the client's room to 15 min. (Pregnant women and children should not be allowed to visit a client who is receiving internal radiation therapy because of the risk for exposure to radiation emissions.) b) Pick up a radiation implant with a double-gloved hand if it becomes dislodged. (The nurse should use forceps to pick up a radiation implant if it becomes dislodged. c) Limit time spent in the client's room to 2 hr during an 8 hr shift. (The nurse should limit time spent in the client's room to 30 min during an 8 hr shift.) d) Dispose of radiation implants in a lead container. (Lead impairs the emission of radiation. Therefore, the nurse should dispose of radiation implants in a lead container in accordance with facility protocol.) 24. A nurse in a long-term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. Which of the following findingsshould indicates to the nurse that the client might have a fecal impaction? a) Halitosis (Halitosis, or bad breath, is associated with the ingestion of certain foods and medications, and it can also be an indication of infection.) b) Hemorrhoids (Hemorrhoids indicate that the client is straining when defecating. However, the presence of hemorrhoids does not indicate fecal impaction.) c) Rebound tenderness (Rebound tenderness is an indication of appendicitis. A client who has a fecal impaction can experience abdominal cramping and distention.) d) Small liquid stools (Small liquid stools can be the result of fecal material being expelled around an impaction.) 25. A nurse is providing discharge teaching for the family of a client who has Parkinson’s disease. Which of the following information should the nurse include in the teaching? a) Place the client on a low-calorie diet to prevent weight gain. (The nurse should instruct the client's family to provide the client with extra calories and protein to prevent unintentional weight loss from expenditure of energy due to tremors, dyskinesia, and difficulty swallowing.) b) Remind the client to avoid watching her feet when walking. (The nurse should instruct the client's family to frequently remind the client to maintain correct posture and prevent falls by not watching her feet when walking.) c) Use small area rugs in the client's home for traction. (The nurse should instruct the client's family to avoid using area rugs in the client's home because her foot may drag or be stiff and catch on an area rug, which can cause a fall.) d) Instruct the client to take tub baths instead of showers. (The nurse should instruct the family to encourage the client to take walk-in, sit-down showers, because skeletal muscle rigidity can cause difficulty in moving, coordination, and balance, which increases the risk of a fall.) 26. A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that client is adhering to the nurse’s instructions? a) "I apply rubbing alcohol to my feet every day to prevent infection." (Rubbing alcohol has a drying effect on skin and can increase cracking, allowing an entry point for infection. The client should apply lotions that do not contain alcohol.) b) "I will wear clean, knee-high wool socks every day to help improve my circulation." (Wool socks can result in perspiration, which puts the client at risk for developing a fungal infection. The client should use light-weight socks to promote arterial blood flow.) c) "I use hot water bottles to keep my feet warm at night." (Clients who have peripheral vascular disease have decreased sensation of the affected extremities. Therefore, they are unable to detect the temperature of the water bottle, which increases the risk for burns.) d) "I don't cross my legs anymore." (Clients who have peripheral vascular disease should not cross their legs because it can impede circulation 27. A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure? a) Sodium 136 mEq/L (Sodium 136 mEq/L is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider before the client has a CT scan with an IV contrast agent.) b) Potassium 4.8 mEq/L (Potassium 4.8 mEq/L is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider before the client has a CT scan with an IV contrast agent.) c) Creatinine 1.9 mg/dL (Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse should report the finding to the provider before the client has a CT scan with an IV contrast agent. This finding places the client at risk for developing contrast-induced nephropathy.) d) Calcium 10 mg/dL (Calcium 10 mg/dL is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider before the client has a CT scan with an IV contrast agent.) 28. A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infections in a surgical wound. Which of the following information should the nurse plan to share with visitors? a) Visitors should call prior to visiting the client. (Visitors do not need to make arrangements prior to visiting a client who is on contact isolation precautions, but visitors should receive assistance before entering the client's room.) b) Visitors must don a gown and gloves prior to entering the client's room. (The nurse should provide teaching to the visitors regarding the infection control measures for a client who is on contact isolation precautions. Contact precautions require visitors to put on a gown and gloves prior to entering the room of a client who has MRSA to prevent the spread of infection.) c) Visitors need to wear a mask when in close proximity to the client. (The nurse should identify that visitors of clients who are on airborne or droplet precautions should wear a mask when within 3 feet of the client. However, MRSA is not spread through the respiratory tract and does not require airborne or droplet precautions.) d) Visitors may not bring fresh flowers into the client's room. (The nurse should identify that fresh flowers are contraindicated for a client who is on neutropenic precautions. However, they are not contraindicated for a client who has MRSA.) 29. A nurse is reinforcing teaching about dietary changes with a client who has cardiovascular disease. Which of the following images indicates the type of cooking fat the nurse should recommend the client use when preparing meals? a) Butter is high in saturated fat, which contributes to the development of cardiovascular disease. It should be used sparingly or avoided. b) Coconut oil is high in saturated fat, which contributes to the development of cardiovascular disease. It should be used sparingly or avoided. c) The nurse should instruct the client who has cardiovascular disease to consume foods which contain primarily monounsaturated and polyunsaturated fats, such as olive oil or other vegetable oils, rather than foods that are high in saturated fat. The nurse should reinforce that oils high in monounsaturated fats help decrease the client's cardiovascular risk by lowering LDL cholesterol and triglyceride levels. d) Shortening is high in saturated fat, which contributes to the development of cardiovascular disease. It should be used sparingly or avoided. 30. A nurse is reinforcing teaching with a client who has heart failure and a new prescription for hydrochlorothiazide. Which of the following findings should the nurse instruct the client to report to the provider? a) Onset of nausea (The nurse should instruct the client to report a new onset of nausea, which can be an indication of hyponatremia or hypokalemia resulting from the diuretic effects of the hydrochlorothiazide. b) Increased urinary output (The nurse should remind the client that an increase in urinary output is a desired effect of hydrochlorothiazide.) c) Weight loss of 0.9 kg (2 lb) per week (The nurse should remind the client to report weight gain of 0.9 kg (2 lb) or more per week to the provider.) d) Missed dose of the medication (The nurse should instruct the client to take a missed dose of the medication as soon as the client remembers. However, the client should not take a double-dose of the medication.) 31. A nurse is preparing to suction a client who has a tracheostomy. Which of the following actions should the nurse take first? a) Insert the suction catheter into the tracheostomy. (The nurse should insert the catheter tip into the tracheostomy during inspiration until it meets resistance, then pull back 2.5 cm (1 in). However, evidence-based practice indicates that there is another action the nurse should take first.) b) Rinse the catheter with sterile 0.9% sodium chloride. (The nurse should rinse or flush the catheter with 0.9% sodium chloride to clear the catheter of secretions before repeating the suctioning procedure. However, evidence-based practice indicates that there is another action the nurse should take first.) c) Ventilate with 100% oxygen. (According to evidence-based practice, the nurse should ventilate the client with 100% oxygen before suctioning to prevent hypoxemia when removing air and debris from the upper airway.) d) Occlude the vent on the catheter for 10 seconds. (The nurse should occlude the vent on the catheter for 10 to 15 seconds while removing the catheter during suctioning. However, evidence-based practice indicates that there is another action the nurse should take first.) 32. A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how to improve the taste of bland food. Which of the following should the nurse recommend? a) Ketchup (The nurse should not recommend ketchup to the client because it is high in sodium.) b) Mayonnaise (The nurse should not recommend mayonnaise to the client because it is high in sodium.) c) Soy sauce (The nurse should not recommend soy sauce to the client because it is high in sodium.) d) Lemon juice (The nurse should recommend that the client use lemon juice to flavor his food because it is low in sodium.) 33. A nurse is reviewing the medical record of a client who has a prescription for morphine. Which of the following findings should the nurse reports to the provider? a) Urinary retention (The nurse should recognize that administering morphine to the client can cause urinary retention. Therefore, the nurse should report this finding to the provider.) b) Administration of celecoxib 24 hr ago (Celecoxib is not a contraindication to morphine administration.) c) History of immunosuppression (A history of immunosuppression is not a contraindication to morphine administration.) d) Administration of levothyroxine 12 hr ago (Levothyroxine is not a contraindication to morphine administration.) 34. A nurse is caring for a client who is 13 days postoperative following a total right hip arthroplasty. Which of the following actions should the nurse take? a) Use a traction boot to keep the client's right leg internally rotated. (The nurse should not apply any type of traction boot or allow the client's leg to rotate internally or externally because it can cause a dislocation of the affected hip.) b) Have the client sit in a reclining chair when out of bed. (The nurse should provide a chair that does not allow the client to recline because a reclining chair increases the risk of the client flexing at the hips beyond 90° when moving to a standing position.) c) Maintain abduction of the client's right leg while in bed. (The nurse should maintain abduction of the client's right leg to prevent dislocation of the affected hip by placing an abductor pillow between the client's legs when resting in bed.) d) Encourage the client to perform passive range-of-motion exercises. (The nurse should encourage the client to stand at the bedside on the day of surgery and, if prescribed by the provider, to walk using a walker. Passive range-of-motion exercises require flexion and extension of the joints and are not recommended 3 days following surgery.) 35. A nurse is monitoring a client who is taking acarbose. Which of the following findings should the nurse identify as an adverse effect of the medication? a) Polyuria (Polyuria is an adverse effect of furosemide.) b) Abdominal cramps (Acarbose affects the gastrointestinal system. Therefore, the nurse should monitor the client for abdominal cramping, rumbling bowel sounds, and diarrhea as adverse effects of this medication.) c) Renal insufficiency (Long-term and high-dose use of acarbose can cause liver dysfunction, not renal insufficiency.) d) Insomnia (Insomnia is an adverse effect of methylphenidate.) 36. A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is receiving epoetin alfa. The nurse should identify that which of the following laboratory values indicates the treatment is effective? a) BUN 40 mg/dL (Clients who have chronic kidney failure will demonstrate elevated BUN levels, but this does not measure the effectiveness of epoetin alfa.) b) Hgb 11 g/Dl (Epoetin alfa stimulates the production of erythropoietin and red blood cells, resulting in increased hemoglobin levels. Therefore, a hemoglobin level of 11 g/dL indicates the epoetin alfa treatment is effective.) c) Urine specific gravity 1.035 (Clients who have chronic kidney failure will demonstrate concentrated urine and elevated specific gravity, but this does not measure the effectiveness of epoetin alfa.) d) Blood glucose 105 mg/dL (Epoetin alfa does not affect blood glucose levels.) 37. A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client? a) Rephrase client instructions when not understood. (When communicating with a client who has hearing loss, the nurse should rephrase, rather than repeat, discharge instructions when they are not understood.) b) Cup hands around the mouth and direct speech toward the client. (When communicating with a client who has hearing loss, the nurse should keep hands away from the mouth to promote lip reading.) c) Accentuate vowel sounds by using a higher pitch when speaking. (When communicating with a client who has hearing loss, the nurse should speak in a lower tone of voice and use a lower pitch. Higher pitched sounds can impede hearing by accentuating vowel sounds and concealing consonants.) d) Sit to the side of the client and speak instructions into her best ear. (When communicating with a client who has hearing loss, the nurse should sit or stand facing the client on the same level so that the nurse's mouth and lips can be seen for lip reading.) 38. A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate which of the following complications? a) Wound infection (Manifestations of a wound infection include fever, inflammation of the incision, and foul-smelling drainage. Hypotension, tachycardia, and tachypnea do not indicate a wound infection in a client who is 1 day postoperative.) b) Pulmonary embolism (Manifestations of a pulmonary embolism include hypotension, tachycardia, and tachypnea.) c) Thrombophlebitis (Thrombophlebitis is the inflammation of a blood vessel, which can lead to a thrombus formation. Hypotension, tachycardia, and tachypnea do not indicate thrombophlebitis.) d) Paralytic ileus (Paralytic ileus is the absence of bowel peristalsis, or movement. Hypotension, tachycardia, and tachypnea do not indicate a paralytic ileus.) 39. A nurse is monitoring a client who recently had a cast placed on the right lower extremity for a bone fracture. Which of the following findings should the nurse recognize as abnormal? a) Report of a dull, throbbing pain (Dull, throbbing pain is an expected finding for a client who has a bone fracture. b) Extremities that are cool bilaterally) (Cool, bilateral extremities are an indication of the client's overall body temperature and general circulatory status and are an expected finding.) c) Capillary refill of 3 seconds in the nail beds of the toes (A capillary refill of 3 seconds in the nail beds of the toes is slowed but still within the expected reference range after application of a cast.) d) Lack of sensation between the first and second toes (Lack of sensation between the toes indicates peripheral nerve impairment and is an abnormal finding that can indicate the client has compartment syndrome. The nurse should notify the provider immediately.) 40. A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client? a) Intrauterine device (The nurse should identify that the use of an intrauterine device requires the client to check the placement monthly and is not contraindicated for this client.) b) Latex condom (The nurse should identify that the use of latex condoms is contraindicated for clients, or their partners, who are allergic to latex. However, it is not contraindicated for this client.) c) Combination oral contraceptives (The nurse should identify that combination oral contraceptives are contraindicated for this client because they increase estrogen levels, which can stimulate the growth of any remaining cancerous breast cells.) d) Contraceptive sponge (The nurse should identify that prolonged use of a contraceptive sponge can increase the risk for toxic shock syndrome. However, it is not contraindicated for this client.) 41. A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcome from the medication should the nurse expect? a) Increased weight (The nurse should expect the client's weight to decrease because of the increased excretion of fluid that is caused by improved cardiac output.) b) Increased heart rate (The nurse should expect the client's heart rate to decrease because digoxin decreases the client's sympathetic nerve tone, which slows the heart rate.) c) Decreased urinary output (The nurse should expect the client to have an increase in urinary output because digoxin improves cardiac output and increases the client's renal blood flow through the kidneys, which results in an increased excretion of urine.) d) Decreased shortness of breath (The nurse should expect the client to have decreased shortness of breath. Digoxin increases the contractility of the heart, which decreases pulmonary congestion.) 42. A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. Which of the following statements should the nurse include in the teaching? a) "Take the medication on an empty stomach." (The client should take glucocorticoids with food to prevent gastrointestinal upset and bleeding.) b) "Limit contact with large groups of people." (Glucocorticoids cause immunosuppression and may mask infection. The client should limit contact with sources of possible infections, such as large groups of people.) c) "Avoid taking over-the-counter calcium supplements." (Clients who take glucocorticoids are at risk for osteoporosis, so they should take additional vitamin D and calcium supplements.) d) "Follow a low-protein diet." (It is not necessary for a client who has SLE and is taking a glucocorticoid to restrict protein intake.) 43. A nurse is caring for a client who is 24 hr. postoperative following abdominal surgery and has an NG tube. Which of the following actions should the nurse plan to take to decrease the risk of postoperative complications? a) Offer sips of water to the client following oral care. (The nurse should provide frequent oral care and the use of moistened oral swabs to alleviate dry mucous membranes. However, oral fluids are contraindicated for a client who had abdominal surgery and has an NG tube.) b) Massage the client's lower extremities with lotion every 2 hr. (The nurse should monitor the client's lower extremities for tenderness, warmth, or redness. However, massaging the client's lower extremities is contraindicated because, if there is a blood clot formation in the a lower extremity, it can loosen the clot and cause a pulmonary embolism. c) Encourage the client to use an incentive spirometer every hour while awake. (The nurse should assist the client to use the incentive spirometer in addition to coughing and deep breathing every hour while awake for the first 24 hr postoperatively and at least every 2 hr while awake thereafter. An incentive spirometer will inflate the client's alveoli and improve ventilation to prevent postoperative pneumonia.) d) Place one or two pillows beneath the client's knees while he is in bed. (The nurse should elevate the foot of the bed slightly and apply prescribed compression stockings or sequential compression devices to promote venous return. However, pillows beneath the client's knees can create pressure and decrease venous return in the lower extremities, which can lead to thrombosis.) 44. A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? a) Consume a low-purine diet. (The nurse should recommend a low-purine diet for a client who has gout and a prescription for colchicine.) b) Avoid stopping this medication suddenly. (The nurse should instruct the client to avoid stopping baclofen suddenly because it can result in adverse reactions, including seizures, paranoia, and hallucinations.) c) Use chamomile tea to alleviate insomnia. (The nurse should instruct the client to avoid chamomile because it can interact with baclofen to increase CNS depression.) d) Take this medication on an empty stomach. (The nurse should instruct the client to take baclofen with milk or food to minimize gastric upset.) 45. A nurse reviewing the laboratory results of a client who has type 2 diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing? a) HbA1c 6% (This laboratory value indicates glycemic control and does not indicate that the client is at risk for delayed wound healing. The nurse should identify that elevated HbA1c levels can increase the risk for delayed wound healing.) b) Prealbumin 12 mg/dL (This laboratory value is below the expected reference range, indicating that the client's protein status is inadequate and that he is at risk for delayed wound healing due to malnutrition.) c) WBC 8,000/mm3 (This laboratory value is within the expected reference range and indicates immune function. The nurse should identify that an elevated WBC count increases the risk for delayed wound healing.) d) Creatinine 0.8 mg/dL (This laboratory value is within the expected reference range and indicates adequate kidney function. The nurse should identify that the client who is diabetic is at increased risk for the development of renal failure, which can increase the risk for infection and delayed wound healing.) 46. A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan? a) Expect decreased sensation for the first postoperative week. (The nurse should instruct the client to report decreased sensation in the affected foot or leg because this can indicate neurovascular compromise.) b) Avoid lying on the operative side. (The nurse should instruct the client that lying on the operative side is allowed but the client should place pillows between the legs to prevent dislocation of the hip.) c) Obtain a raised toilet seat. (The nurse should instruct the client to use a raised toilet seat to avoid flexing the hip more than 90°, which increases the risk for dislocation.) d) Cross legs at the ankles. (The nurse should instruct the client to avoid crossing her legs to prevent dislocation of the hip.) 47. A nurse is preparing to move a client’s NG tube. Which of the following interventions should the nurse take to decrease the risk of aspiration? a) Instill 10 mL of air through the NG tube. (The nurse should instill 50 mL of air through the NG tube to remove mucus and gastric secretions from the tube and to prevent aspiration of these secretions.) b) Place the client in the supine position. (The nurse should place the client in a sitting position to prevent the risk of aspiration.) c) Irrigate the NG tube. (The nurse should identify that irrigating the NG tube before removal can put the client at risk for aspiration and should be avoided.) d) Pinch the NG tube. (The nurse should pinch the NG tube to prevent secretions from draining into the client's throat, which can cause aspiration.) 48. A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. Which of the following findings should the nurse expect related to hyperkalemia? a) Polyuria (Polyuria is a manifestation of hypokalemia.) b) Constipation (Constipation is a manifestation of hypokalemia.) c) Anorexia (Anorexia is a manifestation of hypokalemia.) d) Bradycardia (The client who has hyperkalemia can have an irregular, slow heart rate, known as bradycardia.) 49. A nurse is reinforcing teaching with a client who has asthma. Which of the following client statements indicate an understanding of the use of budesonide and albuterol inhalers? (Select all that apply.) a) "I should expect to feel sleepy after using my albuterol inhaler" (The client should recognize that albuterol stimulates the sympathetic nervous system, which can cause nervousness and insomnia, along with increased heart rate and blood pressure.) b) "I never forget to rinse my mouth after using my budesonide inhaler. (The client should rinse his mouth after using a budesonide inhaler to reduce the risk for oral fungal infection.) c) "Between office visits, I keep a record of how many times I use my albuterol inhaler" (The client should record the number of times that he uses his albuterol inhaler. This information can assist the provider to determine the effectiveness of the medication.) d) "I use my albuterol inhaler before I go swimming" (The client should use the albuterol inhaler before exercise to prevent exercise-induced bronchospasms.) e) "I should use my budesonide inhaler before using my albuterol inhaler" (The client should first use the albuterol inhaler, a bronchodilator, to open the airway and enhance the absorption of the budesonide, which is an inhaled corticosteroid.) 50. A nurse is caring for a client and administers penicillin IM. the client begins exhibiting hives and has severe difficulty breathing. After establishing a patent airway, which of the following actions should the nurse take next? a) Administer epinephrine. (The greatest risk to the client is death from anaphylaxis. Therefore, the nurse should administer epinephrine to reduce bronchospasms and laryngeal edema.) b) Monitor the client's vital signs. (The nurse should monitor the client's vital signs during the crisis to detect a decrease in blood pressure and an increase in respiratory effort. However, there is another action the nurse should take first.) c) Monitor the client's oxygen saturation level. (The nurse should monitor the client's oxygen saturation level to ensure respiratory support. However, there is another action the nurse should take first.) d) Administer an antihistamine. (The nurse should administer an antihistamine to treat the hives and reduce the histamine release. However, there is another action the nurse should take first.) 51. A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process? a) "I should call my doctor if I get a headache." (Headaches are not a complication of mitral valve disease.) b) "I may develop gastric reflux." (Mitral valve disease does not cause gastric reflux.) c) "I may develop excessive bruising." (A provider may prescribe anticoagulants to prevent thrombus formation on the valve, which can cause excessive bruising for a client who has mitral valve disease. However, excessive bruising is not a direct result of the disease.) d) "I should call my doctor if my ankles swell." (Swelling of the ankles can indicate heart failure. The client should report this finding to the provider.) 52. A nurse is monitoring an older adult client who has a history of an enlarged prostate and is experiencing suprapubic discomfort. Which of the following actions should the nurse take first? a) Administer doxazosin. (The nurse may need to administer doxazosin to relax the smooth muscle of the bladder to increase urine flow. However, the nurse should use a less restrictive intervention first.) b) Palpate the abdomen. (When providing client care, the nurse should first use the least restrictive intervention. Therefore, the nurse should palpate the abdomen to determine if the client has a distended bladder from urinary retention.) c) Insert an indwelling urinary catheter. (The nurse may need to insert an indwelling urinary catheter for a distended bladder. However, the nurse should use a less restrictive intervention first.) d) Notify the primary care provider. (The nurse may need to notify the primary care provider if the client has a distended bladder. However, the nurse should use a less restrictive intervention first.) 53. A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary disease (COPD) and is dyspneic. Which of the following interventions should the nurse include in the plan? a) Encourage abdominal breathing. (The nurse should encourage abdominal breathing, which reduces the workload on the accessory muscles of respiration during dyspneic episodes.) b) Direct the client to inhale with pursed lips. (The nurse should direct the client to exhale using pursed-lip breathing during dyspneic episodes to maintain positive airway pressure.) c) Set the oxygen therapy at 5 L/min. (The nurse should set the oxygen therapy between 1 to 3 L/min to prevent the client's urge to breathe from decreasing during dyspneic episodes. d) Instruct the client to lean back when coughing. (The nurse should instruct the client to lean forward and repeatedly "huff" followed by relaxed breathing to clear secretions during dyspneic episodes.) 54. A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first? a) Collect a sputum culture. (The nurse should collect a sputum culture to identify the organism causing the client's infection. Antimicrobial sensitivities are obtained from the sputum culture to guide the provider in prescribing antibiotics. However, there is another prescription the nurse should implement first.) b) Administer ceftriaxone by intermittent IV bolus. (The nurse should administer antibiotics to treat the infection. A broad spectrum antibiotic, such as ceftriaxone, is administered when sepsis is suspected because it treats both gram-positive and -negative bacteria. After the results of the blood and sputum cultures are obtained, the provider will often change to a more specific antibiotic. However, there is another prescription the nurse should implement first.) c) Initiate oxygen at 4 L/min via nasal cannula. (When using the airway, breathing, circulation approach to client care, the first action the nurse should take is to initiate oxygen. Clients who have manifestations of sepsis are often hypoxic, tachypneic, or have a PaCO2 level less than 32 mm Hg. The nurse should provide supplemental oxygen to keep the client's oxygen saturation levels at 95% or greater, which will maximize the ability of the hemoglobin to support the oxygen needs of the body.) d) Obtain blood cultures. (The nurse should obtain blood cultures to identify the organism causing the client's infection. Antimicrobial sensitivities obtained from the blood cultures will guide the provider in prescribing treatment. However, there is another prescription the nurse should implement first.) 55. A nurse is caring for a client who has terminal pancreatic cancer. The client states, “I don’t think i can go on any longer.” Which of the following responses should the nurse make? a) "Can I get you something for the pain?" (The nurse should monitor the client's pain level and provide analgesics as needed. However, this response changes the subject, does not acknowledge the client's feelings, and is a barrier to a continued trusting relationship.) b) "You should talk about this with your family." (This response is an example of giving common advice and is dismissive of the client's feelings, which are barriers to a trusting relationship and open communication.) c) "Tomorrow will be a better day." (This response is an example of false reassurance and is dismissive of the client's feelings, provides false hope, and does not promote open communication.) d) "Tell me more about the way you are feeling." (The nurse is establishing a trusting relationship by seeking clarification and encouraging the client to verbalize feelings.) 56. A nurse is collecting data from a 55-year old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT? a) Five-year history of menopause manifestations (The nurse should identify that manifestations of menopause can last for 10 years or more and HRT is not contraindicated for a client whose menopause manifestations began 5 years ago.) b) History of treatment for blood clots (Estrogen increases the risk of blood clots. Therefore, a woman who has a history of blood clots should not receive HRT.) c) Topiramate use for migraine headaches (The nurse should identify that the use of topiramate to treat migraine headaches can cause decreased absorption of estrogen when used as a contraceptive. However, topiramate is not a contraindication to HRT.) d) Increased serum cholesterol levels (The nurse should identify that one of the benefits of HRT is a decrease in LDL and an increase in HDL levels. Therefore, HRT is not contraindicated for a client who has increased serum cholesterol levels.) 57. A nurse in an oncology clinic is reinforcing teaching is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which for the following information should the nurse include in the teaching? a) Mohs surgery is a horizontal shaving of thin layers of the tumor. (Mohs surgery is performed to treat basal and squamous cell carcinoma. The procedure, which involves a horizontal shaving of thin layers of a tumor, has a high treatment rate.) b) Mohs surgery uses liquid nitrogen to destroy the cancerous tissue. (Cryosurgery, rather than Mohs surgery, uses liquid nitrogen to destroy cancerous tissue.) c) Mohs surgery is the preferred treatment for melanoma skin cancer. (Mohs surgery is the preferred treatment for basal and squamous cell carcinoma. The preferred treatment for melanoma is a wide, full thickness surgical excision.) d) Mohs surgery is a palliative treatment for metastatic skin cancer. (Radiation, rather than Mohs surgery, can be used as a palliative treatment for metastatic skin cancer.) 58. A nurse i performing ECG on a client who is scheduled for surgery the following morning. In which of the following locations should the nurse place the V1 electrode? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer) a) A is incorrect. The nurse should identify that the Right Arm (RA) electrode should be positioned just below the right clavicle. b) B is incorrect. The nurse should identify that the Left Arm (LA) electrode should be positioned just below the left clavicle. c) C is correct. The nurse should identify that the V1 electrode should be placed in the 4th intercostal space just to the right of the sternum. Correct placement of the electrodes is vital in obtaining accurate information about the electrical activity of the heart. d) D is incorrect. The nurse should identify that the V2 electrode should be placed in the 4th intercostal space just to the left of the sternum. 59. A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority? a) Muscle weakness (The nurse should address muscle weakness to prevent injury for a client who has hypokalemia. However, another finding is the priority.) b) Dysrhythmia (When using the airway, breathing, circulation approach to client care, the nurse should identify that the priority finding for a client who has hypokalemia is dysrhythmia.) c) Abdominal pain (The nurse should address abdominal pain to promote comfort for a client who has hypokalemia. However, another finding is the priority.) d) Lethargy (The nurse should address lethargy for a client who has hypokalemia to prevent injury. However, another finding is the priority.) 60. A nurse is caring for an older adult client who has reddened area over the sacrum. Which of the following actions should the nurse take? a) Minimize the time the head of the bed is elevated. (The nurse should minimize the time the head of the bed is elevated to reduce pressure on the sacral area.) b) Apply a sterile gauze dressing to the site. (The nurse should collect further data before determining what type of dressing is needed. For a stage I pressure injury, skin preparation can be applied to preserve the integrity of the skin and prevent further direct injury. Alternatively, a dressing such as a hydrocolloid or transparent dressing can be applied. However, gauze dressings are not used in the treatment of a stage I pressure injury.) c) Massage the site with moisturizing lotion. (The nurse should not massage nor apply moisturizing lotion to a reddened area because it can cause further skin injury.) d) Place a donut-shaped cushion under the client's sacral area. (The nurse should not place a donut-type device under the client's sacral area because it can contribute to the development of a pressure injury.) 61. A nurse is caring for a client who is in Buck’s traction. Which of the following interventions should the nurse perform to reduce skin breakdown? a) Keep the skin dry and free of perspiration. (The nurse should not leave moisture on the skin for prolonged periods of time because it can cause skin breakdown.) b) Use hot water and antibacterial soap to bathe the client. (The nurse should bathe the client in tepid water and use mild soap to prevent skin breakdown.) c) Massage the skin over bony prominences to promote circulation. (The nurse should not massage bony prominences because it can cause skin damage.) d) Limit the use of moisturizers on the skin over bony prominences. (The nurse should moisturize skin that is intact to help prevent cracks and breaks in the skin.) 62. A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infections and is on contract isolation precaustions. Which of the following actions should the nurse take? a) Keep the door of the client's room closed at all times. ()The nurse should keep the door of a client's room closed at all times if the client requires airborne precautions. b) Remove gloves after leaving the client's room. (The nurse should remove gloves before leaving the client's room.) c) Wear a mask when working within 1 m (3 feet) of the client. (The nurse should wear a mask when working within 1 m (3 feet) of a client who requires droplet precautions.) d) Have a designated stethoscope in the client's room. (The nurse should designate equipment to leave in the client's room to avoid cross-contamination. The designated equipment should be disposed of or decontaminated before leaving the client's room.) 63. A nurse is caring for a client who has a prescription for phenazopyridine. Which of the following findings should the nurse identify as a therapeutic effect of the medication? a) Reduces bacteria in the urinary tract (Bacteria in the urinary tract is reduced with the use of an antimicrobial medication, such as fosfomycin.) b) Suppresses urge to void (The urge to void is suppressed with the use of an antispasmodic for urinary incontinence, such as oxybutynin.) c) Prevents nerve stimulation to the bladder muscle (Nerve stimulation to the bladder muscle is prevented with the use of an antispasmodic, such as hyoscyamine.) d) Decreases pain during urination (Phenazopyridine reduces pain and burning during urination by exerting an anesthetic effect on the mucosa of the urinary tract.) 64. A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include? a) "You can take acetaminophen for pain." (The nurse should instruct the client to avoid taking any over-the-counter medications, including acetaminophen, which is toxic to the liver.) b) "Consume a diet high in animal protein." (The nurse should instruct the client to increase vegetable proteins and reduce animal proteins in the diet to limit the development of encephalopathy.) c) "Sleep lying flat on your back." (The nurse should instruct the client to elevate the head of the bed while sleeping to prevent shortness of breath from the pressure of ascites or hydrothorax.) d) "Consume foods low in sodium." (The nurse should instruct the client to consume foods low in sodium to reduce the development of edema and ascites.) 65. A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care? a) Apply a mask on the client if transport is needed. (The nurse should apply a mask to the client who has manifestations of pertussis during transport to prevent exposure to others.) b) Wear a mask when working within 4 feet of the client. (The nurse should wear a surgical mask when working within 1 m (3 feet) of the client who has manifestations of pertussis.) c) Don a gown when visiting with the client. (The nurse should wear a gown when providing direct care to a client if there is potential for soiling clothes during contact. However, it is not required for the care of the client who requires droplet precautions; unwarranted use of the gown increases costs.) d) Wear an N95 mask when entering the client's room. (The nurse should wear an N95 mask when caring for a client who has been placed on airborne precautions, such a client who has tuberculosis.) 66. A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities should the nurse recommend to promote sleep? a) Get out of bed if unable to fall asleep within 60 min. (The client should get out of bed after 30 min if unable to fall asleep.) b) Take a brisk walk before sleeping. (The client should avoid stimulating activities, such as exercise, before bedtime.) c) Listen to soft music before sleeping. (Listening to soft music can help the client to relax and reduces environmental stressors.) d) Drink adequate amounts of fluids before sleeping. (The client should reduce fluids 2 to 4 hr before sleep. Drinking fluids before bedtime can cause the client to wake up during the night to use the bathroom.) 67. A nurse is caring for a client who has an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration? a) Allow for 30 min of rest before meals. (The nurse should allow the client to rest for 30 min before meals to prevent aspiration.) b) Provide a straw for drinking liquids. (The nurse should provide a cup for drinking liquids, rather than a straw.) c) Serve foods at room temperature. 9The nurse should serve foods that are cold or heated. It is more difficult for the client to swallow food that is lukewarm or at room temperature.) d) Place 2 tsp of food in the client's mouth at a time. (The nurse should place only 1 tsp of food in the client's mouth at a time.) 68. A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. Which of the following actions should the nurse perform first? a) Count the client's respiratory rate. (The nurse should take the client's vital signs, which includes counting the client's respiratory rate. However, evidence-based practice indicates that the nurse should take a different action first.) b) Ask the client if chest pain is present. (The nurse should inquire about the presence of chest pain and other manifestations to determine the severity of the reaction. However, evidence-based practice indicates that the nurse should take a different action first.) c) Stop the infusion. (Evidence-based practice indicates the nurse should stop the infusion of the blood product as soon as manifestations occur because they can indicate a transfusion reaction.) d) Administer an antihistamine. (The nurse should administer antihistamines when allergic transfusion manifestations are present. However, evidence-based practice indicates that the nurse should take a different action first.) 69. A nurse is reinforcing teaching with the family of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching? a) Clean the pin sites every 72 hr. (The nurse should instruct the family to clean the pin sites every day to decrease the risk for infection.) b) Use the halo ring to reposition the client when in bed. (The nurse should instruct the family to never lift or reposition the client by pulling on the halo ring, which can cause further cervical injury.) c) Change the sheepskin liner weekly. (The nurse should provide instruction regarding the care and maintenance of the vest. The instruction should include changing the sheepskin liner when soiled, or at least once per week, to prevent skin irritation.) d) Tighten the traction bar as needed. (The nurse should instruct the family to call a provider if the pins or traction bar is loose. The pin sites or traction bar supports should not be manipulated in any way because it could cause injury to the client.) 70. A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening in the left upper quadrant, the nurse should identify this sound as which of the following? (Click on the audio button to listen to the clip.) a) Hyperactive bowel sounds (A mechanical bowel obstruction prevents a portion or all of the bowel contents from moving forward through the bowel. The nurse should expect to auscultate high-pitched, hyperactive bowel sounds above the point of the intestinal obstruction as the intestines attempt to propel the blockage forward. b) Friction rub (The nurse should expect to auscultate a pericardial friction rub, a high-pitched scratchy sound over the heart, for a client who has pericarditis.) c) Normal bowel sounds (When auscultating normal bowel sounds, the nurse should expect to hear 5 to 35 gurgles and clicks in 1 min.) d) Abdominal bruit (When auscultating an abdominal bruit, the nurse should expect to hear a whooshing sound that indicates impaired blood flow through an artery.) 71. A nurse is reinforcing teaching with a client a client who has gonorrhea. Which for the following information should the nurse include? a) "Your partner will not require treatment for this infection." (The nurse should inform the client that sexual partners will require treatment to prevent the risk of reoccurrence of the infection.) b) "You can resume sexual activity as soon as you begin treatment." (The nurse should instruct the client to abstain from sexual contact until treatment is completed and cultures are negative.) c) "You are at risk for infertility with this infection, regardless of treatment." (The nurse should inform the client that there is a risk for infertility as a result of this infection.) d) "You will not be at further risk for this infection following treatment." (The nurse should inform the client that immunity does not occur with this infection and that reoccurrence is possible.) 72. A nurse is assisting in the plan of care regarding bowel retraining for a client who has cervical spinal cord injury. Which of the following interventions should the nurse plan to implement first? a) Determine the client's daily elimination habits. (The first action the nurse should take using the nursing process is to collect data on the client's daily bowel elimination habits to establish a routine defecation time.) b) Administer a suppository to the client 30 min prior to defecation time. (The nurse should administer a suppository to the client 30 min prior to defecation time to stimulate bowel elimination. However, there is another action the nurse should take first.) c) Offer the client 4 oz of warm prune juice to promote elimination. (The nurse should offer the client warm prune juice to stimulate peristalsis to promote elimination. However, there is another action the nurse should take first.) d) Provide dietary bulk to the client to ease the passage of stool. (The nurse should provide dietary bulk to the client to ease the passage of stool and stimulate bowel elimination. However, there is another action the nurse should take first.) 73. A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr. ago. Which of the following interventions should the nurse identify as the priority? a) Encourage the client to participate in self-care. (The nurse should encourage the client to complete self-care to the extent that he is able. Self-care promotes mobility of the joints and increases the client's feelings of independence and self-esteem. However, there is another intervention that is the priority.) b) Assist the client with active range-of-motion exercises. (The nurse should assist the client with active range-of-motion exercises and should provide passive range-of-motion exercises to the client's affected side to maintain joint mobility and improve muscle strength. However, there is another intervention that is the priority.) c) Keep the client in a side-lying position. (The greatest risk to the client following a stroke is aspiration. The nurse should position the client in a lateral, or side-lying position, which will allow any secretions to drain out of the mouth, decreasing the risk for aspiration. Additionally, the nurse should have suction available in the event that any secretions are present in the oral cavity.) d) Maintain the client's body alignment. (The nurse should keep the client's body in alignment to maintain joint function and prevent skin breakdown caused by pressure on bony prominences. However, there is another intervention that is the priority.) 74. A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication? a) Elevated sodium (The nurse should report a decreased sodium level to the provider before administering the medication because furosemide can cause hyponatremia.) b) Elevated blood pressure (The nurse should expect the client who has heart failure to have an elevated blood pressure and does not need to report this finding to the provider before administering the medication. Furosemide is a diuretic that should help to lower the client's blood pressure.) c) Decreased potassium (The nurse should notify the provider immediately of a decreased potassium level because potassium is lost when a diuretic such as furosemide is administered, which can cause hypokalemia.) d) Decreased urine output (The nurse should expect the client who has heart failure to have a decreased urine output and does not need to report this finding to the provider before administering the medication. Furosemide is a diuretic, which should cause an increase in urine output for a client who has heart failure.) 75. A nurse observes a client who is lying in bed experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? a) Lower the side rails of the client's bed. (The nurse should leave the bed rails up to prevent the client from falling out of bed, which can cause injury. b) Apply wrist restraints to the client. (The nurse should not apply restraints that can place the client at risk for a fracture injury c) Position the client in the semi-Fowler's position. (The nurse should place the client in a lateral position to allow for the drainage of oral secretions and to maintain an open airway.) d) Loosen clothing around the client's neck. (The nurse should loosen clothing around the client's neck to maintain an open airway and prevent aspiration.) 76. A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching? a) Apply cold packs to the inflamed joints. (The nurse should instruct the client to use both warm and cold packs on inflamed joints to decrease pain.) b) Participate in high-impact exercise. (The nurse should instruct the client to participate in low-impact aerobic exercises, which will not inflame the client's joints.) c) Carry a hand purse rather than a shoulder bag. (The nurse should instruct the client to carry a shoulder bag, which places the stress on larger muscles.) d) Sleep on a soft foam mattress. (The nurse should instruct the client to sleep on a firm mattress to support the joints.) 77. A nurse is participating in a health fair for older adult clients. Which for the following immunizations should the nurse recommend for this age group? a) Meningococcal (The nurse should recommend the meningococcal immunization to college students and military recruits living in shared housing.) b) Herpes zoster (The nurse should recommend the herpes zoster immunization for adults 60 years of age and older.) c) Human papillomavirus (HPV) (The nurse should recommend the HPV immunization for clients who are 9 to 26 years old.) d) Measles, mumps, and rubella (MMR) (The nurse should recommend the MMR immunization to clients who were born after 1956.) 78. A nurse is caring for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration? a) Provide small, frequent meals. (Providing small, frequent meals can improve the client's nutritional intake, but it does not decrease the risk for aspiration.) b) Tell the client to extend his neck when swallowing. (The client should tilt his neck forward while swallowing to decrease the risk for aspiration.) c) Provide mouth care before meals. (Mouth care can enhance the client's sense of taste, but it does not decrease the risk for aspiration.) d) Give the client liquids with increased viscosity. (Thickened liquids are easier for the client to swallow and can prevent aspiration.) 79. A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan? a) Use a commercial mouthwash before taking the medication. (The client should avoid commercial mouthwashes while the mouth infection is present because using mouthwash can increase pain and does not contribute to treatment of the infection.) b) Instruct the client to swish the medication in her mouth. (The nurse should instruct the client to place half the dose in each side of her mouth, swish the medication, and then swallow. This action will allow the medication to coat the entire oral mucosa and treat the fungal infection.) c) Discontinue the medication as soon as the lesions are healed. (The client should continue nystatin for two days after the lesions have healed.) d) Combine the medication with applesauce. (The client should not mix nystatin with food because it will alter the absorption of the medication and prevent adequate coating of the oral lesions.) 80. A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate? a) Blurred vision (The nurse should identify that blurred vision is a manifestation of hyperthyroidism.) b) Insomnia (The nurse should identify that insomnia is a manifestation of hyperthyroidism that is caused by an increase in the client's metabolic rate.) c) Bradycardia (The nurse should identify that bradycardia is a manifestation of hypothyroidism that is caused by a decrease in the client's metabolic rate.) d) Weight loss (The nurse should identify that weight loss is a manifestation of hyperthyroidism caused by an increase in the client's metabolic rate.) 81. A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include? a) "You should have a screening for glaucoma every 5 years." (The nurse should remind the client to have a screening for glaucoma every 2 to 3 years along with an annual visual accuity exam. ) b) "You should have a physical examination every other year." (The nurse should remind the client to have a physical examination every year.) c) "You should have your hearing checked every 2 years." (The nurse should remind the client to have her hearing checked every year.) d) "You should have a pneumococcal immunization every 10 years." (The nurse should remind the client to have a pneumococcal immunization at age 65 and every 10 years thereafter to protect her from acquiring pneumonia.) 82. A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion. The client reports pain and swelling at the IV site. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in order of performance. Use all the steps.) Notify the charge nurse Check the IV site Stop the infusion. Stop the infusion. Elevate the affected arm. Withdraw the IV catheter. Withdraw the IV catheter. Elevate the affected arm. Check the IV site. Notify the charge nurse The first action the nurse should take using the nursing process is to check the IV site for infiltration. If infiltration is found, the next step is to stop the infusion to prevent vein and tissue damage. Once the infusion is stopped, the nurse should remove the IV catheter. Then, the nurse should elevate the affected extremity to decrease swelling and notify the charge nurse. 83. A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care? a) Store the CPM machine on the floor when it is not in use. (The nurse should avoid placing the CPM machine on the floor, as this exposes it to potential contamination, which can increase the client's risk for infection.) b) Keep a sheepskin pad between the client's extremity and the CPM. (The nurse should plan to keep a sheepskin pad between the client's extremity and the CPM machine to protect the client's skin. The nurse should check the client's skin condition frequently while the client is using the CPM.) c) Check the cycle and range-of-motion settings at least every 12 hr. (The nurse should plan to check the settings of the CPM machine at least every 8 hr.) d) Align the frame joint of the CPM with the middle of the client's calf. (The nurse should plan to align the frame joint of the CPM with the client's knee joint to provide appropriate flexion and extension.) 84. A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of which of the following? a) Cirrhosis of the liver (A client who has cirrhosis of the liver can have a manifestation of bluish varicose veins that radiate from the umbilicus, which can indicate portal hypertension. However, cirrhosis of the liver does not cause ecchymosis around the umbilicus.) b) Hypermotility of the bowel (A client who has hypermotility of the bowel can exhibit diarrhea as a manifestation, not ecchymosis around the umbilicus.) c) Intra-abdominal bleeding (Ecchymosis around the umbilicus is a sign of intra-abdominal bleeding, which is a finding consistent with pancreatitis.) d) Acute cholecystitis (A client who has acute cholecystitis has an inflammation of the gallbladder that can indicate gallstones, but acute cholecystitis does not cause ecchymosis around the umbilicus.) 85. A nurse is caring for a client who is receiving chemotherapy. The client mentions that she has a loss of appetite because she has sores in her mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make? a) Drink water before and after each bite. (The nurse should suggest that the client add gravy, broth, or sauces to foods to increase the moisture content of the food. Drinking water before and after each bite can lead to early satiety, which might cause the client to consume less food.) b) Consume foods that are served hot rather than cold. (Cold foods are usually tolerated better by a client who is receiving chemotherapy because they emit less odor.) c) Rinse with a glycerin-based mouthwash before meals. (Clients who have sores in their mouths or mucositis should rinse with a solution of water and 0.9% sodium chloride, or with water and baking soda. Using a glycerin- or alcohol-based mouthwash can lead to irritation and burning of the oral mucosa.) d) Eat several, small-portioned meals daily. (Clients who have difficulty eating because of pain or anorexia can usually tolerate small amounts of food at one time. Eating several small meals daily can increase the client's caloric intake.) 86. A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke. Which of the following interventions should the nurse plan to implement first? a) Collaborate with a dietitian. (The nurse should collaborate with the dietician to evaluate the client's nutritional status and incorporate the client's food likes and dislikes into the meal plan. However, there is another intervention the nurse should plan to implement first.) b) Provide nutritional supplements. (The nurse should provide nutritional supplements as needed to ensure the client's nutritional needs are being met. However, there is another intervention the nurse should plan to implement first.) c) Recommend a referral for a speech language pathologist. (The greatest risk to the client following a stroke is injury from aspiration. Therefore, the first intervention the nurse should include in the plan of care is to recommend a referral for a speech language pathologist. A speech language pathologist can conduct a swallow study to determine the client's risk for aspiration, provide teaching to the client regarding swallowing techniques, and recommend the consistency of foods and liquids.) d) Inform assistive personnel about proper positioning. (The nurse should provide instruction to assistive personnel regarding proper positioning of the client during mealtimes. The client should be positioned upright during meals to help prevent aspiration and facilitate swallowing and should remain in this position for at least 45 min after eating. However, there is another intervention the nurse should plan to implement first.) 87. Following a blood draw procedure for a fasting blood sugar (FBS) test, a client tells the nurse, “I’m glad they took my blood because I’m really hungry. All I’ve had since midnight is water and some juice.” Which of the following actions should the nurse take? a) Offer the client breakfast then repeat the FBS request. (An FBS test requires the client to have no food or juice for at least 8 hr. The result of the FBS test would be invalid after the client had breakfast.) b) Reschedule the FBS test for early the next morning. (An FBS test requires the client to have no food or juice for at least 8 hr. The result of the FBS test would be invalid because the client drank juice during the fasting time period. The nurse should reinforce with the client to only drink water and have no food or other beverages for 8 hr before the phlebotomist obtains the blood specimen.) c) Request that the phlebotomist obtain another specimen. (The client had juice within the past 8 hr. The nurse should request that the phlebotomist obtain another specimen when the client has ingested no food or other beverages for 8 hr.) d) Ask the laboratory technician to repeat the test on the same specimen. (Repeating the test on the same specimen will yield the same result, which will also be invalid.) 88. A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should he nurse include? a) Apply hot packs to the client's muscles. (The nurse should avoid exposing the client's muscles to extreme temperatures because it decreases muscle strength.) b) Schedule physical therapy in the afternoon. (The nurse should schedule physical therapy and other activities in the morning when the client's strength is at its peak. Fatigue increases in the afternoon.) c) Encourage the client to complete ADLs. The nurse should encourage the client to complete ADLs and provide assistance as needed. Performing self-care increases the client's independence, strength, and level of functioning.) d) Administer valerian to promote sleep. (The nurse should instruct the client to avoid using valerian to promote sleep because this herbal supplement can increase CNS depression when taken with dantrolene.) 89. A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.) Exhibit 1 History and Physical History of type 2 diabetes mellitus and Allergies: 1) Penicillin reaction severe 2) Aspirin 3) Heparin Exhibit 2 Nurses’ Note 0730 Vital signs Temperature 38° C (100.4° F) Heart rate 72/min and regular Respiratory rate 16/min Blood pressure 128/78 mm Hg Pain rating 6/10 Exhibit 3 Diagnostic results Capillary glucose 102 mg/dL a) Ceftriaxone (Clients who have a severe sensitivity to penicillin can have a cross-sensitivity reaction to ceftriaxone, a cephalosporin. Therefore, the nurse should contact the provider to clarify the prescription.) b) Diltiazem (The nurse should administer diltiazem because the client's heart rate and blood pressure are within the expected reference ranges.) c) Pioglitazone. (The nurse should administer pioglitazone because the client's blood glucose level is within the expected reference range.) d) Hydrocodone 5 mg/acetaminophen 500 mg (The nurse should administer hydrocodone and acetaminophen to manage the client's pain because the client's respiratory rate is within the expected reference range.) 90. A nurse is caring for a client who is postoperative and is receiving an IV infusion of cefzolin. Ten minutes after beginning the infusion, the client reports intense itching. Which of the following actions should the nurse take first? a) Stop the medication infusion. (The greatest risk to the client is injury from an allergic response to the medication. Therefore, the priority action the nurse should take is to stop the medication infusion.) b) Notify the charge nurse. (The nurse should notify the charge nurse about what has occurred. However, there is another action the nurse should take first.) c) Administer a PRN dose of diphenhydramine. (The nurse should administer a PRN dose of diphenhydramine to keep the allergic reaction from worsening. However, there is another action the nurse should take first.) d) Follow facility policy for appropriate reporting of the adverse reaction. (The nurse should follow facility policy when reporting an adverse reaction. However, there is another action the nurse should take first.)