A nurse is reinforcing teaching with a client about the use of a straight legged cane. which of the following actions indicates an understanding of the teaching?
The client holds the cane on the unaffected side.
Rationale: The nurse should instruct the client to hold the cane on the unaffected side to provide a wide base of support and stability.
A nurse is preparing to assist an older adult client with ambulation; the client has been on bed rest for 3 days. which of the following actions should the nurse take to decrease the risk of a fall?
Use a gait belt during ambulation
Rationale: The nurse should use a gait belt to keep the client's center of gravity and to decrease the risk of a fall.
A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing?
Rationale: After inserting an indwelling urinary catheter, the nurse should secure the catheter tubing to the client's upper thigh or lower abdomen by using adhesive tape or catheter securement device. this location will decrease tension and trauma to the urethra.
A nurse is developing a plan of care for a client. Which of the following pieces of information should the nurse consider when planning care that is culturally congruent?
The meaning of disease can vary widely across cultures.
Rationale: A client may define and react to disease based on his or her unique cultural perspective. The nurse should seek to understand a client's culture and life experiences in order to provide care that is effective, evidence-based, and culturally congruent.
A nurse is auscultating the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse hears a high-pitched scratching sound with the diaphragm of the stethoscope placed at the third intercostal space of left sternal border. which of the following heart sounds should the nurse document?
Pericardial friction rub
Rationale: A pericardial friction rub has a scratching, grating, or squeaking leathery sound.
A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
"I will make sure to replace my pouch around 4 hours after I eat".
Rationale: It is best for the client to replace the pouch at a time when the bowel is least active, either after arising in the morning or at least 2 to 4 hours after a meal. Otherwise, the client risks releasing stool while there is no pouch in place.
A nurse is assisting with the care of a client who requires ventilatory assistance with breathing following a motor vehicle crash. The nurse should suspect that the client has an injury to which of the following parts of the brain?
Rationale: The nurse should identify an injury to the medulla and pons of the brainstem for a client who is experiencing difficulty with breathing. The brainstem serves as the respiratory control center, and a neurological injury can impair this center and inhibit respiratory effort.
A nurse is caring for a client who requires a protective environment. Which of the following precautions should the nurse implement for this client?
Make sure the client wears a mask when outside his room.
Rationale: Clients who require a protective environment have a compromised immune system, increasing their risk of infection. This client will need protection from breathing any harmful microorganisms in the environment.
A nurse is collecting data from a client at admission. The client reports a latex allergy. Which of the following precautions should the nurse take when caring for this client?
Wrap IV tubing with tape.
Rationale: Although latex- free products are widely available, the nurse might encounter some products that contain latex such as IV tubing and monitoring cords devices. The nurse should create a barrier between these items and the client by wrapping them in non-latex tape or stockinette.
A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the administration of internal feeding. Which of the following methods should the nurse use to verify correct tube placement? (Select all that apply.)
- Verify initial X-ray examination
- Measure the length of the exposed tube
- Determine the pH of the aspirated fluid
Rationale: The nurse should confirm NG tube placement by checking the X-ray results following the insertion of the NG tube. Also, the nurse should check the length of the NG tube that is exposed by comparing the markings on the tube to the client's nose to verify tube placement. Finally, the nurse should check the pH of the aspirated fluid to verify the tube placement.
A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand washing technique?
The nurse washes with her hands higher than her elbows.
Rationale: The nurse who is performing a surgical hand-washing technique should wash with her hands held higher than the elbows so that water and soapsuds can drain away from the clean area toward the dirty area.
A nurse is collecting data regarding a client's nutritional status during a community health screening. The nurse determines the client is consuming 500 calories per day more than his energy level requires. When will the client have gained 4.5 kg(10 lbs)?
Rationale: Because 1 lb of body fat is equivalent to 3,500 calories, 500 calories each day for 7 days would mean 3,500 total and a 1 lb gain per week. So, at the rate of 1 lb per week, the client would gain 10 lb in 10 weeks.
A nurse is assisting with the admission of a client who has tuberculosis. In addition to standard precautions, which of the following transmission-based precautions can be added to the client's plan of care?
Rationale: Tuberculosis requires airborne precautions, which are protocols that prevent the spread of infections via small droplets such as measles, varicella, and tuberculosis.
A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?
Place the stool specimen collection container in a biohazard bag
Rationale: The nurse should place the specimen collection in a biohazard bag with the client label placed on the container and the bag for easy identification and to prevent contamination with microorganisms.
A nurse is preparing to administer a bolus feeding to a client through an NG tube and observes that the exit mark on the tube has moved since the last feeding. Which of the following actions should the nurse plan to take?
Request an X-ray of the client's abdomen
Rationale: The nurse should request an X-ray to verify the placement of the NG tube both after the initial insertion of the tube and if displacement of the tube is suspected. The nurse should verify NG tube placement prior to administering a bolus feeding.
A nurse is evaluating a client for conductive hearing loss. Using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear?
Air conduction is less than bone conduction in the left ear.
Rationale: This finding indicates conductive hearing loss of the left ear.
A nurse is caring for client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume?
Rationale: The nurse should identify that sodium regulates extracellular fluid balance as well as nerve impulse transmission, acid-base balance, and various other cellular activities.
A nurse is administering an IM injection to a 5 month old infant. Which of the following injection sites should the nurse use?
Rationale: The nurse should use the vastus lateralis site over the anterior thigh for IM injections for infants and children.
A nurse is collecting data about a client who is unconscious. Family members are present and answer the nurse's questions about the client's medical history. The nurse should document this information as which of the following types of data?
Secondary source data
Rationale: Information provided by someone other than the client is secondary source data.
A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?
Insert the tip of the tubing 8 cm
Rationale: The nurse should insert the tip of the tubing 7 to 10 cm along the rectal wall to prevent dislodging of the tube during the procedure and injury to the rectal mucosa.
A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur?
Rationale: Stress causes an increase in the secretion of cortisol (sugar) which can cause hypertension and hyperglycemia.
A nurse is reviewing the laboratory results of a client and notes a WBC count of 3,600/mm^3. The nurse should identify this result as indication of which of the following conditions?
Rationale: The nurse should identify that leukopenia occurs when there is a decrease int he production of WBCs. This alteration plans the client at an increased risk of infection.
A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the take?
Hyper-oxygenate the client before suctioning.
Rationale: The nurse should use a manual resuscitation bag to hyper oxygenate the client for several minutes prior to suctioning.
A nurse is collecting data as part of a comprehensive physical examination a client. The nurse should use inspection to evaluate which of the following?
Rationale: Inspection is the technique of looking or observing. Gait inspection involves watching the client's walking movements and observing for any unusual findings.
A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media(middle ear infection or inflammation). Which of the following actions should the nurse plan to take?
Hold the dropper 1 cm above the ear canal during administration.
Rationale: The nurse should administer the otic medication by holding the dropper 1 cm above the ear canal.
A nurse is collecting data from a client. Which of the following actions should the nurse take to determine the client's tissue perfusion(blood flow)?
Perform a blanch test
Rationale: The blanch test is used to check capillary refill, which is an indicator of peripheral circulation(transport of blood) and tissue perfusion.