Name: _________________________________________________________________ Date:_______________1. Elizabeth Kubler-Ross identified five stages of death and dying. Loss, grief, and intensesadness are symptoms of which stage?a. Denial and isolationb. Depressionc. Angerd. BargainingRATIONALE: According to Kübhler-Ross, the five stages of death and dying are denial and isolation,anger, bargaining, depression, and acceptance. In denial, the client denies aspects of the illness anddeath. Loss, grief, and intense sadness indicate depression. In anger, the client has hostility that maybe directed to family members, God, heath care workers, and others. In bargaining, the client asksGod for more time, and in return promises to do something good.2. To help minimize calcium loss from a hospitalized client's bones, the nurse should:a. reposition the client every 2 hours.b. encourage the client to walk in the hallc. provide the client daily products at frequent intervalsd. provide supplemental feedings between meals.RATIONALE: Calcium absorption diminishes with reduced physical activity because of decreased bonestimulation. Therefore, encouraging the client to increase physical activity such as by walking the hall,helps minimize calcium loss. Turning or repositioning the client every 2 hours wouldn’t increaseactivity sufficiently to minimize bone loss, Providing dairy products and supplemental feedingswouldn't lessen calcium loss - even if the dairy products and feedings contained extra calcium —because the additional calcium doesn’t increase bone stimulation or osteoblast activity.3. Which statement regarding heart sounds is correct?a. S1 and s2 sound equally loud over the entire cardiac area.b. S1 and sound fainter at the apex than at the base.c. S and 2 sound fainter at the base than at the apex.d. S1 is loudest at the apex, and S2 is loudest at the base.Rationale: The S1 sound — the “lub” sound — is loudest at the apex of the heart. It sounds longer,lower, and louder there than the S2 — the “dub” sound — is loudest at the base. It sounds shorter,sharper, higher, and louder there than the S1.4. A client has a nursing diagnosis of Ineffective airway clearance related to poor coughing.When planning this client’s care, the nurse should include which intervention?a. Increasing fluids to 2,500 ml/dayb. Teaching the client how to deep-breathe and coughc. Improving airway clearanced. Suctioning the client every 2 hoursRATIONALE: Interventions should address the etiology of the client's problem — poor coughing.Teaching deep breathing and coughing addresses this etiology. Increasing fluids may improve theclient’s condition, but this intervention doesn't address poor coughing. Improving airway clearance istoo vague to be considered an appropriate intervention. Suctioning isn't indicated unless othermeasures fail to clear the airway.

5. A nurse is using the computer when a client calls for pain medication. Which action by thenurse is the best?a. Staying logged on, leaving the terminal on, and administering the medicationimmediatelyb. telling the client that he’ll have to wait 15 minutes while she completes the entryc. Asking a coworker to log out for her and administering the medicine right awayd. Logging out of the computer, then administering the pain medicationRATIONALE: A nurse should meet a client’s request for pain medication as quickly as possible after shelogs out of the computer. A nurse shouldn't ask a client to wait for as long as 15 minutes for requestedpain medication. If the nurse leaves the terminal without logging out, others may view confidentialinformation or use her password. Asking a coworker to log her out isn't safe computer practice.6. What is the most appropriate nursing diagnosis for the client with acute pancreatitis?1a. Deficient fluid volumeb. Excess fluid volumec. Decreased cardiac outputd. Ineffective gastrointestinal tissue perfusionRATIONALE: Clients with acute pancreatitis often experience deficient fluid volume, whichcan lead to hypovolemic shock. Vomiting, hemorrhage (in hemorrhagic pancreatitis), andplasma leaking into the peritoneal cavity may cause the volume deficit. Hypovolemic shockwill cause a decrease in cardiac output. Gastrointestinal tissue perfusion will be ineffective ifhypovolemic shock occurs, but this wouldn't be the primary nursing diagnosis.7. One aspect of implementation related to drug therapy is:a. developing a plan of careb. documenting drugs given.c. establishing outcome criteria.d. setting realistic client goals.RATIONALE: Athough documentation isn't a step in the nursing process, the nurse is legallyrequired to document activities related to drug therapy, including the time of administration,the quantity, and the client's reaction. Developing a plan of care, establishing outcomecriteria, and setting realistic client goals are parts of planning rather than implementation.8. A nurse notes that a client’s I.V. insertion site is red, swollen, and warm to the touch.which action should the nurse take first?a. Discontinue the I.V. infusion.b. Apply a warm, moist compress to the I.V. site.c. Assess the I.V. infusion for patency.d. Apply an ice pack to the I.V. site.RATIONALE: Because redness, swelling, and warmth at an I.V. site are signs of infection, thenurse should discontinue the infusion immediately and restart at another site. After doing

this, the nurse should apply warmth to the original site. Checking infusion patency isn'twarranted because assessment findings suggest infection and inflammation, not infiltration.Heat, not cold is the appropriate treatment for inflammation.9. A nurse is caring for a client with a history of falls. The nurse's first priority when caringfor a client at risk for falls is:a. placing the call light for easy access.b. keeping the bed in the lowest possible position.c. instructing the client not to get out of the bed without assistanced. keeping the bedpan available so that the client doesn’t have to get out of bed.RATIONALE: Keeping the bed at the lowest possible position the first priority for clients atrisk for falling. Keeping the call light easy accessible is important but isn’t a top priority.Instructing the client not to get out of bed may not effectively prevent falls — for example, ifthe client is confused. Even when the client needs assistance to get out of bed, the nurseshould place the bed in the lowest position. The client may not require a bedpan.10. A nurse is caring for a client who is exhibiting signs and symptoms characteristic of amyocardial infarction (MI). which statement describes priorities the nurse should establishwhile performing the physical assessment?a. Assess the client's level of pain and administer prescribed analgesics.b. Assess the client’s level of anxiety and provide emotional support.c. Prepare the client for pulmonary artery catheterization.d. Ensure that the client's family is kept informed of his status.RATIONALE: The cardinal symptom of MI is persistent, crushing substernal pain or pressure.The nurse should first assess the client's pain and prepare to administer nitroglycerin ormorphine for pain control. The client must be medically stabilized before pulmonary arterycatheterization can be used as a diagnostic procedure. Anxiety and a feeling of impendingdoom are characteristic of MI, but the priority is to stabilize the client medically. Althoughthe client and his family should be kept informed at every step of the recovery process, thisaction isn’t the priority when treating a client with a suspected MI.211. A nurse is monitoring a client for adverse reactions during barbiturate therapy. What isthe major disadvantage of barbiturate use?a. Prolonged half-lifeb. Poor absorptionc. Potential for drug dependenced. Potential for hepatotoxicityRATIONALE: Clients can become dependent on barbiturates, especially with prolonged use.Because of the rapid distribution of some barbiturates, no correlation exists betweenduration of action and half-life. Barbiturates are absorbed well and don't cause

hepatotoxicity, but because barbiturates are metabolized in the liver, existing hepaticdamage does require cautious use of these drugs.12. A nurse is caring for a client who required chest tube insertion for a pneumothorax. Toassess for pneumothorax resolution, the nurse anticipates that the client will require:a. monitoring of arterial oxygen saturation ,b. arterial blood gas (ABG) studies.c. chest auscultation.d. a chest x-ray.Rationale: Chest x-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2values may initially decrease with a pneumothorax but typically return to normal within 24hours. ABG studies may show hypoxemia, possibly with respiratory acidosis andhypercapnia not related to a pneumothorax. Chest auscultation will determine overall lungstatus, but it's difficult to determine if the chest has reexpanded sufficiently.13. During her morning assessment, a nurse notes that a client has severe dyspnea, hisrespirations are 34 breaths/minute and labored. Oxygen saturation is 79% on 3L of oxygen.The nurse remembers that the client's chart includes his living will, When considering bestpractice, the nurse should:a. withhold all potentially life-prolonging treatments in accordance with the client's living willb. increase the oxygen flow rate to 4L, but avoid initiating other interventionsc. call the client’s family and ask what they think is best.d. initiate potentially life-prolonging treatment unless the client refuses.RATIONALE: A living will doesn't go into effect unless the client is unable to make his owndecisions. A nurse shouldn't withhold care for an alert client unless he specifically refusescare. The nurse should give all appropriate care while also maintaining the client's right torefuse treatment. Increasing the oxygen flow rate might be an appropriate response, butisn't the best action at this time. The family isn't responsible for determining care at thistime.14. A client is to receive a glycerin suppository. Which nursing action is appropriate whenadministering a suppository?a. Removing the suppository from the refrigerator 30 minutes before insertionb. Applying a lubricant to the suppositoryc. Dissolving the suppository in 3 ml of warm waterd. Instructing the client to bear down during insertionRATIONALE: A suppository must be lubricated before insertion. Because suppositories meltat body temperature, they usually require refrigeration until administration. It isn’tappropriate to dissolve a suppository in warm water. It should remain in a solid state.Instructing the client to bear down would cause the anal sphincter to contract, makinginsertion difficult.

15. A physician orders regular insulin 10 units LV. along with 50 ml of dextrose 50% for aclient with acute renal failure. What problem is this client most likely experiencing?a. Hypercalcemiab. Hypernatremiac. Hyperglycemiad. HyperkalemiaRationale: Administering regular IV concomitantly with 50 ml of dextrose 50% helps shiftpotassium from the extracellular fluid into the cell, which normalizes serum potassium levelsin the client with hyperkalemia. This combination doesn't he reverse the effects ofhypercalcemia, hypenatremia, or hyperglycemia.316. A nurse identifies a client’s responses to actual or potential health problems duringwhich step of the nursing process?a. Assessmentb. Diagnosisc. Planningd. EvaluationRATIONALE: The nurse identifies human responses to actual or potential health problemsduring the diagnosis step of the nursing process, which encompasses the nurse’s ability toformulate a nursing diagnosis. During the assessment step, the nurse systematically collectsdata about the client or his family. During the planning step, she develops strategies toresolve or decrease the client’s problem. During the evaluation step, the nurse determinesthe effectiveness of the care plan.17. In a client with a urine specific gravity of 1.040, a subnormal serum osmolality, and aserum sodium level of 128 mEq/L, the nurse should question an order for which I.V. fluid?a. dextrose 5% in half-normal saline solution.b. normal saline solution.c. dextrose 5% on water (D5W)d. lactated Ringer’s solution.RATIONALE: An elevated urine specific gravity, a subnormal serum osmolality, and asubnormal serum sodium level indicate that the client is excreting too many solutes.Because the client is in a hypotonic state, the nurse shouldn't give him a hypotonic I.V.solution. D5W, also referred to as free water, is hypotonic when given I.V. and can furtherhemodilute the clent. Dextrose 5% half-normal saline solution is hypertonic, normal salinesolution is isotonic, and lactated Ringer's solution is isotonic. For this client, each of thesethree choices are more acceptable than D5w.18. A 10-year-old child with rheumatic fever must have his heart rate measured while he'sawake and while he’s sleeping. Why are two readings necessary?a. To obtain a heart rate that isn't affected by medication

b. To eliminate interference from the jerky movements of choreac. To ensure that the child can't consciously raise or lower his heart rated. To compensate for activity's effects on the child’s heart rateRATIONALE: Tachycardia may be a sign of heart failure. The nurse can detect mildtachycardia more easily when the child is asleep than when he's awake because activity canincrease his heart rate. Medications given for rheumatic fever and rheumatic heart disease,such as digoxin (Lanoxin), exert their influence both day and night. Chorea, a symptom ofrheumatic fever, is the loss of voluntary muscle control. It doesn't affect pulse because thechild would be sitting quietly while the nurse measured his heart rate and wouldn't beinvolved in purposeful movement. A 10-year-old child probably doesn't know how toconsciously raise or lower his heart rate.19. A nurse preparing to administer a sustained-release capsule to a client. Which is anappropriate nursing intervention?a. Administering the capsule whole with a glass of waterb. Crushing the capsule and mixing the medication with applesaucec. Opening the capsule, shaking the contents into water, and administering it to the clientd. Having the client chew the capsule before swallowing20. After receiving an I.M. injection, a client complains of burning pain at the injection site.which nursing action would be most appropriate at this time?a. Applying a cold compress to decrease swellingb. Applying a warm compress to dilate the blood vesselsc. Massaging the area to promote absorption of the drugd. Instructing the client to tighten his gluteal muscles to promote better absorption of thedrugRATIONAI.E: Applying heat increases blood flow to the area, which, in turn, increasesmedication absorption. Cold decreases pain but allows the medication to remain in themuscle longer. Massage is a good intervention, but applying a warm compress is better.Tightening the gluteal muscles may cause additional burning if the drug irritates musculartissues.421. A client undergoes a total abdominal hysterectomy. When assessing the client 10 hourslater, the nurse identifies which finding as an early sign of shock?a. Confusionb. Pale, warm, dry skinc. Heart rate of 110 beats/minuted. Urine output of 30 ml/hourRATIONALE: Early in shock, inadequate perfusion leads to anaerobic metabolism, whichcauses metabolic acidosis. As the respiratory rate increases to compensate, the client’scarbon dioxide level decreases, causing alkalosis and subsequent confusion and

combativeness. Inadequate tissue perfusion causes pale, cool, clammy skin (not pale, warm,dry skin). An above-normal heart rate is a late sign of shock. A urine output of 30 ml/hour iswithin normal limits.REFERENCE: Smeltzer, S.C., and Bare, B. Brunner&Suddarth’s Texthook of MedicalSurgicalNursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2526.22. Cross-tolerance to a drug is defined as:a. one drug that can prevent withdrawal symptoms from another drug.b. an allergic reaction to a class of drugs.c. one drug reduces response to another drug.d. one drug increases another drug’s potency.RATIONALE: Cross-tolerance occurs when a drug with a similar action causes a decreasedresponse to another drug. A drug that can prevent withdrawal symptoms from another drugdescribes cross-dependence. Cross-tolerance isn't an allergic reaction to a class of drugs. Adrug's ability to increase the potency of another drug describes potentiating effects.23. A nurse caring for a client wth a fecal impaction should watch for:a. liquid or semiliquid stools.b. hard, brown, formed stools.c. loss of urge to defecate.d. increased appetite.RATIONALE: Passage of liquid or semiliquid stools results from seepage of unformed bowelcontents around the impacted stool in the rectum. Clients with fecal impaction don’t passhard, brown, formed stools because the feces can't move past the impaction. These clientstypically report the urge to defecate (although they can't pass stool) and decreasedappetite.24. A physician orders an intestinal tube to decompress a client's GI tract. when gatheringequipment for this procedure, a nurse should obtain a:a. Sengstaken-Blakemore tube.b. Miller-Abbott tube.c. Levin tube.d. Salem sump tube.RATIONALE: A Miller-Abbott tube is an intestinal tube. A Sengstaken-8lakemore tube is anesophageal tube. Levin tubes and Salem sump tubes are nasogastric tubes.REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth’s Textbook of Medical SurgicaNursing, 2008, p. 1175.25. A client has a blood pressure of 152/86 mm Hg. The nurse should document the client’spulse pressure as:a. 66mm Hg.b. 238 mm Hg.c. 86 mm Hg.d. 152 mm Hg.RATIONALE: Pulse pressure is the difference between the systolic and diastolic pressures —

in this case, 66 mm Hg.26. A client has a nursing diagnosis of Risk for Injury related to adverse effects of potassiumwastingdiuretics. What is a correctly written client outcome for this nursing diagnosis?a. “By discharge, the client correctly identifies three potassium-rich foodsources.”b. “The client knows the importance of consuming potassium-rich foods daily.”c. “Before discharge, the client knows which food sources are high in potassium.”d. “The client understands all complications of the disease process."RATIONALE: A client outcome must be measurable, objective, concise, realistic for the client,and attainable through nursing management. For each client outcome, the nurse shouldinclude only one client behaviour. She should express that behaviour in terms of clientexpectations and should indicate a time frame in which to accomplish. Knowing theimportance of consuming potassium-rich foods and knowing which foods are high in5potassium aren't measurable outcomes. Understanding all complications of a diseaseprocess isn't measurable or specific to the nursing diagnosis listed.27. When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which actionmay the nurse institute independently?a. Using a povidone-iodine wash on the ulceration three times per dayb. Using normal saline solution to clean the ulcer and applying a protectivedressing as necessaryc. Applying an antibiotic cream to the area three tines per dayd. Massaging the area with an astringent every 2 hours28. A client with burns on his groin has developed blisters. As the client is bathing, a fewblisters break. The best action tor the nurse to take is to:a. remove the raised skin because the blister has already broken.b. wash the area with soap and water to disinfect it.c. apply a weakened alcohol solution to clean the area.d. clean the area with normal saline solution and cover it with a protectivedressing.RATIONALE: The nurse should clean the area with a mild solution such as normal saline, andthen cover it with a protective dressing. Soap and water and alcohol are too harsh. Thebody's first line of defense broke when the blisters opened: removing the skin exposes alarger area to the risk of infection.29. A nurse is assisting with a subclavian vein central be insertion when the client's oxygensaturation drops rapidly. He complains of shortness of breath and becomes tachypneic. Thenurse suspects the chent has developed a pneumothorax. Further assessment findingssupporting the presence of a pneumothorax include:a. diminished or absent breath sounds on the affected sideb. paradoxical chest wall movement with respirations.c. tracheal deviation to the unaffected side.d. muffled or distant heart sounds.RATIONALE: In the case of a pneumothorax, auscultating for breath sounds will reveal

absent or diminished breath sounds on the affected side. Paradoxical chest wall movementsoccur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax. Muffledor distant heart sounds occur in cardiac tamponade.30. During a meal, a client with hepatitis B dislodges her IV line and bleeds onto the surfaceof the overbed table. It would be most appropriate for the nurse to instruct a housekeeper toclean the table with:a. alcohol.b. ammonia.c. acetone.d. bleach.RATIONALE: Blood infected with the hepatitis B virus should be removed from the table orother surfaces with bleach. Alcohol, ammonia, and acetone are less effective n destroyingthe hepatitis B virus.31. A nurse determines that a client has 20/40 vision. Which statement about this client’svision is true?a. The client can read the entire vision chart at a distance of 40 feet.b. The client can read from a distance of 20 feet what a person with normal visioncan read at a distance of 40 feet.c. The client can read the vision chart from a distance of 20 feet with the right eye and from40 feet with the left eye.d. The client can read at a distance of 40 feet what a person with normal vision can read at adistance of 20 feet.RATIONALE: The numerator, which is always 20, is the distance in feet between the visionchart and the client. The denominator indicates from what distance a person with normalvision can read the chart.32. For the past few days, a client has been having calf pain and notices that the painful calfis larger than the other one. The right calf is red, warm, achy, and tender to touch. Whichquestion about the pain should a nurse include in the assessment?a. “Does the pain worsen when you get up in the morning?”6b. “Does the pain increase with activity and lessens with rest?"c. “Is the pain relieved when you change position?”d. “Is the pain worse when you point your toes toward your knee?”RATIONALE: The client's symptoms indicate deep vein thrombosis (DVT). Pointing toestoward the knee will cause discomfort in a client with DVT. Time of the day doesn’t influencethe pain associated with DVT. A client with intermittent claudication experiences pain thatincreases during activity and decreases with rest. A dependent position, not a position

change, will increase venous stasis and the pain associated with DVT.33. A physician orders the following preoperative medications to be administered to a clientby the I.M. route: meperidine (Demerol), 50 mg: hydroxyzine pamoate (Vistaril), 25 mg; andglycopyrrolate (Robinul), 0.3 mg. The medications are dispensed as follows: meperidine, 100mg/ml; hydroxyzine pamoate, 100 mg/2 ml; and glycopyrrolate, 0.2 mg/ml. How manymilliliters in total should the nurse administer?a. 5mlb. 2 mlc. 2.5 mld. 3.8 mlComputation:0.5 ml + 0.5 ml + 1.5 ml = 2.5 ml34. What is a common source of airway obstruction in an unconscious client?a. A foreign objectb. Saliva or mucusc. The tongued. EdemaRATIONALE: In an unconscious client, the muscles controlling the tongue commonly relax,causing the tongue to obstruct the airway. When this situation occurs, the nurse should usethe head-tilt, chin-lift maneuver to cause the tongue to fall back into place. If she suspectsthe client has a neck injury she must perform the jaw-thrust maneuver.35. After undergoing small-bowel resection, a client is ordered Metronidazole (Flagyl) 500mg IV The mixed IV solution contains 100 ml. The nurse is to run the drug over 30 minutes.The drip factor of the available IV tubing is 15 gtts/ml. What is the drip rate? Round youranswer to the nearest whole number.a. 50 gtt/minb. 45 gtt/minc. 48 gtt/mind. 40 gtt/minRationale: Use the following equation: 100 ml/30 minutes x 15 gtt/1 ml = 49.9 gtt/minute(50 gtt/minute)36. An elderly client who experiences several adverse drug reactions may benefit from:a. reduced drug dosages.b. nursing home placement.c. increased drug doses at longer intervals.d. frequent visits to the physician.RATIONALE: In older clients, diminished hepatic and renal function commonly reduces drugmetabolism and excretion. Because adverse reactions are frequently related to drug bloodlevel, the client may benefit from reduced drug dosages. Adverse drug reactions don’t

represent a reason for nursing home placement. Increased drug doses at longer intervalsmay increase adverse reactions rather than decrease them. Although frequent visits to thephysician may benefit the client, the visits themselves won't alter how the client's bodyreacts to the drug.37. When examining a client who has abdominal pan, a nurse should assess:a. any quadrant first.b. the symptomatic quadrant first.c. the symptomatic quadrant last.d. the symptomatic quadrant either second or third.Rationale: The nurse should systematically assess all areas of the abdomen, if time and theclient's condition permit, concluding with the symptomatic area. Otherwise, the nurse mayelicit pain in the symptomatic area, causing the muscles in other areas to tighten. Thistightening would interfere with further assessment.738. A nurse is teaching a group of nursing assistants about infection-control measures. Thenurse tells the group that the first line of intervention for preventing the spread of infectionis:a. wearing gloves.b. administering antibiotics.c. washing hands.d. assigning clients to private rooms.RATIONALE: Hand washing is the first line of intervention for preventing the spread ofinfection. Wearing gloves and assigning private rooms for clients can also decrease thespread of infection and should be implemented according to standard precautions.Antibiotics should be initiated when a causative organism is identified.39. A nurse caring for a client who has suffered a severe stroke. During routine assessment,the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are:a. progressively deeper breaths followed by shallower breaths with apneicperiods.b. rapid, deep breaths with abrupt pauses between each breath.c. rapid, deep breaths and irregular breathing without pauses.d. shallow breaths with an increased respiratory rate.RATIONALE: Cheyne-Stokes respirations are breaths that become progressively deeperfollowed by shallower respirations with apneic periods. Biot’s respirations are rapid, deepbreaths with abrupt pauses between each breath, and equal depth between each breath.Kussmaul’s respirations are rapid, deep breaths without pauses. Tachypnea is abnormallyrapid respirations.40. When positioned properly, the top of a central venous catheter should lie in the:a. superior vena cava.b. basilic vein.c. jugular vein.

d. subclavian vein.RATIONALE: When positioned correctly, the top of a central venous catheter lies in thesuperior vena cava, inferior vena cava, or right atrium — that is, in the central venouscirculation. Blood flows unimpeded around the tip, allowing the rapid infusion of largeamounts of fluid directly into circulation. The basilic, jugular, and subclavian veins arecommon insertion sites for central venous catheters.41. A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia:pH, 7.51, PaCO2, 28 mm Hg; PaO2, 70 mm Hg: and HCO3, 24 mEq/L. What do these valuesindicate?a. Metabolic acidosisb. Metabolic alkalosisc. Respiratory acidosisd. Respiratory alkalosisRATIONALE: A client with pneumonia may hyperventilate in an effort to increase oxygenintake. Hyperventilation leads to excess carbon dioxide (Co2) loss, which causes alkalosis —indicated by this client's elevated pH value. with respiratory alkalosis, the kidneys’bicarbonate (HCO3

-) response is delayed, so the client's HCO3

- level remains normal. Thebelow-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2

loss and signals a respiratory component. Because the HCO3

- level is normal, this imbalancehas no metabolic component. Therefore, the client is experiencing respiratory alkalosis.42. The ear canal of an infant or young child:a. slants upward.b. slants downward.c. is horizontal.d. slants backward.Rationale: The ear canal slants up in a younger child and down in an older child or adult.43. When a central venous catheter dressing becomes moist or loose, what should a nursedo first?a. Draw a circle around the moist spot and note the date and time.b. Notify the physician.c. Remove the catheter, check for catheter integrity, and send the tip for culture.d. Remove the dressing, clean the site, and apply a new dressing.Rationale: A nurse maintaining a central venous catheter should change the dressing every72 hours or when it becomes soiled, moist, or loose. After removing the soiled dressing, the8nurse should use sterile technique to clean around the site in accordance with facility policy.After the cleaning solution has dried, the nurse should cover the site with a transparent

semipermeable dressing. A nurse who notes drainage on a wound dressing should draw acircle around the moist spot and note the date and time. She should notify the physician ifshe observes any catheter-related complications. Only a nurse with the appropriatequalifications may remove a central venous catheter, and a moist or loose dressing isn’t areason to remove the catheter.References: Smeltzer, S.C., and Bare, B. Brunner&Suddarth’s Texthook of MedicalSurgicalNursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 100544. A nurse is assigned to care for a client with a tracheostomv tube. How can the nursecommunicate with this client?a. By providing a tracheostomy plug to use for verbal communicationb. By placing the call button under the client's pillowc. By supplying a magic slate or similar deviced. By suctioning the client frequentlyRATIONALE: The nurse should use a nonverbal communication method, such as a magicslate, note pad and picture boards (if the client can’t write or speak English). The physicianorders a tracheostomy plug when a client is being weaned off a tracheostomy; it doesn’tenable the client to communicate. The call button, which should be within reach at al timesfor all clients, can summon attention but doesn't communicate additional information.Suctioning clears the airway but doesn't enable the client to communicate.