Unit : - Fundamentals of NursingChepter :- Basic Physical Care

1001As a nurse helps a client ambulate, the client says, "I had trouble sleeping last night." Which action should the nurse take first?1. Recommending warm milk or a warm shower at bedtime2. Gathering more information about the client's sleep problem3. Determining whether the client is worried about something4. Finding out whether the client is taking medication that may impede sleepCorrect answer: 2RATIONALE: The nurse first should determine what the client means by "trouble sleeping." The nurse lacks sufficient information to recommend warm milk or a warm shower or to make inferences about the cause of the sleep problem, such as worries or medication use. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 32.

1002A client who recently immigrated to the United States from Korea is hospitalized with second- and third-degree burns. He speaks little English and has been lying quietly in bed. Ten hours after the client's admission, the nurse conducts a serial assessment and asks him whether he's in pain. He smiles and shakes his head vigorously back and forth. Which nursing action is most appropriate at this time?1. Documenting that the client is resting quietly and denies pain2. Calling a family member to obtain information about the client3. Giving the client the ordered as-needed pain medication4. Checking vital signs and assessing for nonverbal indications of painCorrect answer: 4RATIONALE: The nurse should consider the possibility that the client didn't understand the question or has been conditioned culturally not to complain openly of pain. Checking vital signs and assessing for nonverbal indications of pain help the nurse determine whether the client is in pain. Accepting the client's response without question or further assessment may result in inadequate intervention. Calling the family or giving pain medication isn't warranted at this time because the client denies pain and the nurse needs to obtain more information. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1375.

1003When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching?1. "I will administer the enema while sitting on the toilet."2. "I will administer the enema while lying on my left side with my right knee flexed."3. "I will administer the enema while lying on my right side with my left knee flexed."4. "I will administer the enema while lying on my back with both knees flexed."Correct answer: 2RATIONALE: Lying on the left side allows the enema solution to flow downward by gravity into the rectum and sigmoid colon. The other options don't accomplish this goal and, therefore, are less effective in evacuating the lower bowel. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Comprehension REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1588.

1004A physician orders hourly urine output measurement for a postoperative client with an indwelling catheter. The nurse records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take?1. Continue to monitor and record hourly urine output.2. Notify the physician.3. Irrigate the indwelling urinary catheter.4. Increase the I.V. fluid infusion rate.Correct answer: 1RATIONALE: Normal urine output for an adult with an indwelling catheter is at least 30 ml/hour. Therefore, this client's output is normal. Beyond continued evaluation, no nursing action is warranted. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Analysis REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.1079.

1005Nursing licensure and practice are regulated by:1. Nurse practice acts.2. Standards of care.3. Civil law.4. The American Nurses Association.Correct answer: 1RATIONALE: Nurse Practice acts regulate nursing licensure and practice. Each state has its own nurse practice act. Standards of care offer guidelines for providing care and criteria for evaluating care. Civil law protects an individual's rights and isn't associated with regulation of nursing licensure or practice. The American Nurses Association, the professional organization for registered nurses in the United States, helps make policy and establish nursing care standards. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Knowledge REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p.20.

1006Which action should a nurse take when making a surgical bed?1. Leave the bed in the high position when finished.2. Place the pillow at the head of the bed.3. Tuck the top sheet and blanket under the bottom of the bed.4. Roll the client to the far side of the bed.Correct answer: 1RATIONALE: When making a surgical bed, the nurse should leave the bed in the high position when finished. After placing the top linens on the bed without touching them, the nurse should fanfold these linens to the side opposite the side from which the client will enter and place the pillow on the bedside chair. All of these actions promote transfer of the postoperative client from the stretcher to the bed. When making an occupied or unoccupied bed, the nurse should place the pillow at the head of the bed and tuck the top sheet and blanket under the bottom of the bed. When making an occupied bed, the nurse should roll the client to the far side of the bed. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Application REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.159.

1007When moving a client in bed, the nurse can ensure proper body mechanics by:1. Standing with her feet apart.2. Lifting the client to the proper position.3. Straightening her knees and back.4. Standing several feet from the client.Correct answer: 1RATIONALE: When moving a client in bed, the nurse should stand with her feet apart to establish a wide base of support. To reduce the amount of energy needed to move the client's weight against gravity, the nurse should slide, roll, push, or pull rather than lift the client. The nurse should flex her knees and use her arm and leg muscles instead of her back. To minimize stress, the nurse should stand as close to the client as possible. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Knowledge REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p.1267.

1008A client with heart failure must be monitored closely after starting diuretic therapy. The best indicator for the nurse to monitor is:1. Fluid intake and output.2. Urine specific gravity.3. Vital signs.4. Weight.Correct answer: 4RATIONALE: Heart failure typically causes fluid overload, resulting in weight gain. Therefore, weight is the best indicator of this client's status. One pound gained or lost is equivalent to 500 ml. Fluid intakes and output and vital signs are less accurate indicators than weight. Urine specific gravity reflects urine concentration, indicating over hydration or dehydration. Numerous factors can influence urine specific gravity, so it isn't the most accurate indicator of the client's status. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Application REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 953.

1009A nurse will use surgical asepsis for which procedure?1. Hand washing2. Nasogastric tube irrigation3. I.V. catheter insertion4. Colostomy irrigationCorrect answer: 3RATIONALE: Caregivers must use surgical asepsis when performing wound care or any procedure that involves entering a sterile body cavity or breaking skin integrity. To achieve surgical asepsis, objects must be sterilized or kept free of all pathogens. Because inserting an I.V. catheter disrupts skin integrity and involves entry into a sterile cavity (a vein), surgical asepsis is required. Hand washing ensures medical asepsis or clean technique to prevent the spread of infection. The GI tract isn't sterile; therefore, irrigating a nasogastric tube or a colostomy requires only clean technique. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Comprehension REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 533.

1010A nurse is transferring a client from the bed to a chair. Which action should the nurse take during this client transfer?1. Position the head of the bed flat.2. Help the client dangle his legs.3. Stand behind the client.4. Place the chair facing away from the bed.Correct answer: 2RATIONALE: After placing the client in high Fowlers position and moving the client to the side of the bed, the nurse should help him sit on the edge of the bed and dangle his legs. The nurse should then face the client and place the chair next to and facing the head of the bed. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Knowledge REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 812.

1011A physician orders supplemental oxygen for a client with a respiratory problem. Which oxygen delivery device should the nurse use to provide the highest possible oxygen concentration?1. Nasal cannula2. Venturi mask3. Simple mask4. Nonrebreather maskCorrect answer: 4RATIONALE: A nonrebreather mask provides the highest possible oxygen concentration up to 95%. A nasal cannula doesnt deliver concentrations above 40%. A Venturi mask delivers precise concentrations of 24% to 44%, regardless of the client's respiratory pattern; because the same amount of room air always enters the mask opening. A simple mask delivers 2 to 10 L/minute of oxygen in uncontrollable concentrations. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Knowledge REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1630.

1012A 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?1. Increasing fluids to 2,500 ml/day2. Teaching the client how to deep-breathe and cough3. Improving airway clearance4. Suctioning the client every 2 hoursCorrect answer: 2RATIONALE: Interventions should address the etiology of the client's problem poor coughing. Teaching deep breathing and coughing addresses this etiology. Increasing fluids may improve the client's condition, but this intervention doesn't address poor coughing. Improving airway clearance is too vague to be considered an appropriate intervention. Suctioning isn't indicated unless other measures fail to clear the airway. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 873.

1013A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?1. Measuring and recording fluid intake and output2. Weighing the client daily at the same time each day3. Assessing the client's vital signs every 4 hours4. Checking the client's lungs for crackles during every shiftCorrect answer: 2RATIONALE: Increased fluid volume leads to rapid weight gain 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles , which represent pulmonary edema . The nurse should plan to detect fluid accumulation before pulmonary edema occurs. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 957.

1014A client has a wound with a drain. When cleaning around the drain, the nurse should wipe in which direction?1. Laterally, from the center to the opposite side2. From top to bottom3. In a circle around the drain, outward from the center4. In a circle around the drain, from the outer border to the centerCorrect answer: 3RATIONALE: When cleaning the area around the drain, the nurse should wipe in a circle around the drain, working from the center outward. The nurse wipes laterally, from the center to the opposite side, when cleaning a large horizontal wound and wipes from top to bottom when cleaning a vertical incision. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Knowledge REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 159.

1015To follow standard precautions , the nurse should carry out which measure?1. Recapping needles after use2. Wearing a gown when bathing a client3. Wearing gloves when administering I.M. medication4. Wearing gloves for all client contactCorrect answer: 3RATIONALE: To follow standard precautions , caregivers must place used, uncapped needles and syringes in a puncture-resistant container; wear gloves when anticipating contact with a client's blood, body fluid, mucous membranes, or nonintact skin (such as when administering an I.M. injection); and wear a gown during procedures that are likely to generate splashes of blood or body fluids. Standard precautions don't call for caregivers to wear a gown or gloves when bathing a client because this activity isn't likely to cause contact with blood or body fluids. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Knowledge REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 531.

1016A nurse is performing a sterile dressing change. Which action contaminates the sterile field?1. Holding sterile objects above the waist2. Pouring solution onto a sterile field cloth3. Leaving a 1 (2.5-cm) edge around the sterile field4. Opening the outermost flap of a sterile package away from the bodyCorrect answer: 2RATIONALE: Pouring solution onto a sterile field cloth contaminates the sterile field because moisture penetrating the cloth can carry microorganisms to the sterile field via capillary action. Holding sterile objects above the waist, leaving a 1 edge around the sterile field, and opening the outermost flap of a sterile package away from the body maintain the sterile field. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Knowledge REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 475.

1017A client is placed in isolation. Client isolation techniques attempt to break the chain of infection by interfering with the:1. agent.2. susceptible host.3. transmission mode.4. portal of entry.Correct answer: 3RATIONALE: Client isolation techniques attempt to break the chain of infection by interfering with the transmission mode. These techniques don't affect the agent, host, or portal of entry. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Knowledge REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p.530.

1018A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the care plan?1. Putting on an individually fitted mask when entering the client's room2. Instructing the client to wear a mask at all times3. Wearing a gown and gloves when providing direct care4. Keeping the door to the client's room open to observe the clientCorrect answer: 1RATIONALE: Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a mask when entering the client's room. Occupation Safety and Health Administration standards require an individually fitted mask. Having the client wear a mask at all times would hinder sputum expectoration and respirations would make the mask moist. A nurse who doesn't anticipate contact with the client's blood or body fluids need not wear a gown or gloves when providing direct care. A client with TB should be in a room with laminar airflow, and the room's door should be shut at all times. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Comprehension REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 645.

1019To help minimize calcium loss from a hospitalized client's bones, the nurse should:1. reposition the client every 2 hours.2. encourage the client to walk in the hall.3. provide the client dairy products at frequent intervals.4. provide supplemental feedings between meals.Correct answer: 2RATIONALE: Calcium absorption diminishes with reduced physical activity because of decreased bone stimulation. Therefore, encouraging the client to increase physical activity, such as by walking in the hall, helps minimize calcium loss. Turning or repositioning the client every 2 hours wouldn't increase activity sufficiently to minimize bone loss. Providing dairy products and supplemental feedings wouldn'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. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 645.

1020When providing oral hygiene for an unconscious client , the nurse must perform which action?1. Swab the client's lips, teeth, and gums with lemon glycerin.2. Clean the client's tongue with gloved fingers.3. Place the client in semi-Fowler's position.4. Place the client in a side-lying position.Correct answer: 4RATIONALE: An unconscious client is at risk for aspiration. To decrease this risk, the nurse should place the client in a side-lying position when performing oral hygiene. Swabbing the client's lips, teeth, and gums with lemon glycerin would promote tooth decay. Cleaning an unconscious client's tongue with gloved fingers wouldn't be effective in removing oral secretions or debris. Placing the client in semi- Fowler's position would increase the risk of aspiration. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1165.

1021A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?1. Turning the client every 2 hours2. Elevating the head of the bed 30 degrees3. Encouraging increased fluid intake4. Maintaining a cool room temperatureCorrect answer: 3RATIONALE: Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions and ensures adequate hydration. Turning the client every 2 hours would help prevent pressure ulcers but wouldn't help with the secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 640.

1022Which option is an example of a primary preventive measure?1. Participating in a cardiac rehabilitation program2. Having an annual physical examination3. Practicing monthly breast self-examination4. Avoiding overexposure to the sunCorrect answer: 4RATIONALE: Primary prevention involves promoting health and helping clients achieve maximum wellness. Primary preventive measures are designed to prevent or delay the onset of specific illnesses; these measures typically include lifestyle changes such as avoiding overexposure to the sun to prevent skin cancer. Participating in a cardiac rehabilitation program is an example of a tertiary preventive measure, which attempts to prevent complications of an existing disease. Annual physical examinations and monthly breast self-examinations are examples of secondary preventive measures, which promote early detection and treatment of disease. CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Comprehension REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 73.

1023A nurse is assigned to a client with a cardiac disorder. The nurse should question an order to monitor the client's body temperature by which route?1. Rectal2. Oral3. Axillary4. TympanicCorrect answer: 1RATIONALE: When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take temperature. Using this route could stimulate the vagus nerve, possibly leading to vasodilation and bradycardia . The other options are appropriate routes for measuring the temperature of a client with a cardiac disorder. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Comprehension REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 487.

1024To evaluate a client for hypoxia , the physician is most likely to order which laboratory test?1. Red blood cell count2. Sputum culture3. Total hemoglobin4. Arterial blood gas (ABG) analysisCorrect answer: 4RATIONALE: Red blood cell count, sputum culture, total hemoglobin, and ABG analysis all help evaluate a client with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about the client's oxygenation status. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Comprehension REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 334.

1025A client, age 43, has no family history of breast cancer or other risk factors for this disease . The nurse should instruct her to have a mammogram how often?1. Once, to establish a baseline2. Once per year3. Every 2 years4. Twice per yearCorrect answer: 2RATIONALE: Yearly mammograms should begin at age 40 and continue for as long as the woman is in good health. If health risks exist, such as family history, genetic tendency, or past breast cancer, more frequent examinations may be necessary. CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Knowledge REFERENCE: American Cancer Society. "American Cancer Society Guidelines for Early Detection of Cancer, 2006." [Online]. Available: http://caonline.amcancersoc.org/cgi/content/full/56/1/11. [2007, January 8].

1026A client asks to be discharged from the health care facility against medical advice (AMA). What should the nurse do first?1. Prevent the client from leaving.2. Notify the physician.3. Have the client sign an AMA form.4. Call a security guard to help detain the client.Correct answer: 2RATIONALE: If a client requests a discharge AMA, the nurse should notify the physician immediately. If the physician can't convince the client to stay, the physician will ask the client to sign an AMA form, which releases the facility from legal responsibility for any medical problems the client may experience after discharge. If the physician isn't available, the nurse should discuss the AMA form with the client and obtain the client's signature. A client who refuses to sign the form shouldn't be detained because this would violate the client's rights. After the client leaves, the nurse should document the incident thoroughly and notify the physician that the client has left. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Knowledge REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 182.

1027When bandaging a client's ankle , the nurse should use which technique?1. Figure-eight2. Circular3. Recurrent4. Spiral reverseCorrect answer: 1RATIONALE: The nurse uses a figure-eight technique to bandage a joint, such as an ankle, elbow, wrist, or knee. The nurse uses the circular bandaging technique to anchor a bandage; the recurrent technique to bandage a stump, hand, or scalp; and the spiral reverse bandaging technique to accommodate the increasing circumference of a body part such as when in a cast. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Knowledge REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1215.

1028When placing an indwelling urinary catheter in a female client, the nurse should advance the catheter how far into the urethra?1. (1 cm)2. 2 (5 cm)3. 6 (15 cm)4. 8 (20 cm)Correct answer: 2RATIONALE: In a female client, the nurse should advance an indwelling urinary catheter 2 to 3 (5 to 7.5 cm) into the urethra. In a male client, the nurse should advance the catheter 6 to 8. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Knowledge REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1105.

1029A scrub nurse in the operating room has which responsibility?1. Positioning the client2. Assisting with gowning and gloving3. Handing surgical instruments to the surgeon4. Applying surgical drapesCorrect answer: 3RATIONALE: The scrub nurse assists the surgeon by providing appropriate surgical instruments and supplies, maintaining strict surgical asepsis and, with the circulating nurse, accounting for all gauze sponges, needles, and instruments. The circulating nurse assists the surgeon and scrub nurse, positions the client, assists with gowning and gloving, applies appropriate equipment and surgical drapes, and provides the surgeon and scrub nurse with supplies. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Knowledge REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 656.

1030A nurse is recording a client's complaint of painful urination . When documenting this symptom, the nurse should use which term?1. Oliguria2. Anuria3. Pyuria4. DysuriaCorrect answer: 4RATIONALE: The nurse should document painful urination as dysuria. Oliguria refers to a decrease in the amount of urine excreted; anuria , to a urine output below 50 ml/day; and pyuria , to pus in the urine. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Knowledge REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed.Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1084.

1031A client has left-sided paralysis . The nurse should document this condition as left-sided:1. monoplegia.2. hemiplegia.3. paraplegia.4. quadriplegia.Correct answer: 2RATIONALE: Hemiplegia refers to paralysis of one side of the body; therefore, the nurse should document that the client has left-sided hemiplegia. Monoplegia refers to paralysis of one extremity; paraplegia , to paralysis of both lower limbs; and quadriplegia , to paralysis of all four extremities and usually also the trunk. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Comprehension REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1284.

1032Which member of the health care team is responsible for obtaining informed consent from a client?1. The primary nurse2. The physician involved with the procedure3. The nurse working with the physician4. The social workerCorrect answer: 2RATIONALE: The physician involved with the procedure is responsible for obtaining the client's informed consent. The primary nurse or the nurse working with the physician may witness the client's signature. The social worker may not obtain informed consent. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Knowledge REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 100.

1033A nurse implements a teaching plan for a client who's scheduled for discharge. Which client behavior best demonstrates effective teaching?1. Exhibiting a positive change in behavior2. Verbally repeating the instruction3. Making statements indicating understanding4. Exhibiting nonverbal signs such as nodding the head to indicate "yes"Correct answer: 1RATIONALE: Exhibiting a positive change in behavior best demonstrates that the client understands and is complying with discharge teaching. Merely repeating what has been said, telling the nurse that the client understands, or nodding the head to indicate "yes" wouldn't demonstrate that the client has learned anything. CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Application REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 414.

1034Which strategy can help make the nurse a more effective teacher?1. Including the client in the discussion2. Using technical terms3. Providing detailed explanations4. Using loosely structured teaching sessionsCorrect answer: 1RATIONALE: An effective teacher always involves the client in the discussion. Using technical terms and providing detailed explanations usually confuse the client and act as barriers to learning. Using loosely structured teaching sessions permits distractions and deviations from teaching goals. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Application REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 413.

1035A client complains of dyspnea . Which action by the nurse is most appropriate?1. Placing the client in Trendelenburg position2. Placing the client in Sims' position3. Placing the client in Fowler's position4. Placing the client in the supine positionCorrect answer: 3RATIONALE: Fowler's position the posture assumed by the client when the head of the bed is elevated 40 to 60 degrees promotes breathing by allowing the thoracic cavity to expand. The Trendelenburg, Sims', and supine positions wouldn't facilitate breathing. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 870.

1036A client has a blood pressure of 152/86 mm Hg. The nurse should document the client's pulse pressure as:1. 66 mm Hg.2. 238 mm Hg.3. 86 mm Hg.4. 152 mm Hg.Correct answer: 1RATIONALE: Pulse pressure is the difference between the systolic and diastolic pressures in this case, 66 mm Hg. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Comprehension REFERENCE: Weber, J., and Kelley, J. Health Assessment in Nursing, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 102.

1037A physician orders chest physiotherapy for a client with pulmonary congestion. When should the nurse plan to perform chest physiotherapy?1. After meals2. Before meals3. When the client has time4. When the nurse has timeCorrect answer: 2RATIONALE: To avoid tiring the client or inducing vomiting, chest physiotherapy is best performed before meals. Scheduling chest physiotherapy around client or nurse convenience is inappropriate. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Comprehension REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1626.

1038A physician orders a bland, full-liquid diet for a client. The nurse tells the client that his diet may include:1. orange juice, farina, and coffee.2. apple juice, cream of chicken soup, and vanilla ice cream.3. pineapple juice, a bran muffin, and milk.4. orange juice, custard, and tea.Correct answer: 2RATIONALE: A bland, full-liquid diet may include fruit juices and foods from all of the food groups. On this diet, the client should avoid gastric irritants, such as coffee, tea, colas, cocoa, breads, bran (fiber), and highly seasoned foods. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Comprehension REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 989.

1039A nurse is preparing a client for bronchoscopy . Which instruction should the nurse give to the client?1. Don't walk.2. Don't cough.3. Don't talk.4. Don't eat.Correct answer: 4RATIONALE: Bronchoscopy involves visualization of the trachea and bronchial tree. To prevent aspiration of stomach contents into the lungs, the nurse should instruct the client not to eat or drink anything for approximately 6 hours before the procedure. It isn't necessary for the client to avoid walking, talking, or coughing. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Knowledge REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 581.

1040When providing discharge teaching to a client with a fractured toe , the nurse should include which instruction?1. Apply heat to the fracture site.2. Apply ice to the fracture site.3. Perform ankle dorsiflexion three times per day.4. Use crutches for 1 week.Correct answer: 2RATIONALE: Applying ice to the injury site soon after an injury causes vasoconstriction , helping to relieve or prevent swelling and bleeding. Applying heat to the fracture site may increase swelling and bleeding. Ankle dorsiflexion has no therapeutic use after a toe fracture. It's unlikely the client would need crutches after a toe fracture. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 2426.

1041A nurse is to collect a sputum specimen from a client. The best time to collect this specimen is:1. early in the evening.2. any time during the day.3. in the morning, as soon as the client awakens.4. before bedtime.Correct answer: 3RATIONALE: Because sputum accumulates in the lungs during sleep, the nurse should collect a sputum specimen in the morning, as soon as the client awakens. This specimen will be concentrated, increasing the likelihood of an accurate culture. Sputum specimens collected at other times during the day aren't concentrated and may not provide an accurate culture. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Knowledge REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 288.

1042A nurse-manager notes that a staff nurse isn't working to full potential. Which strategy by the nurse-manager would best benefit the staff nurse?1. Assigning the staff nurse several clients with multiple physical problems2. Allowing the staff nurse to select her own assignments3. Discussing the staff nurse's performance and ways she can improve4. Assigning the staff nurse fewer patients than her coworkersCorrect answer: 3RATIONALE: The nurse-manager should meet with the staff nurse to discuss her performance and ways she can improve. Assigning the staff nurse several clients with multiple physical problems would be overwhelming, counterproductive, and unsafe because she has yet to demonstrate the priority-setting and decision-making leadership skills that this client load would require. Letting her select her own assignments or giving her fewer patients could impair the morale of other staff nurses. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Application REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 115.

1043Which client would qualify for hospice care?1. A client with late-stage acquired immunodeficiency syndrome (AIDS)2. A client with left-sided paralysis resulting from a stroke3. A client who's undergoing treatment for heroin addiction4. A client who had coronary artery bypass surgery 2 weeks earlierCorrect answer: 1RATIONALE: Hospices provide supportive, palliative care to terminally ill clients, such as those with late-stage AIDS , as well as their families. Hospice services wouldn't be appropriate for a client with left-sided paralysis resulting from a stroke, a client who's undergoing treatment for heroin addiction, or one who recently had coronary artery bypass surgery because these health problems aren't necessarily terminal. CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Comprehension REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 159.

1044A nurse should question an order for a heating pad for a client who has:1. active bleeding.2. a reddened abscess.3. an edematous lower leg.4. purulent wound drainage.Correct answer: 1RATIONALE: Heat application increases blood flow and therefore is contraindicated in active bleeding. For the same reason, however, applying heat to a reddened abscess, an edematous lower leg, or a wound with purulent drainage promotes healing. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Analysis REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1223.

1045Which action must a nurse perform when cleaning the area around a Jackson-Pratt wound drain?1. Clean from the center outward in a circular motion.2. Remove the drain before cleaning the skin.3. Clean briskly around the site with alcohol.4. Wear sterile gloves and a mask.Correct answer: 1RATIONALE: The nurse should move from the center outward in ever-larger circles when cleaning around a wound drain because the skin near the drain site is more contaminated than the site itself. The nurse should never remove the drain before cleaning the skin. Alcohol should never be used to clean around a drain; it may irritate the skin and, because it evaporates, has no lasting effect on bacteria. The nurse should wear sterile gloves to prevent contamination, but need not wear a mask. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Comprehension REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 159.

1046A client who suffered a stroke has a nursing diagnosis of Ineffective airway clearance. The goal of care for this client is to mobilize pulmonary secretions . Which intervention helps meet this goal?1. Repositioning the client every 2 hours2. Restricting fluids to 1,000 ml/24 hours3. Administering oxygen by nasal cannula as ordered4. Keeping the head of the bed at a 30-degree angleCorrect answer: 1RATIONALE: Repositioning the client every 2 hours helps prevent secretions from pooling in dependent lung areas. Restricting fluids would make secretions thicker and more tenacious, thereby hindering their removal. Administering oxygen and keeping the head of the bed at a 30-degree angle might ease respirations and make them more effective but wouldn't help mobilize secretions. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 873.

1047A nurse caring for a client with a fecal impaction should watch for:1. liquid or semiliquid stools.2. hard, brown, formed stools.3. loss of urge to defecate.4. increased appetite.Correct answer: 1RATIONALE: Passage of liquid or semiliquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clients with fecal impaction don't pass hard, brown, formed stools because the feces can't move past the impaction. These clients typically report the urge to defecate (although they can't pass stool) and decreased appetite. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1575.

1048A nurse is obtaining a sterile urine specimen from a client's indwelling urinary catheter. During the procedure, the nurse should:1. aspirate urine from the tubing port, using a sterile syringe and needle.2. disconnect the catheter from the tubing and collect urine.3. open the drainage bag and pour out some urine.4. wear sterile gloves when collecting urine.Correct answer: 1RATIONALE: To collect urine properly, the nurse should aspirate it from a port, using a sterile syringe and needle after cleaning the port. Opening a closed urine-drainage system, which would occur if the nurse disconnected the catheter from the tubing or opened the drainage bag, would increase the risk of urinary tract infection . Although standard precautions specify wearing gloves during contact with body fluids, the nurse need not wear sterile gloves for this procedure. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Comprehension REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1495.

1049Which nursing action is essential when providing continuous enteral feeding?1. Elevating the head of the bed2. Positioning the client on his left side3. Warming the formula before administering it4. Adding methylene blue to the enteral feeding to detect aspirationCorrect answer: 1RATIONALE: Elevating the head of the bed during enteral feeding minimizes the risk of aspiration and allows the formula to flow into the client's intestines. When such elevation is contraindicated, the client should be positioned on his right side. The nurse should give enteral feedings at room temperature to minimize GI distress. Because methylene blue can cause adverse effects, it isn't a recommended enteral feeding additive. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Application REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1452.

1050A client is admitted with multiple pressure ulcers . When developing the client's diet plan, the nurse should include:1. fresh orange slices.2. ground beef patties.3. steamed broccoli.4. ice cream.Correct answer: 2RATIONALE: Meat is an excellent source of complete protein, which this client needs to repair the tissue breakdown caused by pressure ulcers. Oranges and broccoli supply vitamin C but not protein. Ice cream supplies only some incomplete protein, making it less helpful in tissue repair. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Analysis REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1014.

1051A client is admitted to the facility with a productive cough , night sweats, and a fever. Which action is most important in the initial care plan?1. Assessing the client's temperature every 8 hours2. Placing the client in respiratory isolation3. Monitoring the client's fluid intake and output4. Wearing gloves during all client contactCorrect answer: 2RATIONALE: Because the client's signs and symptoms suggest a respiratory infection (possibly tuberculosis ), respiratory isolation is indicated. Every 8 hours isn't frequent enough to assess the temperature of a client with a fever. Monitoring fluid intake and output may be required, but the client should first be placed in isolation. The nurse should wear gloves only for contact with mucous membranes, broken skin, blood, and other body fluids and substances. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Analysis REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 644.

1052A client is being discharged after abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care?1. Notifying the American Cancer Society of the client's diagnosis2. Requesting Meals On Wheels to provide adequate nutritional intake3. Referring the client to a home health nurse for follow-up visits to provide colostomy care4. Asking an occupational therapist to evaluate the client at homeCorrect answer: 3RATIONALE: Many clients are discharged from acute care settings so quickly that they don't receive complete instructions. Therefore, the first priority is to arrange for colostomy care. The American Cancer Society often sponsors support groups, which are helpful when the person is ready, but contacting this organization doesn't take precedence over ensuring proper colostomy care. Requesting Meals On Wheels and asking for an occupational therapy evaluation are important, but these actions can occur later in rehabilitation. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Analysis REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 179.

1053A client's rights to information, informed consent , and treatment refusal are addressed in the:1. standards of nursing practice.2. Patient Care Partnership.3. nurse practice act.4. code for nurses.Correct answer: 2RATIONALE: The Patient Care Partnership addresses the client's rights to information, informed consent, timely responses to requests for services, and treatment refusal. It's a legal document and serves as a guideline for decision making by the nurse. Standards of nursing practice, the nurse practice act, and the code for nurses contain nursing practice parameters and primarily describe use of the nursing process in providing care. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Knowledge REFERENCE: American Hospital Association. "What to expect during your hospital stay." [Online]. Available: http://www.aha.org/aha/content/2003/pdf/pcp_english_030730.pdf. [2007, January 8].

1054An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion?1. Primary prevention2. Secondary prevention3. Tertiary prevention4. Passive preventionCorrect answer: 1RATIONALE: Primary prevention precedes disease and applies to healthy clients. Secondary prevention focuses on clients who have health problems and are at risk for developing complications. Tertiary prevention focuses on rehabilitating clients who already have a disease or disability. Passive prevention enables clients to gain health as a result of others' activities without doing anything themselves. CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Comprehension REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 73.

1055When following standard precautions , a nurse's primary responsibility is to:1. wear gloves for all client contact.2. consider all body substances potentially infectious.3. place a body substance isolation sign on the client's door.4. wear gloves and a gown if the client is in respiratory isolation.Correct answer: 2RATIONALE: Standard precautions are based on the concept that all body substances are potentially infectious and that direct contact with them must be avoided. The nurse should wear gloves when contact with body substances not unsoiled articles or intact skin is anticipated. Because all body substances from all clients are considered potentially infectious, signs on doors are unnecessary. Gloves and gowns are inappropriate when caring for a client in respiratory isolation because they don't prevent transmission of airborne respiratory infections. The nurse should wear a mask as a barrier to such infections. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Knowledge REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 531.

1056When changing a sterile surgical dressing, a nurse first must:1. wash her hands.2. put on sterile gloves.3. remove the old dressing while wearing clean gloves.4. open sterile packages and moisten the dressings with sterile saline solution.Correct answer: 1RATIONALE: To prevent the spread of microorganisms, the nurse should always wash her hands before providing client care. When changing a sterile surgical dressing, the nurse also must put on sterile gloves, remove the old dressing while wearing clean gloves, open sterile packages, and moisten the dressings with sterile saline. However, these actions follow hand washing. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Knowledge REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1210.

1057After suctioning a client, a nurse should expect to find:1. a respiratory rate of 28 breaths/minute.2. a heart rate of 104 beats/minute.3. brisk capillary refill.4. clear breath sounds.Correct answer: 4RATIONALE: Clear breath sounds, which indicate that secretions have been removed, indicate effective suctioning. An above-normal respiratory rate, such as a rate of 28 breaths/minute, may indicate that the airway isn't clear of secretions and the client's respiratory rate has increased to compensate. A slightly increased heart rate, such as a rate of 104 beats/minute, may indicate health concerns unrelated to suctioning. Brisk capillary refill indicates adequate cardiovascular function and is unrelated to suctioning. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1649.

1058A client twists his right ankle while playing basketball and seeks care for ankle pain and swelling. After the nurse applies ice to the ankle for 30 minutes, which client statement suggests that ice application has been effective ?1. "I need something stronger for pain relief."2. "My ankle looks less swollen now."3. "My ankle appears redder now."4. "My ankle feels very warm."Correct answer: 2RATIONALE: Ice application decreases pain and swelling. Continued or increased pain, redness, and increased warmth are signs of inflammation that shouldn't occur after ice application. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1222.

1059A client suddenly loses consciousness. What should the nurse do first ?1. Call for assistance.2. Assess for responsiveness.3. Palpate for a carotid pulse.4. Assess for pupillary response.Correct answer: 2RATIONALE: A nurse always should assess for responsiveness first to prevent injuries to a client who isn't in cardiac or respiratory arrest. After assessing the client, the nurse should call for assistance, open the client's airway, check for breathing, and palpate for a carotid pulse. Assessing for pupillary response would waste valuable time and is inappropriate. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Analysis REFERENCE: ECC Committee, Subcommittees and Task Force of the American Heart Association. "2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Part 4: Adult Basic Life Support. Circulation 112(24 Suppl IV):IV19-IV34, December 13, 2005.

1060When leaving the room of a client in strict isolation, the nurse should remove which protective equipment first ?1. Cap2. Mask3. Gown4. GlovesCorrect answer: 4RATIONALE: When leaving a strict-isolation room, the nurse should remove her gloves first because they're considered the most contaminated protective equipment. Removing other protective equipment before removing her gloves and washing her hands could contaminate her hair and uniform and promote pathogen transmission. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Knowledge REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 531.

1061A client has a soft wrist-safety device. Which assessment finding should the nurse investigate further?1. A palpable radial pulse2. A palpable ulnar pulse3. Cool, pale fingers4. Pink nail bedsCorrect answer: 3RATIONALE: A wrist-safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the client for signs of impaired circulation such as cool, pale fingers. A palpable radial or ulnar pulse and pink nail beds are normal findings. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Comprehension REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 693.

1062Which nursing theorist addressed self-care deficits in her nursing theory?1. Dorothy Johnson2. Virginia Henderson3. Dorothea Orem4. Martha RogersCorrect answer: 3RATIONALE: Dorothea Orem's general theory of nursing addresses self-care deficits as the basis for nursing care. This theory posits that the nurse intervenes to reestablish the client's self-care capacity. Dorothy Johnson's behavioral systems theory views nursing as a means to reestablish balance in the client's behavioral subsystems, which have been disrupted by stress. According to Virginia Henderson's theory of nursing, the nurse focuses on the client's basic needs. In Martha Rogers' unitary human beings theory, the nurse helps the client balance the changes that occur as he constantly evolves. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Knowledge REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 59.

1063A physician orders an intestinal tube to decompress a client's GI tract. When gathering equipment for this procedure, a nurse should obtain a:1. Sengstaken-Blakemore tube.2. Miller-Abbott tube.3. Levin tube.4. Salem sump tube.Correct answer: 2RATIONALE: A Miller-Abbott tube is an intestinal tube. A Sengstaken-Blakemore tube is an esophageal tube. Levin tubes and Salem sump tubes are nasogastric tubes. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1175.

1064During assessment, a nurse measures a client's respiratory rate at 32 breaths/minute with a regular rhythm. When documenting this pattern, the nurse should use which term?1. Eupnea2. Bradypnea3. Apnea4. TachypneaCorrect answer: 4RATIONALE: A respiratory rate of 32 breaths/minute with a regular rhythm is faster than normal and should be documented as tachypnea . Eupnea is a respiratory rate of 12 to 20 breaths/minute with a regular rhythm. Bradypnea refers to a respiratory rate below 12 breaths/minute with a regular rhythm. Apnea refers to absence of breathing. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 571.

1065Which nursing intervention is appropriate for a client with an arm restraint?1. Applying the restraint loosely to prevent pressure on the skin2. Tying the restraint to the side rail3. Positioning the restrained arm in full extension4. Monitoring circulatory status every 2 hoursCorrect answer: 4RATIONALE: A nurse must assess the circulatory status of a restrained extremity every 2 hours to prevent circulatory impairment. To make sure the restraint is secure without compromising the circulation, the nurse should leave approximately one fingerbreadth between the restraint and the extremity. Tying a restraint to the side rail or an immovable bed part may cause client injury if the rail or bed is moved before the restraint is released. The restrained arm or leg should be flexed slightly to allow joint movement without reducing the effectiveness of the restraint. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Application REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 692.

1066A nurse is reviewing a client's laboratory test results. Which electrolyte is the major cation controlling a client's extracellular fluid (ECF) osmolality ?1. Potassium2. Sodium3. Chloride4. CalciumCorrect answer: 2RATIONALE: Sodium, the major ECF cation, maintains ECF osmolality. Potassium is the major cation in intracellular fluid. Chloride is the major anion in the ECF. Calcium, found primarily in the intravascular fluid compartment of ECF, is the major cation involved in the structure and function of the teeth and bones. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 920.

1067 Standard precautions include which measure?1. Wearing gloves when changing a dressing2. Disposing of needles in a puncture-resistant container3. Wearing eye protection during tracheal suctioning4. All of the aboveCorrect answer: 4RATIONALE: To follow standard precautions, caregivers must wear gloves when there is the potential for contact with a client's body fluids; place used, uncapped needles and syringes in a puncture-resistant container; and wear goggles during procedures that are likely to generate splashes of blood or body fluids. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Comprehension REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 531.

1068A nurse has been teaching a client how to use an incentive spirometer that he must use at home for several days after discharge. Which client action indicates an accurate understanding of the technique?1. The client takes slow, deep breaths to elevate the spirometer ball.2. The client takes rapid, shallow breaths to elevate the ball.3. The client tilts the spirometer down when using it.4. The client uses the device while lying supine.Correct answer: 1RATIONALE: When using an incentive spirometer, the client should take slow, deep breaths. This action ensures maximum ventilation, which elevates the ball (or disk) inside the spirometer. Rapid, shallow breathing doesn't allow maximum ventilation and lung expansion. The client should hold the spirometer upright; when tilted, a spirometer requires less effort to raise the ball. During spirometry, the client should sit upright rather than lie supine to promote maximum ventilation. CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Comprehension REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 846.

1069A nurse is caring for an elderly client with a pressure ulcer on the sacrum. When teaching the client about dietary intake, which foods should the nurse emphasize ?1. Legumes and cheese2. Whole grain products3. Fruits and vegetables4. Lean meats and low-fat milkCorrect answer: 4RATIONALE: Although the client should eat a balanced diet, including foods from all food groups, the diet should emphasize foods that supply complete protein, such as lean meats and low-fat milk. Protein helps build and repair body tissue, which promotes healing. Legumes provide incomplete protein. Cheese contains complete protein, but it also includes fat, which should be limited to 30% or less of caloric intake. Whole grain products supply incomplete proteins and carbohydrates. Fruits and vegetables provide mainly carbohydrates. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1014.

1070To collect a clean-catch midstream urine specimen from a female client, the nurse instructs her to clean the area at the external urinary meatus with an antiseptic. How should the client clean the area?1. By swabbing the labia minora from front to back2. By cleaning the labia minora from back to front3. By cleaning the labia majora from back to front4. By swabbing the entire perineal areaCorrect answer: 1RATIONALE: The client should swab the labia minora from front to back, using one swab for each wipe. This technique cleans from the area of least contamination to the area of greatest contamination. The labia minora shouldn't be cleaned from back to front because doing so increases the risk of contamination. The labia majora should be cleaned with soap and water from front to back not back to front. Before swabbing the labia minora with an antiseptic, the client should wash the perineal area with soap and water. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Comprehension REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 286.

1071A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?1. By providing a tracheostomy plug to use for verbal communication2. By placing the call button under the client's pillow3. By supplying a magic slate or similar device4. By suctioning the client frequentlyCorrect answer: 3RATIONALE: The nurse should use a nonverbal communication method, such as a magic slate, note pad and pencil, and picture boards (if the client can't write or speak English). The physician orders a tracheostomy plug when a client is being weaned off a tracheostomy; it doesn't enable the client to communicate. The call button, which should be within reach at all times for all clients, can summon attention but doesn't communicate additional information. Suctioning clears the airway but doesn't enable the client to communicate. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 750.

1072A nurse must apply a wet-to-damp dressing over an ulcer on a client's left ankle. How should the nurse proceed?1. Apply the saturated fine-mesh gauze dressings over the wound.2. Apply an occlusive dressing over the saturated fine-mesh gauze dressings.3. Cover the saturated fine-mesh gauze dressings with an elastic bandage.4. Pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound.Correct answer: 4RATIONALE: The nurse should pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound because necrotic tissue is usually more prevalent in those areas. The nurse should wring out excess moisture from saturated fine-mesh gauze dressings because saturated dressings won't dry properly. The nurse shouldn't apply an occlusive dressing or elastic bandage because these products can prevent air circulation and hinder drying of the fine-mesh gauze. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application REFERENCE: Ellis, J.R., and Bentz, P.M. Modules for Basic Nursing Skills, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 753.

1073A nurse must irrigate a gaping abdominal incision with sterile normal saline, using a piston syringe. How should she proceed?1. Irrigate continuously until the solution becomes clear.2. After the irrigation, moisten the area around the wound with normal saline.3. After the irrigation, apply a wet-to-damp dressing to the wound.4. Rapidly instill a stream of irrigating solution into the wound.Correct answer: 1RATIONALE: To wash away tissue debris and drainage effectively, the nurse should irrigate the wound until the solution becomes clear. After irrigation, the nurse should dry the area around the wound; moistening this area promotes microorganism growth and skin irritation. When the area is dry, the nurse should apply a dry, sterile dressing rather than a wet-to-damp dressing . The nurse should always instill the irrigating solution gently. Rapid or forceful instillation can damage tissues. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1237.

1074Which intervention should a nurse use when administering oxygen by face mask to a client?1. Secure the elastic band tightly around the client's head.2. Assist the client to the semi-Fowler's position if possible.3. Apply the face mask from the client's chin up over the nose.4. Loosen the connectors between the oxygen equipment and humidifier.Correct answer: 2RATIONALE: By assisting the client to the semi- Fowler's position , the nurse promotes easier chest expansion, breathing, and oxygen intake. The nurse should secure the elastic band so that the face mask fits comfortably and snugly rather than tightly, which could cause irritation. The nurse should apply the face mask from the client's nose down to the chin not vice versa. The nurse should ensure that the connectors between the oxygen equipment and humidifier are airtight; loosened connectors can cause loss of oxygen. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Application REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 852.

1075During a teaching session, a nurse demonstrates to a client how to change a tracheostomy dressing. Then the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure?1. The client cleans around the incision site, using gauze squares and full-strength hydrogen peroxide.2. The client rinses around the clean incision site, using gauze squares moistened with normal saline.3. The client rinses around the clean incision site, using gauze squares moistened with tap water.4. After cleaning around the incision site, the client applies cotton-filled gauze squares as the sterile dressing.Correct answer: 2RATIONALE: To change a tracheostomy dressing effectively, the client should rinse around the clean incision site, using gauze squares moistened with normal saline. If crusts are difficult to remove, the client may use a solution of 50% hydrogen peroxide and 50% sterile saline not full-strength hydrogen peroxide. The client shouldn't use tap water, which may contain chemicals and other harmful substances. To prevent lint or fiber aspiration and subsequent tracheal abscess, the client should use sterile dressings made of nonraveling material instead of cotton-filled gauze squares. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 862.

1076A client who's scheduled for open-heart surgery in 2 days has been having circulation problems in the feet and legs. The physician orders antiembolism stockings . The nurse is teaching the client about this treatment. What is the purpose of antiembolism stockings?1. To decrease arterial blood circulation to the legs and feet2. To decrease venous blood circulation from the legs and feet3. To reduce or prevent edema of the legs and feet4. To maintain warmth in the legsCorrect answer: 3RATIONALE: Made of elastic material, antiembolism stockings are designed to reduce or prevent edema of the legs or feet by promoting venous return. They do this by increasing not decreasing arterial and venous blood circulation to the legs and feet. They don't maintain warmth in the legs. Blankets can be used for this purpose. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 897.

1077A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic . The nurse suspects the client has developed a pneumothorax . Further assessment findings supporting the presence of a pneumothorax include:1. diminished or absent breath sounds on the affected side.2. paradoxical chest wall movement with respirations.3. tracheal deviation to the unaffected side.4. muffled or distant heart sounds.Correct answer: 1RATIONALE: In the case of a pneumothorax, auscultating for breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Tracheal deviation occurs in a tension pneumothorax . Muffled or distant heart sounds occur in cardiac tamponade. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Analysis REFERENCE: Smeltzer, S.C., and Bare, B. Brunner & Suddarth's Textbook of Medical Surgical-Nursing, 11th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 696.

1078A physician inserts a chest tube into a client to treat a pneumothorax . The tube is connected to a water-seal drainage system. The nurse can prevent chest tube air leaks by:1. keeping the chest drainage system below chest level.2. keeping the head of the bed slightly elevated.3. checking and taping all connections.4. checking patency of the chest tube.Correct answer: 3RATIONALE: Air leaks commonly occur if the system isn't secure. Checking and taping all connections will prevent air leaks. The chest drainage system is kept below chest level, and the head of the bed may be elevated to promote drainage not to prevent air leaks. Chest tubes that aren't patent may lead to tension pneumothorax but wouldn't cause an air leak. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1633.

1079A client is unable to take a deep breath and doesn't want to get out of bed because his chest tube is causing discomfort. To increase client adherence to the treatment plan, the nurse should:1. administer pain medication and delay client activity.2. tell the client why lung expansion is important.3. arrange a care schedule that includes rest periods.4. teach the client how to use an incentive spirometer.Correct answer: 1RATIONALE: Administering pain medication and delaying any activity until the medication takes effect will increase client adherence to the treatment plan. Explaining the purpose of the intended treatment is important but won't decrease the discomfort of the chest tube. Providing rest periods is essential but won't relieve the client's discomfort. An incentive spirometer measures deep-breathing ability, prevents atelectasis , and acts as a visual progress chart for the client. Teaching the client about incentive spirometry won't alleviate his discomfort. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis REFERENCE: Craven, R.F., and Hirnle, C.J. Fundamentals of Nursing: Human Health and Function, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1191.

1080To assess effectiveness of incentive spirometry, a nurse can use a pulse oximeter to monitor a client's:1. oxygen saturation.2. hemoglobin level.3. partial pressure of carbon dioxide (PaCO2).4. partial pressure of oxygen (PaO2).Correct answer: 1RATIONALE: A pulse oximeter is a noninvasive method of monitoring oxygen saturation. It doesn't measure hemoglobin, PaCO2, or PaO2 levels. Hemoglobin, the main component of the red blood cell that carries oxygen from the lungs, is measured by a simple laboratory test. Arterial blood gas analysis evaluates gas exchange in the lungs by measuring PaCO2 and PaO2. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1615.

1081A nurse is caring for a client who required chest tube insertion for a pneumothorax . To assess for pneumothorax resolution , the nurse can anticipate that the client will require:1. monitoring of arterial oxygen saturation (SaO2).2. arterial blood gas (ABG) studies.3. chest auscultation.4. a chest X-ray.Correct answer: 4RATIONALE: Chest X-ray confirms diagnosis by revealing air or fluid in the pleural space. SaO2 values may initially decrease with a pneumothorax but typically return to normal within 24 hours. ABG studies may show hypoxemia , possibly with respiratory acidosis and hypercapnia not related to a pneumothorax. Chest auscultation will determine overall lung status, but it's difficult to determine if the chest has reexpanded sufficiently. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1633.

1082A nurse is teaching the parents of a child with cystic fibrosis about proper nutrition. Which instruction should the nurse include?1. Encourage a high-calorie, high-protein diet.2. Restrict fluids to 1,500 ml per day.3. Limit salt intake to 2 g per day.4. Encourage foods high in vitamin B.Correct answer: 1RATIONALE: The child should be encouraged to eat a high-calorie, high-protein diet. In cystic fibrosis, the pancreatic enzymes (lipase, trypsin, and amylase) become so thick that they plug the ducts. In the absence of these enzymes, the duodenum can't digest fat, protein, and some sugars; therefore, the child can become malnourished. A child with cystic fibrosis needs to drink plenty of fluid and take salt supplements, especially on warm days or when exercising, to help maintain hydration and adequate sodium levels. Water-soluble forms of the fat-soluble vitamins (A, D, E, and K) are essential. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1271.

1083A child with rheumatic fever complains of painful joints. Which nonpharmacologic measures should the nurse use to reduce the child's pain?1. Perform gentle passive range-of-motion exercises.2. Gently massage the painful joints.3. Use a bed cradle to keep linens from pressing on the child's joints.4. Encourage the child to change position in bed every 2 hours.Correct answer: 3RATIONALE: In rheumatic fever, the joints may be so sensitive that even the weight of the bed linens can cause pain. A bed cradle reduces pain by lifting the linens off the child. Moving the affected joint may increase pain; therefore, passive range-of-motion exercises aren't recommended. Massaging the joints isn't likely to relieve pain. The nurse should encourage the child to change positions at least every 2 hours to reduce the risk of skin breakdown, but this is unlikely to relieve joint pain. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application REFERENCE: Hatfield, N. Broadribb's Introductory Pediatric Nursing, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2004, p. 383.

1084A nurse is giving nutritional counseling to the mother of a child with celiac disease . Which statement by the mother indicates understanding ?1. "My son can't eat wheat, rye, oats, or barley."2. "My son needs a gluten-rich diet."3. "My son must avoid potatoes, rice, and cornstarch."4. "My son can safely eat frozen and packaged foods."Correct answer: 1RATIONALE: A child with celiac disease must follow a gluten-free diet. If the child eats foods containing gluten, changes in the intestinal mucosa will prevent the absorption of fats and other foods. Therefore, all foods containing wheat, rye, oats, and barley must be eliminated from the diet. Such foods as potatoes, rice, and cornstarch may be included in a gluten-free diet. Frozen and packaged foods, which may contain gluten fillers, should be avoided. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Comprehension REFERENCE: Hatfield, N. Broadribb's Introductory Pediatric Nursing, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2003, p. 261.

1085A nurse is caring for a child with celiac disease . How should the nurse evaluate the effectiveness of nutritional therapy?1. Monitor vital signs every 4 hours.2. Monitor the appearance, size, and number of stools.3. Measure blood urea nitrogen and serum creatinine levels.4. Measure intake and output.Correct answer: 2RATIONALE: A gluten-free diet should eliminate fat, bulky, foul-smelling stools in a child with celiac disease. This finding indicates that the disease is controlled and the child is using nutrients effectively. Taking vital signs, measuring blood urea nitrogen and serum creatinine levels, and measuring intake and output don't indicate the effectiveness of nutritional therapy. CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Analysis REFERENCE: Hatfield, N. Broadribb's Introductory Pediatric Nursing, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2003, p. 261.

1086Policy and procedure require hand washing when caring for clients. Which statement about hand washing is true?1. Frequent hand washing reduces transmission of pathogens from one client to another.2. Wearing gloves is a substitute for hand washing.3. Bar soap, which is generally available, should be used for hand washing.4. Waterless products shouldn't be used in situations in which running water is unavailable.Correct answer: 1RATIONALE: Even if the nurse wears gloves, she must wash her hands before and after client contact because thorough hand washing reduces the risk of cross-contamination. She shouldn't use bar soap because it's a potential carrier of bacteria. Soap dispensers are preferable, but they must be checked for bacteria. When water is unavailable, the nurse should use a liquid hand sanitizer to wash her hands. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Comprehension REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 708.

1087A nurse is evaluating a postoperative client for infection . Which sign or symptom is most indicative of infection?1. The presence of an indwelling urinary catheter2. Rectal temperature of 100 F (37.8 C)3. Red, warm, tender incision4. White blood cell (WBC) count of 8,000/lCorrect answer: 3RATIONALE: Redness, warmth, and tenderness in the incision area indicate a postoperative infection. The presence of an invasive device predisposes a client to infection, but that alone doesn't indicate infection. A rectal temperature of 100 F would be a normal expectation in a postoperative client because of the inflammatory process. A normal WBC count ranges from 4,000 to 10,000/l. This client's WBC count falls within this normal range. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Analysis REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 1192.

1088A nurse is caring for a client with a fractured hip. The client is combative, confused, and trying to pull out necessary I.V. lines and an indwelling urinary catheter. The nurse should:1. leave the client and get help.2. obtain a physician's order to restrain the client.3. read the facility's policy on restraints.4. order soft restraints from the storeroom.Correct answer: 2RATIONALE: In most settings, the nurse must have a physician's order before restraining a client. A client should never be left alone while the nurse summons assistance. All staff members must receive annual instruction on the use of restraints, and the nurse should be familiar with the facility's policy. CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Analysis REFERENCE: Taylor, C., et al. Fundamentals of Nursing: The Art and Science of Nursing Care, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2008, p. 680.

1089A nurse is assessing a client for the risk of falls. The nurse should obtain:1. gait and balance information.2. the facility's restraint policy.3. the family's psychosocia