Fundamentals
A nurse is caring for a client who requires the insertion of a nasogastric tube. Which of the following actions should the nurse take when preparing to insert the tube?
Wear sterile gloves for the insertion procedure
Assist the client into a side-lying position
Measure the distance from the nose to the earlobe to the xiphoid
Lubricate the tip of the tube with petroleum jelly
Correct Answer: C.
Measure the distance from the nose to the earlobe to the xiphoid
The nurse should use the tube to measure from the tip of the client's nose to the tip of the earlobe and then to the tip of the xiphoid and mark that as the length of the tube to insert.
A nurse is caring for a client who has a new diagnosis of pernicious anemia. The nurse should expect the client's provider to prescribe which of the following medications for this client?
Ferrous sulfate
Epoetin alfa
Vitamin B12
Folic acid
Correct Answer: C.
Vitamin B12
The nurses should expect the client's provider to prescribe vitamin B12 to a client who has pernicious anemia.
A nurse is contributing to the plan of care for a client who has been admitted for the treatment of a malignant melanoma of the upper leg without metastasis. The nurse should expect the provider to perform which of the following procedures?
Curettage
External radiation therapy
Regional chemotherapy
Surgical excision
Correct Answer: D.
Surgical excision
The therapeutic approach to malignant melanoma depends on the level of invasion and the depth of the lesion. Surgical excision is the treatment of choice for small, superficial lesions. Deeper lesions require wide, local excision followed by skin grafting.
A nurse is assisting with the care of a child who had her spleen removed following a bicycle accident. The child's parent asks the nurse about the role of the spleen in the body. The nurse should reply that the spleen performs which of the following functions?
Maintains fluid balance
Regulates calcium in the blood
Destroys old blood cells
Produces prothrombin
Correct Answer: C.
Destroys old blood cells
A function of the spleen is to destroy old blood cells. The spleen also filters antigens and stores platelets. A client with the spleen removed is at an increased risk of infection and sepsis due to reduced immune function
A nurse is talking with an older adult client who is at risk for osteoporosis about strategies for preventing bone loss. Which of the following instructions should the nurse provide?
Begin a program of brisk walking
Take 800 mg of calcium per day
Drink plenty of sparkling water
Drink 8 oz of red wine each day
Correct Answer: A.
Begin a program of brisk walking
Weight-bearing exercises help maintain bone mass and prevent osteoporosis. Walking is generally a safe activity for older clients.
A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein?
Eggs
Cereal
Peanut butter
Pasta
Correct Answer: A.
Eggs
Complete proteins contain all of the essential amino acids to support growth and homeostasis. Examples of complete proteins include eggs, meat, poultry, seafood, milk, yogurt, cheese, soybeans, and soybean products.
A nurse is caring for a client who has femoral thrombophlebitis and a prescription for enoxaparin. Which of the following actions should the nurse take?
Elevate the affected leg
Place the client on bed rest
Massage the affected leg
Administer aspirin for discomfort
Correct Answer: A.
Elevate the affected leg
The nurse should elevate the client's affected leg when the client is in bed to reduce inflammation.
A nurse in a provider’s office is caring for a client who has a new diagnosis of herpes zoster. The nurse should anticipate a prescription for which of the following medications?
Zoster vaccine
Acyclovir
Amoxicillin
Infliximab
Correct Answer: B.
Acyclovir
The nurse should anticipate a prescription for acyclovir, an antiviral medication that inhibits replication of the virus that causes herpes zoster.
A nurse is reinforcing teaching about hypoglycemia with a client who has diabetes mellitus. Which of the following manifestations should the nurse include? (Select all that apply.)
Bradycardia
Diaphoresis
Deep, rapid respirations
Palpitations
Shakiness
Correct Answers: B.
Diaphoresis
D.
Palpitations
E.
Shakiness
A nurse is reviewing the medical record of a client who has a prescription for probenecid to treat gout. The nurse should identify that which of the following medications can interact with probenecid?
Colchicine
Naproxen
Aspirin
Prednisone
Correct Answer: C.
Aspirin
Aspirin can decrease the effectiveness of probenecid. The nurse should caution the client to avoid any interaction between probenecid and salicylate medications.
A nurse is collecting data for a client who has had diarrhea and decreased urination for several days. Which of the following actions should the nurse take to determine if the client is dehydrated?
Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink
Grasp a skinfold on the chest under the clavicle, release it, and note whether it springs back
Press the skin in above the ankle for 5 sec, release it, and note the depth of the impression
Measure the skin fold thickness at the upper arm using a pair of calibrated skinfold calipers
Correct Answer: B.
Grasp a skinfold on the chest under the clavicle, release it, and note whether it springs back
The nurse should use this technique for collecting data on skin turgor. If the client has good turgor and is properly hydrated, the skin will immediately return to normal; in dehydration, the skin will remain tented. The nurse can also collect data on skin turgor by grasping a skinfold on the back of the forearm.
A nurse is collecting data from a client. Which of the following findings should the nurse identify as a risk factor for coronary artery disease? (Select all that apply.)
Hypothyroidism
Hypertension
Diabetes mellitus
Hyperlipidemia
Tobacco smoking
Correct Answers: B.
Hypertension
C.
Diabetes mellitus
D.
Hyperlipidemia
E.
Tobacco smoking
A nurse is collecting data from a client who is 3 days postoperative following abdominal surgery. The client's incision is slightly edematous, appears pink with crusting on the edges, and is draining serosanguinous fluid. Which of the following statements describes this incision?
The incision is showing early signs of infection.
The incision is showing early signs of dehiscence.
The incision is showing signs of healing without complications.
The incision is showing signs of developing a fistula.
Correct Answer: C.
The incision is showing signs of healing without complications.
The nurse's findings are consistent with appropriate healing without complications
A nurse in a provider's office is collecting data from a client who has GERD. When documenting the client's history, the nurse should expect the client to report that symptoms worsen with which of the following actions?
Stair climbing
Bending over
Sitting
Walking
Correct Answer: B.
Bending over
Gastroesophageal reflux symptoms are most evident with activities that increase intraabdominal pressure such as bending over, straining, lifting, and lying down.
A nurse is reinforcing teaching about disease management with a client who has rheumatoid arthritis. Which of the following responses by the client indicates an understanding of this information?
"I will take a hot bath every morning to decrease my stiffness."
"When my arthritis acts up, I will rest all day and avoid exercising."
"I will have handrails installed in my bathroom and hall."
"I will avoid taking naps so I will sleep better at night."
Correct Answer: C.
"I will have handrails installed in my bathroom and hall."
The nurse should instruct the client to have handrails installed in the bathroom and hall to promote safety as the disease progresses.
A nurse is caring for a client who has chronic kidney disease. The kidneys regulate body fluids and assist with which of the following functions?
Regulation of acid-base balance
Reabsorption of nutrients for cellular growth
Regulation of body temperature
Secretion of hormones needed for growth
Correct Answer: A.
Regulation of acid-base balance
The nurse should identify that the kidneys assist with the regulation of acid-base balance in the body by retaining bicarbonate as they excrete hydrogen ions.
A nurse is caring for a client who is undergoing conservative treatment for deep-vein thrombosis. The client asks the nurse what will happen to the clot. Which of the following responses should the nurse make?
"Your body has a process called fibrinolysis that will eventually dissolve the clot."
"Your body has a mechanism that will keep the clot stable in its present location."
"The clot will break into tiny fragments and float harmlessly in your bloodstream."
"Treatment with heparin will dissolve the clot and keep other clots from forming."
Correct Answer: A.
"Your body has a process called fibrinolysis that will eventually dissolve the clot."
Fibrinolysis is a process that breaks a clot down over time in the body. It is a treatment option for clots that are not immediately life-threatening.
A nurse is assisting with planning care for a client who has deep partial-thickness and full-thickness thermal burns over 40% of his total body surface. The client is in the acute phase of burn injury. Which of the following interventions should the nurse include in the plan?
Initiate range-of-motion exercises.
Use clean technique to provide wound care.
Place the client on a low-protein diet.
Maintain the client on bed rest.
Correct Answer: A.
Initiate range-of-motion exercises.
The nurse should begin performing active and passive range-of-motion exercises with the client to maintain mobility and prevent contractures.
A nurse is assisting with the planning of an in-service session for a group of nurses regarding the role of enzymes in digestion. Which of the following enzymes has a role in the digestion of protein?
Amylase
Lipase
Steapsin
Pepsin
Correct Answer: D.
Pepsin
Pepsin is an enzyme secreted by the gastric mucosa that breaks down protein into polypeptides. Other enzymes such as trypsin and aminopeptidase further break down the polypeptides into amino acids, which can be used by the body.
A nurse is reinforcing teaching with a client who has a cast on his left arm to treat a forearm fracture. Which of the following statements indicates that the client understands the instructions?
"I'll call the doctor's office if my fingers get colder on the arm with the cast."
"If I have any itching under the cast, I'll try to reach it with a cotton swab."
"If my fingers swell, I should just put a heating pad on them and rest."
"If I have any tingling under my cast, I'll know I need to move my fingers more."
Correct Answer: A.
"I'll call the doctor's office if my fingers get colder on the arm with the cast."
The nurse should emphasize the importance of doing neurovascular checks and notifying the provider of any unexpected findings such as temperature variances.
A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing?
Lateral thigh
Upper inner thigh
Mid-abdominal region
Upper abdomen
Correct Answer: B.
Upper inner thigh
After inserting an indwelling urinary catheter, the nurse should secure the catheter tubing to the client’s upper inner thigh, by using adhesive tape or catheter securement device. This location will decrease tension and trauma to the urethra.
A nurse is assisting with the preparation of an in-service presentation about the management of myocardial infarction (MI). The nurse should identify that death following MI is most often a result of which of the following complications?
Cardiogenic shock
Dysrhythmias
Heart failure
Pulmonary edema
Correct Answer: B.
Dysrhythmias
According to evidence-based practice, the nurse should identify that dysrhythmias, specifically ventricular fibrillation, are the most common cause of death following MI. Therefore, nurses should monitor clients' ECGs carefully for dysrhythmias and report and treat them immediately.
A nurse is reinforcing teaching with a client who has a large wound healing by secondary intention. The nurse should instruct the client that which of the following nutrients promotes wound healing?
Vitamin B1
Calcium
Vitamin C
Potassium
Correct Answer: C.
Vitamin C
A diet high in protein and vitamin C is recommended because these nutrients promote wound healing.
A nurse is caring for a client who has acute diverticulitis. While the client has active inflammation, the nurse should instruct the client to include which of the following foods in her diet?
White bread and plain yogurt
Shredded wheat cereal and blueberries
Broccoli and kidney beans
Oatmeal and pears
Correct Answer: A.
White bread and plain yogurt
During the acute inflammation of diverticulitis, the client should maintain a diet that is low in fiber (e.g. white bread, low-fat milk, yogurt with active cultures, poached eggs, and canned, soft fruit).
A nurse is assisting in the preparation of a community education program about reducing the risks of osteoporosis. Which of the following pieces of information should the nurse include?
Avoid sun exposure.
Take a calcium supplement once each day if at risk for osteoporosis.
Walking is the preferred exercise to maintain strong bones.
Caffeine intake minimizes the risk of developing osteoporosis.
Correct Answer: C.
Walking is the preferred exercise to maintain strong bones.
The nurse should emphasize that regular walks are the preferred weight-bearing exercise to build and maintain strong bones.