Practice
The nurse is caring for a client on the postoperative unit. Which nursing diagnosis is the priority for this client?
1. Self-Care Deficit
2. Disturbed Body Image
3. Ineffective Airway Clearance
4. Risk for Falls
Answer: 3
Explanation: When prioritizing, the nurse should remember the ABCs. Airway should always be the priority.
Page Ref: 886
The nurse is reviewing collected data from a client. Which information should the nurse identify as a physiological barrier to defend the client's body from microorganisms?
1. Heavy smoking
2. Moisturizing the skin
3. Breakdown of skin
4. Voiding quantity sufficient
Answer: 4
Explanation: 4. Voiding quantity sufficient is a barrier that helps the body defend itself against microorganisms. The act of voiding flushes those organisms that might try to enter the body through the urinary meatus.
Page Ref: 607
The nurse wants to protect a client from developing an infection. Which action should the nurse take to break a link in the chain of infection?
1. Cover the mouth and nose when sneezing.
2. Place contaminated linens in a paper bag.
3. Use personal protective equipment (PPE) sparingly.
4. Wear gloves at all times.
Answer: 1
Explanation: Covering the mouth and nose when sneezing prevents airborne droplets from escaping into the air for others to contract in the chain of infection.
Page Ref: 612
The nurse is concerned that a break occurred in a sterile field. Which action occurred that caused this break?
1. Grasping the edge of the outermost flap and opening it away from oneself
2. Keeping objects on the field 1 inch from the edge
3. Keeping the sterile field in eyesight
4. Transferring a sterile object to a sterile field with a clean gloved hand
Answer: 4
Explanation: 4. Transferring a sterile object onto a sterile field with a gloved hand would render the field unsterile only if the gloves are not sterile.
Page Ref: 627
A client diagnosed with tuberculosis is being admitted to a care area. Which nursing action prevents the transmission of the disease?
1. Have the client wear a mask when coming from admission.
2. Stock the supply cart at the beginning of each shift.
3. Wash the hands only after leaving the room.
4. Wear a mask when exiting the room.
Answer: 1
Explanation: 1. When a client has an airborne disease and must go elsewhere in the hospital, the client must wear a mask.
Page Ref: 626
The nurse is assessing an abdominal wound in the postoperative period. Which sign should indicate to the nurse that an infection is present?
1. Absence of bleeding
2. Edges warm to the touch
3. Edges well approximated
4. Sutures in place
Answer: 2
Explanation: If the wound becomes warm, red, and edematous, the nurse should suspect an infection and notify the physician.
Page Ref: 891
The nurse assesses phase 1 Korotkoff's sound occurring at 136 and phase 5 Korotkoff's sound occurring at 72. How should the nurse document this client's blood pressure reading?
1. 136/72
2. 72/136
3. 136 - 72
4. 72 - 136
Answer: 1
Explanation: The first tapping phase 1 Korotkoff's sound is the systolic blood pressure. The last sound heard during phase 5 Korotkoff's sound is the diastolic blood pressure. The nurse would document the blood pressure as being 136/72.
Page Ref: 503
A client recovering from surgery asks the nurse why turning, deep breathing, and coughing exercises need to be done. What should the nurse respond?
1. "These exercises help prevent pneumonia."
2. "The doctor ordered the exercises."
3. "All surgical clients must do these exercises."
4. "These exercises prevent thrombophlebitis."
Answer: 1
Explanation: By increasing lung expansion and preventing accumulation of secretions, deep breathing helps prevent pneumonia and atelectasis.
Page Ref: 887
The nurse determines that a client has adequate physiological barriers to defend the body against infection. What did the nurse assess in this client? Select all that apply.
1. Intact and dry skin
2. Intact oral mucous membranes
3. Bowel sounds present in all four quadrants
4. Nasal congestion
5. Urinary retention
Answer: 1, 2, 3
Explanation: 1. Intact skin is the body's first line of defense against microorganisms.
2. Intact mucous membranes are the body's first line of defense against microorganisms.
3. Peristalsis tends to move microbes out of the body.
Page Ref: 607
The nurse is concerned that a client is at risk for a nosocomial infection. What did the nurse assess to make this clinical decision? Select all that apply.
1. Client is receiving intravenous fluids.
2. Client has an indwelling urinary catheter.
3. Client is recovering from surgery.
4. Client is receiving pain medication.
5. Client is ambulating twice a day with assistance.
Answer: 1, 2, 3
Explanation: 1. Bacteremia can occur from an intravascular line.
2. The client could develop an infection from an invasive procedure or device such as an indwelling urinary catheter.
3. After surgery, the client's health status is compromised, lowering the client's defenses to fight infection.
Page Ref: 604
The nurse needs to apply personal protective equipment before entering a client's room. In which order should the nurse perform the following actions?
Place the steps in the order in which they should be performed.
1. Apply gloves.
2. Apply eyewear.
3. Apply the gown.
4. Apply the face mask.
5. Perform hand hygiene.
Answer: 5, 3, 4, 2, 1
Explanation: 1. Gloves are applied last.
2. Protective eyewear is applied after the face mask.
3. The gown is applied after hand hygiene.
4. The face mask is applied after the gown.
5. Before applying personal protective equipment, hand hygiene should be performed.
Page Ref: 621
A client is diagnosed with a communicable disease, and must be placed in isolation. The nurse should identify which diagnosis as a priority for this client?
1. Social Isolation
2. Anxiety
3. Acute Pain
4. Imbalanced Nutrition: Less Than Body Requirements
Answer: 1
Explanation: 1. Social Isolation would be appropriate for the client who needs to be separated from others during a contagious episode.
Page Ref: 611
While irrigating a client's abdominal wound, the irrigate splashes into the nurse's nose and eyes. What should the nurse do?
1. Flush the nose and eyes for 5 to 10 minutes with water or normal saline.
2. Begin HIV high-risk exposure prophylaxis within 24 hours.
3. Wash the areas with soap and water.
4. Have blood drawn for hepatitis B antibodies
Answer: 1
Explanation: 1. After an exposure to the mucous membranes, the area should be flushed for 5 to 10 minutes with saline or water.
Page Ref: 636
The RN assesses a client who is recovering from femoral popliteal bypass surgery and discovers that it is difficult to assess the dorsalis pedis pulses. Which nursing intervention would be most appropriate for the nurse to use?
1. Ask another nurse to assess the pulses.
2. Document the findings.
3. Obtain a Doppler ultrasound stethoscope.
4. Wait and try again later.
Answer: 3
Explanation: Obtaining a Doppler ultrasound stethoscope is the appropriate action to take. The Doppler will ensure accuracy by helping to exclude environmental sounds.
Page Ref: 488
A client comes to the emergency department with a temperature of 104°F. Which assessment findings should the nurse use to determine if this client is experiencing heat stroke? Select all that apply.
1. Delirious
2. Pale and dizzy
3. Skin warm and flushed
4. No evidence of sweating
5. Had been playing tennis in the sun
Answer: 1, 3, 4, 5
Explanation: Persons experiencing heat stroke may be delirious.
Persons experiencing heat stroke generally have warm, flushed skin.
Persons experiencing heat stroke often do not sweat.
Persons experiencing heat stroke generally have been exercising in hot weather.
Page Ref: 479
As the RN is suctioning a client, the pulse oximetry reading drops to 83%. What should the nurse do?
1. Allow the client to take some extra deep breaths.
2. Continue to suction but only intermittently.
3. Keep the catheter in place and wait a few minutes.
4. Stop suctioning and give supplemental oxygen.
Answer: 4
Explanation: Not only does suctioning remove secretions, but it also removes the client's air. By stopping suctioning, the RN stops removing both. This allows the client to recoup from the procedure, and giving oxygen will also increase the saturation ability back to a normal range.
Page Ref: 509
During the assessment of a client recovering from surgery, the nurse notes decreased breath sounds in both lower lobes bilaterally. What should the nurse do?
1. Coach the client to deep-breathe and cough.
2. Restrict fluids.
3. Remind the client to perform leg exercises.
4. Maintain on bed rest.
Answer: 1
Explanation: The reduction of breath sounds could indicate the pooling of secretions in the lower lobes. The nurse should coach the client to deep-breathe and cough.
Page Ref: 884
The nurse is caring for a postoperative client with an abdominal wound and a drain. What can the nurse delegate to unlicensed assistive personnel? Select all that apply.
1. Clean the wound.
2. Assess the skin around the wound.
3. Determine the effectiveness of pain medication.
4. Report if the dressing is soiled.
5. Report if the dressing is loose.
Answer: 4, 5
Explanation: 4. The nurse can ask the UAP to report soiled dressings that need to be changed.
5. The nurse can ask the UAP to report if the dressing is loose and needs to be reinforced.
Page Ref: 893
The nurse is assessing a client's blood pressure. What should the nurse hear during phase 2 of Korotkoff's sounds?
1. A muffled, whooshing, or swishing sound
2. Disappearance of sound
3. Faint, clear tapping sound
4. Increased intensity of sound
Answer: 1
Explanation: Phase 2 produces a muffled, whooshing, or swishing sound.
Page Ref: 503
The nurse is going to assess the apical-radial pulse of a client with a cardiovascular disorder. Which rationale did the RN use to make this decision?
1. A forceful radial pulse is much too difficult to count correctly.
2. Both arteriole and venous sounds were heard simultaneously.
3. The pulse was bounding and easily obliterated.
4. The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse site.
Answer: 4
Explanation: Knowing there is a history of a cardiovascular disorder would alert the RN to the importance of the utmost accuracy for the client's pulse assessment. The apical-radial pulse is used to assess this type of client due to the feebleness of the wave of blood flow felt at the peripheral sites.
Page Ref: 494
The nurse is planning to remove the sutures from a client's surgical wound. What should the nurse do before removing the sutures? Select all that apply.
1. Apply clean gloves.
2. Verify the order for suture removal.
3. Ambulate the client to the bathroom.
4. Read the order to determine whether a dressing is to be applied after removal.
5. Remove the dressing and clean the incision.
Answer: 2, 4, 5
Explanation: 2. Before removing skin sutures, the nurse should verify that there is an order for suture removal.
4. Before removing skin sutures, the nurse should verify whether a dressing is to be applied following the suture removal.
5. Before removing skin sutures, the nurse should remove the dressing and clean the incision.
Page Ref: 896
Even though a UAP is available to assist with vital sign assessment, the nurse is going to conduct these assessments independently in which situations? Select all that apply.
1. Client who complains of chest pain
2. Client returning from surgery
3. Prior to administering a medication that affects blood pressure
4. Client who complains of dizziness after ambulating
5. Client being admitted to the care area
Answer: 1, 2, 3, 4
Explanation: When a client reports symptoms such as chest pain, the nurse should conduct the assessment.
When a client returns from surgery, the nurse should conduct the assessment.
When the client is prescribed a medication that could affect the vital signs, the nurse should conduct the assessment.
When the client reports symptoms such as dizziness after ambulation, the nurse should conduct the assessment.
Page Ref: 478
The nurse determines that unlicensed assistive personnel (UAP) are not to be delegated client blood pressure measurements. What did the nurse observe to make this clinical decision? Select all that apply.
1. The valve on the bulb was closed.
2. The client was sitting with the legs crossed.
3. The arm was below the level of the heart.
4. The UAP waited 2 minutes before re-measuring.
5. The cuff bladder was placed over the brachial artery.
Answer: 2, 3
Explanation: The adult client should be sitting with both feet on the floor. Crossed legs can cause elevations in systolic and diastolic blood pressures.
The elbow should be slightly flexed with the palm of the hand facing up and the arm supported at heart level. The blood pressure increases when the arm is below heart level.
Page Ref: 504
The nurse has removed the sutures from a client's surgical wound. What should the nurse document about this procedure? Select all that apply.
1. Number of sutures removed
2. Appearance of the incision
3. Client teaching
4. Client tolerance of the procedure
5. Name of the surgeon
Answer: 1, 2, 3, 4
Explanation: 1. The nurse should document the number of sutures removed.
2. The nurse should document the appearance of the incision.
3. The nurse should document any client teaching.
4. The nurse should document the client's tolerance of the procedure.
Page Ref: 897
The nurse is preparing to change the dressing on a client's postoperative wound. Place in order the steps the nurse should perform when removing the soiled dressing.
1. Assess the location, type, and odor of wound drainage.
2. Remove the outer dressing.
3. Discard the under dressing in a moisture-proof bag, and remove and discard gloves.
4. Remove the under dressing.
5. Apply clean gloves.
6. Place the soiled dressing in a moisture-proof bag.
Answer: 5, 2, 6, 4, 1, 3
Explanation: 1. Once the under dressing is removed, the nurse should assess the location, type, and odor of any wound drainage.
2. The nurse should then remove the outer dressing.
3. The nurse should then discard the under dressing in a moisture-proof bag and remove and discard the gloves.
4. The nurse should next remove the under dressing.
5. The nurse first should apply clean gloves.
6. The nurse should place the soiled outer dressing in a moisture-proof bag.
Page Ref: 893