Fundamentals
A nurse is collecting health history data from a client who is deaf and uses American Sign Language (ASL) to communicate. The nurse will be working with an ASL interpreter. Which of the following actions should the nurse perform when working with the interpreter?
Face away from the client to avoid creating a distraction
Pace speech to allow time for the interpreter to convey the words
Make eye contact with the interpreter when explaining the procedure
Stand in the background while the interpreter translates the message
Correct Answer: B.
Pace speech to allow time for the interpreter to convey the words
The nurse should speak distinctly and at a rate that allows time for the interpreter to convey the message and for the client to receive it.
A nurse is reviewing the laboratory results of a client who has end-stage renal disease and reports fatigue. The client's hemoglobin is 8 g/dL. The nurse should expect a prescription for which of the following medications?
Erythropoietin
Erythromycin
Filgrastim
Calcitriol
Correct Answer: A.
Erythropoietin
Erythropoietin stimulates the production of RBCs and is used to treat anemia associated with chronic renal failure.
A nurse is collecting data from a client who has Addison's disease. Which of the following findings should the nurse expect?
Hypotension
Weight gain
Sugar craving
Pale skin tone
Correct Answer: A.
Hypotension
The nurse should expect hypotension in a client who has adrenal insufficiency (Addison's disease). The nurse should monitor the client's blood pressure closely. If an Addisonian crisis occurs, the client's hypotension can become severe due to blood volume depletion caused by the loss of aldosterone.
A nurse is collecting data from a client who has chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the client’s condition?
High-calorie diet
Prior gastrointestinal illnesses
Tobacco use
Alcohol use
orrect Answer: D.
Alcohol use
Alcohol consumption is a major cause of chronic pancreatitis in the US. Long-term alcohol use disorder produces hypersecretion of protein in pancreatic secretions, resulting in protein plugs and calculi within the pancreatic ducts. Alcohol also has a direct toxic effect on the cells of the pancreas. Damage to these cells is more likely to occur and to be more severe in clients whose diets are poor in protein content and either very high or very low in fat.
nurse is providing teaching for a client following a below-the-knee amputation. Which of the following should the nurse include in the teaching?
Instruct the client to lie prone while in bed
Ensure the client sleeps on a soft mattress
Pull up the residual limb while in bed
Keep the residual limb exposed to air to heal
Correct Answer: A.
Instruct the client to lie prone while in bed
The nurse should instruct the client to lie in a prone position for 20 to 30 minutes every 3 to 4 hours to avoid developing contractures while in bed.
A nurse is caring for a client who is postoperative and has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hours. Which of the following actions should the nurse take first?
Check to determine if the catheter tubing is kinked
Palpate the bladder
Obtain a prescription to irrigate the catheter with 0.9% sodium chloride
Encourage the client to drink more fluids
Correct Answer: A.
Check to determine if the catheter tubing is kinked
The nurse should apply the least invasive priority-setting framework, which assigns priority to nursing interventions that are least invasive to the client, as long as those interventions do not jeopardize client safety. The nurse should take interventions that are not invasive to the client before interventions that are invasive. This reduces the number of organisms introduced into the body, decreasing the number of facility-acquired infections. Therefore, the nurse first should inspect the tubing carefully, straighten any kinks, and ensure there are no dependent loops. A lack of drainage may be due to a kink in the tubing or the client lying on a part of it.
A nurse is reinforcing teaching about a low-cholesterol diet with a client who had a myocardial infarction. Which of the following meal selections by the client indicates an understanding of the teaching?
Chicken breast and corn on the cob
Shrimp and rice
Cheese omelet and turkey bacon
Liver and onions
Correct Answer: A.
Chicken breast and corn on the cob
The nurse should identify that chicken breast is low in cholesterol and all vegetables, including corn, are cholesterol-free; therefore, this food selection by the client indicates an understanding of the teaching
A nurse is reinforcing teaching with a client who had a vaginal hysterectomy with a bilateral oophorectomy. Which of the following pieces of information should the nurse include in the teaching?
"Plan to use some type of birth control for up to 6 weeks after surgery."
"Use a water-based lubricant when having sexual intercourse."
"Expect to have an increase in bloody vaginal drainage during the first 10 days after surgery."
"Plan to start some type of aerobic exercise such as swimming within a week after surgery."
Correct Answer: B.
"Use a water-based lubricant when having sexual intercourse."
Vaginal dryness is a manifestation of menopause after the ovaries are removed, and the client might require a water-based lubricant when having sexual intercourse.
A nurse is caring for a client who has ulcerative colitis. The provider prescribes bed rest with bathroom privileges. When the client asks why he has to say in bed, how should the nurse respond to explain the most important reason for this prescription?
"You need to conserve energy at this time."
"Lying quietly in bed helps slow down the activity in your intestines."
"Staying in bed helps promote the rest and comfort you need."
"Staying in bed will help prevent injury and minimize your fall risk."
Correct Answer: B.
"Lying quietly in bed helps slow down the activity in your intestines."
The greatest risk to the client is complications from severe diarrhea such as dehydration, electrolyte imbalances, and gastrointestinal bleeding and trauma. Activity restriction can help reduce intestinal peristalsis and diarrhea.
A nurse is caring for a client who is postoperative following a total knee arthroplasty and has been prescribed a continuous passive motion (CPM) machine and PCA. The client tells the nurse, "I am in so much pain." Which of the following actions should the nurse take first?
Remind the client to push the button for the PCA device
Discuss activities the client can use to distract from the pain
Ask the client to describe the characteristics of the pain
Pause the CPM machine briefly to apply a cold pack to the client’s knee
Correct Answer: C.
Ask the client to describe the characteristics of the pain
This situation requires the application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with the knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to acquire further data by asking the client to describe the characteristics of the pain.
A nurse is assisting with an admission interview for a client. Which of the following items of data should the nurse collect during the introduction phase of the interview?
Client's comfort and ability to participate in the interview
Previous illnesses and surgeries
Events surrounding the recent illness
Sociocultural history
Correct Answer: A.
Client's comfort and ability to participate in the interview
The nurse should collect data about the client's comfort and establish a rapport with the client during the introductory or orientation phase. The nurse should engage in active listening and present a relaxed attitude to place the client at ease and encourage client participation.
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A nurse is assisting with the care of a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should plan to administer which of the following IV solutions?
0.45% sodium chloride
Dextrose 5% in 0.9% sodium chloride
Dextrose 10% in water
0.9% sodium chloride
Correct Answer: D.
0.9% sodium chloride
Solutions of 0.9% sodium chloride, as well as lactated Ringer’s solution, are used for fluid-volume replacement. Sodium chloride, a crystalloid, is a physiologically isotonic solution that replaces lost volume in the bloodstream and is the only solution to use when infusing blood products.
A nurse is reinforcing teaching with a client who has hyperthyroidism about managing this disorder. Which of the following recommendations should the nurse include?
Reduce her total hours of sleep
Keep her immediate environment warm
Increase her caloric intake with meals
Gradually increase her activity
Correct Answer: C.
Increase her caloric intake with meals
Clients whose thyroid hormone levels are high have increased protein, lipid, and carbohydrate metabolism, resulting in a loss of protein stores and a negative nitrogen balance. Even with an increased appetite, it is often difficult to meet energy demands, and weight loss is common. Muscle weakness and wasting can develop without adequate caloric and protein intake.
A nurse is assisting with the planning of an in-service training session regarding nutrition. Which of the following minerals should the nurse include as a factor in oxygen transportation?
Zinc
Iron
Phosphorus
Magnesium
Correct Answer: B.
Iron
Iron transports oxygen via hemoglobin and myoglobin. It is also a component of enzyme systems.
A nurse is preparing a client for magnetic resonance imaging (MRI) of the spine. Which of the following pieces of information should the nurse give the client prior to the procedure?
"You can have a mild sedative before the procedure."
"You'll have to lie still on your back for 15 to 20 minutes."
"You can't have this test if you’ve had cataract surgery."
"Your exposure to radiation will be minimal."
Correct Answer: A.
"You can have a mild sedative before the procedure."
Some clients need mild sedation, especially when it is an older, closed MRI machine. Clients can feel claustrophobic and anxious as they slowly pass through what seems like a tunnel
A nurse is preparing to administer ondansetron 4 mg IM to a client who has postoperative nausea. Ondansetron injection 2 mg/mL is available. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if applicable but do not use a trailing zero.)
the nurse should administer ondansetron 2 mL IM.
A nurse is monitoring a client for reperfusion following thrombolytic therapy to treat acute myocardial infarction (MI). Which of the following indicators should the nurse identify to confirm reperfusion?
Ventricular dysrhythmias
Appearance of Q waves
Elevated ST segments
Recurrence of chest pain
Correct Answer: A.
Ventricular dysrhythmias
The appearance of ventricular dysrhythmias following thrombolytic therapy is a sign of reperfusion of the coronary artery.
A nurse is monitoring a client following a thyroidectomy. Which of the following findings should the nurse identify as an indication of hypoparathyroidism?
Elevated blood pressure
Involuntary muscle spasms
Cold intolerance
Weight loss
Correct Answer: B.
Involuntary muscle spasms
The nurse should identify involuntary muscle spasms as an indication of hypoparathyroidism, which can occur if the parathyroid glands are damaged or removed during a thyroidectomy. Muscle twitching and paresthesias can result due to decreased parathyroid hormone levels and calcium deficiency.
A nurse is caring for a client who is 4 hours postoperative following a laparoscopic cholecystectomy. Which of the following findings should the nurse expect?
Right shoulder pain
Urine output 20 mL/hr
Temperature 38.4°C (101.1°F)
Oxygen saturation 92%
Correct Answer: A.
Right shoulder pain
The client can experience pain in the right upper shoulder due to gas (carbon dioxide) injected into the abdominal cavity during the laparoscopic procedure, which can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1 to 2 days. Mild analgesics and a recumbent position can help relieve the client’s pain.
A nurse is collecting data from a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider as an indication of fat emboli?
Ecchymosis of the thigh
Serous drainage at the pin site
Chest petechiae
Muscle spasms in the left leg
Correct Answer: C.
Chest petechiae
The nurse should identify chest petechiae as an indication of a fat embolism. Clients who have fractures of the long bones such as the femur are at increased risk for fat emboli. Fat emboli typically occur 12 to 48 hours after the injury when fat droplets from the marrow enter into the systemic circulation and are deposited in the lungs. The nurse should immediately notify the provider because the client could progress to acute respiratory failure.
A nurse is collecting data about a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings?
Peripheral pulses equal bilaterally at a rate of 60/min
Radial, brachial, and pedal pulses bilaterally weak
Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities
Brachial, radial, popliteal, and dorsalis pedis pulses regular, 58, and bilaterally palpable
Correct Answer: C.
Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities
The nurse does not evaluate the peripheral pulses routinely when measuring vital signs. Peripheral pulse evaluation is for specific clinical indications such as circulatory impairment to an extremity or during a comprehensive physical examination. A full evaluation of peripheral pulses typically includes palpation of the radial, brachial, ulnar, femoral, popliteal, tibial, and dorsalis pedal pulses. Documentation of peripheral pulse evaluation should include the strength of pulsations as well as their equality and symmetry in all 4 extremities.
A nurse is assisting with the preparation of an in-service presentation about collecting data from clients who are having acute myocardial infarction (MI). The nurse should identify that the most common finding of acute MI is which of the following?
Dyspnea
Pain in the shoulder and left arm
Substernal chest pain
Palpitations
Correct Answer: C.
Substernal chest pain
Evidence-based practice indicates that the most common manifestation of acute MI is substernal chest pain that does not subside with rest or with nitroglycerin. Therefore, nurses should make pain management with morphine a priority to reduce myocardial oxygen demand and increase oxygenation.
A nurse is collecting data from a client who has Graves' disease. Which of the following findings should the nurse expect the client to display?
Constipation
Cold intolerance
Difficulty sleeping
Anorexia
Correct Answer: C.
Difficulty sleeping
A client who has Graves' disease can have difficulty sleeping and anxiety due to the overproduction of thyroid hormone.
A nurse is caring for a client who has cholelithiasis and will undergo a cholecystectomy. The client says she does not understand how she will be alright without her gallbladder. The nurse should explain that which of the following is the main function of the gallbladder?
Producing bile
Adding digestive enzymes to bile
Storing bile
Eliminating bile
Correct Answer: C.
Storing bile
The primary function of the gallbladder is to store bile. Because this organ is only for storage, the client’s liver will still produce the bile needed for digestion. Small amounts of bile will continuously enter the duodenum and perform various functions.
A nurse in an ambulatory clinic is caring for a client who sustained facial trauma to the nose. Which of the following actions should the nurse take first?
Determine the client’s ability to take deep breaths
Place a cold compress on the nasal area
Palpate the nasal area for crepitation
Offer the client an analgesic medication
Correct Answer: A.
Determine the client’s ability to take deep breaths
The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse’s priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the first action the nurse should take is to acquire further data by determining the client's ability to take deep breaths.