Fundamentals
A nurse is providing palliative care for a client who is at the end of life. The client is having difficulty breathing and has audible respiratory gurgling. Which of the following actions should the nurse take?
Increase the amount of light in the room
Reposition the client from side to side every 4 hours
Elevate the head of the client's bed
Apply an electric blanket
Correct Answer: C.
Elevate the head of the client's bed
This action promotes postural drainage and allows maximal chest expansion. The nurse should also turn the client's head to the side to allow secretions to drain. Speaking gently to the client can also help calm her and possibly ease her efforts to breathe. Suctioning the airway is an option, but it can be distressing for the client.
A nurse is reviewing the menu selections of a client who has heart failure and anticipates being discharged home the following day. Which of the following lunch menu choices should the nurse identify as an indication that the client understands his dietary instructions?
Turkey on whole wheat bread
Hamburger and french fries
Frankfurter on a white roll
Macaroni and cheese
Correct Answer: A.
Turkey on whole wheat bread
The primary dietary alteration for a client who has heart failure is sodium restriction. A turkey sandwich with whole wheat bread has a relatively low sodium content.
A nurse in a provider’s office is collecting data from a client who has skin lesions. The nurse notes that the lesions are 0.5 cm (0.20 in) in size, elevated, and solid with distinct borders. The nurse should document these findings as which of the following skin lesions?
Papules
Macules
Wheals
Vesicles
Correct Answer: A.
Papules
A papule is a small, solid, elevated lesion with distinct borders. It is usually <10 mm in diameter. Warts and elevated moles are examples of papules.
A nurse is recommending dietary modifications for a client who has GERD. The nurse should suggest eliminating which of the following foods from the client's diet?
Oranges and tomatoes
Carrots and bananas
Potatoes and squash
Whole grains and beans
Correct Answer: A.
Oranges and tomatoes
Symptoms of GERD worsen following oral intake of substances that decrease lower esophageal stricture (LES) pressure. These include alcohol, caffeine, nicotine, chocolate, fatty foods, citrus fruits, tomatoes, and peppermint.
A nurse is caring for a client who has a pelvic fracture. The client reports sudden shortness of breath, stabbing chest pain, and anxiety. The nurse should notify the charge nurse that this client is experiencing which of the following complications?
Pneumonia
Pulmonary embolus
Tension pneumothorax
Tuberculosis
Correct Answer: B.
Pulmonary embolus
Immobility following musculoskeletal trauma places the client at an increased risk for pulmonary embolus. The client might also exhibit tachycardia and chest petechiae and have a decreased SaO2. The nurse should notify the rapid response team immediately.
A nurse is teaching a client who has asthma about the proper use of an albuterol inhaler. Which of the following client statements indicates an understanding of the teaching?
"I should rinse my mouth right before I use the inhaler."
"After the first puff, I will wait 10 seconds before taking the second puff."
"I will shake the inhaler well right before I use it."
"I will tilt my head forward while inhaling the medication."
Correct Answer: C.
"I will shake the inhaler well right before I use it."
A nurse is caring for a client who has pernicious anemia. Which of the following factors is associated with this condition?
Iron deficiency
Hemolytic blood loss
Folic acid deficiency
Vitamin B12 deficiency
Correct Answer: D.
Vitamin B12 deficiency
A client who has pernicious anemia is deficient in vitamin B12 due to a deficiency in an intrinsic factor normally supplied by the gastric mucosa that is essential for the absorption of vitamin B12.
A nurse is caring for a client who has smoke inhalation and full-thickness burns covering 63% of her body. Which of the following nursing actions is the nurse's priority?
Monitor intake and output
Administer antibiotics
Monitor respiratory status
Encourage fluid and food intake
Correct Answer: C.
Monitor respiratory status
The priority action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to monitor the client's respiratory status closely. Smoke inhalation most likely includes a thermal injury to the tracheobronchial tree. Edema from the inflammatory response to heat can obstruct the airway. Endotracheal intubation might become necessary to maintain a patent airway.
A nurse is reinforcing teaching with a client who has Barrett’s esophagus and is scheduled to undergo an esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in the teaching?
"This procedure is performed to measure the presence of acid in your esophagus."
"This procedure can determine how well the lower part of your esophagus works."
"This procedure is performed while you are under general anesthesia."
"This procedure can determine if you have colon cancer."
Correct Answer: B.
"This procedure can determine how well the lower part of your esophagus works."
An EGD is useful in determining the function of the esophageal lining and the extent of inflammation, potential scarring, and strictures
A nurse is caring for a client who had a below-the-knee amputation for gangrene of the right foot. The client reports sensations of burning and crushing pain in the absent toes of the right foot. Which of the following statements should the nurse make?
"An anticonvulsant medication can be helpful in relieving this type of pain."
"Try to look at the surgical wound to remind yourself that the limb is gone."
"Use a cold compress intermittently to decrease these pain sensations."
"Grief over the lost limb can sometimes make you deny the limb is really gone."
Correct Answer: A.
"An anticonvulsant medication can be helpful in relieving this type of pain."
The nurse should recognize that the client is reporting phantom limb pain, a frequent complication following amputation. The nurse should instruct the client that several medications can be used to treat the pain, including anticonvulsants and antidepressant
A nurse is instructing a client about collecting a 24-hour urine specimen for creatinine clearance. Which of the following statements should the nurse identify as an indication that the client understands the procedure?
"The next time I urinate will be the first specimen of the collection."
"I'll make sure to keep the collection bottle in the container of ice they gave me."
"Once the container is half full, I no longer have to add any more urine."
"It's okay if a piece of toilet paper gets in the bottle. They'll remove it when they do the test."
Correct Answer: B.
"I'll make sure to keep the collection bottle in the container of ice they gave me."
The urine collection must remain chilled to prevent any change in urine composition during the collection.
A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take?
Position the client supine with his legs elevated when in bed
Encourage the client to ambulate for 15 minutes every hour while awake for the first 24 hours
Tell the client to sit with his legs dependent after ambulating
Recommend wearing knee-length socks for 2 weeks after surgery
Correct Answer: A.
Position the client supine with his legs elevated when in bed
The nurse should elevate the client's legs above his heart to promote venous return by gravity. During discharge teaching, the nurse should reinforce the importance of periodic positioning of the legs above the heart.
A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client’s questions about the dressing, the nurse explains that it is obtained from which of the following sources?
Cadaver skin
Pig skin
Amniotic membranes
Beef collagen
Correct Answer: B.
Pig skin
Heterografts are obtained from an animal, usually a pig.
A nurse is caring for a client who had a gastric resection to treat adenocarcinoma of the stomach. The client tells the nurse in the PACU that he does not remember why the surgeon said he had to have a tube in his nose. The nurse should explain that the NG tube serves which of the following purposes?
Preventing excessive pressure on suture lines
Allowing gastric lavage after surgery
Allowing early postoperative feeding
Obtaining gastric specimens for testing
Correct Answer: A.
Preventing excessive pressure on suture lines
The NG tube remains in place after surgery to prevent excessive pressure on suture lines postoperatively. It drains the air and fluid that can cause pressure from inside the gastrointestinal (GI) tract. In doing so, it also prevents vomiting and GI distention.
A nurse is assisting with the care of a client who is scheduled to undergo surgery to repair an open hip fracture. In which of the following positions should the nurse plan to place the client postoperatively?
With the leg on the affected side adducted
With the hip externally rotated on the affected side
With the leg on the affected side abducted
With the hip flexed at 90° on the affected side
Correct Answer: C.
With the leg on the affected side abducted
The nurse should plan to place the client with the leg abducted on the affected side postoperatively. Adduction or external rotation of the leg will cause the hip to dislocate.
A nurse is reinforcing teaching for a client about performing range-of-motion exercises of the wrist. To have the client demonstrate adduction, which of the following instructions should the nurse give?
"With your palm facing down, move your wrist sideways toward your thumb."
"Move your palm toward the inner part of your forearm."
"With your palm facing down, move your wrist sideways toward your little finger."
"Bring the back of your hand as far back toward the wrist as you can."
Correct Answer: A.
"With your palm facing down, move your wrist sideways toward your thumb."
This motion is adducting the wrist. The client should be able to move her wrist 30º to 50º with this motion.
A nurse is reinforcing teaching with a client who has a prescription for a low-sodium diet to manage hypertension. Which of the following client statements indicates the teaching has been understood?
"I can snack on fresh fruit."
"I can continue to eat lunchmeat sandwiches."
"I can have cottage cheese with my meals."
"Canned soup is a good lunch option for me."
Correct Answer: A.
"I can snack on fresh fruit."
The nurse should identify that fresh fruits contain little to no sodium and are a good snack for a client who has hypertension.
A nurse is collecting data from a client who sustained superficial partial-thickness and deep partial-thickness burns 72 hours ago. Which of the following findings should the nurse report to the provider?
Edema in the affected extremities
Severe pain at the burn sites
Urine output of 30 mL/hr
Temperature of 39.1° C (102.4°F)
Correct Answer: D.
Temperature of 39.1° C (102.4°F)
An elevated temperature is an indication of infection, and the nurse should report this finding to the provider. Sepsis is a critical finding following a major burn injury. Initially, burn wounds are relatively pathogen-free. On approximately the third day following the injury, early colonization of the wound surface by gram-negative organisms changes to predominantly gram-positive opportunistic organisms.
A nurse is caring for a client who has abdominal pain and possibly pancreatitis. Which of the following laboratory results should the nurse identify as an indication of pancreatitis?
Decreased white blood cell count
Increased albumin level
Increased serum lipase level
Decreased blood glucose level
Correct Answer: C.
Increased serum lipase level
Due to the release of lipase into the pancreas and autodigestion, pancreatitis causes an increased serum lipase level.
A nurse is collecting data from a client who is 48 hours postoperative following open reduction and external fixation of a fractured tibia. Which the following findings should the nurse report to the provider?
Toes that are cold to the touch
Serous drainage from the pin sites
Blanching of the toenail beds with pressure
Pink tissue around the fixator insertion sites
Correct Answer: A.
Toes that are cold to the touch
The nurse should monitor for and report manifestations of compartment syndrome following internal fixation. Therefore, the nurse should contact the provider immediately if the client's toes are cold to the touch.
A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse take?
Wear sterile gloves when collecting the specimen
Cleanse the wound with 0.9% sodium chloride irrigation
Allow the collection swab to absorb old exudate
Rotate the collection swab over the edges of the wound
Correct Answer: B.
Cleanse the wound with 0.9% sodium chloride irrigation
The nurse should cleanse the wound with sterile water or 0.9% sodium chloride irrigation to remove any surface debris or old exudate
A nurse is administering a loop diuretic to a client who has 3+ pitting edema in the lower extremities. Which of the following actions should the nurse take?
Weigh the client weekly
Monitor the client for ototoxicity
Place the client on a 24-hour urine collection analysis
Monitor for hypoglycemia
Correct Answer: B.
Monitor the client for ototoxicity
The nurse should monitor the client for ototoxicity, and the client should report any manifestations of hearing impairment while on the loop diuretic. The nurse should use caution when a loop diuretic is used in conjunction with other ototoxic medications such as aminoglycoside antibiotics.
A nurse is reinforcing teaching with a group of clients about skin cancer. The nurse should explain that basal cell carcinoma originates from which of the following tissues?
Subcutaneous
Epidermis
Dermis
Stratum corneum
Correct Answer: B.
Epidermis
Basal cell carcinoma originates from the epidermal layer of the skin. It is the most common form of skin cancer.
A nurse is caring for a client who is NPO and has an NG tube to suction. The client reports nausea. Which of the following actions should the nurse take?
Irrigate the tube with a normal saline solution
Provide oral hygiene
Clamp the tube for 30 minutes
Increase the amount of suction
Correct Answer: A.
Irrigate the tube with a normal saline solution
When caring for a client with an NG tube who develops nausea, the nurse should first attempt to irrigate the tube to determine patency. If the tube is not patent, gastric pressure cannot decrease, and the steady or increasing pressure can cause nausea.
A nurse is caring for a client following a hip arthroplasty. The nurse should place an abduction pillow on the client for which of the following purposes?
Raising the bed linens off the client's feet to prevent plantar flexion
Keeping the client’s heels off the bed to prevent pressure ulcers
Positioning the client off the operative site while in bed
Preventing dislocation of the hip during position changes or movement
Correct Answer: D.
Preventing dislocation of the hip during position changes or movement
Following surgery, the nurse should use an abduction pillow to prevent dislocation of the new hip joint. The nurse should place the wedge-shaped pillow between the client’s legs. The purpose of the abduction pillow is to prevent adduction beyond the midline of the body during position changes or client movement, which can lead to subluxation or total dislocation of the hip joint.