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HI there....welcome To test visual acuity, the nurse should ask the patient to cover each eye separately and read the eye chart with glasses and without, as appropriate. Fundamental of Nursing Before teaching any procedure to the patient, the nurse must first assess the patient’s willingness to learn and his current knowledge. Fundamentals of Nursing A blood pressure cuff that is too narrow can cause a falsely elevated blood pressure reading. Fundamentals of Nursing When preparing a single injection for a patient who takes regular and NPH insulin, the nurse should draw the regular insulin into the syringe first because it is clear and can be measured more accurately than the NPH insulin, which is turbid. Fundamentals of Nursing Rhonchi refers to the rumbling sounds heard on lung auscultation; they are more pronounced during expiration than during inspiration. Fundamentals of Nursing Gavage refers to forced feeding, usually through a gastric tube (a tube passed into the stomach by way of the mouth). Fundamentals of Nursing According to Maslow’s hierarchy of needs, physiologic needs (air, water, food, shelter, sex, activity, and comfort) have the highest priority. Fundamentals of Nursing Checking the identification band on a patient’s wrist is the safest and surest way to verify a patient’s identity. Fundamentals of Nursing A patient’s safety is the priority concern in developing a therapeutic environment. Fundamentals of Nursing The nurse should place the patient with a Sengstaken-Blakemore tube in semi-Fowler’s position. Fundamentals of Nursing The nurse can elicit Trousseau’s sign by occluding the brachial or radial artery; hand and finger spasms during occlusion indicate Trousseau’s sign and suggest hypocalcemia. Fundamentals of Nursing For blood transfusion in an adult, the appropriate needle size is 16 to 20G. Fundamentals of Nursing Pain that incapacities a patient and can’t be relieved by drugs is called intractable pain. Fundamentals of Nursing In an emergency, consent for treatment can be obtained by fax, telephone, or other telegraphic transmission. Fundamentals of Nursing Decibel is the unit of measurement of sound. Fundamentals of Nursing Informed consent is required for any invasive procedure. Fundamentals of Nursing A patient who can’t write his or her name to give consent for treatment must have his or her X witnessed by two persons, such as a nurse, priest, or doctor. Fundamentals of Nursing The Z-track I.M. injection technique seals medication deep into the muscle, thereby minimizing skin irritation and staining. It requires a needle that is 1’’ (2.5 cm) or longer. Fundamentals of Nursing A registered nurse (RN) should assign a licensed vocational nurse (LVN) or licensed practical nurse (LPN) to perform bedside care, such as suctioning and medication administration. Fundamentals of Nursing The therapeutic purposed of a mist tent is to increase hydration of secretions. Fundamentals of Nursing If a patient can’t void, the first nursing action should be bladder palpation to assess for bladder distention. Fundamentals of Nursing The patient who uses a cane should carry it on the unaffected side and advance it at the same time as the affected extremity. Fundamentals of Nursing To fit a supine patient for crutches, the nurse should measure from the axilla to the sole and add 2” (5 cm) to that measurement. Fundamentals of Nursing Assessment begins with the nurse’s first encounter with the patient and continues throughout the patient’s stay. The nurse obtains assessment data through the health history, physical examination, and review of diagnostic studies. Fundamentals of Nursing The appropriate needle size for an insulin injection is 25G and ⅝" (1.5 cm) long. Fundamentals of Nursing Residual urine refers to urine that remains in the bladder after voiding. The amount of residual urine normally ranges from 50 to 100 ml. Fundamentals of Nursing The five stages of the nursing process are assessment, nursing diagnosis, planning, implementation, and evaluation. Fundamentals of Nursing Planning refers to the stage of the nursing process in which the nurse assigns priorities to nursing diagnoses, defines short-term and long-term goals and expected outcomes, and establishes the nursing care plan. Fundamentals of Nursing Implementation refers to the stage of the nursing process in which the nurse puts the nursing care plan into action, delegates specific nursing interventions to members of the nursing team, and charts patient responses to nursing interventions. Fundamentals of Nursing Evaluation refers to the stage of the nursing process in which the nurse compares objective and subjective data with the outcome criteria and, if needed, modifies the nursing care plan, making the nursing process circular. Fundamentals of Nursing In the event of fire, the nurse should (1) remove the patient, (2) call the fire department, (3) attempt to contain the fire by closing the door, and (4) extinguish the fire, if it can be done safely. Fundamentals of Nursing Before administering any as need pain medication, the nurse should ask the patient to indicate the pain’s location. Fundamentals of Nursing Jehovah’s Witnesses believe that they shouldn’t receive blood components donated by other people. Fundamentals of Nursing When providing oral care for an unconscious patient, the nurse should position the patient on the side to minimize the risk of aspiration. Fundamentals of Nursing During assessment of distance vision, the patient should stand 20’ (6.1 m) from the chart. Fundamentals of Nursing The ideal room temperature for a geriatric patient or one who is extremely ill ranges form 66º to 76º F (18.8º to 24.4º C). Fundamentals of Nursing Normal room humidity ranges from 30% to 60%. Fundamentals of Nursing Hand washing is the single best method of limiting the spread of microorganisms. Hands should be washed for 10 seconds after routine contact with a patient and after gloves are removed. Fundamentals of Nursing To catheterize a female patient, the nurse should place her in the dorsal recumbent position. Fundamentals of Nursing A positive Homan’s sign may indicate thrombophlebitis. Fundamentals of Nursing Electrolytes in a solution are measured in milliequivalents per liter (mEq/L). A milliequivalent equals the number of milligrams per 100 milliliters of a solution. Fundamentals of Nursing Metabolism takes a place in two phases: anabolism (the constructive phase) and catabolism (the destructive phase). Fundamentals of Nursing The basal metabolic rate represents the amount of energy needed to maintain essential body functions. It is measured when the patient is awake and resting, hasn’t eaten for 14 to 18 hours, and is in a comfortable, warm environment. Fundamentals of Nursing Dietary fiber (roughage), which is derived from cellulose, supplies bulk, maintains adequate intestinal motility, and helps establish regular bowel habits. Fundamentals of Nursing Alcohol is metabolized primarily in the liver. Smaller amounts are metabolized by the kidneys and lungs. Fundamentals of Nursing Petechiae refers to tiny, round, purplish red spots that appear on the skin and mucous membranes as a result of intradermal or submucosal hemorrhage. Fundamentals of Nursing Purpura refers to a purple skin discoloration caused by blood extravasation. Fundamentals of Nursing Glucose-6-phosphate dehydrogenase (C6PD) deficiency is an inherited metabolic disorder characterized by red blood cells that are deficient in G6PD, a critical enzyme in aerobic glycolysis. Fundamentals of Nursing According to the standard precautions recommended by the Centers for Disease Control and Prevention, the nurse shouldn’t recap needles after use because most needle sticks result from missed needle recapping. Fundamentals of Nursing The nurse administers a drug by I.V. push by delivering the dose directly into a vein, I.V. tubing, or catheter with a needle and syringe. Fundamentals of Nursing When changing the ties on a tracheostomy tube, the nurse should leave the old ties in place until the new ones are applied. Fundamentals of Nursing A nurse should have assistance when changing the ties on a tracheostomy tube. Fundamentals of Nursing A filter is always used for blood transfusions. Fundamentals of Nursing A four-point (quad) cane is indicated when a patient needs more stability than a regular cane can provide. Fundamentals of Nursing The patient should carry a cane on the unaffected side to promote a reciprocal gait pattern and distribute weight away from the affected leg. Fundamentals of Nursing A good way to begin a patient interview is to ask “What made you seek medical help?” Fundamentals of Nursing The nurse should adhere to standard precautions for blood and body fluids when caring for all patients. Fundamentals of Nursing Potassium (K+) is the most abundant cation in intracellular fluid. Fundamentals of Nursing In the four-point gait (or alternating gait), the patient first moves the right crutch followed by the left foot and then the left crutch followed by the right foot. Fundamentals of Nursing In the three-point gait, the patient moves two crutches and the affected leg simultaneously and then moves the unaffected leg. Fundamentals of Nursing In the two-point gait, the patient moves the right leg and the left crutch simultaneously and then moves the left leg and the right crutch. Fundamentals of Nursing Vitamin B complex, the water-soluble vitamins essential for metabolism, include thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), and cyanocobalamin (B12). Fundamentals of Nursing When being weighed, an adult patient should be lightly dressed and shoeless. Fundamentals of Nursing Before taking an adult’s oral temperature, the nurse should ensure that the patient hasn’t smoked or consumed hot or cold substances in the past 15 minutes. Fundamentals of Nursing The nurse shouldn’t take a rectal temperature on an adult patient if the patient has a cardiac disorder; anal lesions, or bleeding hemorrhoids or has recently undergone rectal surgery. Fundamentals of Nursing In a patient with cardiac problems, rectal temperature measurement may stimulate a vagal response, leading to vasodilation and decreased cardiac output. Fundamentals of Nursing When recording pulse amplitude and rhythm, the nurse should use these descriptive measures: +3 indicates a bounding pulse (readily palpable and forceful); +2, a normal pulse (easily palpable); +1, a thready or weak pulse (difficult to detect); and 0, an absent pulse (not detectable). Fundamentals of Nursing The intraoperative period begins when a patient is transferred to the operating room bed and ends when the patient is admitted to the postanesthesia recovery unit. Fundamentals of Nursing On the morning of surgery, the nurse should ensure that the informed consent form has been signed; that the patient hasn’t taken anything by mouth since midnight, has taken a shower with antimicrobial soap, has had mouth care (without swallowing the water, has removed common jewelry, and has received preoperative medication as prescribed; and that vital signs have taken and recorded. Artificial limbs and other prostheses are usually removed. Fundamentals of Nursing Comfort measures, such as positioning the patient, performing backrubs, and providing a restful environment, may decrease the patient’s need for analgesics or may enhance their effectiveness. Fundamentals of Nursing A drug has three names: its generic name, which is used in official publications; its trade name or brand name (such as Tylenol), which is selected by the drug company; and its chemical name, which describes the drug’s chemical composition. Fundamentals of Nursing The patient should take a liquid iron preparation through a straw to avoid staining the teeth. Fundamentals of Nursing The nurse should use the Z-track method to administer an I.M. injection of iron dextran (Imferon). Fundamentals of Nursing An organism may enter the body through the nose, mouth, rectum, urinary or reproductive tract, or skin. Fundamentals of Nursing In descending order, the levels of consciousness are alertness, lethargy, stupor, light coma, and deep coma. Fundamentals of Nursing To turn a patient by logrolling, the nurse folds the patient’s arms across the chest; extends the patient’s legs and inserts a pillow between them, if indicated; places a draw sheet under the patient; and turns the patient by slowly and gently pulling on the draw sheet. Fundamentals of Nursing The diaphragm of the stethoscope is used to hear high-pitched sounds such as breath sounds. Fundamentals of Nursing A slight blood pressure difference (5 to 10 mm Hg) between right and left arms is normal. Fundamentals of Nursing The nurse should place the blood pressure cuff 1'' (2.5 cm) above the antecubital fossa. Fundamentals of Nursing When instilling ophthalmic ointments, waste the first bed of ointment and then apply from the inner canthus to the outer canthus; twist the medication tube to detach the ointment. Fundamentals of Nursing The nurse should use a leg cuff to measure blood pressure in an obese patient. Fundamentals of Nursing If the blood pressure cuff is applied too loosely, the reading will be falsely elevated. Fundamentals of Nursing Ptosis refers to eyelid drooping. Fundamentals of Nursing A tilt table is useful for a patient with a spinal cord injury, orthostatic hypotension, or brain damage because it can move the patient gradually from a horizontal to a vertical (upright) position. Fundamentals of Nursing To perform venipuncture with the least injury to the vessel, the nurse should turn the bevel upward when the vessel’s lumen is larger than the needle and turn it downward when the lumen is only slightly larger than the needle. Fundamentals of Nursing To move the patient to the edge of the bed for transfer, follow these steps: (1) Move the patient’s head and shoulders toward the edge of the bed. (2) Move the patient’s feet and legs to the edge of the bed (crescent position). (3) Place both the arms well under the patient’s hips and straighten the back while moving the patient toward the edge of the bed. Fundamentals of Nursing When being measured for crutches, a patient should wear his or her shoes. Fundamentals of Nursing The nurse should attach a restraint to a part of the bed frame that moves with the head, not to the mattress or side rails. Fundamentals of Nursing The mist in a mist tent should never become so dense that it obscures clear visualization of the patient’s respiratory pattern. Fundamentals of Nursing To administer heparin subcutaneously, the nurse should follow these steps: (1) Clean, but don’t rub, the site with alcohol. (2) Stretch the skin taut or pick up a well-defined skin fold. (3)Hold the shaft of the needle in a dart position. (4)Insert the needle into the skin at a right (90-degree) angle. (5)Firmly depress the plunger; but don’t aspirate. (6)Leave the needle in place for 10 seconds. (7)Withdraw the needle gently at the same angle it was inserted. (8)Apply pressure to the injection site with an alcohol pad. Fundamentals of Nursing For a sigmoidoscopy, the nurse should place the patient in a knee-chest or Sims’ position, depending on the doctor’s preference. Fundamentals of Nursing Maslow’s hierarchy of needs must be met in the following order: physiologic (oxygen, food, water, sex, rest, and comfort) safety and security, love and belonging, self-esteem and recognition, and self-actualization. Fundamentals of Nursing When caring for patient with a nasogastric tube, the nurse should apply a water-soluble lubricant to the nostril to prevent soreness. Fundamentals of Nursing During gastric lavage, a nasogastric tube is inserted, the stomach is flushed, and ingested substances are removed through the tube. Fundamentals of Nursing In documenting drainage on a surgical dressing, the nurse should include the size, color, and consistency of the drainage, for example, “10 mm of brown mucoid drainage noted on dressing.” Fundamentals of Nursing To elicit Babinski’s reflex, the nurse strokes the sole of the patient’s foot with a moderately sharp object, such as thumbnail. Fundamentals of Nursing In a positive Babinski’s reflex, the great toe dorsiflexes and the other toes fan out. Fundamentals of Nursing When assessing a patient for bladder distention, the nurse should check the contour of the lower abdomen for a rounded mass above the symphysis pubis. Fundamentals of Nursing The best way to prevent pressure ulcers is to reposition the bedridden patient at least every 2 hours. Fundamentals of Nursing Antiembolism stockings decompress the superficial blood vessels, thereby reducing the risk of thrombus formation. Fundamentals of Nursing The most convenient veins for venipuncture in a adult patient are the basilic and median cubital veins in the antecubital space. Fundamentals of Nursing From 2 to 3 hours before beginning a tube feeding, the nurse should aspirate the patient’s stomach contents to verify adequate gastric emptying. Fundamentals of Nursing People with type O blood are considered to be universal donors. Fundamentals of Nursing People with type AB blood are considered to be universal recipients. Fundamentals of Nursing Herts (Hz) refers to the unit of measurement of sound frequency. Fundamentals of Nursing Hearing protection is required when the sound intensity exceeds 84 dB; double hearing protection is required if it exceeds 104 dB. Fundamentals of Nursing Prothrombin, a clotting factor, is produced in the liver. Fundamentals of Nursing If a patient is menstruating when a urine sample is collected, the nurse should note this on the laboratory slip. Fundamentals of Nursing During lumbar puncture, the nurse must note the initial intracranial pressure and the cerebrospinal fluid color. Fundamentals of Nursing A patient who can’t cough to provide a sputum sample for culture may require a heated aerosol treatment to facilitate removal of a sample. Fundamentals of Nursing If eye ointment and eyedrops must be instilled in the same eye, the eyedrops should be instilled first. Fundamentals of Nursing When leaving an isolation room, the nurse should remove the gloves before the mask because fewer pathogens are on the mask. Fundamentals of Nursing Skeletal traction is applied to a bone using wire pins or tons. It is the most effective means of traction. Fundamentals of Nursing The total parenteral nutrition solution should be stored in a refrigerator and removed 30 to 60 minutes before use because delivery of a chilled solution can cause pain, hypothermia, venous spasm, and venous constriction. Fundamentals of Nursing Medication isn’t routinely injected I.M. into edematous tissue because it may not be absorbed. Fundamentals of Nursing When caring for a comatose patient, the nurse should explain each action to the patient in a normal voice. Fundamentals of Nursing When cleaning dentures, the sink should be lined with a washcloth. Fundamentals of Nursing A patient should void within 8 hours after surgery. Fundamentals of Nursing An EEG identifies normal and abnormal brain waves. Fundamentals of Nursing Stool samples for ova and parasite tests should be delivered to the laboratory without delay or refrigeration. Fundamentals of Nursing The autonomic nervous system regulates the cardiovascular and respiratory systems. Fundamentals of Nursing When providing tracheostomy care, the nurse should insert the catheter gently into the tracheostomy tube. When withdrawing the catheter, the nurse should apply intermittent suction for no more than 15 seconds and use a slight twisting motion. Fundamentals of Nursing A low-residue diet includes such as foods as roasted chicken, rice, and pasta. Fundamentals of Nursing A rectal tube should not be inserted for longer than 20 minutes; it can irritate the mucosa of the rectum and cause a loss of sphincter control. Fundamentals of Nursing A patient’s bed bath should proceed in this order: face, neck, arms, hands, chest, abdomen, back, legs, perineum. Fundamentals of Nursing When lifting and moving a patient, the nurse should use the upper leg muscles most to prevent injury. Fundamentals of Nursing Patient preparation for cholecystography includes ingestion of a contrast medium and a low-fat evening meal. Fundamentals of Nursing During occupied bed changes, the patient should be covered with a black blanket to promote warmth and prevent exposure. Fundamentals of Nursing Anticipatory grief refers to mourning that occurs for an extended time when one realizes that death is inevitable. Fundamentals of Nursing The following foods can alter stool color: beets (red), cocoa (dark red or brown), licorice (black), spinach (green), and meat protein (dark brown). Fundamentals of Nursing When preparing a patient for a skull X-ray, have the patient remove all jewelry and dentures. Fundamentals of Nursing The fight-or-flight response is a sympathetic nervous system response. Fundamentals of Nursing Bronchovesicular breath sounds in peripheral lung fields are abnormal and suggest pneumonia. Fundamentals of Nursing Wheezing refers to an abnormal, high-pitched breath sound that is accentuated on expiration. Fundamentals of Nursing Wax or a foreign body in the ear should be gently flushed out by irrigation with warm saline solution. Fundamentals of Nursing If a patient complains that his hearing aid is “not working,” the nurse should check the switch first to see if it’s turned on and then check the batteries. Fundamentals of Nursing The nurse should grade hyperactive biceps and triceps reflexes +4. Fundamentals of Nursing If two eye medications are prescribed for twice-daily instillation, they should be administered 5 minutes apart. Fundamentals of Nursing In a postoperative patient, forcing fluids helps prevent constipation. Fundamentals of Nursing The nurse must administer care in accordance with standards of care established by the American Nurses Association, state regulations, and facility policy. Fundamentals of Nursing The kilocalorie (kcal) is a unit of energy measurement that represents the amount of heat needed to raise the temperature of 1 kilogram of water 1º C. Fundamentals of Nursing As nutrients move through the body, they undergo ingestion, digestion, absorption, transport, cell metabolism, and excretion. Fundamentals of Nursing The body metabolizes alcohol at a fixed rate regardless of serum concentration. Fundamentals of Nursing In an alcoholic beverage, its proof reflects its percentage of alcohol multiplied by 2. For example, a 100-proof beverage contains 50% alcohol. Fundamentals of Nursing A living will is a witnessed document that states a patient’s desire for certain types of care and treatment, which depends on the patient’s wishes and views and quality of life. Fundamentals of Nursing The nurse should flush a peripheral heparin lock every 8 hours (if it wasn’t used during the previous 8 hours) and as needed with normal saline solution to maintain patency. Fundamentals of Nursing Quality assurance is a method of determining whether nursing actions and practices meet established standards. Fundamentals of Nursing The five rights of medication administration are the right patient, right medication, right dose, right route of administration, and the right time. Fundamentals of Nursing Outside of the hospital setting, only the sublingual and transligual forms of nitroglycerin should be used to relieve acute anginal attacks. Fundamentals of Nursing The implementation phase of the nursing process involves recording the patient’s response to the nursing plan, putting the nursing plan into action, delegating specific nursing interventions, and coordinating the patient’s activities. Fundamentals of Nursing The Patient’s Bill of Rights offers guidance and protection to patients by stating the responsibilities of the hospital and its staff toward patients and their families during hospitalization. Fundamentals of Nursing To minimize the omissions and distortion of facts, the nurse should record information as soon as it is gathered. Fundamentals of Nursing When assessing a patient’s health history, the nurse should record the current illness chronologically, beginning with the onset of the problem and continuing to the present. Fundamentals of Nursing Drug administration is a dependent activity. The nurse can administer or withhold a drug only with the doctor’s permission. Fundamentals of Nursing The nurse shouldn’t give false assurance to a patient. Fundamentals of Nursing After receiving preoperative medication, a patient isn’t competent to sign an informed consent form. Fundamentals of Nursing When lifting a patient, a nurse uses the weight of her body instead of the strength in her arms. Fundamentals of Nursing A nurse may clarify a doctor’s explanation to a patient about an operation or a procedure but must refer questions about informed consent to the doctor. Fundamentals of Nursing The nurse shouldn’t use her thumb to take a patient’s pulse rate because the thumb has a pulse of its own and may be confused with the patient’s pulse. Fundamentals of Nursing An inspiration and an expiration count as one respiration. Fundamentals of Nursing Normal respirations are known as eupnea. Fundamentals of Nursing During a blood pressure measurement, the patient should rest the arm against a surface because using muscle strength to hold up the arm may raise the blood pressure. Fundamentals of Nursing Major unalterable risk factors for coronary artery disease include heredity, sex, race, and age. Fundamentals of Nursing Inspection is the most frequently used assessment technique. Fundamentals of Nursing Family members of an elderly person in a long-term care facility should transfer some personal items (such as photographs, a favorite chair, and knickknacks) to the person’s room to provide a homey atmosphere. Fundamentals of Nursing The upper respiratory tract warms and humidifies inspired air and plays a role in taste, smell, and mastication. Fundamentals of Nursing Signs of accessory muscle use include shoulder elevation, intercostal muscle retraction, and scalene and sternocleidosmastoid muscle use during respiration. Fundamentals of Nursing When patients use axillary crutches, their palms should bear the brunt of the weight. Fundamentals of Nursing Activities of daily living include eating, bathing, dressing, grooming, toileting, and interacting socially. Fundamentals of Nursing Normal gait has two phases: the stance phase, in which the patient’s foot rests on the ground, and the swing phase, in which that patient’s foot moves forward. Fundamentals of Nursing The phases of mitosis are prophase, metaphase, anaphase, and telophase. Fundamentals of Nursing The nurse should follow standard precautions in the routine care of all patients. Fundamentals of Nursing The nurse should use the bell of the stethoscope to listen for venous hums and cardiac murmurs. Fundamentals of Nursing The nurse can assess a patient’s general knowledge by asking questions such as “Who is the president for the United States?” Fundamentals of Nursing Cold packs are applied for the first 20 to 48 hours after an injury; then heat is applied. During cold application, the pack is applied for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation (rebound phenomenon) and frostbite injury. Fundamentals of Nursing The pons is located above the medulla and consists of white matter (sensory and motor tracts) and gray matter (reflex centers). Fundamentals of Nursing The autonomic nervous system controls the smooth muscles. Fundamentals of Nursing A correctly written patient goal expresses the desired patient behavior, criteria for measurement, time frame for achievement, and conditions under which the behavior will occur. It is developed in collaboration with the patient. Fundamentals of Nursing The optic disk is yellowish pink and circular with a distinct border. Fundamentals of Nursing A primary disability results from a pathologic process; a secondary disability, from inactivity. Nurses usually are held liable for failing to keep an accurate count of sponges and other devices during surgery. Fundamentals of Nursing The best dietary sources of vitamin B6 are liver, kidney, pork, soybeans, corn, and whole-grain cereals. Fundamentals of Nursing Iron-rich foods, such as organ meats, nuts, legumes, dried fruit, leafy vegetables, eggs, and whole gains, generally have low water content. Fundamentals of Nursing Collaboration refers to joint communication and decision making between nurses and doctors designed to meet patients’ needs by integrating the care regimens of both professions in one comprehensive approach. Fundamentals of Nursing Bradycardia refers to a heart rate of fewer than 60 beats/minute. Fundamentals of Nursing A nursing diagnosis is a statement of a patient’s actual or potential health problems that can be resolved, diminished, or otherwise changed by nursing interventions. Fundamentals of Nursing During the assessment phase of the nursing process, the nurse collects and analyzes three types of data: health history, physical examination, and laboratory and diagnostic test data. Fundamentals of Nursing The patient’s health history consists primarily of subjective data, information supplied by patient. Fundamentals of Nursing The physical examination includes objective data obtained by inspection, palpation, percussion, and auscultation. Fundamentals of Nursing When documenting patient care, the nurse should write legibly, use only standard abbreviations, and sign every entry. The nurse should never destroy or attempt to obliterate documentation or leave vacant lines. Fundamentals of Nursing Factors that affect body temperature include time of day, age, physical activity, phase of menstrual cycle, and pregnancy. Fundamentals of Nursing The most accessible and commonly used artery for measuring a patient’s pulse rate is the radial artery, which is compressed against the radius to take the pulse rate. Fundamentals of Nursing The normal pulse rate of a resting adult is 60 to 100 beats/minute. The rate is slightly faster in women than in men and much faster in children than in adults. Fundamentals of Nursing Laboratory test results are an objective form of assessment data. Fundamentals of Nursing The measurement systems most often used in clinical practice are the metric system, apothecaries’ system, and household system. Fundamentals of Nursing Before signing an informed consent, a patient should know whether other treatment options are available and should understand what will occur during the preoperative, intraoperative, and postoperative phase; the risk involved; and the possible complications. The patient also should have a general idea of the time required from surgery to recovery and should have an opportunity to ask questions. Fundamentals of Nursing A patient must sign a separate informed consent form for each procedure. Fundamentals of Nursing During percussion, the nurse uses quick, sharp tapping of the fingers or hands against body surfaces to produce sounds (that helps determine the size, shape, position, and density of underlying organs and tissues), elicit tenderness, or assess reflexes. Fundamentals of Nursing Ballottement is a form of light palpation involving gentle, repetitive bouncing of tissues against the hand and feeling their rebound. Fundamentals of Nursing A foot cradle keeps bed linen off the patient’s feet, which prevent skin irritation and breakdown, especially in a patient with peripheral vascular disease or neuropathy. Fundamentals of Nursing If the patient is a married minor, permission to perform a procedure can be obtained form the patient’s spouse. Fundamentals of Nursing Gastric lavage is the flushing of the stomach and removal of ingested substances through a nasogastric tube. It can be used to treat poisoning or drug overdose. Fundamentals of Nursing During the evaluation step of the nursing process, the nurse assesses the patient’s response to therapy. Fundamentals of Nursing Bruits commonly indicate a life- or limb-threatening vascular disease. Fundamentals of Nursing O.U. means each eye; O.D., right eye; and O.S, left eye. Fundamentals of Nursing To remove a patient’s artificial eye, the nurse depresses the lower lid. Fundamentals of Nursing The nurse should use a warm saline solution to clean an artificial eye. Fundamentals of Nursing A thready pulse is very fine and scarcely perceptible. Fundamentals of Nursing Axillary temperature usually is 1º F lower than oral temperature. Fundamentals of Nursing After suctioning a tracheostomy tube, the nurse must document the color, amount, consistency, and odor of secretions. Fundamentals of Nursing On a medication prescription, the abbreviation p.c. means that the medication should be administered after meals. Fundamentals of Nursing After bladder irrigation, the nurse should document the amount, color, and clarity of the urine and the presence of clots or sediment. Fundamentals of Nursing Laws regarding patient self-determination vary from state to state. Therefore, the nurse must be familiar with the laws of the state in which she works. Fundamentals of Nursing Gauge refers to the inside diameter of a needle. The smaller the gauge, the larger the diameter. Fundamentals of Nursing An adult normally has 32 permanent teeth. Fundamentals of Nursing After turning a patient, the nurse should document the position used, time turned, and skin assessment findings. Fundamentals of Nursing PERRLA is an abbreviation for normal pupil assessment findings: pupils equal, round, and reactive to light with accommodation. Fundamentals of Nursing When purcussing a patient’s chest for postural drainage, the nurse’s hands should be cupped. Fundamentals of Nursing When measuring a patient’s pulse, the nurse should assess the rate, rhythms, quality, and strength. Fundamentals of Nursing Before transferring a patient from a bed to a wheelchair, the nurse should push the wheelchair’s footrests to the sides and lock its wheels. Fundamentals of Nursing When assessing respirations, the nurse should document the rate, rhythm, depth, and quality. Fundamentals of Nursing For a subcutaneous injection, the nurse should use a ⅝" 25G needle. Fundamentals of Nursing The notation “AA & O x 3” indicates that the patient is awake, alert, and oriented to person (knows who he is), place (knows where he is), and time (knows the date and time). Fundamentals of Nursing Fluid intake includes all fluids taken by mouth, including foods that are liquid at room temperature, such as gelatin, custard, and ice cream; I.V. fluids; and fluids administered in feeding tubes. Fluid output includes urine, vomitus, and drainage (such as from a nasogastric tube or from a wound) as well as blood loss, diarrhea or stool, and perspiration. Fundamentals of Nursing After administering an intradermal injection, the nurse shouldn’t massage the area because massage can irritate the site and interfere with results. Fundamentals of Nursing When administering an intradermal injection, the nurse should hold the syringe almost flat against the patient’s skin (at about a 15-degree angle) with the bevel up. Fundamentals of Nursing To obtain an accurate blood pressure, the nurse should inflate the manometer 20 to 30 mm Hg above the disappearance of the radial pulse before releasing the cuff pressure. Fundamentals of Nursing The nurse should count an irregular pulse for 1 full minute. Fundamentals of Nursing A patient who is vomiting while lying down should be placed in a lateral position to prevent aspiration of vomitus. Fundamentals of Nursing Prophylaxis is disease prevention. Fundamentals of Nursing Body alignment is achieved when the body parts are in proper relation to their natural position. Fundamentals of Nursing Trust is the foundation of a nurse-patient relationship. Fundamentals of Nursing Blood pressure in the force exerted by the circulating volume of blood on arterial walls. Fundamentals of Nursing Malpractice refers to the professional’s wrongful conduct, improper discharge of duties, or failure to meet standers of care, which causes harm to another. Fundamentals of Nursing As a general rule, nurses can’t refuse a patient care assignment; however, they may refuse to participate in abortions in most states. Fundamentals of Nursing A nurse can be found negligent if a patient is injured because the nurse failed to perform a duty that a reasonable and prudent person would perform or because the nurse performed an act that a reasonable and prudent person wouldn’t perform. Fundamentals of Nursing States have enacted Good Samaritan laws to encourage professionals to provide medical assistance at the scene of an accident without fear of a lawsuit arising from such assistance. These laws don’t apply to care provided in a health care facility. Fundamentals of Nursing A doctor should sign verbal and telephone orders within the time established by institutional policy, usually within 24 hours. Fundamentals of Nursing A competent adult has the right to refuse lifesaving medical treatment; however, the individual should be fully informed of the consequences of this refusal. Fundamentals of Nursing Although a patient’s health record or chart is the health care facility’s physical property, its contents belong to the patient. Fundamentals of Nursing Before a patient’s record can be released to a third party, the patient or patient’s legal guardian must give written consent. Fundamentals of Nursing Under the Controlled Substances Act, every dose of a controlled drug dispensed by the pharmacy must be counted for, whether the dose was administered to a particular patient or discarded accidentally. Fundamentals of Nursing A nurse can’t perform duties that violate a rule or regulation established by a state licensing board even if it is authorized by a health care facility or doctor. Fundamentals of Nursing The nurse should select a private room, preferably with a door that can be closed, to minimize interruptions during a patient interview. Fundamentals of Nursing In categorizing nursing diagnosis, the nurse should address actual life-threatening problems first, followed by potentially life-threatening concerns. Fundamentals of Nursing The major components of a nursing care plan are outcome criteria (patient goals) and nursing interventions. Fundamentals of Nursing Standing orders, or protocols, establish guidelines for treating a particular disease or set of symptoms. Fundamentals of Nursing In assessing a patient’s heart, the nurse normally finds the point of maximal impulse at the fifth intercostals space near the apex. Fundamentals of Nursing The S1 sound heard on auscultation is caused by closure of the mitral and tricuspid valves. Fundamentals of Nursing To maintain package sterility, the nurse should open the wrapper’s top flap away from the body, open side flap by touching only the outer part of the wrapper, and open the final flap by grasping the turned-down corner and pulling it toward the body. Fundamentals of Nursing The nurse shouldn’t use a cotton-tipped applicator to dry a patient’s ear canal or remove wax because it may force cerumen against the tympanic membrane. Fundamentals of Nursing A patient’s identification bracelet should remain in place until the patient has been discharged from the health care facility and has left the premises. Fundamentals of Nursing The Controlled Substances Act designated five categories, or schedules, that classify controlled drugs according to their abuse liability. Fundamentals of Nursing Schedule I drugs, such as heroin, have a high abuse potential and have no currently accepted medical use in the United States. Fundamentals of Nursing Schedule II drugs, such as morphine, opium, and meperidine (Demerol), have a high abuse potential but have currently accepted medical uses. Their use may lead to physical or psychological dependence. Fundamentals of Nursing Schedule III drugs, such as paregoric and butabarbital (Butisol), have a lower abuse potential than Schedule I or II drugs. Abuse of Schedule III drugs may lead to moderate or low physical or psychological dependence, or both. Fundamentals of Nursing Schedule IV drugs, such as chloral hydrate, have a low abuse potential compared with Schedule III drugs. Fundamentals of Nursing Schedule V drugs, such as cough syrups that contain codeine, have the lowest abuse potential of the controlled substances. Fundamentals of Nursing Activities of daily living are actions that the patient must perform every day to provide self-care and interact with society. Fundamentals of Nursing Testing of the six cardinal fields of gaze evaluates the function of all extraocular muscles and cranial nerves III, IV, and VI. Fundamentals of Nursing The six types of heart murmurs are graded from 1 to 6. A grade 6 heart murmur can be heard with stethoscope slightly raised from the chest. Fundamentals of Nursing The most important goal to include in a care plan is the patient’s goal. Fundamentals of Nursing Fruits are high in fiber and low in protein and should be omitted from a low-residue diet. Fundamentals of Nursing The nurse should use an objective scale to assess and quantify pain because postoperative pain varies greatly among individuals. Fundamentals of Nursing Postmortem care includes cleaning and preparing the deceased patient for family viewing, arranging transportation to the morgue or funeral home, and determining the disposition of belongings. Fundamentals of Nursing The nurse should provide honest answers to the patient’s questions. Fundamentals of Nursing Milk shouldn’t be included in a clear liquid diet. Fundamentals of Nursing Consistency in nursing personnel is paramount when caring for a child, and infant, or a confused patient. Fundamentals of Nursing The hypothalamus secretes vasopressin and oxytocin, which are stored in the pituitary gland. Fundamentals of Nursing The three membranes that enclose that brain and spinal cord are the dura mater, pia mater, and arachnoid. Fundamentals of Nursing A nasogastric tube is used to remove fluid and gas from the small intestine preoperatively or postoperatively. Fundamentals of Nursing Psychologists, physical therapists, and chiropractors aren’t authorized to write prescriptions for medication. Fundamentals of Nursing The area around a stoma should be cleaned with mild soap and water. Fundamentals of Nursing Vegetables have a high fiber content. Fundamentals of Nursing The nurse should use a tuberculin syringe to administer an S.C. injection of less than 1 ml. Fundamentals of Nursing For adults, S.C. injections require a 25G 1" needle; for infants, children, elderly, or very thin patients, they require a 25G to 27G ½" needle. Fundamentals of Nursing Before administering medication, the nurse should identify the patient by checking the identification band and asking the patient to state his name. Fundamentals of Nursing To clean the skin before an injection, the nurse should use a sterile alcohol swab and wipe from the center of the site outward in a circular motion. Fundamentals of Nursing The nurse always should inject heparin deep into S.C. tissue at a 90-degree angle (perpendicular to the skin) to prevent skin irritation. Fundamentals of Nursing If blood is aspirated into the syringe before an I.M. injection, the nurse should withdraw the needle, prepare another syringe, and repeat the procedure. Fundamentals of Nursing The nurse shouldn’t cut the patient’s hair without written consent from the patient or an appropriate relative. Fundamentals of Nursing If bleeding occurs after an injection, the nurse should apply pressure until the bleeding stops; if bruising occurs, the nurse should monitor the site for an enlarging hematoma. Fundamentals of Nursing When providing hair and scalp care, the nurse should begin combing at the end of the hair and work toward the head. Fundamentals of Nursing Frequency of patient hair care depends on the length and texture of the hair, duration of hospitalization, and patient’s condition. Fundamentals of Nursing Proper hearing aid function requires careful handling during insertion and removal, regular cleaning of the ear piece to prevent wax buildup, and prompt replacement of dead batteries. Fundamentals of Nursing The hearing aid marked with a blue dot is for the left ear; the one with the red dot is for the right ear. Fundamentals of Nursing A hearing aid shouldn’t be exposed to heat or humidity and shouldn’t be immersed in water. Fundamentals of Nursing The nurse should instruct a patient not to use hair spray while wearing a hearing aid. Fundamentals of Nursing The five branches of pharmacology are pharmacokinetics, pharmacodynamics, pharmacotherapeutics, toxicology, and pharmacognosy. Fundamentals of Nursing The nurse should remove heel protectors every 8 hours to inspect the foot for signs of skin breakdown. Fundamentals of Nursing The purpose of heat application is to promote vasodilation, which reduces pain caused by inflammation. Fundamentals of Nursing A sutured surgical incision is an example of healing by first intention (healing directly, without granulation). Fundamentals of Nursing Healing by secondary intention (healing by granulation) is closure of the wound by the granulation tissue filling the defect and allowing reepithelialization to occur, beginning at the wound edges and continuing to the center, until the entire wound is covered. Fundamentals of Nursing Keloid formation is an abnormality in healing characterized by overgrowth of scar tissue at the wound site. Fundamentals of Nursing The nurse should administer procaine penicillin by deep I.M. injection in the upper outer portion of the buttocks in the adult or in the midlateral thigh in the child. The nurse shouldn’t massage the injection site. Fundamentals of Nursing The ascending colostomy drains fluid feces; the descending colostomy drains solid fecal matter. Fundamentals of Nursing A folded towel (called a scrotal bridge) can provide scrotal support for the patient with scrotal edema caused by vasectomy, epididymitis, or orchitis. Fundamentals of Nursing When giving an injection to the patient with a bleeding disorder, the nurse should use a small-gauge needle and apply pressure to the site for 5 minutes after the injection. Fundamentals of Nursing Platelets are the smallest and most fragile formed element of the blood and are essential for coagulation. Fundamentals of Nursing To insert a nasogastric tube, the nurse should first instruct the patient to tilt the head back slightly and then insert the tube. When the tube is felt curving at the pharynx, the nurse should tell the patient to tilt the head forward to close the trachea and open the esophagus by swallowing. (Sips of water can facilitate this action.) Fundamentals of Nursing According to families whose loved ones are in intensive care units, their four most important needs are to have questions answered honestly, to be assured that the best possible car is being provided, to know the prognosis, and to feel there is hope. Fundamentals of Nursing A double-bind communication when the verbal message contradicts the nonverbal message and the receiver is unsure of which message to respond to. Fundamentals of Nursing A nonjudgmental attitude displayed by the nurse demonstrates that she neither approves nor disapproves of the patient. Fundamentals of Nursing Target symptoms are those that the patient and others find most distressing. Fundamentals of Nursing Advise the patient to take aspirin on an empty stomach with a full glass of water and to avoid foods with acid such as coffee, citrus fruits, and cola. Fundamentals of Nursing For every patient problem, there is a nursing diagnosis; for every nursing diagnosis, there is a goal; and for every goal, there are interventions designed to make the goal a reality. The keys to answering examination questions correctly are identifying the problem presented, formulating a goal for that specific problem, and then selecting the intervention from the choices provided that will enable the patient to reach that goal. Fundamentals of Nursing Fidelity means loyalty and can be shown as a commitment to the profession of nursing and to the patient. Fundamentals of Nursing Giving an I.M. injection against the patient’s will and without legal authority is battery. Fundamentals of Nursing An example of a third-party payor is an insurance company. Fundamentals of Nursing On-call medication should be given within 5 minutes of receipt of the call. Fundamentals of Nursing Generally, the best method to determine the cultural or spiritual needs of the patient is to ask him. Fundamentals of Nursing An incident report shouldn’t be made part of the patient’s record but is an in-house document for the purpose of correcting the problem. Fundamentals of Nursing Critical pathways are a multidisciplinary guideline for patient care. Fundamentals of Nursing When prioritizing nursing diagnoses, use this hierarchy: (1) problems associated with airway, (2) those concerning breathing, and (3) those related to circulation. Fundamentals of Nursing The two nursing diagnoses with the highest priority that the nurse can assign are Ineffective airway clearance and Ineffective breathing pattern. Fundamentals of Nursing A subjective sign that a sitz bath has been effective is that patient expresses a decrease in pain or discomfort. Fundamentals of Nursing For the nursing diagnosis Diversional activity deficit to be valid, the patient must make the statement that he’s “bored, there is nothing to do” or words to that effect. Fundamentals of Nursing The most appropriate nursing diagnosis for an individual who doesn’t speak English is Communication, impaired, related to inability to speak dominant language (English). Fundamentals of Nursing The family of the patient who has been diagnosed as hearing impaired should be instructed to face the individual when they speak to him. Fundamentals of Nursing Up to age 3, the pinna should be pulled down and back to straighten the eustachian tube before instilling medication. Fundamentals of Nursing When administering eyedrops, the nurse should waste the first drop and instill the medication in the lower conjunctival sac to prevent injury to the cornea. Fundamentals of Nursing When administering eye ointment, the nurse should waste the first bead of medication and then apply the medication from the inner to the outer canthus. Fundamentals of Nursing When removing gloves and mask, the gloves, which most likely contain pathogens and are soiled, should be removed first. Fundamentals of Nursing Crutches should placed 6" (15 cm) in front of the patient and 6" to the side to assume a tripod position. Fundamentals of Nursing Listening is the most effective communication technique. Fundamentals of Nursing Process recording is a method of evaluating one’s communication effectiveness. Fundamentals of Nursing When feeding the elderly, limit high-carbohydrate foods because of the risk of glucose intolerance. Fundamentals of Nursing Passive range of motion maintains joint mobility whereas resistive exercises increase muscle mass. Fundamentals of Nursing Isometric exercises are performed on an extremity in a cast. Fundamentals of Nursing A back rub is an example of the gate-control theory of pain. Fundamentals of Nursing Anything below the waist is considered unsterile, a sterile field becomes unsterile when it comes in contact with nay unsterile item, a sterile field must be continuously monitored, and the 1" (2.5 cm) border around a sterile field is considered unsterile. Fundamentals of Nursing A “shift to the left” is evident when there is an increase in immature cells (bands) in the blood to fight an infection. Fundamentals of Nursing A “shift to the right” is evident when there is an increase in mature cells in the blood as seen in advanced liver diseases and pernicious anemia. Fundamentals of Nursing Before administering preoperative medication, make sure that an informed consent form has been signed and attached to the patient’s record. Fundamentals of Nursing The nurse should spend no more than 30 minutes per 8-hour shift in providing care to the patient with a radiation implant. Fundamentals of Nursing The nurse should stand near the patient’s shoulders for cervical implants and at the foot of the bed for head and neck implants. Fundamentals of Nursing The nurse should never be assigned to care for more than one patient with radiation implants. Fundamentals of Nursing Long-handled forceps and a lead-lined container should be in the room of the patient who has a radiation implant. Fundamentals of Nursing Generally, patients who have the same infection and are in strict isolation can share the same room. Fundamentals of Nursing Diseases requiring strict isolation include chickenpox, diphtheria, and viral hemorrhagic fever such as Marburg virus disease. Fundamentals of Nursing For the patient abiding by Jewish custom, milk and meat shouldn’t be served in the same meal. Fundamentals of Nursing Whether the patient can perform a procedure (psychomotor domain of learning) is a better indicator of the effectiveness of patient teaching than whether the patient can simply state the steps of the procedure (cognitive domain of learning). Fundamentals of Nursing Developmental stages according to Erik Erikson are trust versus mistrust (birth to 18 months), autonomy versus shame and doubt (18 months to 3 years), initiative versus guilt (3 to 5 years), industry versus inferiority (5 to 12 years), identity versus identity diffusion (12 to 18 years), intimacy versus isolation (18 to 25 years), generativity versus stagnation (25 to 60 years), and ego integrity versus despair (older than 60 years). Fundamentals of Nursing Face the hearing impaired patient when communicating with him. Fundamentals of Nursing A proper nursing intervention for the spouse of the patient who has suffered a serious incapacitating disease is to assist him in mobilizing a support system. Fundamentals of Nursing Hyperpyrexia refers to extreme elevation in temperature above 106º F (41.1º C). Fundamentals of Nursing

Fundamentals of Nursing Drill 14 answers

Question Number 1
The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4 year-old child?



A) "I strap the infant car seat on the front seat to face backwards."
B) "I place my infant in the middle of the living room floor on a blanket to play with my 4 year old while I make supper in the kitchen."
C) "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while the four year old naps on the sofa."
D) "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I make supper."

The correct answer is D: "I have the four year-old hold and help feed the four month-old a bottle in the kitchen while I make supper."
The infant seat is to be placed on the rear seat. Small children and infants are not to be left unsupervised. Infants are to be placed on their "back when they go back" to sleep or are lying in a crib. A 4 year-old could assist with the care of an infant with proper supervision. This enhances bonding with the infant and the developmental needs of the preschooler to "help" and not feel left out.

Question Number 2
Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take?



A) Record the information on the chart
B) Give information about advance directives
C) Assume that this client wishes a full code
D) Refer this issue to the unit secretary

The correct answer is B: Give information about advance directives
For each admission, nurses should request a copy of the current advance directive. If there is none, the nurse must offer information about what an advance directive implies. It is then the client’s choice to sign it. In option 1 just recording the information is not sufficient. In option 3 the nurse should not assume that the client has been informed of choices for emergency care. In option 4 this represents an inappropriate delegation approach.

Question Number 3
A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to






A) Maintain the airway
B) Administer epinephrine 1:1000 as ordered
C) Monitor for hypotension with shock
D) Administer diphenhydramine as ordered

The correct answer is B: Administer epinephrine 1:1000 as ordered
All the answers are correct given the circumstances. The correct sequence of care is to administer the epinephrine, then maintain airway. In the early stages of anaphylaxis, when the patient has not lost consciousness and is normatensive, administering the epinephrine and then applying the oxygen, watching for hypotension and shock are later responses. The prevention of a severe crisis is maintained by using diphenhydramine.

Question Number 4
Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category?



A) An infant with intermittent buldging anterior fontonel between crying episodes
B) A toddler with severe deep abrasions over 98% of the body
C) A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture
D) A school-age child with singed eyebrows and hair on the arms

The correct answer is B: A toddler with severe deep abrasions over 98% of the body
This child has the least chance of survival. Severe deep abrasions are to be thought of as second and third degree burns. The child has great risk of shock and infection combined.

Question Number 5
When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse’s best action is to



A) change whichever item is incorrect to the correct information
B) use the bracelet and admission form until a replacement is supplied
C) notify the admissions office and wait to apply the bracelet
D) make a corrected identification bracelet for the client

The correct answer is C: notify the admissions office and wait to apply the bracelet
The Admissions Office has the responsibility to verify the client’s identity and keep all the records in the system consistent. Making the changes puts the client at risk for misidentification. Using an incorrect identification bracelet is unsafe. Making a new bracelet on the unit is not appropriate.

Question Number 6
The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken?



A) Leave the order for the oncoming staff to follow-up
B) Contact the charge nurse for an interpretation
C) Ask the pharmacy for assistance in the interpretation
D) Call the provider for clarification

The correct answer is D: Call the provider for clarification
Relying on anyone else''s interpretation is very risky. When in doubt, check it out with the person who wrote the illegible order. Order entry systems help to minimize this problem.

Question Number 7
An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to:


A) check the cartoid pulse
B) deliver 5 abdominal thrusts
C) give 2 rescue breaths
D) open the client's airway

The correct answer is D: open the client''s airway
According to the ABCs of CPR the first step in rescuing an unresponsive victim after checking responsiveness and calling for help is to open the victims airway. The airway must be opened appropriately before the need for rescue breaths can be determined. The pulse is assessed, after breathing is evaluated. The need for abdominal thrusts is determined by inability to achieve chest rise when ventilation is attempted.

Question Number 8
A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action?



A) Ask the client if there are any breathing problems
B) Have the client void as much as possible
C) Check the vital signs
D) Ausculate the lungs

The correct answer is D: Ausculate the lungs
All of the options would be part of the evaluation for the effects of the large amount of fluid in a short period of time. However the worst result is heart failure with lung congestion so the auscultation of the lungs is the priority action. The sequence of actions would be 4 1 3 2.

Question Number 9
Following change-of-shift report on an orthopedic unit, which client should the nurse see first?






A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago
B) 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
C) 72 year-old recovering from surgery after a hip replacement 2 hours ago
D) 75 year-old who is in skin traction prior to planned hip pinning surgery.

The correct answer is C: 72 year-old recovering from surgery after a hip replacement 2 hours ago
Look for the client who is in the least stable condition. The client who returned from surgery 2 hours ago is at risk for hemorrhage and should be seen first. The 16 year-old should be seen next because it is still the first post-op day. The 75 year-old in skin traction should be seen next. The client who can safely be seen last is the 20 year-old who is 2 weeks post-injury.

Question Number 10
A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?



A) Why don’t we now have the client turn back to the left side.
B) That was done correctly. Did you have any problems with the insertion?
C) Let’s check to see if the suppository is in far enough.
D) Did you feel any stool in the intestinal tract?

The correct answer is B: That was done correctly. Did you have any problems with the insertion?
Left side-lying position is the optimal position for the client receiving rectal medications. Due to the position of the descending colon, left side-lying allows the medication to be inserted and move along the natural curve of the intestine and facilitates retention of the medication. After a short time it will not hurt the client to turn in any manner. The suppository should be somewhat melted after 10 to 15 minutes. The other responses are incorrect since no data is in the stem to support such comments.

Question Number 11
A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care?


A) airborne precautions
B) droplet precautions
C) contact precautions
D) compromised host precautions

The correct answer is C: contact precautions
The resistant bacteria remain alive for up to 3 days post death. Therefore, contact precautions must still be implemented. Also label the body so that the funeral home staff can protect themselves as well. Gown and gloves are required.



Question Number 12
The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching?



A) void a little, clean the meatus, then collect specimen
B) clean the meatus, begin voiding, then catch urine stream
C) clean the meatus, then urinate into container
D) void continuously and catch some of the urine


The correct answer is B: clean the meatus, begin voiding, then catch urine stream
A clean catch urine is difficult to obtain and requires clear directions. Instructing the client to carefully clean the meatus, then void naturally with a steady stream prevents surface bacteria from contaminating the urine specimen. As starting and stopping flow can be difficult, once the client begins voiding it''s best to just slip the container into the stream. Other responses are not correct technique.

Question Number 13
The provider orders Lanoxin (digoxin) 0.125 mg po and furosomide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily?



A) spaghetti
B) watermelon
C) chicken
D) tomatoes

The correct answer is B: watermelon
Watermelon is high in potassium and will replace any potassium lost by the diuretic. The other foods are not high in potassium.

Question Number 14
A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take?



A) Look up the policy on needle sticks
B) Contact employee health services
C) Immediately wash the hands with vigor
D) Notify the supervisor and risk management

The correct answer is C: Immediately wash the hands with vigor
The immediate action of vigorously washing will help remove possible contamination. Then the sequence would then be options 4, 1, 2.



Question Number 15
As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do?



A) Ask the student: "What did you forget to do?”
B) Stop. Tell me why aspiration is needed.
C) Loudly state: “You forgot to aspirate.”
D) Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.”




The correct answer is D: Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.”
This action is a direct threat to the client if the medication enters into the blood stream instead of the muscle. The purpose of aspiration with IM injections is to prevent the injection of the drug directly into the blood stream. Option 4 protects the client and is the most professional.

Question Number 16
A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is
independent. What should the nurse document to most accurately describe the client's condition?



A) Comatose, breathing unlabored
B) Glascow Coma Scale 8, respirations regular
C) Appears to be sleeping, vital signs stable
D) Glascow Coma Scale 13, no ventilator required


The correct answer is B: Glascow Coma Scale 8, respirations regular
The Glascow Coma Scale provides a standard reference for assessing or monitoring level of consciousness. Any score less than 13 indicates a neurological impairment. Using the term comatose provides too much room for interpretation and is not very precise.

Question Number 17
A client enters the emergency department unconscious via ambulance from the client’s work place. What document should be given priority to guide the direction of care for this client?



A) The statement of client rights and the client self determination act
B) Orders written by the health care provider
C) A notarized original of advance directives brought in by the partner
D) The clinical pathway protocol of the agency and the emergency department

The correct answer is C: A notarized original of advance directives brought in by the partner
This document specifies the client''s wishes.

Question Number 18
The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager?



A) An admission at the change of shifts with atrial fibrillation and heart failure - PN
B) Client who had a major stroke 6 days ago - PN nursing student
C) A child with burns who has packed cells and albumin IV running - charge nurse
D) An elderly client who had a myocardial infarction a week ago - UAP

The correct answer is A: An admission at the change of shifts with atrial fibrillation and heart failure - PN
The care for a new admissions should be performed by an RN. Since the client was admitted at the change of shifts, the stability of the client would not have been established. The charge nurse should take this client. The PN could monitor the IV fluids in option C. Tasks that do not require independent judgment should be delegated. The nurse may delegate the care for a stable client to a UAP.

Question Number 19
A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment?



A) Increased temperature and lethargy
B) Restlessness and increased mucus production
C) Increased sleeping and listlessness
D) Diarrhea and poor skin turgor

The correct answer is B: Restlessness and increased mucus production
This infant could be experiencing gastroesophageal reflux, or could be allergic to the formula. Restlessness, irritability and increased mucus production can develop if an allergy is present. Soy based formula is often recommended.

Question Number 20
As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis?



A) "The child has been listless and has lost weight."
B) "The urine is dark yellow and small in amounts."
C) "Clothes are becoming tighter across her abdomen."
D) "We notice muscle weakness and some unsteadiness."

The correct answer is C: "Clothes are becoming tighter across her abdomen."
One of the most common signs of neuroblastoma is increased abdominal girth. The parents'' report that clothing is tight is significant, and should be followed by additional assessments.

Question Number 21
A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse?



A) Ask the teenager to wait until a parent or legal guardian can be contacted
B) Withhold treatment until telephone consent can be obtained from the partner
C) Refer the teenager to a community pediatric hospital emergency department
D) Proceed with the triage process in the same manner as any adult client


The correct answer is D: Proceed with the triage process in the same manner as any adult client
Minors may become known as an "emancipated minor" through marriage, pregnancy, high school graduation, independent living or service in the military. Therefore, this client, who is married, has the legal capacity of an adult.

Question Number 22
A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)?



A) Converse with the client to determine if the mucuous membranes are impaired
B) Report hourly outputs of less than 30 ml/hr
C) Monitor client's ability for movement in the bed
D) Check skin turgor every 4 hours

The correct answer is B: Report output of less than 30 ml/hr
When directing a UAP, the nurse must communicate clearly about each delegated task with specific instructions on what must be reported. Because the RN is responsible for all care-related decisions, only implementation tasks should be assigned because they do not require independent judgment.

Question Number 23
The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease?



A) Our child had chickenpox 6 months ago.
B) Strep throat went through all the children at the day care last month.
C) Both ears were infected over 3 months age.
D) Last week both feet had a fungal skin infection.

The correct answer is B: Strep throat went through all the children at the day care last month.
Evidence supports a strong relationship between infection with Group A streptococci and subsequent rheumatic fever (usually within 2 to 6 weeks). Therefore, the history of playmates recovering from strep throat would indicate that the child diagnosed with rheumatic fever most likely also had strep throat. Sometimes, such an infection has no clinical symptoms.

Question Number 24
A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to interact with the client. The next action by the nurse should be to



A) Discuss the feeling of reluctance with an objective peer or supervisor
B) Limit contacts with the client to avoid reinforcement of the manipulative behavior
C) Confront the client about the negative effects of behaviors on other clients and staff
D) Develop a behavior modification plan that will promote more functional behavior

The correct answer is A: Discuss the feeling of reluctance with an objective peer or supervisor
The nurse who experiences stress in the therapeutic relationship can gain objectivity through supervision. The nurse must attempt to discover attitudes and feelings in the self that influence the nurse-client relationship.

Question Number 25
A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse’s action



A) May result in charges of unlawful seclusion and restraint
B) Leaves the nurse vulnerable for charges of assault and battery
C) Was appropriate in view of the client’s history of violence
D) Was necessary to maintain the therapeutic milieu of the unit

The correct answer is A: May result in charges of unlawful seclusion and restraint
Seclusion should only be used when there is an immediate threat of violence or threatening behavior to the staff, the other clients, or the client upon himself.

Question Number 26
A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority?



A) Pain related to ischemia
B) Risk for altered elimination: constipation
C) Risk for complication: dysrhythmias
D) Anxiety related to pain

The correct answer is A: Pain related to ischemia
Pain is related to ischemia, and relief of pain will decrease myocardial oxygen demands, reduce blood pressure and heart rate and relieve anxiety. Pain also stimulates the sympathetic nervous system and increased preload, further increasing myocardial demands.

Question Number 27
The provisions of the law for the Americans with Disabilities Act require nurse managers to



A) Maintain an environment free from associated hazards
B) Provide reasonable accommodations for disabled individuals
C) Make all necessary accommodations for disabled individuals
D) Consider both mental and physical disabilities


The correct answer is B: Provide reasonable accommodations for disabled individuals
The law is designed to permit persons with disabilities access to job opportunities. Employers must evaluate an applicant’s ability to perform the job and not discriminate on the basis of a disability. Employers also must make "reasonable accommodations."

Question Number 28
A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement s from the assessment data is likely to explain his noncompliance?



A) "I have problems with diarrhea."
B) "I have difficulty falling asleep."
C) "I have diminished sexual function."
D) "I often feel jittery."

The correct answer is C: "I have diminished sexual function."
Inderal, beta-blocking agent used in hypertension, prohibits the release of epinephrine into the cells; this may result in hypotension which results in decreased libido and impotence.

Question Number 29
A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate?



A) "I will keep the cast for the next day uncovered to prevent burning of the skin."
B) "I can apply an ice pack over the area to relieve itching inside the cast."
C) "The cast should be propped on at least 2 pillows when my child is lying down."
D) "I think I remember that standing cannot be done until after 72 hours."

The correct answer is D: "I think I remember that standing cannot be done until after 72 hours."
Applying ice is a safe method of relieving the itching. Synthetic casts will typically set up in 30 minutes and dry in a few hours. Thus, standing can be done within the initial 24 hours. With plaster casts the set up and drying time, especially in a long leg cast which is thicker than an arm cast, can take up to 72 hours to dry. Both types of cast give off a lot of heat when drying and it is preferred to keep the cast uncovered in the initial 24 hours. Clients may complain of chilling from the wet cast and therefore can simply be covered lightly with a sheet or blanket.

Question Number 30
Which statement best describes time management strategies applied to the role of a nurse manager?



A) Schedule staff efficiently to cover the needs on the managed unit
B) Assume a fair share of direct client care as a role model
C) Set daily goals with a prioritization of the work
D) Delegate tasks to reduce work load associated with direct care and meetings



The correct answer is C: Set daily goals with a prioritization of the work
Time management strategies include setting goals and prioritization . This is similar to time management of direct care for clients

Question Number 31
The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated with this problem include which of these?



A) Lymphedema and nerve palsy
B) Hearing loss and ataxia
C) Headaches and vomiting
D) Abdominal mass and weakness

The correct answer is D: Abdominal mass and weakness
Clinical manifestations of neuroblastoma include an irregular abdominal mass that crosses the midline, weakness, pallor, anorexia, weight loss and irritability.

Question Number 32
A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching?



A) "I will only have to wear this for 6 months."
B) "I should inspect my skin daily."
C) "The brace will be worn day and night."
D) "I can take it off when I shower."

The correct answer is A: "I will only have to wear this for 6 months."
The brace must be worn long-term, during periods of growth, usually for 1 to 2 years. It is used to correct curvature of the spine.

Question Number 33
The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that this method will



A) Improve the quality of care
B) Decrease staff turnover
C) Minimize the amount of overtime payouts
D) Improve team morale

The correct answer is D: Improve team morale
Nurses are more satisfied when opportunites exist for autonomy and control. The nurse manager becomes the facilitator of scheduling rather than the decision-maker of the schedule when self-scheduling exists.

Question Number 34

A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse?



A) Diffuse expiratory wheezing
B) Loose, productive cough
C) No relief from inhalant
D) Fever and chills

The correct answer is A: Diffuse expiratory wheezing
In asthma, the airways are narrowed - creating difficulty getting air in and a wheezing sound.

Question Number 35
The nurse manager hears a health care provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the health care provider's complaints. The nurse manager's next action should be to



A) Walk up to the health care provider and quietly state: "Stop this unacceptable behavior."
B) Allow the staff nurse to handle this situation without interference
C) Notify the of the other administrative persons of a breech of professional conduct
D) Request an immediate private meeting with the health care provider and staff nurse

The correct answer is D: Request an immediate private meeting with the health care provider and staff nurse .Assertive communication respects the needs of all parties to express themselves, but not at the expense of others. The nurse manager needs first to protect clients and other staff from this display and come to the assistance of the nurse employee.




Question Number 36
A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states “I demand to be released now!” The appropriate action is for the nurse to



A) You cannot be released because you are still suicidal.
B) You can be released only if you sign a no suicide contract.
C) Let’s discuss your decision to leave and then we can prepare you for discharge.
D) You have a right to sign out as soon as we get an order from the health care provider's discharge order.


The correct answer is C: Let’s discuss your decision to leave and then we can prepare you for discharge.
Clients voluntarily admitted to the hospital have a right to demand and obtain release. Discussing the decision initially allows an opportunity for other interventions.
Question Number 37
A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition?



A) Dyspnea
B) Heart murmur
C) Macular rash
D) Hemorrhage

The correct answer is B: Heart murmur
Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off, causing emboli and leaving ulcerations on the valve leaflets. These emboli produce symptoms of cardiac murmur, fever, anorexia, malaise and neurologic sequelae of emboli. Furthermore, the vegetations may travel to various organs such as spleen, kidney, coronary artery, brain and lungs and obstruct blood flow.

Question Number 38
A nurse admits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to



A) Stabilize thermoregulation
B) Maintain alveolar surface tension
C) Begin normal pulmonary blood flow
D) Regulate intracardiac pressure

The correct answer is B: Maintain alveolar surface tension
Respiratory distress syndrome is primarily a disease related to the developmental delay in lung maturation. Although many factors may lead to the development of the problem, the central factor is the lack of a normally functioning surfactant system in the alveolar sac from immaturity in lung development since the infant is premature.

Question Number 39
An 18 year-old client is admitted to intensive care from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's priority assessment should be



A) Response to stimuli
B) Bladder control
C) Respiratory function
D) Muscle weakness

The correct answer is C: Respiratory function
Spinal injury at the C-2 level results in quadriplegia. While the client will experience all of the problems identified, respiratory assessment is a priority.

Question Number 40
The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care?



A) Hourly urine output
B) White blood count
C) Blood glucose every 4 hours
D) Temperature every 2 hours

The correct answer is A: Hourly urine output
Clients who have had an episode of decreased glomerular perfusion are at risk for pre-renal failure. This is caused by any abnormal decline in kidney perfusion that reduces glomerular perfusion. Pre-renal failure occurs when the effective arterial blood volume falls. Examples of this phenomena include a drop in circulating blood volume as in a cardiac arrest state or in low cardiac perfusion states such as congestive heart failure associated with a cardiomyopathy. Close observation of hourly urinary output is necessary for early detection of this condition.

Question Number 41
The charge nurse on the night shift at an urgent care center has to deal with admitting clients of a higher acuity than usual because of a large fire in the area. Which style of leadership and decision-making would be best in this circumstance?



A) Assume a decision-making role
B) Seek input from staff
C) Use a non-directive approach
D) Shared decision-making with others

The correct answer is A: Assume a decision-making role
Authoritarian leadership assumes that decision-making is the role of the leader with little input by subordinates. This style is best used in emergency situations or as a triage nurse.

Question Number 42
The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance?



A) Metabolic acidosis
B) Metabolic alkalosis
C) Some increase in the serum hemaglobin
D) A little decrease in the serum potassium

The correct answer is B: Metabolic alkalosis
Vomiting causes loss of acid from the stomach. Prolonged vomiting can result in excess loss of acid and lead to metabolic alkalosis. Options c and d are corrrect answers but not the best answer since they are too general.

Question Number 43
Which activity can the RN ask an unlicensed assistive personnel (UAP) to perform?



A) Take a history on a newly admitted client
B) Adjust the rate of a gastric tube feeding
C) Check the blood pressure of a 2 hours post operative client
D) Check on a client receiving chemotherapy

The correct answer is C: Check the blood pressure of a 2 hours post operative client
UAPs must be assigned tasks that require no nursing judgment or decision making situations. Vital signs on stable clients are commonly assigned to unlicensed staff.

Question Number 44
A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is



A) Call for emergency transport to the hospital
B) Immobilize the limb and joints above and below the injury
C) Assess the child and the extent of the injury
D) Apply cold compresses to the injured area

The correct answer is C: Assess the child and the extent of the injury
When applying the nursing process, assessment is the first step in providing care. The 5 "Ps" of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis).



Question Number 45
When interviewing the parents of a child with asthma, it is most important to gather what information about the child's environment?



A) Household pets
B) New furniture
C) Lead based paint
D) Plants such as cactus

The correct answer is A: Household pets
Animal dander is a very common allergen affecting persons with asthma. Other triggers may include pollens, carpeting and household dust.


Question Number 46
An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 180/110 to 160/100 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the health care provider?



A) Slurred speech
B) Incontinence
C) Muscle weakness
D) Rapid pulse

The correct answer is A: Slurred speech
Changes in speech patterns and level of conscious can be indicators of continued intercranial bleeding or extension of the stroke. Further diagnostic testing may be indicated.

Question Number 47
A 3 year-old child is brought to the clinic by his grandmother to be seen for "scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would initially assess for which problem?



A) Allergies
B) Scabies
C) Regression
D) Pinworms

The correct answer is D: Pinworms
Signs of pinworm infection include intense perianal itching, poor sleep patterns, general irritability, restlessness, bed-wetting, distractibility and short attention span. Scabies is an itchy skin condition caused by a tiny, eight-legged burrowing mite called Sarcoptes scabiei . The presence of the mite leads to intense itching in the area of its burrows.

Question Number 48
A 72 year-old client with osteomyelitis requires a 6 week course of intravenous antibiotics. In planning for home care, what is the most important action by the nurse?



A) Investigating the client's insurance coverage for home IV antibiotic therapy
B) Determining if there are adequate hand washing facilities in the home
C) Assessing the client's ability to participate in self care and/or the reliability of a caregiver
D) Selecting the appropriate venous access device

The correct answer is C: Assessing the client''s ability to participate in self care and/or the reliability of a caregiver
The cognitive ability of the client as well as the availability and reliability of a caregiver must be assessed to determine if home care is a feasible option.

Question Number 49
The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse?



A) "Folic acid should be taken before and after conception."
B) "Multivitamin supplements are recommended during pregnancy."
C) "A well balanced diet promotes normal fetal development."
D) "Increased dietary iron improves the health of mother and fetus."

The correct answer is A: "Folic acid should be taken before and after conception."
The American Academy of Pediatrics recommends that all childbearing women increase folic acid from dietary sources and/or supplements. There is evidence that increased amounts of folic acid prevents neural tube defects.

Question Number 50
A PN is assigned to care for a newborn with a neural tube defect. Which dressing if applied by the PN would need no further intervention by the charge nurse?



A) Telfa dressing with antibiotic ointment
B) Moist sterile nonadherent dressing
C) Dry sterile dressing that is occlusive
D) Sterile occlusive pressure dressing

The correct answer is B: Moist sterile nonadherent dressing
Before surgical closure the sac is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. Dressings are changed frequently to keep them moist.



Question Number 51
A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning?



A) Use ready-to-feed commercial infant formula
B) Boil the tap water for 10 minutes prior to preparing the formula
C) Let tap water run for 2 minutes before adding to concentrate
D) Buy bottled water labeled "lead free" to mix the formula
The correct answer is C: Let tap water run for 2 minutes before adding to concentrate
Use of lead-contaminated water to prepare formula is a major source of poisoning in infants. Drinking water may be contaminated by lead from old lead pipes or lead solder used in sealing water pipes. Letting tap water run for several minutes will diminish the lead contamination.

Question Number 52
A client is admitted to the rehabilitation unit following a CVA and mild dysphagia. The most appropriate intervention for this client is



A) Position client in upright position while eating
B) Place client on a clear liquid diet
C) Tilt head back to facilitate swallowing reflex
D) Offer finger foods such as crackers or pretzels

The correct answer is A: Position client in upright position while eating
An upright position facilitates proper chewing and swallowing.

Question Number 53
The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, "I will receive tissue from…



A) a tissue bank."
B) a pig."
C) my thigh."
D) synthetic skin."

The correct answer is C: my thigh."
Autografts are done with tissue transplanted from the client''s own skin.

Question Number 54
The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority?



A) Risk for dehydration
B) Ineffective airway clearance
C) Altered nutrition
D) Risk for injury

The correct answer is B: Ineffective airway clearance
The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula at or near the bifurcation. Thus, a priority is maintaining an open airway, preventing aspiration. Other nursing diagnoses are then addressed.

Question Number 55
A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to



A) Promote the client's comfort
B) Reduce the drying time
C) Decrease irritation to the skin
D) Improve venous return

The correct answer is D: Improve venous return
Elevating the leg both improves venous return and reduces swelling.

Question Number 56
During the initial home visit a nurse is discussing the care of a newly diagnosed client with Alzheimer's disease with family members. Which these interventions would be most helpful at this time?



A) Leave a book about relaxation techniques
B) Write out a daily exercise routine for them to assist the client to do
C) List actions to improve the client's daily nutritional intake
D) Suggest communication strategies

The correct answer is D: Suggest communication strategies
Alzheimer''s disease, a progressive chronic illness greatly challenges caregivers. During the initial visit the nurse can be of greatest assistance in helping family to use communication strategies to enable identification of language changes in the client. By use of select verbal and nonverbal communication strategies the client’s aberrant behavior may be minimized.

Question Number 57
The nurse is teaching a client with non-insulin dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to



A) Maintain previous calorie intake
B) Keep a candy bar available at all times
C) Reduce carbohydrates intake to 25% of total calories
D) Keep a regular schedule of meals and snacks

The correct answer is D: Keep a regular schedule of meals and snacks
Currently, calorie-controlled diets with strict meal plans are rarely suggested for clients who have diabetes. Try to incorporate schedule or food changes into clients'' existing dietary patterns. Help clients learn to read labels and identify specific canned foods, frozen entrees, or other foods which are acceptable and those which should be avoided.

Question Number 58
The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby's record and expect which of the following?



A) DTaP
B) Hepatitis B
C) Polio
D) H. Influenza



The correct answer is A: DTaP
The majority of reactions occur with the administration of the DTaP vaccination. Contradictions to giving repeat DTaP immunizations include the occurrence of severe side effects after a previous dose as well as signs of encephalopathy within 7 days of the immunization.

Question Number 59
The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk?



A) Donating blood
B) Using public bathrooms
C) Unprotected sex
D) Touching a person with AIDS

The correct answer is C: Unprotected sex
Because HIV is spread through exposure to bodily fluids, unprotected intercourse and shared drug paraphernalia remain the highest risk for infection.

Question Number 60
The charge nurse is planning assignments on a medical unit. Which client should be assigned to the unlicensed assistive presonnel (UAP)? A client with



A) Difficulty swallowing after a mild stroke
B) an order of enemas until clear prior to colonoscopy
C) an order for a post-op abdominal dressing change
D) transfer orders to a long term facility

The correct answer is B: an order of enemas until clear prior to colonoscopy
The UAP can be assigned routine tasks which have predictable outcomes.

Question Number 61
A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has deformities of the joints, limbs, and fingers, thinned upper lip, and small teeth with faulty enamel. The mother states: ”My child seems to have problems in learning to count and recognizing basic colors.” Based on this data, the nurse suspects that the child is most likely showing the effects of which problem?



A) Congenital abnormalities
B) Chronic toxoplasmosis
C) Fetal alcohol syndrome
D) Lead poisoning



The correct answer is C: Fetal alcohol syndrome
Major features of fetal alcohol syndrome consist of facial and associated physical features, such as small head circumference and brain size (microcephaly), small eyelid openings, a sunken nasal bridge, an exceptionally thin upper lip, a short, upturned nose and a smooth skin surface between the nose and upper lip. Vision difficulties include nearsightedness (myopia). Other findings are mental retardation, delayed development, abnormal behavior such as short attention span, hyperactivity, poor impulse control, extreme nervousness and anxiety. Many behavioral problems, cognitive impairment and psychosocial deficits are also associated with this syndrome.

Question Number 62
The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the health care provider immediately?



A) Prolonged inspiration with each breath
B) Expiratory wheezes that are suddenly absent in 1 lobe
C) Expectoration of large amounts of purulent mucous
D) Appearance of the use of abdominal muscles for breathing

The correct answer is B: Expiratory wheezes that are suddenly absent in one lobe
Acute asthma is characterized by expiratory wheezes caused by obstruction of the airways. Wheezes are a high pitched musical sounds produced by air moving through narrowed airways. Clients often associate wheezes with the feeling of tightness in the chest. However, sudden cessation of wheezing is an omnious or bad sign that indicates an emergency in that the small airways are now collasped.

Question Number 63
The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which dinner menu would be best?



A) Fish sticks, french fries, banana, cookies, milk
B) Ground beef patty, lima beans, wheat roll, raisins, milk
C) Chicken nuggets, macaroni, peas, cantaloupe, milk
D) Peanut butter and jelly sandwich, apple slices, milk

The correct answer is B: Ground beef patty, lima beans, wheat roll, raisins, milk
Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, and dried fruits such as raisins. This dinner is the best choice, high in iron and is appropriate for a toddler.

Question Number 64
A 10 year-old client is recovering from a splenectomy following a traumatic injury. The clients laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use is to





A) Limit milk and milk products
B) Encourage bed activities and games
C) Plan nursing care around lengthy rest periods
D) Promote a diet rich in iron

The correct answer is C: Plan nursing care around lengthy rest periods
The initial priority for this client is rest due to the inability of red blood cells to carry oxygen.

Question Number 65
The nurse planning care for a 12 year-old child with sickle cell disease in a vaso-occlusive crisis of the elbow should include which one of the following as a priority?



A) Limit fluids
B) Client controlled analgesia
C) Cold compresses to elbow
D) Passive range of motion exercise

The correct answer is B: Client controlled analgesia
Management of a crisis is directed towards supportive and symptomatic treatment. The priority of care is pain relief. In a 12 year-old child, client controlled analgesia promotes maximum comfort.

Question Number 66
As the nurse provides discharge teaching to the parents of a 15 month-old child with Kawasaki disease. The child has received immunoglobulin therapy. Which instruction would be appropriate?







A) High doses of aspirin will be continued for some time
B) Complete recovery is expected within several days
C) Active range of motion exercises should be done frequently
D) The measles, mumps and rubella vaccine should be delayed

The correct answer is D: The measles, mumps and rubella vaccine should be delayed
Discharge instructions for a child with Kawasaki Disease should include immunoglobulin therapy may interfere with the body''s ability to form appropriate amounts of antibodies and live immunizations should be delayed.

Question Number 67
The nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse would emphasize that pancreatic enzymes should be taken



A) Once each day
B) 3 times daily after meals
C) With each meal or snack
D) Each time carbohydrates are eaten

The correct answer is C: With each meal or snack
Pancreatic enzymes should be taken with each meal and every snack to allow for digestion of all foods that are eaten.

Question Number 68
The nurse is assessing an 8 month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be most likely to exhibit?



A) Lethargy
B) Irritability
C) Negative Moro
D) Depressed fontanel

The correct answer is B: Irritability
Signs of IICP (increased intracranial pressure) in infants include bulging fontanel, instability, high-pitched cry, and cries when held. Vital sign changes include pulse that is variable, i.e., rapid, slow and bounding, or feeble. Respirations are more often slow, deep, and irregular.

Question Number 69
The nurse is performing a physical assessment on a toddler. Which of the following should be the first action?







A) Perform traumatic procedures
B) Use minimal physical contact
C) Proceed from head to toe
D) Explain the exam in detail

The correct answer is B: Use minimal physical contact
The nurse should approach the toddler slowly and use minimal physical contact initially so as to gain the toddler''s cooperation. Be flexible in the sequence of the exam, and give only brief simple explanations just prior to the action.

Question Number 70
A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse?



A) A report of 10 pounds weight loss in the last month
B) A comment by the client "I just can't sit still."
C) The appearance of eyeballs that appear to "pop" out of the client's eye sockets
D) A report of the sudden onset of irritability in the past 2 weeks


The correct answer is C: The appearance of eyeballs that appear to "pop" out of the client''s eye sockets
Exophthalmos or protruding eyeballs is a distinctive characteristic of Graves'' Disease. It can result in corneal abrasions with severe eye pain or damage when the eyelid is unable to blink down over the protruding eyeball. Eye drops or ointment may be needed.

Question Number 71
Which serum blood findings with diabetic ketoacidosis alerts the nurse that immediate action is required?



A) pH below 7.3
B) Potassium of 5.0
C) HCT of 60
D) Pa O2 of 79%

The correct answer is C: HCT of 60
This high HCT is indicative of severe dehydration which requires priority attention in diabetic ketoacidosis. Without sufficient hydration all systems of the body are at risk for hypoxia from a lack of or sluggish circulation. In the absence of insulin, which facilitates the transport of glucose into the cell, the body breaks down fats and proteins to supply energy ketones, a by-product of fat metabolism. These accumulate causing metabolic acidosis (pH < 7.3), which would be the second concern for this client. The potassium and PaO2 are near normal.


Question Number 72
The nurse is preparing the teaching plan for a group of parents about risks to toddlers. The nurse plans to explain proper communication in the event of accidental poisoning. The nurse should plan to tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate?



A) The parents' name and telephone number
B) The currency of the immunization and allergy history of the child
C) The estimated time of the accidental poisoning and a confirmation that the parents will bring the containers of the ingested substance
D) The affected child's age and weight

The correct answer is D: The affected child''s age and weight
All of the above information is important. However, once the substance is stated the age and weight is a priority. This gives the appropriate healthcare providers an opportunity to calculate the needed dosage for an antidote while the child is being transported to the emergency department. After this information, the time of the accidental poisoning is next in importance to report.

Question Number 73
A 2 year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement?



A) Place the child on clear liquids and gelatin for 24 hours
B) Continue with the regular diet and include oral rehydration fluids
C) Give bananas, apples, rice and toast as tolerated
D) Place NPO for 24 hours, then rehydrate with milk and water

The correct answer is B: Continue with the regular diet and include oral rehydration fluids
Current recommendations for mild to moderate diarrhea are to maintain a normal diet with rehydration fluids.

Question Number 74
The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What is the nurse's best recommendation to improve delivery of the medication?



A) Nebulized treatments for home care
B) Adding a spacer device to the MDI canister
C) Asking a family member to assist the client with the MDI
D) Request a visiting nurse to follow the client at home

The correct answer is B: Adding a spacer device to the MDI canister
If the client is not using the MDI properly, the medication can get trapped in the upper airway, resulting in dry mouth and throat irritation. Using a spacer will allow more drug to be deposited in the lungs and less in the mouth. It is especially useful in the elderly because it allows more time to inhale and requires less eye-hand coordination.

Question Number 75
Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students?



A) Scratching the head more than usual
B) Flakes evident on a student's shoulders
C) Oval pattern occipital hair loss
D) Whitish oval specks sticking to the hair

The correct answer is D: Whitish oval specks sticking to the hair
Diagnosis of pediculosis capitis is made by observation of the white eggs (nits) firmly attached to the hair shafts. Treatment includes shampoo application, such as lindane for children over 2 years of age, and meticulous combing and removal of all nits.
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