ctivity
C. Cleaning windows
-incorrect: Cleaning windows is a moderate-intensity activity
D. Washing dishes
-Washing dishes requires a low level of
... [Show More] activity and is appropriate for this client.
16. A nurse is caring for a client who is receiving dextrose 5% in water IV at 150 mL/hr and has
ingested 4 oz of water and ½ pint of milk. What is the total 8-hr fluid intake in milliliters that the
nurse should document for this client? (round to nearest whole number)
-1560
17. A nurse is performing a physical examination of a client. The nurse should use percussion to
evaluate which of the following parts of the client’s body?
A. Heart
-incorrect: The nurse uses inspection, palpation, and auscultation to evaluate the heart.
B. Lungs
-Percussion creates a vibration that helps the examiner determine the density of the underlying
tissue. The lungs are hollow organs that can produce sounds such as resonance (a hollow sound
over alveoli) or dullness (a dull sound over consolidated areas of the lungs or diaphragm). The
nurse also uses auscultation and palpation when evaluating the lungs.
C. Thyroid gland
-incorrect: The nurse uses inspection and palpation to evaluate the thyroid gland.
D. Skin
-incorrect: The nurse uses inspection and palpation to evaluate the skin.
18. A nurse is supervising a newly licensed nurse who is administering a controlled substance.
Which of the following actions by the newly licensed nurse indicates an understanding of the
procedure?
A. Placing an unused portion of the medication in a sharps box
-incorrect: The nurse should not dispose of an unused portion of a controlled substance in the
sharps container because this action does not maintain safe control of the narcotic.
B. Asking another nurse to observe the disposal of an unused portion of the medication
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-The nurse should ask another nurse to witness the disposal of a controlled substance to maintain
safe control of the narcotic.
C. Counting the inventory of the available narcotic after administering the medication
-incorrect: The nurse should count the inventory of the controlled substance before removing a
dosage to maintain safe control of the narcotic.
D. Ensuring that another nurse signs the control inventory form after disposal of an unused
portion of medication
-incorrect: Two nurses should sign the control inventory form after the disposal of a portion of a
narcotic to maintain safe control.
19. A nurse is caring for a client who has acute renal failure. Which of the following assessments
provides the most accurate measure of the client’s fluid status?
A. Daily weight
-According to the evidence-based priority-setting framework, daily weight provides important
information about the client’s fluid status. A gain or loss of 1 kg (2.2 lb) indicates a gain or loss
of 1 L of fluid; therefore, weighing the client daily will provide the most accurate fluid status
measurement.
B. Blood Pressure
-incorrect: While blood pressure can indicate a client’s fluid gain or losses, it is not the most
accurate method of measuring fluid changes.
C. Specific gravity
-incorrect: Specific gravity reflects the kidney’s ability to concentrate urine. While specific
gravity reflects client’s fluid gains or losses, it is not the most accurate method used to measure
fluid changes.
D. Intake and Output
-incorrect: Intake and output reflect a client’s fluid status. However, this is not the most accurate
method to measure fluid changes.
20. A nurse in a long-term care facility is admitting a client who is incontinent and smells
strongly of urine. His partner, who has been caring for him at home, is embarrassed and
apologizes for the smell. Which of the following responses should the nurse make?
A. “A lot of clients who are cared for at home have the same problem”
-incorrect: This automatic response implies that caregivers in the home are not able to keep
client’s odor-free. It is a judgmental statement that is not therapeutic.
B. “Don’t worry about it. He will get a bath, and that will take care of the odor.”
-incorrect: Telling the partner not to worry blocks communication by devaluing her feelings and
her concern about the odor.
C. “It must be difficult to care for someone who is confined to bed.”
-This response addresses the feelings of the partner by reflecting her feelings, which facilitates
therapeutic communication because it is nonjudgmental and encourages the partner to express
her feelings.
D. “When was the last time that he had a bath?”
-incorrect: This response implies that the odor of urine has developed because she has not bathed
her husband for some time, which is judgmental and nontherapeutic.
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21. A nurse in an emergency department is assessing a client who reports diarrhea and decreased
urination for 4 days. Which of the following actions should the nurse take to assess the client’s
skin turgor?
A. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to
become pink.
-incorrect: This technique assesses capillary refill.
B. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs
back.
-The nurse should use this technique to assess skin turgor. If the client has good turgor and is
properly hydrated, the skin will immediately return to normal; in dehydration, the skin will
remain tented. The nurse can also assess turgor by grasping a skinfold on the back of the
forearm.
C. Press the skin above the ankle for 5 seconds, release it, and note the depth of the impression.
-incorrect: This technique determines the extent of a client’s pitting edema.
D. Measure the skinfold thickness on the upper arm using a pair of calibrated skinfold calipers.
-incorrect: This technique determines a client’s body fat percentage.
22. A nurse discovers that a client received the wrong medication. Which of the following
actions should the nurse take first?
A. Complete a medication error report
-incorrect: The nurse should follow the facility’s protocol for documenting the incident;
however, this is not the first action the nurse should take.
B. Notify the prescribing provider
-incorrect: The nurse should follow the facility’s protocol for reporting a medication error, which
usually involves notifying the prescribing provider; however, this is not the first action the nurse
should take.
C. Assess the client
-The greatest risk to the client’s safety is adverse effects from either receiving the wrong
medication or not receiving the prescribed medication. The nurse should assess the client first for
any possible adverse effects. This assessment also serves as a baseline for further monitoring for
adverse effects.
D. Notify the charge nurse
-The nurse should follow the facility’s protocol for reporting a medication error, which usually
involves notifying the charge nurse; however, this is not the first action the nurse should take.
23. A nurse is performing a breast examination for a female client. Which of the following
techniques should the nurse use first?
A. Inspect both breasts simultaneously
-According to evidence-based practice, the nurse should first inspect both breasts with the
client’s arms in several different positions to look for asymmetry, masses, retraction, lesions,
inflammation, and dimpling.
B. Squeeze the nipples
-incorrect: The nurse should compress the nipples to identify the presence of any discharge.
However, evidence-based practice indicates that the nurse should use a different technique
before compression.
C. Palpate the breast and tail of Spence
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-incorrect: The nurse should palpate the breast and tail of Spence to determine the consistency of
breast tissue and assess the presence of masses. However, evidence-based practice indicates that
the nurse should use a different technique before palpation of the breast because doing so can
alter the accuracy or effectiveness of another phase of the examination.
D. Palpate the axillary lymph nodes
-incorrect: The nurse should palpate the axillary lymph nodes, which become involved when
cancerous lesions metastasize. However, evidence-based practice indicates that the nurse should
use a different technique before palpation of the axillary lymph nodes because doing so can alter
the accuracy or effectiveness of another phase of the examination.
24. A nurse is helping a client change his hospital gown. The client has an IV infusion via an
infusion pump. Which of the following actions should the nurse take first?
A. Remove the sleeve of the gown from the arm without the IV line.
-According to evidence-based practice, the nurse should first remove the gown from the client’s
arm without the IV line. Beginning this process will enable the nurse to move the gown fully off
the client before stopping the system to remove the gown from the line, resulting in minimal
interruption of the IV flow.
B. Slow the infusion using a roller clamp
-incorrect: The nurse should slow the infusion using the roller clamp to prevent a large volume
infusion of IV solution while changing the gown. However, evidence-based practice indicates
that the nurse should take a different action first.
C. Disconnect the IV line from the pump
-incorrect: The nurse should disconnect the IV line from the pump while removing and
reapplying the gown quickly to maintain the infusion rate prescribed with the pump, however,
evidence-based practice indicates that the nurse should take a different action first.
D. Bring the IV solution and tubing from the outside to the inside of the sleeve of the gown
-incorrect: The nurse should bring the IV solution and tubing through the outside to the inside of
the sleeve of the gown to avoid tangling of the tubing and the gown. However, evidence-based
practice indicates that the nurse should take a different action first.
25. A nurse is preparing to administer a unit of packed RBC’s to a client when she discovers that
the IV line is no longer patent. The IV team informs her that someone can come to initiate a new
line in 30 min. Which of the following actions should the nurse take?
A. Return the blood to the laboratory
-Because the nurse knows that the delay will be more than a few minutes, she should return the
unit of packed RBCs immediately to the laboratory where the technician will maintain it at the
appropriate temperature until the client is ready to receive it.
B. Place the blood in the medication room
-incorrect: The unit of packed RBCs should not be at room temperature for any length of time
because the lack of temperature control could damage the blood.
C. Place the blood in the refrigerator
Incorrect: Blood products require specific temperature regulation, which is not consistently
possible in a standard nursing unit refrigerator.
D. Leave the blood at the client’s bedside
-The nurse should never leave blood products or medication at the bedside due to the potential
for loss, misuse, or contamination.
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26. A hospice nurse is reviewing religious practices of a group of clients with a newly licensed
nurse. Which of the following statements by the newly licensed nurse indicates an understanding
of the teaching?
A. People who practice the Islamic faith pray over the deceased for a period of 5 days before
burial.
-incorrect: For those who practice the Islamic faith, the body of the deceased is washed and
wrapped during a ritual and then buried as soon as possible following death.
B. People who practice the Hindu faith bury the deceased with their head facing north.
-incorrect: People who practice the Hindu faith may place the body with the head facing north
following death. However, cremation rather than burial is practiced by those of the Hindu faith.
C. People who practice Judaism stay with the body of the deceased until burial.
-In the Jewish faith, a family member often stays with the body until burial occurs.
D. People who are practicing the Buddhist faith have the female family members prepare the
body following death.
-incorrect: Male family members prepare the body following death for individuals practicing the
Buddhist faith.
27. A nurse is planning an in-service training session about nutrition. Which of the following
statements should the nurse include in the teaching?
A. “Fats provide energy”
-Fat serves as a stored energy source for the body, providing 9 cal/g of energy.
B. “Carbohydrates repair body tissue”
-incorrect: Proteins play a role in tissue repair.
C. “Fats regulate fluid balance”
-incorrect: Protein is primarily responsible for regulating fluid balance.
D. “Carbohydrates prevent interstitial edema”
-incorrect: The presence of protein prevents interstitial edema. An appropriate amount of
albumin in blood keeps interstitial edema from occurring.
28. A nurse is caring for a client who requires fluid restriction and may drink only 1 oz of water
with each oral medication. How many milliliters of water should the nurse document as intake
for the 3 separate medications the client receives during 12-hour night shift? (round to the
nearest whole number)
90
29. A nurse is caring for a client who is dehydrated. The nurse should expect that insensible fluid
loss of approximately 500 to 600 mL occurs each day through which of the following organs?
A. Kidney’s
-incorrect: The kidneys excrete approximately 1,200 to 1,500 mL of urine daily. However, urine
is not considered insensible fluid loss. This can increase depending on the client’s intake of
water.
B. Lungs
-incorrect: The lungs excrete approximately 400 mL of insensible fluid loss each day.
C. Gastrointestinal Tract
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-incorrect: The GI tract loses approximately 100-200 mL of fluid each day through feces.
However, this is not considered insensible fluid loss.
D. Skin
-The skin can excrete approximately 500 to 600 mL of insensible fluid loss. This type of fluid
loss is continuous and can increase if the client is experiencing a fever or has had a recent burn to
the skin. [Show Less]