Which nursing intervention is most appropriate for a client in skeletal traction?

1 Add and remove weights as the client desires.

2 Assess the pin sites at least every shift and as needed.
3. Ensure that the knots in the rope are tied to the pulley.
4 .Perform range of motion to joints proximal and distal to the fracture at least once a day.

Nursing care for a client in skeletal traction may include assessing pin sites every shift and as
needed. The needed weight for a client in skeletal traction is prescribed by the physician not as
desired by the client. The nurse also should ensure that the knots are not tied to the pulley and
move freely. The performance of range of motion is indicated for all joints except the ones
proximal and distal to the fracture, since this area is immobilized by the skeletal traction to
promote healing and prevent further injury and pain.2.

The most effective time to teach clients who have sustained a sudden, traumatic, major loss
is most often during the acceptance or adaptation stage of coping. The rationale for this fact is
that clients in this stage are:
1 Ready for discharge and therefore in need of preparation
2 At the peak of mental anguish and therefore open to change
3 Less angry and therefore more compliant and more receptive
Correct4 Less anxious and more aware of reality and therefore ready to learn
Anxiety or anger associated with other stages of coping interfere with learning. This is too late to
start preparation for discharge and teaching. Many factors influence readiness for learning;
planning for teaching must begin on the day of admission. The anxiety associated with mental
anguish will interfere with the ability to process new information; mental anguish is associated
with an earlier stage. Although clients in the acceptance or adaptation phase are less angry, the
reason teaching is most effective is not because of their compliance but because new information
can be processed more easily.4.

Nursing actions for the older adult should include health education and promotion of self-care.
Which is most important when working with the older adult client?
1
Encouraging frequent naps
2
Strengthening the concept of ageism
Correct3
Reinforcing the client's strengths and promoting reminiscing
4
Teaching the client to increase calories and focusing on a high-carbohydrate diet
Reinforcing strengths promotes self-esteem; reminiscing is a therapeutic tool that provides a life
review that assists adaptation and helps achieve the task of integrity associated with older
adulthood. Frequent naps may interfere with adequate sleep at night. Reinforcing ageism may
enhance devaluation of the older adult. A well-balanced diet that includes protein and fiber
should be encouraged; increasing calories may cause obesity.3.

The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by
repositioning. What nursing diagnosis should be included on the client's plan of care?
1
Risk for pressure ulcer
2
Risk for impaired skin integrity
3
Impaired skin integrity, related to infrequent turning and repositioning
Correct4
Impaired skin integrity, related to the effects of pressure and shearing force

The impaired skin integrity is physiologically a result of unrelieved pressure and shearing force.
This is supported by the data provided that the client is non-ambulatory and has a reddened
sacrum. Risk for pressure ulcer is not an approved NANDA-I nursing diagnosis. The client's
problem is not being "at risk" because the client already has an actual problem. Not enough
information is provided to make the assumption that the impaired skin integrity is related to
infrequent turning and repositioning.4.

A client presents with bilateral leg pain and cramping in the lower extremities. The client has a
history of cardiovascular disease, diabetes, and varicose veins. To guide the assessment of the
pain and cramping, the nurse should include which question when completing the initial
assessment?
Correct1
"Does walking for long periods of time increase your pain?"
2
"Does standing without moving decrease your pain?"
3
"Have you had your potassium level checked recently?"
4
"Have you had any broken bones in your lower extremities?"

Clients with a medical history of heart disease, hypertension, phlebitis, diabetes, or varicose
veins often develop vascular related complications. The nurse should recognize that the
relationship of symptoms to exercise will clarify whether the presenting problem is vascular or
musculoskeletal. Pain caused by a vascular condition tends to increase with activity.
Musculoskeletal pain is not usually relieved when exercise ends. Low potassium levels can cause
cramping in the lower extremities, however, given the client's health history, vascular
insufficiency should be suspected. Previously healed broken bones do not cause cramping and
pain.1.

A nurse is caring for a postoperative client who had general anesthesia during surgery. What
independent nursing intervention may prevent an accumulation of secretions?
1
Postural drainage
2
Cupping the chest
3
Nasotracheal suctioning
Correct4
Frequent changes of position

Frequent changes of position minimize pooling of respiratory secretions and maximize chest
expansion, which aids in the removal of secretions; this helps maintain the airway and is an
independent nursing function. Postural drainage and cupping the chest are part of pulmonary
therapy that requires a health care provider's prescription. Nasotracheal suctioning will remove
secretions once they accumulate in the upper airway, not prevent their accumulation.4.

A weak, dyspneic, terminally ill client is visited frequently by the spouse and teenage children.
What should the client's plan of care include?
1
Foster self-activity whenever possible.
2
Plan care to be completed at one time followed by a long rest.
Correct3
Teach family members how to assist with the client's basic care.
4
Limit visiting to evening hours before the client goes to sleep.

Because family members are old enough to understand the client's needs, they should be
encouraged to participate in the care. Self-care increases oxygen use, thereby increasing fatigue
and dyspnea. Overworking the client causes undue fatigue; there should be frequent rest periods
between different aspects of care. Limiting visiting to evening hours deprives the client of a
support system.3.

A client with osteoporosis is encouraged to drink milk. The client refuses the milk, explaining
that it causes gas and bloating. Which food should the nurse suggest that is rich in calcium and
digested easily by clients who do not tolerate milk?
1
Eggs
Correct2
Yogurt
3
Potatoes
4
Applesauce

Yogurt, which contains calcium, is digested more easily because it contains the enzyme lactase,
which breaks down milk sugar. Yogurt contains approximately 274 to 415 mg of calcium for an
8-oz container depending on how it is prepared. Eggs contain approximately 22 mg of calcium.
One potato contains approximately 7 to 20 mg of calcium depending on how it is prepared. Eight
ounces of applesauce contain approximately 3 mg of calcium.2.

The nurse providing care for a client with a diagnosis of neutropenia reviews isolation
procedures with the client's spouse. The nurse determines that the teaching was effective when
the spouse states that protective environment isolation helps prevent the spread of infection:
Correct1
To the client from outside sources.
2
From the client to others.
3
From the client by using special techniques to destroy infectious fluids and secretions.
4
To the client by using special sterilization techniques for linens and personal items.

Protective environment isolation implies that the activities and actions of the nurse will protect
the client from infectious agents because the client's own immune defense ability is
compromised (neutropenia). Protective environment isolation is also referred to as reverse
isolation. The other answer options are concepts related to protective environment isolation.1.

Which medication requires the nurse to monitor the client for signs of hyperkalemia?
1
Furosemide (Lasix)
2
Metolazone (Zaroxolyn)
Correct3
Spironolactone (Aldactone)
4
Hydrochlorothiazide (HydroDIURIL)

Spironolactone is a potassium-sparing diuretic; hyperkalemia is an adverse effect. Furosemide,

metolazone, and hydrochlorothiazide generally cause hypokalemia.3.

The nurse is preparing to perform endotracheal suctioning of a client with respiratory difficulties.
Before beginning the procedure, the nurse should:
1
Ask the client to take several deep breaths.
2
Instruct the client to cough before suctioning.
Correct3
Administer 100% oxygen to the client.
4
Change the suctioning equipment to ensure sterility.

Before suctioning, regardless of the means, oxygen should be administered, because the
suctioning procedure depletes oxygen from the respiratory tract, causing a potential drop in
oxygen saturation levels. In a client with an endotracheal tube, manually bagging with 100%
oxygen will hyperoxygenate the lungs. The client who has an endotracheal tube may not be able
to follow commands to take deep breaths, cough, or have the strength to do either, which is why
manual bagging is preferred. A new sterile suction catheter should be used each time the client is
suctioned, but the suction tubing and equipment need not be changed.3.

A nurse educator is presenting information about the nursing process to a class of nursing
students. What definition of the nursing process should be included in the presentation?
1
Procedures used to implement client care
Correct2
Sequence of steps used to meet the client's needs
3
Activities employed to identify a client's problem
4
Mechanisms applied to determine nursing goals for the client

The nursing process is a step-by-step method that scientifically provides for a client's nursing
needs. Procedures used to implement client care, activities employed to identify a client's
problem, and mechanisms applied to determine nursing goals for the client are only one step in
the nursing process.2.
An older client develops hypokalemia, and an intravenous infusion containing 40 mEq of
potassium is instituted. The client tells the nurse that the IV stings a little. What is the
nurse's best reply?
1
"I'll restart the IV in a different vein. This may help to relieve the pain."
2
"Try to imagine a sunny beach with gentle waves, and soon you won't notice the discomfort."
Correct3
"You are receiving a large dose of potassium, and unfortunately it often causes a stinging
sensation."
4
"Some people are more sensitive to pain than others. I'll get a prescription for pain medication
for you."

The response "You are receiving a large dose of potassium, and unfortunately it often causes a
stinging sensation." validates the client's concerns and provides information. The potassium
solution will be irritating to other peripheral veins as well. Although imagery may help to distract
the client from discomfort, this response provides no information as to why the stinging
sensation is occurring. The response "Some people are more sensitive to pain than others. I'll get
a prescription for pain medication for you." belittles the client and implies that the client is
intolerant of pain. Also, pain medication is not needed in this situation.3.

Which landmark is correct for a nurse to use when auscultating the mitral valve?
1
Left 5th intercostal space, midaxillary line
Correct2
Left 5th intercostal space, midclavicular line
3
Left 2nd intercostal space, sternal border
4
Left 5th intercostal space, sternal border

The correct landmark for auscultating the mitral valve (apical pulse) is found at the left 5th
intercostal space in the midclavicular line. Auscultation at the 5th intercostal space (ICS),
midaxillary line would yield breath sounds of the lateral lung field. Auscultation at the left 2nd
ICS sternal border is best to hear the pulmonic valve, and at the left 5th ICS sternal border for the
tricuspid valve. 2.

A client is hospitalized because of severe depression. The client refuses to eat, stays in bed most
of the time, does not talk with family members, and will not leave the room. The nurse attempts
to initiate a conversation by asking questions but receives no answers. Finally the nurse tells the
client that if there is no response, the nurse will leave and the client will remain alone. How
should the nurse's behavior be interpreted?
1
A system of rewards and punishment is being used to motivate the client.
2
Leaving the client alone allows time for the nurse to think of other strategies.
3
This behavior indicates the client's desire for solitude that the nurse is respecting.
Correct4
This threat is considered assault, and the nurse should not have reacted in this manner.

This response is a threat (assault) because the nurse is attempting to put pressure on the client to
speak or be left alone. This is not a reward and punishment technique that is used in behavior
modification therapy. Clients in emotional crisis should not be left alone.4.

When assessing a client, the nurse auscultates a murmur at the 2nd left intercostal space (ICS)
along the sternal border. This reflects sound from which valve?
1
Aortic
2
Mitral
Correct3
Pulmonic
4
Tricuspid

The 2nd left intercostal space (ICS) along the sternal border reflects sounds from the pulmonic
valve. The correct landmark for auscultating the aortic valve is at the right 2nd ICS sternal
border; for the mitral valve (apical pulse) at the left 5th ICS, midclavicular line; and for the
tricuspid valve at the left 5th ICS sternal border.3.

A client spends several minutes making negative comments to the nurse about numerous aspects
of the hospital stay. What is the nurse's best initial response?
1
Describe the purpose of different hospital therapies to decrease the client's anxiety.
2
Explain that becoming so upset does not allow the client to get much-needed rest.
Correct3
Refocus the conversation on the client's fears, frustrations, and anger about the condition.
4
Permit the client to release feelings and then leave the room to allow the client to regain
composure.

Refocusing the conversation on the client's fears, frustrations, and anger about the condition
provides an opportunity for the client to verbalize the feelings underlying the behavior.
Describing the purpose of different hospital therapies will have no effect on decreasing the
client's anxiety or on allowing ventilation of feelings. Explaining that becoming so upset
dangerously blocks the need for rest will not decrease anxiety so that the client can rest.
Although allowing release of feelings is therapeutic, leaving denies the client the opportunity for
verbalization and discussion.3.

A nurse teaches a client about wearing thigh-high antiembolism elastic stockings. What would be
appropriate to include in the instructions?
1
"You do not need to wear them while you are awake but it is important to wear them at night."
Correct2
"You will need to apply them in the morning before you lower your legs from the bed to the
floor."
3
"If they bother you, you can roll them down to your knees while you are resting or sitting down."
4
"You can apply them either in the morning or at bedtime but only after the legs are lowered to
the floor."

Applying antiembolism elastic stockings in the morning before the legs are lowered to the floor
prevents excessive blood from collecting and being trapped in the lower extremities as a result of
the force of gravity. Elastic stockings are worn to prevent the formation of emboli and thrombi,
especially in clients who have had surgery or who have limited mobility, by applying constant
compression. It is contraindicated for antiembolism elastic stockings to be applied and worn at
night, rolled down, or applied after the legs are lowered to the floor.2.

A nurse is assisting a client to transfer from the bed to a chair. What should the nurse do to
widen the client's base of support during the transfer?
Correct1
Spread the client's feet away from each other.
2
Move the client on the count of three.
3
Instruct the client to flex the muscles of the internal girdle.
4
Stand close to the client when assisting with the move.
Spreading the feet apart widens the base of support . A wide base of support lowers the center of
gravity, thereby increasing stability. Counting to three does not widen the base of support.
Counting to three ensures a coordinated effort on behalf of the client and nurse to affect the
move, which may alleviate some of the burden borne by the nurse. Flexing the muscles of the
internal girdle (contracting the gluteal muscles in the buttocks downward and the abdominal
muscles upward) stabilizes the pelvis and protects the abdominal viscera when lifting, pulling,
reaching, or stooping, but it does not widen the base of support. Working close to the client is not
based on the principle of widening the base of support. This action brings the center of gravity
close to the client being moved permitting the muscles of the nurse's legs and arms to carry the
burden of the transfer rather than the muscles of the back.1.

What should the nurse do initially when obtaining consent for surgery?
1
Describe the risks involved in the surgery.
2
Explain that obtaining the signature is routine for any surgery.
3
Witness the client's signature, which the nurse's signature will document.
Correct4
Determine whether the client's knowledge level is sufficient to give consent.

Informed consent means the client must comprehend the surgery, the alternatives, and the
consequences. Describing the risks involved in the surgery is not within nursing's domain.
Although obtaining a signature is routine, explaining that obtaining the signature is routine for
any surgery does not determine the client's ability to give informed consent. Although witnessing
the client's signature will be done, the nurse first should assess the client's knowledge of the
surgery.4.

What should the nurse do initially when obtaining consent for surgery?
1
Describe the risks involved in the surgery.
2
Explain that obtaining the signature is routine for any surgery.
3
Witness the client's signature, which the nurse's signature will document.
Correct4
Determine whether the client's knowledge level is sufficient to give consent.

Informed consent means the client must comprehend the surgery, the alternatives, and the
consequences. Describing the risks involved in the surgery is not within nursing's domain.
Although obtaining a signature is routine, explaining that obtaining the signature is routine for
any surgery does not determine the client's ability to give informed consent. Although witnessing
the client's signature will be done, the nurse first should assess the client's knowledge of the
surgery.4.

A nurse reviews a list of medications that have been prescribed for a client. The nurse is aware
that it is unsafe to administer which medication as an IV bolus?
1
Saline flush
Correct2
Potassium chloride
3
Naloxone (Narcan)
4
Adenosine (Adenocard)

Potassium chloride given as an IV bolus can cause cardiac arrest. It should never be administered
intravenously without being diluted and infused slowly through an IV infusion pump. Saline
flush, naloxone (Narcan), and adenosine (Adenocard) are appropriate to be given as IV bolus
undiluted.2.

When assessing an obese client, a nurse observes dehiscence of the abdominal surgical wound
with evisceration. The nurse places the client in the low-Fowler's position with the knees slightly
bent and encourages the client to lie still. What is the next nursing action?
1
Obtain vital signs.
2
Notify the health care provider.
3
Reinsert the protruding organs using aseptic technique.
Correct4
Cover the wound with a sterile towel moistened with normal saline.

This covering will not adhere to the wound, and it will protect the area until the health care
provider arrives. Obtaining vital signs and notifying the health care provider are not the priority;
the client has needs that must be met first. Reinserting the protruding organs is contraindicated
because it may injure delicate tissues and organs; also it is not within the scope of nursing
practice.4.

A nurse provides discharge teaching related to intermittent urinary self-catheterization to a client

with a new spinal cord injury. Which instruction is most important for the nurse to include?
1
"Wear sterile gloves when doing the procedure."
Correct2
"Wash your hands before performing the procedure."
3
"Perform the self-catheterization every 12 hours."
4
"Dispose of the catheter after you have catheterized yourself."

To avoid transferring organisms to the urinary system, the client is taught to wash his or her
hands thoroughly with soap and water before inserting a clean catheter. Sterile gloves are not
required for this procedure in the home care setting. Every 12 hours is too long of a time frame
between catheterizations. The client should be taught to recognize when self-catheterization is
needed and develop a 2 to 3 hour catheterization schedule. Some home care settings may require
the client to clean and re-use catheters.2.

A nurse is caring for an elderly client who has constipation. Which independent nursing
intervention helps to reestablish normal bowel pattern?
1
Administer a mineral oil enema.
2
Offer one cup of fluid every hour.
3
Manually remove fecal impactions.
Correct4
Offer a cup of prune juice.

Prune juice does not require a health practitioner order and helps to promote bowel movement
because it contains sorbitol that increases water retention in feces. Administration of mineral
enema requires an order from a health care provider. Encouraging the client's fluid intake by
offering one cup of fluid every hour is helpful in preventing constipation but not as effective in
resolving constipation as a prune juice. Removing impactions does not establish regular bowel
patterns.4.

The nurse is interviewing a client admitted for uncontrolled diabetes after binging on alcohol for
the past two weeks. The client states "I am worried about how I am going to pay my bills for my
family while I am hospitalized." Which statement by the nurse would best elicit information
from the client?
Correct1
"You are worried about paying your bills?"
2
"Don't worry; your bills will get paid eventually."
3
"When was the last time you were admitted for hyperglycemia?"
4
"You really shouldn't be drinking alcohol because of your diagnosis of diabetes"

Reflection can help the client to elaborate. The other examples are false assurance, use of
professional jargon, and offering advice, which can all restrict the client's response.1.

An 82-year-old retired schoolteacher is admitted to a nursing home. During the physical

assessment, the nurse identifies an ocular problem common to persons at this client's
developmental level, which is:
1 Tropia
2 Myopia
3 Hyperopia
4 Presbyopia

Presbyopia is the decreased accommodative ability of the lens that occurs with aging. Tropia
(eye turn) generally occurs at birth. Myopia(nearsightedness) can occur during any
developmental level or be congenital. Hyperopia (farsightedness) can occur during any
developmental level or be congenital.4.

The nurse is preparing discharge instructions for a client that acquired a nosocomial
infection, Clostridium difficile. What should the nurse include in the instructions?
1 Anticipate that nausea and vomiting will continue until the infection is no longer present.
Correct2 The infection causes diarrhea accompanied by flatus and abdominal discomfort.
3 Consume a diet that is high in fiber and low in fat.
4 Other than routine handwashing, it is not necessary to perform special disinfection
procedures.

The main clinical manifestation of Clostridium difficile is diarrhea accompanied by excessive

flatus and abdominal discomfort. Nausea and vomiting is not associated with this infectious
disease. Clients should follow a nutritionally balanced diet high in fiber and low in fats with no
specific restrictions. Cleaning and disinfection of items in the home is key to preventing spread
of the infection because the C. difficile spore is relatively resistant.2.

A nurse is teaching a group of parents about child abuse. What definition of assault should the
nurse include in the teaching plan?
Correct1 Assault is a threat to do bodily harm to another person.
2 It is a legal wrong committed by one person against the property of another.
3 It is a legal wrong committed against the public that is punishable by state law.
4 Assault is the application of force to another person without lawful justification.

Assault is a threat or an attempt to do violence to another. Assault implies harm to persons rather
than property. A legal wrong committed against the public that is punishable by state law is too
broad to describe assault. Application of force to another person without lawful justification is
the definition of battery.1.

A client is admitted to the hospital because of multiple chronic health problems. What is
the priority nursing intervention at this time?
1 Advising the client to join a support group immediately after discharge
2 Assuring the family that staff members will take care of the client's needs
3 Reminding the client to keep medical follow-up appointments after discharge
Correct4 Conducting a multidisciplinary staff conference early during the client's
hospitalization

Collaboration of all team members involved in the client's care early during hospitalization will
allow for efficient planning of care and help prepare for discharge. The client may or may not be
ready to join a support group at this time. Assuring the family that staff members will take care
of the client's needs may promote dependence. The client should be encouraged to assume self-
care gradually. Although this should be done eventually, it is not the priority at this time.4.

A 2 g sodium diet is prescribed for a client with stage 2 hypertension, and the nurse teaches the
client the rationale for this diet. The client reports distaste for the food. The primary nurse hears
the client request that the family "bring in a ham and cheese sandwich and fries." What is
the most effective nursing intervention?
Correct1 Discuss the diet with the client and family.
2 Tell the client why salty foods should not be eaten.
3 Explain the dietary restriction to the client's visitors.
4 Ask the dietitian to teach the client and family about sodium restrictions.

The client and significant family members should be included in dietary teaching; families
provide support that promotes adherence. The client already has received information about why
salty foods should not be eaten. Explaining the dietary restriction to the client's visitors could
violate confidentiality. The client should be involved in his or her own care; the client ultimately
will assume the responsibility. The dietitian is a resource person who can give specific, practical
information about diet and food preparation once there is a basic understanding of the reasons for
the diet.1.

A health care provider prescribes a vitamin tablet that contains vitamin B complex. What should
the nurse teach the client?
Correct1 It may turn the urine bright yellow.
2 The daily fluid intake should be increased.
3 The drug should be taken on an empty stomach.
4 It may accumulate in the body if an excessive amount is taken.

Bright yellow urine is an expected, insignificant side effect of vitamin B complex. There is no
need to increase oral fluids; the client may consume the usual daily intake of fluid. Taking the
drug on an empty stomach may precipitate nausea; therefore, it should be taken with food.
Vitamin B complex is a water-soluble vitamin, and excess amounts are excreted in urine.1.

A client who is to receive radiation therapy for cancer says to the nurse, "My family said I will
get a radiation burn." What is the nurse's best response?
1 "Your skin will look like a blistering sunburn."
Correct2 "A localized skin reaction usually occurs."
3 "A daily application of an emollient will prevent a burn."
4 "Your family must have had experience with radiation therapy."

Radiodermatitis occurs three to six weeks after the start of treatment. The word "burn" should be
avoided because it may increase anxiety. Emollients are contraindicated; they may alter the
calculated x-ray route and injure healthy tissue. The response about the client's family does not
address the client's concern.2.

An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary
intention and requires repacking and redressing every four hours. Which diet should the nurse
expect the health care provider to prescribe to best meet this client's immediate nutritional needs?
1
Low in fat and vitamin D
2
High in calories and fiber
3
Low in residue and bland
Correct4
High in protein and vitamin C

Protein and vitamin C promote wound healing; this is a postoperative priority. Although a low-
fat diet is preferred for an obese client, vitamin D, as well as other vitamins, should not be
limited. A high-calorie diet can increase obesity, and there is no indication that this client is at
risk for constipation requiring a high-fiber diet. A low-residue bland diet can cause constipation;
the priority is for nutrients to promote healing.
What nursing actions best promote communication when obtaining a nursing history? Select all
that apply.
1
Establishing eye contact
2
Paraphrasing the client's message
3
Asking "why" and "how" questions
4
Using broad, open-ended statements
5
Reassuring the client that there is no cause for alarm
6
Asking questions that can be answered with a "yes" or "no
Eye contact indicates to the client that the nurse is listening and interested. Paraphrasing is an
effective interviewing technique; it indicates to the client that the message was heard and invites
the client to elaborate further. Open-ended statements provide a milieu in which people can
verbalize their problems rather than be placed in a situation of providing a forced response.
Asking "why" and "how" questions can be threatening to the client, who may not have the
answer to these questions. False reassurance is detrimental to the nurse-client relationship and
does not promote communication. Direct questions do not open or promote communication.1.2.4

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which
of the following are considered within normal range for this client? Select all that apply.
Correct1
Oral temperature of 98.2° F
Correct2
Apical pulse of 88 beats per minute and regular
3
Respiratory rate of 30 per minute
Correct4
Blood pressure of 116/78 mm Hg while in a sitting position
5
Oxygen saturation of 92%

The client's temperature, pulse, and blood pressure are within normal ranges for a 50-year-old
female. The client's respirations are mildly elevated and the oxygen saturation level is below
normal. A normal respiratory rate for a female client in this age-group would be 12 to 20 per
minute, and oxygen saturation level should be 95%.
A client is diagnosed with AIDS. When examining the client's oral cavity, the nurse assesses
white patchy plaques on the mucosa. The nurse recognizes that this finding most likely
represents what opportunistic infection?
1
Cytomegalovirus
2
Histoplasmosis
Correct3
Candida albicans
4
Human papillomavirus

White patchy plaques on the oral mucosa would most likely be a result of C. albicans, a yeastlike
fungal infection. This condition is also known as "thrush." Cytomegalovirus may cause a serious
viral infection in persons with HIV, resulting in retinal, gastrointestinal, and pulmonary
manifestations. Histoplasmosis is an infection caused by inhalation of spores of the
fungus Histoplasma capsulatum and is characterized by fever, malaise, cough, and
lymphadenopathy. Human papillomavirus typically manifests as warts on the hands and feet as
well as mucous membrane lesions of the oral, anal, and genital cavities. It may be transmitted
without the presence of warts through body fluids with some forms associated with cancerous
and precancerous conditions.

When caring for a client with venous insufficiency, the nurse would implement which nursing
measure?
1
Apply abdominal girdle as needed.
2
Remove compression stockings for client ambulation.
Correct3
Elevate the client's legs above heart level.
4
Keep the upper extremities elevated.

Venous insufficiency occurs when vascular damage impedes the body's ability to move blood
from the legs towards the heart. This causes blood to pool in the legs, where it can cause
swelling, pain, and in some cases, leaking fluid in the skin or ulcers. Elevation of the legs above
the level of the heart makes use of gravitational forces to drain blood through the veins towards
the heart. Clients should not wear tight restrictive pants; clients should avoid wearing a girdle or
garter as they may impede venous return. Elevating the upper extremities will not decrease
edema in lower extremities. Compression stockings prevent blood pooling.
A nurse is caring for a client for whom segmental postural drainage treatments are prescribed.
The nurse should avoid scheduling the treatment at what time?
1
At bedtime
Correct2
After a meal
3
One hour before a meal
4
One hour after awakening

Productive coughing induced by postural drainage can cause nausea and vomiting. Because
coughing must be encouraged after treatment, sleep will be postponed; however, as breathing is
facilitated, sleep may become more restful. Approximately one hour before meals is a preferred
time for postural drainage; the resulting cough and production of mucus will subside before
eating. Upon awakening, mucous secretions are plentiful and tenacious; postural drainage at this
time will be most beneficial.

A client had a surgical fusion of the fourth and fifth lumbar vertebrae. When a nurse and an
unlicensed assistive personnel (UAP) enter the room to provide evening care on the day of
surgery, the client becomes anxious about being moved. How should the nurse respond?
Correct1
Reassure the client that they will be careful.
2 Explain that this surgery is not life threatening.
3 Describe the need for numerous personnel during turning.
4 Suggest that the client can turn on the television for diversion.

The client's major concern at this time is most likely pain caused by inappropriate handling.
Explaining that this surgery is not life threatening is false reassurance and should not be given.
The number of personnel will not ensure careful handling; this does not address the client's most
likely primary concern. Diversion is not an appropriate response to the client's primary concern.

A nurse is assessing the therapeutic action of drugs classified as tumor necrosis factor (TNF)
inhibitors. What client response indicates to the nurse that a drug with this classification is
effective?
1 Continued remission in a client with ovarian cancer
2 Increased insulin production in a client with diabetes mellitus
3 Vasodilation of coronary arteries in a client with ischemic heart disease
Correct4 Reduction of inflammatory joint pain in a client with rheumatoid arthritis
TNF is produced mainly by macrophages in synovium; over time, through various mechanisms,
the presence of TNF causes inflammation of synovium, destruction of bone and cartilage, joint
stiffness, and pain. TNF inhibitors or blockers neutralize TNF, thereby interrupting the
inflammatory cascade; this inhibits the inflammatory response and other mechanisms, thereby
slowing tissue damage. TNF inhibitors are not prescribed for clients with ovarian cancer,
diabetes mellitus, or ischemic heart disease.4.

A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. The
nurse reviews a list of vitamins and expects that which medication will be prescribed because of
its major role in wound healing?
1 Vitamin A (Aquasol A)
2 Cyanocobalamin (Cobex)
3 Phytonadione (Mephyton)
Correct4 Ascorbic acid (Ascorbicap)

Vitamin C (ascorbic acid) plays a major role in wound healing . It is necessary for the
maintenance and formation of collagen, the major protein of most connective tissues. Vitamin A
is important for the healing process; however, vitamin C is the priority because it cements the
ground substance of supportive tissue. Cyanocobalamin is a vitamin B12 preparation needed for
red blood cell synthesis and a healthy nervous system. Phytonadione is vitamin K, which plays a
major role in blood coagulation.4.

The nurse recognizes that which are important components of a neurovascular

assessment? Select all that apply.
1 Orientation
Correct2 Capillary refill
3 Pupillary response
4 Respiratory rate
Correct5 Pulse and skin temperature
Correct6 Movement and sensation

A neurovascular assessment involves evaluation of nerve and blood supply to an extremity

involved in an injury. The area involved may include an orthopedic and/or soft tissue injury. A
correct neurovascular assessment should include evaluation of capillary refill, pulses, warmth
and paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory
rate are components of a neurological assessment.2.5.6

The nurse assesses a client's pulse and documents the strength of the pulse as 2. Using a 4-point
scale for pulse strength, the nurse understands that this indicates the pulse is
1 faint, barely detectable.
2 slightly weak, palpable.
Correct3 normal.
4 bounding.

The strength of a pulse is a measurement of the force at which blood is ejected against the
arterial wall. Some examiners use a scale rating from 0 to 4 for the strength of a pulse:
0: Absent, not palpable
1: Pulse diminished, barely palpable
2: Expected
3: Full, increased
4: Bounding, aneurysmal
(3.)

To prevent septic shock in the hospitalized client, the nurse should:

1 Maintain the client in a normothermic state.
2 Administer blood products to replace fluid losses.
Correct3 Use aseptic technique during all invasive procedures.
4 Keep the critically ill client immobilized to reduce metabolic demands.

Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using
correct infection control practices. These include aseptic technique during all invasive
procedures. Maintaining the client in a normothermic state, administering blood products, and
keeping the critically ill client immobilized are not directly related to the prevention of septic
shock.3.

The way individuals cope with an unexpected hospitalization depends on many factors.
However, the one that is most significant is:
1 Cognitive age
Correct2 Basic personality
3 Financial resources
4 General physical health

Lifelong coping styles are most important in how a person will deal with stress. Age may
influence defense mechanisms but lifelong coping styles will most significantly affect a person's
behavior. Financial resources are a factor to be considered, but past coping ability is the most
significant factor to predict future coping. General physical health is a factor to be considered,
but past coping ability is the most significant factor to predict future coping.2.

A client who is suspected of having tetanus asks a nurse about immunizations against tetanus.
Before responding, what should the nurse consider about the benefits of tetanus antitoxin?
1 It stimulates plasma cells directly.
Correct2 A high titer of antibodies is generated.
3 It provides immediate active immunity.
4 A long-lasting passive immunity is produced.

Tetanus antitoxin provides antibodies, which confer immediate passive immunity. Antitoxin does
not stimulate production of antibodies. It provides passive, not active, immunity. Passive
immunity, by definition, is not long-lasting.2.

An emaciated older adult with dementia develops a large pressure ulcer after refusing to change
position for extended periods of time. The family blames the nurses and threatens to sue. What is
considered when determining the source of blame for the pressure ulcer?
Correct1 The client should have been turned regularly.
2 Older clients frequently develop pressure ulcers.
3 The nurse is not responsible to the client's family.
4 Nurses should respect a client's right not to be moved.

Clients should change position at least every two hours to prevent pressure ulcers. The nurse
should not deviate from this standard of practice because of the cognitively-impaired client's
refusal to move. The nurse was negligent for not changing the client's position. Although
pressure ulcers may occur, nursing care must include preventive measures. The family is
included in the health team. When a capable client refuses necessary health care, the nurse
should provide health teaching to promote understanding of the treatment plan. If the client
makes an informed decision after an explanation, then the client's rights must be respected;
however, this client is cognitively impaired.1.