TEST BANK for NCLEX _ Nursing Interventions Revised version with referenced Answers

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Question 1: (see full question)

When performing an abdominal assessment, the nurse uses a different order of techniques than with other systems. Which of the following represents this order

You selected:

Inspection, auscultation, percussion, palpation

Correct

Explanation:

In an abdominal assessment, start with inspection, then auscultation, percussion, and palpation. This is the preferred approach because palpation and percussion before auscultation may alter the sounds heard. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 658.

Chapter 25: Health Assessment - Page 658

Question 2: (see full question)

You selected:

The nurse in post-anesthesia recovery (PAR) is caring for a 27year-old client following an appendectomy. Twenty minutes after receiving 4 mg of intravenous (IV) morphine for abdominal pain, the client continues to report abdominal discomfort and requests more morphine. Which action by the nurse is best?

Observe the abdomen for distention and rigidity.

Correct

Explanation:

Continued abdominal pain after administration of IV morphine is an unexpected occurrence and requires further assessment by the nurse to rule out peritonitis or internal bleeding by observing the abdomen for distention and rigidity. Administration of more morphine could mask the cause of the abdominal pain and delay diagnosis of a possible postoperative complication. Applying heat to the abdomen would increase blood flow to the area and potentially increase pain or internal bleeding. Positioning the client in a kneesflexed position may relieve the discomfort, but an assessment is needed before any intervention is implemented. (less)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Reference:

Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 658.

Chapter 25: Health Assessment - Page 658

Question 3: (see full question)

The nurse will obtain the greatest amount of information about the thyroid gland by using which technique of assessment?

You selected:

Palpation

Correct

Explanation:

The thyroid gland is assessed by palpation, although it is not normally palpable in some patients.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, pp. 647-648.

Chapter 25: Health Assessment - Page 647

Question 4: (see full question)

You selected:

The nurse is asking admission interview questions and the client has explained the reason for seeking care. Which of the following is the most appropriate way to document the response?

Client describes shortness of breath and increased sputum production.

Incorrect

Correct response:

Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm."

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Explanation:

The client's reason for seeking care should always be stated in the client's own words.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 628.

Chapter 25: Health Assessment - Page 628

Question 5: (see full question)

The nurse in the emergency department observes a client experiencing a generalized tonic–clonic seizure. What is the priority intervention for the nurse to take?

You selected:

Assess and maintain the client's airway.

Correct

Explanation:

Risk for aspiration is a concern during a seizure because the client will have copious oral secretions that will need to be suctioned and allowed to drain out of the mouth. The nurse should assess the client's airway and maintain it by placing the client in a side-lying position, which will allow the oral secretions to drain from his mouth and not accumulate in his throat and compromise the airway. It is contraindicated to place anything in the mouth of a person who is actively convulsing. Reorienting the client and documenting the seizure are important actions after the postictal phase, but client safety is the priority intervention during a seizure. (less)

Reference:

Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 625.

Chapter 25: Health Assessment - Page 625

Question 6: (see full question)

The nurse is caring for a client who just informed her that he noticed some blood in the toilet after a bowel movement. The nurse

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers assesses the client's anal area and notes a deep linear separatio in the skin that extends into the dermis. The nurse recognizes than t this skin lesion is characteristic of which of the following?

You selected:

Erosion

Incorrect

Correct response:

Fissure

Explanation:

A fissure is characterized as a deep linear separation in the skin that extends into the dermis. Erosion is a loss of superficial epidermis; it is moist and may bleed. An ulcer appears as a loss o epidermis and dermis and may bleed. Crusts are dried residue f (serum, pus, or blood) on the skin. (less)

Reference:

Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapt er 25: Health Assessment, p. 641, Table 25-4.

Chapter 25: Health Assessment - Page 641

Reference:

Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapt er 25: Health Assessment, p. 654, Box 25-5.

Chapter 25: Health Assessment - Page 654

Question 7: (see full question)

The nurse is auscultating an apical pulse on a 39-year-old client admitted with pneumonia. In counting the apical pulse, the nurse recognizes which characteristic about heart sounds?

You selected:

Each lub-dub is one beat.

Correct Explanation:

Each lub (the first heart sound) represents the closure of the

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers mitral and tricuspid valves during systole, and the dub (the second heart sound) represents the closure of the aortic and pulmonic valves during diastole. Together the lub-dub sounds are counted as one beat. The two sounds occur within 1 second or less of each other, depending on the heart rate. (less)

Question 8: (see full question)

Which assessment measure would the nurse use to assess the location, shape, size, and density of a tumor?

You selected:

Percussion

Correct

Explanation:

Percussion is the act of striking one object against another to produce sound. The fingertips are used to tap the body over body tissues to produce vibrations and sound waves. The location, shape, size, and density of organs or tumors are assessed with t his method. Observation is visually looking at an object. The characteristics that can be determined about a tumor by palpation include shape, size, consistency, surface, mobility, tenderness, a nd pulsatile. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolte rs Kluwer Health, 2015, Chapter 25, Health Assessment, p. 635

Question 9:

The nurse is palpating the skin of a 30-year old patient and documents that when picked up in a fold, the skin fold slowly returns to normal. What would be the next action of the nurse based on this finding?

(see full question)

You selected:

Correct

Assess the patient for dehydration.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Explanation:

Turgor is the fullness or elasticity of the skin. The patient should be further assessed for signs and symptoms of dehydration because poor skin turgor is a sign of dehydration. When the patient is dehydrated, the skin’s elasticity is decreased, and the skin fold returns slowly. Poor skin turgor is neither a sign of cardiovascular disease, nor cystic fibrosis. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 25, Health Assessment, p. 639

Question 10:

The nurse is using a bed scale to weigh a patient, and the patient becomes agitated as the sling rises in the air. What would be the priority nursing intervention in this situation?

(see full question)

You selected:

Enlist the help of another nurse to hold the patient steady during the procedure.

Incorrect

Correct response:

Stop lifting the patient and reassess him or her.

Explanation:

The nurse should stop lifting the patient and reassure him or her. If the patient continues to be agitated, the nurse lowers the patient back to the bed, and reevaluates the necessity of obtaining weight at that exact time. Continuing to lift the patient may result in injury to the patient. An order for sedation would only be requested if it was absolutely necessary to obtain the patient’s weight at this time.

Another nurse holding the patient steady does not address the patient’s agitation. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 25, Health Assessment, p. 674

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Question 11: (see full question)

To obtain subjective data about a newly admitted client's sleep pattern, the nurse

You selected:

Asks the client what promotes sleep

Correct

Explanation:

The assessment of sleep and rest focuses on the client's normal sleep patterns, alterations from the normal pattern, and satisfaction with quality of rest and sleep.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 625.

Chapter 25: Health Assessment - Page 625

Question 12: (see full question)

A nurse performs an assessment on a client who has been admitted to a long-term care facility for physical rehabilitation. What is the term for this type of assessment?

You selected:

Comprehensive assessment

Correct

Explanation:

A comprehensive assessment with a detailed health history and complete physical examination are usually conducted when a client enters a health care setting. An ongoing and focused assessment is conducted at regular intervals during client care. An emergency assessment is a rapid, focused assessment conducted to determine potentially fatal situations. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers 25: Health Assessment, p. 626.

Chapter 25: Health Assessment - Page 626

Question 13: (see full question)

You selected:

A 57-year-old male client is admitted to the medical unit with a 3day history of sharp, nonradiating epigastric pain and vomiting. He denies seeing blood in his stool. When assessing this client's abdomen, what assessment technique would the nurse perform last?

Palpation

Correct

Explanation:

The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation are done after auscultation because they stimulate bowel sounds. (less)

Reference:

Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 659.

Chapter 25: Health Assessment - Page 659

Question 14: (see full question)

You selected:

You are assessing a patient's thorax and lungs. Which of the following findings would indicate the need for further assessment?

Auscultation of short, high-pitched popping sounds during inspiration

Correct

Explanation:

Crackles (short, high-pitched popping sounds) may indicate

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers disease, such as pneumonia or heart failure.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 648.

Chapter 25: Health Assessment - Page 648

Question 15: (see full question)

A nurse assesses a patient for blood pressure. Which of the following techniques would be used for this assessment?

You selected:

Inspection

Incorrect

Correct response:

Auscultation

Explanation:

Auscultation is the act of listening with a stethoscope to sounds produced within the body. This technique is used to listen for blood pressure, heart sounds, lung sounds, and bowel sounds. Inspection is the process of performing deliberate, purposeful observations in a systematic manner. It uses the senses of smell, hearing, and sight. The hands and fingers are sensitive tools of palpation and can assess temperature, turgor, texture, moisture, pulsations, vibrations, shape and masses, and organs. Percussion is used to assess the location, shape, and size of organs, and the density of other underlying structures or tissues. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 632.

Chapter 25: Health Assessment - Page 632

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Question 16: (see full question)

The charge nurse is observing a new nurse perform an assessment of a client's head and neck. Which of the following actions, if observed, would require the charge nurse to intervene?

You selected:

Palpation of both carotid arteries at the same time

Correct

Explanation:

Palpation of both arteries at once can obstruct blood flow to the brain.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 655.

Chapter 25: Health Assessment - Page 655

Question 17: (see full question)

You selected:

The nurse is caring for an 88-year-old male admitted 2 days ago for dehydration. The nurse brings the client his breakfast tray and notes that the client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate?

Check the client’s ear canals for cerumen.

Correct

Explanation:

Ear wax (cerumen) becomes drier in the elderly and can block the ear canal and cause decreased hearing. Asking the client if he has earplugs in his ears is not appropriate. Using facial expressions and sign language is appropriate in communicating with the hard of hearing, but this client’s hearing loss was acute and requires further assessment. When speaking to the elderly who are hearingimpaired, one needs to use low tones to facilitate communication; high-frequency tones are problematic for the elderly. (less)

Reference:

Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers 25: Health Assessment, p. 646.

Chapter 25: Health Assessment - Page 646

Question 18: (see full question)

The acute care nurse is assessing a newly admitted client's abdomen. Which of the following findings would indicate the need to contact the primary care provider?

You selected:

Auscultation of a bruit

Correct

Explanation:

A bruit on auscultation suggests an aneurysm or arterial stenosis.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 654.

Chapter 25: Health Assessment - Page 654

Question 19: (see full question)

You selected:

A nurse who works on a day-surgery unit conducts a thorough, head to toe assessment of each client prior to the client's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a client's ...

peripheral pulses.

Correct

Explanation:

Nonpalpable peripheral pulses are an unexpected finding, which warrants further assessment and follow-up. The liver, lymph nodes, and thyroid are not normally palpable in healthy individuals. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia:

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, pp. 652-655.

Chapter 25: Health Assessment - Page 652

Question 20: (see full question)

Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound?

You selected:

Wheezes

Correct

Explanation:

Wheezes are continuous sounds originating in small air passages that are narrowed by secretions, swelling, or tumors; the wheezes may be inspiratory or expiratory. A pleural friction rub is a grating sound caused by an inflamed pleura rubbing against the chest wall.

Crackles are fine to coarse crackling sounds made as air moves through wet secretions. Stertorous breathing describes noisy, strenuous respirations. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 652.

Chapter 25: Health Assessment - Page 652

Question 18: (see full question)

The acute care nurse is assessing a newly admitted client's abdomen. Which of the following findings would indicate the need to contact the primary care provider?

You selected:

Auscultation of a bruit

Correct Explanation:

A bruit on auscultation suggests an aneurysm or arterial stenosis.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 654.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Chapter 25: Health Assessment - Page 654

Question 19: (see full question)

You selected:

A nurse who works on a day-surgery unit conducts a thorough, head to toe assessment of each client prior to the client's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a client's ... peripheral pulses.

Correct Explanation:

Nonpalpable peripheral pulses are an unexpected finding, which warrants further assessment and follow-up. The liver, lymph nodes, and thyroid are not normally palpable in healthy individuals. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, pp. 652-655.

Chapter 25: Health Assessment - Page 652

Question 20: (see full question)

Upon auscultation of a client's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound?

You selected:

Wheezes

Correct Explanation:

Wheezes are continuous sounds originating in small air passages that are narrowed by secretions, swelling, or tumors; the wheezes may be inspiratory or expiratory. A pleural friction rub is a grating sound caused by an inflamed pleura rubbing against the chest wall.

Crackles are fine to coarse crackling sounds made as air moves through wet secretions. Stertorous breathing describes noisy, strenuous respirations. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 652.

Chapter 25: Health Assessment - Page 652

Answer Key

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Question 1: (see full question)

You selected:

The nurse is caring for a client after a stroke that left the client's right side weaker than the left. The nurse coordinates the plan of care with the physical therapist. The nurse's interventions reflect which one of nursing's four broad goals?

• To restore health

Correct Explanation:

The four broad aims of nursing practice are to promote health, prevent illness, restore health, and facilitate coping with death and/or disability. In the example, the nurse is coordinating care with the other disciplines in an attempt regain some of the strength in the client's right side. This is an example of restoring a client's health.

The nurse is not preventing the stroke or promoting health prior to the stroke or facilitating coping with the stroke. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 10.

Chapter 1: Introduction to Nursing - Page 10

Question 2: A man age 61 years is distraught because he has just learned that his most recent (see full computed tomography (CT) scan shows that his colon cancer has metastasized to question) his lungs. Which of the following nursing aims should the nurse prioritize in the immediate care of this patient?

You selected:

Facilitating coping

Correct Explanation:

This patient's care in the coming weeks or months will likely encompass all of the four foundational roles of the nurse. However, because the patient has just recently received bad news and is emotionally distraught, helping the patient cope is an appropriate priority in his immediate care. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 13.

Chapter 1: Introduction to Nursing - Page 13

Question 3: The nurse working with an LPN understands which of the following about LPNs? (see full question)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers You selected:

They may work independently.

Incorrect Correct response:

They must take a licensure exam.

Explanation:

Schools for practical nursing programs are located in varied settings. Most programs are 1 year in length. Upon completion of the program, graduates can take the National Council Licensure Examination-Practical Nurse (NCLEX-PN) for licensure as an LPN. LPNs work under the direction of a physician or RN to give direct care to clients, focusing on meeting healthcare needs in hospitals, nursing homes, and home health agencies. (less)

Question 4: A group of nursing students has attended a presentation about the National Student (see full Nurses' Association (NSNA). Which statement by the group indicates that they have question) understood the information presented?

You selected:

The organization provides programs of current professional interest.

Correct Explanation:

The National Student Nurses' Association provides programs of current professional interest. It is not run by a group of registered nurses, but by nursing students themselves. It is student-funded, not funded by the national government. The Commission on Collegiate Nursing Education, not the National Student Nurses' Association, contributes to the improvement of public health. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 17.

Chapter 1: Introduction to Nursing - Page 17

Question 5: Which nursing actions demonstrate the aim of nursing to facilitate coping? (Select all (see full that apply.) question)

You selected:

• Assisting a patient and his/her family to prepare for death • Teaching a patient and his/her family how to live with diabetes • Providing counseling for the family of a teenager with an eating disorder

Correct Explanation:

Coping is another important broad aim of nursing. Nurses facilitate client and family coping with altered function, life crisis, and death. Examples of coping would be

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers teaching a client and the client’s family about how to live with diabetes. Another example would be assisting a client and the client’s family to prepare for death. A third example would be providing counseling for the family of a teenager with an eating disorder. Changing bandages, starting an IV, or teaching a class on an expected healthcare issue or need would not be examples of the aim of facilitating coping with disability or death. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 1: Introduction to Nursing, p. 13.

Chapter 1: Introduction to Nursing - Page 13

Question 6: (see full question)

You selected:

What was one barrier to the development of the nursing profession in the United States after the Civil War?

Lack of educational standards

Correct Explanation:

A lack of educational standards was one barrier to the development of the nursing profession after the Civil War. Other barriers included a male dominance of health care and the pervading belief that women were dependent on men. The location of nursing schools, a lack of influence from nursing leaders, and independent nursing orders were not barriers to the development of the nursing profession after the Civil War. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 7.

Chapter 1: Introduction to Nursing - Page 7

Question 7:

In what time period did nursing care as we now know it begin?

(see full question)

You selected:

18th to 19th century

Correct Explanation:

From the middle of the 18th century to the 19th century, social reforms changed the roles of nurses and of women in general. It was during this time that nursing as we now know it began, based on the beliefs of Florence Nightingale. (less)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 7.

Chapter 1: Introduction to Nursing - Page 7

Question 8:

During the Reformation, what factor influenced the decline of nursing?

(see full question)

You selected:

Women's subordination to men

Correct Explanation:

Women were viewed as subordinate to men and were expected to remain at home caring for children; this decreased the number of qualified women practicing nursing.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 7.

Chapter 1: Introduction to Nursing - Page 7

Question 9: (see full question)

You selected:

Which of the following nursing interventions would be the most appropriate for a new mother that calls the nursery for help with breastfeeding?

Refer the mother for a home care visit.

Correct Explanation:

It is the role of the nurse to encourage health promotion by providing information and referrals; therefore, the nurse should refer the mother for a home care visit, as this will enable the mother to receive all of the breast feeing help that is needed.

Emailing a link for breastfeeding provides information, but not the support that is needed if a mother is having difficulty with breastfeeding. Suggesting bottle feeding and/or going to the emergency room is inappropriate. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 11.

Chapter 1: Introduction to Nursing - Page 11

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Question 10: (see full question)

You selected:

A nurse is providing care for patients in a long-term care facility. Based on the definitions of nursing in the textbook, what should be the central focus of this care?

The nurse as the caregiver

Incorrect Correct response:

The patient receiving the care

Explanation:

The client receiving the care is always the central focus of the nursing care provided.

The central focus is not the nurse, the nursing actions, or nursing as a profession.

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 1: Introduction to Nursing, p. 5.

Chapter 1: Introduction to Nursing - Page 5

Question 11: (see full question)

You selected:

The nurse is evaluating client health. Which of the following clients should the nurse determine to be exhibiting the most signs of health?

A client with a leg amputation that performs activities of daily living with a prothesis

Correct Explanation:

As defined by the World Health Organization, one’s health includes physical, social, and mental components and is not merely the absence of disease or infirmity. Health is often a subjective state—a person may be medically diagnosed with an illness, but still consider himself or herself healthy. The client with an amputee is performing activities of daily living, thereby demonstrating healthy behaviors. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 11.

Chapter 1: Introduction to Nursing - Page 11

Question 12: (see full question)

You

The nurse utilizing the nursing process includes which of the following steps? Select all that apply.

• Assess

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers selected:

• Implement • Plan • Evaluate

Correct Explanation:

The nursing process consists of assessing the client, planning the client's care, implementing the planned interventions, and evaluating the effectiveness of those interventions. Prescribing is not a part of the nursing process. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 19.

Chapter 1: Introduction to Nursing - Page 19

Question 13: (see full question)

You selected:

During the course of any given day of work in the acute care setting, the nurse may need to perform which of the following roles? Select all that apply.

• Communicator • Teacher • Counselor

Correct Explanation:

The roles and functions of the nurse are many and include: caregiver, communicator, teacher, counselor, leader, researcher, and advocate. Acting as financier and statistician are not the roles of the nurse. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 11.

Chapter 1: Introduction to Nursing - Page 11

Question 14: (see full question)

You selected:

Florence Nightingale introduced the concept of apprenticeship for nurses. Which of the following statements is an example of this?

Completing clinical hours supervised by a nursing instructor

Correct Explanation:

Florence Nightingale's concept of apprenticeship involved training student nurses in

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers a hospital setting. Completing clinical hours is an example of this. The other choices do not reflect this concept. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 7.

Chapter 1: Introduction to Nursing - Page 7

Question 15: (see full question)

You selected:

The nurse caring for a client with a new diagnosis of cancer allows the client to verbalize fears relating to how to tell the children. The nurse's intervention reflects which aspect of nursing?

Art of nursing

Correct Explanation:

In this example, the nurse is utilizing a holistic approach to the provision of nursing care based on the knowledge of providing psychosocial interventions, such as allowing the client to verbalize feelings/fears. This application of knowledge is the art of nursing. The science of nursing is the knowledge base for the provision of care.

Evidence-based practice and application of research is using research to make decisions on how to care for clients. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 5.

Chapter 1: Introduction to Nursing - Page 5

Question 16: (see full question)

You selected:

The registered nurse is teaching a community health class about illness prevention.

Which of the following statements reflects understanding of this concept?

"It is important to enroll in a smoking cessation class."

Correct Explanation:

Enrolling in a smoking cessation class is an example of illness prevention. It will prevent conditions such as asthma and COPD. A hospice evaluation is for someone who is terminally ill, hypertension is already a disease entity, and an ambulance for injury does not denote illness prevention. (less)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 12.

Chapter 1: Introduction to Nursing - Page 12

Question 17: (see full question)

You selected:

A registered nurse wishes to work as a nurse researcher. Which of the following is true regarding nurse researchers?

They are responsible for the continued development and advancement of nursing.

Correct Explanation:

Nurse researchers are responsible for the continued development and refinement of nursing. They usually have advanced education in addition to a baccalaureate degree in nursing. Nurse administrators, not nurse researchers, serve as liaisons between staff members and directors of nursing. Nurse researchers tend to work in large teaching hospitals, research centers, and academic institutions, not community health centers and long-term care units. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 16.

Chapter 1: Introduction to Nursing - Page 16

Question 18: (see full question)

The nurse is conducting a community education class on the 2011 Institute of Medicine Report on the role of nursing in transforming healthcare. Which of the following statements should the nurse include?

You selected:

• Nurses should follow physicians' lead for changing the healthcare system.

• The infrastructure for data collection related to nursing is

in place.

Incorrect Correct response:

• Barriers to diploma nurses achieving a BSN should be removed.

• Nurse practitioners should be allowed to practice independently.

Explanation:

In 2011, the Institute of Medicine (IOM) released four key messages underlying their recommendations for transforming the nursing profession. These include that nurses should practice to the full extent of their education and training. Therefore, the nurse should include that nurse practitioners be allowed to practice independently and to practice at the full extent of their training. The IOM also recommended that nurses

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers achieve higher levels of education and training through an improved educational system promoting seamless academic progression. Therefore, the nurse should include that barriers to diploma nurses receiving their BSN be removed. The IOM recommendations do not include that baccalaureate trained nurses do not need further academic training. The IOM recommends that nurses be full partners versus follow the lead of physicians in changing the healthcare system. The IOM also recommended that there be better data collection and improved information infrastructure. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 20.

Chapter 1: Introduction to Nursing - Page 20

Question 19: (see full question)

You selected:

The diploma nurse is considering obtaining a baccalaureate degree. Which degree should the nurse investigate?

RN to BSN

Correct Explanation:

The diploma nurse considering obtaining a baccalaureate degree should investigate RN to BSN programs. This degree is designed for registered nurses with a diploma degree. The DNP is designed as the terminal degree (doctorate degree) for nursing practice. The accelerated degree is designed for people with a baccalaureate degree, not in nursing to obtain their BSN in 1 to 2 years. The MSN is designed for nurses with a baccalaureate degree to obtain a masters degree in nursing. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, pp.

14-16.

Chapter 1: Introduction to Nursing - Page 14

Question 20:

Which of the following is the best example of a nurse in the role of counselor?

(see full question)

You selected: Correct

A nurse allowing a crying client to verbalize their fears of death

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Explanation:

When the nurse is acting as a counselor, the nurse uses therapeutic interpersonal skills to facilitate the client's problem-solving and decision-making skills. The best example is the nurse allowing the client to verbalize their feelings, as verbalizing feelings lets the client gain a better perspective of their situation for problem solving and for coming to terms with the situation. Telling the client about the side effects of a medication is a form of teaching. Providing test results to the physician is communication, and ensuring a client has follow-up

care at a free clinic is advocacy. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 1: Introduction to Nursing, p. 11.

Chapter 1: Introduction to Nursing - Page 11

congrats!

Congratulations! You've reached Mastery Level 2 for Chapter 23: Asepsis and Infection Control!

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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Congratulations! You've reached Mastery Level 2 for Chapter 23: Asepsis and Infection Control!

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Answer Key Question 1: (see full question)

You selected:

An infection-control nurse is discussing needlestick injuries with a group of newly hired nurses. The infection control nurse informs the group that most needlestick injuries result from which of the following?

Recapping a needle

Correct Explanation:

Most needlesticks occur during recapping, so nurses are instructed to never recap needles.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 552.

Chapter 23: Asepsis and Infection Control - Page 552

Question 2: (see full question)

You selected:

Which of the following practices is a correct application of infection control practices?

A nurse performs handwashing each time she removes a pair of gloves.

Correct Explanation:

Handwashing should be performed after the removal of a pair of gloves. Gloves are not required for each and every patient contact and visibly soiled hands require a wash with soap and water. Alcohol-based handrubs are not followed by a rinse. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 542.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers (see full question)

Which level of health care provider may make the decision to apply physical restraints to a client?

You selected:

Nurse practitioner

Question 1:

Correct Explanation:

Current evidence-based research has shown that physical restraints should only be used as a last resort, and only used to prevent injury to staff, clients, or others. Federal and state guidelines, as well as accrediting bodies, such as The Joint Commission, require that restraints be applied only when ordered by a prescriber such as a physician, nurse practitioner, or physician's assistant. (less)

Reference:

Taylor, C. R. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 709.

Chapter 26: Safety, Security, and Emergency Preparedness - Page 709

Question 2: (see full question)

You selected:

An boy 18 years of age is brought to the emergency department with a head injury. The nurse knows that adolescents are vulnerable to injuries related to which of the following?

Automobile accidents

Correct Explanation:

Adolescents are prone to injuries related to activities that involve high risk, such as driving. Adolescents tend to be impulsive and take unnecessary risks as a result of peer pressure. Falling from the bed is common in infants. Play-related injuries are commonly seen in school-age children, and falling from staircases is a common injury among toddlers. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, pp. 702704.

Chapter 26: Safety, Security, and Emergency Preparedness - Page 702

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Question 3: (see full question)

You selected:

Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for their 9-month-old infant?

"We place our baby in a rear-facing car seat in the back seat of the car."

Correct Explanation:

The American Academy of Pediatrics recommends that all children from birth to 2 years of age remain in a rear-facing car seat in the back seat of the car until they are 2 years, or until they reach the maximum height and weight for the car seat. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 700701.

Chapter 26: Safety, Security, and Emergency Preparedness - Page 700

Question 4: (see full question)

You selected:

One of the leading causes of death in the United States, particularly in southwestern states, is drowning. How can the nurse assist in lowering this statistic?

Implement drowning-prevention strategies

Correct Explanation:

The principles of injury control have interventions centered at three primary levels: the individual level, providing education about safety hazards and prevention strategies; the design phase, using engineering and environmental controls; and the regulatory level, creating, monitoring, and enforcing regulations to ensure safe products and environments among manufacturers, retailers, employers, workers, and product users. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 696.

Chapter 26: Safety, Security, and Emergency Preparedness - Page 696

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Question 5: (see full question)

You selected:

A home care nurse provides health education to parents regarding the care of their toddler. Which of the following precautions should the nurse suggest the parents take to protect the toddler from drowning?

Avoid unattended baths for the toddler.

Correct Explanation:

The parents should not leave the toddler for an unattended bath. Toddlers are naturally inquisitive, and instructing them to stay away from the pool may make them more curious. Monitoring the activities of the toddler is not always feasible. Allowing the child to swim with friends does not ensure safety. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, pp. 700701.

Chapter 26: Safety, Security, and Emergency Preparedness - Page 700

Question 6: (see full question)

The nurse is applying wrist restraints on a client and notes that the client is unable to move his right arm.

What is the appropriate action by the nurse?

You selected:

Apply only the left wrist restraint.

Correct Explanation:

The nurse should apply only the left wrist restraint.

As the client is unable to move the right arm, this arm does not need restraining. Vest restraints and wrist restraints are typically utilized to meet different client needs, so they are not usually interchanged for one another. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 722.

Chapter 26: Safety, Security, and Emergency Preparedness - Page 722

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Question 7: (see full question)

You selected:

Which of the following statements about restraints used in the acute care setting is true?

A physician's order for use of a restraint is valid for 24 hours only.

Correct Explanation:

A valid physician or licensed independent practitioner's order is required for the use of restraints, regardless of setting.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 719.

Chapter 26: Safety, Security, and Emergency Preparedness - Page 719

Question 8: (see full question)

You selected:

An administrative assistant of a large factory visits the medical unit and tells the nurse she is having pain in the right wrist, numbness in the index finger, and decreased mobility of the right hand. The nurse suspects the client has what?

Carpal tunnel syndrome

Correct Explanation:

Adults with jobs that require repetitive movement (typists, assembly line workers, supermarket checkers, computer operators) may develop carpal tunnel syndrome, a compression of th ... (more)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 689.

Chapter 26: Safety, Security, and Emergency Preparedness - Page 689

Question 9: (see full question)

You selected: Correct

The nurse needs to plan the interventions necessary to reduce fall risks for the older adult clients at her facility. Which is the strongest indicator that a client is at risk for falls?

The client has fallen before.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Explanation:

Documentation that a client has sustained previous falls is a strong predictor of a risk for future falls.

Cardiovascular medications, being forgetful, or using an assistive device do not necessarily predispose a client to falling. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 687.

Chapter 26: Safety, Security, and Emergency Preparedness - Page 687

Question 10: (see full question)

You selected:

A nurse responds to the call bell and finds another nurse evacuating the client from the room, which has caught fire. Which of the following actions should the nurse take?

Pull the fire alarm lever.

Correct Explanation:

The nurse should pull the fire alarm lever. As per the RACE principle of fire management, the flow of activities should be rescue, alarm, confine, and extinguish. The client had already been evacuated by another nurse, so the next action should be to pull the fire alarm lever, followed by confinement of the fire and extinguishing. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 710.

Chapter 26: Safety, Security, and Emergency Preparedness - Page 710

Question 11: (see full question)

You selected:

What is an appropriate nursing intervention to include in the plan of care for a client with smallpox?

Strict contact and airborne precautions for the duration of the illness

Correct Explanation:

Clients with smallpox should receive strict contact and airborne precautions for duration of illness and supportive care.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and emergency Preparedness, p. 715.

Chapter 26: Safety, Security, and Emergency Preparedness - Page 715

Question 12: (see full question)

If a client is exposed to Viral Hemorrhagic Fevers, which clinical manifestations would the nurse assess in the client?

You selected:

Flu-like symptoms and a characteristic rash

Incorrect Correct response:

Petechial hemorrhages and hypotension

Explanation:

Anthrax exposure can result in skin lesions that progress to necrotic ulcers and fever. Exposure to viral hemorrhagic fevers can result in Petechial hemorrhages and hypotension. Botulism exposure presents with Skeletal muscle paralysis and blurred vision. Small pox exposure presents with flu-like symptoms and a characteristic rash. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 715.

Chapter 26: Safety, Security, and Emergency Preparedness - Page 715

Question 13: (see full question)

The school nurse is preparing a presentation about safety promotion for middle school students. Which topic should the nurse plan to include?

You selected:

The importance of consistent seat belt use

Correct Explanation:

Seat belt use is an important safety precaution to teach audience of all ages. Improper or lack of seat belt use increases the risk for injury. It is not appropriate to teach middle school children about moderation with alcohol, workplace injury, or falls. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 689.

Chapter 26: Safety, Security, and Emergency Preparedness - Page 689

Question 14: (see full question)

Which of the following reasons best explains why adolescents behave in an unsafe manner despite knowledge of a particular activity's risk?

You selected:

Social pressure

Correct Explanation:

As adolescents explore opportunities, they may know that certain behaviors are unsafe, but social pressure can persuade them to act against their better judgment.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 689.

Chapter 26: Safety, Security, and Emergency Preparedness - Page 689

Question 15: (see full question)

You selected:

The nurse is caring for an 80-year-old patient who was admitted to the hospital in a confused and dehydrated state. After the patient got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has blackand-blue marks on her wrists from the restraints.

What would be the most appropriate nursing intervention for this patient?

Take the restraints off, stay with her, and talk gently to her.

Correct Explanation:

Physical restraints increase the possibility of the occurrence of falls, skin breakdown and contractures, incontinence, depression, delirium, anxiety, aspiration respiratory difficulties, and even death. The best action in this situation is for the nurse to remove the restraint, stay with the patient and gently talk to her. Sedating her with sleeping pills is a chemical form of restraint. Leaving the restraints on the patient to talk to her is going to cause further agitation and bruising of her wrists.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers The patient’s condition dictates when the patient is discharged, not confusion and agitation. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 26, Safety, Security, and Emergency Preparedness, pp. 708-710

Question 16:

An 8-year-old boy fell off his bicycle. He was not wearing a helmet and has sustained a concussion.

What information should the nurse teach the parents about concussions?

(see full question)

You selected:

“It is important to monitor frequently for headache, vomiting, visual disturbances, and changes in alertness.”

Correct Explanation:

Frequent neurologic assessments are crucial after a traumatic brain injury, to assess for subtle changes as they begin. Helmets are meant to protect the wearer, but head injury can still occur. "Passing off" an injury as something that kids get and then they are fine is wrong and potentially harmful. Watching TV and video games stimulates brain activity and may worsen the child’s symptoms and the injury itself. (less)

Reference:

Taylor, C. R. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 701702.

Chapter 26: Safety, Security, and Emergency Preparedness - Page 701

Question 17: (see full question)

You selected:

A school-aged child is admitted to the Emergency Room with the diagnosis of a concussion following a collision when playing football. After the collision, the parents state that he was “knocked out” for a few minutes before recognizing his surroundings. What is the priority assessment when the nurse first sees the patient?

Assessment of vital signs and respiratory status

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Correct Explanation:

Assessment after a head injury includes immediate evaluation of airway, breathing, and circulation.

Therefore, assessment of vital signs and respiratory status is a priority for this client. Head circumference is only beneficial in children less than two years old and/or with open fontanels. Evaluation of all of his cranial nerves does not take priority over cardiopulmonary assessment, and assessment comes before intervention in the nursing process and more assessment is needed for this client before the need for an IV line is determined. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 699, 702.

Chapter 26: Safety, Security, and Emergency Preparedness - Page 699

Question 18: (see full question)

You selected:

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which of the following measures would be a high priority recommendation for this client?

Placing the client in a bed with a bed alarm

Correct Explanation:

Raising all side rails on the bed would be a restraint, and may increase the client’s risk of a fall if he or she climbs out of bed. Providing a bed that is elevated would put the client at a greater risk for a fall. Using restraints are not an option at this time, but placing the client in a bed with a bed alarm would help to prevent a fall. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015,Chapter 26: Safety, Security, and Emergency Preparedness, p. 709.

Chapter 26: Safety, Security, and Emergency Preparedness - Page 709

Question 19:

The nurse is providing care for a client that was

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers (see full question)

involved in a nuclear terrorism attack, and, as a result, has sustained radiation burns. The nurse also knows that the client's history states that he was exposed to a high dose of radiation. What can the nurse expect this client to be at risk for based on the degree of exposure to the radiation?

You selected:

Cancer

Correct Explanation:

Bone marrow depression and cancer can occur later in clients that are exposed to high doses of radiation exposure. The skin, kidneys, and intestines are organs most sensitive to radiation, but these diseases are not specific to this exposure. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 716.

Chapter 26: Safety, Security, and Emergency Preparedness - Page 716

Question 20: (see full question)

You selected:

A student nurse overhears another nurse talking to a group of students about work relate injuries. The student nurse understands that the nurse needs further education when she makes which statement?

"Some injuries are just part of the job and cannot be prevented."

Correct Explanation:

Injuries should never be considered “part of the job.”

OSHA standards and the involvement of safety committees help ensure a safe workplace.

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and emergency Preparedness, p. 689.

Chapter 26: Safety, Security, and Emergency Preparedness - Page 689

Answer Key Question 1:

The nurse is creating a plan of care for the older adult that has multiple medications and a difficult time reading medication labels

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers (see full question)

due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care?

You selected:

Risk for poisoning related to poor eyesight and the inability to read medication labels

Correct

Explanation:

Older adults are at an increased risk for falls and can have an altered sensory perception. However, neither of those diagnoses address this client's lack of vision, causing difficulty in reading the labels of his multiple medications and thereby causing a risk for injury by overdose. There is no indication of substance abuse in this client. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 705-706.

Chapter 26: Safety, Security, and Emergency Preparedness Page 705

Question 2: (see full question)

The nurse caring for a client with smallpox would anticipate this client being on which type of precautions? Select all that apply.

You selected:

Contact

Correct

Explanation:

Smallpox is spread via direct contact and inhalation of droplets.

Therefore, the client would be put on contact precautions, as well as respiratory precautions.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 715.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Chapter 26: Safety, Security, and Emergency Preparedness Page 715

Question 3: (see full question)

You selected:

A school nurse is providing information to a group of older adults during Fire Prevention Week. Which statement is correct regarding fires in the home?

Most people who die in house fires die of smoke inhalation, rather than burns.

Correct

Explanation:

Most people who die in house fires die of smoke inhalation, rather than burns. About 50% of home fire deaths occur in a home without a smoke detector. Many home fires are started because someone fell asleep smoking in bed or on a sofa, and most fatal home fires occur while people are sleeping. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 693.

Chapter 26: Safety, Security, and Emergency Preparedness Page 693

Question 4: (see full question)

What is the primary role of the nurse in the care of clients that experience domestic violence?

You selected:

Identifying health education and counseling measures for the family

Incorrect

Correct response:

Providing prompt recognition of the potential or actual threat to safety

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Explanation:

The nurse is often the initial health care provider in contact with an abused child or a battered woman or man. Prompt recognition of the potential or actual threat to safety is crucial, and the nursing assessment may play a vital role in identifying a harmful environment. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 704-705.

Chapter 26: Safety, Security, and Emergency Preparedness Page 704

Question 5: (see full question)

A staff development nurse is providing an in-service to a group of nurses on the use of restraints in healthcare facilities. Which of the following is an example of a chemical restraint?

You selected:

A dose of an analgesic

Incorrect

Correct response:

A dose of an antipsychotic

Explanation:

Drugs that are used to control behavior and are not included in the person's normal medical regimen can be considered a chemical restraint. Side rails and a geriatric chair with a tray are examples of physical restraints. Analgesics address pain and are not a restraint. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 707.

Chapter 26: Safety, Security, and Emergency Preparedness Page 707

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Question 6: (see full question)

When educating families on fire safety in the home, which information is important for the nurse to emphasize?

You selected:

Keep a fire extinguisher in a closet.

Incorrect

Correct response:

Have a meeting place outside the home in case of fire.

Explanation:

The whole family should regularly practice a fire escape plan, such as crawling on the floor, using escape routes, and having a meeting place outside the home in case of fire. Attempting to account for all family members before exiting the burning structure is dangerous and may result in the loss of life. Shock is possible with extension cords. Having a fire extinguisher is important, but it should be kept in a area with access and not a closet. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 694.

Chapter 26: Safety, Security, and Emergency Preparedness Page 694

Question 7: (see full question)

You selected:

During a course on terrorism, a group of emergency room nurses learns about terrorists who use bombs or other explosives to inflict injury on numerous people and cause multiple fatalities. This is an example of what type of terrorism?

Nuclear terrorism

Incorrect

Correct response:

Mass trauma terrorism

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Explanation:

Mass trauma terrorism is caused by bombs and other explosives that are used to inflict mass trauma and cause multiple fatalities.

Bioterrorism involves the deliberate spread of pathogenic organisms into the community. Chemical terrorism involves the deliberate release of a chemical compound for the purpose of causing mass destruction. Nuclear terrorism involves the dispersal of radioactive materials into the environment for the purpose of causing injury and death. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, pp. 714-716.

Chapter 26: Safety, Security, and Emergency Preparedness Page 714

Question 8:

What best describes the nurse’s role in disaster preparedness?

(see full question)

You selected:

Multiple roles including triage and the distribution of resources

Correct

Explanation:

Nurses will perform multiple roles when assisting with a disaster, including triage, procedures, counseling, and distribution of resources.

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 717.

Chapter 26: Safety, Security, and Emergency Preparedness Page 717

Question 9:

The nurse is conducting a community program on car seat safety.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers (see full question)

The nurse determines that additional education is needed when a participant states which of the following?

You selected:

"I should secure the car seat tightly with the seat belt."

Incorrect

Correct response:

"I should buy a front facing car seat when my child is 1 year old."

Explanation:

The nurse should determine that additional information is needed when the participant states that a front facing car seat should be bought when the child is 1 year old. The child should be kept in the rear facing car seat until 2 years of age. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 700.

Chapter 26: Safety, Security, and Emergency Preparedness Page 700

Question 10: (see full question)

You selected:

A nurse is teaching a community group about bicycle safety. Which statement should be included when creating a teaching plan regarding bicycle safety?

"Parents are effective role models for children when they also wear helmets while riding."

Correct

Explanation:

Parents are effective role models for children when they also wear helmets while riding. Helmets that have been damaged in a crash should not be worn. The chinstrap should fit snuggly, not loosely, and young children that are secured in a bicycle passenger seat must also wear a helmet. (less)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 701.

Chapter 26: Safety, Security, and Emergency Preparedness Page 701

Question 11: (see full question)

You selected:

The nurse overhears an older client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation?

Ask to examine the client alone in order to speak to her privately.

Correct

Explanation:

In 90% of elder abuse cases that are reported, the person doing the abusing is a family member. The best thing to do would be for the nurse to get the client alone so that she can discuss the relationship that was observed. Documenting the behaviors is appropriate, but not enough. More assessment is needed to prevent possible injury to the client. The nurse must address what could be a sign of elder abuse, and reporting it to authorities may be appropriate after more assessment and following protocols. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 706.

Chapter 26: Safety, Security, and Emergency Preparedness Page 706

Question 12: (see full question)

An elderly woman in a long-term care facility has fallen and sustained several injuries. Which of her injuries would be the most serious fall-related injury?

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers You selected:

fractured hip

Correct

Explanation:

Falls can occur at any age, but a large percentage of elderly adults in long-term settings suffer a fall. Hip fractures are among the most serious fall-related injuries. Fractures can cause pain, permanent disability, and even death. A fractured ulna may be painful but would not cause the same potential for complications as a hip fracture. Lacerations and contusions may be uncomfortable for the client but will heal with limited risk for further complications. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 692.

Chapter 26: Safety, Security, and Emergency Preparedness Page 692

Question 13: (see full question)

You selected:

The nurse is caring for a client in a posey vest restraint. The restraint was ordered at 0800. The last nursing client assessment and need for restraint was documented at 1000. It is now 1200.

What is the appropriate action by the nurse?

Assess the client and document findings immediately.

Correct

Explanation:

Assessment and documentation of a client in restraints should occur at least every hour. Although it has been longer than an hour since the last documented assessment, the nurse should immediately assess the client and document the findings. The nurse should never falsify documentation by documenting that an assessment was done at at time when it was not completed. The restraints should not be discontinue unless it is appropriate to do so, and there is no need to contact the physician at this time. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 709.

Chapter 26: Safety, Security, and Emergency Preparedness Page 709

Question 14: (see full question)

A nurse is caring for a client who is receiving an intravenous therapy through an IV pump. Which of the following interventions should the nurse implement to ensure electrical safety?

You selected:

Obtain a three-prong grounded plug adapter.

Correct

Explanation:

The nurse should obtain a three-prong grounded plug adapter, as it carries any stray electricity back to the ground. Using an extension cord may be an electrical hazard. Taping the electrical cord to the ground and running the electrical cord under the carpet are not appropriate actions for electrical safety. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 712.

Chapter 26: Safety, Security, and Emergency Preparedness Page 712

Question 15: (see full question)

The unlicensed personnel tells the nurse that a client is very confused and trying to get out of bed without assistance. What is the appropriate action by the nurse?

You selected:

Initiate use of a bed alarm.

Correct

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Explanation:

The nurse should attempt to prevent the client confused client from getting out of bed by themselves to prevent a fall using the least restrictive action first. In this case, it would be to initiate the use of a bed alarm. Putting up all 4four siderails and use of a sedative are considered forms of restraints, and restraints should be used only as a last resort when the client is in danger of harming themselves or others. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 710.

Chapter 26: Safety, Security, and Emergency Preparedness Page 710

Question 16: (see full question)

You selected:

A child is playing soccer and is involved in a head collision with another player. Which assessment findings should the nurse be alert to that may indicate a concussion? (Select all that apply.)

• Headache • Vomiting • Drowsiness

Correct

Explanation:

Concussions are a frequently seen sports injury in school age children. Nurses should be aware of symptoms that may indicate that a concussion or more serious head injury is present.

Symptoms of a concussion include headache, vomiting, problems with balance, fatigue, dazed or stunned appearance, difficulty concentrating and remembering, confusion, forgetfulness, irritability, nervousness, very emotional behavior, drowsiness, difficulty falling asleep, and sleeping more or less than usual. Fever and increased thirst are not symptoms usually seen with a concussion. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 702.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Chapter 26: Safety, Security, and Emergency Preparedness Page 702

Question 17: (see full question)

You selected:

Which statement indicates that a family understands the teaching that has been provided by the nurse related to car seat safety for their 3-year-old child?

"We place our child in a front-facing car seat in the back seat of the car."

Correct

Explanation:

The American Academy of Pediatrics recommends that all children over the age of 2 be placed in a front-facing car seat based on the child’s weight and height.

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p 701.

Question 18: (see full question)

A nurse is preparing discharge education for a client with a newborn baby. What is the highest priority item that must be included in the education plan?

You selected:

Restrain the baby in a car seat.

Correct

Explanation:

The client should restrain the baby in a car seat when driving.

Infants are especially vulnerable to injuries resulting from falling off changing tables or being unrestrained in automobiles. Locking the cabinets and giving warm bottles of formula to the baby are secondary teachings. (less)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, pp. 699-700.

Chapter 26: Safety, Security, and Emergency Preparedness Page 699

Question 19: (see full question)

You selected:

A child football player has been diagnosed with an uncomplicated concussion and is being discharged home on cognitive rest. When preparing this child’s teaching plan, what should the nurse include that will help the family understand what is meant by cognitive rest?

Reading, watching television, and playing games of any kind should be avoided until he is cleared.

Correct

Explanation:

The treatment for an uncomplicated concussion is physical and cognitive rest. Reading, watching television, and playing games of any kind are examples of cognitive activities that should be avoided until the athlete is cleared. Lifting objects and playing football are examples of physical activities only, and the need for 8 hours of sleep does not direct the family in the limitations of cognitive activity. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, p. 702.

Chapter 26: Safety, Security, and Emergency Preparedness Page 702

Question 20: (see full question)

A nurse is preparing to file a safety event report after a client experienced a fall. The nurse is aware that which statement below

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers is correct regarding the filing of a safety event report?

You selected:

The nurse should record the incident in the client's medical record and fill out a safety event report separately.

Correct

Explanation:

The nurse completes the safety event report immediately after an accident and is responsible for recording the incident and its effect on the client in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 26: Safety, Security and Emergency Preparedness, p. 712.

Chapter 26: Safety, Security, and Emergency Preparedness Page 712

Answer Key Question 1: (see full question)

A client has a diagnosis of bathing/hygiene self-care deficit due to recent surgery and decreased strength. An appropriate goal to include in the client’s plan of care would be which of the following?

You selected:

Client will recognize the need for self-care.

Incorrect

Correct response:

Client will participate in self-care measures by the end of the week.

Explanation:

Bathing/hygiene self-care deficits resulting from hospitalization and complications require return of strength and motor abilities. It does not mean the client does not want to participate in hygiene and personal care. An appropriate goal would be to have the client actively participate in hygiene and self-care. (less)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 910.

Chapter 30: Hygiene - Page 910

Question 2: (see full question)

A nurse is caring for a client who has had difficulty sleeping. What nursing intervention may facilitate the client's rest?

You selected:

Providing a backrub before bed

Correct

Explanation:

A backrub is used after a bath or as a nursing intervention for the following: assessment of skin, improving circulation, decreasing pain, decreasing anxiety, improving sleep, and providing a means of communication between the nurse and the client. Stimulating the environment through conversation or multiple stimuli will only increase the level of alertness of the client. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 917.

Chapter 30: Hygiene - Page 917

Question 3: (see full question)

You selected:

Which of the following is a recommended guideline when removing contact lenses from a client's eyes?

Before removing hard or gas-permeable lenses, use gentle pressure to center the lens on the cornea.

Correct

Explanation:

Gentle pressure should be used to center hard or gas-permeable lenses on the cornea. Once removed, lenses should be placed in the appropriate container, identifying the right and left lens. If an

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers eye injury is present, the lenses should not be removed because of the danger of causing an additional injury. If the lenses cannot be removed, they should be removed with the appropriate tool designated for the type of lenses in place. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 919920.

Chapter 30: Hygiene - Page 919

Question 4: (see full question)

The nurse is caring for a female client who is unconscious. You should pay special attention to cleaning which of the following areas of the body?

You selected:

Underneath the breasts and in between skin folds

Correct

Explanation:

Skin fold areas may be sources of odor and skin breakdown if not cleaned and dried properly.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 934.

Chapter 30: Hygiene - Page 934

(see full question)

A nurse is assessing the client’s ability to perform ear care. Which statement by the client requires further teaching by the nurse?

You selected:

“I use cotton-tipped applicators daily to remove cerumen.”

Question 5:

Correct

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Explanation:

Healthy ears require little to no care. Cerumen (ear wax) can accumulate causing discomfort or decreased hearing. To care for ears, a washcloth is used to wipe the auricles and the twisted end of a washcloth can be used to clear cerumen from the ear canal.

Clients should be educated to not use cotton-tipped applicator because it may push cerumen further back into the ear canal.

Bobby pins and sharp objects should never be used to remove cerumen because they can puncture the tympanic membrane. If a client has a hearing aid device, care includes careful handling, wiping of the mold, and monitoring for dead batteries. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 921.

Chapter 30: Hygiene - Page 921

Question 6: (see full question)

You selected:

A nursing instructor is explaining the benefits of bathing to a group of nursing students. She states there are numerous benefits beyond hygiene. A student understands the concepts when she lists the following benefits orally to the class. Select all that apply.

• Bathing can improve appearance and self-image.

• Bathing can stimulate circulation.

• Bathing removes organisms from the skin, reducing infection.

Correct

Explanation:

Bathing serves a variety of purposes including: cleansing; acting as a skin conditioner; helping to relax a person; promoting circulation by stimulating the skin’s peripheral nerve endings and underlying tissues; serving as a musculoskeletal exercise through activity involved in bathing, thereby improving joint mobility and muscle tone; stimulating the rate and depth of respiration; promoting comfort through muscle relaxation and skin stimulation; providing sensory input; and helping improve self-image. Bathing also provides a means to establishing a therapeutic relationship. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, pp. 911-912.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Chapter 30: Hygiene - Page 911

Question 7: (see full question)

You selected:

When an adult client from Indonesia refuses a complete bath on the day after abdominal surgery, the nurse should ...

Understand that his culture may influence his hygiene and ask him his preference

Correct

Explanation:

Preferences for hygiene vary widely among individuals and across cultures.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 903.

Chapter 30: Hygiene - Page 903

Question 8: (see full question)

A nurse is teaching a patient how to care for her dentures. Which of the following is a recommended teaching guideline?

You selected:

Store dentures in cold water when not in use.

Correct

Explanation:

Encourage the patient to wear her dentures, if not contraindicated.

Dentures enhance appearance, assist with eating, facilitate speech, and maintain the gum line. Denture fit may be altered with long periods of nonuse. Encourage the patient to refrain from wrapping the denture in paper towels or napkins because they could be mistaken for trash. Encourage the patient to refrain from placing the dentures in the bed clothes because they can be lost in the laundry.

Store dentures in cold water when not in the patient's mouth.

Leaving dentures dry can cause warping, leading to discomfort when worn (Holman, et al., 2005). (less)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 918.

Chapter 30: Hygiene - Page 918

Question 9: (see full question)

You selected:

A nurse is performing an admission assessment on a client. What is an appropriate question to ask when assessing the client’s self-care hygiene measures?

“Do you feel you will have difficulty performing self-care while in the hospital?”

Correct

Explanation:

When assessing a client’s self-care patterns and feelings, it is important to understand the client’s perceptions regarding bathing and elicit personal care preferences. Although it is important to incorporate preferences, it may not be possible to allow clients to bring products from home if they are in specialty care environments. Asking questions about body odor may sound judgmental and may cause the client to feel judged, which may prohibit the ability to form a trusting relationship with the nurse. A clear threat to health must be present before a nurse can decide a client's hygiene practices are inadequate. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 912.

Chapter 30: Hygiene - Page 912

Question 10: (see full question)

You selected:

A nurse caring for the skin of patients of different age groups should consider which accurately described condition?

An adolescent’s skin ordinarily has enlarged sebaceous glands and increased glandular secretions.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Correct

Explanation:

Adolescents have enlarges sebaceous glands and increased glandular secretions, which predisposes them to acne. Infants have natural immunities, but not pertaining to the mucous membranes.

Secretions from skin glands occur later than age 3 months. While the skin may have more wrinkles as a person ages, the skin actually becomes thinner with age. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 30, Hygiene, p. 900

Question 11:

A 55-year-old client has just undergone surgery for a knee replacement. He asks the nurse if he can shave because his face is itching from the stubble. What information is a priority for the nurse to verify prior to shaving the client?

(see full question)

You selected:

Medications listed on the clients MAR

Correct

Explanation:

Shaving guidelines note that pharmacological considerations are important because clients on anticoagulant therapy or low-dose aspirin will need to use an electric razor for safety. Although it is important to assess cultural views related to shaving, the client is asking to shave so this is not a priority consideration. Allergies to soap are important to assess prior to shaving. However, shaving cream is not contraindicated. Shaving is performed as needed at the client’s request. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, pp. 922-923.

Chapter 30: Hygiene - Page 922

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Question 12: (see full question)

A nurse is examining an adult client with inflammation of the gums.

The nurse observes bleeding gums. How should the nurse record the findings in the client's medical record?

You selected:

Gingivitis

Correct

Explanation:

The nurse should record the findings as gingivitis. Gingivitis is a condition in which there is inflammation of the gums. This usually happens when there is improper cleaning of teeth or injury to the gums from overly vigorous brushing or flossing. Gingivitis is usually associated with bleeding gums. Caries, plaque, and tartar do not show inflammation of the gums. Cavities usually occur when there is combination of sugar, plaque, and bacteria in the teeth, which eventually erode the tooth enamel. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 907.

Chapter 30: Hygiene - Page 907

Question 13: (see full question)

When providing oral care, which of the following does the nurse recognize as the most important component of the oral care process?

You selected:

A thorough mechanical cleaning

Correct

Explanation:

Following the steps for cleaning the mouth thoroughly is more important than the agent used. No mouthwash, breath freshener, ointment, or paste replaces a thorough mechanical cleaning of the oral cavity. (less)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 917.

Chapter 30: Hygiene - Page 917

Question 14: (see full question)

Which of the following health problems is most clearly suggestive of a history of inadequate dental care?

You selected:

Periodontitis

Correct

Explanation:

Periodontitis, or periodontal disease, is a marked inflammation of the gums that also involves degeneration of the dental periosteum (tissues) and bone; it is suggestive of deficits in dental and oral hygiene. Cheilosis is indicative of vitamin deficiency while dry oral mucosa is not indicative of inadequate dental hygiene. Alopecia is hair loss. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 907.

Chapter 30: Hygiene - Page 907

Question 15: (see full question)

Which group of individuals is most likely to show increasing concern regarding their personal appearance and adopt new hygiene measures, such as more frequent showers?

You selected:

Adolescents

Correct

Explanation:

As adolescents become more concerned about their personal appearance, they may adopt new hygiene measures, such as taking showers more frequently and wearing deodorant. As a

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers person ... (more)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 903.

Chapter 30: Hygiene - Page 903

Question 16: (see full question)

You selected:

A client has been recently admitted to the hospital unit following a suspected stroke, and a family member states that the client's soft contact lenses are still in place. Which of the following solutions should the nurse use for the storage of the client's lenses after removal?

Normal saline

Correct

Explanation:

Contact lenses are most commonly stored in normal saline.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 919920.

Chapter 30: Hygiene - Page 919

Question 17: (see full question)

A patient with iron deficiency has a common complication that results in an inflammation of the tongue. What is the term used for this condition?

You selected:

Glossitis

Correct

Explanation:

Glossitis is an inflammation of the tongue. Gingivitis is an

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers inflammation of the gingival, the tissue that surrounds the teeth (gums). Periodontitis is a marked inflammation of the gums that also involves degeneration of the periosteum and bone. Stomatitis is an inflammation of the oral mucosa. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 907.

Chapter 30: Hygiene - Page 907

Question 18: (see full question)

You selected:

A client is being discharged today from the hospital. The nurse delegates morning care to the unlicensed assistive personnel (UAP). The assessment finds that the client is able to stand and ambulate independently without weakness or dizziness. The nurse will delegate what type of care to be provided based on the assessment findings?

Independent showering

Correct

Explanation:

Weakness, dizziness, and fear of falling may prevent a person from entering a tub or shower or from bending to wash their lower extremities. Even while hospitalized, independence is encouraged so allowing the client to shower independently would be appropriate. The client is not unstable enough to prohibit hygiene measures. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 30: Hygiene, pp. 903-904.

Chapter 30: Hygiene - Page 903

Question 19:

Foot care is an essential part of routine hygiene. What is an

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers (see full question)

important nursing consideration when planning foot care for diabetic patients?

You selected:

Foot care should not include soaking the feet.

Correct

Explanation:

Foot care is an essential part of routine hygiene. Clients with diabetes have decreased sensation, placing them at risk for injury and burns. Soaking the feet should be avoided. Feet should be inspected daily, cleaned with warm water and mild soap, carefully dried, especially between the toes, and lotion should be applied to the tops of the toes and bottom of the feet but not between the toes, because increased moisture can lead to infection. The cutting of toenails is institution specific and if cutting is permitted, attention should be given to not cutting the toenails too close to the skin, cutting straight across, and using emery boards for sharp edges. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, pp. 923-924.

Chapter 30: Hygiene - Page 923

Question 20: (see full question)

You selected:

The acute care nurse is preparing to bathe a patient and notices that the patient is wearing a regular hospital gown and has continuous intravenous (IV) fluids infusing. Which of the following actions by the nurse is most appropriate?

Carefully thread the IV bag and tubing though the arm of the regular gown, then replace it with a snap-arm gown at the end of the bath.

Correct

Explanation:

The gown should be removed without disconnecting the IV equipment or cutting the gown.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 936937.

Chapter 30: Hygiene - Page 936

Answer Key Question 1: (see full question)

You selected:

A nurse is promoting exercise and activities for an elderly patient.

Which teaching point would be appropriate for this patient?

Encourage the patient to warm up before beginning exercises and to cool down after exercising.

Correct

Explanation:

The client should be encouraged to develop an exercise program that specifies warm-up and cool-down activities (walking, stretching). The client should not be encouraged to quickly increase the repetitions for arm and leg exercises. The client should not continue to exercise when feeling weak, this could lead to injury.

The client should not be taught to force joints to meet their natural limit and beyond prior to modifying exercises. This could lead to injury. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1082.

Chapter 32: Activity - Page 1082

Question 2: (see full question)

The nurse has been teaching a client about health promotion and exercise. The nurse knows the client understands the teaching when the client states what?

You selected:

"I should exercise for an hour everyday.”

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Incorrect

Correct response:

“I will invite a friend to exercise with me."

Explanation:

Inviting a friend to exercise with will add the support of a buddy.

Joining a spa, health club, or exercise group is also recommended to provide support to exercise. Exercise sessions should be built gradually to prevent overexertion and injury to muscles. Clients should be encouraged to exercise for 30 to 45 minutes three or four times per week. Alternating types of exercise will help to avoid boredom. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1080.

Chapter 32: Activity - Page 1080

Question 3: (see full question)

The nursing student learns in Fundamentals that the primary purpose for using proper body mechanics is for which of the following reasons?

You selected:

Primarily protects the nurse from injury

Incorrect

Correct response:

Acts to prevent injury to the client and/or nurse

Explanation:

When nurses use their bodies to perform therapies, to assist clients with movement, or to move equipment, they benefit from the effective use of body mechanics to prevent injury to themselves and others. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1060.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Chapter 32: Activity - Page 1060

Question 4:

What is a benefit of regular exercise over time?

(see full question)

You selected:

Decreased heart rate

Correct

Explanation:

Regular physical activity over time results in cardiovascular conditioning, thus decreasing heart rate. Regular exercise increases circulating fibrinolysin that serves to breakup small clots, thus decreasing the risk for blood clots. Over time, regular exercise leads to improved pulmonary function, including decreased work of breathing. Venous return is improved when contracting muscles compress superficial veins and push blood back to the heart against gravity. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1048.

Chapter 32: Activity - Page 1048

Question 5: (see full question)

You selected:

Which nursing actions would the nurse perform when assisting patients with passive ROM exercises? (Select all that apply.)

• Begin ROM exercises at the patient’s head and move down one side of the body at a time.

• Move each joint in a smooth, rhythmic manner.

• Adjust the bed to the flat position or as low as the patient can tolerate.

Correct

Explanation:

The nurse would adjust the bed to the flat position or as low as the client can tolerate. The nurse would begin ROM exercises at the

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers client’s head and move down one side of the body at a time. The nurse would move each joint in a smooth, rhythmic manner. The nurse would not raise the bed to the highest position, but at a position that is waist high to the nurse. The nurse would not perform each exercise 10 to 15 times, rather 2 to 5 times. The nurse would not use a flat palm, rather a cupping hold to support joints during ROM exercises. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1105.

Chapter 32: Activity - Page 1105

Question 6: (see full question)

When moving a client up in bed with the assistance of another caregiver, the nurse should:

You selected:

have the client fold the arms across the chest.

Correct

Explanation:

Positioning the arms across the chest proves assistance, reduces friction, and prevents hyperextension of the neck. Before attempting to move a client up in bed, the nurse should review the medical record and the nursing plan of care. This validates the correct client and correct procedure, identification of limitation, and ability.

Reviewing the medical record and plan of care also identifies use of an algorithm to prevent injury and assistance in determining the best plan for client movement. The head of the bed should be flat, or as low as the client can tolerate that will help to decrease the gravitational pull of the upper body. If tolerated, a slight Trendelenburg position aids in movement. Pillows should be removed from under the client’s head facilitates movement. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, pp. 1096-1098.

Chapter 32: Activity - Page 1096

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Question 7: (see full question)

You selected:

A nurse is caring for patients with alterations in mobility. Which nursing interventions are recommended for these patients? (Select all that apply.)

• For constipation, increase fluid intake and roughage.

• For impaired skin integrity, reposition the patient in correct alignment at least every 1 to 2 hours.

Incorrect

Correct response:

• For orthostatic hypotension, have the patient sleep sitting up or in an elevated position.

• For constipation, increase fluid intake and roughage.

• For impaired skin integrity, reposition the patient in correct alignment at least every 1 to 2 hours.

Explanation:

The nurse would implement the following nursing interventions when caring for clients with alterations in mobility. The nurse would have the client sleep sitting up or in an elevated position for orthostatic hypotension. The nurse would have the client increase fluid intake and roughage (if not contraindicated) to address constipation concerns. The nurse would reposition the client in correct alignment at least every 1 to 2 hours to address impaired skin integrity issues. The client would decrease the cardiac workload if lying in the prone position. Shallow breathing would not be encouraged with a client with ineffective breathing patterns.

Range of motion (ROM) exercises would not be performed as often as every 2 hours for a client with impaired physical mobility. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1052.

Chapter 32: Activity - Page 1052

Question 8: (see full question)

When assisting a client from the bed into a wheelchair, the nurse assesses the client for signs of dizziness upon standing. For what

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers adverse condition is the nurse assessing the client?

You selected:

Orthostatic hypotension

Correct

Explanation:

The nurse would stand in front of the client and assess for any balance problems or complaints of dizziness upon standing, due to orthostatic hypotension. Standing in front of the client prevents falls or injuries. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1075.

Chapter 32: Activity - Page 1075

Question 9: (see full question)

A nurse is preparing to turn a hospitalized client age 65 years.

Which of the following is a recommended guideline for performing this skill?

You selected:

Position a friction-reducing sheet under the client.

Correct

Explanation:

After placing the bed in a comfortable working position (usually elbow height of the caregiver), position a nurse on either side of the bed, put a friction-reducing sheet under the client, and use the leg muscles to pull the client to the side. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1063.

Chapter 32: Activity - Page 1063

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Question 10: (see full question)

The nurse is caring for a client who is on bed rest and was just turned to the left side. Which of the following actions should you take next to decrease the risk of impaired skin integrity?

You selected:

Pull the shoulder blade forward and out from under the client.

Correct

Explanation:

Positioning the shoulder blade in this manner removes pressure from the bony prominence.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1095.

Chapter 32: Activity - Page 1095

Question 11: (see full question)

You selected:

The nurse is teaching a new graduate nurse about the most common causes of back injuries. The nurse knows that the new graduate understands the concepts of back injuries when she/he states that back injuries:

can occur when repositioning uncooperative clients.

Correct

Explanation:

Many nurses believe that back pain is a routine consequence of the job, but it need not be. Employing principles of body mechanics, use of algorithms, and guidelines for transferring or lifting clients contribute to the prevention of back injuries and pain. Back injuries can occur when repositioning uncooperative clients. Back injuries cannot be prevented by use of a gait belt. Inappropriate use of the gait belt and other factors can contribute to back injuries. Standing, not sitting, for long periods of times can contribute to back injuries. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, pp. 1059-1061.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Chapter 32: Activity - Page 1059

Question 12: (see full question)

A nurse applies padded boots to maintain the foot in dorsiflexion on a client who is comatose. The nurse is protecting the client from what?

You selected:

Foot drop

Correct

Explanation:

A footboard or boots should be applied to maintain dorsiflexion and tendon flexibility. Footdrop is a contracture in which the foot is fixed in plantar flexion.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1066.

Chapter 32: Activity - Page 1066

Question 13: (see full question)

When a client is lifted or held by a nurse, the additional weight becomes a part of the nurse's weight and should be ...

You selected:

balanced over the center of gravity

Correct

Explanation:

Maintaining balance involves keeping the spine in vertical alignment, the feet positioned for a broad base of balance, and the body weight close to the center of gravity.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp.

1060-1061.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Chapter 32: Activity - Page 1060

Question 14: (see full question)

You selected:

The nurse uses gait belts when assisting patients to ambulate.

Which patient would be a likely candidate for this assistive device?

A patient who has leg strength and can cooperate with the movement

Correct

Explanation:

The gait belt is used to help the patient stand and provides stabilization during pivoting. Gait belts also allow the nurse to assist in ambulating patients who have leg strength, can cooperate, and require minimal assistance. A gait belt is not used on clients who have either an abdominal or thoracic incision. A gait belt would not be used on a client who is confined to bedrest. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1064.

Chapter 32: Activity - Page 1064

Question 15: (see full question)

The nurse is assisting a patient from the bed into a wheelchair.

Which of the following is a recommended guideline for this procedure?

You selected:

Put the chair at the foot of the bed.

Incorrect

Correct response:

Raise the head of the bed to a sitting position.

Explanation:

When assisting a client from the bed into a wheelchair, the nurse would place the bed in the lowest position and raise the head of the

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers bed to a sitting position. The nurse would make sure the bed brakes are locked and put the wheelchair next to the bed, locking the brakes of the chair. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp.

1102-1105.

Chapter 32: Activity - Page 1102

Question 16: (see full question)

You selected:

The nurse adjusts a client's bed to a comfortable working height in order to turn a patient. What would be the nurse's next action?

Move the client to edge of the bed opposite the side that client will be turning.

Correct

Explanation:

When turning a client in bed, the nurse would use a frictionreducing sheet to pull the client to the edge of the bed that is opposite the side the client will be turning. Consult a Safe Patient Handling Algorithm to determine whether assistive devices or additional nurses are needed, depending on the individual client. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp.

1095-1098.

Chapter 32: Activity - Page 1095

Question 17: (see full question)

The nurse moves a person’s arm from an outstretched position to a position at the side of the patient’s body. What is the term used to describe this type of body movement?

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers You selected:

Adduction

Correct

Explanation:

Adduction is a lateral movement of a body part toward the midline of the body. An example of adduction is when a person’s arm is moved from an outstretched position to a position alongside the body. Abduction is a lateral movement of a body part away from the midline of the body. An example of abduction is when a person’s arm is moved away from the body. Circumduction is turning in a circular motion. This motion combines abduction, adduction, extension, and flexion. An example of this movement is the circling of the arm at the shoulder, as in bowling or a serve in tennis.

Extension is the state of being in a straight line. An example of extension is when a person’s cervical spine is extended, the head is held straight on the spinal column. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1041.

Chapter 32: Activity - Page 1041

Question 18: (see full question)

A nurse is recommending aerobic exercise for a patient who is overweight. Which exercise might the nurse suggest?

You selected:

Swimming

Correct

Explanation:

The exercise that is aerobic in this question is swimming. Aerobic exercise is also known as cardio exercise. The other options listed are anaerobic exercise.

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1082

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Question 19: (see full question)

You selected:

A home care nurse visits a client with Parkinson's disease. The nurse observes that the client has rhythmic, repetitive movements of the hands. The home care nurse documents this as which of the following?

Tremor

Correct

Explanation:

Tremors are rhythmic, repetitive movements that can occur at rest or when movement is initiated. A tremor usually interferes with fine motor control, but in Parkinson's disease it also can interfere with coordinated ambulation. Athetosis is movement characterized by slow, irregular, twisting motions. Dystonia is similar to athetosis but usually involves larger areas of the body. Ataxia is a general term used to describe impaired muscle coordination. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1047.

Chapter 32: Activity - Page 1047

Question 20: (see full question)

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight?

You selected:

Shift their weight back and forth, from back leg to front leg.

Correct

Explanation:

The nurses would use a rocking motion to counteract the client's weight. The nurses would shift their weight back and forth, from back leg to front leg, count to three, and then move the client up toward the head of the bed. (less)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1096.

Chapter 32: Activity - Page 1096

Answer Key Question 1: (see full question)

Which of the following conditions will lead to an increase in cardiac output?

You selected:

Exercise

Correct

Explanation:

Cardiac output increases during exercise and decreases during sleep. When cardiac output is decreased, blood pressure falls.

Hemorrhage and dehydration can result in decreased cardiac output and decreased blood pressure. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 588.

Chapter 24: Vital Signs - Page 588

Question 2: (see full question)

A client has smoked most of his life and has labored respirations.

He is experiencing

You selected:

Dyspnea

Correct

Explanation:

Dyspnea describes respirations that require excessive effort.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 594.

Chapter 24: Vital Signs - Page 594

Question 3: (see full question)

You selected:

A client being treated for hypertension is monitoring her own BP at home. She was informed by the nurse to take three measurements at one sitting and average them together to get a BP to record. Her measurements at one sitting were 140/86, 125/78, and 130/82. She wants to know if she averaged them correctly. Which is the correct average?

130/82

Incorrect

Correct response:

132/82

Explanation:

Ideally it is recommended that when monitoring BP at home, the client should use a validated BP monitor and measure the BP three times at one sitting and then average them together. To average, the three systolic BPs are added together and the divided by 3 to get to the nearest whole number using normal rounding rules. Then add the three diastolic BP readings and divide that number by 3 also to give the client an average BP. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 604.

Chapter 24: Vital Signs - Page 604

Question 4: (see full question)

A client is taking medications to treat a heart dysrhythmia. Which site should be used to assess pulse in this client?

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers You selected:

Apical

Correct

Explanation:

An apical pulse is assessed when giving medications that alter heart rate and rhythm.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 591.

Chapter 24: Vital Signs - Page 591

Question 5: (see full question)

You selected:

While assessing vital signs of a client with a head injury and increased intracranial pressure (IICP), a nurse notes that the client's respiratory rate is 8 breaths/minute. How will the nurse interpret this finding?

Bradypnea is a response to IICP.

Correct

Explanation:

The normal respiratory rate for adults is 12 to 20 breaths/min.

Bradypnea, a decrease in respiratory rate, characteristically occurs in some pathologic conditions. An increase in intracranial pressure depresses the respiratory center, resulting in slow breathing. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 594.

Chapter 24: Vital Signs - Page 594

Question 6: (see full question)

A client with newly diagnosed hypertension on BP medication has been taking her own BP at home for two weeks. When she calls and reports her BP readings to the nurse, the nurse notes an

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers elevated BP in the morning. The client states that she wakes up, has her daily cup of coffee and takes her BP before eating as she was instructed. What should the nurse recommend to this client?

You selected:

Take her BP before drinking her morning cup of coffee.

Correct

Explanation:

A client should be taught to avoid food, coffee, and alcohol 30 minutes before taking a measurement. There is no need for this client to come immediately to the office; it is usually recommended that clients take their BP in the morning and the evening to get a record of BP readings over time. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 603.

Chapter 24: Vital Signs - Page 603

Question 7: (see full question)

Which of the following sites results in measuring a client's core body temperature?

You selected:

Rectal

Correct

Explanation:

Rectal temperature is considered to be the most accurate route for obtaining core body temperature. Surface body temperatures are measured at oral (sublingual), temporal, and axillary sites. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p.588.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Chapter 24: Vital Signs - Page 588

Question 8: (see full question)

Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?

You selected:

5:00 PM

Correct

Explanation:

Body temperature fluctuates throughout the day. Temperature is usually lowest around 3 AM and highest from 5 to 7 PM.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 582.

Chapter 24: Vital Signs - Page 582

Question 9: (see full question)

You selected:

An older adult client monitors her BP at home. Lately she has been experiencing dizziness and nausea, followed by a headache when she arises from lying down for a nap. She was worried it was her BP so she began taking it after she arose from her nap and found that her BP would drop shortly after getting up from her nap. She followed up with her health care practitioner and was diagnosed with orthostatic hypotension. What is the most appropriate nursing diagnosis to be included in the teaching plan for this patient at this time?

Risk for falls related to inadequate physiologic response to postural (positional) changes

Correct

Explanation:

Orthostatic hypotension (postural hypotension) is a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within 3 minutes of standing when

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers compared with blood pressure from the sitting or supine position. It results from an inadequate physiologic response to postural (positional) changes in blood pressure. Orthostatic hypotension may be acute or chronic, as well as symptomatic or asymptomatic.

It is associated with dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, and headache. Older adults may experience orthostatic hypotension without associated symptoms, leading to falls. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 597.

Question 10: (see full question)

A nurse is assessing the pulse volume of a client with influenza.

The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?

You selected:

Pulse is felt with difficulty and disappears with slight pressure.

Correct

Explanation:

Thready pulse is felt with difficulty or not easily felt, and slight pressure causes it to disappear. A weak pulse is stronger than a thready pulse, and light pressure causes it to disappear. A normal pulse is felt easily, and moderate pressure causes it to disappear. A bounding pulse is strong and does not disappear with moderate pressure. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 589.

Chapter 24: Vital Signs - Page 589

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Question 11: (see full question)

An 80-year-old client has a body temperature of 97°F. Which condition best accounts for this client's temperature reading?

You selected:

Temperature drops with age

Correct

Explanation:

It is not uncommon for elderly persons to have body temperatures less than 97.6° because normal temperature drops as a person ages.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 582.

Chapter 24: Vital Signs - Page 582

Question 12: (see full question)

You selected:

The nurse has just measured an adult client's oral temperature and obtained a result of 102.4ºF (39.1ºC). The client states, "I just finished my coffee right before you came in. Can I have another cup?" Which of the following responses by the nurse is most appropriate?

"I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return."

Correct

Explanation:

Although an inaccurate thermometer may have caused a falsely elevated temperature, the more likely reason is consumption of a hot beverage; drinking another hot beverage would make any other oral thermometer's result inaccurate. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers 24: Vital Signs, p. 603.

Chapter 24: Vital Signs - Page 603

Question 13:

Clients demonstrating apnea have what?

(see full question)

You selected:

Usually have a temporary cessation of breathing

Correct

Explanation:

Apnea, the absence of respirations, is often described by the length of time in which respirations do not occur.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 594.

Chapter 24: Vital Signs - Page 594

Question 14: (see full question)

You selected:

Correct

A client that has been taught to monitor her pulse calls the nurse because she is having difficulty feeling it strongly enough to count.

She states that she takes her pulse before taking her cardiac medication. She sits down with her nondominant arm on a firm service, palm up. She uses her three fingers to feel just below the wrist on the side closest to the body. She does not press hard and she has a watch with a second hand to use to count it, but she has a very difficult time feeling it. What does the nurse recognize that she is doing wrong?

She should place her three fingers just below the wrist on the outside of the arm with the palm up.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Explanation:

A client is taught to take his or her own pulse before certain medications or after exercise, depending on the individual client's needs. When teaching a client to take his or her own pulse, the nurse should teach the client to sit down and place an arm on a hard service with the palm upward. Then using three fingers, the client should feel just below the wrist on the outer side of the arm for the pulse. The client should be taught not to press too hard or the pulse can be obliterated and to use a watch or clock with a second hand to count the pulse. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 604.

Chapter 24: Vital Signs - Page 604

Question 15: (see full question)

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac medication. The nurse can anticipate that the digoxin will do what?

You selected:

Decrease the blood volume.

Incorrect

Correct response:

Decrease the apical pulse.

Explanation:

Some cardiac medications, such as digoxin, whose action is specific to the work of the heart, slow the heart rate while also strengthening the force of contraction to increase cardiac output. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 589.

Chapter 24: Vital Signs - Page 589

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Question 16: (see full question)

You selected:

A nurse can most accurately assess a client's heart rate and rhythm by which of the following methods?

Listen with the stethoscope at the fifth intercostals space left midclavicular line

Correct

Explanation:

To assess the apical pulse, the nurse places the stethoscope over the left ventricle. The stethoscope is placed at the level of the fifth intercostals space left mid-clavicular line. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 592.

Chapter 24: Vital Signs - Page 592

Question 17: (see full question)

You selected:

The nurse is taking a rectal temperature on a patient who reports feeling lightheaded during the procedure. What would be the nurse’s priority action in this situation?

Remove the thermometer and assess the blood pressure and heart rate.

Correct

Explanation:

Vagal nerve stimulation may occur when obtaining a rectal temperature. Vagal nerve stimulation can cause the pulse and blood pressure to drop significantly causing the patient to feel lightheaded; therefore the thermometer should be removed immediately and the pulse and blood pressure assessed. The physician can be called after assessing the patient. The temperature is not the priority at this time. Assistance for CPR would be determined if the patient’s condition worsens. (less)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 24, Vital Signs, p. 588-589

Question 18:

A pulse deficit is the difference between ...

(see full question)

You selected:

the apical pulse and the radial pulse rate

Correct

Explanation:

When a pulse deficit is present, the radial pulse is always lower than the apical pulse rate.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 591.

Chapter 24: Vital Signs - Page 591

Question 19: (see full question)

A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL and a pulse of 78 beats/minute. What number would the nurse document for this assessment?

You selected:

5,850 mL

Correct

Explanation:

Cardiac output is determined by multiplying the stroke volume by the heart rate/minute, which equals 5,850 mL. Cardiac output and peripheral resistance determine both systolic and diastolic pressures. (less)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 24, Vital Signs, p. 594

Question 20:

A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which of the following health problems should the nurse consider when client falls occur?

(see full question)

You selected:

Orthostatic hypotension

Correct

Explanation:

Orthostatic hypotension is associated with weakness or fainting when one rises to an erect position. Hypertension and dyspnea do not typically result in loss of balance and/or consciousness. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 597.

Chapter 24: Vital Signs - Page 597

Answer Key Question 1: (see full question)

You selected:

Correct

When teaching a client about factors that may increase his or her BP readings, what should the nurse include in the teaching plan?

Select all that apply.

• Circadian rhythm • Food • Age

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Explanation:

Some factors that may cause the BP to increase include age, circadian rhythm (late afternoon), food, exercise, weight (obesity), emotional state, race, and medications. Female gender before menopause and prone body position are usually associated with lower BP readings. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 596.

Chapter 24: Vital Signs - Page 596

Question 2: (see full question)

You selected:

A nurse applies a cuff of the automated blood pressure device around the client's arm in preparation for serial blood pressure recordings. The nurse checks the cuff frequently based on which rationale?

Promote speedy venous return to the heart

Incorrect

Correct response:

Ensure adequate arterial perfusion

Explanation:

When using electronic automated blood pressure devices for serial blood pressure recording, frequently checking the cuffed limb ensures adequate arterial perfusion and venous drainage between measurements. The nurse does not check the cuffed limb to see if it is warm or cold, but to ensure that there is adequate arterial perfusion and venous drainage between measurements. Elevating the arm above the head between cuff measurements automatically speeds venous return to the heart. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 599.

Chapter 24: Vital Signs - Page 599

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Question 3: (see full question)

You selected:

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which of the following observations can be made by the nurse and athletes by measuring the blood pressure?

The ability of the arteries to stretch

Correct

Explanation:

Measuring the blood pressure helps to assess the efficiency of the client's circulatory system. Blood pressure measurements reflect the ability of the arteries to stretch, the volume of circulating blood, and the amount of resistance the heart must overcome when it pumps blood. Measuring the blood pressure does not help in assessing the thickness of blood, oxygen level in the blood, or the volume of air entering the lungs. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 597.

Chapter 24: Vital Signs - Page 597

Question 4: (see full question)

What is the pulse pressure of a client whose blood pressure is 132/82 mm Hg?

You selected:

50

Correct

Explanation:

Blood pressure is measured in millimeters of mercury (mm Hg) and is recorded as a fraction. The numerator is the systolic pressure; the denominator is the diastolic pressure. The difference between the two is called the pulse pressure. (less)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 594.

Chapter 24: Vital Signs - Page 594

Question 5: (see full question)

You selected:

A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound disappears for 2 seconds. What should the nurse document on the progress record?

There is an auscultatory gap

Correct

Explanation:

An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mm Hg. A widening in the diameter of the artery takes place in the phase II of the Korotkoff sound technique. An adult diastolic pressure takes place in the phase IV of the Korotkoff sound technique. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 601.

Chapter 24: Vital Signs - Page 601

Question 6: (see full question)

You selected:

The nurse is assessing a patient’s brachial artery blood pressure.

Which nursing actions are performed correctly? (Select all that apply.)

• The nurse notes the point on the gauge at which the first faint but clear sound appears • The nurse centers the bladder of the cuff over the brachial artery about midway on the arm.

• The nurse has the patient lying or sitting down with the forearm supported at the level of the heart and the palm of the hand

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers upward.

Incorrect

Correct response:

• The nurse centers the bladder of the cuff over the brachial artery about midway on the arm.

• and increases in intensity as the diastolic pressure.

• The nurse has the patient lying or sitting down with the forearm supported at the level of the heart and the palm of the hand upward.

• The nurse wraps the cuff around the arm smoothly and snugly and fastens it

Explanation:

Pressure in the cuff applied directly to the artery provides the most accurate readings. BP measured with the arm below the level of the right atrium of the heart may produce a falsely high reading; if below the level of the heart the readings may be falsely too low. A smooth cuff and snug wrapping produce equal pressure and help promote an accurate measurement. A cuff wrapped too loosely results in an inaccurate reading. Placing the cuff over the patient’s clothing prevents hearing the blood pressure accurately. The first faint but clear sound is the systolic pressure. False readings are likely to occur if there is congestion of blood in the limb while obtaining repeated readings that are less than 1 minute apart. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 24, Vital Signs, p. 616-619

Question 7:

A nurse is assessing the respirations of a 60-year-old female patient and finds that the patient is breathing so shallowly that the respirations cannot be counted. What would be the appropriate initial nursing intervention in this situation?

(see full question)

You selected:

Correct

Auscultate the lung sounds and count respirations.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Explanation:

If the respirations are too shallow to count it is easier to count respirations by auscultating the lung sounds. The nurse should auscultate lung sounds and count respirations for 30 seconds, then multiply by 2 to calculate the respiratory rate per minute. If the respiratory rate is irregular, the nurse should count for a full minute.

The nurse notifies the physician of the respiratory rate and the shallowness of the respirations following assessment. Pain typically causes vital signs to elevate. The nurse cannot administer oxygen without a physician’s order. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 24, Vital Signs, p. 615

Question 8: (see full question)

You are preparing to assess a patient's oral temperature. You should plan to place the thermometer probe in which of the following areas of the patient's mouth?

You selected:

Deep in the posterior sublingual pocket

Correct

Explanation:

When the probe rests deep in the posterior sublingual pocket, it is in contact with blood vessels lying close to the surface. None of the other areas provide as much contact with blood vessels. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 611.

Chapter 24: Vital Signs - Page 611

Question 9:

The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant’s pulse is very

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers (see full question)

high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant’s pulse rate?

You selected:

The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant’s apical pulse.

Correct

Explanation:

If a peripheral pulse is difficult to assess accurately because it is irregular, weak, or very rapid, the apical rate should be assessed using a stethoscope. An apical pulse is also assessed when giving medications that alter heart rate and rhythm. Apical pulse measurement is also the preferred method of pulse assessment for infants and children younger than 2 years of age. Families can be taught to use a stethoscope to check a pulse. This infant does not need a cardiac monitor, the parents should not be encouraged to get a neighbor or family friend to help, and these parents can be taught to check this infant’s pulse accurately. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 590.

Chapter 24: Vital Signs - Page 590

Question 10: (see full question)

You selected:

The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as which of the following?

Orthopnea

Correct

Explanation:

Dyspneic people can often breathe more easily in an upright position, a condition known as orthopnea, because sitting or standing allows gravity to lower organs from the abdominal cavity away from the diaphragm. Bradypnea is a decrease in respiratory rate. Tachypnea is an increased respiratory rate. Apnea refers to

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers periods during which there is no breathing. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 594.

Chapter 24: Vital Signs - Page 594

CHAPTER 23 FUNDAMENTALS: ACTIVITY

articulation, joint The terms and

refer to where the bone meet.

?? skeletal The framework of bones, the joints between them, and cartilage that protects our organs and allows us to move is called the system.

?? skeletal Functions of the system include: supporting the soft tissue of the body maintaining body form and posture; protecting crucial components of the body such as the brain, lungs, heart, and spinal cord; furnishing surfaces for the attachment of muscles, tendons, and ligaments, which pull on the individual bones to produce movement; providing storage for minerals like calcium and fat; and producing blood cells through hemopoiesis.

?? long bones are found in the upper and lower extremities and contribute to height and length. Ex: femur, humerus.

?? short bones are located in the wrist and ankle and contribute to movement.

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers flat bones are relatively thin and contribute to shape (structural contour). Ex: ribs and several skull bones.

?? irregular bones are all those bones not included in the long, short, or flat classifications. Ex: bones of the spinal column and jaw.

?? diarthrosis , or synovial joints, joints in which there is a a potential space between the articulating bones, are freely moving joints.

?? ball and socket joints are freely movable joints where the rounded head of one bone fits into a cup-like cavity in the other; flexion-extensionabduction-adduction, and rotation can occur. Ex: shoulder and hip joints.

?? condyloid joints are freely movable joints where the oval head of one bone fits into a shallow cavity of another bone; flexion-extension and abduction-adduction can occur. Ex: wrist joint.

?? gliding joints are freely movable joints where articular surfaces are flat; flexion-extension and abduction-adduction can occur. Ex: carpal bones of wrist and tarsal bones of feet.

?? hinge joints are freely movable joints where a spool-like surface of one bone fits into a concave surface of another bone; only flexion-extension can occur. Ex: elbow, knee, ankle joints.

?? pivot joints are freely movable joints where a ringlike structure turns on a pivot; movement is limited to rotation, for example, turning a door knob. Ex: joints between the atlas and axis and between the proximal ends of the radius and the ulna.

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers saddle joints are freely movable joints where bone surfaces are convex on one side and concave on the other; movements are side to side and back and forth. Ex: joint between the trapezium and metacarpal of the the thumb.

?? diarthrodal Movements possible at rotation.

joints include abduction, adduction, flexion, extension, and

?? fibrous joints are immovable (synarthrosis) joints where there is no joint cavity; connective tissue between the bones. Ex: sutures between the bones of the skull.

?? cartilaginous joints are slightly movable (amphiarthrosis) joints where there is no joint cavity; cartilage between the bones. Ex: pubic symphysis, joints between the bodies of vertebrae.

?? synovial joints are freely movable (diarthrosis) joints where there is a joint cavity containing fluid. Ex: gliding, hinge, pivot, condyloid, saddle, ball and socket joints.

?? ligaments are tough fibrous bands of connective tissue that bind joints together and connect bones and cartilage.

?? tendons are strong, flexible, inelastic fibrous bands and flattened sheets of connective tissue that attach muscle to bone.

?? cartilage is hard, non-vascular connective tissue found in the joints as well as in the nose, ear, thorax, trachea, and larynx. It functions as a shock absorber and as a bearing surface that reduces friction between the moving parts of the joint.

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers skeletal muscle works with tendons and bones to move the body.

?? cardiac muscle forms the bulk of the heart and produces the regular contractions that create the heartbeat.

?? smooth (visceral) muscle forms the walls of the hollow organs, such as the stomach and intestines, and is in the walls of blood vessels and other hollow tubes, such as ureters, that connect internal organs.

?? afferent The nervous systems conveys information from receptors in the periphery of the body to the CNS. Ex: light pressure on the nose.

?? efferent The system conveys the response form the CNS to skeletal muscles by way of the somatic nervous system. Ex: muscle in the arm, wrist and hand contract, and the fingers brush a fly from the face.

?? labyrinthine sense is the sense of position and movement is provided by the sensory organ in the inner ear, which are stimulated by body movement (changes in head position) and transmit these impulses to the cerebellum.

?? proprioceptor (kinesthetic) sense informs the brain of the location of a limb or body part as a result of joint movement stimulating special nerve endings in muscles, tendons, and fascia.

?? visual (optic) reflexes impressions contribute to posture by alerting the person to spatial relationship with the environment (nearness of ceilings, walls, furniture, condition of the floor, etc.)

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers extensor (stretch) reflexes; when they are stretched beyond a certain point (when knees buckle under), their stimulation causes a reflex contraction that aids a person to re-establish erect posture (straighten the knee).

?? patient care ergonomics is the practice of designing equipment and work tasks to conform to the capability of the worker in relation to patient care.

?? orthopedics refers to the correction or prevention of disorders of body structure used in locomotion.

?? tonus A patient on complete bed rest is in danger of losing muscle slight contraction.

, which is used the state of

?? contractures If bed rest is prolonged there is danger of developing which is permanent contraction of a muscle if the patient does not have exercise and joint motion and if good posture is not maintained.

?? negative Disease characterized by a larger breakdown of protein than that which is manufactured leads to nitrogen balance (anorexia nervosa and certain cancers) that results in muscle wasting and decreased physical energy for movement and work.

?? b A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food.

How should the nurse best position the client? a) Semi-Fowler's b) Fowler's c) Low-Fowler's d) Protective supine

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers a The nurse is helping a client walk in the hallway when the client suddenly reaches for the handrail and states, "I feel so weak. I think I am going to pass out." Which of the following initial actions by the nurse is appropriate? a) Support the client's body against yours and gently slide the client onto the floor. b) Firmly grasp the client's gait belt. c) Apply oxygen and wait several minutes for the weakness to pass. d) Ask the client to lean against the wall while you obtain a wheelchair. e) Ask the patient, "When was the last time you ate?"

?? d A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client? a) The client's age b) The client's cognitive status c) The client's body weight d) The client's ability to assist

?? b The nurse adjusts a client's bed to a comfortable working height in order to turn a patient. What would be the nurse's next action? a) Push the client to the edge of the bed to which the client will be turning. b) Move the client to edge of the bed opposite the side that client will be turning. c) Pull the client to the edge of the bed to which the patient will be turning. d) Push the client to the opposite side of the bed.

?? a A patient is preparing to mobilize for the first time following the surgical removal of a bunion on her left foot. How should the nurse instruct the patient to ambulate with her crutches? a) "Try to avoid putting too much pressure on your armpits with the tops of the crutches." b) "Keep your crutches as close as possible to your feet when you're walking." c) "When you rise from a chair, use your left foot to stabilize yourself." d) "Keep your elbows well away from your sides in order to keep yourself as stable as possible."

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers c A client 86 years of age with a diagnosis of late-stage Alzheimer's disease requires full assistance with transfers to and from his bed. Which of the following nursing actions is most likely to promote safe handling of this client? a) Post written instructions at the client's bedside to supplement spoken instructions. b) Ask for the client's feedback frequently during transfers. c) Provide to the client brief, clear instructions that are phrased positively. d) Ask for the client's input on the timing and technique for transfers.

?? c A nurse teaches a student nurse the importance of ambulating patients to prevent the effects of immobility on body systems. Which of the following is one of these effects? a) Decreased cardiac workload b) Increased appetite c) Impaired circulation d) Increased muscle mass

?? b, c, f Select all answer choices that apply.

A nurse is teaching an elderly patient how to use a walker. Which of the following instructions ensures accurate use of this device? Select all that apply. a) Move the walker forward 12 to 18 inches and set it down. b) Line up the top of the walker with the crease on the inside of your wrist. c) Keep arms relaxed at the side. d) Step forward with your right foot supporting weight on your legs. e) Place your hands on the grips and flex your elbows about 10 degrees. f) Stand between the back legs of the walker.

?? c A nurse is preparing to turn a hospitalized client age 65 years. Which of the following is a recommended guideline for performing this skill? a) Use back muscles to pull the client to the side. b) Position a nurse at the top and bottom of the bed. c) Position a friction-reducing sheet under the client. d) Place the bed in its lowest position.

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers isotonic exercise involves muscle shortening and active movement. Ex: ADL, swimming, walking, jogging, biking.

?? isometric exercise involves muscle contraction without shortening. Ex: contraction of the quads and gluteal muscles.

?? isokinetic exercise involves muscle contraction with resistance. The resistance is provided at a constant rate by an external device, which has a capacity for variable resistance. Ex: rehabilitation for knee and elbow injuries and lifting weights; weight training.

?? d While performing passive range-of-motion exercises on the lower extremities of a patient with a spinal cord injury, the nurse assesses permanent flexion of the muscles. What term will the nurse use to document this finding related to the muscles? a) Ankylosis b) Tonus c) Atrophy d) Contractures

?? ankylosis is a consolidation and immobilization of a joint.

?? b The nurse is preparing to move a patient using a powered full-body sling lift. Which of the following is a recommended action in this procedure? a) Place the sling evenly on top of the patient. b) Lower the side rail on the side of the bed being worked on. c) Roll the patient to the middle of the bed. d) Lower the side rail on the opposite side of the bed being worked on.

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers b The nurse is preparing a client to be turned in bed. In what position would the nurse place the client to begin this procedure? a) Lying prone b) Lying flat c) Lying flat with feet raised slightly d) Sitting up

?? c After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client to sit up on the side of the bed? a) To the dominant side of the client, with legs together and one foot near the head of the bed b) Near the client's hip, with legs together c) Near the client's hip, with legs shoulder-width apart and one foot near the head of the bed d) To the nondominant side of the client, with legs together and one foot near the head of the bed.

?? d During a physical examination, the patient reports that he is a marathon runner when the nurse inquires about the patient's level of physical activity. The nurse identifies running as which type of exercise? a) Passive exercise b) Isometric exercise c) Isokinetic exercise d) Isotonic exercise

?? c Which of the following is an accurate step to prevent or minimize damage from this fall? a) The nurse should grasp the gait belt and pull the client's body backward away from his or her body. b) The nurse should place his or her feet close together with one foot in front of the other. c) The nurse should gently slide the client down his or her body to the floor. d) The nurse should rock his or her pelvis out on the opposite side of the client.

?? paresis Impaired muscle strength or weakness is termed

.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

?? paralysis The absence of strength secondary to nervous impairment is called

.

?? b When an older adult client walks with her knees slightly flexed and body leaning, the nurse determines that the client ... a) requires a better walking shoe b) is demonstrating a common gait for the older adult c) should have an orthopedic consultation d) requires crutches for mobility

?? a When a patient independently moves all of the joints through their normal motions, it is referred to as active range of motion (AROM). a) True b) False

?? tremors are rhythmic, repetitive movements that can occur at rest or when movement is initiated. They usually interferes with fine motor control, but in Parkinson's disease it also can interfere with coordinated ambulation.

?? b A home care nurse visits a client with Parkinson's disease. The nurse observes that the client has rhythmic, repetitive movements of the hands. The home care nurse documents this as which of the following? a) Dystonia b) Tremor c) Ataxia d) Athetosis

?? c A client who is immobile complains of severe pain in the right flank. The physician diagnoses the client with renal calculi. This condition often results from

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers a) Increased serum phosphorous b) Decreased serum phosphorous c) Increased serum calcium d) Decreased serum calcium

?? calculi Urinary stasis and an increased serum calcium level promote the formation of renal

.

?? d When the client restricts use of her dominant arm because of pain and the nurse notes that the measurement of the circumference of the client's nondominant arm is greater than her dominant arm, the nurse determines that the lack of use has resulted in the dominant arm's a) Dystrophy b) Hypertrophy c) Malrotation d) Atrophy

?? b A nurse is teaching a patient how to walk with a cane. Which of the following is an accurate guideline for using this device? a) The patient should hold the cane in the hand on the same side as the leg with the most severe deficit. b) When taking a step forward, the heel of the foot should be slightly beyond the tip of the cane. c) The patient should stand with as much weight as possible placed on the feet, using the cane for balance. d) When taking a step, the patient should advance the stronger leg forward ahead of the cane and follow with the weaker leg.

?? d The cardiac response to exercise is well-researched and documented. Which of the following is a cardiovascular response to regular exercise? a) Decreased circulation of fibrinolysin b) Increased heart rate and blood pressure c) Decreased blood flow to all body parts d) Increased efficiency of the heart

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

?? exercise Regular produces cardiovascular responses such as an increased efficiency of the heart, decreased heart rate and blood pressure, increased blood flow to all body parts, and increased circulation of fibrinolysin.

?? d Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight? a) Shift their weight back and forth from the legs to the back muscles. b) Rock the client back and forth to raise the client up in bed. c) Turn the client from side to side while pushing upward. d) Shift their weight back and forth, from back leg to front leg.

?? a When turning a patient in bed, what positioning instructions would the nurse give the patient before using the friction-reducing sheet to turn the patient? a) Cross the arms across the chest and cross the legs. b) Cross the arms across the chest and keep the legs straight. c) Keep the arms at the sides and the legs crossed. d) Keep the arms folded loosely at the abdomen and the legs straight.

?? a When assisting a client from the bed into a wheelchair, the nurse assesses the client standing up and notices the client is weak and unsteady. What would be the recommended nursing intervention in this situation? a) Return the client to the bed. b) Place the client into the wheelchair. c) Use the call bell to summon the assistance of another nurse. d) Allow the client to keep standing for several minutes until balance returns.

?? b A group of nursing students are reviewing the aspects of motor function control by the nervous system. The students demonstrate understanding of this information when they identify which of the following as a function of the cerebellum?

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers a) Transmissing of impulses to the spinal cord b) Coordination of movement motor activities c) Inhibition with dampening of impulses d) Initiation of voluntary motor activity

?? cerebellum The coordinates motor activities of movement.

?? cerebral cortex The initiates voluntary motor activity.

?? pyramidal, extrapyramidal The tract transmits impulses to the spinal cord. The dampens impulses.

tract inhibits and

?? c A client who is postoperative from a hip fracture repair should be turned on the a) Affected side b) Back c) Unaffected side d) Stomach

?? d An orthopedic client is instructed to tighten the gluteus muscles and relax. This is an example of an a) Anaerobic exercise b) Isotonic exercise c) Aerobic exercise d) Isometric exercise

?? isometric exercise is static exercise by which the client tenses a muscle, holding it stationary while maintaining tension.

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers b Once applied, antiembolism stockings should not be removed until the primary care provider writes an order to discontinue them. a) True b) False

?? c The nurse is teaching a patient how to perform range-of-motion exercises on the toes. What motions would be accomplished by curling the toes downward, spreading the toes apart, and then bringing them together? a) Rotation, extension, abduction, and adduction b) Rotation, dorsiflexion, and plantar flexion c) Flexion, extension, abduction, and adduction d) Flexion, inversion, and eversion

?? a For which one of the following patients would a pneumatic compression device (PCD) be indicated? a) A postoperative patient with a knee replacement who has a history of cancer b) A postoperative patient suspected of having deep vein thrombosis (DVT) c) A postoperative patient with arterial occlusive disease d) A patient with severe edema following a hip replacement

??

PCD (pneumatic compression device) 's are contraindicated in patients with suspected or existing DVT. They should not be used for patients with arterial occlusive disease, severe edema, cellulitis, phlebitis, a skin graft, or an infection of the extremity.

?? d The nurse has asked the client to grasp his overbed trapeze and pull his torso up off the surface of the bed. What movement will the client perform with his arms? a) Adduction b) Abduction c) Dorsiflexion d) Flexion

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

?? flexion is achieved when a body part is bent, as when the elbow is bent and the upper arm and forearm are brought together.

?? adduction, abduction and denote lateral movement to and from the body, and dorsiflexion is backward bending of the hand or foot.

?? c A client is discharged to his daughter's home. He weighs 250 pounds and is immobile. The nurse should instruct the daughter on the use of a a) Three-person lift b) Transfer with a gait belt c) Hydraulic lift d) Stand-up assist lift

?? d When transferring a client from bed to a stretcher, the nurses working together turn the client to position a transfer board partially underneath the patient. What is the rationale for using a transfer board in this procedure? a) To protect the client's head from hitting the headboard. b) To lift the client off the bed. c) To slide the board with the client onto the stretcher. d) To reduce friction as the client is pulled laterally onto the stretcher.

?? a A nurse uses proper body mechanics to move a client up in bed. Which of the following is a guideline for using these techniques properly? a) Face the direction of movement. b) Twist body at the waist when lifting. c) Keep feet together to provide a base of support. d) Keep body weight higher than center of gravity.

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers b The physician's admitting orders indicate that the client is to be placed in a Fowler's position.

Upon positioning this client, how much will the nurse elevate the head of the bed? a) 90 degrees b) 45 to 60 degrees c) 30 degrees d) 15 to 20 degrees

?? d While receiving a report, the nurse learns that a client has paraplegia. The nurse will plan care for this client based upon the understanding that the client has which of the following? a) Paralysis affecting one-half of the body b) Weakness affecting one-half of the body c) Paralysis of the legs and arms d) Paralysis of the legs

?? b When teaching range-of-motion exercises to a caregiver, a nurse moves the arm of the patient laterally to an upright position above the head, and then returns it to the original position. What term is used to describe this body movement? a) Extension b) Abduction c) Flexion d) Rotation

?? c What motion is being provided for the shoulder when the nurse raises a patient's arm at the side until the upper arm is in line with the shoulder, bends the elbow at a 90-degree angle, moves the forearm upward and downward, and returns the arm to the side? a) Abduction b) Adduction c) Rotation d) Flexion

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers a A nurse is teaching a patient how to walk with a cane. Which of the following is an accurate guideline for using this device? a) When taking a step forward, the heel of the foot should be slightly beyond the tip of the cane. b) When taking a step, the patient should advance the stronger leg forward ahead of the cane and follow with the weaker leg. c) The patient should hold the cane in the hand on the same side as the leg with the most severe deficit. d) The patient should stand with as much weight as possible placed on the feet, using the cane for balance.

?? d Which of the following would the nurse expect to assess when a patient experiences a greater breakdown of protein than that which is manufactured? a.Fluid volume excess b. A contracture c. Osteoporosis d. Negative nitrogen balance

?? b When a patient is using a cane for maximal support, the nurse is aware that the patient should do which of the following? a. Hold the cane on the weaker side b. Distribute weight evenly between the feet and the cane c. Keep the elbow that is holding the cane straight and stiff d. Advance the weaker foot ahead of the cane

?? a The nurse is turning a patient in bed. Where would the nurse stand when using the frictionreducing sheet to turn the patient to the opposite side of the bed? a) Opposite the patient's center. b) At the patient's center.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers c) At the patient's head. d) At the patient's feet.

?? d Which of the following clients would be an appropriate candidate to move by using a powered stand-assist device? a) A comatose client who is being taken for x-rays b) A car accident victim with fractures in both legs who is being moved to another room c) An obese client who has Alzheimer's disease and is being escorted to the shower room d) An alert client after knee replacement surgery who is being assisted to ambulate

?? b The nurse recognizes the value of passive range-of-motion exercises in the care of patients who have been confined to bed for extended periods. The nurse should use particular caution if performing these exercises with which patients? a) Elderly patients b) Nonresponsive patients c) Obese patients d) Acutely ill patients

?? c, e, f Select all answer choices that apply.

Which of the following are effects of immobility on the body? Select all that apply. a) Cerumen buildup b) Decreased anal tone and sensation c) Impaired circulation and skin breakdown d) Diminished saliva production e) Urinary stasis, infection f) Decreased muscle strength

?? b The nurse is helping a patient with musculoskeletal alterations to perform range-of-motion exercises. In what order would the nurse perform the exercises for the patient? a) From the feet, to the arms, to the head. b) From the head and down one side of the body at a time.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers c) From the head, to the arms, to the legs. d) From the arms, to the head, to the legs.

Answer Key Question 1: (see full question)

You selected:

The nursing assistant is preparing to help the client make a lateral transfer from the bed to a stretcher. The client informs the nurse that he is able to move onto the stretcher without her help. What is the nurse's best response?

"You cannot transfer without my help because you need a frictionreducing device to prevent harm to your skin."

Incorrect

Correct response:

"You are free to move onto the stretcher without assistance, but I will supervise for your safety."

Explanation:

If the client is fully able to assist in the transfer, the nurse should allow the client to complete the movement independently, with supervision for safety.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp.

1071-1072.

Chapter 32: Activity - Page 1071

Question 2: (see full question)

You selected:

After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client to sit up on the side of the bed?

Near the client's hip, with legs shoulder-width apart and one foot near the head of the bed

Correct

Explanation:

When assisting the client from the bed into a wheelchair, the nurse would take position near the client's hip, with legs shoulder-width

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers apart and one foot near the head of the bed. This ensures that the nurse's center of gravity is placed near the client's greatest weight, to assist the client to a sitting position safely. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp.

1102-1105.

Chapter 32: Activity - Page 1102

Question 3: (see full question)

You selected:

During range-of-motion exercises, the nurse turns the sole of a patient's foot toward the midline and then turns the sole of the foot outward. Which type of movement is this nurse promoting by these actions?

Internal and external rotation of the ankle

Incorrect

Correct response:

Inversion and eversion of the ankle

Explanation:

Inversion and eversion are movements of the ankle. Inversion is the movement of the sole of the foot inward. Eversion is the movement of the sole of the foot outward. Internal rotation is the turning of a body part on its axis toward the midline of the body. External rotation is the turning of a body part on its axis away from the midline of the body. Dorsiflexion is the backward bending of the hand or foot. Plantar flexion is flexion of the foot. Flexion is the state of being bent. Extension is the state of being in a straight line. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1041.

Chapter 32: Activity - Page 1041

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Question 4: (see full question)

When working with a client who has a fractured wrist, the nurse applies what knowledge about the bones in the body?

You selected:

The wrist is classified as an irregular bone.

Incorrect

Correct response:

Short bones contribute to movement.

Explanation:

Short bones contribute to movement and are located in the wrist and ankle. The wrist is classified as a short bone. Long bones, such as the femur and humerus, are located in the upper and lower extremities and contribute to height and length. The flat bones are relatively thin and contribute to shape. The flat bones are found in the ribs and several of the skull bones and contribute to shape (structural contour). (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1038.

Chapter 32: Activity - Page 1038

Question 5: (see full question)

The nurse is assisting an elderly client with dementia to get dressed after morning care. Which statement would be most beneficial to the patient?

You selected:

“Put your arm in this sleeve.”

Correct

Explanation:

When communicating with client’s with dementia, instructions should be given in clear, short sentences that offer simple, step-bystep instructions. “Put your arm in this sleeve” gives one step in the process of getting dressed. “Put on your shirt” involves many steps and should be broken down into the steps of putting on a shirt.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Similarly, “Put your pants on and zip the zipper,” should be broken down into steps and given in clear, short sentences. Further, putting on pants and zipping a zipper involves many steps and may be too complicated for the client with dementia to follow. Instructions should be phrased positively as the client may not register the “Don’t” and may put the shoes on, if the nurse states “Don’t put on your shoes yet.” (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1061.

Chapter 32: Activity - Page 1061

Question 6: (see full question)

When an older adult client walks with her knees slightly flexed and body leaning, the nurse determines that the client ...

You selected:

is demonstrating a common gait for the older adult

Correct

Explanation:

Many older people have more difficulty overcoming inertia and using gravity efficiently. One contributing factor is the shift in the center of gravity. To compensate for this shift, the knees flex slightly for support. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1045.

Chapter 32: Activity - Page 1045

Question 7: (see full question)

A nurse is teaching a patient how to walk with crutches. Which teaching points are recommended guidelines for this activity?

(Select all that apply.)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers You selected:

• Keep elbows close to sides.

• Prevent crutches from getting closer than 3 inches to the feet.

• Use the swing-to gait for patients who may bear weight on one foot.

Incorrect

Correct response:

• Keep elbows close to sides.

• Prevent crutches from getting closer than 3 inches to the feet.

• Use the four-point gait for patients who may bear weight on both feet.

Explanation:

The client should keep the elbows close to their sides. The crutches should not be any closer than 12 inches from the feet. The client should use the four-point gait if they can bear weight on both feet.

When climbing stairs, the client should advance the unaffected leg past the crutches, then place weight on the unaffected leg. Then the client should advance the affected leg and then the crutches to the step. The swing-to gait is for individuals who can bear weight on both feet. This technique cannot be used with individuals who can bear weight on only one foot. The two-point gait is used with individuals who can bear weight on both feet. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1079.

Chapter 32: Activity - Page 1079

Question 8: (see full question)

One of the most common injuries/risks associated with exercise in a healthy person is:

You selected:

muscle injury.

Correct

Explanation:

Orthopedic problems caused by irritation of bones, tendons, ligaments, and sometimes muscles are the most common injuries associated with exercise. With exercise, healthy individuals benefit

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers from improved respiratory functioning, including improved alveolar ventilation, decreased work of breathing and improved diaphragmatic excursion. Major cardiac events in a healthy person is minimal, although the risk is much higher for those with known or suspected cardiovascular disease. The rhythmic contraction and relaxation of muscle groups during exercise results in increased muscle mass, tone, strength, and increased joint mobility. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1051.

Chapter 32: Activity - Page 1051

Question 9: (see full question)

The nurse is assisting a patient from the bed into a wheelchair.

Which of the following is a recommended guideline for this procedure?

You selected:

Raise the head of the bed to a sitting position.

Correct

Explanation:

When assisting a client from the bed into a wheelchair, the nurse would place the bed in the lowest position and raise the head of the bed to a sitting position. The nurse would make sure the bed brakes are locked and put the wheelchair next to the bed, locking the brakes of the chair. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp.

1102-1105.

Chapter 32: Activity - Page 1102

Question 10:

The nurse is assisting a client with limited mobility to turn in bed.

After successfully turning the client to the side, where would the

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers (see full question)

nurse place an additional pillow?

You selected:

Supporting the client's back.

Correct

Explanation:

The nurse would place the pillow under the client's back to provide support and help maintain the proper position. More than one pillow under the client’s head is not necessary.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp.

1095-1098.

Chapter 32: Activity - Page 1095

Question 11: (see full question)

The nurse is preparing a client to be turned in bed. In what position would the nurse place the client to begin this procedure?

You selected:

Lying flat

Correct

Explanation:

The nurse would position the bed so that the client is lying flat on his/her back and then raise the bed to a comfortable working height. This facilitates moving the client to the side in order to perform the turn in bed. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1071.

Chapter 32: Activity - Page 1071

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Question 12: (see full question)

Logrolling requires the nurse to use supportive devices in turning the client, in order to ...

You selected:

maintain the natural alignment of the body

Correct

Explanation:

Logrolling is a technique used for turning clients who have had surgery or an injury involving the back or spine.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1073.

Chapter 32: Activity - Page 1073

Question 13: (see full question)

The client is ambulating in the room and walks around a bedside table. What is the best explanation for why the client does not bump into the table?

You selected:

The client is aware of spatial relationships to avoid the table.

Correct

Explanation:

The client has awareness of spatial relationships (where objects are located in space). This ability comes from the visual or optic reflexes. The labyrinthine sense relates to the sensory organs in the inner ear and provides a sense of position, orientation, and movement. It does not contribute to where objects are in space.

When the extensor muscles are stretched beyond a certain point, their stimulation causes a reflex contraction that aids a person to reestablish erect posture, such as when the knee buckles under, the reflex contraction aids the person to straighten the knee. This does not contribute to perception of where objects are in space. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1043.

Chapter 32: Activity - Page 1043

Question 14: (see full question)

You selected:

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling.

What statement is correct regarding logrolling?

Use a drawsheet or a friction-reducing sheet to facilitate smooth movement.

Correct

Explanation:

Logrolling requires the assistance of two or three nurses. Logrolling will maintain straight alignment when the client is being turned. The nurse should avoid twisting the client's head, spine, shoulders, knees, or hips while logrolling. The nurse should use a drawsheet or a friction-reducing sheet to facilitate smooth movement. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp.

1072-1073.

Chapter 32: Activity - Page 1072

Question 15: (see full question)

You selected:

Correct

A nurse performing range of motion exercises on a bed-fast patient moves the patient’s chin down onto the chest and then back to an upright position. The nurse then tilts the head as far as possible to each shoulder. What therapeutic movement is the nurse achieving with this exercise?

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Explanation:

When a client has a spinal injury or is recovering from neck, back, or spinal surgery, it is often necessary to keep the body in straight alignment when turning the client. Two or three nurses can accomplish this safely by logrolling a patient. Do not try to logroll the client without enough help. Do not twist the client’s head, spine, shoulders, knees, or hips while logrolling. A friction-reducing sheet is used for other transfers, but not with the logrolling technique. The nurse would have a client cross their arms on their chest with other transfers, but not with the logrolling technique. A nurse should be on both sides of the bed of a client who is being logrolled, not just on the side that the client is being turned. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1072.

Chapter 32: Activity - Page 1072

Question 16: (see full question)

You selected:

A nurse performing range-of-motion exercises on a bedfast patient moves the patient's chin down onto the chest and then back to an upright position. The nurse then tilts the head as far as possible to each shoulder. What therapeutic movement is the nurse achieving with this exercise? Select all that apply.

“You have lost the padding in your joints and the friction causes pain.”

Correct

Explanation:

Osteoarthritis is a common disorder as people age. It is a noninflammatory, progressive disorder of movable joints particularly weight-bearing joints, characterized by the deterioration of articular cartilage and pain with motion. Cartilage acts as a shock absorber and provides a smooth surface that reduces friction between the moving parts of the joint. If the client experienced a fall and subsequent hip fracture, mobility would be more impaired. The client would have difficulty walking. Also, this does not address the client’s question of why pain accompanies osteoarthritis. Although it

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers is true that osteoarthritis is painful and common as people age, this response does not answer the client’s question of why there is pain.

Further, although it is also true that loss of muscle tone is common as people age, it may cause weakness, but not cause pain with walking. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1045.

Chapter 32: Activity - Page 1045

Question 17: (see full question)

Which type of mobility aids would be most appropriate for a client who has poor balance?

You selected:

A single-ended cane with a straight handle

Incorrect

Correct response:

A cane with four prongs on the end (quad cane)

Explanation:

Canes with three (tripod) or four prongs (quad cane) or legs to provide a wide base of support are recommended for clients with poor balance. Single-ended canes with half-circle handles are recommended for clients requiring minimal support and those who will be using stairs frequently. Single-ended canes with straight handles are recommended for clients with hand weakness because the handgrip is easier to hold, but are not recommended for clients with poor balance. Axillary crutches are used to provide support for patients who have temporary restrictions on ambulation. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015,Chapter 32: Activity, p. 1078.

Chapter 32: Activity - Page 1078

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Question 18: (see full question)

The nurse is assessing a patient who is bedridden. For which condition would the nurse consider this patient to be at risk?

You selected:

Predisposition to renal calculi

Correct

Explanation:

In a bedridden client, the kidneys and ureters are level, and urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder. Urinary stasis favors the growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increase the risk for urinary tract infection in an immobile patient. Immobility also predisposes the patient to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone; the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume. The client would be at risk for decreased movement of secretion in the respiratory tract, due to lack of lung expansion. The client would suffer from decreased metabolic rate due to being bedridden. The client would not have an increase in circulating fibrinolysin. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1053.

Chapter 32: Activity - Page 1053

(see full question)

The nurse would like to elevate the client’s arms to promote ventilation in a client with chronic obstructive pulmonary disease.

What intervention should the nurse implement?

You selected:

Instruct the client to place arms on the side rails.????????

Question 19:

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Correct

Explanation:

A small pillow may be used to elevate the extremities, shoulders, or incisional wounds. Instructing the client to place the arms on the side rails will place pressure on the arms and affect circulation to the extremity. Elevating the head of the bed (fowler’s) will not elevate the arms. Trochanter rolls are used to support the hips and legs so that the femurs do not rotate outward. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 8: The Healthcare Delivery System, p. 60

Question 20: (see full question)

When assessing the physical activity of clients, the nurse would be most concerned about which client?

You selected:

The middle aged computer programmer

Correct

Explanation:

Although further assessments should be done to avoid assumptions and stereotypes, there are many variables that may contribute to a sedentary lifestyle, such as occupations. A computer programmer has a job that is inactive. The nurse would be concerned about this client and would need to do further assessments to determine activity, frequency, and intensity that occur outside of work. The mother of small children would be involved in housecleaning and chasing after the 2- and 4-year old.

Walking is a commonly prescribed exercise and going to the mall provides a safe environment where walking would be available. A Native American who hunts is engaging in culturally related physical activity. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1054.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Chapter 32: Activity - Page 1054

Chapter 23: Activity

A group of nursing students are reviewing the aspects of motor function control by the nervous system. The students demonstrate understanding of this information when they identify which of the following as a function of the cerebellum? a) Coordination of movement motor activities b) Initiation of voluntary motor activity c) Transmissing of impulses to the spinal cord d) Inhibition with dampening of impulses Answer: Coordination of movement motor activities Explanation: The cerebellum coordinates motor activities of movement. The cerebral cortex initiates voluntary motor activity. The pyramidal tract transmits impulses to the spinal cord.

The extrapyramidal tract inhibits and dampens impulses.

??

A nurse recommends a regular exercise program for a patient who has difficulty sleeping. The patient asks how this will help. How would the nurse respond? a) "Exercise can help you control your weight." b) "The fresh air will stimulate your metabolism." c) "Take my word for it. It sure helped me." d) "Improved sleep is one benefit of regular exercise."

Answer: "Improved sleep is one benefit of regular exercise."

Explanation: Some of the most important benefits of regular exercise are psychological.

Improved sleep is a benefit of regular exercise.

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Which of the following postural deformities might be assessed in a teenager? a) rickets b) scoliosis c) osteoporosis d) kyphosis Answer: scoliosis Explanation: Scoliosis, a lateral curvature of the spine, would most likely be assessed in a teenager. Kyphosis and osteoporosis are seen in older adults. Rickets is seen in children.

??

A college student fell and sprained his right ankle. The student health physician recommends the student use crutches to facilitate healing. Which of the following would the nurse teach the student? a) The crutches should be as long as the student is tall. b) Walk fast and use long steps when using the crutches. c) The support of the body should be in the axilla. d) The support of the body should be the hands and arms.

Answer: The support of the body should be the hands and arms.

Explanation: Teach the patient that the support of body weight should come primarily on the hands and arms when using the crutches, not in the axillary area, where pressure may damage nerves and cut off circulation.

??

A nurse is following a plan of care for passive range-of-motion (ROM) exercises. What specifics will be included on the plan? a) Request family be available twice a day to perform ROM. b) Do ROM exercises two times a day, each exercise two to five times. c) Move each joint until the patient complains of pain. d) Ask the patient to demonstrate ROM at 9 a.m. each day.

Answer: Do ROM exercises two times a day, each exercise two to five times.

Explanation: Do not move joints to the point of pain. Passive ROM exercises should be done twice a day, with each exercise carried out two to five times.

??

An 80-year-old patient experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the patient?

Answer: High-Fowler's Explanation: A high-Fowler's position optimizes cardiac function and respiratory function in addition to being the best position for eating. The patient's risk of aspiration would be extreme

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers in a supine position. Low-Fowler's and semi-Fowler's are synonymous, and this position does not aid swallowing as much as a high-Fowler's position.

??

A nurse is ambulating a patient who has had a stroke. The patient has paresis on the right side of the upper body. Where would the nurse stand to walk the patient?

Answer: on the weak side

??

A nurse is caring for an elderly client at a health care facility. What problem might a nurse observe in an elderly client as a result of age-related postural changes?

Answer: Limited or unsteady mobility

??

Which of the following ambulatory aids could a nurse suggest to assist a client who has weakness in one side of his body?

Cane

??

The nurse is assisting a patient with limited mobility to turn in bed. After successfully turning the patient to the side, where would the nurse place an additional pillow?

Supporting the back

??

A nurse is demonstrating the proper use of body mechanics to a group of nursing students. Which of the following would be most appropriate for the nurse to do? a) Keep knees locked in position b) Stand with legs wide apart c) Hold objects away from the body d) Approach the work from the side Stand with legs wide apart

??

The nurse is assisting with range-of-motion exercises for a patient who is on bed rest following surgery. How often would the nurse perform each range-of-motion exercise? a) One time b) Eight times c) Ten to twelve times d) Two to five times Two to five times

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Two nurses are moving a patient up in bed. What motion would the nurses use to counteract the patient's weight?

Shift their weight back and forth, from back leg to front leg

??

A nurse is assisting a client to ambulate at the health care facility using a walking belt.

How does the walking belt assist the client when ambulating? a) Allows the nurse to support the client b) Helps the client to practice ambulating c) Enables the client to stand and support body weight d) Aids the client in extending the leg Allows the nurse to support the client

??

A patient with a hip fracture is returning to the orthopedic unit, and the orders indicate that the patient should be turned by logrolling. What statement is correct regarding logrolling? a) Use a drawsheet or a friction-reducing sheet to facilitate smooth movement. b) Logrolling will maintain straight alignment when the patient is sitting in a chair. c) Logrolling can be performed by one experienced nurse. d) It is acceptable to twist the patient's head, but not the hips, while logrolling.

Use a draw sheet

??

A nurse uses proper body mechanics to move a patient up in bed. Which of the following is a guideline for using these techniques properly? a) Face the direction of movement. b) Keep feet together to provide a base of support. c) Keep body weight higher than center of gravity. d) Twist body at the waist when lifting.

Face the direction of movement

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A patient is preparing to mobilize for the first time following the surgical removal of a bunion on her left foot. How should the nurse instruct the patient to ambulate with her crutches? a) "Keep your elbows well away from your sides in order to keep yourself as stable as possible." b) "When you rise from a chair, use your left foot to stabilize yourself." c) "Keep your crutches as close as possible to your feet when you're walking." d) "Try to avoid putting too much pressure on your armpits with the tops of the crutches."

"Try to avoid putting too much pressure on your armpits with the tops of the crutches."

??

A nurse at a health care facility is caring for clients using crutches to ambulate. In which of the following clients would the nurse observe a four-point walking gait? a) Clients with amputated limbs who are learning to use prosthetic limbs b) Clients who have more coordination and balance c) Clients with one amputated, injured, or disabled extremity d) Clients with disabilities such as arthritis or cerebral palsy Clients with disabilities such as arthritis or cerebral palsy

??

While performing passive range-of-motion exercises on the lower extremities of a patient with a spinal cord injury, the nurse assesses permanent flexion of the muscles.

What term will the nurse use to document this finding related to the muscles? a) Contractures b) Atrophy c) Tonus d) Ankylosis Contractures

??

You are helping a patient walk in the hallway when the patient suddenly reaches for the handrail and states, "I feel so weak. I think I am going to pass out." Which of the following initial actions by are appropriate? Select all that apply. a) Support the patient's body against yours and gently slide the patient onto the floor. b) Ask the patient to lean against the wall while you obtain a wheelchair. c) Apply oxygen and wait several minutes for the weakness to pass. d) Ask the patient, "When was the last time you ate?" e) Firmly grasp the patient's gait belt.

Support the patient's body against yours and gently slide the patient onto the floor

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

??

The cardiac response to exercise is well-researched and documented. Which of the following is a cardiovascular response to regular exercise? a) Increased efficiency of the heart b) Decreased blood flow to all body parts c) Decreased circulation of fibrinolysin d) Increased heart rate and blood pressure Increased efficiency of the heart

??

When explaining the benefits of isotonic exercises to promote cardiorespiratory conditioning and increase lean muscle mass, which of the following exercises should the nurse tell the client to perform? a) Aerobic exercise b) Body building c) Weight lifting d) Push-ups Aerobic exercise

??

What term is used to document impaired muscle strength or weakness? a) paresis b) paralysis c) spasticity d) flaccidity Paresis

??

A 60-year-old client who uses a walker to aid ambulation is being discharged from the health care facility. Which of the following changes should be made to the homes of older adults to increase safety? Select all that apply. a) Ensure that there are no electric cords in the passageway. b) Repaint the house to a color that promotes well-being. c) Add railings and grab bars to the bathrooms and entrance. d) Replace scatter rugs with secure mats. e) Ensure that all the rooms in the house are brightly lit.

Replace scatter rugs with secure mats. Ensure that there are no electric cords in the passageway. Add railings and grab bars to the bathrooms and entrance.

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse is working with a female client with osteoporosis on an exercise program. The nurse instructs the client to increase her tolerance gradually. The nurse determines that the teaching was effective when the client states which of the following? a) "My initial goal is to exercise every day of the week." b) "I need to avoid weight-bearing exercises." c) "Strength training will be of little benefit to me." d) "If I experience pain when I'm exercising, I should stop."

"If I experience pain when I'm exercising, I should stop."

??

A nurse is performing a general physical assessment for a client. What is the most important thing the client can do to promote work endurance? a) Hold objects closer to the body b) Rest between periods of exertion c) Keep the feet apart when holding objects d) Twist and stretch muscles during work Rest between periods of exertion

??

A physician has directed a nurse to assist a client to perform exercises in order to prevent ankylosis. What type of exercise should the nurse assist the client with in this case? a) Continuous passive motion machine b) Range of motion exercises c) Active exercises d) Aerobic exercises Range of motion exercises

??

The nurse is assisting a patient from the bed into a wheelchair. Which of the following is a recommended guideline for this procedure? a) Raise the head of the bed to a sitting position. b) Place the bed in the highest position. c) Put the chair at the foot of the bed. d) Make sure the bed brakes are unlocked.

Raise the head of the bed to a sitting postion

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse is assessing the musculoskeletal system of a client during an initial visit to the clinic. The assessment reveals insufficient joint lubrication in the knees. The nurse documents this finding as which of the following? a) Crepitus b) Chorea c) Scoliosis d) Swelling Crepitus

??

A nurse is caring for an inactive client and assisting the client in performing range-ofmotion exercises. What care should the nurse take when performing range-of-motion exercises? a) Change the pattern of exercises each time b) Perform different movements with each extremity c) Place pillows and other positioning devices d) Move each joint until there is resistance but no pain Move each joint until there is resistance but no pain

??

A nurse performing range-of-motion exercises on a bedfast patient moves the patient's chin down onto the chest and then back to an upright position. The nurse then tilts the head as far as possible to each shoulder. What therapeutic movement is the nurse achieving with this exercise? Select all that apply. a) Dorsiflexion b) Extension c) Pronation d) Flexion e) Adduction • Flexion • Extension

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers An obstetrical nurse is preparing to help a patient up from her bed and to the bathroom 3 hours after the woman delivered her baby. Which of the following actions should the nurse perform first? a) Position a walker in front of the patient to provide stability. b) Explain to the patient how the nurse will assist her. c) Have the patient stand for 30 seconds prior to walking. d) Enlist the assistance of another nurse or the physiotherapist.

Explain to the patient how the nurse will assist her.

??

The nurse adjusts a patient's bed to a comfortable working height in order to turn a patient. What would be the nurse's next action? a) Move the patient to edge of the bed opposite the side that patient will be turning. b) Push the patient to the edge of the bed to which the patient will be turning. c) Push the patient to the opposite side of the bed. d) Pull the patient to the edge of the bed to which the patient will be turning.

Answer: Move the patient to edge of the bed opposite the side that patient will be turning.

??

Bedrest, with resultant immobility, affects the whole body. What is one effect on the musculoskeletal system? a) impaired gas exchange b) decreased sensory stimulation c) increased risk for contractures d) increased risk for venous thrombosis increased risk for contractures

??

A nurse is providing care for a patient who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the patient? a) The patient's body weight b) The patient's cognitive status c) The patient's ability to assist d) The patient's age Patient's ability to assist

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers When assisting a client with ambulation using an assistive device such as parallel bars or a walking belt, what should the nurse observe the client for? a) Tone and strength of the muscles b) Upper arm strength c) Walking gait d) Pallor, weakness, or dizziness Pallor, weakness, or dizziness

??

The nurse is preparing to move a patient using a powered full-body sling lift. Which of the following is a recommended action in this procedure? a) Lower the side rail on the side of the bed being worked on. b) Place the sling evenly on top of the patient. c) Lower the side rail on the opposite side of the bed being worked on. d) Roll the patient to the middle of the bed.

Lower the side rail on the side of the bed being worked on.

??

A nurse is caring for an athlete who has been provided with a cervical collar to immobilize the neck following a neck injury. What is the most important advantage of mechanical immobilization of a body part? a) Heals wounds and infected injuries b) Treats structural damage and deformity c) Allows movement while injuries heal d) Relieves pain and muscle spasm Relieves pain and muscle spasm

??

The nurse has asked the patient to grasp his overbed trapeze and pull his torso up off the surface of the bed. What movement will the patient perform with his arms? a) Abduction b) Flexion c) Adduction d) Dorsiflexion Flexion

??

Moving joint or extremity toward the midline of the body Adduction

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Moving a joint or extremity away from the midline of the body Abduction

??

Turning a joint or extremity on its axis toward the body's midline Rotation, internal

??

Turning a joint or extremity on its axis away from the body's midline Rotation, external

??

Decreasing the angle between two bones Flexion

??

Straightening a joint Extension

??

Moving a joint past normal extension Hyperextension

??

Turning the body or a body part to face upward Supination

??

Turning the body or a body part facing downward Pronation

??

Moving a body part in widening circles Circumduction

??

Turning the feet inward so toes point toward the mid line ` Inversion

??

Turning the feet outward so toes point away from the midline Eversion

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

??

Touching the thumb to each finger Opposition

??

Anaerobic excercise= endurance training. can't extract enough oxygen

?? aerobic exercise promotes Cardiovascular conditioning

??

Static excerise by which the patient tenses a muscle, holding it stationary while maintaining tension Isometric

??

Client lays face down.Arms cushion head or may be flexed. After abdominal surgery and in clients with respiratory or spinal problems Prone

??

Client lays flat on back.Alternative for people on bed rest Supine

??

Sitting position raises the client's head 80 to 90 degrees. Improves cardiac output, promotes ventilation, and eases eating,talking and watching tv.

Fowler's When explaining the benefits of isotonic exercises to promote cardiorespiratory conditioning and increase lean muscle mass, which of the following exercises should the nurse tell the client to perform? aerobic exercise

??

Which of the following ambulatory aids could a nurse suggest to assist a client who has weakness in one side of his body?

A cane

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers The nurse is teaching a new graduate nurse about the most common causes of back injuries. The nurse knows that the new graduate understands the concepts of back injuries when she/he states that back injuries: can occur when repositioning uncooperative clients.

??

A client who tore his quadriceps muscle during a soccer match is being treated at a health care facility. The physician has prescribed exercise for the quadriceps muscles in order to rehabilitate the client. How should the client perform quadriceps setting exercises?

By alternatively tensing and relaxing the muscles

??

A nurse is providing care for a client who has been newly admitted to the long-term care facility. What is the primary criterion for the nurse's decision whether to use a mechanized assistive device for transferring the client? the clients ability to assist

??

A nurse is assisting a client to ambulate at the health care facility using a walking belt.

How does the walking belt assist the client when ambulating? allows the nurse to support the client

??

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. What statement is correct regarding logrolling?

Use a drawsheet or a friction-reducing sheet to facilitate smooth movement.

??

A nurse is caring for a client whose fractured leg is in a cast. Which of the following ambulatory devices could the nurse suggest for the client to ambulate at the health care facility? axillary crutch

??

The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair three times a day. Which of the following actions will be most effective to transfer the client safely into the chair?

Have the client sit on the side of the bed for several minutes before moving to the chair.

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Which postural deformity might be assessed in a teenager? scoliosis

??

When moving a client up in bed with the assistance of another caregiver, the nurse should: have the client fold the arms across the chest.

??

What body system benefits the most from aerobic exercises? cardiovascular

??

The cardiac response to exercise is well-researched and documented. Which of the following is a cardiovascular response to regular exercise?

Increased efficiency of the heart

??

A nurse is preparing to turn a hospitalized client age 65 years. Which of the following is a recommended guideline for performing this skill?

Position a friction-reducing sheet under the client.

??

A physician has directed a nurse to assist a client to perform exercises in order to prevent ankylosis. What type of exercise should the nurse assist the client with in this case?

Range of motion exercises

??

A client 80 years of age experienced dysphagia (impaired swallowing) in the weeks following a recent stroke, but his care team wishes to now begin introducing minced and pureed food. How should the nurse best position the client? fowlers

??

When assisting a client with ambulation using an assistive device such as parallel bars or a walking belt, what should the nurse observe the client for? pallor, weakness, and dizziness

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A college student fell and sprained his right ankle. The student health physician recommends the student use crutches to facilitate healing. Which of the following would the nurse teach the student?

A college student fell and sprained his right ankle. The student health physician recommends the student use crutches to facilitate healing. Which of the following would the nurse teach the student?

??

An immobile person has decreased movement of respiratory secretions. What condition is a greater risk as a result? respiratory tract infection

??

The 55 year-old client who is newly diagnosed with osteoarthritis of the hips asks the nurse why it hurts when walking. What is the nurse's best response?

"You have lost the padding in your joints and the friction causes pain."

??

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client?

The 24-month-old child who is unable to walk unassisted

??

A nurse is caring for an inactive client and assisting the client in performing range-ofmotion exercises. What care should the nurse take when performing range-of-motion exercises?

Move each joint until there is resistance but no pain

??

A nurse teaches a student nurse the importance of ambulating patients to prevent the effects of immobility on body systems. Which of the following is one of these effects? impaired circulation

??

A nurse is assessing the musculoskeletal system of a client during an initial visit to the clinic. The assessment reveals insufficient joint lubrication in the knees. The nurse documents this finding as which of the following? crepitus

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse uses proper body mechanics to move a client up in bed. Which of the following is a guideline for using these techniques properly?

Face the direction of movement.

??

A group of nursing students are reviewing the aspects of motor function control by the nervous system. The students demonstrate understanding of this information when they identify which of the following as a function of the cerebellum?

Coordination of movement motor activities

??

The nurse is assisting an elderly client with dementia to get dressed after morning care.

Which statement would be most beneficial to the patient?

"Put your arm in this sleeve."

??

The nurse is caring for a client who is on bed rest and was just turned to the left side.

Which of the following actions should you take next to decrease the risk of impaired skin integrity?

Pull the shoulder blade forward and out from under the client.

??

The nurse is assessing the client for muscle mass, tone, and strength and determines that there is increased tone that interferes with movement. The nurse documents this finding as: spasticity.

??

A home care nurse visits a client with Parkinson's disease. The nurse observes that the client has rhythmic, repetitive movements of the hands. The home care nurse documents this as which of the following? tremor

??

A nurse is demonstrating the proper use of body mechanics to a group of nursing students. Which of the following would be most appropriate for the nurse to do?

Stand with legs wide apart

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers While performing passive range-of-motion exercises on the lower extremities of a patient with a spinal cord injury, the nurse assesses permanent flexion of the muscles.

What term will the nurse use to document this finding related to the muscles? contractures

??

What is a benefit of regular exercise over time? decreased heart rate

??

A nurse is caring for a comatose patient. What can happen to the feet if they are unsupported in the dorsiflexed position? plantar flexion and footdrop

??

A patient is preparing to mobilize for the first time following the surgical removal of a bunion on her left foot. How should the nurse instruct the patient to ambulate with her crutches?

"Try to avoid putting too much pressure on your armpits with the tops of the crutches."

??

A nurse is working with a female client with osteoporosis on an exercise program. The nurse instructs the client to increase her tolerance gradually. The nurse determines that the teaching was effective when the client states which of the following?

Answer Key Question 1: (see full question)

Two nurses are moving a client up in bed. What motion would the nurses use to counteract the client's weight?

You selected:

Shift their weight back and forth, from back leg to front leg.

Correct

Explanation:

The nurses would use a rocking motion to counteract the client's weight. The nurses would shift their weight back and forth, from back leg to front leg, count to three, and then move the client up toward the head of the bed. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia:

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1096.

Chapter 32: Activity - Page 1096

Question 2: (see full question)

The nurse has asked the client to grasp his overbed trapeze and pull his torso up off the surface of the bed. What movement will the client perform with his arms?

You selected:

Adduction

Incorrect

Correct response:

Flexion

Explanation:

Flexion is achieved when a body part is bent, as when the elbow is bent and the upper arm and forearm are brought together.

Adduction and abduction denote lateral movement to and from the body, and dorsiflexion is backward bending of the hand or foot. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1041.

Chapter 32: Activity - Page 1041

Question 3: (see full question)

The nurse has been teaching the client about how to use a walker safely. The nurse knows the teaching has been effective when the client:

You selected:

steps into the walker when walking.

Correct

Explanation:

A walker is mechanical aide that enhances the client's balance and

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers ability to bear weight. Teaching is usually done by physical medicine or physical therapy, but the nurse should continue to assess the client’s ability to use it properly. The client should step into the walker when walking, rather than walking behind it. When rising from a seated position, the arms of the chair should be used for support, not the walker. The client should be cautioned to avoid pushing the walker out too far in front. Also, the client should avoid leaning over the walker, but should stay upright as he/she moves. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, pp. 1077-1078.

Chapter 32: Activity - Page 1077

Question 4: (see full question)

The nurse is caring for a client who is on bed rest and was just turned to the left side. Which of the following actions should you take next to decrease the risk of impaired skin integrity?

You selected:

Pull the shoulder blade forward and out from under the client.

Correct

Explanation:

Positioning the shoulder blade in this manner removes pressure from the bony prominence.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1095.

Chapter 32: Activity - Page 1095

Question 5:

Which patient would the nurse place in a protective prone position?

(see full question)

You selected:

A patient prone to hyperextension of the spine

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Correct

Explanation:

A nurse would place a client prone to hyperextension of the spine in a protective prone position. A nurse would place a client prone to edema of the hand in Fowler’s position. A nurse would place a client prone to internal shoulder rotation and adduction in protective supine position. A nurse would place a client prone to flexion contracture of the neck in protective supine position. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1069.

Chapter 32: Activity - Page 1069

Question 6: (see full question)

You selected:

The nurse adjusts a client's bed to a comfortable working height in order to turn a patient. What would be the nurse's next action?

Move the client to edge of the bed opposite the side that client will be turning.

Correct

Explanation:

When turning a client in bed, the nurse would use a frictionreducing sheet to pull the client to the edge of the bed that is opposite the side the client will be turning. Consult a Safe Patient Handling Algorithm to determine whether assistive devices or additional nurses are needed, depending on the individual client. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp.

1095-1098.

Chapter 32: Activity - Page 1095

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Question 7: (see full question)

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client?

You selected:

The 24-month-old child who is unable to walk unassisted

Correct

Explanation:

At 15 months of age, most toddlers can walk unassisted; there would be concern for a 24-month-old child who could not. At 3 months of age, an infant may be able to raise the head, but this is not expected at this age for all 3-month olds. Rolling over is usually accomplished between 6 and 9 months of age, so it would not be expected for all 6-month olds. Stacking blocks is accomplished by most 3-year olds, although 18 months is early. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1045.

Chapter 32: Activity - Page 1045

Question 8: (see full question)

You selected:

Using proper body mechanics, which motions would the nurse make to move an object?

The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.

Correct

Explanation:

Use the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. The internal girdle is made by contracting the gluteal muscles in the buttocks downward and the abdominal muscles upward. It is helped further by making a long midriff by stretching the muscles in the waist. The nurse would not relax the stomach

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers muscles or use the muscles of the back when moving an object.

The nurse would not lift an object when it can be safely slid, rolled, pushed, or pulled. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1060.

Chapter 32: Activity - Page 1060

(see full question)

The nurse is performing range-of-motion exercises on a patient’s arm. The nurse starts by lifting the arm forward to above the head of the patient. Which action would the nurse perform next?

You selected:

Return the arm to the starting position at the side of the body.

Question 9:

Correct

Explanation:

The nurse would return the joint to a neutral position, that is, its normal position of alignment, when finishing each exercise.

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1073.

Chapter 32: Activity - Page 1073

Question 10: (see full question)

A nurse applies padded boots to maintain the foot in dorsiflexion on a client who is comatose. The nurse is protecting the client from what?

You selected:

Foot drop

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Correct

Explanation:

A footboard or boots should be applied to maintain dorsiflexion and tendon flexibility. Footdrop is a contracture in which the foot is fixed in plantar flexion.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1066.

Chapter 32: Activity - Page 1066

Chapter 29:Medications A client is to take Demerol 35 mg IM. You have Demerol 50 mg per cc. How many cc will you administer?

0.7 cc p.737

??

A nurse is administering medication to a patient via a gastric tube and finds that the medicine enters the tube and then the tube becomes clogged. What is the appropriate intervention in this situation?

Use a syringe to plunge the tube to try to dislodge the medication. p.744

??

The medical chart of a newly admitted patient notes a penicillin allergy, yet the physician has just written an order for an antibiotic in the same drug family after reviewing the patient's wound culture and sensitivity. How should the nurse respond to this situation?

Withhold the medication until the potential drug allergy has been addressed by the care team p.735

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse is caring for a client undergoing IV therapy. The nurse knows that intravenous administration of medication is appropriate in which of the following situations?

When the client has disorders that affect the absorption of medications p.755

??

A nurse is performing a sensitivity test on a patient. What would be the best type of injection to use for this procedure?

Intradermal p.749

??

The nurse transcribes an order that reads: Colace 100 mg PO daily. This is an example of which type of order?

Standing order p.733

??

A nurse is explaining to a client the correct method of using a metered-dose inhaler when self-administering a prescribed dose of medication. Which of the following is a feature of a metered-dose inhaler?

It is a canister that contains pressurized medication. p.763

??

A nurse needs to administer a continuous medication drip to a client. The nurse knows that, for a continuous infusion, he or she will likely need to add medication to which of the following volumes of IV solution?

500 to 1,000 mL p.756

??

A nurse needs to use a moisturizer for an elderly client with dry skin. Why is the onset of the medication action atypical in an elderly client?

Diminished subcutaneous fat p.730

??

To which of the following patients would the nurse be most likely to administer a PRN medication?

A patient who is complaining of pain near her surgical site p.733

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

??

When educating an elderly client about the administration of medication during discharge teaching, the nurse notes that the client is having difficulty comprehending the instruction. What intervention should the nurse follow in this case to ensure the client's safety?

Involve a second responsible person in the instruction. p.744

??

An elderly client with pneumonia has been prescribed the use of a bronchodilator by the physician. What should the nurse monitor in a client taking an inhaled bronchodilator?

Heart rate pp.763-764

??

The "Rights of Medication Administration" help to ensure accuracy when administering medications. Which of the following represent these five rights? Select all that apply.

• Medication • Patient • Route • Dosage p.738

??

A nurse is using an 18-gauge needle to administer a medication to a client. The nurse knows that when compared to a 27-gauge needle, an 18-gauge needle has which of the following features?

Larger diameter p.745

??

A nurse educator is teaching a student nurse how to choose the correct needle for an injection. Which of the following guidelines for needle selection might they discuss?

As the gauge number becomes larger, the size of the needle becomes smaller p.745

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers The primary reason for the Controlled Substances Act is To prevent drug abuse p.739

??

A nurse is administering a hepatitis B shot intramuscular. What would be the appropriate site for administration?

Deltoid p.752

??

A nurse is caring for a client who has been prescribed codeine, a narcotic medication to relieve severe postoperative pain. Which of the following responsibilities does the nurse have to complete when handling narcotic medications? Select all that apply.

• Count each narcotic medication at the change of each shift • Record each medication used from the stock supply • Maintain an accurate account of the use of the medication p.739

??

A nurse needs to administer an intradermal tuberculin skin test injection to a client.

Which of the following is the most suitable angle when administering an intradermal injection?

10-degree angle p.788

??

Which of the following patients receives a drug that requires parenteral route?

A woman who has been ordered intravenous antibiotics p.735

??

A nurse is providing care for a patient who has a history of dementia. Which of the following methods should the nurse use in order to determine the patient's identity prior to medication administration?

Check the patient's identification band. p.739

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Which of the following accurately describes a recommended guideline when administering oral medications to patients?

If a child refuses to take medication, the medication can be crushed and added to a small amount of food. p.744

??

When administering heparin subcutaneously, the nurse should Never aspirate p.750

??

Which medication system allows for client independence?

Self-administered medication system p.741

??

The maintenance of client safety with medication administration is of primary importance in healthcare. The most commonly used system for billing and record keeping is the Automated medication-dispensing system p.736

??

An acute care facility follows the unit dose supply method to supply medication to the clients. What is meant by the unit dose supply method?

Self-contained packets that hold one tablet or capsule for individual clients p.773

??

Which of the following are included in the "five rights for medication administration"?

Select all that apply.

• Right medication • Right route • Right dose • Right time p.738

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers The nurse is preparing to administer a medication via a nasogastric tube. What guideline is appropriate for the nurse to follow when administering a drug via this route?

Flush the tube with water between each drug administered. p.744

??

What is the term used for the concentration of drug in the blood serum that produces the desired effect without causing toxicity?

Therapeutic range p.732

??

A client with dry skin has been prescribed inunction. Which of the following should the nurse do to promote absorption of the ointment?

Rubbing the ointment into the skin p.757

??

A nurse needs to administer a prescribed injection to a toddler. Which of the following injection sites is most suitable for the client?

Vastus lateralis site p.752

??

A graduate nurse is administering several medications to a newly admitted patient.

Who is legally responsible for the drugs administered by this nurse?

The nurse administering the drugs p.735

??

A nurse should read the instructions stated on a vial container before reconstituting it and administering it to a client. Which of the following instructions are stated on the label of a vial container?

Amount of diluent to be added p.749

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers The nurse is caring for a client who has problems coordinating his breathing with the inhaler use. Therefore, the client is unable to receive the full dose. Which of the following would help maximize drug absorption in this client?

Spacer p.764

??

A nurse is administering a prescribed dose of medication to a client through a medication lock. How often should the nurse flush the medication lock to maintain patency?

Every 8 to 12 hours p.806-807

??

A client has been prescribed nasal medication. What care should the nurse take to avoid potential complications due to the administration of this medication?

Review the client's medication, allergy, and medical history p.735

??

When treating a client at a health care facility with nitroglycerin paste, how can the nurse prevent contamination in the client during application?

Avoid touching the application with bare fingers p.758

??

A physician has ordered the nurse to administer a subcutaneous injection to a client.

Which of the following factors should the nurse consider when selecting a syringe and needle? Select all that apply.

• Viscosity of the drug • Size of the client • Type of medication p.746

??

A nurse at the health care facility needs to administer an otic application for a client with an earache. What should the nurse do after instilling the prescribed eardrops in the client's ear?

Ask the client to maintain the position for some time p.761

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse is administering a subcutaneous injection to a client. What is the common maximum volume of a subcutaneous injection?

1 mL p.749

??

A nurse is caring for a client in the nursing unit when the physician, during the rounds, prescribes a medication for the client. What appropriate action should the nurse take to ensure the accuracy of the verbal medication order?

Ask the physician to write out the order p.732

??

A physician at a health care facility suggests the use of a metered-dose inhaler for an asthmatic client. Which of the following describes the mechanism of a metered-dose inhaler?

A canister containing medication that is released when the container is compressed p.763

??

A nurse is using a volume control set to administer a dose of prescribed medication to a client. The nurse opens the lower clamp until the tubing is filled with fluid and then reclamps it. Which of the following statements explains the nurse's action?

Purges air from the tubing p.804

??

A nurse brings a client the prescribed dose of medication and finds that the client is not in the unit. What should the nurse do in this case?

Return the medication to the medication cart or medication room. p.739

??

A nurse is administering an injection to a client at a 15-degree angle. The client has a venous access port. Which of the following injections can be administered at this angle?

Intradermal p.789

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse needs to administer a prescribed medication to a client using IV push. In which of the following ways is the medication being administered to the client?

Bolus administration p.756

??

A patient with a complex cardiac history has been prescribed digoxin (Lanoxin) 0.0625 mg PO. The drug is available as 125 mcg tablets. How many of the tablets will the nurse administer?

0.5 125 mcg = 0.125 mg. 0.0625 mg/0.125 mg = 0.5 tablets p.737

??

A nurse has to administer a subcutaneous injection to a client. For which of the following clients can the nurse administer a subcutaneous injection at a 90-degree angle?

Obese clients p.750

??

After teaching a group of nursing students about pharmacokinetics, the instructor determines that the teaching was successful when the students identify which of the following as the process by which the medication is delivered to the target cells and tissues?

Distribution p.727

??

A nurse needs to administer a prescribed dosage of oral medication to a client with influenza. Which of the following actions should the nurse perform when administering oral medication to the client?

Avoid administering medication prepared by another nurse. p.738-739

??

Which of the following clients is likely to have altered metabolism of medications?

Elderly p.730

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A client suffers from infectious diarrhea. Based on her loss of fluid, her protein level is below normal. What blood product will the physician order to restore intravascular volume?

Albumin p.730

??

A nurse is administering intermittent IV medication to an active adolescent. Which of the following IV systems could be used to allow the patient more freedom?

Peripheral venous access device p.757

??

A nurse at the health care facility is preparing the medication dosage for a client. Why should the nurse read and compare the label on the medication with the MAR at least three times (before, during, and after) while preparing the medication for administration?

Ensures that the right medication is given at the right time by the right route p.738

??

Which of the following medication-administration systems protects the client by identifying the rights of medication administration?

Barcode Medication Administration p.736.

??

A nurse is caring for a client who is being tube fed. What care should the nurse take when administering medications through an enteral tube?

Avoid crushing sustained-release pellets p.743

??

A nurse needs to administer medications to a client through an intravenous port.

Which of the following actions should the nurse perform to ascertain that the IV catheter is in the vein?

Observe the tubing near the insertion device p.800

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse is applying a nitroglycerine transdermal patch to a patient. Which of the following is the preferred site to use? chest p.758

??

A nurse is administering insulin to a diabetic patient. Which of the following are three recommended times to check the label before administration? Select all that apply.

• When reaching for the container or unit dose package • After retrieval from the drawer and compared with the CMAR • When replacing the container to the drawer or shelf p.738

??

According to the nurse practice act, the nurse is liable for Clarifying a physician order p.777

??

A nurse is administering enoxaparin, (blood thinner) to a patient with DVT, via the subcutaneous route. Which of the following is a recommended guideline when administering a subcutaneous injection?

Subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis p.750

??

The nurse is preparing the dosage for a client as per the medication administration record. Which of the following precautions should the nurse take when preparing medications?

Avoid relabeling containers with missing labels p.738

??

Children's medication dosages are most often calculated using the child's body surface area and weight p.738

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse is applying a vaginal cream to a patient with a vaginal infection. Which of the following is a recommended guideline for this application?

Cleanse area at vaginal orifice with washcloth and warm water p.763

??

A nurse at a health care facility has to instill ear drops in a client. The nurse knows that which of the following techniques varies for an adult and child client?

Manipulation of the client's ear to straighten the auditory canal p.761

??

What is involved in the absorption, distribution, metabolism, and excretion of medication?

Pharmacokinetics p.725

??

A nurse needs to withdraw a prescribed medication from an ampule and administer it to a client. Which of the following actions should the nurse perform to ensure that all the medication is equally distributed when withdrawing?

Tap the top of the ampule before withdrawing the medicine Tapping the top of the ampule distributes all the medication to the lower portion of the ampule.

Tapping the barrel of the syringe near the hub does not distribute medication equally but moves the air toward the needle. Inserting the filter needle in the ampule ensures sterility of the needle. Using a smaller or bigger gauge needle does not ensure that all the medication is equally distributed when withdrawing. p.746

??

When the client demonstrates a rash 30 minutes after she has taken a dose of penicillin, the nurse recognizes that the client is likely demonstrating which type of drug reaction?

Allergy p.728

??

Following an allergic reaction to a medication, the nurse should Instruct the client to wear an identification addressing the allergy p.770

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse caring for a client with diarrhea needs to establish an intravenous (IV) access to administer fluids and medication. When explaining intravenous access to the client, which of the following would the nurse most likely incorporate into the description?

Insertion of a needle into a peripheral vein p.755

??

A nurse is using an IV port when administering medication to a client. Which of the following IV administrations has the greatest potential to cause life-threatening changes?

Bolus administration p.756

??

Which parenteral route of administration has the longest absorption time?

Intradermal p.749

??

A nurse needs to combine two different prescribed drugs in a syringe and then administer them to a client with influenza. Which of the following precautions should the nurse take when combining drugs?

Withdraw exact amounts of each drug from each container. p.748

??

A physician has prescribed the use of Lubriderm lotion, which is an inunction application, for a client with complaints of dry skin. Which of the following information should the nurse tell the client regarding the correct method of usage?

The medication is administered by rubbing it into the skin p.735

??

A client with an infection is receiving intravenous antibiotic therapy. The client has an intermittent infusion device in place. The nurse flushes the device with normal saline solution before administering the antibiotic based on which rationale?

To prevent blood clot formation p.756

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse is caring for a client with an intravenous catheter. When administering medication through the intravenous port, the nurse pinches the tubing upstream from the port when instilling it with the drug. Which of the following reasons explains the nurse's action?

Ensures administration of medication to the client p.800

??

A nurse instills eardrops into a patient's ear to soften a wax buildup. Which of the following is a guideline the nurse should follow?

If both ears are to be treated, wait 5 minutes before instilling drops in the second ear. p.761

??

A nurse has administered an injection to a client. Which of the following interventions should the nurse perform to reduce discomfort and provide quick relief?

Apply pressure to the site during needle withdrawal. p.797

??

A client diagnosed with anemia is receiving a blood transfusion. The client develops urticaria accompanied by wheezing and dyspnea not long after the transfusion starts.

The nurse interprets this as indicative of which of the following?

Allergic reaction p.728

??

When performing a piggyback infusion, the nurse lowers the container of primary solution approximately 10 inches below the height of the secondary solution. Which of the following reasons explains the nurse's action?

Uses gravity to infuse the secondary medication p.804

??

A nurse is bunching the tissue of a client when administering a subcutaneous injection to a client. The nurse knows that which of the following is the reason for bunching when injecting subcutaneously?

To avoid instilling medication within the muscle p.750

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers You are preparing supplies for a tuberculosis screening. You should choose which of the following syringes and needles?

1 mL syringe; 1/2 half-inch, 26-gauge needle p.749

??

The nurse is preparing to administer meperidine (Demerol) as an intramuscular injection in an adult patient's deltoid site. Which of the following needles should the nurse select for this injection?

1"; 22 gauge p.754

??

When administering oral medications, which of the following practices should the nurse follow? Select all that apply.

• Perform hand hygiene before and after medication administration.

• Stay at the bedside until the patient has swallowed all the medications.

• Verify the patient's response to the medication 30 minutes after administration, or as appropriate for the drug. p.733

??

A nurse is administering medications through an enteral tube to a client with swallowing difficulties due to a cerebrovascular accident (CVA). Which of the following actions should the nurse perform to prevent gastric reflux?

Help the client into a Fowler's position.

P.744

??

Which of the following actions are included in the required "checks" for safe medication administration? Select all that apply • Read the medication label when reaching for the unit dose package.

• Read the medication label just before administering a unit dose medication to the patient.

• Read the medication label after retrieving the medication from the drawer. p.738

??

A client with allergy has been advised to have an allergy test. The nurse needs to administer an injection to the client for allergy testing. Which of the following injection routes is most suitable for allergy testing?

Intradermal p.749

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

??

A nurse needs to administer a prescribed dose of a narcotic medication to a client with acute neck pain. Which of the following precautions should the nurse take when storing narcotic medications?

In a double-locked drawer p.739

??

A client has an order for an intermittent infusion of 250 mL of 0.9 normal saline. The nurse understand that this type of infusion is used for which situation?

Medications that need to be infused over 20 to 60 minutes p.756

??

You are caring for a patient who just returned from the postanesthesia care unit (PACU) and rates current pain as "9 out of 10." Which of the following prescribed medications will provide the fastest relief from pain?

Intravenous morphine sulfate p.755

??

Which of the following are recommended guidelines for the nurse who is administering a piggyback intermittent intravenous infusion of medication?

Attach infusion tubing to the medication container by inserting the tubing spike into the port with a firm push and twisting motion. p.802

??

A nurse is administering an intramuscular injection to a client using the zig-zag technique. Which of the following actions should the nurse perform to prevent leaking and ensure sealing of medication in the subcutaneous and dermal layers of tissue?

Withdraw the needle and release taut skin immediately after injection. p.797

??

You need to prepare an insulin pen for injection of a prescribed dose of insulin.

Arrange the following steps in the correct order.

Clean the tip of the pen with alcohol.

Screw the correct needle onto the tip of the pen.

Dial the dose selector to 2 units.

Hold the pen upright and press the plunger firmly.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Watch for a drop of insulin at the needle tip.

Verify the dose selector returned to "0." p.751

??

You are preparing to administer an intramuscular injection. After inserting the needle, you should gently pull back on the syringe plunger and observe for blood in the syringe.

True p.750

??

A nurse is administering a piggyback infusion to a client with second-degree burns.

Which of the following describes the most important feature of a piggyback infusion?

A parenteral drug is given in tandem with IV solution pp.756-757

??

A nurse is caring for an elderly client with a vaginal yeast infection. Which of the following actions should the nurse perform when instilling the medication in the client's vagina?

Apply the medication before the client goes to sleep. p.763

??

You are preparing to draw up a medication that is supplied in a glass ampule. Arrange the following steps in the correct order.

Wrap a small gauze pad around neck of ampule.

Break off top of the ampule.

Attach filter needle to the syringe.

Withdraw medication.

Discard filter needle.

Attach sterile administration device to the syringe. p.778

??

A nurse receives doctor's orders to mix a patient's insulin in a syringe with two other medications. What is the recommended guideline in this situation?

Call the pharmacist to determine compatibility of the drugs. p.748

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse needs to administer a subcutaneous injection to a client. Which of the following alternative techniques should the nurse use to reduce discomfort? Select all that apply.

• Numb the skin with an ice pack before the injection • Insert and withdraw the needle without hesitation • Instill the medication slowly and steadily p.755

??

A nurse is reviewing information about prescribed drug in a drug handbook in preparation for administration to a client. When reading about the drug, the nurse identifies which name as the generic name?

Ampicillin sodium p.725

??

Regarding medication administration, what must occur at the change of shifts?

The narcotics for the division are counted p.739

??

A nurse at a health care facility administers a prescribed drug to a client and does not record doing so in the medical administration record. The nurse who comes during the next shift, assuming that the medication has not been administered, administers the same drug to the client again. The nurse on the previous shift calls to inform the health care facility that the administration of the drug to this client in the earlier shift was not recorded. What should the nurse on duty do immediately upon detection of the medication error?

Check the client's condition. p.767

??

A post-surgical patient's MAR provides for PRN administration of a number of analgesics by various routes. Which of the following routes will likely provide the most rapid pain relief for the patient?

Intravenous p.755

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A physician at the health care facility orders 500 mg of a medication to be administered by the oral route, four times a day for a client. The medication is available in a form of 250 mg per 5 mL. What quantity of the medication should the nurse administer to the client?

10 mL The nurse needs to administer 10 mL of the medication as per the physician's prescription in the medication order. The nurse uses the following formula in order to calculate the amount of medication to administer: Desired Dose/Dose on Hand (supplied dose) Quantity. Applying the formula to the information provided in the medication order: 500 mg/250 mg 5 mL = 10mL. p.737

??

The nurse is educating a client with a peripheral intravenous infusion of dextrose 5%.

What is the most important information to share with the client who has an IV infusing in the right hand?

Caution the client not to bend the right wrist p.757

??

Which of the following is an accurate guideline for patient teaching regarding the use of a DPI? Instruct the patient that if mist can be seen from the mouth or nose, the DPI is being used incorrectly. p.766

??

A nurse is caring for a patient with pancreatic cancer who is receiving continuous morphine for pain. Which of the following would be the most effective method to administer this medication?

Administer a continuous subcutaneous infusion of morphine. p.750

??

A nurse uses a nitroglycerin paste to dilate the coronary arteries of a client at the health care facility. What should the nurse do facilitate the medication absorption?

Place application paper on a non-hairy area of skin p.758

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse needs to administer an injection to a client in the deltoid site. Which of the following actions should the nurse perform to avoid the risk of damaging the radial nerve and artery?

Draw an imaginary line at the axilla between the acromion and brachial vessels. p.753

??

You are preparing to administer a rectal suppository to an adult patient. How far should you plan to insert the suppository?

Three inches p.764

??

The physiologic and biochemical effects of a drug on the body defines Pharmacodynamics p.727

??

A 17-year-old girl is admitted to pediatrics with a diagnosis of diabetic ketoacidosis.

She requires intravenous therapy to Provide access for the administration of insulin p.755

??

A nurse is preparing a prescribed dosage of an inhalant medication for a client with asthma. Which of the following explains why inhalation is a good route for medication administration?

It allows the lungs to quickly absorb the medication. p. 763 Please allow access to your computer’s microphone to use Voice Recording.

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Chapter 23: Activity

A nurse is assisting a client with his bed bath. The client states, "I can do it myself."

The nurses best response is?

"I will set up your bath for you. I will come back and help you with your back."

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A 78 year old client with diabetes needs to have his toenails trimmed. It is important for the nurse to ?

A - Remove ingrown toenails B - protect the foot from blisters C - Cut the nail straight across D - Soak the foot in witch hazel C

??

For which of the following patients is foot care likely the highest priority?

A - A patient who has experience postoperative pneumonia and has been placed on a ventilator B - A patient who has been diagnosed with Alzheimer disease and whose mobility is decreasing C - A patient who is obese and has a diagnosis of type 1 diabetes D - A patient who has chronic renal failure and requires hemodialysis three times weekly.

C

??

Upon review of the patient's orders, the nurse notes that the patient was recently starting on an anticoagulant. What is an appropriate consideration when assisting the patient with morning hygiene?

Provide the patient with an electric shaver.

??

Upon assessment, the nurse determines the patient has a body mass index (BMI) of 45.

This finding indicates the patient is which of the following?

Extremely Obese

??

A nurse is caring for a client with a history of cardiac and vascular disease. Which of the following fats should the nurse allow in the client's diet for his condition? a) Unsaturated fats b) Saturated fats c) Hydrogenated fats d) Trans fats A - Unsaturated Fats

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Prior to starting a tube feeding, the nurse assesses the pH and color of the patient's gastric contents and receives a pH reading of 6.2 and the aspirate is off-white in color.

Based upon these findings, where is the tip of the tube most likely located? a) Large intestine b) Respiratory tract c) Small intestine d) Stomach B - Respiratory Tract

??

Mrs. R. has developed an abscess following abdominal surgery and her food intake has been decreasing over the past 2 weeks. Which of the following laboratory findings may suggest the need for nutritional support? a) Low random blood glucose levels b) Low serum albumin levels c) Proteinuria d) Increased white blood cells B - Low serum albumin levels

??

Which of the following nutritional guidelines should a nurse provide to a patient who is entering the second trimester of her pregnancy? a) "You'll need to eat more calories and to make sure you eat a balanced diet high in nutrients." b) "Maintain your regular calorie intake, but take some supplements and emphasize organic foods." c) "The more food energy you consume, the greater the chances that you will have a healthy pregnancy." d) "Try to eat your normal number of calories, but aim to eat a diet that's higher in fruits and vegetables."

A - Youll need to eat more calories and to make sure you eat a balanced diet high in nutrients.

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers During a visit to the pediatrician's office, a mother inquires about adding solid foods to the diet of her 6-month-old infant. What does the nurse inform the mother? a) Adding solid foods is fine at this age, but avoid iron-fortified foods. b) New foods should be introduced one at a time for a period of 5 to 7 days. c) A new solid food should be introduced daily to the infant's diet for a week. d) It is too early to add solid foods to the infant's diet.

B - New foods should be introduced one at a time for a period of 5-7 days.

??

The nurse has observed that a patient's food intake has diminished in recent days.

What intervention should the nurse perform in order to stimulate the patient's appetite? a) Offer nutritional supplements and explain the potential benefits of each. b) Reduce the frequency of meals in order to allow the patient to develop an appetite. c) Offer larger meals and encourage the patient to eat as much as he or she is comfortable with. d) Try to ensure that the patient's food is attractive and sufficiently warm.

D - Try to ensure that the patient's food is attractive and sufficiently warm.

??

A nurse is caring for a visually impaired client. How should the nurse manage the feeding for this client? a) Inform the client about what kind of food is being offered with each mouthful. b) Request a full-liquid, mechanically soft diet for the client. c) Ensure that one portion of food is swallowed before offering another. d) Develop a rapport with the client, and promote continuity of care.

A - Inform the client about what kind of food is being offered with each mouthful.

??

The nurse is preparing to administer a patient's tube feeding. How should the nurse position the patient prior to beginning the infusion? a) With the head of the bed at 30 to 45 degrees b) Supine c) In a left side-lying position d) In the high Fowler's position A - With the head of the bed at 30-45 degrees.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

??

The nurse should begin the process of removing a patient's nasogastric (NG) tube by doing which of the following?

Confirming the physician's order to remove the tube.

??

The nurse is caring for a patient on a telemetry unit following a myocardial infarction.

The patient has undergone numerous medication changes since the event. Which of the following foods should be avoided when a client is taking Coumadin following a myocardial infarction? a) Orange juice b) Spinach c) Milk d) Wheat bread B - Spinach

??

A client who has bleeding tendencies has a deficiency in which vitamin? a) Vitamin B b) Vitamin C c) Vitamin K d) Vitamin A C - Vitamin K

??

The nurse is caring for a client with dysphagia. Which of the following is a primary responsibility of the nurse with regard to feeding the client? a) Reinforce the desired response by praising, touching, and smiling at the client. b) Inform the client about the kind of food being offered with each mouthful. c) Keep oral and pharyngeal suctioning equipment at the client's bedside. d) Develop a rapport with the client and promote continuity of care.

C - Keep oral and pharyngeal suctioning equipment at the client's bedside.

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers The nurse caring for a patient for several days has assessed that he has been eating poorly during his hospitalization. Which nursing measure should the nurse implement to assist the patient in improving his nutritional intake? a) Encourage his daughter to prepare food at home and bring it to the patient. b) Provide bland meals. c) Provide distractions while the patient is fed so that he will eat more. d) Serve large meals and encourage the patient to eat as much as possible.

A - encourage his daughter to prepare food at home and bring it to the patient.

??

Which type of feeding tube would be most appropriate for a patient requiring enteral feeding for a long period of time.

Gastrostomy tube

??

A nurse is administering a prescribed dose of IV fluid to a young client with anorexia at the healthcare facility. When reviewing the client's medical record, which of the following would the nurse identify as a possible cause for the client's anorexia? a) Motion sickness b) General anesthesia c) Gastrointestinal dysfunction d) Inner ear infection C - Gastrointestinal dysfunction

??

A nurse is caring for a client with a wound infection. The dietician has prescribed a diet rich in vitamin A. The client asks the nurse, "Why do I need Vitamin A?" The nurse integrates an understanding of which of the following as a major reason when responding to the client? a) It helps maintain healthy epithelium b) It maintains normal mineralization of cartilage c) It promotes renal reabsorption of calcium d) It mobilizes phosphorus from bone A - It helps maintain healthy epithelium

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Which of the following is a fat-soluble vitamin? a) Vitamin B12 b) Vitamin B6 c) Vitamin E d) Vitamin C C - Vitamin E

??

The charge nurse is observing a new nurse care for a patient who is receiving a continuous feeding through a nasogastric feeding tube. Which of the following actions by the new nurse would require intervention by the charge nurse? a) The new nurse places the patient in the left lateral recumbent position. b) The new nurse changes gloves before preparing the feeding bag. c) The new nurse interrupts the feeding every 4 hours and aspirates gastric contents. d) The new nurse asks the patient if nausea or abdominal pain is present.

A - The new nurse places the patient in the left lateral recumbent position.

??

A nurse is preparing a teaching plan for a client who is obese and has diabetes mellitus.

Which of the following would the nurse include when discussing the the effect of diabetes on nutrition? a) Cells cannot use glucose to produce energy. b) The digestion of fats and protein is altered. c) Intolerance to gluten occurs. d) Glucose levels of the blood are reduced A - Cells cannot use glucose to produce energy.

??

Which of the following laboratory results indicates the presence of malnutrition? a) Hemoglobin (Hgb) 11.3 g/dL b) Hematocrit (Hct) 56% c) Creatinine 1.9 mg/dL d) Serum albumin 2.8 g/dL D - Serum albumin 2.8 g/dL

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A physician orders nutritional therapy administered via a central vein for a patient who cannot take foods orally. What is the term for this type of nutrition? a) Total parenteral nutrition (TPN) b) Percutaneous endoscopic jejunostomy tube (PEJ) c) Percutaneous endoscopic gastrostomy tube (PEG) d) Partial or peripheral parenteral nutrition (PPN) A - Total parenteral nutrition (TPN)

??

A 20-year-old woman has announced her intention to implement a zero-fat diet in order to lose weight and maximize her health. What is a potential consequence of completely eliminating fat sources from the woman's diet? a) Decreased production of antibodies b) Decreased water absorption in the colon c) Impaired vitamin absorption d) Impaired tissue growth and repair C - Impaired vitamin absorption

??

A nurse prepares to insert a nasointestinal tube to provide nutrition to a patient. Which of the following is a recommended guideline for this procedure? a) Measure tube from the tip of the nose to the ear lobe and from the ear lobe to the xiphoid process. b) Place the patient on his or her left side. c) Add 10 to 12 inches for intestinal placement. d) Place the tube in the intestine and allow it to advance through peristalsis A - Measure tube from the tip of the nose to the ear lobe and from the ear lobe to the xiphoid process.

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers You are the nurse caring for a client with an enlarged thyroid. What nutritional deficiency is linked to an enlarged thyroid? a) Potassium b) Iodine c) Sodium d) Magnesium B - Iodine

??

A nurse is caring for a pregnant client who is a strict vegetarian. What type of diet should the client follow? a) A diet rich in sodium b) A diet rich in protein c) A diet lower in calcium and iron d) A diet rich in fat B - A diet rich in protein

??

A nutritionist helps to plan a diet for a patient with type 2 diabetes. Which of the following foods is a carbohydrate that should be included to help improve glucose tolerance? a) Milk b) Oatmeal c) Nuts d) Eggs B - Oatmeal

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers You are caring for a patient who has dysphagia and is unable to eat independently. You are preparing to assist the patient in eating a meal. Which of the following actions is appropriate? a) Create a positive social environment by asking the patient about childhood food memories. b) Arrange food items in a clock face pattern and inform the patient what time on a clock corresponds to each food item. c) Encourage the patient to eat using a consistent, efficient pace to prevent hot foods from becoming too cool and cool foods from becoming too warm. d) Speak to the patient but limit the need for the patient to respond verbally while chewing and swallowing.

D - Speak to the patient but limit the need for the patient to respond verbally while chewing and swallowing.

??

A patient is interested in losing 15 pounds, and she informs the nurse she is counting her calorie intake each day. The patient has a goal of losing 1 pound a week until she reaches her goal. The patient asks the nurse how many calories she should decrease daily to lose a pound a week. What is the nurse's best response? a) 300 calories/day b) 400 calories/day c) 200 calories/day d) 500 calories/day D - 500 calories/day

??

You are using a large syringe to administer an intermittent feeding to a patient who has a nasogastric feeding tube. Which of the following methods should you use to increase the flow rate of the formula? a) Attach the syringe to a syringe pump and set the infusion rate to 250 mL/hr. b) Raise the height of the syringe. c) Ask the patient to bear down while the formula is infusing. d) Using the plunger of the syringe, steadily infuse the formula over the desired period of time.

D - Using the plunger of the syringe, steadily infuse the formula over the desired period of time.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

??

Insertion of a nasogastric tube into a patient who has facial fractures can result in misplacement of the tube into the patient's brain. a) False b) True B - True

??

Which of the following is an appropriate intervention when unexpected situations occur during the administration of a tube feeding? a) If the patient complains of nausea after tube feeding, lower the head of the bed and administer an antiemetic. b) If the tube becomes clogged when aspirating contents, use warm water and gentle pressure to remove the clog. c) If the tube is found to be in the stomach instead of the esophagus, follow the recommended steps to replace the tube. d) When checking for residue, if a large amount is aspirated, replace the residue before feeding.

B - If the tube becomes clogged when aspirating contents, use warm water and gentle pressure to remove the clog

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers The AACN has provided a directive regarding best practice for verification of feeding tube placement. Which of the following is NOT an expected practice for tube placement? a) Bedside techniques, including measuring the pH and observing the appearance of fluid withdrawn from the tube, should be used to assess tube location at regular intervals. b) The mark on the tube's entrance site to the nose or mouth should be observed routinely to assess for a change in length of the external portion of the tube. c) Radiographic confirmation of correct tube placement on all critically ill patients who are to receive feedings or medications via blindly inserted gastric or small bowel tubes following initial use. d) The tube's entrance site to the nose or mouth should be marked and the length documented immediately after radiographic confirmation of correct tube placement.

C - radiographic confirmation of correct tube placement on all critically ill patients who are to receive feedings or medications via blindly inserted gastric or small bowel tubes following initial use.

??

Which of the following is an accurate step when removing a nasogastric tube? a) Before removing the tube, discontinue suction and separate the tube from suction. b) Attach a syringe and flush with 30 mL of water or normal saline solution. c) Place the patient in a protective supine position. d) Quickly and carefully remove tube while the patient breathes out.

A - Before removing the tube, discontinue suction and separate the tube from suction.

??

Regarding medication administration, what must occur at the change of shifts? a) The narcotics for the division are counted b) The LPNs only on the division count medications c) The medications for the division are counted d) The client's medications must be drawn up A - The narcotics for the division are counted

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers What is involved in the absorption, distribution, metabolism, and excretion of medication? a) Pharmacodynamics b) Pharmacotherapeutics c) Pharmacology d) Pharmacokinetics D - Pharmacokinetics

??

A nurse is caring for a client who is being tube fed. What care should the nurse take when administering medications through an enteral tube? a) Avoid crushing sustained-release pellets b) Add medications to the formula c) Use cold water when mixing powdered medications d) Mix all the medications together in 15 mL of water A - avoid crushing sustained-release pellets

??

If the dosage is inappropriate for a client, who is responsible? a) Nurse b) Medical technician c) Physician d) Pharmacist A - Nurse

??

Which one of the following medications would most likely be administered via a transdermal patch? a) Hormonal medications b) Antidepressants c) Antibiotics d) Epinephrine A - Hormonal medications

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse is caring for a client undergoing IV therapy. The nurse knows that intravenous administration of medication is appropriate in which of the following situations? a) When the drug needs to be administered only once b) When the client wants to avoid the discomfort of an intradermal injection c) When the drug needs to act on the client very slowly d) When the client has disorders that affect the absorption of medications D - When the client has disorders that affect the absorption of medications

??

At what point should the nurse perform the first of the three checks of medication administration? a) When reviewing the patient's medication administration record (MAR) b) After retrieving the drug from the drawer of a drug cart c) As the nurse reaches for the drug package or container d) At the beginning of a shift C - As the nurse reaches for the drug package or container

??

A nurse is using an 18-gauge needle to administer a medication to a client. The nurse knows that when compared to a 27-gauge needle, an 18-gauge needle has which of the following features? a) Shorter length b) Greater length c) Smaller diameter d) Larger diameter D - Larger Diameter

??

Drugs known to cause birth defects are called a) Pregnancy sensitivity b) Umbilical cross c) Teratogenic d) Nosocomial C - Teratogenic

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse is caring for a client with typhoid at a health care facility. The nurse checks the medication order in the client's chart for the drugs prescribed to the client. Which of the following is a required component of the medication order? a) Client's age b) Client's name c) Client's diagnosis d) Client's signature A - Clients name

??

A nurse educator is teaching a student nurse how to choose the correct needle for an injection. Which of the following guidelines for needle selection might they discuss? a) When giving an injection, the amount of the medication directs the choice of gauge. b) When looking at a needle package, the first number is the length in inches and the second number is the gauge or diameter of the needle. c) The size of the syringe is directed by the viscosity of the medication to be given. d) As the gauge number becomes larger, the size of the needle becomes smaller.

D - As the gauge number becomes larger, the size of the needle becomes smaller.

??

Children's medication dosages are most often calculated using the child's body surface area and a) Height b) Weight c) Diagnosis d) Age B - Weight

??

You are preparing to administer a transdermal medication. How should this be accomplished? a) You should inject the medication into a body cavity. b) You should inject the medication just below the dermis of the skin. c) You should apply the medication directly to the skin. d) You should ask the patient to swallow the medication.

C - You should apply the medication directly to the skin.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

??

A nurse brings a client the prescribed dose of medication and finds that the client is not in the unit. What should the nurse do in this case? a) Inform the head nurse about the client's absence. b) Return the medication to the medication cart or medication room. c) Leave the medication on the client's bedside table. d) Inform the physician about the client's absence.

B - Return the medication to the medication cart or medication room

??

An elderly client with pneumonia has been prescribed the use of a bronchodilator by the physician. What should the nurse monitor in a client taking an inhaled bronchodilator? a) Heart rate b) Body temperature c) Physical mobility d) Pupil dilation A - Heart rate

??

A client at a health care facility has been prescribed scopolamine, to be administered transdermally. Which of the following statements describes transdermal application? a) Drugs within a thick base applied, not rubbed, into the skin b) Drugs placed against the mucous membrane of the inner cheek c) Drugs bonded to an adhesive and applied to the skin d) Drugs placed under the tongue and allowed to dissolve slowly C - Drugs bonded to an adhesive and applied to the skin

??

Which medication system allows for client independence? a) Self-administered medication system b) Bar Code Medication Administration c) Automated medication-dispensing system d) Unit dose system A - Self-administered medication system

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

??

A nurse needs to administer an insulin injection to a client with diabetes. Which of the following actions should the nurse perform to prevent bruising of the injection site?

Select all that apply. a) Change the needle before injecting b) Avoid aspirating the plunger after placing the needle c) Stretch the injection site taut before administering the injection d) Rotate the injection sites with each injection e) Massage the site before administering the injection A - Change the needle before injecting.

D - Rotate the injection sites with each injection B - Avoid aspirating the plunger after placing the needle

??

A nurse is performing a sensitivity test on a patient. What would be the best type of injection to use for this procedure? a) Intradermal b) Intramuscular c) Subcutaneous d) None of the above A - Intradermal

??

A nurse at a health care facility has to instill ear drops in a client. The nurse knows that which of the following techniques varies for an adult and child client? a) Amount of time before instilling medication in the client's opposite ear b) Position in which the client remains until medication reaches the eardrum c) Dilution of the medication drops before instilling in the client's ear d) Manipulation of the client's ear to straighten the auditory canal D - Manipulation of the medication drops before instilling in the client's ear

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers To which of the following patients would the nurse be most likely to administer a PRN medication? a) A patient whose asthma is treated with inhaled corticosteroids b) A patient who is complaining of pain near her surgical site c) A patient who requires daily medication to control hypertension d) A patient who is experiencing severe and unprecedented chest pain B - A patient who is complaining of pair near her surgical site

??

A nurse is administering intermittent IV medication to an active adolescent. Which of the following IV systems could be used to allow the patient more freedom? a) Peripheral venous access device b) Intravenous infusion c) Volume-control administration set d) Continuous intravenous infusion A - peripheral venous access device

??

When administering heparin subcutaneously, the nurse should a) Never aspirate b) Aspirate before the injection c) Aspirate after injection d) Vigorously massage the site A - Never aspirate

??

A nurse needs to administer an intradermal injection to a client. Which of the following is the most common site for administering an intradermal injection? a) Chest b) Back c) Forearm d) Stomach C - Forearm

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers When instructing a client regarding sublingual application, the nurse should inform the client that which of the following is contraindicated when administering the drug? a) Swallowing the medication b) Talking when taking the medication c) Performing physical activities d) Taking the medication on an empty stomach A - Swallowing the medication

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A nurse is providing care for a patient who has a history of dementia. Which of the following methods should the nurse use in order to determine the patient's identity prior to medication administration? a) Cross-reference the MAR with the patient's medical record. b) Ask the patient his or her name prior to giving the drug. c) Check the patient's identification band. d) Enlist the help of a colleague who is familiar with the patient.

C - Check the patient's identification band

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A nurse is administering medications through an enteral tube to a client with swallowing difficulties due to a cerebrovascular accident (CVA). Which of the following actions should the nurse perform to prevent gastric reflux? a) Administer the medication over several minutes. b) Help the client into a Fowler's position. c) Check for drug allergies in the client's history. d) Add diluted medication to the syringe.

B - Help the client into a Fowler's position

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse needs to administer an intramuscular injection to a thin and frail elderly client. Which of the following actions should the nurse perform to avoid striking the bone when injecting? a) Pinch the muscular tissue. b) Obtain an x-ray of the injection site. c) Massage the injection site. d) Inject using subcutaneous rather than intramuscular technique.

A - Pinch the muscular tissue

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The Z-track technique is utilized during drug administration by which of the following routes? a) Intramuscular b) Intravenous c) Intradermal d) Subcutaneous A - Intramuscular

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A nurse is administering a hepatitis B shot intramuscularly. What would be the appropriate site for administration? a) Scapula b) Ventrogluteal c) Vastus lateralis d) Deltoid D - deltoid

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What is the term used for the concentration of drug in the blood serum that produces the desired effect without causing toxicity? a) Half-life b) Peak level c) Trough level d) Therapeutic range D - Therapeutic range

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers The "Rights of Medication Administration" help to ensure accuracy when administering medications. Which of the following represent these five rights? Select all that apply.

a) Pharmacy b) Route c) Prescribing physician d) Medication e) Dosage f) Patient Medication Patient Dosage Route

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A severe allergic reaction from a medication requires a) Atarax b) Asprin c) Epinephrine d) Dopamine C - Epinephrine

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A nurse is administering a prescribed dose of medication to a client through a medication lock. How often should the nurse flush the medication lock to maintain patency? a) Every 36 to 48 hours b) Every 8 to 12 hours c) Every 1 or 2 hours d) Every 72 to 96 hours B - Every 8-12 hours

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Which of the following accurately describes a recommended guideline when administering oral medications to patients? a) Assume that the patient is the authority on whether or not the medication was swallowed. b) If a pill is dropped, it should be briefly immersed in saline to remove any dirt or germs. c) If a child refuses to take medication, the medication can be crushed and added to a small amount of food. d) If a patient vomits immediately after receiving oral medications, readminister the medication.

C - If a child refuses to take medication, the medication can be crushed and added to a small amount of food

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A nurse is preparing a prescribed dosage of an inhalant medication for a client with asthma. Which of the following explains why inhalation is a good route for medication administration? a) It allows the lungs to quickly absorb the medication. b) It prevents unpleasant aftertastes associated with oral medications. c) It eliminates the potential of suffocation and asphyxia. d) It eliminates bad breath.

It allows the lungs to quickly absorb the medication

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A nurse is administering a subcutaneous injection to a client. What is the common maximum volume of a subcutaneous injection? a) 3 mL b) 0.01 mL c) 1 mL d) 0.05 mL 1 mL

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse needs to instill eye medication in a client with conjunctivitis. Which of the following actions should the nurse take to distribute the medication over the surface of the eye? a) Ask the client to blink his eye. b) Make a pouch in the lower eyelid. c) Gently rub the client's eyelids. d) Instill medication drops in the upper eyelid.

Ask the client to blink his eye

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A nurse is administering an injection to a client at a 15-degree angle. The client has a venous access port. Which of the following injections can be administered at this angle? a) Intradermal b) Intramuscular c) Intravenous d) Subcutaneous Intravenous

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A client with dry skin has been prescribed inunction. Which of the following should the nurse do to promote absorption of the ointment? a) Rubbing the ointment into the skin b) Applying inunction with a cotton ball c) Shaking the contents of the ointment d) Warming the inunction before application Rubbing the ointment into the skin

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A nurse is bunching the tissue of a client when administering a subcutaneous injection to a client. The nurse knows that which of the following is the reason for bunching when injecting subcutaneously? a) To prevent needle-stick injuries b) To avoid instilling medication within the muscle c) To facilitate blood circulation at injection site d) To ensure the accuracy of landmarking to avoid instilling medication within the muscle

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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A nurse needs to administer an intradermal tuberculin skin test injection to a client.

Which of the following is the most suitable angle when administering an intradermal injection? a) 180-degree angle b) 10-degree angle c) 90-degree angle d) 45-degree angle 10-degree angle

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A nurse needs to use a moisturizer for an elderly client with dry skin. Why is the onset of the medication action atypical in an elderly client? a) Diminished subcutaneous fat b) Decreased body temperature c) Diminished physical mobility d) Decreased appetite Diminished subcutaneous fat

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A physician at a health care facility suggests the use of a metered-dose inhaler for an asthmatic client. Which of the following describes the mechanism of a metered-dose inhaler? a) A device that forces liquid drug through a narrow channel using pressurized air b) A propeller-driven device that spins and suspends a finely powdered medication c) A device that forces medication through a narrow channel with the help of inert gas d) A canister containing medication that is released when the container is compressed A canister containing medication that is released when the container is compressed

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers The process by which a drug moves through the body and is eventually eliminated is a) Pharmacokinetics b) Pharmacotherapeutics c) Pharmacology d) Pharmacodynamics Pharmacokinetics

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A client with allergy has been advised to have an allergy test. The nurse needs to administer an injection to the client for allergy testing. Which of the following injection routes is most suitable for allergy testing? a) Intramuscular b) Intradermal c) Subcutaneous d) Intravenous Intradermal

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A nurse needs to administer a prescribed injection to a toddler. Which of the following injection sites is most suitable for the client? a) Dorsogluteal site b) Ventrogluteal site c) Deltoid site d) Vastus lateralis site Vastus lateralis site

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An acute care facility follows the unit dose supply method to supply medication to the clients. What is meant by the unit dose supply method? a) Systems that contain frequently used medication for that unit b) Self-contained packets that hold one tablet or capsule for individual clients c) A supply that remains on the nursing unit for use in emergency d) A container with enough prescribed medications for several days for a client Self-contained packets that hold one tablet or capsule for individual clients

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Medications administered that are renal toxic should have frequent assessments of which blood values? a) WBC and platelets b) BUN and creatinine c) RBC and differential d) AST and ALT BUN and creatinine

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A nurse is administering pain medication to an 80-year-old man. What altered drug response might be expected due to the patient's age? a) Increased possibility of drug toxicity due to increased distribution of water-soluble drugs b) Increased possibility of drug toxicity due to higher drug plasma concentrations c) Decreased gastric pH causing stomach irritation d) Increased excretion of drugs, leading to possible increased serum levels/toxicity Increased possibility of drug toxicity due to higher drug plasma concentrations

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A nurse is caring for a client in the nursing unit when the physician, during the rounds, prescribes a medication for the client. What appropriate action should the nurse take to ensure the accuracy of the verbal medication order? a) Ask the physician to repeat the dosage b) Ask a second nurse to listen for accuracy c) Ask the physician to spell out the medication name d) Ask the physician to write out the order Ask the Physician to write out the order

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse at the health care facility is preparing the medication dosage for a client. Why should the nurse read and compare the label on the medication with the MAR at least three times (before, during, and after) while preparing the medication for administration? a) Complies with the medical order and ensures that the right dose is given b) Ensures that the medication has been administered to the right client c) Demonstrates timely administration and compliance with the medical order d) Ensures that the right medication is given at the right time by the right route Ensures that the right medication is given at the right time by the right route

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A nurse is using an IV port when administering medication to a client. Which of the following IV administrations has the greatest potential to cause life-threatening changes? a) Secondary administration b) Electronic infusion device c) Continuous administration d) Bolus administration Bolus administration

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A client is ordered to receive an intramuscular injection of medication. When preparing to administer the injection, the nurse selects the ventrogluteal site based on which reason? a) The area is free of major blood vessels and fat. b) The site is in close proximity to the sciatic nerve. c) There is a high possibility of injecting into subcutaneous fat. d) The site lies close to the radial nerve.

The area is free of major blood vessels and fat

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers When performing a piggyback infusion, the nurse lowers the container of primary solution approximately 10 inches below the height of the secondary solution. Which of the following reasons explains the nurse's action? a) Instills secondary infusion within specified time b) Prevents backfilling with the primary solution c) Prevents separation from the port d) Uses gravity to infuse the secondary medication uses gravity to infuse the secondary medication

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When educating an elderly client about the administration of medication during discharge teaching, the nurse notes that the client is having difficulty comprehending the instruction. What intervention should the nurse follow in this case to ensure the client's safety? a) Write discharge instructions on the medication containers. b) Involve a second responsible person in the instruction. c) Ask the client's physician to provide instruction. d) Ask a second nurse to repeat the instruction.

Involve a second responsible person in the instrustion

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In administering medications, the five rights include patient, drug, route, and time.

What is the fifth right? a) Heart rate b) Dosage c) Intrathecal d) Pain level Dosage

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse is caring for a patient with pancreatic cancer who is receiving continuous morphine for pain. Which of the following would be the most effective method to administer this medication? a) Administer a continuous subcutaneous infusion of morphine. b) Administer a piggyback intermittent intravenous infusion of morphine. c) Administer an intermittent intravenous infusion of morphine via a volume-control administration set. d) Administer morphine by intravenous bolus or push through an intravenous infusion.

Administer a continuous subcutaneous infusion of morphine

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A client has been prescribed nasal medication. What care should the nurse take to avoid potential complications due to the administration of this medication? a) Read and compare labels on the medication with the medical record b) Administer medication within 30 to 60 minutes of the scheduled time c) Review the client's medication, allergy, and medical history d) Allow sufficient time to prepare the medication with minimal distraction review the client's medication, allergy, and medical history

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A nurse needs to administer a prescribed dosage of oral medication to a client with influenza. Which of the following actions should the nurse perform when administering oral medication to the client? a) Check the label of the medication container three times at the bedside. b) Avoid administering medication prepared by another nurse. c) Bring the prescribed medication in a ceramic cup or glass container. d) Prepare the exact dosage of medication in front of the client.

Avoid administering medication prepared by another nurse

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers When treating a client at a health care facility with nitroglycerin paste, how can the nurse prevent contamination in the client during application? a) Place an application paper on a clean area of skin. b) Rotate the site of medication placement. c) Avoid touching the application with bare fingers. d) Remove one application before applying another. avoid touching the application with bare fingers

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A nurse is using a volume control set to administer a dose of prescribed medication to a client. The nurse opens the lower clamp until the tubing is filled with fluid and then reclamps it. Which of the following statements explains the nurse's action? a) Purges air from the tubing b) Removes colonizing microorganisms c) Mixes the drug throughout the fluid d) Provides diluent for the medication Purges air from the tubing

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A nurse is administering medication to a patient via a gastric tube and finds that the medicine enters the tube and then the tube becomes clogged. What is the appropriate intervention in this situation? a) Remove the tube and replace it with a new tube. b) Wait the prescribed amount of time and attempt to administer the medication again before calling the physician. c) Use a syringe to plunge the tube to try to dislodge the medication. d) Call the physician before instituting any corrective interventions.

Use a syringe to plunge the tube to try to dislodge the medication

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse is applying a vaginal cream to a patient with a vaginal infection. Which of the following is a recommended guideline for this application? a) Spread the labia with dominant hand and introduce the applicator with the nondominant hand gently, using pushing motion. b) Cleanse area at vaginal orifice with washcloth and warm water. c) Position the patient in the prone position. d) Wipe from the sacrum to the vaginal orifice upward (back to front).

Cleanse area at vaginal orifice with washcloth and warm water.

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Upon assessment of a patient's wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment? a) Maturation phase b) Hemostasis c) Proliferation phase d) Inflammatory phase Proliferation Phase

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Which of the following activities should the nurse implement to decrease shearing force on the client with a stage II pressure ulcer? a) Support the client from sliding in bed b) Improve the client's hydration c) Lubricate the area with skin oil d) Pull client up under the arms Support the client from sliding in bed

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When measuring the size, depth, and wound tunneling of a patient's stage IV pressure ulcer, what action should the nurse perform first? a) Insert a swab into the wound at 90 degrees. b) Perform hand hygiene. c) Assess the condition of the visible wound bed. d) Measure the width of the wound with a disposable ruler.

Perform hand hygiene

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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A nurse assessing the wound healing of a patient, documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by: a) Primary intention b) Secondary intention c) Tertiary intention d) None of the above Primary intention

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A nurse is removing sutures from the surgical wound of a patient after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation? a) Pick the crusts off the sutures with the forceps before removing them. b) Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. c) Do not attempt to remove the sutures because they need more time to heal. d) Moisten sterile gauze with sterile saline to loosen crusts before removing sutures.

Moisten sterile gauze with sterile saline to loosen crusts before removing sutures

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Upon responding to the patient's call bell, the nurse discovers the patient's wound has dehisced. Initial nursing management includes calling the physician and which of the following? a) Pouring sterile hydrogen peroxide into the abdominal cavity and packing with gauze b) Covering the wound area with sterile towels moistened with sterile 0.9% saline c) Holding the wound together until the physician arrives d) Closing the wound area with Steri-Strips Covering the wound area with sterile towels moistened with sterile 0.9% saline

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse caring for a patient who has a surgical wound following a cesarean section notes dehiscence of the wound and contacts the surgeon. Which of the following is a finding related to this condition? a) The edges of the wound are lightly pulled together. b) There is an accumulation of fluid in the interstitial tissue. c) There is redness or inflammation of an area as a result of dilation. d) There is an accidental separation of the wound.

There is an accidental separation of the wound

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An elderly patient has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the patient's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the patient's venous access site? a) A gauze dressing precut halfway to fit around the IV line b) A transparent film c) A dressing with a nonadherent coating d) A gauze dressing premedicated with antibiotics A transparent film

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A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red raised rash under the client's breasts. This manifestation is most consistent with which of the following conditions? a) A rash related to immobility b) A rash related to a yeast infection c) An allergic reaction to medications d) An allergic reaction to detergent A rash related to a yeast infection

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse notes a number of laceration wounds around the cervix of the uterus due to childbirth. How could the nurse describe the laceration wound in the client's medical record? a) A separation of skin and tissue in which the edges are torn and irregular b) A clean separation of skin and tissue with a smooth, even edge c) A shallow crater in which skin or mucous membrane is missing d) A wound in which the surface layers of skin are scraped away A separation of skin and tissue in which the edges are torn and irregular

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A nurse is treating the pressure ulcer of an African American patient. How would the nurse assess for deep tissue injury in this patient? a) Upon palpation, the nurse determines that the area preceded by deep tissue injury is painful, firm, boggy, and warmer or cooler as compared with adjacent tissue. b) Upon inspection the nurse would notice a purple or maroon localized area of discolored intact skin. c) Upon inspection the nurse notes partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. d) Upon inspection, the nurse would see a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

Upon palpation, the nurse determines that the area preceded by deep tissue injury is painful, firm, boggy, and warmer or cooler as compared with adjacent tissue

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Dehiscence is the softening of tissue due to excessive moisture. a) False b) True False

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A medicalsurgical nurse is assisting a wound care nurse with the debridement of a patient's coccyx wound. What is the primary goal of these nurses' action? a) Stimulating the wound bed to promote the growth of granulation tissue b) Removing purulent drainage from the wound bed in order to accurately assess it c) Removing dead or infected tissue to promote wound healing d) Removing excess drainage and wet tissue to prevent maceration of surrounding skin Removing dead or infected tissue to promote would healing

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A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? a) A child's skin becomes less resistant to injury and infection as the child grows. b) An individual's skin changes little over the life span. c) In children younger than 2 years, the skin is thicker and stronger than in adults. d) An infant's skin and mucous membranes are easily injured and at risk for infection. an infants skin and mucous membranes are easily injured and at risk for infection

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The nurse would recognize which of the following patients as being particularly susceptible to impaired wound healing? a) A patient whose breast reconstruction surgery required numerous incisions b) An obese woman with a history of type 1 diabetes mellitus c) A patient who is NPO (nothing by mouth) following bowel surgery d) A man with a sedentary lifestyle and a long history of cigarette smoking An obese woman with a history of type 1 diabetes mellitus

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A home care nurse is visiting an older adult client. During the visit, the client's spouse sustains a minor thermal injury when cooking. The nurse intervenes, doing which of the following first? a) Apply any antimicrobial ointment available at home b) Pull off any clothes sticking to the burnt area c) Flush the area with copious amounts of cool water d) Refrain from removing any of the client's jewelry Flush the area with copious amounts of cool water

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse notes a number of laceration wounds around the cervix of the uterus due to childbirth. How could the nurse describe the laceration wound in the client's medical record? a) A clean separation of skin and tissue with a smooth, even edge b) A shallow crater in which skin or mucous membrane is missing c) A wound in which the surface layers of skin are scraped away d) A separation of skin and tissue in which the edges are torn and irregular A separation of skin and tissue in which the edges are torn and irregular

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You are preparing to measure the depth of a patient's tunneled wound. Which of the following implements should you use to measure the depth accurately? a) A sterile tongue blade lubricated with water soluble gel b) An otic curette c) A sterile, flexible applicator moistened with saline d) A small plastic ruler A sterile flexible applicator moistened with saline

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A nurse is cleaning the wound of a gunshot victim. Which of the following is a recommended guideline for this procedure? a) Once the wound is cleaned, dry the area with an absorbent cloth. b) Use clean technique to clean the wound. c) Clean the wound from the bottom to the top and outside to center. d) Clean the wound from the top to the bottom and center to outside.

Clean the would from the top to the bottom and center to outside

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers The acute care nurse is caring for a patient whose large surgical wound is healing by secondary intention. The patient asks, "Why is my wound still open? Will it ever heal?" Which of the following responses by the nurse is most appropriate? a) "As soon as the infection clears, your surgeon will staple the wound closed." b) "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." c) "Your wound will heal slowly as granulation tissue forms and fills the wound." d) "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal."

Your wound will heal slowly as granulation tissue forms and fills the wound

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Upon assessment of the skin of a patient recovering from cardiac surgery, the nurse notes that ecchymosis is present around the incision. What are the physical findings of this condition? a) A purplish discoloration due to a collection of blood in the subcutaneous tissues b) Small hemorrhagic spots caused by capillary bleeding c) Softening of tissue due to excessive moisture d) Accumulation of fluid in the interstitial tissues A purplish discoloration due to a collection of blood in the subcutaneous tissues

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While performing a bedbath, you noted an area of tissue injury on the patient's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. Which of the following is the correct name of this wound? a) Stage I pressure ulcer b) Stage IV pressure ulcer c) Stage II pressure ulcer d) Stage III pressure ulcer Stage II pressure ulcer

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers You are applying a saline-moistened dressing to a patient's wound. The patient asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which of the following responses is most appropriate? a) "Allowing a scab to form would prevent us from observing the wound for signs of infection." b) "This wound is too large for a scab to form over it, so a moist dressing is the best alternative." c) "Wounds heal better when a moist wound bed is maintained." d) "You may be correct. I will check with your primary healthcare provider."

Wounds heal better when a moist wound bed is maintained

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A nurse inspecting a patient's pressure ulcer documents the following: full-thickness tissue loss; visible subcutaneous fat; bone, tendon, and muscle are not exposed. This pressure ulcer is categorized to be at which of the following stages? a) Stage II b) Stage III c) Stage IV d) Stage I State III

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A nurse bandages the knee of a client who has recently undergone a knee surgery.

Which of the following is the major purpose of the bandage? a) Reduces swelling and inflammation b) Supports the area around the wound c) Maintains a moist environment d) Keeps the wound clean Supports the area around the knee

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse caring for a post-operative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as which of the following? a) Serosanguineous b) Serous c) Sanguineous d) Purulent Serosanguineous

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A Penrose drain typically exits a patient's skin through a stab wound created by the surgeon. a) True b) False True

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What type of dressing has the advantages of remaining in place for 3 to 7 days, resulting in less interference with wound healing? a) Hydrogels b) Alginates c) Transparent films d) Hydrocolloid dressings Hydrocolloid dressings

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An elderly client has edema of the right lower extremity with redness and clear drainage. This is most likely related to a) Venous insufficiency b) Age c) Beta-hemolytic streptococcus d) Hemangioma Venous insufficiency

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers In the elderly client, wrinkling is related to a) Loss of elasticity b) Loss of circulation c) Loss of fat d) Loss of protein loss of elasticity

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The nurse is caring for a woman has a labile carbuncle. Which of the following interventions will most likely be included in the plan of care? a) Soak in a warm bath for drainage b) Expose the area to a heat lamp c) Cleanse labia with scented soap d) Apply an ice pack to relieve pain Soak in a warm bath for drainage

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A postoperative client describes the following during a transfer, "I feel like something just popped." The nurse immediately assesses for

a) Herniation b) Dehiscence c) Evisceration d) Infection Dehiscence

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Which of the following nutrients will prevent abnormal pigmentation? a) Vitamin D b) Vitamin E c) Fat d) Copper Vitamin E

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers The nurse would recognize which of these devices as an open drainage system? a) Jackson-Pratt drain b) Negative pressure dressing c) Hemovac d) Penrose drain Penrose drain

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The wound care nurse evaluates a patient's wound after being consulted. The patient's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to patient's state of dehydration and dehydrated tissues in the wound that are crusty.

What is another term for localized dehydration in a wound? a) Necrosis b) Maceration c) Evisceration d) Desiccation Desiccation

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A client has a small wound with moderate drainage. The nurse should apply a) Hydrogels b) Collagens c) Hydrophilic polyurethane d) Silver dressings Hydrogels

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Upon review of a postoperative patient's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? a) Antihypertensive drugs b) Corticosteroids c) Potassium supplements d) Laxatives Corticosteroids

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse applies an aquathermia pad on the back of a patient with arthritis. What is the expected action that will occur with this application of heat? a) Decreased blood flow to the area b) Dilated peripheral blood vessels c) Decreased inflammatory response d) Increased venous congestion Dilated peripheral blood vessels

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A nurse prepares to give a sitz bath to a client after perianal surgery. Which of the following would be most important for the nurse to do? a) Assess for rapid pulse and facial pallor b) Keep the feet and torso uncovered c) Encourage use of sitz bath for about an hour d) Maintain the temperature of water at 100F Assess for a rapid pulse and facial pallor

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You are caring for a patient who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, you note that the packing material is dry and adheres to the wound bed. Which of the following modifications is most appropriate? a) Reduce the time interval between dressing changes. b) Use less packing material. c) Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead. d) Assure that the packing material is completely saturated when placed in the wound.

Reduce the time interval between dressing changes

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It is customary for the registered nurse to perform the initial postoperative dressing change. a) True b) False False

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse is treating the pressure ulcer on the scapula of a bedridden patient. Which of the following must be used during this procedure? a) Sterile Technique b) Clean technique c) Transmission-Based Precautions d) Aseptic technique Clean Technique

Chapter 29: Medications

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A nurse is administering a subcutaneous injection to a client. What is the common maximum volume of a subcutaneous injection?

1 mL

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Drugs known to cause birth defects are called Teratogenic

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What is involved in the absorption, distribution, metabolism, and excretion of medication?

Pharmacokinetics

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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A client is ordered to receive an intramuscular injection of medication. When preparing to administer the injection, the nurse selects the ventrogluteal site based on which reason? free of major blood vessels and fat. It is considered the safest and least painful site

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A nurse is providing care for a patient who has a history of dementia. Which of the following methods should the nurse use in order to determine the patient's identity prior to medication administration?

Check the patient's identification band.

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The nurse is preparing to administer a medication via a nasogastric tube. What guideline is appropriate for the nurse to follow when administering a drug via this route? position the patient with the head of the bed elevated, administering the medication at room temperature, flushing the tube with water between each drug administered, and avoiding the use of suction for 20 to 30 minutes after the drug is administered

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A nurse is reviewing information about prescribed drug in a drug handbook in preparation for administration to a client. When reading about the drug, the nurse identifies which name as the generic name?

Ampicillin sodium

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse is caring for a client who has been prescribed codeine, a narcotic medication to relieve severe postoperative pain. Which of the following responsibilities does the nurse have to complete when handling narcotic medications? Select all that apply • Maintain an accurate account of the use of the medication • Record each medication used from the stock supply • Count each narcotic medication at the change of each shift

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A nurse is administering medications through an enteral tube to a client with swallowing difficulties due to a cerebrovascular accident (CVA). Which of the following actions should the nurse perform to prevent gastric reflux?

Help the client into a Fowler's position

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A nurse is caring for a client in the nursing unit when the physician, during the rounds, prescribes a medication for the client. What appropriate action should the nurse take to ensure the accuracy of the verbal medication order? ask the physician for a written order. When obtaining phone orders, it is important to repeat the dosages of medications and to spell medication names for confirmation of accuracy

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse needs to administer a subcutaneous heparin injection to a client. Which of the following injection sites is most suitable for heparin?

The abdomen, because of less pain intensity

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You are preparing to administer a sublingual medication. Which of the following instructions to the patient is correct? not to swallow while the pill dissolves

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Which one of the following medications would most likely be administered via a transdermal patch? hormones, narcotic analgesics, cardiac medications, and nicotine

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The primary reason for the Controlled Substances Act is to prevent drug abuse and dependence, provide treatment and rehabilitation for people who are dependent on drugs, and strengthen drug abuse laws

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A nurse is explaining to a client the correct method of using a metered-dose inhaler when self-administering a prescribed dose of medication. Which of the following is a feature of a metered-dose inhaler?

It is a canister that contains pressurized medication

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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A nurse at the health care facility needs to instill eye medication in a client with conjunctivitis. What care should the nurse take to avoid injury when instilling the medication?

Ask the client to blink his eye

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You are preparing to administer a transdermal medication. How should this be accomplished? adsorbed through the skin

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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A nurse needs to use a moisturizer for an elderly client with dry skin. Why is the onset of the medication action typical in an elderly client?

Diminished subcutaneous fat

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An elderly client with pneumonia has been prescribed the use of a bronchodilator by the physician. What should the nurse monitor in a client taking an inhaled bronchodilator? heart rate and blood pressure of the elderly client who uses inhaled bronchodilators. It is important to monitor the vital signs because these medications commonly cause tachycardia and hypertension. Either or both of these effects increase the risks of complications, especially in elderly clients with underlying cardiovascular disease

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A patient with chronic obstructive pulmonary disease has been prescribed an inhaled bronchodilator. Which of the following techniques should the nurse implement in order to ensure safe and complete delivery of the prescribed medication?

The use of an extender or spacer ensures that the patient receives as much of the inhaled medication as possible

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Regarding medication administration, what must occur at the change of shifts? perform a count of controlled medications at specified times (each shift) or when removed from an automated dispensing machine

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The "Rights of Medication Administration" help to ensure accuracy when administering medications. Which of the following represent these five rights?

(1) Right medication is given to the (2) right patient in the (3) right dosage through the (4) right route at the (5) right time

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To which of the following patients would the nurse be most likely to administer a PRN medication?

A complaint of "breakthrough" pain, especially postsurgery

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The nurse of a newly admitted patient notes a penicillin allergy, yet the physician has just written an order for an antibiotic in the same drug family; after reviewing the patient's wound culture and sensitivity. How should the nurse respond to this situation?

Withhold the medication until the potential drug allergy has been addressed by the care team

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What is the term used for the concentration of drug in the blood serum that produces the desired effect without causing toxicity?

Therapeutic range

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Children's medication dosages are most often calculated using the child's body surface area and Weight

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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A nurse needs to administer an intradermal tuberculin skin test injection to a client.

Which of the following is the most suitable angle when administering an intradermal injection? hold the syringe almost parallel to skin at a 10-degree angle with the bevel pointing upward.

This facilitates delivering the medication between the layers of the skin and advances the needle to the desired depth

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A client with dry skin has been prescribed inunction. Which of the following should the nurse do to promote absorption of the ointment? rub the ointment into the client's skin

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The nurse transcribes an order that reads: Colace 100 mg PO daily. This is an example of which type of order? standing order, which is to be carried out as specified until it is cancelled by another order

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Which organ is the primary site for drug metabolism?

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A nurse has to administer a subcutaneous injection to a client. For which of the following clients can the nurse administer a subcutaneous injection at a 90-degree angle? in a normal-size or obese client who has a 2-inch tissue fold when it is bunched. For thin clients who have a 1-inch fold of tissue, the nurse inserts the needle at a 45-degree

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A nurse educator is teaching a student nurse how to choose the correct needle for an injection. Which of the following guidelines for needle selection might they discuss?

The larger the gauge, the smaller the needle

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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A nurse is using an 18-gauge needle to administer a medication to a client. The nurse knows that when compared to a 27-gauge needle, an 18-gauge needle has which of the following features?

For most injections, 18- to 27-gauge needles are used; the smaller the number, the larger the diameter

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Medications administered that are renal toxic should have frequent assessments of which blood values?

BUN and creatinine

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A nurse is bunching the tissue of a client when administering a subcutaneous injection.

The nurse knows that which of the following is the reason for bunching when injecting subcutaneously?

Nurses bunch tissue between the thumb and fingers before administering the injection to avoid instilling medication within the muscle

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse at a health care facility administers a prescribed drug to a client and does not record doing so in the medical administration record. The nurse who comes during the next shift, assuming that the medication has not been administered, administers the same drug to the client again. The nurse on the previous shift calls to inform the health care facility that the administration of the drug to this client in the earlier shift was not recorded. What should the nurse on duty do immediately upon detection of the medication error? immediately check the client's condition. When medication errors occur, nurses have an ethical and legal responsibility to report them to maintain the client's safety. As soon as the nurse recognizes an error, he or she should check the client's condition and report the mistake to the prescriber and supervising nurse immediately.

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A nurse needs to administer an intramuscular injection to a thin and frail elderly client.

Which of the following actions should the nurse perform to avoid striking the bone when injecting?

The muscular tissue should be pinched together to avoid striking the bone when administering an intramuscular injection if the older person has decreased subcutaneous fat

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A nurse is caring for a client undergoing IV therapy. The nurse knows that intravenous administration of medication is appropriate in which of the following situations? when clients have disorders, such as severe burns, that affect the absorption and metabolism of medications. IV therapy is also used in an emergency when a quick response is needed

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A nurse is using the Z-track technique to administer an injection to a client. Which of the following injection routes utilizes the Z-track technique?

Intramuscular

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse needs to combine two different prescribed drugs in a syringe and then administer them to a client with influenza. Which of the following precautions should the nurse take when combining drugs?

Withdraw exact amounts of each drug from each container

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A nurse needs to administer a prescribed dose of a narcotic medication to a client with acute neck pain. Which of the following precautions should the nurse take when storing narcotic medications? place narcotic drugs in a double-locked drawer. Narcotics are controlled substances, meaning that federal laws regulate their possession and administration

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The process by which a drug moves through the body and is eventually eliminated is Pharmacokinetics is the process by which a drug moves through the body and is eventually eliminated

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A severe allergic reaction from a medication requires anaphylactic reaction, requires immediate medical intervention because it can be fatal.

Treatment includes discontinuing the medication and administering epinephrine, IV fluids, and antihistamines

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A nurse is assigned to a nursing unit where bar-coded identification systems are used for medication distribution. Which of the following should the nurse do when administering medication to clients wearing bar-coded identification bracelets?

• Scan the client's identification bracelet • Tally the bar code with packaged medication • Check for client confirmation by the system

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Which of the following patients receives a drug that requires parenteral route? drugs administered by intravenous, injections, & syringe

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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An acute care facility follows the unit dose supply method to supply medication to the clients. What is meant by the unit dose supply method? self-contained packets hold one tablet or capsule for an individual client

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A nurse is administering a prescribed intramuscular injection to a client by the Z-track technique. Which of the following actions ensures that the medicine remains sealed? pull the tissue laterally until the tissue is taut

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A client has been prescribed nasal medication. What care should the nurse take to avoid potential complications due to the administration of this medication?

Review the client's medication, allergy, and medical history

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse is administering medication to a patient with a gastrointestinal tube. Which of the following is a recommended guideline for medication administration using this route?

Medications should be crushed to a fine powder and mixed with 15 to 30 mL of water before delivery through the tube. Use liquid medications when possible, because they are readily absorbed and less likely to cause tube occlusions

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A nurse needs to administer a prescribed injection to a toddler. Which of the following injection sites is most suitable for the client? vastus lateralis site is the most desirable site for administering injections to infants and small children and clients who are thin or debilitated with poorly developed gluteal muscles

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If the dosage is inappropriate for a client, who is responsible?

Whereas physicians and other healthcare providers prescribe and pharmacists dispense therapeutic agents, it is the nurse's legal domain to administer medications in a safe and timely manner

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The nurse is caring for a client who has problems coordinating his breathing with the inhaler use. Therefore, the client is unable to receive the full dose. Which of the following would help maximize drug absorption in this client?

A spacer would help maximize the absorption of the drug in a client who is having problems coordinating his breathing with the inhaler use. A spacer provides a reservoir for the aerosol medication. As the client takes additional breaths, he continues to inhale the medication held in the reservoir. This tends to maximize the drug's absorption because it prevents drug loss

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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A nurse is using a volume control set to administer a dose of prescribed medication to a client. The nurse opens the lower clamp until the tubing is filled with fluid and then reclamps it. Which of the following statements explains the nurse's action? purges air from the tubing

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When instructing a client regarding sublingual application, the nurse should inform the client that which of the following is contraindicated when administering the drug? the client should avoid swallowing or chewing the medication. Eating or smoking during administration is also contraindicated

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A nurse should read the instructions stated on a vial container before reconstituting it and administering it to a client. Which of the following instructions are stated on the label of a vial container?

Amount of diluent to be added

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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A nurse is administering a prescribed dose of medication to a client through a medication lock. How often should the nurse flush the medication lock to maintain patency? flush medication locks every 8 to 12 hours with saline or heparin

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A nurse is administering an injection to a client at a 15-degree angle. The client has a venous access port. Which of the following injections can be administered at this angle?

When giving an intradermal injection, instills the medication shallowly at a 10- to 15-degree angle of entry

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Which of the following are recommended guidelines for the nurse who is administering a piggyback intermittent intravenous infusion of medication?

Attach infusion tubing to the medication container by inserting the tubing spike into the port with a firm push and twisting motion

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers When administering heparin subcutaneously, the nurse should Never aspirate

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If an elderly client is having difficulty comprehending the discharge instruction, the nurse should involve a second responsible person in the instruction in order to ensure client safety A referral for skilled nurse visits is appropriate for homebound older adults who need additional instructions about medication routines after discharge

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A nurse is caring for a client with difficulty breathing due to nasal congestion. What care should the nurse take to prevent the client from inhaling large droplets of the medication when the nasal spray is being administered? instruct the client to breathe through her mouth. Place the tip of the container just inside the nostril confines the spray within the nasal passage. In order to facilitate depositing the drug where its effect is desired, the nurse should help the client to a sitting or lying position with her head tilted backward or to the side if the drug needs to reach one or the other sinus

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The nurse is preparing to administer meperidine (Demerol) as an intramuscular injection in an adult patient's deltoid site. Which of the following needles should the nurse select for this injection?

1" with a 22 gauge

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A nurse at the health care facility needs to administer an otic application for a client with an earache. What should the nurse do after instilling the prescribed eardrops in the client's ear? ask the client to maintain the position until the solution travels toward the eardrum. When instilling the medication in the client's ear, the nurse first manipulates the client's ear to straighten the auditory canal. Tilting the client's head away, the nurse then administers the

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers prescribed number of drops of medication. The client remains in this position briefly as the solution travels toward the eardrum. The nurse then places a cotton ball loosely in the ear to absorb the excess medication. The nurse then waits for at least 15 minutes before administering the medication in the opposite ear if prescribed

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A nurse is caring for a patient with pancreatic cancer who is receiving continuous morphine for pain. Which of the following would be the most effective method to administer this medication? a continuous subcutaneous infusion of morphine - longer rate of absorption

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A nurse is caring for a client with an intravenous catheter. When administering medication through the intravenous port, the nurse pinches the tubing upstream from the port when instilling it with the drug. Which of the following reasons explains the nurse's action?

Ensure administration of medication. Pinching ensures that the tube does not get backfilled and that the drug gets administered to the client

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A nurse needs to administer a prescribed medication to a client using IV push. In which of the following ways is the medication being administered to the client?

A bolus is a large amount of medication given all at once; bolus administration is described as a drug given by IV push, or rapid IV

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The physiologic and biochemical effects of a drug Pharmacodynamics refers to the physiologic and biochemical effects of a drug on the body

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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Which of the following medication-administration systems protects the client by identifying the rights of medication administration?

The Barcode Medication Administration system will warn of a potential error

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A nurse is applying a vaginal cream to a patient with a vaginal infection. Which of the following is a recommended guideline for this application?

Cleanse area at vaginal orifice with wash cloth and warm water

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After teaching a group of nursing students about pharmacokinetics, the instructor determines that the teaching was successful when the students identify which of the following as the process by which the medication is delivered to the target cells and tissues? distribution, absorption is the process by which a medication enters the bloodstream

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A nurse caring for a client with diarrhea needs to establish an intravenous (IV) access to administer fluids and medication. When explaining intravenous access to the client, which of the following would the nurse most likely incorporate into the description?

Insertion of a needle into a peripheral vein

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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A client suffers from infectious diarrhea. Based on his loss of fluid, his protein level is below normal. What blood product will the physician order to restore intravascular volume?

Albumin

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The maintenance of client safety with medication administration is of primary importance in healthcare. The most commonly used system for billing and record keeping is the Automated dispensing system - keeps an account of all medication used for billing, controlled substance & record keeping. Access by using a password or by fingerprint. The medication is delivered in a unit-dose package.

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A nurse needs to administer a prescribed dosage of oral medication to a client with influenza. Which of the following actions should the nurse perform when administering oral medication to the client? never administer medications prepared by another nurse. Prepare and bring oral medications to the client's bedside in a paper or plastic cup, not in a glass container or ceramic cup, in order to avoid accidents and spills. Check the label of the medication container three times when preparing it

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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During a visit to the clinic, the physician prescrbes an intramuscular injection of a medication for an 8-month old. When administering this medication to the child, which of the following sites would the nurse be least likely to select?

The dorsogluteal is not used in infants and toddlers. Muscles in this site are not well developed until children begin to walk

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A nurse is administering intermittent IV medication to an active adolescent. Which of the following IV systems could be used to allow the patient more freedom?

A peripheral venous access device allows the patient more freedom. The patient is connected to the IV line when it is time to receive the medication and disconnected when the medication is completed. The device is kept patent (working) by flushing with small amounts of saline pushed through the device on a routine basis

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A nurse is administering medication to a patient via a gastric tube and finds that the medicine enters the tube and then the tube becomes clogged. What is the appropriate intervention in this situation?

When medication becomes clogged in the tube, you should attach a 10-mL syringe onto the end of the tube, pull back, and then lightly apply pressure to the plunger in a repetitive motion

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse needs to administer an insulin injection to a client with diabetes. Which of the following actions should the nurse perform to prevent bruising of the injection site?

Select all that apply.

• Change the needle before injecting • Rotate the injection sites with each injection • Avoid aspirating the plunger after placing the needle

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A nurse needs to administer medications to a client through an IV port. Which of the following actions should she perform to ascertain that the IV catheter is in the vein?

The nurse should observe for blood in the tubing near the IV catheter or insertion device because blood validates that the IV catheter is in the vein

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A nurse needs to withdraw a prescribed medication from an ampule and administer it to a client. Which of the following actions should she perform to ensure that all the medication is equally distributed when withdrawing?

Tapping the top of the ampule distributes all the medication to the lower portion of the ampule

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A nurse is caring for a client who is being tube fed. What care should the nurse take when administering medications through an enteral tube? avoid crushing sustained-release pellets because keeping them whole ensures their sequential rate of absorption

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A nurse is administering enoxaparin, (blood thinner) to a patient with DVT, via the subcutaneous route. Which of the following is a recommended guideline when administering a subcutaneous injection?

Subcutaneous injections are administered into the adipose tissue layer just below the epidermis and dermis

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A 17-year-old girl is admitted to pediatrics with a diagnosis of diabetic ketoacidosis. She requires intravenous therapy to Provide access for the administration of insulin

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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Which parenteral route of administration has the longest absorption time?

Intradermal injections administered into the dermis, just below the epidermis, this route has the longest absorption time

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A post-surgical patient's MAR provides for PRN administration of a number of analgesics by various routes. Which of the following routes will likely provide the most rapid pain relief for the patient?

Intravenous drugs, because they are introduced directly into the circulatory system

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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A client has an order for an intermittent infusion of 250 mL of 0.9 normal saline. The nurse understand that this type of infusion is used for which situation?

Medications that need to be infused over 20 to 60 minutes

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Which of the following actions are included in the required "checks" for safe medication administration? Select all that apply.

• Read the medication label when reaching for the unit dose package.

• Read the medication label after retrieving the medication from the drawer.

• Read the medication label just before administering a unit dose medication to the patient.

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A nurse is administering pain medication to an 80-year-old woman. What altered drug response might be expected due to the patient's age?

Increased possibility of toxicity due to higher drug plasma concentrations & a decreased number of protein-binding sites

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The nurse is administering a hepatitis B shot intramuscularly. What would be the appropriate site for administration? the deltoid, children are administered at the vastus lateralis

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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What is an venous access port? for patients who require long-term IV medication. The port is usually placed just under the skin on the upper part of the chest

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Subcutaneous injections administered into the adipose tissue layer The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. Which of the following would be most appropriate for the nurse to do next?

Use Doppler ultrasonography to locate the pulse.

A Doppler ultrasound device is helpful when it is impossible or difficult to assess a pulse or when pulses are not palpable. The nurse would need to attempt to assess the pulse, and if the pulse could not be obtained via Doppler, then it would be appropriate to document the absence of the pulse and include attempts to assess it, such as via palpation and Doppler ultrasound.

Asking another nurse to assess the pulse would be helpful in confirming the finding, especially if no pulse was obtained via Doppler. Auscultating with a stethoscope would not be helpful.

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When analyzing the nursing history recently taken on a client, which factor would alert the nurse to a significantly increased risk for chronic arterial insufficiency?

Cigarette smoking The use of any form of tobacco significantly increases a person's risk for chronic arterial insufficiency. The risk increases according to the length of time a person smokes and amount of tobacco smoked. Daily exercise would be a measure to reduce a person's risk for vascular disease. Family history of diabetes, hypertension, coronary heart disease, intermittent claudication, or elevated lipid levels would be important because these disorders tend to be heredity and cause damage to the blood vessels. Alcohol intake is unrelated to the development of chronic arterial insufficiency.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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A nurse observes a decrease in hair on the lower extremities of an elderly client. What is an appropriate action by the nurse in regards to this finding?

Elevate the legs and observe for the onset of pallor.

Loss of hair can be a normal finding in the elderly client, but the nurse should perform further assessment before making this judgment. Loss of hair is seen with arterial insufficiency. Ulcers on the medial aspect of the ankle are a sign of venous stasis as is the presence of edema. Pallor, or loss of color, is seen in arterial insufficiency, especially when the legs are elevated.

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Which of the following assessment findings is most congruent with chronic arterial insufficiency?

Cool foot temperature and ulceration on the client's great toe Pigmentation, medial ankle ulceration, and thickened, scarred skin are associated with venous insufficiency, while low temperature and toe ulceration are more commonly found in cases of arterial insufficiency.

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The nurse documents a 2+ radial pulse. What assessment data indicated this result? brisk, expected (normal) pulse

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A client reports pain in the legs that begins with walking but is relieved by rest. Which condition should the nurse assess the client for?

Peripheral vascular problems

The nurse should assess the client for peripheral vascular problems in both the legs.

Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. In case of an acute obstruction, the leg pain would persist even when the client stopped walking. Diabetes can cause pain as a result of diabetic neuropathy, which is unrelated to walking. Low calcium level may cause leg cramps but would not necessarily be related to walking.

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When assessing the lymph system of a 52-year-old patient, the nurse notes that the epitrochlear nodes are nonpalpable. What does this indicate?

Normal finding Normally, the epitrochlear nodes are not palpable. Normal palpable nodes are 2 cm or less.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Nonpalpable epitrochlear nodes are not an indication of lymphoma or atherosclerosis. They are not related to lymphedema or its absence

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A nurse is unable to palpate a client's radial and ulnar pulses. Which of the following would the nurse do next?

Palpate the brachial pulse.

When unable to palpate a peripheral pulse, the pulse area immediately proximal to it should be palpated. In this case, the brachial pulse is indicated. Inability to palpate the client's pulses suggests arterial insufficiency.

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Walking contracts the calf muscles and forces blood away from the heart.

False

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While performing a routine check-up on an 81-year-old retired grain farmer in the vascular surgery clinic, the nurse notes that he has a history of chronic arterial insufficiency. Which of the following physical examination findings of the lower extremities would be expected with this disease?

Thin, shiny, atrophic skin Thin, shiny, atrophic skin is more commonly seen in chronic arterial insufficiency; in chronic venous insufficiency the skin often has a brown pigmentation and may be thickened.

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Which of the following wounds is most likely attributable to neuropathy?

A painless wound on the sole of the client's foot, which is surrounded by calloused skin

Neuropathic ulcers tend to develop on pressure points, such as the sole of the foot, and are often free of pain. Painful wounds surrounded by healthy skin are associated with arterial insufficiency and moderately painful ankle wounds surrounded by pigmented skin are often associated with venous ulcers.

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If palpable, superficial inguinal nodes are expected to be: Nontender, mobile, and 1 cm in diameter Healthy lymph nodes are nontender and mobile. Inguinal lymph nodes can be 1 to 2 cm in diameter.

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A client asks the nurse about the function that the lymph system plays in the body.

Which of the following would be most appropriate for the nurse to include when responding to the client?

It filters harmful substances from the body.

Explanation: The lymphatic system's primary function is to drain excess fluid and plasma proteins, not capillary blood, from body tissues and return them to the venous system. The system contains lymph nodes that filter microorganism, foreign materials, dead blood cells, and abnormal cells and trap and destroy them. Antibodies and T lymphocytes are produced by the immune system.

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Which of the following clients is most likely at the greatest risk of acute compartment syndrome?

A 17-year-old who has just been fitted with an arm cast following a fracture of his radius Application of a cast that is too tight is a central risk factor for the development of compartment syndrome. Immobility and smoking are not key to the development of compartment syndrome, while pregnancy and IV drug use constitute a risk of thrombosis.

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A nurse cares for a client who is postoperative cholecystectomy. Which action by the nurse is appropriate to help prevent the occurrence of venous stasis?

Assist the client to walk as soon and as often as possible.

Immobility creates an environment in which clotting (embolism formation) can be caused by venous stasis. Active exercise such as having the client ambulate as soon as possible will stimulate circulation and venous return. This reduces the possibility of clot formation. Raising the foot of the bed, vigorous massage, and active range of motion of the upper body may not prevent venous stasis.

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The nurse is palpating the pulse just under the inguinal ligament. The nurse is assessing which pulse?

Femoral

The femoral pulse is palpated in the groin (inguinal area) by compressing the femoral artery between skin and bone. The temporal pulse is located on the head. The brachial pulse is

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers palpated medial to the biceps tendon in and above the bend in the elbow. The popliteal pulse is palpated behind the knee.

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A finding on palpation that suggests venous insufficiency is: Diminished dorsalis pedis pulse in an edematous foot Venous insufficiency is associated with significant edema, and possibly diminished pedal pulses as a result. Ulceration, if present, tends to be on the sides of the foot and temperature is usually normal. Sensation does not tend to diminish.

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A 57-year-old maintenance worker comes to the office for evaluation of pain in his legs.

He is a two-pack per day smoker since the age of 16, but he is otherwise healthy. The nurse is concerned that the client may have peripheral vascular disease. Which of the following is part of common or concerning symptoms for the peripheral vascular system?

Intermittent claudication Intermittent claudication is leg pain that occurs with walking and is relieved by rest. It is a key symptom of peripheral vascular disease. This symptom is present in only about one third of clients with significant arterial disease and, if found, calls for more aggressive management of cardiovascular risk factors. Screening with ankle-brachial index can help detect this problem.

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The veins from where drain into the superior vena cava? (Mark all that apply.)

• Upper torso • Head • Upper extremities The veins of the upper extremities, upper torso, head, and neck drain into the superior vena cava and then the right atrium.

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When administering heparin subcutaneously, the nurse should Never aspirate When administering heparin subcutaneously, never aspirate before administration

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse is administering a hepatitis B shot intramuscularly. What would be the appropriate site for administration?

Deltoid

The deltoid is the best site for this medication. Biologicals for infants and young children are administered at the vastus lateralis. The ventrogluteal site is used for depot formulations and irritating mediations. The scapula is a site for an intradermal injection.

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A nurse is performing a sensitivity test on a patient. What would be the best type of injection to use for this procedure?

Intradermal

Intradermal injections are administered into the dermis, just below the epidermis. The intradermal route has the longest absorption time of all parenteral routes. For this reason, intradermal injections are used for sensitivity tests, such as tuberculin and allergy tests, and local anesthesia. The advantage of the intradermal route for these tests is that the body's reaction to substances is easily visible, and degrees of reaction are discernible by comparative study.

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A patient with a complex cardiac history has been prescribed digoxin (Lanoxin) 0.0625 mg PO. The drug is available as 125 mcg tablets. How many of the tablets will the nurse administer?

0.5 125 mcg = 0.125 mg. 0.0625 mg 0.125 mg = 0.5 tablets

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A nurse needs to administer a prescribed injection to a toddler. Which of the following injection sites is most suitable for the client?

Vastus lateralis site The vastus lateralis site is the most desirable site for administering injections to infants and small children and clients who are thin or debilitated with poorly developed gluteal muscles.

The dorsogluteal site is avoided in clients younger than 3 years because their gluteus maximus muscle is not sufficiently developed; whereas, the ventrogluteal site is safe for children. The deltoid site is the least-used intramuscular injection site because it is a smaller muscle than the others. It is used only for adults because the muscle is not sufficiently developed in infants and children.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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Drugs known to cause birth defects are called Teratogenic Drugs know to cause birth defects are called teratogenic.

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If the dosage is inappropriate for a client, who is responsible?

Nurse

Whereas physicians and other healthcare providers prescribe and pharmacists dispense therapeutic agents, it is the nurse's legal domain to administer medications in a safe and timely manner.

??

A nurse at a health care facility has to instill ear drops in a client. The nurse knows that which of the following techniques varies for an adult and child client?

Manipulation of the client's ear to straighten the auditory canal

The nurse should be aware that the method of manipulation of the client's ear to straighten the auditory canal varies between an adult and child client. In a young client, the nurse pulls the ear down; in an adult client, the nurse pulls the ear up and back. The medication is not diluted; the number of medication drops instilled is as per the physician's prescription and does not depend on the client's age. The position in which the client remains until the medication reaches the eardrum and the amount of time before instilling medication in the client's opposite ear does not differ with the age of the client.

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A nurse is providing care for a patient who has a history of dementia. Which of the following methods should the nurse use in order to determine the patient's identity prior to medication administration?

Check the patient's identification band.

For all patients, the preferred method of confirming identity is to read the patient's identification band.

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers The primary reason for the Controlled Substances Act is To prevent drug abuse The primary reason for the Controlled Substances Act is to prevent drug abuse and dependence, provide treatment and rehabilitation for people who are dependent on drugs, and strengthen drug abuse laws.

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The nurse transcribes an order that reads: Colace 100 mg PO daily. This is an example of which type of order?

Standing order This is an example of a standing order, which is to be carried out as specified until it is cancelled by another order.

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When the client demonstrates a rash 30 minutes after she has taken a dose of penicillin, the nurse recognizes that the client is likely demonstrating which type of drug reaction?

Allergy

Explanation: Allergic reactions result from an immunologic response to a substance to which the client is sensitized.

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A nurse needs to use a moisturizer for an elderly client with dry skin. Why is the onset of the medication action atypical in an elderly client?

Diminished subcutaneous fat

Explanation: The onset of medication action is atypical for topical medications due to diminished subcutaneous fat, resulting in quicker absorption. Decreased appetite, diminished physical mobility, and decreased body temperature may not lead to atypical action with relation to the application of topical medication.

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Which medication system allows for client independence?

Self-administered medication system

Explanation: The self-administered system allows the client independence and responsibility while simultaneously allowing nursing supervision, teaching, and evaluation for client compliance and safety medication management prior to facility discharge.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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A nurse is caring for a client with severe lower back pain. The doctor orders administration of an analgesic as a stat dose. When should the nurse administer the medication?

Immediately

Explanation: The nurse should give the medication immediately. A stat order is a single order for a medication that must be given immediately. An administration order for a specified number of days is a standing order. A medication order that is given only once is a one-time order. PRN medications are given as needed by the client.

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Medications administered that are renal toxic should have frequent assessments of which blood values?

BUN and creatinine

Explanation: If medications are known to cause kidney dysfunction, kidney function tests (serum creatinine, blood urea nitrogen).

??

A severe allergic reaction from a medication requires Epinephrine

Explanation: A severe allergic reaction, called an anaphylactic reaction, requires immediate medical intervention because it can be fatal. Treatment includes discontinuing the medication and administering epinephrine, IV fluids, and antihistamines.

??

A client with dry skin has been prescribed inunction. Which of the following should the nurse do to promote absorption of the ointment?

Rubbing the ointment into the skin

Explanation: In order to promote absorption, the nurse should rub the ointment into the client's skin. Shaking the contents would mix the contents uniformly, whereas applying the with a cotton ball would distribute the substance over a wide area. Warming the ointment before application would provide comfort.

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Which of the following medication-administration systems protects the client by identifying the rights of medication administration?

Barcode Medication Administration

Explanation: The Barcode Medication Administration system will warn of a potential error if the action does not meet the rights of medication administration.

??

What is the term used for the concentration of drug in the blood serum that produces the desired effect without causing toxicity?

Therapeutic range

Explanation: Therapeutic range is the concentration of drug in the blood serum that produces the desired effect without causing toxicity. Peak level is the highest plasma concentration.

Trough level is the point when the drug is at the lowest concentration. Half-life is the amount of time it takes for 50% of the blood concentration of a drug to be eliminated from the body.

??

Which of the following accurately describes a recommended guideline when administering oral medications to patients?

If a child refuses to take medication, the medication can be crushed and added to a small amount of food.

Explanation: Medication can be added to small amounts of food, but should not be added to liquids. If it is questionable whether the medication was swallowed, check the patient's mouth and cheeks. If a pill is dropped, it should be discarded, and if a patient vomits, notify the physician to see if the medication should be readministered.

??

A nurse is caring for a client who has been prescribed codeine, a narcotic medication to relieve severe postoperative pain. Which of the following responsibilities does the nurse have to complete when handling narcotic medications? Select all that apply.

• Count each narcotic medication at the change of each shift • Record each medication used from the stock supply • Maintain an accurate account of the use of the medication

Explanation: When handling narcotic medications, the nurse should have an accurate account of the use of the medications, a record of each medication used from the stock supply, and the nurse should count each narcotic at the change of each shift. Narcotic medications are

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers controlled substances, meaning that federal laws regulate their possession and administration.

The nurse should not place the medication in the container with other prescribed medications or place the medication along with other medications on the nursing unit. An individual supply is placed in a container with enough of the prescribed medication for several days or weeks and is common in long-term care facilities such as nursing homes. A stock supply remains on the nursing unit for use in an emergency or so that a nurse can give a medication without delay.

??

A client is to take Demerol 35 mg IM. You have Demerol 50 mg per cc. How many cc will you administer?

0.7 cc

Explanation: The nurse will administer Demerol 35 mg or 0.7 cc.

??

A nurse is administering medications through an enteral tube to a client with swallowing difficulties due to a cerebrovascular accident (CVA). Which of the following actions should the nurse perform to prevent gastric reflux?

Help the client into a Fowler's position.

Explanation: Assuming Fowler's position can help prevent gastric reflux when medications are administered through an enteral tube. The nurse checks the client's medical history for drug allergies to avoid potential complications. Adding diluted medication to the syringe as it becomes nearly empty prevents instilling air into the syringe. Administering the medication over several minutes has no effect on reflux.

??

A client has been prescribed nasal medication. What care should the nurse take to avoid potential complications due to the administration of this medication?

Review the client's medication, allergy, and medical history

Explanation: To avoid any potential complications, the nurse should review the client's medication, allergy, and medical history. The nurse should read and compare the label on the medication with the medical record at least three timesbefore, during, and after preparing the medicationto ensure that the right medication is given at the right time by the right route.

Administering the medication within 30 to 60 minutes of the scheduled time demonstrates timely administration and compliance with the medical order. Allowing sufficient time to prepare the medication with minimal distraction promotes the safe preparation of medications.

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse needs to administer an intradermal injection to a client. Which of the following is the most common site for administering an intradermal injection?

Forearm

Explanation: The most common site for an intradermal injection is the inner aspect of the forearm. Intradermal injections are commonly used for diagnostic purposes. Examples include tuberculin tests and allergy testing. Small volumes, usually 0.01 to 0.05 mL, are injected because of the small tissue space. Other areas that may be used are the back and upper chest, not the stomach.

??

A nurse is administering a subcutaneous injection to a client. What is the common maximum volume of a subcutaneous injection?

1 mL

Explanation: The volume of a subcutaneous injection is usually up to 1 mL. An intramuscular injection is the administration of up to 3 mL of medication into one muscle or muscle group.

Intradermal injections are commonly used for diagnostic purposes in small volumes, usually 0.01 to 0.05 mL.

Answer Key Question 1: (see full question)

A nurse is administering a subcutaneous injection to a client. What is the common maximum volume of a subcutaneous injection?

You selected:

1 mL

Correct

Explanation:

The volume of a subcutaneous injection is usually up to 1 mL. An intramuscular injection is the administration of up to 3 mL of medication into one muscle or muscle group. Intradermal injections are commonly used for diagnostic purposes in small volumes, usually 0.01 to 0.05 mL. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 778.

Chapter 28: Medications - Page 778

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Question 2: (see full question)

A patient with a complex cardiac history has been prescribed digoxin (Lanoxin) 0.0625 mg PO. The drug is available as 125 mcg tablets. How many of the tablets will the nurse administer?

You selected:

0.5

Correct

Explanation:

125 mcg = 0.125 mg. 0.0625 mg 0.125 mg = 0.5 tablets

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, pp. 765-766.

Chapter 28: Medications - Page 765

Question 3: (see full question)

What is the term used for the concentration of drug in the blood serum that produces the desired effect without causing toxicity?

You selected:

Therapeutic range

Correct

Explanation:

Therapeutic range is the concentration of drug in the blood serum that produces the desired effect without causing toxicity. Peak level is the highest plasma concentration. Trough level is the point when the drug is at the lowest concentration. Half-life is the amount of time it takes for 50% of the blood concentration of a drug to be eliminated from the body. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 835.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Chapter 28: Medications - Page 835

Question 4: (see full question)

You selected:

A nurse educator is teaching a student nurse how to choose the correct needle for an injection. Which of the following guidelines for needle selection might they discuss?

As the gauge number becomes larger, the size of the needle becomes smaller.

Correct

Explanation:

The larger the gauge, the smaller the needle. The first number on a needle package is the gauge or diameter of the needle and the second number is the length in inches. When giving an injection, the viscosity of the medication directs the choice of gauge. The size of the syringe is directed by the amount of the medication to be given. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 774.

Chapter 28: Medications - Page 774

Question 5:

A severe allergic reaction from a medication requires

(see full question)

You selected:

Epinephrine

Correct

Explanation:

A severe allergic reaction, called an anaphylactic reaction, requires immediate medical intervention because it can be fatal. Treatment includes discontinuing the medication and administering epinephrine, IV fluids, and antihistamines. (less)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 756.

Chapter 28: Medications - Page 756

Question 6: (see full question)

A 17-year-old girl is admitted to pediatrics with a diagnosis of diabetic ketoacidosis. She requires intravenous therapy to

You selected:

Provide access for the administration of insulin

Correct

Explanation:

A client with acute diabetic ketoacidosis requires intravenous access for the administration of insulin.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 785.

Chapter 28: Medications - Page 785

Question 7: (see full question)

Regarding medication administration, what must occur at the change of shifts?

You selected:

The medications for the division are counted

Incorrect

Correct response:

The narcotics for the division are counted

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Explanation:

Healthcare facility personnel perform a count of controlled medications at specified times (each shift or when removed from an automated dispensing machine).

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 768.

Chapter 28: Medications - Page 768

Question 8: (see full question)

A nurse needs to administer a subcutaneous heparin injection to a client. Which of the following injection sites is most suitable for heparin?

You selected:

Abdomen

Correct

Explanation:

The abdomen area is the preferred site for a subcutaneous heparin injection because of less pain intensity. The forearm, back, and upper chest are common sites for an intradermal injection, not a subcutaneous injection. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 778.

Chapter 28: Medications - Page 778

Question 9: (see full question)

A nurse is explaining to a client the correct method of using a metered-dose inhaler when self-administering a prescribed dose of medication. Which of the following is a feature of a metered-dose inhaler?

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers You selected:

It is a canister that contains pressurized medication.

Correct

Explanation:

A meter-dose inhaler has a canister that contains medication under pressure. It is much more commonly used than the turbo-inhaler, which is a propeller-driven device that spins and suspends a finely powdered medication. A turbo-inhaler, not a meter-dose inhaler, has propellers that get activated during inhalation. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 792.

Chapter 28: Medications - Page 792

Question 10: (see full question)

You selected:

Which of the following are included in the "five rights for medication administration"? Select all that apply.

• Right route • Right time • Right dose • Right medication

Correct

Explanation:

You should observe the patient take medications and should not leave them at the bedside.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 778.

Chapter 28: Medications - Page 778

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Question 11: (see full question)

You selected:

A nurse is caring for a client with typhoid at a health care facility.

The nurse checks the medication order in the client's chart for the drugs prescribed to the client. Which of the following is a required component of the medication order?

Client's name

Correct

Explanation:

The client's name is an important component of the medication order; without it, the nurse should withhold the administration of the drug. The client's age, diagnosis, and signature are not components of the medication order. Other components of the medication order include the date and time the order is written, the drug name, the dose to be administered, the route of administration, the frequency of administration, and the signature of the person ordering the drug. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 762.

Chapter 28: Medications - Page 762

Question 12: (see full question)

After administering medication to a client subcutaneously, the nurse removes the needle at the same angle at which it was inserted.

Which of the following explains the nurse's action?

You selected:

Minimizes tissue trauma to the client

Correct

Explanation:

Removing the needle at the same angle at which it was inserted to administer medication minimizes tissue trauma and discomfort to the client. To verify correct injection of the drug, the nurse pushes the plunger and watches for a small wheal. To prevent needle-stick injuries, the nurse covers the needle with a protective cap. Holding the client's arm and stretching the skin taut helps to control placement of the needle. (less)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 779.

Chapter 28: Medications - Page 779

Question 13: (see full question)

You selected:

A nurse is using a volume control set to administer a dose of prescribed medication to a client. The nurse opens the lower clamp until the tubing is filled with fluid and then reclamps it. Which of the following statements explains the nurse's action?

Purges air from the tubing

Correct

Explanation:

The nurse opens the lower clamp until the tubing is filled with fluid and then reclamps it because doing so purges air from the tubing.

In order to provide diluent for the medication, the nurse opens the clamp above the calibrated container, fills the chamber with desired volume of fluid, and reclamps. To remove colonizing microorganisms, the nurse swabs the injection port on the calibrated container. To mix the medication thoroughly with the fluid, the nurse rotates the fluid chamber back and forth. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 838.

Chapter 28: Medications - Page 838

Question 14: (see full question)

A client is to take Demerol 35 mg IM. You have Demerol 50 mg per cc. How many cc will you administer?

You selected:

0.7 cc

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Correct

Explanation:

The nurse will administer Demerol 35 mg or 0.7 cc.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 758.

Chapter 28: Medications - Page 758

Question 15: (see full question)

A nurse needs to use a moisturizer for an older adult client with dry skin. Why is the onset of the medication action atypical in an older adult client?

You selected:

Diminished subcutaneous fat

Correct

Explanation:

The onset of medication action is atypical for topical medications due to diminished subcutaneous fat, resulting in quicker absorption.

Decreased appetite, diminished physical mobility, and decreased body temperature may not lead to atypical action with relation to the application of topical medication. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 778.

Chapter 28: Medications - Page 778

Question 16: (see full question)

Drugs known to cause birth defects are called

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers You selected:

Teratogenic

Correct

Explanation:

Drugs know to cause birth defects are called teratogenic.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 756.

Chapter 28: Medications - Page 756

Question 17: (see full question)

A nurse is administering a hepatitis B immunization injection to an adult patient. Which site would the nurse choose for this injection?

You selected:

Deltoid muscle site

Correct

Explanation:

Hepatitis B virus vaccine is one medication that should be given in the deltoid muscle in adults to induce adequate levels of the antibody. The vastus lateralis muscle and the ventrogluteal muscle can be used for other intramuscular injections. The dorsogluteal muscle is no longer a preferred site for intramuscular injections. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 28, Medications, p. 783

Question 18:

The primary reason for the Controlled Substances Act is

(see full question)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers You selected:

To prevent drug abuse

Correct

Explanation:

The primary reason for the Controlled Substances Act is to prevent drug abuse and dependence, provide treatment and rehabilitation for people who are dependent on drugs, and strengthen drug abuse laws. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, pp. 767-768.

Chapter 28: Medications - Page 767

Question 19: (see full question)

You selected:

The nurse is beginning to administer oral medications to a client.

The client states, "I haven't taken that pill before. Are you sure it's correct?" You recheck the CMAR/MAR and find that the medication is scheduled to be administered. Which of the following responses is most appropriate?

"Don't take that pill yet. I will verify that the medication was ordered by your primary care provider."

Correct

Explanation:

This action indicates adherence to the five rights of medication administration.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 767.

Chapter 28: Medications - Page 767

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Question 20: (see full question)

When the client demonstrates a rash 30 minutes after she has taken a dose of penicillin, the nurse recognizes that the client is likely demonstrating which type of drug reaction?

You selected:

Allergy

Correct

Explanation:

Allergic reactions result from an immunologic response to a substance to which the client is sensitized.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 28: Medications, p. 756.

Chapter 28: Medications - Page 756

Answer Key Vital Signs Chapter Question 1: (see full question)

You selected:

A nurse is using a cooling blanket on an adult patient with an uncontrolled fever. Which of the following statements accurately describes a recommended guideline for using this type of equipment?

For patients who are comatose or anesthetized, use a rectal probe to monitor core body temperature.

Incorrect

Correct response:

Position the blanket under the patient so that the top edge of the pad is aligned with the patient's neck.

Explanation:

The nurse should position the blanket under the patient so that the top edge of the pad is aligned with the patient's neck; use an esophageal probe for patients who are comatose or anesthetized; cover the hypothermia blanket with a thin sheet or bath blanket; and apply lanolin or a mixture of lanolin and cold cream to the patient's skin where it will be in contact with the blanket. (less)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 585.

Chapter 24: Vital Signs - Page 585

Question 2: (see full question)

A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL and a pulse of 78 beats/minute. What number would the nurse document for this assessment?

You selected:

5,850 mL

Correct

Explanation:

Cardiac output is determined by multiplying the stroke volume by the heart rate/minute, which equals 5,850 mL. Cardiac output and peripheral resistance determine both systolic and diastolic pressures. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 24, Vital Signs, p. 594

Question 3: (see full question)

What is the ideal method for monitoring response to treatment for high blood pressure (BP)?

You selected:

The review of home blood pressure monitoring (HBPM) readings.

Correct

Explanation:

HBPM readings are the ideal method for monitoring response to treatment for high BP. The client’s BP may require medications to be controlled. HBPM readings tend to be lower and provide for a more consistent view of the clients BP over longer periods rather

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers than just the BP reading during an annual health screening.

Although important, the client’s report of feeling better is not the ideal method for monitoring of response to treatment. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 604.

Chapter 24: Vital Signs - Page 604

Question 4: (see full question)

You selected:

The nurse is taking a rectal temperature on a patient who reports feeling lightheaded during the procedure. What would be the nurse’s priority action in this situation?

Remove the thermometer and assess the blood pressure and heart rate.

Correct

Explanation:

Vagal nerve stimulation may occur when obtaining a rectal temperature. Vagal nerve stimulation can cause the pulse and blood pressure to drop significantly causing the patient to feel lightheaded; therefore the thermometer should be removed immediately and the pulse and blood pressure assessed. The physician can be called after assessing the patient. The temperature is not the priority at this time. Assistance for CPR would be determined if the patient’s condition worsens. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 24, Vital Signs, p. 588-589

Question 5:

A nurse is obtaining vital signs from patients using the tympanic method for measuring temperature. Which of the following

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers (see full question)

guidelines should be followed when taking a tympanic temperature?

You selected:

Do not take a tympanic temperature if the patient has an ear infection.

Incorrect

Correct response:

Do not take a tympanic temperature if the patient has an earache.

Explanation:

If a patient has an earache, the nurse should not use the affected ear to take a tympanic temperature, because the movement of the tragus may cause severe discomfort. The nurse should assess the patient for significant ear drainage or a scarred tympanic membrane, because these conditions can provide inaccurate results and could cause problems for the patient. However, an ear infection or the presence of earwax in the canal will not significantly affect a tympanic thermometer reading. If the patient has been sleeping with the head turned to one side, the nurse should take a tympanic temperature in the other ear. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 587.

Chapter 24: Vital Signs - Page 587

Question 6:

An ultrasonic Doppler is used for

(see full question)

You selected:

Auscultating a pulse that is difficult to palpate

Correct

Explanation:

A Doppler device can be used to detect a pulse that is not easily palpable.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia:

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 590.

Chapter 24: Vital Signs - Page 590

Question 7: (see full question)

You selected:

A nurse applies a cuff of the automated blood pressure device around the client's arm in preparation for serial blood pressure recordings. The nurse checks the cuff frequently based on which rationale?

Ensure adequate arterial perfusion

Correct

Explanation:

When using electronic automated blood pressure devices for serial blood pressure recording, frequently checking the cuffed limb ensures adequate arterial perfusion and venous drainage between measurements. The nurse does not check the cuffed limb to see if it is warm or cold, but to ensure that there is adequate arterial perfusion and venous drainage between measurements. Elevating the arm above the head between cuff measurements automatically speeds venous return to the heart. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 599.

Chapter 24: Vital Signs - Page 599

Question 8: (see full question)

Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period?

You selected:

5:00 PM

Correct

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Explanation:

Body temperature fluctuates throughout the day. Temperature is usually lowest around 3 AM and highest from 5 to 7 PM.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 582.

Chapter 24: Vital Signs - Page 582

Question 9: (see full question)

You selected:

An obese patient has developed peripheral edema as a consequence of heart failure, making it very difficult for the student nurse to accurately palpate the patient's peripheral pulses. How should the nurse proceed with this assessment?

Palpate the patient's apical pulse

Incorrect

Correct response:

Auscultate the patient's apical pulse

Explanation:

When peripheral pulses are difficult to palpate, it is appropriate to auscultate the patient's apex. This is preferable to auscultating a peripheral site, such as the brachial artery, and more accurate than attempting to palpate the apical pulse. Cardiac monitoring is not necessarily indicated in this case. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, pp. 590-591.

Chapter 24: Vital Signs - Page 590

Question 10: (see full question)

A nurse is assessing the blood pressure of a client using the Korotkoff sound technique. The nurse notes that the phase I sound

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers disappears for 2 seconds. What should the nurse document on the progress record?

You selected:

There is an auscultatory gap

Correct

Explanation:

An auscultatory gap is a period during which sound disappears. An auscultatory gap can range as much as 40 mm Hg. A widening in the diameter of the artery takes place in the phase II of the Korotkoff sound technique. An adult diastolic pressure takes place in the phase IV of the Korotkoff sound technique. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 601.

Chapter 24: Vital Signs - Page 601

1. A nurse takes a patient's vital signs. Which of the following is considered a vital sign?

A) mental status B) visual acuity C) blood pressure D) urinary output c

??

2. Which of the following patients should have their vital signs monitored at least every 4 hours?

A) a patient in a critical care unit B) a patient hospitalized for high blood pressure C) a resident in a long-term care facility D) a long-term care resident on Medicare A b

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers 3. In which of the following situations is it protocol for the nurse to take a patient's vital signs? Select all that apply.

A) upon admitting a patient to a hospital B) at a healthcare screening C) when medications are given for a cardiac arrhythmia D) following a diagnostic procedure E) prior to an invasive procedure F) when daily medications are dispensed a,b,c,d,e

??

4. A nurse has an order to take the core temperature of a patient. At which of the following sites would a core body temperature be measured?

A) tympanic B) oral C) axillary D) skin surface a

??

5. Which of the following is the primary source of heat in the body?

A) hormones B) metabolism C) blood circulation D) muscles b

??

6. A nurse places a fan in the room of a patient who is overheated. This is an example of heat loss related to which of the following mechanisms of heat transfer?

A) evaporation B) radiation C) conduction D) convection d

??

7. Which of the following is an average normal temperature in Centigrade for a healthy adult?

A) oral: 37.0°C B) rectal: 36.5°C C) axillary: 37.5°C D) tympanic: 34.4°C a

??

8. What anatomic site regulates the pulse rate and force?

A) thermoregulatory center C) cardiac atria and valves B) cardiac sinoatrial node D) peripheral chemoreceptors b

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers 9. A patient is constipated and trying to have a bowel movement. How does holding the breath and pushing down (the Valsalva maneuver) affect the pulse?

A) left ventricle pumps more forcefully; pulse is stronger B) stimulates the vagus nerve to increase the rate C) stimulates the vagus nerve to decrease the rate D) right ventricle is less efficient; pulse is thready c

??

10. The arterial blood gases for a patient in shock demonstrate increased carbon dioxide and decreased oxygen. What type of respirations would the nurse expect to assess based on these findings?

A) absent and infrequent C) rapid and deep B) shallow and slow D) noisy and difficult c

??

11. A nurse walks into a patient's room and finds him having difficulty breathing and complaining of chest pain. He has bradycardia and hypotension. What should the nurse do next?

A) Take vital signs again in 15 to 30 minutes.

B) Document the data and report it later.

C) Ask the patient if he is anxious or afraid.

D) Report findings to the physician immediately. d

??

12. Which of the following pathologic conditions would result in release of ADH by the posterior pituitary?

A) hemorrhage B) allergies C) obesity D) asthma a

??

13. A student is reading the medical record of an assigned patient and notes the patient has been afebrile for the past 12 hours. What does the term "afebrile" indicate?

A) normal body temperature C) increased body temperature B) decreased body temperature D) fluctuating body temperature a

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers 14. A nurse is assessing a patient who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would be likely?

A) bradycardia B) tachycardia C) dysrhythmia D) bigeminal b

??

15. While assessing vital signs of a patient with a head injury and increased intracranial pressure (IICP), a nurse notes that the patient's respiratory rate is 8 breaths/min. How will the nurse interpret this finding?

A) bradypnea is uncommon in patient with IICP B) IICP most commonly results in tachypnea C) bradypnea is a response to IICP D) this is a normal respiratory rate c

??

16. A nurse is conducting a health history for a patient with a chronic respiratory problem. What question might the nurse ask to assess for orthopnea?

A) "Do you have problems breathing when you walk up stairs?"

B) "Does your medication help you breathe better?"

C) "How many pillows do you sleep on at night to breathe better?"

D) "Tell me about your breathing difficulties since you stopped smoking." c

??

17. What population is at greatest risk for hypertension?

A) Hispanic B) White C) Asian D) African American d

??

18. A middle-aged, overweight adult man has had hypertension for 15 years. What pathologic event is he most at risk for?

A) stroke B) anemia C) cancer D) infection a

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers 19. A nurse educator is teaching a patient about a healthy diet. What information would be included to reduce the risk of hypertension?

A) "Eat a diet high in fruits and vegetables."

B) "Remember to drink 8 to 10 glasses of water a day."

C) "It is important to have increased fats in your diet."

D) "Put away the salt shaker and eat low-salt foods." d

??

20. A nurse is caring for a patient who is ambulating for the first time after surgery.

Upon standing, the patient complains of dizziness and faintness. The patient's blood pressure is 90/50. What is the name for this condition?

A) orthostatic hypotension C) ambulatory bradycardia B) orthostatic hypertension D) ambulatory tachycardia a

??

21. What site for taking body temperature with a glass thermometer is contraindicated in patients who are unconscious?

A) rectal B) tympanic C) oral D) axillary c

??

22. A patient has been diagnosed with peripheral vascular disease of the lower extremities. What site would the nurse use to assess circulation of the legs?

A) radial artery B) dorsalis pedis artery C) temporal artery D) carotid artery b

??

23. A nurse is taking a patient's temperature and wants the most accurate measurement, based on core body temperature. What site should be used?

A) rectal B) oral C) axillary D) forehead a

??

24. A student nurse assesses a blood pressure on an adult and finds it to be 140/86.

What term is used for the top number (140)?

A) systolic pressure B) diastolic pressure C) pulse pressure D) hypotension a

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers 25. A hospital unit has a policy that rectal temperatures may not be taken on patients who have had cardiac surgery. What rationale supports this policy?

A) It is an embarrassing and painful assessment.

B) Thermometer insertion stimulates the vagus nerve.

C) It is less expensive to take oral temperatures.

D) It is to avoid perforating the wall of the rectum. b

??

26. As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure?

A) The blood pressure does not change. C) The blood pressure decreases.

B) The blood pressure is erratic. D) The blood pressure increases. d

??

27. What equipment is needed to take an apical pulse?

A) sphygmomanometer C) stethoscope B) electronic thermometer D) no specific equipment c

??

28. Two nurses collaborate in assessing an apical-radial pulse on a patient. The pulse deficit is 16 beats/min. What does this indicate?

A) The radial pulse is more rapid than the apical pulse.

B) This is a normal finding and should be ignored.

C) The patient's arteries are very compliant.

D) Not all of the heartbeats are reaching the periphery. d

??

29. A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow?

A) reading is erroneously high B) reading is erroneously low C) pressure on the cuff with be painful D) it will be difficult to pump up the bladder a

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers 30. Various sounds are heard when assessing a blood pressure. What does the first sound heard through the stethoscope represent?

A) systolic pressure C) auscultatory gap B) diastolic pressure D) pulse pressure a

??

31. An adult patient is assessed as having an apical pulse of 140. How would the nurse document this finding?

A) bradycardia B) tachycardia C) dysrhythmia D) normal pulse b

??

32. A patient in a physician's office has a single blood pressure (BP) reading of 150/92.

Should the patient be taught about hypertension?

A) It depends on the time of day the BP was taken.

B) It depends on whether the patient is male or female.

C) No, a single BP reading should not be used.

D) Yes, this reading is high enough to be significant. c

??

All of the following patients have a body temperature of 38°C (100.4°F). About which patient would a nurse be most concerned?

A) an older adult C) a junior high football player B) a pregnant adolescent D) a 2-month-old infant d

??

34. A home healthcare nurse notices that his assigned patient uses a mercury thermometer. He asks the nurse what to do if it breaks. Which of the following is not correct?

A) "Just flush the glass and mercury down the toilet."

B) "Do not vacuum the area where it breaks."

C) "Open the windows and close off the room for an hour."

D) "Throw away any clothing exposed to the mercury." a CHAPTER 33

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers 4. A nurse performing range-of-motion exercises on a bedfast patient moves the patient's chin down onto the chest and then back to an upright position. The nurse then tilts the head as far as possible to each shoulder. What therapeutic movement is the nurse achieving with this exercise? Select all that apply.

A) flexion B) adduction C) extension D) dorsiflexion E) pronation F) abduction a,c

??

5. While performing range-of-motion exercises on a patient, a nurse bends a patient's foot so that the toes are brought up, as though to point them at the knee. What is the term for this type of movement?

A) dorsiflexion B) inversion C) rotation D) eversion a

??

6. What term is used to describe the correction or prevention of disorders of body structures used in locomotion?

A) pediatrics B) obstetrics C) geriatrics D) orthopedics d

??

7. A nurse is assessing the activity level of a 5-month-old baby. What normal findings would be assessed?

A) ability to sit and head control B) ability to pick up small objects C) progress toward running and jumping D) progress toward unassisted walking a

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers 8. Which of the following activities are normally acquired in the toddler years? Select all that apply A) rolling over B) pulling to a standing position C) walking D) running E) jumping F) climbing stairs c,d,e

??

9. A nurse is teaching an older adult about activity. What information would be included in the teaching plan?

A) the requirement of frequent inactivity B) the recognition that exercise is not important C) the importance of regular exercise D) the possibility of exercise-induced fractures c

??

10. A nurse is assessing the muscles of an older adult. What will be assessed?

A) temperature, turgor, moisture C) degree of flexion, associated pain B) mass, tone, strength D) reflexes, range of motion b

??

Which of the following postural deformities might be assessed in a teenager?

A) kyphosis B) rickets C) osteoporosis D) scoliosis d

??

12. A nurse is providing home care for an older woman with severe osteoporosis. What complication of this disease process must the nurse consider in the plan of care?

A) diarrhea B) fractures C) visual deficits D) skin disorders b

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers 13. A nurse is teaching an older woman how to move and lift her disabled husband. The woman has osteoarthritis of the hips and knees. What is the goal of the nurse's teaching plan?

A) minimize stress on the wife's joints C) increase socialization with neighbors B) provide exercise for the husband D) maintain self-esteem of the wife a

??

Why is it important for the nurse to teach and role model proper body mechanics?

A) to ensure knowledgeable patient care B) to promote health and prevent illness C) to prevent unnecessary insurance claims D) to demonstrate knowledge and skills b

??

15. Bedrest, with resultant immobility, affects the whole body. What is one effect on the musculoskeletal system?

A) impaired gas exchange C) increased risk for contractures B) increased risk for venous thrombosis D) decreased sensory stimulation c

??

16. A middle-aged man walks 2 miles each day. What type of exercise is he getting by this activity?

A) isotonic B) isometric C) isokinetic D) isostretching a

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers 17. What body system benefits the most from aerobic exercises?

A) musculoskeletal B) neurologic C) respiratory D) cardiovascular d

??

18. A nurse recommends a regular exercise program for a patient who has difficulty sleeping. The patient asks how this will help. How would the nurse respond?

A) "The fresh air will stimulate your metabolism."

B) "Improved sleep is one benefit of regular exercise."

C) "Exercise can help you control your weight."

D) "Take my word for it. It sure helped me." b

??

19. A nurse is assessing the vital signs of a patient who has exercised regularly for several years. What vital sign findings would be expected?

A) increased body temperature and respirations B) increased pulse and blood pressure C) decreased pulse and blood pressure D) exercise has no effect on vital signs c

??

20. A patient at a community health center is discussing a planned exercise program.

The patient is being treated for cardiovascular disease. What would the nurse recommend?

A) "Begin the exercise program immediately."

B) "It would be best if you did not exercise."

C) "Be sure to take your pulse before you begin."

D) "See your doctor and have a checkup first." d

??

21. Of the following guidelines, which would not be recommended to a person who has sustained an orthopedic injury during exercise?

A) ice B) warmth C) rest D) elevation b

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

??

22. Immobility affects the body in many ways. What is one serious effect of immobility on the cardiovascular system?

A) increased cardiac workload C) increased venous return B) decreased cardiac workload D) increased peripheral resistance a

??

23. An immobile person has decreased movement of respiratory secretions. What condition is a greater risk as a result?

A) respiratory tract infection C) greater thoracic expansion B) increased gas exchange D) increased respiratory rate a

??

24. Laboratory results for a patient on prolonged bedrest include a high level of urinary calcium. What risk does this pose for the patient?

A) urinary calcium is not a concern C) increased urinary output B) renal calculi (kidney stones) D) imbalanced intake/output b

??

25. At what time would a nurse assess the gait of an ambulatory patient?

A) after the neurologic assessment B) at the end of the physical examination C) while the patient is lying supine on the examining table D) when the patient walks into the room d

??

26. What term is used to document impaired muscle strength or weakness?

A) paralysis B) paresis C) spasticity D) flaccidity b

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

??

27. A patient has chronic obstructive pulmonary disease and is unable to perform basic self-care activities or activities of daily living. Which of the following would be an appropriate nursing diagnosis?

A) Risk for Injury: Pathologic Fractures C) Altered Tissue Perfusion B) Activity Intolerance D) Altered Thought Processes b

??

28. A nurse is caring for a comatose patient. What can happen to the feet if they are unsupported in the dorsiflexed position?

A) heel extension and pain C) plantar extension and arch loss B) toe contractures and numbness D) plantar flexion and footdrop d

??

29. A nurse is placing a patient in Fowler's position. What should she teach the family about this position?

A) "Use at least two big pillows to support the head."

B) "Cross the arms over the patient's abdomen."

C) "Do not raise the knees with the knee gatch."

D) "Keep the hands lower than the rest of the body." c

??

30. A nurse is ambulating a patient who has had a stroke. The patient has paresis on the right side of the upper body. Where would the nurse stand to walk the patient?

A) on the weak side C) in front of the patient B) on the strong side D) in back of the patient a

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers 31. A college student fell and sprained his right ankle. The student health physician recommends the student use crutches to facilitate healing. Which of the following would the nurse teach the student?

A) The crutches should be as long as the student is tall.

B) The support of the body should be in the axilla.

C) The support of the body should be the hands and arms.

D) Walk fast and use long steps when using the crutches. c

??

32. A nurse is following a plan of care for passive range-of-motion (ROM) exercises.

What specifics will be included on the plan?

A) Ask the patient to demonstrate ROM at 9 a.m. each day.

B) Do ROM exercises two times a day, each exercise two to five times.

C) Request family be available twice a day to perform ROM. D) Move each joint until the patient complains of pain. b What are vital signs?

Temperature, pulse, respiration, and blood pressure.

??

What is the fifth vital sign?

Pain

??

What temperature is highest, ranging around 36.0 C (97.0 F) to 37.5 C (99.5 F) Core body temperature

??

Where are core temperatures measured?

Tympanic or rectal sites. Also esophagus, pulmonary areterty. or bladder by invasive monitoring devices.

??

Where are surface body temperatures measured at? oral (sublingual) axillary, and skin surface sites.

??

What maintains the thermoregulatory set point hypothalamus.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

??

What hormones are released to to maintain balance with additional heat? epi and norepi. (anterior hypothalamus or pituitary) T3 and T4 (thyroid)

??

What connections in the body remain open to allow heat to dissipate to the skin and then to the external environment (Or close to retain heat in the body?) arteriovenous shunts (arterioles and the venules)

??

How is heat transferable? radiation, convection, evaporation, and conduction.

??

A 24 hour cycle is known as Circadian Rhythms.

??

What is the the typical variance in body temperature amoung invdividuals.

0.3 to 0.6 C (0.5-1 F)

??

Febrile fever

??

How does a fever occur (agent) cytokines produced by pyrogens (microorganisms or substances that cause fever)

??

Tissue injury can cause fever. Name some injuries that would cause this MI, pulmonary emboli, cancer, trauma, and surgery.

??

Older adults often have a lower baseline body temp, and a fever elevation (even a slight elevation) may be indicative of what? serious infection.

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers What mechanisms are initiates when the set point is increased from a bacterial or viral infection? shivering, piloerection, vasoconstriction, and increased metabolism.

??

Most fevers are what? self-limiting.

??

Hyperthermia when the set point for the body is not changed, but occurs in extreme conditions of heat.

??

Neurogenic fever result of damage to the hypothalamus from interacranial trauma, intracranial bleeding , or increased intracranial pressure.

??

What type of fever does not respond to antipyretic medication?

Neurogenic fever.

??

What is an FUO A fever of 101 F that lasts for 3 weeks or longer without an identified cause.

?? potentially dangerous complications of fever Fluid, electrolyte and acid-base imbalances

??

What drug should not be given to children and teenagers with chickenpox or flu because of possible association with Reye's syndrome?

Aspirin

??

When using a hypothermia blanket to lower body temperature, how do you monitory body temp? monitor the rectal temperature every 15 min and all vital signs every 30 minutes.

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers What temperature do you start a hypothermia blanket at?

37 C and decrease it 2 to 3 degrees every 15 minutes until the temp that is ordered or that is agency policy is reached.

??

When hypothermia blanket treatment is discontinued, how often does the nurse monitor the temp of the patient? every 2 hours for 24 hours.

Answer Key Question 1: (see full question)

You selected:

A client monitoring his BP at home notices that his BP is higher in one arm than the other so he calls his health care provider for guidance. What is the most appropriate information for the nurse to give this client?

It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results.

Correct

Explanation:

It has been found that most people have differences in BP between arms and that he should use the arm that gives him the highest reading for accurate results.

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 600.

Chapter 24: Vital Signs - Page 600

Question 2: (see full question)

The nurse is assessing the apical pulse of a patient using auscultation. What action would the nurse perform after placing the diaphragm over the apex of the heart?

You selected:

Listen for heart sounds.

Correct

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Explanation:

The apex of the heart is found after palpating between the fifth and sixth ribs, then moving the stethoscope the left midclavicular line.

The apical rate is typically assessed for 1 minute. Each “lub-dub” sound counts as one beat. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 24, Vital Signs, p. 592

Question 3: (see full question)

A nurse is caring for an adult with fever. The nurse determines that which site is most ideal for obtaining the client's core body temperature?

You selected:

Ear

Incorrect

Correct response:

Rectum

Explanation:

The rectal temperature, a core temperature, is considered to be one of the most accurate routes.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 587.

Chapter 24: Vital Signs - Page 587

Question 4: (see full question)

You selected:

During a busy shift, Nurse R. admitted a postsurgical patient who is obese. Nurse R. used the standard size of blood pressure cuff available on the unit, despite the fact that the patient's upper arms have a high circumference. What are the potential consequences of Nurse R.'s action?

Nurse R. may obtain a blood pressure reading that is higher than

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers actual blood pressure.

Correct

Explanation:

If a blood pressure cuff is too narrow, the reading could be erroneously high because the pressure is not evenly transmitted to the artery. This occurs when an average-sized cuff is used on an obese person. This mismatched cuff will not, however, make it particularly difficult to inflate the cuff and brachial occlusion is not a significant risk. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 599.

Chapter 24: Vital Signs - Page 599

Question 5: (see full question)

Which of the following terms indicates a potentially serious patient condition?

You selected:

Pyrexia

Correct

Explanation:

Pyrexia means an increase above normal in body temperature.

Pulse pressure is an objective term related to the pulse. Eupnea means a normal breathing pattern. Afebrile means that the body temperature is not elevated. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015,

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Question 6: (see full question)

You selected:

The nurse is providing discharge teaching for a patient diagnosed with hypertension. Which teaching points about monitoring blood pressure should the nurse include in the plan? (Select all that apply.)

• If using a forearm monitor, tell the patient to keep wrist at heart level when using it.

• Recommend a cuff size appropriate for the patient’s limb size.

• Recommend taking the blood pressure every day at the same time.

Correct

Explanation:

Taking the blood pressure at the same time each day will provide the patient with a more accurate comparison of blood pressure measurements because the blood pressure may fluctuate during different times of the day. Appropriate cuff size directly affects the accuracy of the blood pressure measurement. The patient should not be encouraged to use BP devices in public places as these may be inaccurate and may be the wrong cuff size, leading to further inaccuracy. Keeping the wrist at heart level ensures that this type of BP measurement is accurate. It is difficult for patients to use manual cuffs at home; home electronic devices are generally accurate and should be checked against the health care provider’s manual BP reading every 1 to 2 years. The blood pressure measurement in the lower extremities produces a systolic pressure approximately 10 to 40 mm Hg higher than in the arm. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 24, Vital Signs, p. 620

Question 7:

A nurse attempts to count the respiratory rate for a client via inspection and finds that the client is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this client?

(see full question)

You selected:

Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Correct

Explanation:

Sometimes it is easier to count respirations by auscultating the lung sounds for 30 seconds and multiplying the result by 2. Palpating the posterior thorax excursion detects vibrations in the lungs. Pulse oximeter and arterial blood gas results assess respiratory effectiveness. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 615.

Chapter 24: Vital Signs - Page 615

Question 8: (see full question)

You selected:

A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which of the following observations can be made by the nurse and athletes by measuring the blood pressure?

The ability of the arteries to stretch

Correct

Explanation:

Measuring the blood pressure helps to assess the efficiency of the client's circulatory system. Blood pressure measurements reflect the ability of the arteries to stretch, the volume of circulating blood, and the amount of resistance the heart must overcome when it pumps blood. Measuring the blood pressure does not help in assessing the thickness of blood, oxygen level in the blood, or the volume of air entering the lungs. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 597.

Chapter 24: Vital Signs - Page 597

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Question 9: (see full question)

A patient has been diagnosed with peripheral vascular disease of the lower extremities. What site would the nurse use to assess circulation of the legs?

You selected:

dorsalis pedis artery

Correct

Explanation:

The nurse would assess circulation in the lower extremities by palpating the dorsalis pedis artery. The other arteries listed would not be used to assess circulation to the legs.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 591.

Chapter 24: Vital Signs - Page 591

Question 10: (see full question)

You selected:

A 62-year-old female client being treated for hypertension did not take her daily BP medication over the weekend because she was out of medication and the pharmacy was closed. Her average home blood pressure monitoring (HBPM) reading has been 130/82. Today her BP has been 138/90, 135/85, and 142/86. She calls the on-call nurse for her health care provider. What is the most appropriate thing for this nurse to advise this client?

To take the recommended daily dose of medication and call the health care provider if the average of her HBPM readings increase/decrease by 10, or if she has any other concerns.

Correct

Explanation:

HBPM readings are the ideal method for monitoring response to treatment for high BP. This client’s average BP after not taking her medication is 138/87 and is NOT 10 more than what her HBPM reading has been. Clients should be taught when performing HBPM

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers that they should call the health care provider if the averages of HBPM readings increase/decrease by 10, or if she has any concerns. The client should not be told to take double the dose of medication or to take the doses she missed; this is unsafe advice without consulting a health care provider. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 604.

Chapter 24: Vital Signs - Page 604

Question 11: (see full question)

The temperature is 102°F (39 deg C); during a heat wave. The nurse can expect admissions to the emergency room to present with

You selected:

Increased temperature

Correct

Explanation:

Body temperature can fluctuate with exercise, changes in hormone levels, changes in metabolic rate, and extremes of external temperature.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 583.

Chapter 24: Vital Signs - Page 583

Question 12:

When assessing an infant's axillary temperature, it will be

(see full question)

You selected:

One degree lower than an oral temperature

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Correct

Explanation:

Rectal temperatures may be one degree higher than oral temperatures, and axillary temperatures are one degree lower than oral temperatures.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 588.

Chapter 24: Vital Signs - Page 588

Question 13: (see full question)

You selected:

An older adult client monitors her BP at home. Lately she has been experiencing dizziness and nausea, followed by a headache when she arises from lying down for a nap. She was worried it was her BP so she began taking it after she arose from her nap and found that her BP would drop from 124/82 to 102/70. She called the nurse concerned about her BP. What is the most appropriate information for the nurse to give this client?

You may have orthostatic hypotension and should be seen by your health care provider as soon as you can.

Correct

Explanation:

Orthostatic hypotension (postural hypotension) is a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within 3 minutes of standing when compared with blood pressure from the sitting or supine position. It results from an inadequate physiologic response to postural (positional) changes in blood pressure. Orthostatic hypotension may be acute or chronic as well as symptomatic or asymptomatic. It is associated with dizziness, lightheadedness, blurred vision, weakness, fatigue, nausea, palpitations, and headache. Older adults may experience orthostatic hypotension without associated symptoms, leading to falls. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 597.

Chapter 24: Vital Signs - Page 597

Question 14: (see full question)

A nurse is assessing the pulse volume of a client with influenza.

The nurse notes that the client has a thready pulse. Which of the following is a description of a thready pulse?

You selected:

Pulse is felt with difficulty and disappears with slight pressure.

Correct

Explanation:

Thready pulse is felt with difficulty or not easily felt, and slight pressure causes it to disappear. A weak pulse is stronger than a thready pulse, and light pressure causes it to disappear. A normal pulse is felt easily, and moderate pressure causes it to disappear. A bounding pulse is strong and does not disappear with moderate pressure. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 589.

Chapter 24: Vital Signs - Page 589

Question 15:

A pulse deficit is the difference between ...

(see full question)

You selected:

the apical pulse and the radial pulse rate

Correct

Explanation:

When a pulse deficit is present, the radial pulse is always lower

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers than the apical pulse rate.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, p. 591.

Chapter 24: Vital Signs - Page 591

Question 16: (see full question)

You selected:

A nurse is assessing the pulse rate of a client for one full minute.

Which of the following clients' pulse rates need to be assessed for one full minute? Select all that apply.

• Clients with irregular pulse rates • Clients with fast pulse rates • Clients recovering from anesthesia • Clients with abnormally slow pulse rates

Incorrect

Correct response:

• Clients with abnormally slow pulse rates • Clients with irregular pulse rates • Clients with fast pulse rates

Explanation:

The nurse assesses clients with irregular or abnormally slow or fast pulse rates for one full minute. The time interval used to assess the pulse depends on the client's condition and the agency's norms.

Clients with regular rhythms and normal rates may be assessed for a shorter time. Intervals of 15 seconds may be used for clients with regular rhythms when reassessing the pulse frequently, as during recovery from anesthesia. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 24: Vital Signs, pp. 588-589.

Chapter 24: Vital Signs - Page 588

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Question 17: (see full question)

Which patient would the nurse consider at risk for low blood pressure?

You selected:

A patient with low blood volume

Correct

Explanation:

Low blood volume, such as occurs with hemorrhage, causes hypotension. High blood viscosity and decreased elasticity of the arteriole walls would potentially cause increased blood pressure. A strong pumping action of the heart may not affect the blood pressure, or it may cause the blood pressure to increase. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 24, Vital Signs, p. 597

Question 18: (see full question)

A nurse is taking the vital signs of a 9-year old child who is anxious about the procedures. Which nursing action would be appropriate when assessing this child?

You selected:

Perform the blood pressure measurement last.

Correct

Explanation:

The blood pressure reading is the most invasive procedure performed when measuring vital signs. If the nurse were to perform it first it may upset the child further and prevent obtaining the remainder of the vital signs. Allowing the child to touch the assessment equipment often helps the child be more relaxed for the remainder of the assessment. Lying on the exam table is not necessary for vital signs and will likely call more anxiety. Being quick with a serious demeanor does not help decrease the child’s anxiety. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Kluwer Health, 2015, Chapter 24, Vital Signs, p. 616

Question 19: (see full question)

You selected:

The nurse is teaching the parents of an infant with an irregular heartbeat how to check the pulse rate. The infant’s pulse is very high and irregular. What will the nurse have to do in order to teach these parents how to monitor their infant’s pulse rate?

The parents will have to be taught how to use a stethoscope so that they can listen to and count the infant’s apical pulse.

Correct

Explanation:

If a peripheral pulse is difficult to assess accurately because it is irregular, weak, or very rapid, the apical rate should be assessed using a stethoscope. An apical pulse is also assessed when giving medications that alter heart rate and rhythm. Apical pulse measurement is also the preferred method of pulse assessment for infants and children younger than 2 years of age. Families can be taught to use a stethoscope to check a pulse. This infant does not need a cardiac monitor, the parents should not be encouraged to get a neighbor or family friend to help, and these parents can be taught to check this infant’s pulse accurately. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 590.

Chapter 24: Vital Signs - Page 590

Question 20: (see full question)

A nurse is assessing an apical pulse on a cardiac client. The client is taking digoxin, which is a cardiac medication. The nurse can anticipate that the digoxin will do what?

You selected:

Decrease the apical pulse.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Correct

Explanation:

Some cardiac medications, such as digoxin, whose action is specific to the work of the heart, slow the heart rate while also strengthening the force of contraction to increase cardiac output. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 24: Vital Signs, p. 589.

Chapter 24: Vital Signs - Page 589

Question 1: (see full question)A 57-year-old male client is admitted to the medical unit with a 3-day history of

sharp, nonradiating epigastric pain and vomiting. He denies seeing blood in his stool. When assessing this client's abdomen, what assessment technique would the nurse perform last?You selected:PalpationCorrectExplanation: The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation are done after auscultation because they stimulate bowel sounds. (less)

Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 659.

Chapter 25: Health Assessment - Page 659

Question 2: (see full question)The nurse is asking admission interview questions and the client has explained

the reason for seeking care. Which of the following is the most appropriate way to document the response?You selected:Client states, "I feel winded all of the time and yesterday I started spitting up a lot of phlegm."CorrectExplanation: The client's reason for seeking care should always be stated in the client's own words.

Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 628.

Chapter 25: Health Assessment - Page 628

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Question 3: (see full question)The nurse is preparing to perform an examination of the abdomen of a 23-year-

old male client admitted 3 days ago with gastroenteritis. What sequence of techniques will the nurse use to assess the abdomen of this client?You selected:Inspection, auscultation, percussion, palpationCorrectExplanation: The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation.

Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 658.

Chapter 25: Health Assessment - Page 658

Question 4: (see full question)Which of the following statements accurately represents a characteristic of the

third or fourth heart sound?You selected:S3 is considered normal in children and young adults and abnormal in middle-aged and older adults.CorrectExplanation: S3, the third heart sound, is considered normal in children and young adults and abnormal in middle-aged and older adults. This sound is best heard with the stethoscope bell at the mitral area, with the patient lying on the left side. S4 is represented by “dee-lub-dub” and is considered normal in older adults but abnormal in children and adults. (less)

Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 654.

Chapter 25: Health Assessment - Page 654

Question 5: (see full question)The nurse is caring for an 88-year-old male admitted 2 days ago for dehydration.

The nurse brings the client his breakfast tray and notes that the client appears to be having difficulty understanding what she is saying to him today. Which nursing action is most appropriate?You selected:Check the client’s ear canals for cerumen.CorrectExplanation: Ear wax (cerumen) becomes drier in the elderly and can block the ear canal and cause decreased hearing. Asking the client if he has earplugs in his ears is not appropriate. Using facial expressions and sign language is appropriate in communicating with the hard of hearing, but this client’s hearing loss was acute and requires further assessment. When speaking to the

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers elderly who are hearing-impaired, one needs to use low tones to facilitate communication; highfrequency tones are problematic for the elderly. (less)

Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 646.

Chapter 25: Health Assessment - Page 646

Question 6: (see full question)The nurse in the emergency department observes a client experiencing a

generalized tonic–clonic seizure. What is the priority intervention for the nurse to take?You selected:Assess and maintain the client's airway.CorrectExplanation: Risk for aspiration is a concern during a seizure because the client will have copious oral secretions that will need to be suctioned and allowed to drain out of the mouth. The nurse should assess the client's airway and maintain it by placing the client in a side-lying position, which will allow the oral secretions to drain from his mouth and not accumulate in his throat and compromise the airway. It is contraindicated to place anything in the mouth of a person who is actively convulsing. Reorienting the client and documenting the seizure are important actions after the postictal phase, but client safety is the priority intervention during a seizure. (less)

Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 625.

Chapter 25: Health Assessment - Page 625

Question 7: (see full question)The nurse is caring for a client who just informed her that he noticed some blood

in the toilet after a bowel movement. The nurse assesses the client's anal area and notes a deep linear separation in the skin that extends into the dermis. The nurse recognizes that this skin lesion is characteristic of which of the following?You selected:FissureCorrectExplanation: A fissure is characterized as a deep linear separation in the skin that extends into the dermis.

Erosion is a loss of superficial epidermis; it is moist and may bleed. An ulcer appears as a loss of epidermis and dermis and may bleed. Crusts are dried residue (serum, pus, or blood) on the skin. (less)

Reference:

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 641, Table 25-4.

Chapter 25: Health Assessment - Page 641

Question 8: (see full question)The nurse is caring for a 72-year-old female client who recently arrived from El

Salvador for cancer treatments. The nurse informs the client that she has to sign a consent for the treatments that are scheduled to start the next day. The client tells the nurse that she is expecting her family to arrive later and wants to wait to sign the consent when they are present.

What action by the nurse is the most appropriate?You selected:Ask the client if she has any questions about the cancer treatments.IncorrectCorrect response:Tell the client to call the nurse when her family arrives.Explanation: In Hispanic cultures the family plays a major role in the social organization of the family. The nurse should be sensitive to cultural diversity. Being available when the family arrives is showing respect for the client’s wishes and cultural sensitivity. Asking the client to sign the consent without the presence of her family, notifying the physician, or asking her if she has questions does not address the client’s cultural diversity. (less)

Reference: Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 25: Health Assessment, p. 671.

Chapter 25: Health Assessment - Page 671

Question 9: (see full question)You are assessing a patient's thorax and lungs. Which of the following findings

would indicate the need for further assessment?You selected:Auscultation of short, highpitched popping sounds during inspirationCorrectExplanation: Crackles (short, high-pitched popping sounds) may indicate disease, such as pneumonia or heart failure.

Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 648.

Chapter 25: Health Assessment - Page 648

Question 10: (see full question)The nurse is assessing an older adult’s near vision. Which assessment finding

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers about the client's near vision should the nurse anticipate?

You selected:BlurryCorrectExplanation: A common finding in the older adult is impaired near vision (presbyopia), which makes near vision blurry.

Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 648.

Chapter 25: Health Assessment - Page 648

Answer Key Question 1: (see full question)

The acute care nurse is assessing a newly admitted client's abdomen. Which of the following findings would indicate the need to contact the primary care provider?

You selected:

Auscultation of a bruit

Correct

Explanation:

A bruit on auscultation suggests an aneurysm or arterial stenosis.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 654.

Chapter 25: Health Assessment - Page 654

Question 2: (see full question)

A nurse is assessing the lungs of a patient and auscultates soft, low-pitched sounds over the base of the lungs during inspiration.

What would be the nurse’s next action?

You selected:

Suspect an inflamed pleura rubbing against the chest wall

Incorrect

Correct response:

Document normal breath sounds

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Explanation:

Soft, low-pitched, whispering sounds are normal sounds heard over most of the lung fields. Inflammation of the pleura would result in a friction rub. There are no signs of pneumonia, and recommending testing for pneumonia is not in the nurse’s scope of practice.

Asthma usually results in wheezing. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 25, Health Assessment, p. 651

Question 3: (see full question)

A nurse is performing eye assessments at a community clinic.

Which assessment would the nurse document as normal?

You selected:

The patient’s pupils are black, equal in size, and round and smooth.

Correct

Explanation:

The pupils should be black, equal in size, and round and smooth.

When an object moves towards the patient’s nose, the eyes should converge towards the object. Pale and cloudy pupils are indication of a problem such as cataracts. The patient’s pupils should constrict when looking at a near object and dilate when looking at a distant object. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluw

Answer Key Question 1: (see full question)

The acute care nurse is assessing a newly admitted client's abdomen. Which of the following findings would indicate the need to contact the primary care provider?

You selected:

Auscultation of a bruit

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Correct

Explanation:

A bruit on auscultation suggests an aneurysm or arterial stenosis.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 654.

Chapter 25: Health Assessment - Page 654

Question 2: (see full question)

A nurse is assessing the lungs of a patient and auscultates soft, low-pitched sounds over the base of the lungs during inspiration.

What would be the nurse’s next action?

You selected:

Suspect an inflamed pleura rubbing against the chest wall

Incorrect

Correct response:

Document normal breath sounds

Explanation:

Soft, low-pitched, whispering sounds are normal sounds heard over most of the lung fields. Inflammation of the pleura would result in a friction rub. There are no signs of pneumonia, and recommending testing for pneumonia is not in the nurse’s scope of practice.

Asthma usually results in wheezing. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 25, Health Assessment, p. 651

Question 3:

A nurse is performing eye assessments at a community clinic.

Which assessment would the nurse document as normal?

(see full question)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers You selected:

The patient’s pupils are black, equal in size, and round and smooth.

Correct

Explanation:

The pupils should be black, equal in size, and round and smooth.

When an object moves towards the patient’s nose, the eyes should converge towards the object. Pale and cloudy pupils are indication of a problem such as cataracts. The patient’s pupils should constrict when looking at a near object and dilate when looking at a distant object. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluw

You selected:

The tympanic membrane is translucent, shiny, and gray.

Correct

Explanation:

The tympanic membrane should be intact, translucent, shiny, and gray. The ear canal should be smooth and pink.

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 25, Health Assessment, p. 645-646

Question 7:

A nurse performs an integumentary assessment of a client and documents the following: 5/27/12: Examined skin of Mr. Williams.

Client is a white, 56-year-old male who reports a history of emphysema. Skin coloring is bluish gray.

What is the term for this change in skin color?

(see full question)

You selected:

Cyanosis

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Correct

Explanation:

Cyanosis is a bluish or grayish tinge caused by inadequate oxygenation. Jaundice is a yellow color resulting from liver and gallbladder disease. Erythema is a reddish color associa ... (more)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 638.

Chapter 25: Health Assessment - Page 638

Question 8: (see full question)

During which of the following assessments should the nurse use the bell of the stethoscope during auscultation?

You selected:

Auscultation of a patient's heart murmur

Correct

Explanation:

The bell of the stethoscope is used to listen to low-pitched sounds, such as heart murmurs. The diaphragm of the stethoscope is used to listen to high-pitched sounds such as normal heart sounds, breath sounds, and bowel sounds. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, pp. 632, 654.

Chapter 25: Health Assessment - Page 632

Question 9: (see full question)

A grating feel and noise with joint movement, particularly in the temporomandibular joint, is called what?

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers You selected:

Crepitus

Correct

Correct

Explanation:

Problems with the temporomandibular joint include pain or a grating feeling called crepitus.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 25: Health Assessment, p. 662.

Chapter 25: Health Assessment - Page 662

Question 10: (see full question)

You selected:

A new client is admitted to the hospital and requires a comprehensive admission assessment. What should the nurse include in this assessment? (Select all that apply.)

• Goals with outcome criteria • Collection of subjective data • Complete set of vital signs

Incorrect

Correct response:

• Collection of subjective data • Complete set of vital signs • Functional ability evaluation

Explanation:

Collecting subjective data, vital signs, and functional ability should be included in the initial admission assessment and will help the nurse plan care for the client. The development of the care plan, which includes goals with outcome criteria and client teaching, are done after the admission assessment. (less)

Reference:

Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers 25: Health Assessment, p. 625.

Chapter 25: Health Assessment - Page 625

A nurse is assessing a newborn at the health care facility when the mother of the child asks the nurse why the body temperature of her baby is unstable. Which response by the nurse would be most appropriate? a) "It is because of the immature ability to regulate temperature in general." b) "It is common for newborns to have body temperatures less than 36.4C" c) "The baby is showing how it is adapting to the environmental temperature. d) "It is because of the closely woven, dark fabric wrapped around the baby" a) "It is because of the immature ability to regulate temperature in general."

??

Which of the following is an accurate guideline to follow when assessing blood pressure using a Doppler ultrasound? a) If using a mercury manometer, check to see that the manometer is in the horizontal position and that the mercury is within the zero level. b) Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery itself. c) Using your nondominant hand, place the Doppler tip in the gel and adjust the volume as needed; move the Doppler tip around until you hear the pulse. d) Take the measurement with the client in a standing position with the appropriate limb exposed. b) Center the bladder of the cuff over the artery, lining up the artery marker on the cuff with the artery itself

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers You are preparing to measure an adult's orthostatic blood pressure. Place the following steps of the procedure in the correct order.

1.

Assist the client into a supine position 2.

Assist the client to a standing position.

3.

Assist the client to the sitting position with legs dangling.

4.

Wait one to three minutes, then measure the client's blood pressure.

5.

Wait 2 to 3 minutes, then measure the patient's blood pressure.

6.

Wait three to 10 minutes, then measure the client's blood pressure.

1.

Assist the client into a supine position 6.

Wait three to 10 minutes, then measure the client's blood pressure.

3.

Assist the client to the sitting position with legs dangling.

4.

Wait one to three minutes, then measure the client's blood pressure.

2.

Assist the client to a standing position.

5.

Wait 2 to 3 minutes, then measure the patient's blood pressure.

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Assessment of the pulse amplitude is accomplished by which of the following? a) Palpating the area of the left ventricle b) Auscultating the area of the left ventricle c) Palpating the flow of blood through an artery d) Auscultating the flow of blood through an artery c) Palpating the flow of blood through an artery

??

Upon assessing a client who is hemorrhaging, the nurse is most likely to assess which compensatory change in vital signs? a) Decreased pulse rate b) Increased temperature c) Decreased temperature d) Increased pulse d) Increased pulse

??

Clients demonstrating apnea have what? a) Increased rate and depth of respirations b) Normal respiratory rate of 20 c) Usually have a temporary cessation of breathing d) Decreased rate and depth of respirations c) Usually have a temporary cessation of breathing

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Which peripheral pulse site is generally used in emergency situations? a) Apical b) Temporal c) Carotid d) Radial c) Carotid

??

The nurse places a client experiencing labored breathing in an upright position. The nurse notes that the client is able to breathe more easily in this upright position and documents this condition on the chart as which of the following? a) Tachypnea b) Bradypnea c) Orthopnea d) Apnea c) Orthopnea

??

A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure? a) Radial artery b) Over the lower arm c) Brachial artery d) Over the client's thigh d) Over the client's thigh

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers A nurse is assigned to take vital signs in a pediatric unit. Which of the following sites would be most appropriate for taking the blood pressure of children? a) Temporal b) Popliteal c) Brachial d) Radial b) Popliteal

??

During a routine vital sign assessment, you note the client's blood pressure is 212/110.

Why is this finding particularly significant? a) It allows the nurse to have a baseline value. b) It is due to the fact the client is fearful. c) It is related to a tumor of the adrenal. d) It deviates from normal and is significant. d) It deviates from normal and is significant.

??

While assessing vital signs of a client with a head injury and increased intracranial pressure (IICP), a nurse notes that the client's respiratory rate is 8 breaths/minute.

How will the nurse interpret this finding? a) Bradypnea is a response to IICP. b) Bradypnea is uncommon in a client with IICP. c) This is a normal respiratory rate. d) IICP most commonly results in tachypnea. a) Bradypnea is a response to IICP.

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers The nursing student is selecting a blood pressure cuff prior to obtaining a client's blood pressure. What cuff width is appropriate to obtain an accurate blood pressure reading? a) 60% of the circumference of the limb to be used b) 70% of the circumference of the limb to be used c) 40% of the circumference of the limb to be used d) 50% of the circumference of the limb to be used c) 40% of the circumference of the limb to be used

??

A nurse is filling out an incident report after an older adult client fell while attempting to transfer from her bed to a commode. Which of the following health problems should the nurse consider when client falls occur? a) Secondary hypertension b) Dyspnea c) Primary hypertension d) Orthostatic hypotension d) Orthostatic hypotension

??

A client is taking medications to treat a heart dysrhythmia. Which site should be used to assess pulse in this client? a) Brachial b) Radial c) Dorsalis pedis d) Apical d) Apical

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers The nurse has just measured an adult client's oral temperature and obtained a result of 102.4ºF (39.1ºC). The client states, "I just finished my coffee right before you came in.

Can I have another cup?" Which of the following responses by the nurse is most appropriate? a) "I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return." b) "You will need to remain NPO until I notify your primary health care provider about your increased temperature." c) "I'll be right back with your coffee and a different thermometer. I'm not sure this one measured your temperature correctly." d) "Before you drink another hot beverage, drink some cool water so I can obtain an accurate oral temperature." a) "I will bring you another cup when I return in 30 minutes to reassess your temperature.

Please do not drink any other beverages until I return."

??

A nurse attempts to count the respiratory rate for a client via inspection and finds that the client is breathing at such a shallow rate that it cannot be counted. What is an alternative method of determining the respiratory rate for this client? a) Use a pulse oximeter to count the respirations for one minute. b) Palpate the posterior thorax excursion, count respirations for 30 seconds, and multiply by 2. c) Monitor arterial blood gas results for one minute. d) Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2. d) Auscultate lung sounds, count respirations for 30 seconds, and multiply by 2.

??

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Which of the following terms describes a heart rate that is below the expected norm? a) Apnea b) Tachycardia c) Hypotension d) Bradycardia d) Bradycardia

??

A nurse who provides care on a hospital unit has taken a client's temperature this morning, yielding a reading of 37.6C (99.7F). How should the nurse best interpret this assessment finding? a) The client is at risk of experiencing seizure activity. b) This body temperature may temporarily enhance the client's immune function. c) The client is experiencing dysfunction of the thermoregulatory center. d) This is likely a reflection of normal circadian variations in body temperature.

Question 9: (see full question)

You selected:

When performing fall risk assessments, the nurse understands that which of these clients is most at risk for falls?

An 80-year-old female with a history of falling last year and breaking a hip

Incorrect

Correct response:

A 70-year-old female that has postural hypotension and wears eyeglasses, but has no history of falls

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Explanation:

Risk factors for falls include age older than 65 years, documented history of falls, impaired vision or sense of balance, altered gait or posture, a medication regimen that includes diuretics, tranquilizers, sedatives, hypnotics, or analgesics, postural hypotension, slowed reaction time, confusion or disorientation, impaired mobility, weakness and physical frailty, and/or an unfamiliar environment.

The 70-year-old female that has postural hypotension and wears eyeglasses, but has no history of falls, has three of these risk factors: age, impaired vision, and postural hypotension. Therefore, she is most at risk. All of the other clients only have two risk factors. (less)

Question 6: (see full question)

The community nurse knows that which population of Americans is particularly vulnerable to the aftermath of a disaster?

You selected:

Children

Incorrect

Correct response:

Older adults

Explanation:

Older adults, especially over the age of 85, are particularly vulnerable to the aftermath of a disaster due to their increased presence of altered mobility, altered perception, long-term illnesses, and dependency on equipment. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 713-714.

Chapter 26: Safety, Security, and Emergency Preparedness Page 713

congrats!

Congratulations! You've reached Mastery Level 3 for Chapter 23: Asepsis and Infection Control!

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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Take another quiz to work towards a higher mastery level.

See your overall performance.

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Chapter 23: Asepsis and Infection Control 2 Quizzes taken

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Answer Key Question 1: (see full question)

You selected:

A home health nurse is completing a health history for a patient. What is one question that is important to ask to identify a latex allergy for this patient?

“Have you had any unusual symptoms after blowing up balloons?”

Correct Explanation:

Awareness of a latex allergy is important for safe home care.

Nurses need to ask whether patients have experienced any unusual signs or symptoms when blowing up balloons, using latex condoms, or wearing rubber gloves for dishwashing or cleaning. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 548.

Chapter 23: Asepsis and Infection Control - Page 548

Question 2: (see full question)

You selected:

A child football player has been diagnosed with an uncomplicated concussion and is being discharged home on cognitive rest. When preparing this child’s teaching plan, what should the nurse include that will help the family understand what is meant by cognitive rest?

Reading, watching television, and playing games of any kind should be avoided until he is cleared.

Correct Explanation:

The treatment for an uncomplicated concussion is physical and cognitive rest. Reading, watching television, and playing games of any kind are examples of cognitive activities that should be avoided until the athlete is cleared. Lifting objects

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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Quiz completed in:

5 min

Total Questions:

10

Questions answered:

10

Number correct:

8

Take another quiz to work towards a higher mastery level.

See your overall performance.

80%

Performance by Chapter

Chapter

Chapter 23: Asepsis and Infection Control 3 Quizzes taken

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My Mastery Level: 3.00 Class Average: 3.23

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Answer Key Question 1: (see full question)

You selected:

A nurse follows surgical asepsis techniques for inserting an indwelling urinary catheter in a client. Which of the following is an accurate guideline for using this technique?

Consider the outer 3-inch edge of a sterile field to be contaminated.

Incorrect Correct response:

Hold sterile objects above waist level to prevent accidental contamination.

Explanation:

Holding a sterile object above waist level ensures the object is kept in sight and prevents accidental contamination. The outside of the sterile package and the outer one inch of a sterile field are contaminated. Sterile packages should be opened so that the first edge of the wrapper is directed away from the nurse. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 553.

Chapter 23: Asepsis and Infection Control - Page 553

Question 2: (see full question)

The nurse planning to insert an indwelling urinary catheter into a client should utilize which of the following techniques?

You selected:

Medical asepsis

Incorrect Correct response:

Surgical asepsis

Explanation:

Surgical asepsis, also known as sterile technique, is utilized

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Answer Key Question 1: (see full question)

The nurse determines that which of the following clients is at greatest risk for a wound infection?

You selected:

A two-day postoperative client

Correct Explanation:

The client at greatest risk for a wound infection is the two-day postoperative client, as the surgery disrupted the integrity of the skin, thereby increasing the risk for wound infection.

Although elderly clients are at greater risk for infection, this client's skin is dry (versus having an open or surgical wound); thus, this client is at less risk than the postoperative client. An infant with intact skin is not at risk for a wound infection. A client with a urinary catheter is at risk for a urinary tract infection versus a wound infection. (less)

Reference:

Taylor, C. R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 23: Asepsis and Infection Control, p. 557.

Chapter 23: Asepsis and Infection Control - Page 557

Question 2: (see full question)

You selected:

A nurse is caring for a patient who is diagnosed with tuberculosis. Which nursing intervention promotes infection control based on the QSEN competency of safety?

The nurse places the patient in a private room with monitored negative air pressure.

Correct Explanation:

When a client is diagnosed with tuberculosis it is important for the nurse to remember that the client should be placed in a private room with monitored negative air pressure. The client should not be placed in a room with the door open. The

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Answer Key Question 1: (see full question)

You selected:

The nurse is creating a plan of care for the older adult that has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care?

Risk for poisoning related to poor eyesight and the inability to read medication labels

Correct Explanation:

Older adults are at an increased risk for falls and can have an altered sensory perception. However, neither of those diagnoses address this client's lack of vision, causing difficulty in reading the labels of his multiple medications and thereby causing a risk for injury by overdose. There is no indication of substance abuse in this client. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 26: Safety, Security, and Emergency Preparedness, pp. 705-706.

Chapter 26: Safety, Security, and Emergency Preparedness - Page 705

Question 2: (see full question)

What is an appropriate nursing intervention to include in the plan of care for a client with smallpox?

You selected:

Droplet precautions

Incorrect Correct response:

Strict contact and airborne precautions for the duration of the illness

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

Answer Key Question 1: (see full question)

A nurse attempts to relieve the pain of a patient by using cutaneous stimulation. Which of the following accurately describes usage of this technique?

You selected:

A nurse applies intermittent heat and cold to a patient's leg.

Correct Explanation:

Cutaneous stimulation is the intermittent application of heat or cold, or both. Heat accelerates the inflammatory response to promote healing, reduces muscle tension to promote relaxation, and helps to relieve muscle spasms and joint stiffness. Cold reduces muscle spasm, alters tissue sensitivity, and promotes comfort by slowing the transmission of pain stimuli. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1171.

Chapter 34: Comfort and Pain Management - Page 1171

Question 2: (see full question)

Which of the following is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump?

You selected:

Respiratory

Correct Explanation:

The priority assessment for the nurse caring for a client with a PCA pump is respiratory, with particular attention to the respiratory rate and pattern. Too much narcotic or a displaced catheter may allow the medication to have a depressant effect on the brainstem center, causing life-threatening respiratory depression. (less)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Question 1: (see full question)

You selected:

A nurse is administering prescribed medicine to a client who experienced acute pain in the lower back after a motor vehicle accident. The client tells the nurse that compared to the previous week, his pain had reduced considerably. Which phase of pain is the client experiencing?

Modulation

Correct Explanation:

The client is in the modulation phase of pain, during which the brain interacts with the spinal nerves in a downward fashion to subsequently alter the pain experience. The client is not in the transduction, transmission, or perception phase of pain.

Transduction phase refers to the conversion of chemical information at the cellular level into electrical impulses that move toward the spinal cord.

In transmission phase, the stimuli move from the peripheral nervous system toward the brain, and the perception phase occurs when the pain threshold is reached. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1154.

Chapter 34: Comfort and Pain Management - Page 1154

Question 2: (see full question)

You selected:

A male college student age 20 years has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is the client most likely experiencing?

Visceral pain

Correct Explanation:

Visceral pain occurs when organs stretch abnormally and become distended, ischemic, or inflamed.

Appendicitis is characterized by inflammation of the vermiform appendix. Cutaneous pain is superficial.

Somatic pain is more commonly associated with tendons, ligaments, and bones. Referred pain is perceived distant from its point of origin, but this client's pain is sensed near the location of his appendix. (less)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1155.

Chapter 34: Comfort and Pain Management - Page 1155

Question 3: (see full question)

The nurse recognizes which of the following statements is true of chronic pain?

You selected:

It may cause depression in clients.

Correct Explanation:

Chronic pain may lead to withdrawal, depression, anger, frustration, and dependency. Clients have difficulty describing chronic pain because it may be poorly localized. Moreover, health care personnel have difficulty assessing it accurately because of the unique responses of individual clients to persistent pain. Chronic pain is commonly characterized by periods of remission and exacerbation. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 34: Comfort and Pain Management, p. 1154.

Chapter 34: Comfort and Pain Management - Page 1154

Question 4: (see full question)

You selected:

The nurse is caring for several clients experiencing acute pain. Which of the following would be the most appropriate task to delegate to the unlicensed assistive personnel?

Give the client a back massage.

Correct Explanation:

The most appropriate task for the nurse to delegate to the unlicensed personnel is to give the client a back massage. It is not appropriate to delegate administration of oral and/or intravenous medication to the client. It is also not appropriate for the unlicensed personnel to provide spiritual counseling. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 34: Comfort and Pain Management, pp. 1188-1191.

Chapter 34: Comfort and Pain Management - Page 1188

Question 5: (see full question)

You selected:

The nurse has completed a preoperative education session with a client who will receive morphine via a patient-controlled analgesia pump (PCA) after surgery. Which of the following statements by the client indicates the need for further teaching?

"I will remind my family member to push the PCA pump button for me if I doze off during the day."

Correct Explanation:

Sedation that prevents the client from delivering a dose of opioid contributes to the safety of intravenous PCA drug administration. If the client is too sleepy to push the button (or asks that it be pushed), the button should not be pushed. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1180.

Chapter 34: Comfort and Pain Management - Page 1180

Question 6: (see full question)

A nurse is assessing a client's pain. The nurse notes which of the following database findings that is indicative of acute pain?

You selected:

Increased blood pressure

Correct Explanation:

The increase in blood pressure that may accompany acute pain is believed to be due to overactivity of the sympathetic nervous system.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1162.

Chapter 34: Comfort and Pain Management - Page 1162

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers (see full question)

Which of the following nonpharmacologic pain relief measures has been found to be effective for soothing agitated newborns and comatose clients?

You selected:

Music

Question 7:

Correct Explanation:

Listening to music can relax, soothe, decrease pain, and provide distraction. It has proven effective for soothing agitated newborns and comatose clients.

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1170.

Chapter 34: Comfort and Pain Management - Page 1170

Question 8: (see full question)

You selected:

Three days after surgery, a patient continues to have moderate to severe incisional pain. Based on the gate control theory, what action should the nurse take?

Reposition the patient and gently massage the patient’s back.

Correct Explanation:

The nurse would reposition the client and gently massage the client’s back using the gate control theory of pain. The gate control theory provides the most practical model regarding the concept of pain.

It describes the transmission of painful stimuli and recognizes a relation between pain and emotions.

Nursing measures, such as massage or a warm compress to a painful lower back area, stimulate large nerve fibers to close the gate, thus blocking pain impulses from that area. Decreasing the dosage of the pain medication, but giving the doses more frequently does not follow this theory.

Decreasing external stimuli in the room during painful episodes would not address the gate control theory. Advise the client to sleep following administration of pain medication does not address the gate control theory. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 34, Comfort and Pain Management, p.

1154.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Chapter 34: Comfort and Pain Management - Page 1154

Question 9: (see full question)

Which of the following means of pain control is based on the gate control theory?

You selected:

Acupuncture

Correct Explanation:

Acupuncture is a means of pain control that is based on the gate control theory. Biofeedback, distraction, and hypnosis are alternative and complementary therapies that are nonpharmacological means of pain control. They are not based on the gate control theory. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 34, Comfort and Pain Management, p.

1172.

Chapter 34: Comfort and Pain Management - Page 1172

Question 10: (see full question)

You selected:

A nurse administers pain medication to patients on a med-surg ward. Which patient would benefit from a PRN drug regimen as an effective method of pain control?

A patient experiencing acute pain

Incorrect Correct response:

A patient in the postoperative stage with occasional pain

Explanation:

A PRN (as needed) medication would be most appropriate for a client in the postoperative stage with occasional pain. A client in the early postoperative period would benefit from the dosage of pain medication with around the clock dosing. A client experiencing chronic pain would benefit from the dosage of pain medication with around the clock dosing. A client experiencing acute pain would benefit from the dosage of pain medication with around the clock dosing. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 34, Comfort and Pain Management, p.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers 1177.

Chapter 34: Comfort and Pain Management - Page 1177

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Answer Key Question 1: (see full question)

You selected:

The nurse is providing education to a client about the role of endogenous opioids in the transmission of pain. Which information about the release of endogenous opioids is most accurate?

They bind to opioid receptor sites throughout the CNS.

Correct Explanation:

When endogenous opioids are released, they are believed to produce their analgesic effects by binding to specific opioid receptor sites throughout the central nervous system (C ... (more)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 34: Comfort and Pain Management, p. 1154.

Chapter 34: Comfort and Pain Management - Page 1154

Question 2: (see full question)

You selected:

A client is ordered pain medication every 4 to 6 hours as needed. When the nurse enters the client's room to administer the medication, the client is laughing with visitors.

The client's pulse rate is 64, respirations 16, and blood pressure 120/80. The client states that they are in pain and wants the medication. What is the most appropriate action by the nurse?

Administer the pain medication.

Correct Explanation:

Pain is present whenever the client perceives that they are in pain. The client is ordered the medication, the client's vital signs are within acceptable range, and the client stat ... (more)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Chapter 30: Hygiene - Page 921

Question 8: (see full question)

You selected:

A client is being discharged today from the hospital.

The nurse delegates morning care to the unlicensed assistive personnel (UAP). The assessment finds that the client is able to stand and ambulate independently without weakness or dizziness. The nurse will delegate what type of care to be provided based on the assessment findings?

Independent showering

Correct Explanation:

Weakness, dizziness, and fear of falling may prevent a person from entering a tub or shower or from bending to wash their lower extremities. Even while hospitalized, independence is encouraged so allowing the client to shower independently would be appropriate. The client is not unstable enough to prohibit hygiene measures. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, Chapter 30: Hygiene, pp.

903-904.

Chapter 30: Hygiene - Page 903

Question 9: (see full question)

You selected:

The nurse is assisting a 56-year-old female, who has undergone a mastectomy, with her morning care.

Which action by the client requires further teaching by the nurse?

The client applies deodorant.

Correct Explanation:

Clients who have undergone surgery for a mastectomy should avoid the use of deodorants or antiperspirants post-operatively because they act to close sweat glands and can cause skin irritations. In others, the use of these products may be contraindicated due to personal or cultural values.

Independence with hygiene measures is encouraged and cosmetics may be used for multiple reasons, including self-image enhancement in women. There are several bath preparations and a bag bath is convenient and beneficial to the client's skin. (less)

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 928.

Chapter 30: Hygiene - Page 928

Question 10:

A nurse is washing a patient's hair using a shampoo cap. Which of the following is an accurate step in this procedure?

(see full question)

You selected:

Remove and discard the cap and dry the hair with a towel.

Correct Explanation:

Steps in the procedure include: Place a towel across the patient's chest. Place the shampoo cap on the patient's head. Massage the scalp and hair through the cap to lather the shampoo. Continue to massage according to the time frame specified by the manufacturer's directions. Remove and discard the shampoo cap. Dry the patient's hair with a towel. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 922.

Chapter 30: Hygiene - Page 922

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Answer Key Question 1: (see full question)

You selected:

A nurse is performing an admission assessment on a client.

What is an appropriate question to ask when assessing the client’s self-care hygiene measures?

“Do you feel you will have difficulty performing self-care while in the hospital?”

Correct Explanation:

When assessing a client’s self-care patterns and feelings, it is important to understand the client’s perceptions regarding bathing and elicit personal care preferences. Although it is important to incorporate preferences, it may not be possible to allow clients to bring products from home if they are in specialty care environments. Asking questions about body odor may sound judgmental and may cause the client to feel judged, which may prohibit the ability to form a trusting relationship with the nurse. A clear threat to health must be present before a nurse can decide a client's hygiene practices are inadequate. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p.

912.

Chapter 30: Hygiene - Page 912

Question 2: (see full question)

You selected:

A nurse caring for the skin of patients of different age groups should consider which accurately described condition?

An adolescent’s skin ordinarily has enlarged sebaceous glands and increased glandular secretions.

Correct Explanation:

Adolescents have enlarges sebaceous glands and increased

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers

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Answer Key Question 1: (see full question)

You selected:

A nurse is promoting body movements for a patient during range-of-motion exercises. Which movements provide for flexion? (Select all that apply.)

• Bending the hand or foot backward and forward • Bending the leg and bringing the heel toward the back of the leg and then returning the leg to the straight position.

• Curling the toes downward and then straightening them out

Incorrect Correct response:

• Bending the hand or foot backward and forward • Bending the leg and bringing the heel toward the back of the leg and then returning the leg to the straight position.

• Moving the head from side to side, then bringing the chin toward each shoulder

Explanation:

Flexion is the state of being bent. Bending the hand or foot backward and forward would be an example of flexion.

Bending the leg and bringing the heel toward the back of the leg and then returning the leg to the straight position would be an example of flexion. Moving the head from side to side, then bringing the chin toward each shoulder would include the movement of flexion. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1041.

Chapter 32: Activity - Page 1041

Question 2: (see full question)

The nurse is performing a physical assessment on an adolescent. What assessment priorities are needed for this age group?

You selected:

Scoliosis

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Answer Key Question 1: (see full question)

An immobile client who weighs over 250 pounds is discharged to his daughter's home. The nurse should instruct the family to arrange for which of the following?

You selected:

Bariatric lift

Correct Explanation:

A bariatric lift is a type of hydraulic lift that is a mechanical device, which permits a client to be transferred from the bed to a chair effortlessly. The others would not be beneficial for the daughter and would not be appropriate if used with this type of client. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1063.

Chapter 32: Activity - Page 1063

Question 2: (see full question)

You selected:

A nurse is teaching a patient how to walk with crutches.

Which teaching points are recommended guidelines for this activity? (Select all that apply.)

• Use the four-point gait for patients who may bear weight on both feet.

• Prevent crutches from getting closer than 3 inches to the feet.

• Keep elbows close to sides.

Correct Explanation:

The client should keep the elbows close to their sides. The crutches should not be any closer than 12 inches from the feet. The client should use the four-point gait if they can bear weight on both feet. When climbing stairs, the client should

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Answer Key Question 1: (see full question)

You selected:

Which body system effects would the nurse state as occurring due to immobility? (Select all that apply.)

• Increased cardiac workload • Increased risk for renal calculi • Increased rate of respiration • Increased risk for electrolyte imbalance

Incorrect Correct response:

• Increased cardiac workload • Increased risk for renal calculi • Increased risk for electrolyte imbalance

Explanation:

Increased cardiac workload, increased risk for renal calculi, and increased risk for electrolyte imbalance occur from immobility. The client would have decreased depth of respiration, decreased rate of respiration, and increase in urinary stasis with immobility. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1052.

Chapter 32: Activity - Page 1052

Question 2: (see full question)

When turning a patient in bed, what muscle groups would the nurse use to pull the patient to the opposite side of the bed?

You selected:

Arm

Incorrect Correct response:

Leg

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Answer Key Question 1: (see full question)

The nurse is assessing the developmental level of children in a pediatric clinic. The nurse would be most concerned about which client?

You selected:

The 24-month-old child who is unable to walk unassisted

Correct Explanation:

At 15 months of age, most toddlers can walk unassisted; there would be concern for a 24-month-old child who could not. At 3 months of age, an infant may be able to raise the head, but this is not expected at this age for all 3-month olds.

Rolling over is usually accomplished between 6 and 9 months of age, so it would not be expected for all 6-month olds. Stacking blocks is accomplished by most 3-year olds, although 18 months is early. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p.

1045.

Chapter 32: Activity - Page 1045

Question 2: (see full question)

You selected:

After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client to sit up on the side of the bed?

Near the client's hip, with legs shoulder-width apart and one foot near the head of the bed

Correct Explanation:

When assisting the client from the bed into a wheelchair, the nurse would take position near the client's hip, with legs shoulder-width apart and one foot near the head of the bed.

This ensures that the nurse's center of gravity is placed near

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Answer Key Question 1: (see full question)

The nurse is assessing a patient who is bedridden. For which condition would the nurse consider this patient to be at risk?

You selected:

Predisposition to renal calculi

Correct Explanation:

In a bedridden client, the kidneys and ureters are level, and urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder.

Urinary stasis favors the growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increase the risk for urinary tract infection in an immobile patient.

Immobility also predisposes the patient to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone; the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume. The client would be at risk for decreased movement of secretion in the respiratory tract, due to lack of lung expansion. The client would suffer from decreased metabolic rate due to being bedridden. The client would not have an increase in circulating fibrinolysin. (less)

Reference:

Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 32, Activity, p. 1053.

Chapter 32: Activity - Page 1053

Question 2: (see full question)

You selected:

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. What statement is correct regarding logrolling?

Use a drawsheet or a friction-reducing sheet to facilitate smooth movement.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers Question 7: (see full question)

You selected:

Which characteristics or examples help to define a cartilaginous joint? (Select all that apply.)

• Freely movable • No joint cavity • Cartilage between the bones

Incorrect Correct response:

• Pubis symphysis • Cartilage between the bones • No joint cavity

Explanation:

The pubis symphysis is an example of a cartilaginous joint. The cartilaginous joint has cartilage between bones. There is no joint cavity in a cartilaginous joint. A freely movable joint is a synovial joint, the cartilaginous joint is slightly movable. A fibrous joint has fibrous connective tissue between the bones. The sutures between the bones of the skull are an example of a fibrous joint. (less)

Question 4:

The nurse is assessing an ambulatory patient for gait. Which documentation describes this mobility status?

(see full question)

You selected:

Adequate muscle mass, tone, and strength are available to accomplish movement.

Incorrect Correct response:

Arms swing freely in alternation with legs.

Explanation:

The patient’s movements while walking should be coordinated and the posture well balanced. The arms should swing freely in a rhythm alternating with the legs. Mobility would not be described by the drawing of a straight line from the ear through the shoulder and hip. This does not explain how the client moves. The documentation of full range-ofmotion does not describe the client’s mobility. The documentation of adequate muscle mass, tone, and strength could be important to include in the general documentation, but this description does not explain the client’s mobility status. (less)

Question 8: (see full question)

A nurse assesses a patient's alignment and documents which data as a normal finding?

You selected:

The knees are slightly bent.

Incorrect Correct response:

The base of support is on the soles of the feet.

Explanation:

Documentation of a normal finding of a client’s

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers alignment would be that the base of support is on the soles of the feet, and weight is distributed through the soles and heels. The chest would be held upward, but not backward. The abdominal muscles would be held upward, not downward. The buttocks would be held upward. The knees are extended in a slightly flexed position— not bent or hyperextended in the knee-locked position. (less) Question 3: (see full question)

The nurse should intervene immediately when observing the nursing assistive personnel (NAP) performing which activity with a stable client?

You selected:

Applying graduated compression stockings

Incorrect Correct response:

Teaching a client range of motion exercises

Explanation:

Client teaching regarding range-of-motion (ROM) exercises cannot be delegated to the NAP, although reinforcement or implementation of ROM exercises may be delegated. Transferring a client from the bed to a stretcher may be delegated to the NAP. Transferring a client from the bed to a chair may be delegated to the NAP. Applying and removing graduated compressions stocking may be delegated to the NAP. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1057.

Chapter 32: Activity - Page 1057

Question 5: (see full question)

Three nurses are transferring a patient from a bed to a chair. Which of the following is a recommended guideline for handling patients safely during a transfer?

You selected:

Use assistive devices if lifting over 50 pounds.

Incorrect Correct response:

If patient is in pain, administer analgesics in advance.

Explanation:

If the patient is in pain, administer the prescribed analgesic sufficiently in advance of the transfer to allow the patient to participate in the move comfortably. Patients should be encouraged to assist in their own transfers. During any patient transferring task, if any caregiver is required to lift more than 35

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers pounds of a patient's weight, then the patient should be considered to be fully dependent and assistive devices should be used for the transfer. Handling aids should be used whenever possible to help reduce the risk of injury to the nurse and patient. (less)

Reference:

Taylor, C., et al. Fundamentals of Nursing, 8th ed.

Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1062.

Chapter 32: Activity - Page 1062

Question 7: (see full question)

The nurse is turning a patient in bed. Where would the nurse stand when using the friction-reducing sheet to turn the patient to the opposite side of the bed?

You selected:

At the patient's center.

Incorrect Correct response:

Opposite the patient's center.

Explanation:

When pulling the friction-reducing sheet to turn a patient in bed, the nurse on the side of the bed toward which the patient is turning should stand opposite the center of the patient's body with feet shoulder width apart and one leg in front of the other.

This position ensures that the nurse is stable with good body alignment and is prepared to use large muscle masses to turn the patient. The maneuvers support the patient's body and make use of the nurse's weight to assist with turning. (less)

Question 8:

Three nurses are transferring a patient from a bed to a chair. Which of the following is a recommended guideline for handling patients safely during a transfer?

(see full question)

You selected:

Use assistive devices if lifting over 50 pounds.

Incorrect Correct response:

If patient is in pain, administer analgesics in advance.

Explanation:

If the patient is in pain, administer the prescribed analgesic sufficiently in advance of the transfer to allow the patient to participate in the move comfortably. Patients should be encouraged to assist in their own transfers. During any patient transferring task, if any caregiver is required to lift more than 35

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers pounds of a patient's weight, then the patient should be considered to be fully dependent and assistive devices should be used for the transfer. Handling aids should be used whenever possible to help reduce the risk of injury to the nurse and patient. (less) Question 10: (see full question)

Using the Katz Index of Independence in Activities of Daily Living, what indicators would cause the nurse to categorize the client as dependent? (Select all that apply.)

You selected:

• Requires someone to prepare meals • Uses the bedpan for toileting

Incorrect Correct response:

• Needs partial assistance with feeding • Uses the bedpan for toileting

Explanation:

The client who needs partial or total help with feeding is dependent. The client is categorized as dependent when help transferring to the toilet or cleaning self is needed, and when use of a bedpan or commode is required. The client who is able to get clothes from closets and drawers and puts on clothes and outer garments complete with fasteners is categorized as independent, even though help tying shoes is needed. The client who is able to bathe self completely or needs help in bathing only a single part of the body, such as the back, genital area, or disabled extremity is categorized as independent. The client is categorized as independent when able to get food from the plate into the mouth without help, even though preparation of meals is required by another person. (less)

Question 18: (see full question)

The nurse is observing an unlicensed assistive personnel (UAP) transferring a client with left sided weakness from the bed to the chair. The nurse should intervene when the (UAP) does which of the following? (Select all that apply.)

You selected:

• Instructs the client to hold to the side rail when standing to move into the chair • Stands near the client’s shoulders before sitting the client up in bed

Incorrect Correct response:

• Instructs the client to hold to the side rail when standing to move into the chair • Stands next to the client when the client is sitting on the side of the bed

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers • Stands near the client’s shoulders before sitting the client up in bed Explanation:

The nurse keeps the client in good body alignment and protects the client from injury while being moved. Safety and comfort are key concerns when assisting a client out of bed. The side rails should be down when transferring a client out of bed. The client should be instructed to use an arm to steady him- or herself on the arm of the chair when getting out of bed for support and stability. The nurse should stand in front of, not next to the client when the client is sitting on the side of the bed to prevent falls or injuries from orthostatic hypotension. When assisting the client to sit up on the side of the bed, the nurse should stand near the patient’s hips. The nurse’s center of gravity is placed near the patient’s greatest weight to assist the client to a sitting position safely.

The head of the bed should be elevated to place the client in a sitting position or as high as the client can tolerate. The amount of energy needed to move from a sitting position or elevated position to a sitting position is decreased. Bracing the knees against a weak extremity prevents a weak knee from buckling and the client from falling. (less)

Question 4: (see full question)

The nurse observes a nurse’s aide placing a client in the fowler’s position. To prevent complications to the client, in which situation should the nurse intervene?

(Select all that apply.)

You selected:

• The knee gatch on the bed is engaged.

• The client’s foot is in the plantar flexion position.

Incorrect Correct response:

• There is a large pillow under the client’s head.

• The knee gatch on the bed is engaged.

• The client’s foot is in the plantar flexion position.

Explanation:

In the fowler’s position, the client’s head should be against the mattress or supported by a small pillow only. Using a large pillow may cause flexion contracture of the neck. The knee gatch should be avoided to prevent pressure on the popliteal artery that may compromise lower extremity circulation.

When the client’s foot is in the plantar flexion position, the client is at risk for developing footdrop.

A footboard, high top sneakers or improvised firm foot support should be used. It is appropriate to place the client’s forearms on pillows. This will prevent pull on the shoulders and help to prevent

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers dislocation of the shoulder. A rolled towel or trochanter roll will help prevent external rotation of the hips. (less) Question 5: (see full question)

A nurse is promoting body movements for a patient during range-of-motion exercises. Which movements provide for flexion? (Select all that apply.)

You selected:

• Bending the hand or foot backward and forward • Bending the leg and bringing the heel toward the back of the leg and then returning the leg to the straight position.

Incorrect Correct response:

• Bending the hand or foot backward and forward • Bending the leg and bringing the heel toward the back of the leg and then returning the leg to the straight position.

• Moving the head from side to side, then bringing the chin toward each shoulder

Explanation:

Flexion is the state of being bent. Bending the hand or foot backward and forward would be an example of flexion. Bending the leg and bringing the heel toward the back of the leg and then returning the leg to the straight position would be an example of flexion. Moving the head from side to side, then bringing the chin toward each shoulder would include the movement of flexion. (less)

Question 10: (see full question)

A patient will be ambulating for the first time since his cardiac surgery. What should the nurse consider when assisting this patient?

You selected:

Patients who can lift their legs only 1 to 2 inches off the bed do not have sufficient muscle power to permit walking.

Incorrect Correct response:

If an ambulating patient whom a nurse is assisting begins to fall, the nurse should slide the patient down his or her own body to the floor, carefully protecting the patient’s head.

Explanation:

The nurse would use the gait belt to ease the client backward against one’s own body and gently ease the client to the floor while protecting the client’s head. The client should not look at their feet, but rather out at eye level at their surroundings. The nurse should consult the plan of care for the client, but the nurse regularly ambulates a client without a physical therapist present. The evaluation of a client’s muscle power to permit walking cannot be measured by their ability to lift their legs off the bed.

NCLEX _ Nursing Interventions TEST BANK Revised version with referenced Answers (less)