MOST NEW HESI RN FUNDAMENTALS

-NEW HESI RN FUNDAMENTALS - REAL QUESTIONS&ANSWERS - HESI RN FUNDAMENTALS 1. The nurse is discharging an adult woman who was hospitalized for 5 days for treatment of pneumonia. While the nurse is reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement? Provide written instructions that are easy to follow. 2. Which assessment finding is most significant in determining the level of assistance a client needs with personal care? Disorientation to time, place, and person 3. Eight hours after the removal of an indwelling catheter, a male client reports low abdominal pain, and palpation of the bladder indicates that it is distended and dull percussion. Even after assistingthe client to a standing position, he is unable to void. What action should the nurse take? Prepare to reinsert the urinary catheter. 4. The nurse notices a male client grimacing as he moves from the bed to a chair, but when asked about his pain he denies having any pain. Which intervention should the nurse implement first? Askthe client what is making him grimace. 5. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first? Respiratory rate 6. The charge nurse observes a new graduate nurse demonstrate the administration of two differentliquid medications through a gastrostomy tube used for continuous feeding, as seen in the video. What actions should the nurse take? (SATA) Confirm that the nurse determined the amount of gastric residualAdd the liquid volumes when documenting fluid intake Instruct the nurse to administer each mediation separately 7. The nurse inserts a catheter for nasotracheal suctioning as seen in the picture. What action shouldthe nurse take nest? Apply intermittent suction 8. A client who is 2 days postoperative for thoracic surgery is complaining of incisional pain 2 hours after receiving his pain medication. He rates his pain as 5 on a pain scale of 1 to 10. After placing a call to the healthcare provider, what action should the nurse implement? Instruct the client to use guided imagery and slow rhythmic breathing. 9. Am unlicensed assistive personnel (UAP) is assigned to help a female client with her bath who has viral hepatitis A and hepatic encephalopathy. What information should the nurse reinforce with the UAP? Wear gloves while giving a bath 10. The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures? Puts on new gloves when entering a client’s room. 11. The nurse is planning care for a group of clients during the night shift on a medical unit. Which client should be assessed regularly during the night for sleep apnea? An older male with multiple problems, including obesity, diabetes, and hypertension. 12. It is most important for the nurse to recalculate the Braden scale for a client who has developed which problem? Urinary incontinence 13. A male client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger-widths betweenthe top of the crutch and the client’s axilla. What action should the nurse take? Proceed with teaching the client how to walk with the crutches. 14. After experiencing symptoms caused by an abnormal heart rhythm, a client is placed on a temporary pacemaker. When the client expresses concern and fear of the pacemaker, how shouldthe nurse respond? Encourage discussion about the concern and fears. 15. Prior to initiating digital removal of a fecal impaction, it is important for the nurse to perform which client assessment? Vital signs 16. The mother of a child with Tetrology of Fallot ask the nurse, “ Why did this happen to my baby? What did I do wrong?” Which response is most helpful? “This must be a very difficult time for you.” 17. The healthcare provider prescribes bladder irrigation to maintain patency of a client’s indwelling urinary catheter. Which intervention should the nurse implement? Use sterile syringe to irrigate the normal saline 20 ml 18. Two nurses assess a client for a pulse deficit and count an apical pulse for 72 beats/minute and a radial pulse of 88 beats/minute. What action should the nurses take? Obtain a second pulse deficit reading 19. A female who is 1 day post mastectomy is crying when the nurse enters the room. What action should the nurse take? Stay with the client in silence while touching her forearm 20. A 24-hour urine collection is in progress. The client tells the nurse that the last voiding was accidentally flushed instead of saving in the container. What intervention should the nurse initiate? Discard the urine and start another 24-hour period 21. A confused elderly male client is having trouble sleeping at night and is sometimes found wandering the hallway. What nursing intervention should the nurse implement first? Provide a back rub at bedtime 22. A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The healthcare provider knows the client has agood prognosis and refuses to write a “do not resuscitate” (DNR) prescription. What action should the nurse take? Initiate an ethics committee review of the case 23. The nurse is preparing to feed a newly admitted elderly male client who is debilitated, but is ableto respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain? Client's ability to chew and swallow 24. The nurse enters the room of a client with a Clostridium difficile infection to administer an intravenous antibiotic. The unlicensed assistive personnel (UAP) is in the room cleaning the client’sbuttocks and states the client has been incontinent with diarrhea. The UAP is wearing gloves but not a gown. What action should the nurse implement first? Tell UAP put a gown on 25. The computer documentation system shuts down while the nurse is entering the client’s physical assessment data. What should the nurse do first? Wait for notification services department of the situation 26. In assessing a client who has a nursing diagnosis ofspiritual distress, which action should thenurse take first? Assist and support the client in establishing short-term goals. 27. During transfer to the medical unit, a client who experienced an acute change in level of consciousness became increasingly confused and combative, justifying soft wrist restraints for the client’s upper and lower extremities. Which intervention is most important for the nurse to implement on admission? Determine baseline neuro status 28. (PICTURE OF EAR AND EAR DROPS) The nurse prepares to administer ear drops to an adolescent client as seen in the picture. What should the nurse do next? Pull ear auricle downward 29. The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than the previous reading. What should the nurse do next? (Select all that apply)Retake the pt's Bp in opposite arm** Determine the pt's activity and feelings prior to bp measurement 30. A male client with limited mobility is discharged with home health services. When the home health nurse arrives, the client asks what he can do for the swelling in his leg. Which actin should the nurse implement? Instruct pt to flex both of his feet several times a day 31. Which information is most important for the nurse to consider when preparing to transfer a client from the bed to a chair? The pt's ability to bear weight on lower extremities 32. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). The pulse oximeter alarm is flashing without displaying a percentage of oxygen. Which action should the nurse implement? exchange pulse ox for another monitor 33. Two days after surgery a male client experiences incisional pain while dangling his feet at the bedside and he refuses to ambulate as prescribed. The nurse establishes a problem of, “Activity intolerance related to pain.” Based in this problem, which outcome statement is best for the nurse to include in the client’s plan of care? The client will Ambulate without discomfort 34. After assessing a client, the nurse identifies three nursing problems. When developing the client’s plan of care, which action should the nurse take next? Prioritize the identified nursing diagnoses 35. After reviewing the admission assessment of a client with chronic pain, which interventions should the nurse include in this client’s plan of care? (Select all that apply) Provide comfort measures such as topical warm application and tactile massageImplement a 24h schedule of routine administration of prescribed analgesic Determine client's subjective measure of pain using a numerical pain scale 36. A client is discharged to a long-term care facility with an indwelling urinary catheter. Which nursing action should be included in the plan of care to reduce the client’s risk for infection related to the catheter? Encourage increased intake of oral fluids 37. The electronic medication system alerts the nurse that the medication dose scanned is two times higher than the dose prescribed. What action should the nurse implement? Convert the dose on hand to match the prescribed dose 38. A male client with chronic debilitating heart disease asks the nurse to help him die because he believes that he will be better off dead rather than living under the current circumstances. The nurse supports the client and considers providing the family with a does of medications that can result in the client’s death. If the nurse acts on this intention, what is the most likely consequence?The nurse will be prosecuted for the murder of the pt 39. While suctioning a client’s nasopharynx, the nurse observes that the client’s oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding? Complete the intermittent suction of nasopharynx 40. The grandmother of a young adult male admitted to the psychiatric unit yesterday requests information about her grandson’s treatment plan. Before answering the family member’s question, what action should the nurse take? Ensure that the signed release of info includes thegrandmother 41. When providing health teaching to elderly clients, what action is most important for the nurse to implement? Use everyday language when explaining issue 42. A male client presents to the clinic stating that he has a high stress job and is having difficulty falling asleep at night. The client complains of a constant headache and is seeking medication to help him sleep. Which intervention should the nurse implement? Determine the client's sleep andactivity pattern 43. To assess the quality of an adult client’s pain. What approach should the nurse use? Ask the pt to describe pain 44. The nurse is planning a weight reduction teaching program to be implemented at a community health center. Which goal is best for clients who are approximately fifteen percent over their ideal wight and wish to participate in the weight loss program? Fat intake between 20 to 30 percent of total daily intake 45. The nurse prepares to irrigate the ear of an adult client. The client is positioned with the head tilted slightly toward the affected side and the emesis basin positioned under the ear. What actionshould the nurse take next? confirm the temperature of the irrigation solution 46. The home health nurse visits a client who has a serum sodium level of 123 mEq/L. To explore possible etiologies for this value, what questions should the nurse ask the client? How much waterand ice chips do you have each day? 47. The healthcare provider prescribes hydroxyzine (Vistaril) 35 mg IM for a client who is vomiting. The available drug is labeled, 50 mg/ml. How many ml should the nurse administer? 0.7ml 48. The nurse finds a confused female client wandering in the hallway during the night. What actionshould the nurse implement? (Select all that apply) Raise the side rails of bed Escort her back to room Secure bed alarm on mattress 49. A client in the outpatient clinic complains of experiencing hard, infrequent stools. Which instruction should the nurse provide this client? Drink 6-8 large glasses of water daily 50. The nurse reviews discharge instructions for a male client with obstructive sleep apnea syndrome (OSAS). The client tells the nurse that he likes to drink a glass of wine before going to bed. How should the nurse respond? Offer to contact healthcare provider about a prescription for a sleepingaid 51. The home care nurse has identified the problem “Risk for hopelessness” for a male client who is terminally ill with a life expectancy for several days. Which instruction should the nurse provide the client’s spouse? Listen for changes in what the client hopes for and try to help meet his goals 52. The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client’s auricle upand back and prepares the thermometer. What action should the nurse implement? A Demonstrate the correct technique for pulling the ear down and back 53. A journalist asks the nurse working in the Emergency Department about condition of a local politician recently admitted to the medical center following a publicly reported building fire. What action should the nurse take? Obtain verbal consent from family member before discussing the client’s condition 54. Which outcome statement can be used in the planning stage of the nursing process? The clientwill demonstrate ability to change ostomy bag in two days 55. The nurse observes an adult woman perform a return demonstration of diaphragmatic breathing. The client inhales while holding her abdomen, then removes her hand to allow expansion of the abdomen during exhalation. What action should the nurse take after observing the client’s demonstration? Demonstrate how to expand the abdomen while inhaling and let it sink in while exhaling 56. The nurse begins to suction a client’s oropharynx as seen in the picture. What action should the nurse take next? Observe the suctioned secretions 57. The nurse is evaluating the fluid balance of a client who was admitted yesterday with dehydration and who has been receiving IV fluidssince admission. An increased in which parameter indicatestothe nurse that the client is rehydrating? Pulse rate 58. The charge nurse is observing a new graduate’s performance of wound care. Which technique indicates that the employee is effectively cleansing the wound? Starts at wound site and moves outward using circular motions 59. While counting the respirations of an adult client who is bedfast, the nurse observes that the client uses the sternocleidomastoid, trapezius, and abdominal muscles during respirations. Whataction should the nurse take in response to this finding? Provide the client an incentive spirometerto increase respiratory effort 60. What assessment is most important for the nurse to perform to the application of a heating pad? Degree of neurosensory impairment 61. The healthcare provider prescribes acetaminophen (Tylenol) elixir 325 mg PO for an older adult who has difficulty swallowing pills. The available oral solution is labeled, acetaminophen elixir 325mg/5ml. How many teaspoons should the nurse administer with each does? 1 teaspoon 62. An elderly woman comesto the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear, which the client reports is likely to have occurred during unprotected sexual intercourse. Which content is most important for the nurse to include in this client’s teaching plan? The importance of using vaginal lubricants. 63. A client who lives in an assisted living facility develops cognitive impairment following a stroke. Informed consent is needed to provide additional nursing services. Who should the nurse contact?A daughter in law designated as the client’s Durable power of Attorney (DPOA) 64. The unlicensed assistive personnel (UAP) describe the appearance of the bowel movement of several clients. Which description warrant additional follow-up be the nurse? (Select all that apply) multiple hard pellets, tarry appearance, and brown liquid -I ALSO ADVISE YOU TO STUDY THIS 2018/2019 FILE-MOST SCHOOLS ARE USING THIS!!!!! 1. A client at an outpatient clinic submits a clean- catch midstream urine specimen for a routine urinalysis. In later review of the client's medical record, which data indicates to the nurse that the specimen collection should be repeated? A. The urine specimen shows multiple organisms in low colony counts. B. The client reported eating a meal before voiding the urine specimen C. There was a total of 30 ml of urine voided into the specimen cup D. The medical record indicates the client is allergic to most antibiotics 2. When assessing a client who starts to wheeze which related data should the nurse obtain? A. Precipitating factors B. Body Temperature C. Presence of radiation D. Heart sounds 3. A client diagnosed with primary open-angle glaucoma received a prescription for miotic eye drops, pilocarpine HCl (Pilocarpine). What instructions should the nurse plan to include in this client’s teaching? A. “Administer the medication directly on the cornea.” B. “Wash your hands after each administration of eye drops.” C. “Do not allow the dropper bottle to touch the eye.” D. “Squeeze your eye closed after administering the drops.” 4. The nurse observes that a male client on a clear liquid diet has a cup of coffee on his breakfast tray. What action should the nurse implement? A. Consult with the dietician to learn if the client is allowed to drink coffee B. Determine which member of the nursing staff brought the cup of coffee to the client C. Remind the client that no milk, or creamer can be added to the coffee. D. Remove the coffee from the tray, advising the client that it is not included in the diet. 5. When evaluating the effectiveness of a client’s nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next? A. Determine if the expected outcomes were realistic B. Modify the nursing interventions to achieve the client’s goals C. Obtain current client data to compare with expected outcomes D. Review related professional standards of care. 6. The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. In designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use? A. Return demonstration B. Journaling C. Analogies D. Role playing 7. The nurse observes the skin over a client's greater trochanter as seen in the picture. What actions should the nurse implement? (select all that apply) A. Remove the eschar before applying and securing a hydrocolliod B. Prepare to implement a pressure redistribution mattress C. Obtain a specimen of the site for culture and sensitivity D. Instruct the Unlicensed assistive personnel to frequently offer oral fluids E. Explain to the client that the wound needs debridement 8. The nurse has removed the barbiturate capsule from the unit dose wrapper to administer to a male client. The client decides he wants to watch a television program and requests not to take the medication. Which action should the nurse implement? A. Credit the medication back and put in the client’s medication box B. Keep the medication and see if the client will want to take it later. C. Have another nurse watch disposal of the medication into disposal container D. Explain that since the medication is a controlled substance it must be taken. 9. The home health nurse is reviewing the personal care needs of an elderly client who lives alone. Which client assessment findings indicate the need to assign an unlicensed assistive personal (UAP) to provide routine foot care and file the client’s toenails? (Select all that apply). A. Shuffling gait. B.Diminished visual acuity. C. Syncope when bending. D. hands tremors. E.Urinary incontinence 10. The charge nurse observes a new graduate's performance of wound care. Which technique indicates that the employee is effectively cleansing the wound? A. Starts at the wound site and moves outward using circular motions. B. Cleanses from the outer area of the wound toward the center C. Uses a sterile swab to go over the wound site twice. D. Scrubs wound vigorously for at least two minutes 11. The nurse is evaluating the fluid balance of the client who was admitted yesterday with dehydration and who has been receiving iv fluids since admission. An increase in which parameter indicates to the nurse that the client is rehydrating. A. Serum haematocrit. B. Urine specific gravity. C. Pulse Rate. D. Urinary output. 12. In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative nurse is arranging for discharge, the client verbalizes concerns about pain. What action should the nurse implement? a. Explain the respiratory problems that can occur with morphine use. b. Teach family how to evaluate the effectiveness of analgesics. c. Recommend asking the healthcare professional for a patient-controlled analgesic (PCA) pump. d. Provide client with a schedule of around-the-clock prescribed analgesic use. 13. The nurse begins to suction a client’s oropharynx as seen in the picture. What action should the nurse take next? a. Position suction in the trachea. b. Apply nasal cannula oxygen. c. Insert a tongue blade. d. Observe the suction secretion. 14. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview? a. The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace. b. Completing the electronic record during an interview is a legal obligation of the examining nurse. c. The nurse has limited ability to observe non-verbal communication while entering the assessment electronically. d. The client’s comfort level is increased when the nurse breaks eye-contact to type notes into the record. 15. The nurse measures the client’s blood pressure(BP) and notes that it is significantly higher than the previous reading. What should the nurse do next? (Select all that apply). a. Determine the client’s activities and feelings prior to the BP measurement. b. Retake the Client's blood pressure in the opposite arm c. Assign the unlicensed assistive personnel to recheck the BP in an hour. (not the answer because it should be rechecked sooner) d. Ask another nurse to assist in assessing for an apical-radial pulse deficit. e. Immediately take two more readings on the same arm. 16. A male Native American presents to the clinic with complaints of frequent abdominal cramping and Nausea. He states that he has chronic constipation and has not had a bowel movement in 5 days, despite trying several home remedies. Which intervention is most important for the nurse to implement. a. Access for the presence of an impaction. b. Evaluate stool sample for the presence of blood. c. Obtain list of prescribed home medications. d. Determine what home remedies where used. 17. The Practice Nurse (PN) applies sterile gloves and opens a pack of sterile sponges to assist the healthcare provider with a bedside procedure. After the Charge Nurse (CN) observes the PN, what actions should the charge nurse take? a. Confirm that PN is ready to assist with the planned procedure. b. Obtain all new supplies and directly assist with the procedure. c. Remove the contaminated package of sponges from the table. d. Instruct the PN to remove the gloves that are now contaminated. 18. A male client with limited mobility is discharged with home-health services. When the home-health nurse arrives, the client asks what he can do for the swelling in his leg. What action should the nurse implement? a. Encourage the client to take short walks around the block. b. Advice the client to dangle his feet during meals and before bedtime. c. Ensure the clients to flex both of his feet, several times a day. d. Explain the need to keep the head of the bed elevated. 19. A male client with a recent diagnosis of terminal cancer, tells his nurse that he wishes to die naturally. The client states that he’s tired of fighting this illness and is only continuing treatment because of his family’s wishes. What actions should the nurse take? a. Request a consultation for a psychologist to talk with the client. b. Call a clergy to discuss end-of-life decisions with the client. c. Determine if he wants to stop radiation and chemotherapy. d. Arrange a meeting with the client, his family and the healthcare provider. 20. A male client who had emergency gallbladder surgery yesterday is getting ready for discharge. The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client’s understanding of self-care at home? a. Have the client demonstrate prescribed wound care. b. Provide written instructions in the client’s native language. c. Have an interpreter repeat the wound care instructions. d. After each instruction, ask the client if he understands. 21. A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What actions should the nurse take first? a. Access for side effects of the medication. b. Document the client’s responses. c. complete a medication error report. d. Determine if the pain was relieved. 22. The nurse is evaluating a client who is admitted to an adult medical unit, and notes that a client’s urine output has been 70 ml/hr. Which action should the nurse implement? a. Recommend drinking cranberry juice with meals. b. Encourage the client to drink more fluids. c. Document the client’s urinary output every hour. (NORMAL RANGE) d. Notify the healthcare provider immediately. 23. A client is admitted with Pneumonia and has a recent history of Methicilline-resistance Staphylococcus aureus (MRSA). The Client is placed in isolation while caring for the client, which client should the nurse place in a designated bio-hazard bag before it is removed from the room? a. A sputum specimen. (BODILY FLUIDS=BIOHAZARD) b. Paper mask and gown. c. The nurse’s stethoscope. d. Bed linens. 24. A client is receiving Ketorolac (Toradol) IM 45mg IM every 6 hours for post operative pain. The available 2ml vile is labeled, Toradol 30mg / ML. How many ML should the nurse administer? (enter numerical value only, If rounding is required round to the nearest Tenths). [1.5 x] 25. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital signs should the nurse obtain first. a. blood pressure. b. Respiratory rate. (Cyanosis caused by low oxygen levels in the RBCs) c. Pulse Rate. d. Temperature. 26. An older male client returns to the clinic for chronic pain management after taking morphine sulphate (MS contin) 25mg every 12hrs. He states he took the medication only when the pain was too severe to sleep. What action should the nurse implement? a. Explain the risk of drug addiction from long term pain medication. b. Tell the client to continue taking the MS contin with severe pain. c. Instruct the client to take the MS Contin every 12 hours as prescribed. d. Teach the client alternative ways to manage his chronic pain. 27. A client is admitted with complaints of shortness of breath (Dyspnea) on exertion, and chest pressure The healthcare provider prescribes a medication that is unfamiliar to the nurse. When checking the drug handbook, the nurse reads that the prescribed amount is an unusually large dose. What actions should the nurse take? a. Consult pharmacists for those clarification. b. Verify the prescribed dosage with a healthcare provider. c. Administer the medication as prescribed. d. Give the dosage recommended in the drug handbook. 28. A client who lives in an assisted living facility; develops cognitive impairment following a stroke. Informed consent is needed to provide additional nursing services. Who should the nurse contact? a. The client’s youngest son was identified by family members as the family’s spokesperson. b. A daughter-in-law designated as the client’s durable power of attorney (DPOA) c. The client’s spouse who lives in the independent living unit of the facility. d. The client's oldest living child, a lawyer who is visiting from out of town. 29. What explanation is best for the nurse to provide a client who asked the purpose of using the log-rolling technique for turning? a. Working together can decrease the risk of back injury to the nurses. b. Turning instead of pulling reduces the likelihood of skin damage. c. The technique is intended to maintain straight spinal alignment. d. Using two or three people increases client’s safety. 30. The nurse is teaching a husband how to care for his wife who recently had a stroke and has residual weakness on her right side. What style shoes does the nurse recommend the client wear when ambulating with her husband’s assistance? a. Slip-on rubber shower shoes. b. Tennis shoes with Velcro. (FALL PRECAUTION) c. Rubber sole slippers. d. Leather sole loafers. 31. A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The healthcare provider knows the client has a good prognosis and refuses to write a “Do Not Resuscitate”(DNR Prescription). What actions should the nurse take? a. Ensure resuscitation equipment is available. b. Ask the family to review options with the client. c. Place a DNR bracelet on the client’s arm. d. Initiate an ethics committee review of the case. 32. A client newly diagnosed with stage 3 lung cancer becomes angry with the healthcare provider and nursing staff. Which intervention is most important for the nurse to implement? a. Arrange for the client to meet with another client who has lung cancer. b. Request a consultation from an oncology social worker. c. Acknowledge the client’s anger and attempt to address its source. d. Allow the client and family time to be alone. 33. Two days after surgery, a male client experiences incisional pain while dangling his feet at the bedside and he refuses to ambulate as prescribed. The nurse establishes a problem of “activity intolerance related to pain”. Which outcome statement is best for the nurse to include in the client’s plan of care? a. To take analgesic as prescribed. b. To ambulate without discomfort. c. To show evidence of incision healing. d. To avoid pain-causing activity. 34. An adult client complains of insomnia and asks the nurse to recommend a sleeping pill. What reply is best for the nurse to provide? a. “Have you discussed this with your healthcare provider?” b. “Zolpidem Tartate (ambien) is used for insomnia.” c. “Sleeping medication require side effects that require caution” d. “Tell me about your insomnia and how you treat it” 35. The healthcare provider prescribes Haloperidol (Haldol) 1.5mg twice daily for a client with Tourette’s syndrome. The drug is available in a Potassium 3.1 mEq/L (3.1 mmol/L) (LOW) solution labeled “2mg / ml” How many ml should the nurse administer?(enter numerical value only, If rounding is required round to the nearest Tenths). 36. A client who has been taking diuretics for premenstrual swelling reports muscle weakness. Which serum electrolyte value should the nurse report to the healthcare provider. a. Total calcium 9.2 mg/dl (2.3 mmol/L) b. c. Chloride 98 mEq/L (98 mmol/L) d. Sodium 142mEq/L (142 mmol/L) 37. The unlicensed assistive personnel (UAP) describes the appearance of the bowel movement of several clients. Which description warrants additional follow up by the nurse? (select all that applies). a. Solid with red streaks. b. Brown liquid. c. Multiple hard pellets. d. Formed but soft. e. Tarry appearance. 38. During the admission assessment of a terminally ill male client, The client states that he is an agnostic. What is the best nursing action in response to this statement. a. Provide information about the hours and location of the chapel. b. Document the statement in the client’s spiritual assessment. c. Offer to contact a spiritual advisor of the client’s choice. d. Invite the client to a healing service for people of all religions. 39. A client is discharged to a long-term care facility. With an indwelling urinary catheter. Which nursing action should be included in the plan of care to reduce the client’s risk of infection related to the catheter. a. Secure the drainage bag at bladder level during transport. b. Flush the catheter daily with sterile saline solution. [0.75 X] c. Administer PRN Antipyretic if a fever develops. d. Encourage increased intake of oral fluids. 40. The community healthcare nurse is making a home visit when the client, who is sitting at the kitchen table begins to have a seizure. What action should the nurse take first? a. Assist the client to the floor. b. Access the client’s vital signs. c. Call 911 for an ambulance. d. Remove nearby furniture. 41. The nurse prefers to implement a prescription for oxygen at 4 L/minute per nasal cannula. For a client with an oxygen saturation of 90%. The nurse observes the flow meter set up provided by the respiratory therapist, as seen in the picture. What action should the nurse take next? a. Adjust the flow rate to 4 L/minute b. Attach oxygen tubing to the flow meter. c. Drain the water out of the humidifier. d. Document the presence of breath sounds. 43. The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bed side rails. Which action is most important for the nurse to implement? a. Initiate the facility’s restraint flow sheet. b. Demonstrate proper securing of the restraint. c. Ensure that the restraints are not too tight. d. Complete an adverse occurrence/incidence report. 44. A nurse administers an opioid analgesic to a post operative client who also has severe obstructive sleep apnea (OSA). What intervention is most important for the nurse to implement before leaving the client alone? a. Apply the client’s positive airway pressure device. b. Lift and lock the side rails in place. c. Remove dentures or other oral appliances. d. Elevate the head of the bed to 45 degree angle (MORE RISK FOR RESPIRATORY COMPLICATIONS) 45. A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved. a. Number of staff induced injury b. Client satisfaction survey c. Health care-associated infection rate. d. Rate of needle-stick injuries by nurse. 46. While suctioning a client’s nasopharynx the nurse observes that the client’s oxygen saturation remains at 94% which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding? a. Complete the intermittent suction of the nasopharynx. b. Reposition the pulse oximeter clip to obtain a new reading. c. Stop suctioning until the pulse oximeter reading is above 95%. d. Apply an oxygen mask over the client’s nose and mouth 47. The nurse is preparing a teaching plan for a client with low back pain. Which sleeping position should be included in the teaching? a. Side-lying with hips and knees flexed. b. Supine with hips and knees and neutral straight position. c. Head of bed elevated to 30 degrees. d. Prone with a pillow under the lower abdomen. 48. What self-care outcome is best for the nurse to use in evaluating a client’s recovery from a stroke that resulted in left-sided hemiparesis? a. Self-care needs to be completed by the unlicensed assistive personnel. b. Participate in self-care to an optimal level of capacity. c. Promote independence by allowing clients to perform all self-care activities. d. Client verbalizes importance of hygienic practices in the recovery process. 49. It is most important for the nurse to recalculate the braden scale score for a client who has developed which problem. a. Urinary incontinence. b. Hypo-active Bowel sound. c. Plus Two ankle Edema. d. Weakened cough efforts. 50. When performing blood pressure measurement to assess for orthostatic hypotension, Which action should the nurse implement first? a. Apply the blood pressure cuffs securely. b. Assist the client to stand at the bedside. c. Position the client supine for a few minutes. d. Record the client’s pulse rate and rhythm . 51. A female nursing home resident and her family only speak Spanish. During a visit, the entire family begins to cry hysterically. When unable to determine why the family is upset, What intervention is most important for the nurse to implement? a. Sit quietly with the family to offer comfort and support. b. Ask a Spanish speaking staff member to talk with the family. c. Use a Spanish translation reference to interview the family. d. Close the door to the client's room to provide family privacy. 52. The nurse uses a sterile syringe to obtain a urine specimen, from a client’s indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the lab. During what part of this procedure should the nurse wear gloves? a. Transporting the urine specimens to the laboratory. b. Using the remove the specimen from the catheter. c. Clamping the urinary catheter prior to the collection. d. Recording the output on the flowsheet in the client’s room. 53. A male hospice client with bone cancer reports to the nurse that his bone pain is not adequately controlled with his current dose of morphine sulfate, and he is experiencing difficulties with constipation. In addition to increasing the client’s dose of laxative, what plan of treatment should the nurse anticipate? a. Reduce the dose of morphine b. Increase the dose of morphine c. Switch from morphine to codeine d. Take no additional morphine 54. What is the best approach for the nurse to use when interviewing a client about sexuality/ reproductive function? a. Ask questions in a vague, non-specific format b. Share personal values to put the client at ease c. Begin with questions that are less sensitive in nature d. Get the most difficult questions over with first 55. A female client’s significant other has been at her bedside providing reassurances and support for the past 3days, as desired by the client. The client’s estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement? a. Obtain a perception from the healthcare provider regarding visitation privileges b. Request a consultation with the ethics committee for resolution of the situation c. Encourage the client to speak with her husband regarding his disruptive behavior d. Communicate the client’s wishes to all members of the multidisciplinary team An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear, which the client reports is likely to have occurred during unprotected sexual intercourse. Which content is most important for the nurse to include in the client's teaching plan? A: The importance of using vaginal lubricants. B: Methods used to practice safe sex. C: Information about alternative ways to express sexuality. D:Intercourse positions that help prevent tears. A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, what action should the nurse take? A) Have the client put both arms around the nurse's neck for support. B) Place the wheelchair on the client's left side. C) Instruct the client to look at his feet. D) Instruct the client total slow, deep breaths while transferring The nurse observes a newly admitted older adult female take short steps and walk very slowly while pushing a walker in front of her. What action should the nurse take in response to these observations? A) Complete a full fall risk assessment of the client. B) Teach the client to take longer steps at a faster pace. C) Suggest that the client use a wheelchair instead of a walker. D) Place the client on bed rest until the healthcare provider is notified. An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take first? A) Discuss with the client her meaning of heroic measures. B) Obtain a "do not resuscitate" (DNR) prescription. C) Set up a family conference to discuss the clients. D) Consult the palliative care team about the client's care. A client is receiving ketorolac (Toradol) IM 45 mg IM 6 hours for postoperative pain. The available 2 ml vial is labeled , Toradol IM 30 mg/ml, How many should the nurse administer? (Round to the nearest tenth.) 1.5mg To assess the quality of an adult client’s pain, what approach should the nurse use? C A) Observe body language and movement. B) Provide a numeric pain scale. C) Ask the client to describe the pain. D) Identify effective pain relief measures. A client who has been diagnosed with terminal cancer tells the nurse, “The doctor told me I have cancer and do not have long to live.” Which response is best for the nurse to provide? A) “That’s correct, you do not have long to live” D B) “Would you like me to call your minister?” C) “Don't give up, you still have chemotherapy to try.” D) “Yes, your condition is serious.” A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instructions should the nurse give to the unlicensed assisstive personnel (UAP) who assissting with client’s care? (Select all that apply.) A) Instruct the client about signs of orthostatic hypertension B) Determine if the client needs to have a gait belt applied C) Measure the clients vital signs before the client walks. D) Offer to assist the client to void prior to walking in the hall. E) Report the onset of any dizziness or light headedness. A client has begun a long-term maintenance therapy with lithium, which has a narrow therapeutic index. Which adverse effect is most important for nurse to include in the teaching plan? A) Dependence. dressing covering the area. What action should the nurse implemented? A) Apply a hydro gel (Duaderm) dressing interventions to prevent multiple re-entries to the client’s room. In which order should the nurse perform the interventions? A) Change coccyx dressing, perform tracheostomy care, restart the IV. B) Perform tracheostomy care, change coccyx dressing, restart the IV. C) D) Restart the IV, perform tracheotomy care, change coccyx dressing. Change coccyx dressing, restart the IV, perform tracheostomy care. The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3L/minute, and the client’s oxygen saturation level is 92%. What intervention should the nurse implement? A) Decrease the flow rate to 1 L/minute. B) Discontinue the use of the nasal cannula. C) Apply lubricant to the cannula tubing. D) Place padding around the cannula tubing. The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant grandution. The wound has a gauze B) Toxicity. C) Interaction. D) Tolerance. A client is in contact isolation due to stage IV coccyx wound infected with methicillin resistant staphylococcus aureus (MRSA). The nurse plans B) Increase the frequency of the dressing changes. C) Replace the gauze with transparent dressing. D) Leave the dressing off until consulting with the healthcare provider. The healthcare provider prescribes haloperidol (Haldol) 1.5mg twice daily for a client with Tourette’s syndrome. The drug is available in a solution labeled, “2 mg/ml.” How many ml should the nurse administer? (Round to the nearest hundredth.) 0.75 The home care nurse is teaching a client how to change the dressing on a new venous stasis ulcer. The client has a history of a deep vein thrombosis and is allergic to latex. When removing the adhesive bandages, the nurse observes skin redness surrounding the draining wound. What action should the nurse implement? A) Replace dressing with cotton pads and silk tape. B) Measure and compare ankle-brachial pressure index. C) Obtain sample of the drainage for culture. D) Apply an antibiotic ointment to the wound. A middle-aged male client tells the nurse that has weeks ago he began exercising four times a week to lose weight and to help him sleep better. He states that it still takes an hour to fall asleep at night. What action should the nurse implement? A) Advice the client that lifestyle changes often take several weeks to be effective. B) Determine the amount of weight the client has lost since increasing his activity. C) Encourage the client to exercise every day to eliminate bedtime wakefulness. D) Ask the client to describe the exercise schedule that he has been following. Which landmarks are useful to the nurse when administering an intramuscular injection in ventrogluteal site? A) The greater trochanter and anterior superior iliac spine. B) The knee and greater trochanter. C) The upper, outer quadrant of the buttock. D) The deltoid muscle. A) Initiate the collection the foll What information is most important for the nurse to obtain in determining a client’s need for referral for obesity counseling? A) Body weight 10% over ideal body weight. B) Body mass index greater than 35. C) Daily caloric intake of 3500 calories. D) Client’s expressed desire to lose 50 pounds. The nurse is caring for a hospitalized client who was placed in restraints due to confusion. The family removes the restraints while they are with the client. When the family leaves, what action should the nurse take first? A) Apply the restraints to maintain the client’s safety. B) Reassess the client to determine the need for continuing restraints. C) Document the time the family left and continue to monitor the client. D) Call the healthcare provider for a new prescription. The nurse is caring for a male client with diminished circulation in the lower extremities. The client washes his feet in the shower, but is unable to bend safely to dry his feet. While drying the client’s feet, the nurse should emphasize the need to thoroughly dry which area of the feet? A) Between the toes. B) Around the ankles. C) On dorsal surfaces D) Over the heels. A 24-hour urine specimen is being collected for analysis clearance. After explaining the procedures, the client tells the nurse that the first sample is in the urinal. When discarding this specimen, what action should the nurse take? A female, unlicensed assistive personnel (UAP) is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requested a change in assignment, stating she has not yet been fitted for a particulate filter mask. What action should the nurse take? -instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next? A. Clamp the catheter and recheck it in 60 minutes. B. Pull the catheter back 3 inches and redirect upward. C. Leave the catheter in place and reattempt with another catheter. D. Notify the health care provider of a possible obstruction. It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in place will help locate the meatus when attempting the second catheterization The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client? A. "Monitoring Your Blood Pressure at Home" B. "Smoking Cessation as a Lifelong Commitment" C. "Decreasing Cholesterol Levels Through Diet" D. "Stress Management for a Healthier You" Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the nurse implement next? A. Make the client comfortable and allow the client to sleep. B. Assess the client's neurologic status. C. Notify the surgeon about the comment. D. Ask the client's family to co-sign the operative permit. The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction? A. Perform range-of-motion exercises to prevent contractures. B. Decrease the client's fluid intake to prevent diarrhea. C. Massage the client's legs to reduce embolism occurrence. D. Turn the client from side to back every shift. The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the priority action for the nurse to take? A. Check the client's carotid pulse. B. Encourage the client to get to the toilet. C. In a loud voice, call for help. D. Gently lower the client to the floor. A female nurse is assigned to care for a close friend, who says, "I am worried that friends will find out about my diagnosis." The nurse tells her friend that legally she must protect a client's confidentiality. Which resource describes the nurse's legal responsibilities? A. Code of Ethics for Nurses B. State Nurse Practice Act C. Patient's Bill of Rights D. ANA Standards of Practice The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later the client reports that he is still unable to sleep, despite following the same routine every night. Which action should the nurse take first? A. Instruct the client to add regular exercise as a daily routine. B. Determine if the client has been keeping a sleep diary. C. Encourage the client to continue the routine until sleep is achieved. D. Ask the client to describe the routine that the client is currently following. A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide? A. Take a vitamin supplement tablet once a day. B. Change positions in the chair at least every hour. C. Increase daily intake of water or other oral fluids. D. Purchase a newer model wheelchair. When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety? A. Securely grasp the client's arm and leg. B. Put bed rails up on the side of bed opposite from the nurse. C. Correctly position and use a turn sheet. D. Lower the head of the client's bed slowly. A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse? A. Orange juice has vitamin C that deters bacterial growth. B. Apple juice is the most useful in acidifying the urine. C. Cranberry juice stops pathogens' adherence to the bladder. D. Grapefruit juice increases absorption of most antibiotics. The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition? A. Low serum albumin level B. Low serum transferrin level C. High hemoglobin level D. High cholesterol level The nurse identifies a potential for infection in a patient with partialthickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection? A. Administration of plasma expanders B. Use of careful hand washing technique C. Application of a topical antibacterial cream D. Limiting visitors to the client with burns Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? A. White blood cell count B. Albumin C. Calcium D. Sodium In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next? A. Witness the client's signature to the permit. B. Answer the client's questions about the surgery. C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery. D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered. The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home? A. Determine how the client feels about changing the dressing. B. Ask the client to describe the procedure in writing. C. Seek a family member's evaluation of the client's ability to change the dressing. D. Observe the client change the dressing unassisted A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first? A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes. B. Notify the health care provider and request a prescription for a largevolume enema. C. Assess the client's medical record to determine the client's normal bowel pattern. D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day. The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client? A. Steak, baked beans, and a salad B. Broiled fish, green beans, and an apple C. Pork chops, macaroni and cheese, and grapes D. Avocado salad, milk, and angel food cake When bathing an uncircumcised boy older than 3 years, which action should the nurse take? A. Remind the child to clean his genital area. B. Defer perineal care because of the child's age. C. Retract the foreskin gently to cleanse the penis. D. Ask the parents why the child is not circumcised. The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take? A. Review the chart for a signed consent for hospitalization. B. Get the health care provider's permission to give the medication. C. Do not give the medication and document the reason. D. Complete an incident report and notify the parents A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first? A. Pulse characteristics B. Open airway C. Entrance and exit wounds D. Cervical spine injury The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best? A. Only refer to the client by gender. B. Identify the client only by age. C. Avoid using the client's name. D. Discuss the client another time. The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery? A. Taking birth control pills for the past 2 years B. Taking anticoagulants for the past year C. Recently completing antibiotic therapy D. Having taken laxatives PRN for the last 6 months When assisting a client from the bed to a chair, which procedure is best for the nurse to follow? A. Place the chair parallel to the bed, with its back toward the head of the bed and assist the client in moving to the chair. B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair. C. Assist the client to a standing position by gently lifting upward, underneath the axillae. D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair. The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug? A. "Fill your lungs with air through your mouth and then compress the inhaler." B. "Compress the inhaler while slowly breathing in through your mouth." C. "Compress the inhaler while inhaling quickly through your nose." D. "Exhale completely after compressing the inhaler and then inhale." The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first? A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client. B. Sit quietly in the client's room until the client leaves the bathroom. C. Allow the client to cry alone and leave the client in the bathroom. D. Talk to the client and attempt to find out why the client is crying. Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply.) A. Place the client in a side-lying position. B. Pull the auricle upward and outward. C. Hold the dropper 6 cm above the ear canal. D. Place a cotton ball into the inner canal. E. Pull the auricle down and back. The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next? A. Document that the client responds to painful stimulus. B. Observe the client's response to verbal stimulation. C. Place the client on seizure precautions for 24 hours. D. Report decorticate posturing to the health care provider. A hospitalized client has had difficulty falling asleep for 2 nights and is becoming irritable and restless. Which action by the nurse is best? A. Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. B. Instruct the UAP not to wake the client under any circumstances during the night. C. Place a "Do Not Disturb" sign on the door and change assessments from every 4 to every 8 hours. D. Encourage the client to avoid pain medication during the day, which might increase daytime napping. While reviewing the side effects of a newly prescribed medication, a 72-yearold client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse? A. "How will this affect your present sexual activity?" B. "How active is your current sex life?" C. "How has your sex life changed as you have become older?" D. "Tell me about your sexual needs as an older adult." The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication? A. The client will experience increased tolerance to the drug's effects and may need a higher dose. B. The onset of action of the drug will occur more rapidly, resulting in a more rapid effect. C. The medication will be more highly protein-bound, increasing the duration of action. D. The therapeutic index will be increased, placing the client at greater risk for toxicity. A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond? A. Ask him to rate his pain on a scale of 1 to 10. B. Encourage him to wait until bedtime so the pill can help him sleep. C. Attend to an acutely ill client's needs first because this client is laughing. D. Instruct him in the use of deep breathing exercises for pain control. The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement? A. Encourage the client to increase ambulation in the room. B. Offer the client a high-carbohydrate snack for energy. C. Force fluids to thin the client's pulmonary secretions. D. Determine if pain is causing the client's tachypnea. Pain, anxiety, and increasing fluid accumulation in the lungs (D) can cause tachypnea (increased respiratory rate). Encouraging (A) when the respiratory rate is rising above normal limits puts the client at risk for further oxygen desaturation. A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first? A. Accept and document the client's wish to refrain from bathing. B. Offer to give the client a bed bath, avoiding the perineal area. C. Obtain written brochures about menstruation to give to the client. D. Teach the importance of personal hygiene during menstruation with the client. Based on the nursing diagnosis of Risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client? A. Maintain standard precautions. B. Initiate contact isolation measures. C. Insert an indwelling urinary catheter. D. Instruct client in the use of adult diapers The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate should the nurse document? A. 14 B. 16 C. 17 D. 28 The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct? (Select all that apply.) A. Place the client in a high Fowler's position. B. Help the patient assume a left side-lying position. C. Measure the tube from the tip of the nose to the umbilicus. D. Instruct the client to swallow after the tube has passed the pharynx. E. Assist the client in extending the neck back so the tube may enter the larynx. During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse? A. Reassure the client that many obese people have concerns about sex. B. Remind the client that sexual relationships need not be affected by obesity. C. Determine the frequency of sexual intercourse. D. Ask the client to talk about specific concerns. When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled "opened" and dated 48 hours prior to the current date. Which is the best action for the nurse to take? A. Use the normal saline solution once more and then discard. B. Obtain a new sterile syringe to