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A powerful study resource designed to support exam success and boost confidence.
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. ------- ✔ CORRECT ANSWER ✓✓B
Rationale: Because the nurse can only stand on one side of the bed, bed rails should be up on
the opposite side to ensure that the client does not fall out of bed. Option A can cause client
injury to the skin or joint. Options C and D are useful techniques while turning a client but have
less priority in terms of safety than use of the bed rails.
The nurse identifies a potential for infection in a client with partial-thickness (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 handwashing technique
C. Application of a topical antibacterial cream
D. Limiting visitors to the client with burns ------- ✔ CORRECT ANSWER ✓✓B
Rationale: Careful handwashing technique is the single most effective intervention for the
prevention of contamination to all clients. Option A reverses the hypovolemia that initially
accompanies burn trauma but is not related to decreasing the proliferation of infective
organisms. Options C and D are recommended by various burn centers as possible ways to
reduce the chance of infection. Option B is a proven technique to prevent infection.
, 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 ------- ✔ CORRECT ANSWER ✓✓A
Rationale: Long-term protein deficiency is required to cause significantly lowered serum
albumin levels. Albumin is made by the liver only when adequate amounts of amino acids (from
protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not
significantly alter serum levels. Option B is a serum protein with a half-life of only 8 to 10 days,
so it will drop with an acute protein deficiency. Options C and D are not clinical measures of
protein malnutrition.
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. ------- ✔ CORRECT ANSWER ✓✓C
Rationale: The surgeon should be informed immediately that the permit is not signed. It is the
surgeon's responsibility to explain the procedure to the client and obtain the client's signature
on the permit. Although the nurse can witness an operative permit, the procedure must first be
explained by the health care provider or surgeon, including answering the client's questions.
The client's questions should be addressed before the permit is signed.
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 ------- ✔ CORRECT ANSWER ✓✓B
Rationale:
Anticoagulants increase the risk for bleeding during surgery, which can pose a threat for the
development of surgical complications. The health care provider should be informed that the
client is taking these drugs. Although clients who take birth control pills may be more
susceptible to the development of thrombi, such problems usually occur postoperatively. A
client with option C or D is at less of a surgical risk than with option B.
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. ------- ✔ CORRECT ANSWER ✓✓B
Rationale: Option B describes the correct positioning of the nurse and affords the nurse a wide
base of support while stabilizing the client's knees when assisting to a standing position. The
chair should be placed at a 45-degree angle to the bed, with the back of the chair toward the
head of the bed. Clients should never be lifted under the axillae; this could damage nerves and
strain the nurse's back. The client should be instructed to use the arms of the chair and should
never place his or her arms around the nurse's neck; this places undue stress on the nurse's
neck and back and increases the risk for a fall.
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.