NSG 4060 COMPREHENSIVE ATI PRACTICE B / NSG4060 COMPREHENSIVE ATI PRACTICE B (2 VERSIONS, 2021): SOUTH UNIVERSITY | 300 Q & A, 100% VERIFIED AND CORRECT ANSWERS |

NSG 4060 COMPREHENSIVE ATI PRACTICE B / NSG4060 COMPREHENSIVE ATI PRACTICE B (2 VERSIONS, 2021): SOUTH UNIVERSITY | 300 Q & A, 100% VERIFIED AND CORRECT ANSWERS | NSG4060 RN Comprehensive Online Practice B/ NSG 4060 RN Comprehensive Online Practice B: South University NSG4060 Comprehensive ATI Practice B / NSG 4060 Comprehensive ATI Practice B: South University 1. Patient refused a newly open fentanyl patch. Which of the following actions should the nurse take? 2. Client receiving heparin continuous IV infusion and warfarin 5 mg PO daily. Lab values are aPTT 98 seconds and INR 1.8 3. A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye . Which indicates the client has a detached retina 4. infant with hydrocephalus 6 hr post op following ventriculoperitoneal shunt placement . finding to report to provider 5. Assessing a newborn heart rate follow actions the nurse should take 6. Caring for a client who has a fecal impaction actions to be taken when digitally evacuating the stool 7. Dietary teaching for a new prescription of phenelzine 8. Nurse administers incorrect dose of medication. Which facts related to incident report should the nurse document in the client's medical record? 9. Nurse on pediatric unit received shift report on 4 children. Which should the nurse assess first? 10. Community health nurse providing teaching on home safety for older adults 11. School age child with scald burns on both hands and wrists suspected abuse 12. Client who has acute blood loss following trauma refuses potentially life saving blood transfusion 13. Discussing common prenatal discomfort 20 weeks gestational 14. Discharge instructions to client to received home oxygen therapy 15. Preparing an educational session about advocacy to a group of nurses 16. Continuous bladder irrigation following transurethral resection of prostate. Bladder spasms and decreased urinary output 17. Child with sickle cell anemia and is having a vaso-occlusive crisis 18. Client teaching about the basal body temp method for birth control 19. Caring for a client who is unconscious and requires emergency medical procedures. Unable to locate family to obtain consent 20. Client who has fluid volume overload. Which tasks can nurse delegate to UAP 21. Checking for Chvostek's sign 22. Reviewing urinalysis report of client with acute glomerulonephritis expected findings 23. Newly admitted child. Which of the following actions should the nurse include in the plan 24. Client with cancer deciding between two treatment plans 25. Caring for a client receiving hemodalysis with AV fistula 26. Oncology unit nurse is administering doxorubicin to breast cancer patient 27. Hospice nurse consulting about receiving home services 28. Client with major depressive disorder has signed informed consetn for ECT. Client states I'm not sure about this now I'm afraid it's too risky 29. Discharge instructions about newborn care to a client 2 days postpartum 30. Assigning task roles for group of clients in community mental health clinic. Which should be assigned to group functioning the orienter 31. Nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster 32. Developing a client education program about osteoporosis for older adult clients 33. Charge is providing educational session about infection control for a group of staff on isolation precautions 34. Preparing to assist with a thoracentesis for a client who has pleurisy 35. Caring for a school age child taking valporic acid. Diagnostic tests 36. Inpatient mental health unit is monitoring a visit between client with aggressive behavior and the client's partner 37. Home health nurse evaluating a school age child with cystic fibrosis initiates a request for high frequency chest compression vest 38. Planning care for a client with left sided weakness following a stroke 39. Caring for a child with a fever and fluid filled vesicles on trunk and extremities. 40. Assessing client for compartment syndrome expected findings 41. Just received change of shift report on 4 clients. Which should the nurse assess first 42. Assessing a client after administering epinephrine for anaphylactic reactions. Identify adverse effect of this med 43. Provide teaching to client 24 wks gestation scheduled for glucose tolerance test 44. Assessing older adult client with pneumonia 45. Teaching for client about right to confidentiality 46. Caring for a client reporting nausea and vomiting the past 2 days 47. Caring for a client postop after receiving moderate conscious sedation suddenly becomes restless and reports feeling lightheaded 48. Assessing client who is 11 wks gestation and reports drinking ginger tea. signs of it's effectiveness 49. Teaching a client who newly diagnosed with DM. Instructions on manifestations of hypoglycemia 50. caring for a client with DVT 51. Providing info to a client immediately before Romberg test 52. Providing teaching to parents of child with autism spectrum disorder 53. Teaching a client undergoing ECT about adverse effects 54. Caring for a client with active TB about disease transmission 55. Assess 1 wk old for palmer grasp reflex 56. Conducting a mental status examination on newly admitted client. Priority assesment 57. Caring for a client with a prescription of chlorpromazine indications of effectiveness 58. Assessing a client whose partner recently died. States I don't know what to do without my partner. Life is not worth living 59. Developing discharge plan for school age child with thrombocytopenia. What should the child avoid 60. Reviewing lab report for client in end stage kidney disease who received hemodialysis 24 hr ago. Findings to report to provider 61. Caring for a client with a magnesium level of 2.5 mEq/l 62. Outpatient mental health clinic clients which of the following clients is effectively using sublimation as a defense mechanism 63. Caring for a group of clients which one should the nurse see first 64. Preparing to teach about dietary management to a client with Crohn's disease with aenteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in his diet 65. Caring for a client who is in resuscitation phase of burn injury 66. Teaching self-administration of insulin to a client with short acting and intermediate acting insulin 67. Teaching a client 26 wks gestation about a glucose tolerance test. 68. Caring for a client who has hyperthyroidism 69. Caring for a newborn with herpes simplex virus which precautions should be initiated 70. Postpartum nurse is caring for 4 clients which one should be on seizure precautions. 71. Assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Assess for adverse effects 72. Caring for older adult who is experiencing chronic anorexia and receiving tube feedings. Lab values that indicate additional nutrients are needed 73. Teaching to school age child with asthma using albuterol dose inhaler instructions 74. Assessing a client with decreased visual acuity due to cataracts. Identify physiological changes 75. Mental health clinic caring for clients. Which of the following clients is using dissociation as a defense mechanism? 76. Assessing a 2 wk old newborn with a birth weight of 3.64 kg being breastfed. Indicators of effective breastfeeding 77. Preparing to administer a blood transfusion to a client . Ensure proper client identification 78. Reviewing client's right with the nurses on the unit. Informed consent promotes which of the following ethical principles 79. Teaching about lithium to client who has bipolar disorder 80. Change of shift report informs of newly admitted client with disoriented and combative during the night. Actions the day shift nurse should take 81. Caring for an 18-month old toddler who has a blood lead level of 3mcb/dL. Which of the following actions should the nurse take 82. Assessing a client who has bipolar. Which of the following alterations in speech is the client using 83. Working in ED triaging 4 clients. Which of the following clients should the nurse recommend for treatment first? 84. Admission assessment on a client who had a recent positive pregnancy test. First day of her last menstrual period was May 8 . Nagel's rule EDB 85. Assessing a client who received 2 units of packed RBCs 48 hr ago. Findings that indicate the therapy is effective? 86. Caring for a client who recently signed informed consent to donate a kidney to her sibling in ERF. States "I don't want my brother to die, but what if I need this kidney one day?" 87. A nurse is preparing to administer an IM injection to a client who is obese 88. Providing education to the parent of school age child with asthma. Indicates understanding? 89. Admitting a client who has pneumonia. Should initiate which type of isolation precautions? 90. Assessing a client who has COPD pH 7.31. 91. Providing teaching for teaching for a client who has a fracture of the right fibula with a short leg cast in place. Client is non weight bearing for 6 weeks. 92. Caring for a child who has hypotonic dehydration and is receiving an oral re-hydration solution. Lab results indicates treatment effective 93. Assessing a client who has pulmonary edema. Finding to expect 94. Received change of shift report on 4 clients. Which one should the nurse intervene to prevent food and medication interaction? 95. Assessing a client following vaginal delivery and notes heavy lochia and a boggy fundus. Which med should be administered 96. Caring for a client with a new diagnosis of terminal cancer. Client states he would like to go home to be with family and loved ones. 97. Caring for a client who is taking valproic acid for seizure control. Adverse effect to monitor and report 98. Manager planning to use a democratic leadership style. Which of the actions demonstrates democratic leadership style? 99. Assessing a client with history of seeking counseling for relationship problems. Shows the nurse multiple superficial self-inflicted lacerations on her forearms. This behavior should be identified as a characteristic of which personality disorder 100. Nurse preceptor is evaluating the performance of newly licensed nurse. which action should the preceptor intervene on 101. Providing teaching about advance directives to a middle adult client. Which response indicates understanding? 102. Teaching a group of newly licensed nurses about the need to complete an incident report. Which of the following is an example of reportable incident and an indication for completing a report 103. Caring for a newborn immediately after delivery. Which interventions should be implemented to prevent heat loss by conduction? 104. Caring for a client in stage 4 of labor who is receiving oxytocin via continuous IV. Priority assessment 105. Preparing to transfer a client from ICU to the medical floor. Client was recently weaned from mechanical ventilation follow a pneumonectomy. Information to include in change of shift report 106. Charge nurse notices one of the nurses on the shift frequently violates unit policies by taking an extended amount of time on break. Statement that addresses the conflict 107. Providing discharge teaching about disease management for a client who has a new diagnosis of DM. Priority activities 108. Caring for a client who has gastrointestinal bleeding and an NG tube in place. Action that should be taken while performing gastric lavage. 109. Planning to delegate client care tasks to an assistive personnel. Which task can be delegated? 110. Providing teaching to client with peripheral arterial disease. Indications of understanding 111. Providing discharge teaching for preschool age child with a new prescription for Amoxicillian/clavulanate suspension. 112. Caring for a client with COPD and becomes extremely short of breath. Interventions by the nurse requires completion of an incident report 113. Assessing correct placement of a client's NG feeding tube prior to administering a bolus feeding. 114. Preparing to transfer a client to a rehab facility who had a stroke Family is concerned about the level of care the client will receive? 115. Caring for a client receiving a continuous heparin infusion. Lab test to review prior to adjusting the client's heparin? 116. Providing care for a client with a colostomy 117. Preparing to mix haloperidol lactate 5 mg/mL and diphenhydramine 25 mg/1.5 mL to administer IM to an agitated client 118. Talking with a client with stage IV breast cancer. Which statement is a constructive use of a defense mechanism 119. Preparing a sterile field for sterile dressing change. 120. Preparing to teach a group of newly licensed nurses about effective time management. Include as priority 121. Reviewing ABG values of a client. Client has a pH of 7.20, PaCO2 of 60 mmHg, and HCO 3 of 25 mEq/l 122. Client receiving IV fluids of 150 mL/h which indicates fluid overload 123. Caring for 4 clients. Which task should be delegated to assistive personnel 124. Caring for a client who is 2 days postpartum. Which behaviors should indicate the client is bonding with newborn 125. Assessing a preschooler with facial laceration. Identify potential indication of sexual abuse 126. Enters a client's room and sees smoke coming from a small fire in the trash can. Action to take first. 127. Rural community health nurse developing a plan to improve health care delivery for migrant farmworkers. 128. Assessing a newborn following vaginal birth. Findings to report to provider 129. Manager in long term care having difficulty with staffing weekend shift is planning to implement changes to the scheduling procedure. 130. Assessing a client who has depressive disorder taking amitriptyline. Identify adverse effects. 131. School nurse is notified of an emergency which several children were injured following the collapse of playground equipment. 132. Manager preparing an educational session for staff about how to provide cost effective care 133. Creating plan of care for child with acute lymphoid leukemia and an absolute neutrophil count of 400/mm3 134. Providing teaching to a client who speaks a different language than the nurse about an upcoming diagnostic procedure. 135. Caring for a client with a prescription for continuous passive motion machine following total knee arthroplasty 136. Caring for a client who is receiving positive end expiratory pressure via mechanical ventilation. Adverse effects of PEEP 137. Performing an abdominal assessment on a client Sequence of actions 138. Caring for a client with a new prescription of Clonidine. Adverse side effects 139. Reviewing lab results of a toddler with hemophilia A. Which aPTT values should the nurse expect? 140. Updating the plan of care for a client who is 48 hr post op following laryngectomy and unable to speak. Plan to take first 141. Caring for a client who asks about taking ginseng to improve her appetite. Identify that ginseng can decrease the effectiveness of which medication. 142. Preparing client for paracentesis. Action to take 143. Rn observing a LPN and a AP move a client up in bed. When should the nurse intervene 144. Assessing a client who has had a stroke. For which should the nurse initiate referral for occupational therapy 145. Assessing a client taking propranolol. Indication of adverse reaction 146. Conducting visual acuity testing using the Snellen letter chart for a school age child with eyeglasses 147. Caring for a multiparous client following a vacuum-assisted birth. Assess for which possible complication. NSG4060 RN Comprehensive Online Practice B/ NSG 4060 RN Comprehensive Online Practice B: South University NSG4060 Comprehensive ATI Practice B / NSG 4060 Comprehensive ATI Practice B: South University A nurse is assessing a client who received 2 units of packed RBCs 48 hrs ago. Which of the following findings should indicate to the nurse that the therapy has been effective? A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first? A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to the CNA? A nurse is preparing to administer mannitol 0.2g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198lb. What is the amount in grams the nurse should administer? A nurse is conduction a physical examination for an adolescent and is assessing the range of motion of the legs. Which of the following images indicates the adolescent is abducting the hip joint? A nurse is caring for a client who has hyperthyroidism. Which of the following findings should the nurse expect? A nurse is assessing a school-aged child who has bacterial meningitis. Which of the following findings should the nurse expect? A nurse is assessing a newborn’s heart rate. Which of the following actions should the nurse take? Answer: Auscultate the apical pulse at least 1 min. The nurse should auscultate the apical pulse to obtain an accurate assessment of heart rate and rhythm. Auscultation of a newborn’s heart sounds can be difficult because of the rapid rate and the transmission of respiratory sounds. A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse should plan to perform which of the following actions? Answer: Instruct the client to avoid coughing during the procedure. It is important for the nurse to remind the client to avoid coughing and to lie still during a thoracentesis to avoid puncturing the pleura. A nurse in the ED is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse? Answer: The child exhibits discomfort while walking. The nurse should identify this finding as a potential indication of child sexual abuse. A nurse is preparing to teach about dietary management to a client who has Crohn’s disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet? Answer: Fiber The nurse should instruct the client to consume a low-fiber diet to reduce diarrhea and inflammation. A nurse is caring for a client who has a prescription for a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take? Answer: Turn off the CPM machine during mealtime. This promotes client comfort and dietary intake. A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for the client? Answer: Radial vein of the inner arm. This site will have adequate subcutaneous tissue. A nurse is developing a client education program about osteoporosis for older adult clients. The nurse should include which of the following variables as a risk factor for osteoporosis? Answer: Sedentary lifestyle. This is a risk factor for osteoporosis. The nurse should encourage older adult clients to engage in weight-bearing exercises because they will promote bone health by increasing calcium and phosphorus levels. A nurse in an ED is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority? Answer: Initiate transmission-based precautions When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority action is to initiate transmission-based precautions for the child. The child most likely has varicella. Therefore, the nurse should isolate the child to prevent the spread of the infection. A nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube. Which of the following actions should the nurse take first? Answer: Change the position of the client. When providing client care, the nurse should use the least restrictive intervention first. Therefore, the nurse should reposition the client to remove any kinks in the tube, which can lead to clogging. If this method is unsuccessful, the nurse should attempt to flush or aspirate the client’s tube to remove the clog. A home health care nurse is developing a teaching plan for a client who has a new ileostomy. Which of the following instructions should the nurse include? Answer: Empty the appliance when it is one-third to one-half full. The ileostomy pouch should be emptied when it is one-third to one-half full to prevent stool leakage and skin irritation. A nurse is reviewing the laboratory report of a client who has end-stage kidney disease and received hemodialysis 24 yr ago. Which of the following lab values should the nurse report to the provider? Answer: Sodium 148 mEq/L The nurse should report this sodium level because it is above the expected reference range of 136 to 145 mEq/L, indicating hypernatremia. Clients who have kidney disease often retain sodium and require sodium-restricted diets. A nurse is caring for four clients. Which of the following tasks should the nurse delegate to a CNA? Answer: Arrange the lunch tray for a client who has a hip fracture. Assisting a client with meals is within the range of function of the CNA. A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take? Answer: Instruct the client to void. The nurse should instruct the client to void prior to the procedure because an empty bladder decreases the risk of a bladder puncture and minimizes the client’s discomfort during the procedure. A nurse has received change of shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction? Answer: A client who is receiving an MAOI and is requesting a cheeseburger for dinner. This client’s food selection contains tyramine. Clients prescribed an MAOI must restrict the intake of foods that contain tyramine due to adverse effects, such as hypertension. A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take? Answer: Allow for frequent rest periods throughout the day. The nurse should encourage the client to balance rest with exercise to maintain muscle strength, joint function, and range of motion. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. The client reports bladder spasms, and the nurse observes a decreased urinary output. Which of the following action should the nurse take? Answer: Irrigate the catheter with 0.9% sodium chloride irrigation. Decreased urine output and bladder spasms indicate internal obstruction of the catheter. Therefore, the nurse should irrigate the catheter with 0.9% sodium chloride irrigation and notify the provider if the obstruction does not clear. A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect? Answer: pH 7.31 Respiratory acidosis is an expected finding for a client who has COPD. The expected reference range of pH is 7.35-7.45. A pH level of less than 7.35 indicates acidosis. For a client who has COPD, a decrease in pH will be accompanied by an increase in the level of carbon dioxide over the expected reference range of 35 to 45 mm Hg, indicating respiratory acidosis. A nurse in a community center is providing an educational session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching? Answer: Abdominal bloating The nurse should include the presence of abdominal bloating as an early manifestation of ovarian cancer. Other manifestations include an increase in abdominal girth, pelvic or abdominal pain, early satiety, and urinary frequency or urgency. A nurse is caring for a client who has active TB. Which of the following actions should the nurse plan to take to prevent the transmission of the disease? Answer: Have the client wear a surgical mask while being transported outside the room. This will prevent the transmission of the disease. A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first? Answer: An older adult client who is anxious and attempting to pull out an IV line. This client is at greater risk of injury. An RN is observing an LPN and a CNA move a client up in bed. For which of the following situations should the nurse intervene? Answer: The LPN and the CNA grasp the client under his arms to lift him up in bed. They should not grasp the client under the arms when lifting, as this can result in shoulder dislocation or other injuries to the client. The RN should intervene and instruct the nurses to use a draw sheet or friction-reducing device to lift the client. A nurse is preparing to administer insulin to a client via a pen device. Which of the following actions should the nurse take? Answer: Hold the insulin pen device perpendicular to the client’s skin to inject the medication. This ensures the insulin enters the subQ tissue. A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take? Answer: Monitor the client’s mouth every 8 hr. Check for manifestations of infection, such as sores or lesions. A nurse is providing teaching about advance directives to a middle-aged adult client. Which of the following client responses indicates an understanding of the teaching? Answer: “I can designate my partner as my health care surrogate.” This statement indicates that the client recognizes that designating a health care surrogate is part of advance directives. A nurse is assessing a client following a vaginal delivery and notes heavy lochia and a boggy fundus. Which of the following medications should the nurse expect to administer? Answer: Oxytocin This is a hormone that stimulates uterine contractions, to decrease vaginal bleeding. A nurse manager is planning to use a democratic leadership style with the nurses on the unit. Which of the following actions by the nurse manager demonstrates a democratic leadership style? Answer: Seeks input from the other nurses. This includes members of the team when making decisions and encourages staff members to participate in the decision-making process. A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer? Answer: Noting the progress of the group toward assigned goals. This is the task of the orienteer. A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include in the plan? See Exhibit button Answer: Administer high-dose antibiotic therapy. Children who have cystic fibrosis metabolize antibiotics more rapidly and require higher doses of antibiotics to help fight aggressive infections such as Burkholderia cepacia. A nurse is caring for a newborn immediately after delivery. Which of the following interventions should the nurse implement to prevent heat loss by conduction? Answer: Use a protective cover on the scale when weighing the infant. Heat loss by conduction is a loss of heat between the newborn’s skin and the cooler surface beneath it. A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse’s priority? Answer: Assist with deep breathing and coughing. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to assist the client with deep breathing and coughing, which reduces the risk of postop pneumonia. A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism? Answer: A client who channels their energy into a new hobby following the loss of their job. Channeling negative feelings over the loss of their job into a new hobby is using the defense mechanism of sublimation. A nurse is assessing for correct placement of a client’s NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take? Answer: Aspirate contents from the tube and verify the pH level. The nurse should verify that the pH level of the client’s gastric aspirate is less than 5 to determine proper placement. An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions? Answer: A client who is at 33 weeks gestation and has severe gestational hypertension. The nurse should initiate seizure precautions for a client who has severe gestational because extremely elevated blood pressure in an antepartum client can trigger seizure activity. The nurse should provide the client with a quiet, darkened environment, place suction equipment and oxygen at the bedside, and position the call light within the client’s reach. A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching? Answer: Wear clothing made with cotton fabrics while oxygen is in use. Woolen and synthetic fabrics can generate static electricity, which increases the risk of a fire. A nurse is providing teaching for a client who has a fracture of the right fibula with a short-leg cast in place and a new prescription for crutches. The client is non-weight bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching? Answer: Use the three-point gait. This allows the client to be mobile without bearing weight on the affected extremity. A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report? Answer: The time of the client’s last dose of pain medication. The nurse should recognize than an effective handoff report provides a baseline of the client’s status for comparison and should include any recent changes or priority situations affecting the client’s condition. The time of the client’s last dose of pain meds is important to include so the receiving nurse can anticipate what time to give the next dose. A nurse is assessing an infant who has hydrocephalus and is 6 hr postop following placement of a ventriculoperitoneal (VP) shunt. Which of the following findings should the nurse report to the provider? Answer: Irritability when being held. This is a manifestation of increased intracranial pressure, which is an indication that the VP shunt is malfunctioning. This finding should be reported to the provider immediately. A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following finding should the nurse identify as an indication that the medication is effective? Answer: Decreased hallucinations. This is an antipsychotic medication administered to decrease hallucinations and other manifestations of schizophrenia. A nurse is providing teaching about lithium to a client who has bipolar disorder. Which of the following statements should the nurse include in the teaching? Answer: “Notify your provider if you experience increased thirst” Increased thirst is a manifestation of lithium toxicity. The nurse should instruct the client to report increased thirst, vomiting, diarrhea, or tremors to the provider. A nurse caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool? Answer: Insert a lubricated gloved finger and advance along the rectal wall. This is the correct way of doing this. A nurse is planning to delegate client care tasks to a CNA. Which of the following tasks should the nurse plan to delegate to the CNA? Answer: Perform gastrostomy feedings through a client’s established gastrostomy tube. This task is within their range of function. A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following methods should the nurse include in the teaching? Answer: Delegate non-nursing tasks to ancillary staff. It is an effective method of providing high-quality, cost-effective care because this will allow additional time for nurses to focus on skilled tasks. A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client’s partner. Which of the following should the nurse identify as an indication of potential violence? Answer: The client is pacing around the chair in which their partner is sitting. Hyperactivity and pacing indicate that this client is at risk for violent behavior. The nurse should assess the situation further and attempt to de-escalate the situation by speaking to the client in a low, calm voice using short sentences. A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse, “I’m not sure about this now. I’m afraid it’s too risky.” Which of the following responses should the nurse make? Answer: “You have the right to change your mind about this procedure at any time.” The client can refuse to consent at any time for a procedure. The nurse is demonstrating advocacy by respecting the client’s wishes regarding care. A rural community health nurse is developing a plan to improve health care delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources? Answer: Agency for Healthcare Research and Quality The goal of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality of health care services for all populations, including low-income groups and minorities. This data should help the nurse to develop an evidence-based plan to improve health care services for specific populations. A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider? Answer: Nasal flaring. This indicates respiratory distress. Signs are nasal flaring, retractions, and grunting. A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation? Answer: Ask the partner to list specific concerns. The first action the nurse should take using the nursing process is to assess the situation by asking the partner to list specific concerns. A nurse is providing information to a client immediately before his scheduled Romberg test. Which of the following statements should the nurse make? Answer: “I will be checking you once with your eyes open and once with them closed.” The Romberg test will be performed once with eyes open and once with eyes closed. This is performed to assess balance and motor function. A nurse is teaching a client who is at 20 weeks of gestation about common discomforts associated with pregnancy. Which of the following statements by the client indicates an understanding of the teaching? Answer: “I will wear a supportive bra overnight.” Wearing a supportive bra even while sleeping can promote comfort by providing support to enlarged breasts during pregnancy. A nurse is caring for a client who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report? Answer: Jaundice. Monitor the client for jaundice and report any indications to the provider. Clients who take valproic acid are at risk for liver damage, which can lead to jaundice. A nurse is providing discharge instructions about newborn care to a client who is postpartum. Which of the following statements indicates to the nurse that the client understands the teaching? Answer: “I will cover my baby’s body when I wash her” “I will use the bulb syringe first in her mouth and then in her nose” Newborns are highly susceptible to heat loss. The client should wrap the newborn in a towel when washing the hair to minimize heat loss. The client should suction the newborn’s mouth first to remove secretions that the newborn could aspirate when suctioning the nares. A nurse on a mental health unit is conducting a mental status examination (MSE) on a newly admitted client. Which of the following components of the MSE is the priority for the nurse to assess? Answer: Ideas of self-harm. The greatest risk to this client is injury from ideas of self-harm. The priority assessment the nurse should make is to determine whether the client has had suicidal or homicidal ideas. A nurse is preparing to administer lactated Ringer’s 1500 mL to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/min. The nurse should set the manual IV infusion to deliver how many gtt/min? Answer: 13 gtt/min A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia? Answer: Irritability The nurse should instruct the client to monitor for irritability, which can indicate decreased blood glucose levels. A nurse is providing teaching to a client who is scheduled for ECT. The nurse should inform the client that which of the following is an adverse effect of ECT? Answer: Short-term memory loss This is a common adverse effect of ECT. A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for a break. Which of the following statements should the charge nurse make to address this conflict? Answer: “I would like to talk to you about the unit policies regarding break time.” The charge nurse is dealing with the conflict in a cooperative, positive manner by using this statement to open the conversation in a nonthreatening way. The focus is on the length of the break time and is not a personal affront. A nurse in an emergency department is caring for a client who is at 9 weeks of gestation and reports nausea and vomiting for the past 2 days. Which of the following findings should the nurse expect? Answer: Urine specific gravity 1.052 The nurse should recognize this urine specific gravity is significantly elevated above the expected reference range of 1.005 to 1.030. An increased urine specific gravity indicates dehydration from vomiting. A nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. Which of the following laboratory values indicates that the client needs additional nutrients added to the feeding? Answer: Albumin 2.8 g/dL The nurse should recognize that an albumin level of less than 3.5 g/dL indicates malnutrition and a need for additional nutritional supplementation. The expected reference range for albumin is 3.5 to 5 g/dL. A nurse is conducting group therapy with clients who have breast cancer. The nurse should recognize which of the following statements by a client as an example of altruism? Answer: “I told my doctor that I would like to start a support group for other women who are sick in my community.” This statement indicates that the client is demonstrating altruism by reaching out and helping others. A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make? Answer: Broccoli, yogurt, cream cheese Clients taking an MAOI should not eat foods that contain tyramine. Fermented meat such as pepperoni and bologna are high in tyramine. A nurse is assessing a client for compartment syndrome. Which of the following findings should the nurse expect? Answer: Edema Compartment syndrome causes increased pain, pallor, and paresthesias from increased edema in the compartment involved. A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse’s priority? Answer: Ensure that the client understands the medication regimen. The priority action the nurse should take when using the safety vs risk reduction approach to client care is to ensure the client understands the medication regimen. The greatest risk to the client is the potential to develop hypoglycemia or hyperglycemia, which can be life-threatening if treated incorrectly. A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye. Which of the following reports by the client should indicate to the nurse that the client has a detached retina? Answer: Floating dark spots These are a manifestation of a detached retina due to bulges, folds, or holes in the affected retina. A nurse on a med-surg unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy? Answer: Difficulty performing ADLs A referral for occupational therapy to teach the client the skills necessary to become independent in performing ADLs such as bathing, dressing, and eating. A nurse is assessing a client following a colonoscopy. Which of the following findings should indicate to the nurse that the client is hemorrhaging? Answer: Rapid decrease in blood pressure This is an indication of hemorrhage. A nurse is caring for a client who recently signed an informed consent form to donate a kidney to her sibling who had end-stage kidney disease. The donor states to the nurse, “I don’t want my brother to die, but what if I need this kidney one day?” Which of the following responses should the nurse make? Answer: “You’re afraid that your other kidney will fail at some point after the organ donation?” The nurse is restating the client’s statement, which lets the client know that the nurse is listening and paying attention to what the client is communicating. A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect? Answer: Pink, frothy sputum A client who has manifestations of pulmonary edema can have pink, frothy sputum due to fluid leaking across the pulmonary capillaries and into the lung tissue. A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client’s medical record? Answer: Time the medication was given The nurse should document the time, the name of the med, the dose, and the route in which the med was given on the client’s MAR immediately after it was administered. The nurse should also document the time that the incorrect med was administered to the client in the incident report, as this is a fact directly related to the occurrence. A nurse is caring for a client who is post-op after receiving moderate (conscious) sedation. The client suddenly becomes restless and reports feeling lightheaded. Which of the following actions should the nurse take? Answer: Check the client’s oxygen saturation level. Restlessness and lightheadedness are indications of hypoxia. The nurse should check the client’s oxygen saturation level. A nurse in an ED is assessing a school-aged child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take? Answer: Contact Child Protective Services The nurse has a legal responsibility to report suspected physical abuse to Child Protective Services. A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD? Answer: The nurse should assess the infant’s abdomen for distention and visible peristalsis, which are manifestations of HD. A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, “My family does not care whether I live or die.” Which of the following responses should the nurse make? Answer: “How does this make you feel?” This response encourages the client to evaluate their feelings. A nurse is providing discharge teaching for the parents of a preschool-age child who has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse include in the teaching? Answer: Shake the medication bottle well before each dose is given. Store the medication in the refrigerator Report diarrhea to the provider immediately A nurse on a med surg unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take? Answer: Make a referral for social services As a client advocate, the nurse should support the client’s decisions and obtain a referral for social services to ensure that the client’s needs at home are met. Social services can set up home care or hospice care services for the client if needed. A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse expect? Answer: Occlusive dressing on the insertion site. This prevents air from leaking and is an expected finding. A nurse is preparing to transfer a client who has had a stroke to a rehabilitation facility. The client’s family tells the nurse they are concerned about the level of care the client will receive. Which of the following actions should the nurse take? Answer: Facilitate an interdisciplinary conference at the new facility for the family. This will address the family’s concerns about providing optimal care for the client. A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following should the nurse identify as an adverse effect of the medication? Answer: Blurred vision This is an adverse effect of amitriptyline and the provider should be notified. A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicates an understanding of isolation precautions? Answer: “A client who requires airborne precautions should be placed in a negative-pressure airflow room.” Airborne precautions require a negative-pressure airflow room that has at least 6-12 air exchanges each hour using a HEPA filtration system. A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification? Answer: Verify the client and blood product information with another licensed nurse. The nurse should compare the blood product label against the medical record and the client’s identification number with another nurse to ensure the correct blood product is administered to the correct client. A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self-inflicted lacerations on their forearms. The nurse should identify these behaviors as characteristics of which of the following personality disorders? Answer: Borderline The nurse should identify that clients who have borderline personality disorder tend to be emotionally unstable, have troubled interpersonal relationships, and often engage in harmful behaviors such as cutting, substance use, and suicidal ideation. A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a step stool at home. Which of the following prescriptions should the nurse clarify with the provider? Answer: Apply a cold pack to the client’s ankle for 30 min/hr The nurse should clarify a prescription for a cold pack to the client’s ankle because type 1 diabetes mellitus is a contradiction for receiving cold therapy. A client who has type 1 diabetes mellitus can have impaired circulation due to arteriosclerosis and a loss of sensory perception due to neuropathy. Ice can further impair circulation. A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider? Answer: Cough This is due to the buildup of bradykinin in the lungs. The client should report this to the provider. A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mm Hg. and HCO3 of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? Answer: Respiratory acidosis A client who has respiratory acidosis will have decreased pH below the expected reference range of 7.35-7.45, an increased PaCO2 above the expected reference range of 35-45 mm Hg, and an HCO3 within the expected reference range of 22-26 mEq/L. A nurse in a provider’s office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this med? Answer: “Have you had any stomach pain or bloody stools?” These are an indication of gastrointestinal bleeding, an adverse effect of ibuprofen. A nurse in a pediatric unit has received a change-of-shift report for four children. Which of the following children should the nurse assess first? Answer: A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain. Using the urgent vs nonurgent approach to client care, the nurse should determine that the client to assess first is the child awaiting an appendectomy who suddenly experiences pain relief as this can be an indication of peritonitis from a ruptured appendix. The nurse should notify the provider immediately. A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take? Answer: Implement fall precautions for the client. Risperidone can cause orthostatic hypotension and dizziness, which can lead to falls. The nurse should initiate fall precautions for the client. A nurse is assessing a client who has decreased visual acuity due to cataracts. The nurse should identify which of the following physiological changes is the cause of the client’s visual loss? Answer: Increased opacity of the lens A cataract is a cloudy or opaque area in the lens of the eye that inhibits light penetration. A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum-assisted birth? Answer: Cervical laceration Complications are perineal, vaginal, or cervical lacerations. A nurse is updating the plan of care for a client who is 48 hr. post-op following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first? Answer: Determine the client’s reading skills Using the nursing process to assess the client, determine the client’s level of reading skills and cognition. The nurse can best provide the client with a variety of customized techniques to practice and use after verbal skills are lost. A nurse is caring for a school-aged child who has dehydration and is receiving an oral rehydration solution. Which of the following lab results indicates that the treatment regimen is effective? Answer: Serum sodium 138 mEq/L Sodium level of 138 mEq/L, is within the expected reference range of 136-145 mEq/L and is an indication that the child is responding to the oral rehydration solution. A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first? Answer: Survey the scene for potential hazards to staff and children. Using the nursing process, assess the situation. By surveying the scene, the nurse can identify potential hazards to staff and children. These findings allow the nurse and staff to enter the scene and safely provide care to injured children and help decrease the risk of further injury. A nurse in an ED is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client’s family to obtain consent. Which of the following actions should the nurse take? Answer: Proceed with provision for medical care. When a client is unable to give informed consent in an emergency, health care personnel can proceed with necessary life-saving care because the law considers this implied consent. A nurse is caring for a school-aged child who is taking valproic acid. The nurse should expect the provider to order which of the following diagnostic tests? Answer: Serum liver enzyme levels. Valproic acid can cause hepatic toxicity. The nurse should expect the provider to prescribe lab tests to assess the child’s liver function prior to and periodically during therapy. A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority? Answer: Making a list of activities to complete. According to evidence-based practice, planning is the most important step in managing time effectively. The nurse manager should include making a list of activities to complete as the priority. Other planning activities include setting goals, establishing priorities, and scheduling activities. A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin via continuous IV infusion at 1200 units/hr and warfarin 5 mg PO daily. The morning lab values for the client are aPTT 98 seconds and INR 1.8. Which of the following actions should the nurse take? Answer: Withhold the heparin infusion. The expected value for aPTT is 40 seconds. A therapeutic level of heparin increases the aPTT by a factor of 1.5-2, making the aPTT 60-80 seconds. An aPTT level of 98 is above the expected reference range, indicating that the dosage should be reduced, or the infusion withheld until the aPTT returns to the therapeutic range. A nurse is providing teaching to a school-age child who has asthma about using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include? Answer: Take the medication 15 mins before playing sports. Take 5-20 min prior to exercise to promote bronchodilation. The meds effects begin immediately, peak in 30-60 min, and can last for up to 5 hr. A home health nurse is evaluating a school aged child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements? Answer: “My child has only a small amount of mucus after percussion therapy.” The nurse should recommend a high-frequency chest compression vest for a child who has inadequate results from other airway clearance therapy techniques. Older children often require other techniques in addition to percussion and postural drainage to achieve adequate mucus expectoration. A nurse is planning care for a patient who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan? Answer: Avoid including raw fruits in the client’s diet. This reduces the risk of bacterial infections. A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse’s priority? Answer: Amount of vaginal bleeding. The first action the nurse should take using the nursing process is assessing the amount of vaginal bleeding. A client who is in the fourth stage of labor is at risk for hemorrhage, so assessing the amount of vaginal bleeding is the nurse’s priority. A nurse is caring for a client who is in the resuscitation phase of burn injury. Which of the following findings should the nurse expect? Answer: Hyponatremia The nurse should expect a decrease in sodium levels because sodium is drawn to the edematous burn areas and lost through plasma leakage. A nurse is teaching a client who has a new prescription for total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching? Answer: “I will need to measure your weight daily.” The nurse should instruct the client that daily weight measurement is a necessary part of administering nutrition through a central line to avoid fluid overload and monitor for adequate weight gain. A nurse is assessing a client who has bipolar disorder. Which of the following alterations in speech is the client using? Answer: Flight of ideas. Flight of ideas is an alteration in speech in which the speaker talks continuously with sudden, frequent topic changes. A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients? Answer: A client whose caregiver requests adult daycare services. The nurse should initiate a referral for PACE for this client because PACE provides adult day care services along with in-home assessments and supportive services. A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism? Answer: A client who was abused as a child describes the abuse as if it happened to someone else. The nurse should identify that this client is using the defense mechanism of dissociation because they are separating painful events from the conscious mind and describing the events as if they happened to another person. A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions should the nurse take? Answer: Assign the client to a private room with negative air pressure. To control the spread of active TB, the nurse should assign the client to a private room with negative air pressure. A nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled for a 3 hr oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching? Answer: “You will need to fast the night before the test.” The nurse should instruct the client that they will need to fast the night before the test to prevent inaccurate test results. A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching? Answer: “I will make sure my child receives a yearly influenza immunization.” Children who have asthma should be immunized and protected from infections. The nurse should educate the parent to ensure the child receives a yearly influenza immunization. A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following lab tests should the nurse review prior to adjusting the client’s heparin? Answer: aPTT Prior to adjusting the client’s continuous heparin infusion, the nurse should review the client’s activated partial thromboplastin (aPTT). The expected reference range for the aPTT is 40 secs. Clients who are receiving continuous heparin therapy should have an aPTT of 60-80 secs, which is 1.5-2 times the expected aPTT level. The nurse should increase or decrease the heparin infusion according to this value. A nurse is assessing a client who is taking propranolol. Which of the following findings should indicate to the nurse that this client is experiencing an adverse reaction to propranolol? Answer: Wheezing The nurse should recognize that wheezing can indicate the client is experiencing an adverse reaction to the med. A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload? Answer: Dyspnea The nurse should recognize that dyspnea indicates the client could be experiencing fluid overload. Fluid overload can lead to the backup of fluid in the pulmonary system resulting in shortness of breath. A nurse is assessing a client whose partner recently died. The client states, “I don’t know what to do without my partner. Life is just not worth living.” Which of the following responses should the nurse make? Answer: “You seem to be having a difficult time right now.” This statement makes an observation, which is a therapeutic response by the nurse. It encourages the client to express their thoughts and feelings. A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend discharge? Answer: A client who has cellulitis and is receiving oral antibiotics every 8 hr. This client can safely continue this treatment at home. A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period (LMP) was May 8. According to Nagele’s rule, which of the following dates should the nurse document as the client’s estimated date of birth (EDB)? Answer: February 15. Add 7 days to the first day of the client’s LMP and then subtract 3 months. A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include? Answer: Use a rewards system to modify the child’s behavior. Children who have autism spectrum disorder respond well to a reward system, which can provide structure and expectations for behavior. A nurse in a provider’s office is caring for an 18-month-old toddler who has a blood level of 3 mcg/dL. Which of the following actions should the nurse take? Answer: Recommend rescreening in 1 year. This level is within the expected reference range. A nurse is caring for a client who has cancer and is deciding between two treatment plans. The client asks the nurse for assistance in making the decision. Which of the following responses should the nurse make? Answer: “Tell me more about your understanding of the options.” This is therapeutic because it is offering a general lead that facilitates communication between the nurse and the client and will help the nurse to explore the client’s feelings about the treatment options. A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this med? Answer: Dry mouth. Clonidine is an indirect-acting antiadrenergic agent used for HTN, severe pain, and ADD. The nurse should inform the client that dry mouth, or xerostomia, is a common adverse effect of this med. A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan? Answer: Support the client’s left arm on a pillow while sitting. This prevents the extremity from hanging freely because this can cause shoulder