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Urinarygcatheterizationgisgprescribedgforgagpostoperativegfemalegclientgwhoghasgbee
ngunablegtogvoidgforg8ghours.gThegnurseginsertsgthegcatheter,gbutgnogurinegisgseengingt
hegtubing.gWhichgactiongwillgthegnursegtakegnext?
A. Clampgthegcathetergandgrecheckgitging60gminutes.
B. Pullgthegcathetergbackg3ginchesgandgredirectgupward.
C. Leavegthegcathetergingplacegandgreattemptgwithganothergcatheter.
D. Notifygtheghealthgcaregprovidergofgagpossiblegobstruction.g-gANSWER:gC
Itgisglikelygthatgthegfirstgcathetergisgingthegvagina,grathergthangthegbladder.gLeaving
gthegfirstgcathetergingplacegwillghelpglocategthegmeatusgwhengattemptinggthegsecon
dgcatheterization
(C).gThegclientgshouldghavegatgleastg240gmLgofgurinegafterg8ghours.
(A)gdoesgnotgresolvegthegproblem.
(B)gwillgnotgchangegtheglocationgofgthegcathetergunlessgitgisgcompletelygremoved,gingwhi
chgcasegagnewgcathetergmustgbegused.
Theregisgnogevidencegofgagurinarygtractgobstructiongifgthegcathetergcouldgbegeasilyginserte
dg(D).
Thegnursegisgteachinggangobesegclient,gnewlygdiagnosedgwithgarteriosclerosis,gaboutg
reducinggthegriskgofgagheartgattackgorgstroke.gWhichghealthgpromotiongbrochuregisg
mostgimportantgforgthegnursegtogprovidegtogthisgclient?
A. "MonitoringgYourgBloodgPressuregatgHome"
,2g|gPg ag gg e
B. "SmokinggCessationgasgagLifelonggCommitment"
C. "DecreasinggCholesterolgLevelsgThroughgDiet"
D. "StressgManagementgforgagHealthiergYou"g-gANSWER:gC
Aghealthgpromotiongbrochuregaboutgdecreasinggcholesterolg(C)gisgmostgimportantgto
gprovidegthisgclient,gbecausegthegmostgsignificantgriskgfactorgcontributinggtogdevelo
pmentgofgarteriosclerosisgisgexcessgdietarygfat,gparticularlygsaturatedgfatgandgcholest
erol.g(A)gdoesgnotgaddressgthegunderlyinggcausesgofgarteriosclerosis.g(BgandgD)gareg
alsogimportantgfactorsgforgreversinggarteriosclerosisgbutgaregnotgasgimportantgasglow
eringgcholesterolg(C).
Tengminutesgaftergsigninggangoperativegpermitgforgagfracturedghip,gangoldergclientgst
ates,g"Thegaliensgwillgbegcominggtoggetgmegsoon!"gandgfallsgasleep.gWhichgactiongsh
ouldgthegnursegimplementgnext?
A. Makegthegclientgcomfortablegandgallowgthegclientgtogsleep.
B. Assessgthegclient'sgneurologicgstatus.
C. Notifygthegsurgeongaboutgthegcomment.
D. Askgthegclient'sgfamilygtogco-signgthegoperativegpermit.g-
gANSWER:gBgThisgstatementgmaygindicategthatgthegclientgisgconfused.gInformedg
consentgmustgbe
providedgbygagmentallygcompetentgindividual,gsogthegnursegshouldgfurthergassessgtheg
client'sgneurologicgstatusg(B)gtogbegsuregthatgthegclientgunderstandsgandgcanglegallygp
rovidegconsentgforgsurgery.g(A)gdoesgnotgprovidegsufficientgfollow-
up.gIfgthegnursegdeterminesgthatgthegclientgisgconfused,gthegsurgeongmustgbegnotifiedg
(C)gandgpermissiongobtainedgfromgthegnextgofgking(D).
Thegnurse-
managergofgagskilledgnursingg(chronicgcare)gunitgisginstructinggUAPsgongwaysgtogpre
ventgcomplicationsgofgimmobility.gWhichginterventiongshouldgbegincludedgingthisgin
struction?
A. Performgrange-of-motiongexercisesgtogpreventgcontractures.
,3g|gPg ag gg e
B. Decreasegthegclient'sgfluidgintakegtogpreventgdiarrhea.
C. Massagegthegclient'sglegsgtogreducegembolismgoccurrence.
D. Turngthegclientgfromgsidegtogbackgeverygshift.g-gANSWER:gA
Performinggrange-of-
motiongexercisesg(A)gisgbeneficialgingreducinggcontracturesgaroundgjoints.g(B,gC,gan
dgD)garegallgpotentiallygharmfulgpracticesgthatgplacegthegimmobilegclientgatgriskgofgc
omplications.
Thegnursegisgassistinggagclientgtogthegbathroom.gWhengthegclientgisg5gfeetgfromgthegb
athroomgdoor,ghegstates,g"Igfeelgfaint."gBeforegthegnursegcanggetgthegclientgtogagchair
,gthegclientgstartsgtogfall.gWhichgisgthegprioritygactiongforgthegnursegtogtake?
A. Checkgthegclient'sgcarotidgpulse.
B. Encouragegthegclientgtoggetgtogthegtoilet.
C. Ingagloudgvoice,gcallgforghelp.
D. Gentlyglowergthegclientgtogthegfloor.g-gANSWER:gD
(D)gisgthegmostgprudentginterventiongandgisgthegprioritygnursinggactiongtogpreventgin
jurygtogthegclientgandgthegnurse.gLoweringgthegclientgtogthegfloorgshouldgbegdonegwh
engthegclientgcannotgsupportghisgowngweight.gThegclientgshouldgbegplacedgingagbedgo
rgchairgonlygwhengsufficientghelpgisgavailablegtogpreventginjury.g(A)gisgimportantgbu
tgshouldgbegdonegaftergthegclientgisgingagsafegposition.gBecausegthegclientgisgnotgsupp
ortingghimself,g(B)gisgimpractical.g(C)gisglikelygtogcausegchaosgongthegunitgandgmight
galarmgthegothergclients.
Agfemalegnursegisgassignedgtogcaregforgagclosegfriend,gwhogsays,g"Igamgworriedgthatgfrie
ndsgwillgfindgoutgaboutgmygdiagnosis."gThegnursegtellsghergfriendgthatglegallygshegmustgp
rotectgagclient'sgconfidentiality.gWhichgresourcegdescribesgthegnurse'sglegalgresponsibilit
ies?
A. CodegofgEthicsgforgNurses
B. StategNursegPracticegAct
C. Patient'sgBillgofgRights
D. ANAgStandardsgofgPracticeg-gANSWER:gB
, 4g|gPg ag gg e
ThegStategNursegPracticegActg(B)gcontainsglegalgrequirementsgforgthegprotectiongofg
clientgconfidentialitygandgthegconsequencesgforgbreachesgingconfidentiality.g(A)gout
linesgethicalgstandardsgforgnursinggcaregbutgdoesgnotgincludeglegalgguidelines.g(Cgan
dgD)gdescribegexpectationsgforgnursinggpracticegbutgdognotgaddressglegalgimplicatio
ns.
Thegnursegisgteachinggagclientghowgtogperformgprogressivegmusclegrelaxationgtechni
quesgtogrelieveginsomnia.gAgweekglatergthegclientgreportsgthatghegisgstillgunablegtogsle
ep,gdespitegfollowinggthegsamegroutinegeverygnight.gWhichgactiongshouldgthegnursegt
akegfirst?
A. Instructgthegclientgtogaddgregulargexercisegasgagdailygroutine.
B. Determinegifgthegclientghasgbeengkeepinggagsleepgdiary.
C. Encouragegthegclientgtogcontinuegthegroutineguntilgsleepgisgachieved.
D. Askgthegclientgtogdescribegthegrouteg-gANSWER:gD
Thegnursegshouldgfirstgevaluategwhethergthegclientghasgbeengadheringgtogthegoriginal
ginstructionsg(D).gAgverbalgreportgofgthegclient'sgroutinegwillgprovidegmoregspecificgi
nformationgthangthegclient'sgwrittengdiaryg(B).gThegnursegcangthengdeterminegwhichg
changesgneedgtogbegmadeg(A).gThegroutinegpracticedgbygthegclientgisgclearlygunsucc
essful,gsogencouragementgalonegisginsufficientg(C).
Ag65-year-oldgclientgwhogattendsgangadultgdaycaregprogramgandgisgwheelchair-
gmobileghasgrednessgingthegsacralgarea.gWhichginstructiongisgmostgimportantgforgtheg
nursegtogprovide?
A. Takegagvitamingsupplementgtabletgoncegagday.
B. Changegpositionsgingthegchairgatgleastgeveryghour.
C. Increasegdailygintakegofgwatergorgothergoralgfluids.
D. Purchasegagnewergmodelgwheelchair.g-gANSWER:gB
Thegmostgimportantgteachinggisgtogchangegpositionsgfrequentlyg(B)gbecausegpressure
gisgthegmostgsignificantgfactorgrelatedgtogthegdevelopmentgofgpressuregulcers.
Increasedgvitamingandgfluidgintakeg(AgandgC)gmaygalsogbegbeneficialgpromote