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103. A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? A. Call for assistance -incorrect: The nurse should call for assistance by activating the emergency response team. However, there is another action the nurse should take first. B. Begin chest compressions -incorrect: The nurse should begin chest compressions. However, there is another action the nurse should take first. C. Confirm unresponsiveness -The nurse should apply the nursing process priority-setting framework to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with an assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client’s status, he or she must first collect adequate data from the client to obtain the knowledge needed to make an appropriate decision. Establishing unresponsiveness is required before beginning CPR. If a client is unresponsive, the nurse should activate the emergency response team. D. Give rescue breaths -incorrect: The nurse should give rescue breaths. However, there is another action the nurse should take first. 104. A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? A. A client who has a prescription for a transfusion of packed RBCs -Administration of blood is a procedure that carries risk; therefore, the client must sign a consent form prior to the procedure. B. A client who is being transported for a radiograph of the kidneys, ureters, and bladder -incorrect: Clients admitted to a hospital sign a general consent form when admitted. This form gives consent for this diagnostic examination. C. A client who has a prescription for a tuberculin skin test -incorrect: Implied consent is given when the client cooperates through actions, such as holding out an arm to allow the nurse to perform the procedure. D. A client who has a distended bladder and needs urinary catheterization -incorrect: Implied consent is given when the client cooperates through actions, such as positioning himself/herself to allow the nurse to perform the procedure. 105. A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take? A. Continue the teaching, but check afterward with the surgeon about informed consent -incorrect: The client’s statement indicates that she has not given informed consent; therefore, the nurse should interrupt the teaching. B. Stop the teaching and check with the surgeon about informed consent -The client’s statement indicates that she has not given informed consent; therefore, the nurse should interrupt the teaching and notify the surgeon. C. Stop the teaching and ask the client to sign an informed consent form -It is not within the nurse’s scope of practice to obtain informed consent from the client. D. Continue the teaching and check the client’s medical record afterward for a signed consent form -The client’s statement indicates that she has not given informed consent; therefore, the nurse should interrupt the teaching. 106. A home health nurse is visiting an older adult client with severe dementia. The client’s son, who serves as her primary caregiver, reports being “exhausted” from working part-time and caring for his mother at home. Which of the following options should the nurse suggest to the caregiver? A. Rehabilitation -incorrect: Rehabilitation programs help clients return to optimal functioning after an illness or injury. However, severe dementia will not improve with rehabilitative services. B. Assisted living facility -incorrect: An assisted living facility provides independence for clients who need only limited personal care. A client who has severe dementia needs total care. C. Respite care -Respite care is a service for caregivers who need time to rest from multiple responsibilities related to the care of a family member who needs assistance. D. Adult day care facility -incorrect: Although adult day care facilities do help family caregivers maintain some aspects of their lifestyle and independence, these facilitates provide care and supervision for clients who need minimal assistance (ex: taking medication, receiving physical therapy, or receiving counseling). They do not provide care for clients who have severe dementia. 107. A nurse is collecting health history data from a client who is deaf and uses American Sign Language (ASL) to communicate. The nurse will be working with an ASL interpreter. Which of the following actions should the nurse take when working with the interpreter? A. Face away from the client to avoid distraction -incorrect: The nurse should face the client while speaking to offer the client the opportunity to observe facial expressions and gestures. B. Pace speech to allow time for the interpreter to convey the words -The nurse should speak clearly and allow time for the interpreter to convey the message and for the client to receive it. C. Make eye contact with the interpreter when explaining the procedure -incorrect: To enhance the nurse-client relationship, the nurse should direct questions, instructions, and information to the client, not to the interpreter. The client’s focus will be on the interpreter, but it is respectful to continue to address the client and not the interpreter. D. Stand in the background while the interpreter translates the message -incorrect: The nurse should sit at the same level as the client to give the client the opportunity to observe facial expressions and gestures. 108. A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions? A. Shaking soiled linen before putting it in a hamper -incorrect: The nurse should not shake soiled linen because this action can transfer microorganisms. B. Removing a face mask when standing 0.5 m (1.6 ft) from the client -incorrect: The nurse should wear a mask when working within 1m (3.3 ft) of a client who is on droplet precautions to reduce the risk of transferring the particle droplets. C. Assigning another client with the same infection to share the room with the client -The nurse can place clients who are infected with the same pathogen in the same room if a private room is not available. D. Allowing the client to visit a family member in the lobby of the facility -incorrect: The nurse should strictly limit the client’s activity outside the room to reduce the risk of transferring microorganisms. Whenever the client has to leave the room, the nurse should place a mask on the client. 109. A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse perform to transfer the client from the stretcher to the bed? A. Lock the wheels on the bed and stretcher -Locking the wheels prevents the client from falling on the floor by not allowing the cart or bed to move apart or away from the client. B. Instruct the client to raise his arms above his head -incorrect: The nurse should ask the client to cross his arms across his chest to avoid injuring the arms during transfer. C. Elevate the stretcher 2.5 cm (1in) above the height of the bed -incorrect: The stretcher should be no more than 1.3 cm (0.5in) above the height of the bed. D. Log-roll the client -incorrect: Log-rolling is a technique used to prevent injury when moving a client who requires immobilization of the neck, back, or spine. It is not indicated for a client following abdominal surgery. 110. A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse that the AP understands how to perform this task? A. Locking the brakes on the bed and the wheelchair before moving the client -Prior to starting the transfer, the AP should make sure that both the wheelchair and the bed are stationary and will not shift when the client moves into the chair. B. Lowering the footplates of the wheelchair before the transfer -incorrect: The AP should lower the footplates after the transfer and lift the client’s feet onto them. C. Placing the wheelchair perpendicular to the bed -incorrect: The AP should place the wheelchair parallel to the bed. D. Placing the wheelchair on the client’s weaker side prior to the transfer -incorrect: The AP should place the wheelchair on the client’s stronger side prior to the transfer to allow the client to move toward the stronger side. 111. A nurse is beginning her shift and reviewing the medication administration records (MARs) for her clients. She notes a dosage of medication above the safe range and sees that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take? A. Call the nurse to verify that the client received that dosage -incorrect: The MAR indicates what dosage the nurse administered. B. Give the medication in a safe dosage -incorrect: It is not within the nurse’s scope of practice to change the medication dosage. C. Give the dose the provider prescribed -incorrect: The nurse has identified a potential problem with the prescribed dosage; therefore, the nurse should not give that dosage. D. Call the provider to clarify the dosage - After assessing the client for adverse effects of the medication, the nurse should notify the provider about her observations to determine the next step. 112. A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse use next when assessing the client’s abdomen? A. Auscultation -According to evidence-based practice, the nurse should listen for bowel sounds in all 4 quadrants before palpating the client’s abdomen. Palpation and percussion can stimulate the bowel and increase the frequency of bowel sounds, leading to false results. B. Light Palpation -incorrect: The nurse should palpate the client’s abdomen to identify any areas of tenderness. However, evidence-based practice indicates that the nurse should use a different technique before palpation. C. Percussion -incorrect: The nurse should percuss the abdomen to identify tympany or dullness. However, evidence-based practice indicates that the nurse should use a different technique before percussion. D. Deep palpation -incorrect: The nurse should palpate the abdomen to identify any areas of tenderness, but deep palpitation generally requires an experienced technician. However, evidence-based practice indicates that the nurse should use a different technique before palpation. 113. During a physical examination of a client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect additional data? A. Confrontation test -incorrect: A confrontation test compares the visual fields of the client with that of the examiner. B. Symmetry of palpebral fissures -incorrect: The palpebral fissure is the space between the eyelids, which is unequal in clients who have ptosis (ex: drooping of one or both of the eyelids) C. Corneal light reflex -The corneal light reflex requires the nurse to shine a penlight at the client’s eyes and visualize whether the light shines on the same spot bilaterally. This test will indicate the alignment of the client’s eyes as well as any deviation inward or outward. With strabismus, the eyes will not align when the client focuses. D. Accommodation test -incorrect: The test for accommodation determines whether the client’s pupils constrict as they focus on an object the examiner brings closer to the eyes. 114. A nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to assess which of the following? A. Liver size -incorrect: Evaluating liver size requires palpation B. Pedal edema -incorrect: Evaluating pedal edema requires palpation