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should be implemented for airborne, droplet precautions, or protective environments. Category: Fundamentals 13. A 35-year-old female client with cancer refuses to allow the nurse to insert an IVfor a scheduled chemotherapy treatment, and states that she is ready to go home to die. What intervention should the nurse initiate? • Review the client's medical record for an advance directive. • Determine if a do-not-resuscitate prescription has been obtained. • Document that the client is being discharged against medical advice. • Evaluate the client's mental status for competence to refuse treatment. CorrectCompetent clients have the right to refuse treatment, so the nurse should first ensure that the client is competent (D). (A and C) are not necessary for a competent client torefuse treatment. The nurse cannot document (C) until the healthcare provider is notified of the client's wishes and a discharge prescription is obtained. 14. What is the most effective way to implement a teaching plan? • Teach the information that the client wants to learn first. Correct • Streamline the teaching plan to include only essential information. • Present to the client all the information necessary to meet the objectives. • Provide the client with written material to review before teaching sessions. Teaching is most effective when it responds to the learner's needs, and learning beginswhen a person identifies a need for knowing or acquiring an ability to do something (A). (B and C) provide widely varied amounts of content, each of which should consider an individual's learning styles, level of education, reading ability, culture, age, and readiness to learn. Providing written information (D) may or may not be the best way to teach when various learning styles and other client factors are considered. Category: Fundamentals 15. A client is receiving an intramuscular injection at the ventrogluteal site. At whatangle should the nurse insert the needle? (Enter numerical value only.) 90 Correct 16. A client who has been on bedrest for several days now has a prescription to progress activity as tolerated. When the nurse assists the client out of bed for the firsttime, the client becomes dizzy. What action should the nurse implement? • Encourage the client to take several slow, deep breaths while ambulating. • Help the client to remain standing by the bedside until the dizziness is relieved. • Instruct the client to remain on bedrest until the healthcare provider is contacted. • Advise the client to sit on the side of the bed for a few minutes before standingagain. Correct The nurse should implement (D), because orthostatic hypotension is a common resultof immobilization, causing the client to feel dizzy when first getting out of bed following a period of bedrest. To prevent this problem, it is helpful to have the body acclimate to a standing position by sitting upright for a short period (D) before risingto a standing position. (A) is unlikely to alleviate the dizziness. (B) may result in a loss of consciousness. (C) is not indicated and will increase the potential for complications associated with prolonged immobility. 17. When examining the wound of a client who had abdominal surgery yesterday, thenurse finds that the wound edges are close together, there is no sign of redness, and there is a slight amount of bright red blood oozing from the incision. What action should the nurse take? • Record these findings in the client's record. Correct • Observe closely for possible dehiscence. • Notify the healthcare provider that the client's wound is producing a sanguineousdrainage. Incorrect • Increase the IV fluid rate and encourage the client to eat more ice chips. These are normal findings for one-day postoperative and indicate that the wound is healing by primary intention (A). Dehiscence (B) is separation of a surgical incision, and there is no indication that this is a possibility at this time. Serosanguineous drainage is thin and red and is composed of serum and blood, and this client is not exhibiting this finding, and even if the wound was producing this drainage, the findingdoes not warrant (C). There is no indication of dehydration, so (D) is not indicated at this time. Category: Fundamentals 18. The nurse assesses an immobile, elderly male client and determines that his bloodpressure is 138/60, his temperature is 95.8° F, and his output is 100 ml of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is most important for the nurse to implement? • Administer a PRN antihypertensive prescription. • Provide the client with an additional blanket. • Encourage additional fluid intake. Incorrect • Turn the client q2h. Correct (D) will help to move and drain respiratory secretions and prevent pneumonia from occurring, so this intervention has the highest priority. Older adults often have an increased BP, and a PRN antihypertensive medication is usually prescribed for a BP over 140 systolic and 90 diastolic (A). Older adults often run a lower temperature, particularly in the morning, and (B) does not have the priority of (D). Even though the client has adequate output, (C) might be encouraged because the urine is concentrated,but this intervention does not have the priority of (D). 19. The nurse is preparing to perform oral care for an unconscious client. In what order should the nurse implement the nursing actions? (Arrange the options in the order they should be performed with the first action on top and the last action on thebottom.) Correct 1. Raise bed to a comfortable working height. 2. Lower the side rail between the nurse and the client.3. Position the client in a flat side-lying position. 4. Place an emesis basin under the client's chin. To ensure client and nurse safety when performing oral care for an unconscious client,first raise the bed to a comfortable working level, then lower the side rail between the nurse and the client, position the client in a flat side-lying position, and place a towel and an emesis basin under the client's chin. Category: Fundamentals 20. The nurse is preparing a male client who has an indwelling catheter and an IV infusion to ambulate from the bed to a chair for the first time following abdominal surgery. What action(s) should the nurse implement prior to assisting the client to thechair? (Select all that apply.) • Pre-medicate the client with an analgesic. Correct • Inform the client of the plan for moving to the chair. Correct • Obtain and place a portable commode by the bed. • Ask the client to push the IV pole to the chair. Correct • Clamp the indwelling catheter. • Assess the client's blood pressure. Correct The nurse should plan to implement (A, B, D, and F). Pre-medicating the client with an analgesic (A) reduces the client's pain during mobilization and maximizes compliance. To ensure the client's cooperation and promote independence, the nurse should inform the client about the plan for moving to the chair (B) and encourage theclient to participate by pushing the IV pole when walking to the chair (D). The nurseshould assess the client's blood pressure (F) prior to mobilization, which can cause orthostatic hypotension. (C and E) are not indicated. 21. When caring for an immobile client, what nursing diagnosis has the highestpriority? • Risk for fluid volume deficit. • Impaired gas exchange. Correct • Risk for impaired skin integrity. • Altered tissue perfusion