1.A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate understanding of the process within the psychomotor domain of learning?
- Ask the client if he wants to self-administer his insulin.
Explanation:
This option is incorrect because simply asking the client if they want to self-administer insulin evaluates their willingness, not their understanding or ability to perform the task. To evaluate the psychomotor domain (which involves physical skills and coordination), the nurse should observe the client performing the task or have them demonstrate the steps of insulin administration. Since this is the only option provided in the image, it seems incomplete. The correct approach would involve observing the client’s ability to physically perform the injection, such as preparing the syringe, selecting the site, and administering the insulin.
2.A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take?
- Insert the rectal tube 15.2 cm (6 in).
- Wear sterile gloves to insert the tubing.
- Position the client on his left side.
- Hold the solution bag 91 cm (36 in) above the client’s rectum.
Explanation:
When administering a cleansing enema, the client should be positioned in the Sims’ position, which involves lying on the left side with the right leg flexed. This position allows the solution to flow into the sigmoid colon more effectively due to the anatomy of the large intestine.
3.A client who reports shortness of breath requests her nurse’s help in changing positions. After repositioning the client, which of the following actions should the nurse take next?
- Encourage the client to take deep breaths.
- Observe the rate, depth, and character of the client’s respirations.
- Prepare to administer oxygen.
- Give the client a back rub to help her relax.
Explanation:
After repositioning a client who is experiencing shortness of breath, the nurse’s priority is to assess the effectiveness of the intervention. Observing the rate, depth, and character of the client’s respirations allows the nurse to determine if the repositioning improved the client’s breathing or if further action is needed.
4.A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding?
- Sit at the bedside while feeding the client.
- Order pureed foods.
- Make sure feedings are at room temperature.
- Offer the client a drink of fluid after every bite.
Explanation:
When a client has bilateral hand casts, they are unable to feed themselves, and the nurse should assist with feeding. Sitting at the bedside ensures the nurse can safely and effectively feed the client while monitoring for any issues, such as choking or discomfort.
5.A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take?
- Place a padded tongue blade in the client’s mouth.
- Lower the client to the floor and place a pad under the client’s head.
- Seek the help of a coworker and lift the client back into bed.
- Use an oropharyngeal airway to keep upper airway passages open.
Explanation:
During a seizure, the priority is to ensure the client’s safety by preventing injury. Lowering the client to the floor and placing a pad under their head protects them from falling or hitting their head on a hard surface.
6.A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?
- Teaching clients to perform self-examinations of breasts and testicles.
- Educating clients about the recommended immunization schedule for adults.
- Teaching clients who have type 1 diabetes mellitus about care of the feet.
- Recommending that clients over the age of 50 have a fecal occult blood test annually.
Explanation:
Primary prevention focuses on preventing disease before it occurs, such as through vaccinations, health education, and lifestyle changes. Educating clients about the recommended immunization schedule for adults is a primary prevention activity because it aims to prevent illness (e.g., flu, pneumonia) before it happens.
7.An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?
- The AP uses soap and water to clean the perineal area.
- The AP tapes the catheter to the client’s inner thigh.
- The AP hangs the collection bag at the level of the bladder.
- The AP ensures that there are no kinks in the drainage tubing.
Explanation:
The collection bag for an indwelling urinary catheter should always be kept below the level of the bladder to ensure proper drainage and prevent backflow of urine, which could lead to infection. Hanging the bag at the level of the bladder indicates a need for further teaching.
8.A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client’s balance?
- Two-point discrimination test
- Glasgow coma scale
- Babinski reflex
- Romberg test
Explanation:
The Romberg test is used to assess balance and coordination. The client stands with their feet together, arms at their sides, and eyes closed; the nurse observes for swaying or loss of balance, which could indicate issues with proprioception or cerebellar function.
9.A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client?
- Sweeping the floor
- Shoveling snow
- Cleaning windows
- Washing dishes
Explanation:
For a client recovering from lung cancer, lower-intensity activities are recommended to avoid overexertion, especially since lung function may be compromised. Washing dishes is a low-intensity activity that can be done while sitting or standing and does not require significant physical effort.
10.A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?
- Repeat each joint motion five times during each session.
- Move the joint to the point of considerable resistance.
- Sit approximately 2 feet from the side of the bed closest to the joint being exercised.
- Exercise the smaller joints first.
Explanation:
When performing passive range-of-motion (PROM) exercises, the nurse should repeat each motion a set number of times, typically 3 to 5 times per joint, to promote flexibility and circulation without causing fatigue or discomfort. Five times per session is a standard practice.
11.A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)
- Set the suction machine at 120 mm HG.
- Provide oral hygiene frequently.
- Measure the amount of drainage from the NG tube every shift.
- Secure the NG tube to the client’s gown.
- Apply petroleum jelly to the client’s nares.
Explanation:
For a client with an NG tube for gastric decompression, the nurse should include the following actions:
- Provide oral hygiene frequently: NG tube can cause dryness and discomfort in the mouth, so frequent oral hygiene is essential to maintain comfort and prevent infection.
- Measure the amount of drainage from the NG tube every shift: Monitoring the output from the NG tube helps assess the client’s gastrointestinal status and ensures the tube is functioning properly.
- Secure the NG tube to the client’s gown: Securing the tube prevents accidental dislodgement and reduces tension on the nares.
12.A nurse is reviewing the laboratory values for a client who has a positive Chvostek’s sign. Which of the following laboratory findings should the nurse expect?
- Decreased calcium
- Decreased potassium
- Increased potassium
- Increased calcium
Explanation:
A positive Chvostek’s sign (facial muscle twitching when the facial nerve is tapped) is a clinical indicator of hypocalcemia (low calcium levels). It is often associated with conditions like hypoparathyroidism or vitamin D deficiency. The nurse should expect decreased calcium levels in the client’s laboratory results.
13.A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take?
- Fasten the ties on the restraint to the side rails of the bed.
- Tie the restraint with a quick-release knot.
- Allow one finger’s breadth between the restraint and the client’s chest.
- Place the restraint under the client’s clothing.
Explanation:
When using a vest restraint, the nurse must ensure safety and accessibility. Tying the restraint with a quick-release knot allows for rapid removal in case of an emergency, such as if the client experiences respiratory distress or the restraint needs to be removed quickly.
14.A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?
- Aim the hose at the base of the fire.
- Squeeze the handle of the extinguisher.
- Remove the safety pin from the extinguisher.
- Sweep the hose from side to side to dispense material.
Explanation:
The correct sequence for using a fire extinguisher follows the PASS acronym: Pull the pin, Aim at the base of the fire, Squeeze the handle, and Sweep from side to side. The first step is to remove the safety pin to unlock the extinguisher and allow it to be used.
15.A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client’s urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?
- Hemolytic
- Febrile
- Circulatory overload
- Sepsis
Explanation:
Flank pain and reddish-brown urine during a blood transfusion are classic signs of a hemolytic transfusion reaction, which occurs when the client’s immune system attacks the transfused red blood cells, leading to hemolysis. The reddish-brown urine indicates hemoglobinuria (hemoglobin in the urine) due to the breakdown of red blood cells.
16.A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?
- Warm, dry skin
- Increased urinary output
- Tachycardia
- Bradypnea
Explanation:
Hypovolemic shock, often caused by significant blood loss (e.g., from abdominal trauma), leads to decreased circulating volume, triggering compensatory mechanisms. Tachycardia (increased heart rate) is a hallmark sign as the body attempts to maintain cardiac output and perfusion.
17.A nurse in a provider’s office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess?
- Sunken eye balls
- Hypotension
- Poor skin turgor
- Bounding pulse
Explanation:
Fluid volume excess, often seen in heart failure, leads to increased preload and cardiac workload, which can result in a bounding pulse (a strong, forceful pulse). Edema in the ankles and weight gain are already indicative of fluid overload, and a bounding pulse is another sign.
18.A nurse is caring for a client who has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take?
- Wear gloves when changing the client’s gown.
- Use alcohol-based sanitizer to cleanse the hands.
- Wear a mask when assisting the client with his meal tray.
- Place the client on complete bed rest.
Explanation:
Clostridium difficile (C. diff) requires contact isolation due to its transmission via the fecal-oral route. The nurse should wear gloves when changing the client’s gown to prevent direct contact with potentially contaminated surfaces or body fluids.
19.A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include?
- Stand 3 feet from the client when assisting with lifting.
- Lock your knees when standing for long periods.
- Lift up to 22.6 kg (50 lbs) without the use of assistive devices.
- When lifting an object, spread your feet apart to provide a wide base of support.
Explanation:
Proper body mechanics are essential to prevent back injuries. Spreading the feet apart provides a wide base of support, which improves stability and reduces strain on the back during lifting.
20.A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states, “All this equipment is making me nervous.” Which of the following responses should the nurse make?
- “You won’t need the equipment very long.”
- “All of this equipment can be frightening.”
- “Why does the equipment bother you?”
- “Let me tell you what each machine does.”
Explanation:
The client’s statement indicates anxiety about the equipment, which is common in a telemetry unit after a myocardial infarction. The best response is to address the client’s anxiety by providing education and reassurance. Explaining what each machine does helps demystify the equipment, reduces fear, and empowers the client with knowledge.
21.A nurse is using the I-SBAR communication tool to provide the client’s provider with information about the client. The nurse should convey the client’s pain status in which portion of the report?
- Assessment
- Background
- Situation
- Recommendation
Explanation:
The I-SBAR tool (Introduction, Situation, Background, Assessment, Recommendation) is a structured method for communicating critical information. The client’s pain status is a clinical finding that should be reported in the Assessment portion, as this section includes the nurse’s observations and evaluation of the client’s current condition (e.g., vital signs, symptoms like pain, or other clinical data).
22.An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?
- “Don’t worry, teenagers often have friends who give them bad advice.”
- “I think you should stop seeing those friends since they discourage you from following your treatment plan.”
- “Tell me more about how your friends discourage you.”
- “Tell me where you met these friends.”
Explanation:
The nurse should use therapeutic communication to explore the client’s concerns and understand the dynamics of the situation. Asking the client to elaborate on how their friends discourage them encourages open dialogue, helps the nurse assess the situation, and allows the client to feel heard.
23.A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?
- Blood loss
- NPO status after surgery
- Nasogastric tube suctioning
- Impaired peristalsis of the intestines
Explanation:
Gas pains 48 hours after a small bowel resection are most likely due to **impaired peristalsis of the intestines**, a common postoperative complication. Surgery on the intestines can cause a temporary ileus (decreased bowel motility), leading to gas buildup and discomfort.
24.A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- “People who practice the Islamic faith pray over the deceased for a period of 5 days before burial.”
- “People who practice the Hindu faith bury the deceased with their head facing north.”
- “People who practice Judaism stay with the body of the deceased until burial.”
- “People who are practicing the Buddhist faith have the female family members prepare the body following death.”
Explanation:
In the Jewish faith, it is customary for someone to stay with the body of the deceased until burial, often as part of the practice of “sitting shiva” or ensuring the body is not left alone (a practice called “shemira”). This statement by the newly licensed nurse is correct.
25.A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take?
- Leave the bag in place for 45 min.
- Fill the bag two-thirds full with ice.
- Place the ice bag uncovered on the client’s ankle.
- Tell the client that it is expected to feel numbness when the ice bag is in place.
Explanation:
When applying an ice bag, the nurse should fill the bag two-thirds full with ice to allow for flexibility and better contact with the skin, ensuring effective cooling without excessive pressure.
26.A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client’s fluid status?
- Daily weight
- Blood pressure
- Specific gravity
- Intake and output
Explanation:
In acute renal failure, the most accurate measure of fluid status is **daily weight**, as it reflects changes in fluid balance (1 kg of weight gain/loss typically equals 1 liter of fluid). Renal failure often leads to fluid retention, and daily weight monitoring helps detect these changes precisely.
27.A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take?
- Place the client in a lateral position with the head turned to the side before beginning the procedure.
- Use the thumb and index finger to keep the client’s mouth open.
- Rinse the client’s mouth with an alcohol-based mouthwash following the procedure.
- Cleanse the client’s mucous membranes with lemon-glycerin sponges.
Explanation:
For an unconscious client, the nurse should place the client in a lateral position with the head turned to the side to prevent aspiration during oral care, as the client cannot protect their airway. This position allows secretions to drain out of the mouth.
28.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 client who has a prescription for a transfusion of packed red blood cells
- A client who is being transported for a radiology of the kidneys, ureters, and bladder
- A client who has a prescription for a tuberculin skin test
- A client who has a distended bladder and needs urinary catheterization
Explanation:
Written informed consent is required for invasive procedures, treatments with significant risk, or those involving blood products. A transfusion of packed red blood cells requires written consent because it carries risks such as transfusion reactions, infections, or allergic responses.
29.A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take?
- Place the client in Trendelenburg position.
- Perform percussions directly over the client’s bare skin.
- Use a flattened hand to perform percussions.
- Remind the client that chest percussions can cause mild pain.
Explanation:
Chest physiotherapy, including percussion, is used to mobilize secretions and improve ventilation in conditions like atelectasis. The nurse should use a flattened hand (cupped hand technique) to perform percussions, as this creates a popping sound and vibration to loosen secretions without causing discomfort.
31.A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching?
- Support the majority of your weight on the axillae.
- Keep your elbows extended.
- Bear weight on both of your legs.
- Move both crutches forward at the same time.
Explanation:
A four-point crutch gait is used for clients with lower extremity weakness to provide maximum stability. In this gait, the client moves one crutch forward, then the opposite leg, then the other crutch, and finally the other leg, creating a four-point pattern. The instruction to bear weight on both of your legs is appropriate because the client should distribute their weight between the legs and crutches for stability. Supporting weight on the axillae can cause nerve damage, elbows should be slightly flexed for control, and moving both crutches at the same time is incorrect for a four-point gait.
32.A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?
- Vastus lateralis
- Dorsogluteal
- Deltoid
- Ventrogluteal
Explanation:
The ventrogluteal site is considered the safest for intramuscular (IM) injections in adults because it avoids major nerves and blood vessels, has a large muscle mass, and is less likely to cause complications like sciatic nerve injury (which can occur with the dorsogluteal site). The vastus lateralis is often used for infants, and the deltoid has a smaller muscle mass, making it less ideal for larger injections. The dorsogluteal site is no longer recommended due to the risk of nerve damage.
33.A nurse is responding to a parent’s question about his infant’s expected physical development during the first year of life. Which of the following information should the nurse include?
- A 2-month-old infant can turn from his abdomen to his back.
- A 10-month-old infant can pull up to a standing position.
- A 4-month-old infant can sit up without support.
- A 6-month-old infant can crawl on his hands and knees.
Explanation:
Developmental milestones for infants follow a predictable pattern. A 10-month-old infant typically can pull up to a standing position, which aligns with expected motor development. A 2-month-old can lift their head briefly but not roll over (that happens around 4-6 months). A 4-month-old can’t sit up without support yet (that’s around 6-7 months). Crawling on hands and knees typically starts around 9-12 months, but 6 months is too early for most infants.
34.A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take?
- Consult the medication reference book available on the unit.
- Ask a more experienced nurse for information about the medication.
- Call the client’s provider and verify the prescription.
- Ask the client if she takes this medication at home.
Explanation:
Patient safety is the priority. If a nurse is unfamiliar with a medication, the most appropriate action is to verify the prescription with the provider to ensure its correct and safe for the client.
35.A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client’s death is imminent?
- Urinary retention
- Cold extremities
- Hypertension
- Tachycardia
Explanation:
In a client with a terminal illness, cold extremities are a sign of imminent death because the body begins to shut down, and circulation prioritizes vital organs, leading to decreased blood flow to the extremities.
36.A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, “You are not putting that hose down my throat.” Which of the following statements should the nurse make?
- “I would try to get it over with because you won’t get better without this tube.”
- “You should talk to your provider about it.”
- “Why don’t you want the tube inserted?”
- “I can see that this is upsetting you.”
Explanation:
The nurse should first acknowledge the client’s feelings to build trust and open communication, which is why “I can see that this is upsetting you” is the best response. It shows empathy and allows the nurse to explore the client’s concerns further.
37.A nurse is caring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces?
- Carminative
- Hypertonic
- Oil retention
- Sodium polystyrene sulfate
Explanation:
An oil retention enema is used to soften hard, impacted feces by lubricating the stool and the rectal mucosa, making digital removal easier and less traumatic.
38.A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include?
- Blow into the spirometer to elevate the balls in the device.
- Cough deeply after each use.
- Clean the mouthpiece with an alcohol swab after each use.
- Use the spirometer every 8 hr.
Explanation:
Using an incentive spirometer helps prevent postoperative lung complications by encouraging deep breathing. Coughing deeply after each use helps clear secretions and maintain airway patency, which is a key part of the teaching.
- A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?
- Autonomy
- Fidelity
- Nonmaleficence
- Justice
Explanation:
Fidelity refers to keeping promises and being faithful to commitments. By returning promptly as promised, the nurse demonstrates fidelity.
40.A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?
- Pain level
- Hydration status
- Airway
- Urinary output
Explanation:
The ABCs (Airway, Breathing, Circulation) are the priority in any assessment, especially for a postoperative client. The nurse should first assess the airway to ensure it’s patent, as airway compromise can be life-threatening.
41.A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client has eviscerated?
- Cover the incision with a moist sterile dressing.
- Have the client lie on his back with his knees flexed.
- Call the client’s surgeon.
- Reassure the client.
Explanation: Evisceration is a medical emergency where the abdominal contents protrude through the surgical incision. The nurse’s first action should be to cover the incision with a moist sterile dressing (moistened with sterile saline) to protect the exposed organs and prevent infection or drying of the tissues.
42.A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching?
- Cream of rice
- Cottage cheese
- Gelatin
- Ice cream
Explanation:
A clear liquid diet includes foods that are liquid at room temperature and leave minimal residue in the gastrointestinal tract, such as gelatin, clear broth, apple juice, and tea. Gelatin is an appropriate choice for a clear liquid diet.
43.A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship?
- Loss
- Trust
- Self-disclosure
- Risk-taking
Explanation:
The termination phase of the nurse-client relationship involves preparing the client for the end of the therapeutic relationship, which can evoke feelings of loss or grief, especially in mental health settings where emotional bonds may have formed. Discussing loss helps the client process these feelings and transition to independence or new care providers.
44.A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration?
- Redness at the infusion site
- Edema at the infusion site
- Warmth at the infusion site
- Oozing of blood at the infusion site
Explanation:
Infiltration occurs when IV fluid leaks into the surrounding tissue instead of the vein, often due to the catheter dislodging. Edema (swelling) at the infusion site is a classic sign of infiltration, as the fluid accumulates in the tissue.
45.A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing?
- Limit total caloric intake to 25 kcal/kg of body weight.
- Provide an intake of 500 mg/day of vitamin E.
- Limit fluid intake to 20 mL/kg of body weight per day.
- Provide a protein intake of 1.5 g/kg of body weight per day.
Explanation:
Adequate protein is essential for wound healing, as it supports tissue repair and immune function. A protein intake of 1.5 g/kg of body weight per day is appropriate for a postoperative client with poor nutritional status to promote healing.
46.A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use?
- BT for bedtime
- SC for subcutaneously
- PC for after meals
- HS for half-strength
Explanation:
In medical documentation, “PC” (post cibum) is a standard abbreviation meaning “after meals” and is appropriate for use.
47.A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family?
- Use battery-operated equipment for personal care.
- Apply mineral oil to protect the facial skin from irritation.
- Remove the television set from the client’s bedroom.
- Wear cotton clothing to avoid static electricity.
Explanation:
Oxygen therapy poses a fire hazard, and static electricity can create sparks that might ignite oxygen. Wearing cotton clothing helps reduce static electricity, making it a key safety instruction. Battery-operated equipment isn’t necessary for personal care, mineral oil can be flammable and isn’t recommended, and removing the TV isn’t a standard precaution unless it’s a fire risk (e.g., due to faulty wiring).
48.A nurse in a provider’s office is collecting information from an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects?
- Constipation
- Gastric ulcers
- Respiratory depression
- Liver damage
Explanation:
Acetaminophen, when taken in large doses or over a prolonged period, can cause liver damage (hepatotoxicity) due to the accumulation of a toxic metabolite. The maximum recommended dose for adults is typically 4,000 mg/day, and 500 mg/day is not excessive, but the nurse should educate about the risk of higher doses.
49.A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the odor. Which of the following responses should the nurse make?
- “A lot of clients who are cared for at home have the same problem.”
- “Don’t worry about it. He will get a bath, and that will take care of the odor.”
- “It must be difficult to care for someone who is confined to bed.”
- “When was the last time that he had a bath?’’
Explanation:
This response shows empathy and acknowledges the partner’s efforts and challenges in caregiving, which helps build rapport and reduce embarrassment.
50.A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first?
- Inspection
- Auscultation
- Percussion
- Palpation
Explanation:
Abdominal assessment follows a specific order to avoid altering findings: inspection, auscultation, percussion, and then palpation. The nurse should start with inspection to visually assess for distension, scars, or other abnormalities, especially since the client reports bloating.
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