FUNDAMENTALS

1. The nurse feels a client is at risk for skin breakdown because the client has only
had clear liquids for the last 10 days (and essentially no protein intake). The
nurse would formulate which diagnostic statement to best reflect this problem?
A. Risk for malnutrition related to clear liquid diet
B. Impaired skin integrity related to no protein intake
C. Risk for impaired integrity related to malnutrition
RATIONALE: This is a risk diagnosis, and diagnostic statement has two parts:
the human response (impaired skin integrity) and the related/risk factor
(malnutrition). Options A and B do not have related factors that are under the
control of the nurse (i.e., type of diet ordered). The diagnosis in option D does
not specify the type of impairment (greater than or less than body
requirements) and is therefore incomplete. It also does not provide direction
for development of goals and interventions.
STRATEGY: The critical phrase is at risk for skin breakdown. Use knowledge
that nursing diagnoses are developed to address client responses that are
amenable to nursing intervention to eliminate options A and B. Note that the
diagnosis in option D is incomplete to choose option C.
D. Impaired nutrition related to current illness
2. A 68-year-old woman is going home to live with her daughter after being
hospitalized and diagnosed with Alzheimers disease. Which statement by the
daughter as caretaker demonstrates the need for further safety education?
A. I have arranged for a sitter to be home with mother on the days that I must
work.
B. I have gotten a medical bracelet for mother to wear in case she should leave
our home.
C. I have had grab bars installed around the bathroom.
D. I purchased a heating pad for mother to use on her hip on the nights she
cannot sleep because of hip pain.
RATIONALE: A heating pad is a dangerous intervention when used with a
confused or elderly client. The client is at risk for burns resulting from
improper use. Options A, B, and C are statements that reflect good safety
measures for a confused elderly client.
STRATEGY: The critical words are 68-year-old woman and Alzheimers
disease. Assess the cognitive and physical abilities of the client when
discharge planning or teaching about safety.
3. A client is to start on sulfamethoxazole (Gantanol) for a urinary tract infection
(UTI). What priority nursing intervention precedes administration of the first
dose?
A. Check the bilirubin level.
B. Have client empty her bladder.
C. Ensure that a urine specimen for culture and sensitivity (C & S) has been
obtained.
RATIONALE: The nurse ensures the urine specimen for C & S is collected prior
to the initial administration of the urinary tract anti-infective agent, so that
the causative microorganism and the anti-infectives to which the organism is
sensitive can be identified. The results of the urine C & S will become

available in several hours, but delaying anti-infective therapy could cause the
UTI to worsen (option D). If the results of the test do not affirm the drugs
efficacy, the nurse will collaborate with the prescriber. Checking the bilirubin
would be appropriate only if attempting to differentiate the cause of existing
jaundice as being hepatic impairment or hemolysis (option A). The urine
specimen should be a clean-catch or catheterized specimen for more
accurate results (option D). Option B is not essential prior to initiating drug
therapy.
STRATEGY: The question is asking for selection of the priority intervention. To
make certain that a client is being given the correct medication for the
infection, a C & S must be performed before beginning the medication. The
other options are incorrect when considering the priority intervention.
D. Analyze results of a random voided urine specimen for culture and sensitivity.
4. The nurse has taught the client with nausea how to use aromatherapy to
alleviate the symptoms. Which statement by the client indicates that he has
demonstrated correct understanding of aromatherapy?
A. If I get the essential oil in my eyes, I need to flush them out with either milk
or a carrier oil.
RATIONALE: If essential oil gets into the eyes, it must be flushed out
immediately with milk or a carrier oil, rather than water, since the oils are not
dissolvable in water. There are some contraindications for some types of
essential oils, so the nurse needs to consult the list of contraindications in the
training manual. The choice to use aromatherapy is best decided by a
professional in the field. Nurses should not administer essential oils orally,
since this is not covered by the nurses scope of practice. Also, some
essential oils can be poisonous if given incorrectly, and should be
administered orally by a trained professional in this field. Oils need to be
stored in a dark, covered bottle and kept away from light and heat.
STRATEGY: To answer this question correctly, the nurse needs to know how to
administer and store oil, and what to do when it accidentally gets in ones
eyes.
B. I can share my treatment with anyone else, since I now know how to use
aromatherapy.
C. I can take it orally, if needed.
D. I need to store my oil in any container as long as it is away from the light.
5. The nurse places highest priority on taking which of the following actions to
reduce the spread of microorganisms when caring for a client at risk for
infection?
A. Wash hands before and after client care.
RATIONALE: Hand hygiene is a core principle of standard precautions. Using
gloves is appropriate when there is a risk of exposure to blood, body fluids,
secretions, and excretions. However, handwashing should be done after
removal of gloves. Not all clients require transmission-based precautions
(option C) or a private room (option D).
STRATEGY: Use the process of elimination based on nursing knowledge of
standard precautions. Elements of transmission-based precautions are not
initiated with all clients.
B. Use clean gloves when implementing client care.

C. Institute transmission-based precautions.

D. Place the client in a private room.
6. A hospital discharge planning nurse is making arrangements for a client (who
has an epidural catheter for continuous infusion of opioids) to be placed on a
long-term care facility in the clients neighborhood to encourage family visiting.
The facility has never cared for a client with this type of need. What would be
the discharge planning nurses best action?
A. Ask physician for an extension of hospitalization until epidural catheter is
discontinued to allow for placement at neighborhood facility
B. Arrange for immediate in-services for long-term care facility staff on pain
management using epidural catheters
C. Explain situation to client and family and seek another long-term care facility
for discharge from the hospital
RATIONALE: According to JCAHO Pain Standards, if a facility cannot treat a
client for pain, the individual must be referred to a facility that can provide
the skill. The physician may not be able to extend hospitalization because of
insurance limitations (option A). It is the long-term care facilitys decision and
responsibility to become prepared to provide a new service (option B).
Private-duty nurses may be cost prohibitive for the family and the long-term
care facility may not have the resources needed to provide safe care for this
client (option D).
STRATEGY: Recall accreditation agencies standards on pain control to allow
you to plan acceptable care measures.
D. Encourage family to hire private duty nurses skilled in epidural catheter pain
management to allow for client transfer to neighborhood facility
7. The nurse is caring for a client with a Hickman central line. While changing the
central line dressing, the nurse notes that the injection cap (e.g., heplock
adapter) is of the slip lock variety instead of a luer lock device. The nurse
recognizes that this adapter puts the client at risk for which of the following
complications?
A. Sepsis
B. Occlusion
C. Phlebitis
D. Air embolism
RATIONALE: One of the complication of IV therapy is air embolism, which is
the introduction of air into the vein. Air embolism can be prevented by using
luer lock devices on all attachments. The other responses are unrelated to
this connection.
STRATEGY: The core issue of the question is the ability of the nurse to detect
situations that could lead to complications of IV therapy. Use knowledge of
these risks to aid in making a selection.
8. The sister of a 76-year-old client with increasing intracranial pressure asks why
the nurse uses the extra oxygen when suctioning. Which of the following
statements is most correct?
A. Your brother seems to pink-up when we give him extra air.
B. The extra oxygen helps relieve the bradykinesia by decreasing the carbon
dioxide.

C. The extra oxygen helps relieve the pressure in his brain by decreasing the
carbon dioxide.
RATIONALE: Increasing intracranial pressure is aggravated by hypercarbia and
suctioning should not be done for longer than 10 seconds. The other three
options are not appropriate.
STRATEGY: Omit options A and D as they refer to extra air as opposed to
extra oxygen. Omit option B is bradykinesia is not the reason for increasing
oxygen.
D. Your brother seems less congested when we give him extra air.
9.