American University

NURSING FUNDAMENTA

1)A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?

1. Press gently on the tragus of the client's ear.
2. Pack a small piece of cotton deep into the client's ear canal.
3. Move the client's auricle down and back toward her head.
4. Tilt the client's head backward for 5 min.

2. A nurse is providing care to four clients. Which of the following situations requires the nurse to complete an incident report?

1. A nurse tied a client's restraint straps to the moveable part of the bed frame.
2. An assistive personnel placed a surgical mask on a client who has tuberculosis before transporting her to radiology.
3. A nurse administers a medication to a client 30 min before the dose is due.
4. A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

3. A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

1. Discuss the risk factors for colon cancer.
2. Focus teaching on what the client will need to do in the future to manage his illness.
3. Provide the client with written information about the phases of loss and grief.
4. Reassure the client that this is an expected response to grief.

4. A nurse is collecting data from a client. Which of the following findings should the nurse report to the charge nurse as an indicator of dehydration?

A). Red mucous membranes B). Jugular vein distention C). Skin tenting

D). BP 178/90 mm Hg

5. A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?

1. Bend at the waist.
2. Keep his feet close together.
3. Use his back muscles for lifting.
4. Stand close to the cabinet when lifting it.

6. A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

1. "I'm having mild pain."
2. "The pain is like a dull ache in my stomach."
3. "I notice that the pain gets worse after I eat."
4. "The pain makes me feel nauseous."

7. A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?

1. BUN 15 mg/dL
2. Creatinine 0.8 mg/dL
3. Sodium 143 mEq/L
4. Potassium 5.4 mEq/L

8. When auscultating a client’s lungs, the nurse identifies crackles in the left posterior base. Which of the following actions should the nurse take?

A). Repeat the auscultation after asking the client to breathe deeply and cough. B). Instruct the client to limit fluid intake to less than 2,000 mL/day.

3. Prepare to administer antibiotics.
4. Initiate bedrest in semi-Fowler’s position.

9. A nurse is assisting a client who is postoperative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client?

1. Side-lying
2. Supine
3. Semi-Fowler's
4. Trendelenburg

10. A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?

1. Assign the client to a room with a negative air-flow system.
2. Use alcohol-based hand sanitizer when leaving the client's room.
3. Clean contaminated surfaces in the client's room with a phenol solution.
4. Have family members wear a gown and gloves when visiting.

11. A nurse is caring for a client who reports constipation. The provider has prescribed an enema. Identify the sequence of steps the nurse should take to administer the enema. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

1. Provide for the client's privacy by closing the curtains.
2. Confirm the client's identity by checking her wristband.
3. Insert the tip of the enema tubing into the client's rectum.
4. Assist the client into the Sims' position.

12. A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following?

1. Narrowed arterial lumen
2. Distended jugular veins
3. Impaired ventricular contraction
4. Asynchronous closure of the aortic and pulmonic valves

13. A nurse is collecting data from a client who is 2 days postoperative. The nurse auscultates bilateral breath sounds but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?

A). Atelectasis B). Rales

3. Rhonchi
4. Pneumothorax

14. A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.)

1. Lacrimal apparatus
2. Pupil clarity
3. Appearance of bulbar conjunctivae
4. Visual fields
5. Visual acuity

15. A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?

1. Purulent exudate
2. Warmth

3. Skin blanching
4. Bleeding

16. A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

1. Gently shake the container of medication prior to administration.
2. Transfer the medication to a medicine cup.
3. Place the client in a semi-Fowler's position prior to medication administration.
4. Verify the dosage by measuring the liquid before administering it.

17. A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects?

1. Auscultate lung sounds.
2. Measure urine output.
3. Monitor blood pressure readings.
4. Monitor serum electrolyte levels

18. A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care?

1. Tell the client which food she should eat first.
2. Provide small-handle utensils for the client.
3. Thicken liquids on the client's tray.
4. Use a clock pattern to describe food on the client's plate.

19. A nurse is assisting with developing the plan of care for a client who requires airborne precautions. Which of the following actions should the nurse suggest?

1. Provide a positive pressure airflow room.
2. Wear an N95 respirator mask.
3. Encourage the client to ambulate in the hall.
4. Wear gloves when entering the client’s room.

20. A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?

1. Use a resuscitation bag with 80% oxygen prior to the procedure.
2. Select a suction catheter that is half the size of the lumen.
3. Place the end of the suction catheter in water-soluble lubricant.
4. Adjust the wall suction apparatus to a pressure of 170 mm Hg.

21. A nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the nurse initiate?

1. Airborne
2. Droplet
3. Contact
4. Protective environment

22. A nurse is caring for a client who requires a clear liquid diet. Which of the following foods should the nurse allow the client to have?

1. Grape juice
2. Lemon sherbet C). Skim milk

D). Carrot juice

23. A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

1. Check the client for injuries.
2. Move hazardous objects away from the client.
3. Notify the provider.
4. Ask the client to describe how she felt prior to the fall.

24. A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?

1. Tomato juice
2. Bananas
3. Pancakes
4. Eggs

25. A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?

1. "When do you usually bathe, in the morning or in the evening?"
2. "Do you prefer a bath or a shower?"
3. "At what temperature do you prefer your bath water?"
4. "Are you able to help with your hygiene care?"

26. A nurse is caring for an older adult client who has confusion and weakness. The client has a Hct of 53%, a BUN of 25 mg/dL, and a urine specific gravity of 1.232. Which of the following actions should the nurse contribute to the client’s plan of care? (Select all that apply.)

1. Restrict the client’s fluid intake.
2. Monitor the client’s intake and output. C). Weigh the client daily.

D). Instruct the client to sit on the side of the bed for a few minutes before standing. E). Check the client’s orientation to person, place, and time regularly.

27. A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

1. Rinse the feeding bag with water between feedings.
2. Tell the client to keep the head of the bed elevated at least 30°.
3. Make sure the enteral formula is at room temperature.
4. Wipe the top of the formula can with alcohol.

28. A nurse is collecting data about the fluid status of four clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

A). A client who has NPO status since midnight for an endoscopy B). A client who has heart failure and is receiving diuretic therapy

C). A client who has end-stage kidney disease who will undergo dialysis D). A client who has gastroenteritis and is receiving oral fluids

29. A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?

1. "I'll get a blood sample from you and send it for a screening test."
2. "Beginning at age 60, you should have a colonoscopy."
3. "You should have a fecal occult blood test every year."
4. "The recommendation is to have a sigmoidoscopy every 10 years

30. When auscultating a client’s lungs, the nurse identifies crackles in the left posterior base. Which of the following actions should the nurse take?

1. Repeat the auscultation after asking the client to breathe deeply and cough.
2. Instruct the client to limit fluid intake to less than 2,000 mL/day.
3. Prepare to administer antibiotics.
4. Initiate bedrest in semi-Fowler’s position.

31. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect?

1. Neck vein distention
2. Urine specific gravity 1.010
3. Rapid heart rate
4. Blood pressure 144/82 mm Hg

32. A nurse is planning an education session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client?

1. Allow extra time for the client to respond to questions.
2. Expect the client to have difficulty understanding the information.
3. Avoid references to the client's past experiences.
4. Keep the learning session private and one-on-one.

33. A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

1. Protective environment
2. Airborne precautions
3. Droplet precautions
4. Contact precautions

34. A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines?

1. A nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse.
2. A nurse asks a nurse from another unit to assist with her documentation.
3. A nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care.
4. A nurse discusses a client's status with the physical therapist that is caring for the client at the client's bedside.

35. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

1. Wear sterile gloves when removing the old dressing.
2. Warm the irrigation solution to 40.5° C (105° F).
3. Cleanse the wound from the center outward.
4. Use a 20-mL syringe to irrigate the wound.

36. A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

1. Ask the client to consider a direct donation.
2. Withhold the blood transfusion.
3. Request a consultation with the ethics committee.
4. Ask the client's family to intervene.

37. A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

1. .3 mg
2. 0.3 mg
3. 0.30 mg
4. 3/10 mg

38. A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

1. Inject 5 units of air into the bottle of regular insulin
2. Withdraw the correct dose of NPH insulin from the bottle
3. Inject 10 units of air into the bottle of NPH insulin
4. Withdraw the correct dose of regular insulin from the bottle

39. A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?

1. "I had a bowel movement, but I was able to save the urine."
2. "I have a specimen in the bathroom from about 30 minutes ago."
3. "I flushed what I urinated at 7:00 a.m. and have saved all urine since."
4. "I drink a lot, so I will fill up the bottle and complete the test quickly."

40. A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?

1. Insert an implanted port.
2. Close a laceration with sutures.
3. Place an endotracheal tube.
4. Initiate an enteral feeding through a gastrostomy tube.

41. A nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

42. A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

1. Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube.
2. Remove the NG tube if the client begins to gag or choke.
3. Apply suction to the NG tube prior to insertion.
4. Have the client take sips of water to promote insertion of the NG tube into the esophagus.

43. A nurse is caring for a client receiving IV therapy in the left forearm and notices that the site is red, swollen, and warm. Which of the following actions should the nurse perform first?

A). Insert an IV catheter in the opposite extremity. B). Discontinue the existing IV infusion.

C). Apply warm, moist compresses to the site. D). Elevate the extremity.

44. A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action?

1. Request that a respiratory therapist discuss the technique for incentive spirometry.
2. Determine the reasons why the client is refusing to use the incentive spirometer.
3. Document the client's refusal to participate in health restorative activities.
4. Administer a pain medication to the client.

45. A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

1. Insert the catheter at a 45° angle.
2. Place the client's arm in a dependent position.
3. Shave excess hair from the insertion site.
4. Initiate IV therapy in the veins of the hand.

46. A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

1. "Use the complete name of the medication magnesium sulfate."
2. "Delete the space between the numerical dose and the unit of measure."
3. "Write the letter U when noting the dosage of insulin."
4. "Use the abbreviation SC when indicting an injection."

47. A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse question?

1. The medication
2. The route
3. The dose
4. The frequency

48. A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take?

1. Apply the stockings so the creases are on the front side of the leg.
2. Apply the stockings while the client's legs are in a dependent position.
3. Remove the stockings at least once per shift.
4. Remove the stockings while the client is sitting in a reclining chair.

49. A nurse is calculating a client's fluid intake over the past 8 hr. The client had one 8-oz cup of coffee, 3 oz of juice, and 12 oz of soda. The client’s water pitcher had 800 mL and 200 mL remain. The client also had IV fluids infusing at 40 mL/hr via an IV pump. How many mL should the nurse document as the client’s total intake for the shift?

50. A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client? (Move the steps, placing them in the order of performance. Use all the steps.)

1. Ask the client if he can bear weight
2. Use the stand-and-pivot technique to move the client to the chair
3. Position the chair on the left side of the bed
4. Have the client sit and dangle his feet at the bedside

51. A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?

1. Critical pathway
2. Situation, background, assessment, and recommendation (SBAR)
3. Transfer report
4. Medication administration record (MAR)

52. A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

1. "I can concentrate best in the morning."
2. "It is difficult to read the instructions because my glasses are at home."

3. "I'm wondering why I need to learn this."
4. "You will have to talk to my wife about this."

53. A nurse is collecting data from a client who sustained blood loss. Which of the following findings should the nurse identify as a manifestation of hypovolemia?

A). Decreased heart rate B). Dyspnea

C). Increased blood pressure D). Thready pulse

54. A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first?

1. Suction the client's airway.
2. Administer a bronchodilator.
3. Increase the humidity in the client's room.
4. Assist the client to an upright position.

55. A charge nurse in a long-term care facility will be implementing a new protocol to meet the Joint Commission’s National Safety Goal of preventing health care-associated pressure ulcers. When informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is the priority?

1. Turn and position each client every 2 hr.
2. Identify the clients at greatest risk for development of pressure ulcers.
3. Use a barrier cream when performing perineal care.
4. Supervise clients to ensure adequate nutritional intake.

56. A nurse is caring for a client whose arterial blood gases include a pH of 7.30, an HCO3- of 18 mEq/L and a PaCO2 of 28 mm Hg. The nurse should suspect that the client has developed which of the following acid-base imbalances?

1. Metabolic acidosis
2. Respiratory acidosis
3. Metabolic alkalosis
4. Respiratory alkalosis

57. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.)

1. Place the client in a room with negative-pressure airflow.
2. Wear gloves when assisting the client with oral care.
3. Limit each visitor to 2-hr increments.
4. Wear a surgical mask when providing client care.
5. Use antimicrobial sanitizer for hand hygiene.

58. A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client’s skin integrity?

1. Reposition the client every 3 hr.
2. Massage bony prominences to promote circulation.
3. Provide the client with a diet high in protein.
4. Apply cornstarch to keep the skin dry.

59. A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?

1. "They allow the court to overrule an adult client's refusal of medical treatment."
2. "They indicate the form of treatment a client is willing to accept in the event of a serious illness."

3. "They permit a client to withhold medical information from health care personnel."
4. "They allow health care personnel in the emergency department to stabilize a client's condition."

60. A nurse is caring for a client who is terminally ill. Which of the following statements should the nurse identify as an indication that the client's family member is coping effectively with the situation?

1. "We are not worried. We still have hope that everything will be okay."
2. "This is a difficult time, but we are helping each other through this."
3. "After he comes home, we can plan our family reunion."
4. "We don't need to talk about funeral arrangements at this time."

61. A client is prescribed antibiotic "A" 50 mg IV. The mixed IV solution contains 100 mL. The nurse is to administer the medication over ½ hour. The drip factor of the available IV tubing is 15gtt/mL. What is the drip rate in drops per minute? (Round to nearest whole number and enter only the number in the answer box).

62. A nurse is providing education to a client with a fractured femur who will need to use crutches for the next 6 weeks. Identify if the following directions provided by the nurse for walking up stairs using crutches are true or false.

1. Hold to rail with one hand and crutches with the other hand.
2. Push down on the stair rail and the crutches and step up with the 'unaffected' leg.
3. If not allowed to place weight on the 'affected' leg, hop up with the 'unaffected' leg.
4. Bring the 'affected' leg and the crutches up beside the 'unaffected' leg.
5. Remember, the 'unaffected' leg goes up first and the crutches move with the 'affected' leg.

63. What is the name of a legal document that instructs health care providers and family members about what, if any, life-sustaining treatment an individual wants if at some time the individual is unable to make decisions?

1. Living will
2. Do Not Resuscitate
3. Informed consent
4. Durable power of attorney for health care

64. A nurse is caring for a client with encephalopathy secondary to liver failure. The client has been prescribed a high calorie, low protein diet. Which of the following meal selections is appropriate for this client?

1. Chicken breast, mashed potatoes, spinach.
2. Steak, french fries, corn.
3. Grilled cheese sandwich, potato chips, chocolate pudding.
4. Scrambled eggs, bacon and pancakes.

65. A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client's risk for falls?

1. Use of a night-light.
2. Demonstrate how to use the call light. C). Place bedside table in close proximity. D). Hourly rounding by the nurse.

66. A nurse's inadvertent medication error results in a severe allergic reaction and prolongs the client’s hospitalization. The client could rightfully sue the nurse for which of the following?

A). Malpractice B). Assault

C). Battery D). Abuse

67. A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?

1. Ask another nurse to observe the medication wastage.
2. Notify the pharmacy when wasting the medication.
3. Lock the remaining medication in the controlled substances cabinet.
4. Dispose of the vial with the remaining medication in a sharps container.

68. A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?

1. Dissolve each medication in 5 mL of sterile water.
2. Draw up medications together in the syringe.
3. Push the syringe plunger gently when feeling resistance.
4. Flush the tube with 15 mL of sterile water.

69. A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?

1. The top of the cane is parallel to the client's waist.
2. When walking, the client moves the cane 46 cm (18 in) forward.
3. The client holds the cane on the stronger side of her body.
4. The client moves her stronger limb forward with the cane.

70. A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

1. Place the client in a side-lying position.
2. Instill 15 mL of irrigation fluid into the catheter with each flush.
3. Subtract the amount of irrigant used from the client's urine output.
4. Perform the irrigation using a 20-mL syringe.

71. A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention?

1. Erythema on pressure points
2. Lower-extremity pulse strength of 2+
3. Fluid intake of 3,000 mL per day
4. A bowel movement every other day

72. A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures should the nurse recommend?

1. Drink a cup of hot cocoa before bedtime.
2. Exercise 1 hr before going to bed.
3. Use progressive relaxation techniques at bedtime.
4. Reflect on the day's activities before going to bed.

73. A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies?

1. Biofeedback
2. Aloe
3. Feverfew
4. Acupuncture

74. A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

1. Ensure sterilization of non-disposable items with ethylene oxide.

2. Wrap monitoring cords with stockinette and tape them in place.
3. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication.
4. Wear hypoallergenic latex gloves that contain powder.

75. A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use?

1. Touch the face with a cotton ball.
2. Apply a vibrating tuning fork to the client's forehead.
3. Have the client stand with her arms at her side and her feet together.
4. Perform direct percussion over the area of the kidneys.

76. A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

1. Place the client in high-Fowler's position.
2. Increase the client's intake of carbohydrates.
3. Massage reddened areas with unscented lotion.
4. Have the client use a trapeze bar when changing position.

77. A nurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress?

1. Role ambiguity
2. Sick role
3. Role overload
4. Role conflict

78. A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?

1. "What could I have done to deserve this illness?"
2. "I blame medical science for not curing me."
3. "Where is my daughter at a time like this?"
4. "Will I ever begin to feel in charge of my life again?"

79. A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?

1. "I'll make sure that, when my friend comes by, she smokes at least 6 feet away from my oxygen tank."
2. "I'll use a woolen blanket if I get chilly while I'm using my oxygen."
3. "I'll check the wires and cables on my TV to make sure they are in good working order."
4. "I'll lay my oxygen tank down on the floor when the grandchildren visit so they don't knock it over."

80. A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?

1. Bladder distention
2. Decreased blood pressure
3. Calf swelling
4. Diminished bowel sounds

81. A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?

1. Walking briskly
2. Riding a bicycle