2023 Fundamentals Retake Exam New Latest Version Updated 2024-2024 Best Study Guide w, Exams of Nursing

Download 2023 Fundamentals Retake Exam New Latest Version Updated 2024-2024 Best Study Guide w and more Exams Nursing in PDF only on Docsity! 2023 ATI Fundamentals Retake Exam New Latest Version Updated 2024-2024 Best Study Guide with All Questions and Answers A nurse is caring for a client who is receiving enteral feedings via NG tube. Which following actions should the nurse take prior to administering the formula? a. Check for gastric residual volume b. Encourage the client to breathe deeply and cough. c. Flush the tube with sterile 0.9% sodium chloride irrigation. d. Encourage the client to take sips of water. --------- Correct Answer -----------check for gastric residual volume A nurse is caring for a client immediately following the insertion of an NG tube. Which of the following should indicate to the nurse that the tube is placed incorrectly? a. The client has a dry mouth b. The client is coughing c. The client has active bowel sounds d. The client is hiccuping --------- Correct Answer -----------The client is coughing A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client's plan of care? a. Schedule the client as the first procedure --------- Correct Answer -----------Schedule the client as the first procedure Type 2 diabetes mellitus patient with corns and calluses. a. I can apply lotion to soften calluses as long as i don't put lotion between my toes ------ --- Correct Answer -----------I can apply lotion to soften calluses as long as i don't put lotion between my toes A nurse is caring for a male client who has a prescription for intermittent catheterization with a coude catheter. Which of the following images show the type of catheter the nurse should use? --------- Correct Answer -----------Bent tip catheter A nurse is preparing to bathe a client who has dementia. Which of the following actions should the nurse take? a. Give detailed instructions for the client to follow. b. Complete the bath even if the client is in distress. c. Use distractions when bathing the client. d. Allow the client to select the temperature of the bath water. --------- Correct Answer --- --------use distractions when bathing the client A nurse is preparing to insert an IV catheter for an adult client. Which of the following actions should the nurse take? A.choose the most proximal site on the extremity selected B. apply a cool compress for several minutes before insertion of the IV catheter C. place the tourniquet below the proposed insertion site D. place the extremity in a dependent position --------- Correct Answer -----------place the extremity in a dependent position A nurse is teaching a client who is about to undergo a bowel resection about advance directives. Which of the following instructions should the nurse include in the teaching? A.Your partner must be present when you sign the advance directives B. You will receive written information about advance directives prior to signing C. You are required to sign advance directives prior to surgery D. Your provider must sign the advance directives before surgery --------- Correct Answer -----------You will receive written information about advance directives prior to signing A hospice nurse is caring for a client who has end stage cancer. Which of the following interventions should the nurse include to promote the client's dignity? a. Provide guided imagery exercises to the client. b. Refrain from discussing the client's prognosis c. Suggest that the client keep a journal. d. Encourage the client to share their life story. --------- Correct Answer -----------refrain from discussing the clients prognosis A nurse is caring for a client who has a closed wound drainage system. Which of the following actions should the nurse take? a. Wear sterile gloves when emptying the container. b. Reset the container with the drainage port closed c. Connect the drain to high pressure suction. d. .Cleanse the drain plug with alcohol after emptying --------- Correct Answer ----------- Cleanse the drain plug with alcohol after emptying A nurse receives a telephone prescription from a provider for a client who is experiencing pain. Which of the following responses should the nurse make? a. " Will you please spell the name of that medication for me?" b. "Let me clarify that you want the medication given qid, correct?" c. " I will sign my name now and leave a space for you to sign your name." d. "Let me provide you with the client's medical record number for identification." --------- Correct Answer -----------Will you please spell the name of that medication for me? During change of shift report, a nurse discovers she overlooked a prescription for a type and cross-match of a client who is to have surgery the next day. Which of the following actions should the nurse take first? a. Inform the provider of the delay in obtaining the type and cross-match. b. Obtain the client's type and cross-match. c. Prepare an incident report for risk management. d. Use friction when cleansing the client's skin --------- Correct Answer -----------Assess the red area for blanching A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care. a. request a prescription for an indwelling urinary cath --------- Correct Answer ----------- request a prescription for an indwelling urinary cath A nurse is teaching a client who had an enucleation about care of an artificial eye. Which of the following information should be included in the teaching? (select all that apply) a. Store the artificial eye in the label container filled with 0.9% sodium chloride irrigation b. Remove from the artificial eye by retracting the upper eyelid c. Apply pressure just below artificial eye to break the suction d. Clear the artificial eye with hydrogen peroxide before storing e. Retract the upper and lower lids to reinsert the artificial eye --------- Correct Answer --- --------Apply pressure just below artificial eye to break the suction Clear the artificial eye with hydrogen peroxide before storing Retract the upper and lower lids to reinsert the artificial eye A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden severe abdominal pain. Which of the following actions should the nurse take first? a. Determine areas of resonance across the abdomen using a systematic approach b. Expose the client's abdomen to look for changes in appearance c. Perform abdominal palpation by pressing gently with the finger pads d. Use the diaphragm of the stethoscope to listen for bowel sounds --------- Correct Answer -----------Expose the client's abdomen to look for changes in appearance A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurses priority? a. Determine the client's reading ability b. Review the use of an artificial larynx c. With the client schedule a support session d. For the client explain the techniques of esophageal speech --------- Correct Answer --- --------For the client explain the techniques of esophageal speech A home care nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (select all that apply) a. I will use the bars when getting in and out of the bath tub b. I need to check my medications for expiration dates c. I need to have a fire escape plan with my family d. I will apply tape over frayed areas of electrical cords e. I need to set my hot water heater to 140 degrees Fahrenheit --------- Correct Answer - ----------I will use the bars when getting in and out of the bath tub I need to check my medications for expiration dates I need to have a fire escape plan with my family a nurse in an emergency department is assessing a client who reports a right lower quadrant pain, nausea and vomiting for the past 48 hours? Which of the following actions should the nurse take first? a. Offer pain medication b. Palpate the abdomen c.Auscultate bowel sounds d.Administer an antiemetic --------- Correct Answer -----------Auscultate bowel sounds A nurse is caring for a client who recently received a diagnosis of terminal cancer. Which of the following statement by the client partner indicates maladaptive coping? a. I don't know if I will be able to meet his physical needs. --------- Correct Answer -------- ---I don't know if I will be able to meet his physical needs A nurse is planning care for a client who has a stage 1 pressure ulcer on the right heel. The nurse should anticipate application of which of the following dressings? a. Dry gauge b. Transparent c. Calcium alginate d. Hydrogel --------- Correct Answer -----------b A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client's son tells the nurse "I don't know what to tell my dad if he asks how he is going to die". Which of the following is an appropriate response from the nurse? a. "lets discuss your concerns about your father," or anything along those lines that is therapeutic. --------- Correct Answer -----------lets discuss your concerns about your father," or anything along those lines that is therapeutic a nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses toes. Which of the following statements by the client indicates understanding of the teaching? a. I can apply lotion to soften the calluses as long as I don't put lotion between my toes b. I can place an oval corn pad over toes that have corns as longs as a remove the pad weekly c. I should soak my feet in warm water daily to soften corns and calluses d. I should use an over the counter liquid medication to remove corns --------- Correct Answer -----------I can apply lotion to soften the calluses as long as I don't put lotion between my toes A nurse is planning care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel? a. Changing the dressing for a client who has a stage 3 pressure injury b. Determining a client's response to a diuretic c. Comparing radial pulses for a client who is postoperative d. Providing postmortem care to a client --------- Correct Answer -----------d. Providing postmortem care to a client A nurse is conducting a health assessment for a client who takes herbal supplements. Which of the following statements by the client indicates an understanding of the use of the supplements? A. I take ginkgo biloba for a headache B. I take echinacea to control my cholesterol C. I use ginger when I get car sick D. I use garlic for my menopausal symptoms --------- Correct Answer -----------I use ginger when I get car sick A nurse is caring for a client who has influenza and isolation precautions in place. Which of the following actions should the nurse take to prevent the spread of infection? A. Wear a mask when working within 3 feet of the client B. Administer metronidazole C. Don protective eyewear before entering the room. D. Place the client in a negative airflow room. --------- Correct Answer -----------Wear a mask when working within 3 feet of the client A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG tube. Which of the following actions should the nurse take? A. Attach the restraints securely to the side rails of the client's bed. B. Apply the restraints to allow as little movement as possible C.Allow room for two fingers to fit between the clients skin and the restraints d. remove the restraints every 4 hours --------- Correct Answer -----------Allow room for two fingers to fit between the clients skin and the restraints A nurse is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the nurse plan to initiate? A. Droplet B. Airborne c. protective environment d. contact --------- Correct Answer -----------Airborne c. Perform range-of-motion exercises d. Prepare hot cocoa or tea for the client --------- Correct Answer -----------Provide a late supper A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first? a. A client who has acute abdominal pain of 4 on a scale from 0 to 10 b. A client who has pneumonia and an oxygen saturation of 96% c. A client who has new onset of dyspnea 24hr after a total hip arthroplasty • d. A client who has a urinary tract infection and low-grade fever --------- Correct Answer -----------A client who has new onset of dyspnea 24hr after a total hip arthroplasty A nurse is reviewing a client's intake and output and notes the following: 0.9% sodium chloride 600mL IV infusion, cefazolin 250 mg in dextrose 5% in water 100mL intermittent IV bolus, 200mL emesis, 40mL voided urine, and 20mL urine from straight catheterization. The nurse should record the client's net fluid intake as how many mL? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) DOSAGE CALCULATION --------- Correct Answer -----------700 mL A nurse is discussing incident reports with a group of newly licensed nurses. The nurse should include that which if the following requires the completion of an incident report? a. A client's prescribed laboratory testing was not obtained b. A client withdrew consent for a procedure c. An oncoming nurse arrived to work late d. A nurse transfused a unit of packed RBCs in 2 hr. --------- Correct Answer -----------A client's prescribed laboratory testing was not obtained A nurse is caring for a client who has a new prescription for negative-pressure therapy for a chronic wound. The nurse is unfamiliar with the procedure. Which of the following resources should the nurse consult to learn more about the intervention. a. The client's plan of care b. The nurse practice act c. The material safety data sheet d. The policy and procedure manual --------- Correct Answer -----------The policy and procedure manual A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take? a. Cover the area of percussion with a towel. b. Instruct the client to exhale quickly during vibration c. Schedule postural drainage after meals d. Perform percussion over the lower back --------- Correct Answer -----------Perform percussion over the lower back A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who has difficulty swallowing pills. Available is diphenhydramine 12.5mg/5ml oral syrup. Which of the following images indicates the correct number of mL the nurse should administer? (round answer to the nearest whole number.) DOSAGE CALCULATION --------- Correct Answer -----------8ml A nurse is admitting a client who is malnourished. The client states, "My wedding ring is loose and I'm worried I will lose it if it falls off."Which of the following is an appropriate response by the nurse? a. " I will place it in your drawer so it won't get lost." b. I can pin it to your hospital gown so you won't lose it." c. "I will hold onto it until a family member can take it home." d. I can put it in a locked storage unit for you --------- Correct Answer -----------I can put it in a locked storage unit for you A charge nurse is teaching a group of newly licensed nurses about the use of restraints. In which of the following clinical situations should the nurse apply restraints? a. If the client is pacing in the hallway b. As a part of a fall prevention program c. At the request of the client's family d. When the client poses a threat to self --------- Correct Answer -----------When the client poses a threat to self To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is the nurse manager functioning? a. Case manager b. Client educator c. Client care provider d. Client advocate --------- Correct Answer -----------Client advocate A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include? a. "Delirium does not affect a client's perception of her environment." b. "Delirium does not affect a client's sleep cycle." c. "Delirium has an abrupt onset." d. "Delirium has a slow progression." --------- Correct Answer -----------Delirium has an abrupt onset A nurse is speaking with a client who has recently received a diagnosis of a chronic illness. The client states, " The doctor must be wrong. I can't be that sick". The nurse should inform the client that their reaction is an example of which of the following expected responses to grief? a. Acceptance b. Denial c. Anger d. Depression --------- Correct Answer -----------Denial A Nurse on a medical-surgical unit is providing care for four clients. The nurse should identify which of the following situations as an ethical dilemma? a. A surgeon who removed the wrong kidney during a surgical procedure refuses to take responsibility for her actions b. A client who has Crohn's disease reports that his prescription drug plan will not pay for his medications. c. A client who has a new colostomy refuses to take instructions from the ostomy therapist because she "doesn't like him." d. the family of a client who has a terminal illness asks the provider not to tell the client the diagnosis --------- Correct Answer -----------the family of a client who has a terminal illness asks the provider not to tell the client the diagnosis A nurse is teaching a client about performing breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching? a. "I should perform my self-exam the week that my period starts" b. "I should make different patterns on each breast when I do my self-exam." c. "I should use the palm of my hand to apply pressure to each breast." d. "I should make circular motions with my fingertips under my arms." --------- Correct Answer -----------I should make circular motions with my fingertips under my arms A nurse is preparing to transfer a client who is partially weight bearing from the bed to the chair. Which of the following actions should the nurse take? a. Keep his knees straight when moving the client b. Position the chair next to the bed as a 90 degree angle c. Stand with his feet together when lifting the client d. Have the client bear weight on her stronger leg --------- Correct Answer -----------Have the client bear weight on her stronger leg A nurse is caring for a client following a laparoscopic cholecystectomy. The client has a prescription for ondansetron 4mg IV bolus every 6hr PRN for nausea and vomiting. Identify the sequence of steps the nurse should follow to administer the medication. ( Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) - Select the injection port of the IV tubing closest to the client. - Cleanse the injection port with an antiseptic swab. - Aspirate for blood return. - Inject the medication. - perform hand hygiene --------- Correct Answer -----------1-perform hand hygiene 2-select the injection port of the IV tubing closest to the client 3-cleanse the injection port with an antiseptic swab 4-aspirate for blood return 5-inject the medication a. " I will have my partner help me change position every 4 hours" b. " I will remove my antiembolic stockings while I am in bed" c." I will hold my breath when rising from a sitting position" d." I will perform ankle and knee exercises every hour." --------- Correct Answer -----------I will perform ankle and knee exercises every hour A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full liquids. Which of the following foods should the nurse offer the client as a part of a full liquid diet? a. Oatmeal b. Applesauce c. Scrambled eggs d. Plain Yogurt --------- Correct Answer -----------Plain yogurt A nurse is preparing a client who has terminal cancer for discharge. Which of the following questions should the nurse ask when assessing the client's psychosocial history? a. " What medications are you currently taking?" b." Are you experiencing any Pain?" c. " Have any of your relatives been diagnosed with cancer?" d. " What Techniques do you use to cope with stress?" --------- Correct Answer ----------- What techniques do you use to cope with stress? A nurse is performing a skin assessment on an older adult client. Which of the following findings should the nurse expect? a. Thickened outer layer of skin b. Increased skin elasticity c. Reduced sweat production d. Increased Production of oils --------- Correct Answer -----------Reduced sweat production A nurse is caring for a client who begins to cry after receiving a diagnosis of cancer. Which of the following responses should the nurse make? a. " I would get a second opinion if I were you." b " it might seem bad now, but things will get better." c " it must be difficult for you to receive this kind of news." d I think you would benefit from speaking with our chaplain." --------- Correct Answer ----- ------it must be difficult for you to receive this kind of news A nurse is preparing to obtain a health history from a client. Which of the following actions should the nurse take? a. Use the client's first name when initially meeting the client. b. Tell the client the purpose for collecting the information. c. Explain to the client the necessity of full disclosure of information. d. Avoid documenting direct quotes from the client as part of subjective data. --------- Correct Answer -----------tell the client the purpose for collecting the information A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client's son tells the nurse, " I don't know what to tell my dad if he asks how he is going to die." Which of the following is an appropriate response by the nurse? a. " Let's talk more about your dad's condition." b. "The social worker will help you answer those questions." c. " Try to help your dad enjoy this time as much as he can." d. " I think that you should discuss this with the hospice nurse." --------- Correct Answer - ----------lets talk more about your dads condition A Nurse is preparing to administer several medications to a client. Which of the following data should the nurse plan to use to confirm the client's identity? a. The client's room number b. The client's admitting diagnosis c. The name of the client's next of kind. d. The client's telephone number --------- Correct Answer -----------the clients telephone number A nurse is caring for a client who is prescribed a special diet. The client is concerned that he does not have the resources to purchase the food he needs to adhere to the diet at home. The nurse should notify which of the following members of the health care team. a. Social worker b. Occupational therapist c. Registered Dietician d. Primary care provider --------- Correct Answer -----------socail worker A nurse is teaching a newly licensed nurse about the care of a client who has a methicillin resistant Staphylococcus aureus (MRSA) infection. Which of the following statements by newly licensed nurse indicates an understanding of the teaching? a. " I will place the client in a Private room." b. " I will remove my gown before my gloves after providing client care." c. " I will wear an N95 respirator mask when caring for the client." d. " I will tell the client's visitors to wear a mask when they are within 3 feet of the client." --------- Correct Answer -----------i will place the client in a private room A nurse is planning care for a client who reports having a latex allergy. Which of the following interventions should the nurse include in the plan? a. Cover the blood pressure cuff with a stockinette. b. Wear powdered gloves when providing care to the client. c. Apply adhesive tape when securing an IV insertion site. d. Use plastic syringes for medication administration. --------- Correct Answer ----------- cover the blood pressure cuff with a stockinette A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, " I trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take? a. Describe the surgery to the client. b. Notify the Provider. c. Complete an incident report d. Provide brochures about the procedure. --------- Correct Answer -----------notify the provider A nurse is documenting client care. Which of the following abbreviations should the nurse use? a. " SQ" for subcutaneous b. "SS" for sliding scale c. "BRP" for bathroom privileges d. "OJ" for orange juice --------- Correct Answer -----------BRP for bathroom privileges A nurse is caring for a client who has wrists restraints after an episode of violent behavior. Which of the following actions should the nurse take? a. Tie the restraints to the side rail b. Secure restraints with a square knot c. Remove one restraint at a time d. Remove the restraints every 3 hours --------- Correct Answer -----------Remove one restraint at a time A nurse is admitting a client who has a clostridium difficile infection. Which of the following actions should the nurse take? Select all that apply a. Use an N95 respirator while providing client care b. wear a gown and gloves when providing client care c. assign the client to a private room with positive air flow d. wash hands with soap and water after contact with the client e. Ensure the client does not receive fresh fruits --------- Correct Answer -----------wear a gown and gloves when providing client care assign the client to a private room with positive air flow wash hands with soap and water after contact with the client A nurse is planning care for a client who has latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the clients plan of care? a. Schedule the client as the first surgical procedure of the day b. Cleanse the stoppers with primidone iodine for withdrawing medication c. Remove the stop stocks from iv tubing d.Ensure the gloves in the surgical suite are powdered gloves --------- Correct Answer --- --------Schedule the client as the first surgical procedure of the day a. Use the television to mask external noises b. Listen to soft music before lying down c. Exercise just prior to bedtime d.Keep the sleeping environment warm --------- Correct Answer -----------Listen to soft music before lying down A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend? a. Eat a light carbohydrate snack before bedtime b. Exercise 1 hour before bedtime c. Drink a cup of hot cocoa before bedtime d.Take a 30 min nap daily --------- Correct Answer -----------a A nurse is caring for a client who has a new diagnosis of fibromyalgia. The client tells the nurse that she wants to use traditional Chinese medicine for treatment instead of the medication prescribed by her provider. Which of the following is an appropriate response by the nurse? a. You should ask the provider if she recommends traditional Chinese medicine. --------- Correct Answer -----------You should ask the provider if she recommends traditional Chinese medicine A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates understanding in the teaching? a. Each element has a range 1 to 5 points b. The higher the score the higher the pressure ulcer risk c. The clients age is part of the measurement d. The scale measures six elements --------- Correct Answer -----------The scale measures six elements A nurse is planning care for client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include? a. Ensure the client is free of metal objects b. Administer 240 ml (8oz) oral contrast before the procedure c. Monitor the client for pain in the suprapubic region d. Assist the client with a bowel cleansing --------- Correct Answer -----------Ensure the client is free of metal objects A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include a. I don't know if I will be able to meet his physical needs. --------- Correct Answer -------- ---I don't know of if I will be able to meet his physical needs A nurse is planning to obtain a blood sample from a client for capillary blood glucose posttest. Which of the following should the nurse take to obtain the sample? a. The pad of the finger tip b. The lateral aspect of the finger c. The pinna of the ear d. The side of the wrist --------- Correct Answer -----------The lateral aspect of the finger A nurse is planning to discharge a client who has diabetes and a new prescription for insulin which of the following actions should the nurse plan to complete first? a. Provide the client with a contact number for a diabetes education specialist b. Make a copy of the medication record of the reconciliation for the client c. Determine whether the client can afford the insulin administration supplies d. Obtain printed information about self-administration --------- Correct Answer ----------- Determine whether the client can afford the insulin administration supplies A nurse is caring for a client who has influenza and isolation precautions in place. Which of the following actions should the nurse take to prevent the spread of infection? a. Wear a mask when working within 3 feet of the client --------- Correct Answer ----------- Wear a mask when working within 3 feet of the client A nurse is delegating client's care to the assistive personnel. Which of the following tasks should the nurse delegate to the AP? obtain input & output for the patient that was stable ADLs specimen collection I&O vital signs if stable --------- Correct Answer -----------obtain input & output for the patient that was stable ADLs specimen collection I&O vital signs if stable A nurse is teaching about home safety with. Which of the following instructions should the nurse include? a. Use electrical tape to secure extension cords next to base boards on the floor b. Replace carpet floors with tiles c. Unplug electronics by grasping the cord d. To use a fire extinguisher, aim high at the top of the flames --------- Correct Answer --- --------Use electrical tape to secure extension cords next to base boards on the floor A nurse is caring for a client who has restraints to each extremity. Which of the following assessment should the nurse perform first? a. Elimination needs b. Comfort level c. Peripheral pulses d. Skin integrity --------- Correct Answer -----------Peripheral pulses A nurse in a long-term care facility is assessing a client. Which of the following findings should the nurse recognize as an indication a fecal impaction? a. Seepage of liquid stool --------- Correct Answer -----------Seepage of liquid stool A nurse is caring for a client who has a tracheostomy which of the following actions should the nurse take? a. Cotton tip applicator to clean the inside of the cannula b. Soak the outer cannula in warm soapy tap water c. Cleanse the skin around the stoma with normal saline d. Secure the tracheostomy ties to allow one finger to fit snuggly underneath --------- Correct Answer -----------Secure the tracheostomy ties to allow one finger to fit snuggly underneath A nurse is caring for a client who has a drainage evacuator. Which of the following is an appropriate action by the nurse? a. I don't know of if I will be able to meet his physical needs. --------- Correct Answer ----- ------I don't know of if I will be able to meet his physical needs A nurse is preparing to transfer a client who is partially weight bearing from the bed to a chair. Which of the following action should the nurse a. Have the client bear weight on her stronger leg --------- Correct Answer -----------Have the client bear weight on her stronger leg A nurse in an acute care facility is preparing to transfer a client to a long-term facility. Which of the following information should be nurse include in the hand off report? a. Effectiveness of the last dose of pain medication --------- Correct Answer ----------- Effectiveness of the last dose of pain medication A nurse is providing teaching to a client who is self-administer an ophthalmic solution. Which of the following statements by the client indicates understanding of the teaching? a. I will keep my eyes closed for 5 mins after inserting drops b. I will insert the drops in the center of the eye c. I will press the inner corner of my eye after insert drops d. I will raise my eye lid up while looking down and insert drops --------- Correct Answer - ----------I will press the inner corner of my eye after insert drops A nurse in a long-term care facility is planning care for 4 clients. Which of the following client's is at greatest risk of developing a pressure ulcer? a. A client who is incontinent of urine 1 to 2 times a day b. A client who is receiving enteral tube feedings c. Client who requires assistance to transfer from the bed to a chair d. Client who is unresponsive to pain stimuli --------- Correct Answer -----------Client who is unresponsive to pain stimuli A nurse is caring for a client who has wrist restraints after an episode of violent behavior. Which of the following actions should the nurse take? a. Remove one restraint at a time --------- Correct Answer -----------Remove one restraint at a time A nurse is preparing to administer several medications via NG tube to a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take? A. Dilute each crushed medication with sterile water B. Mix the medication together in a single syringe C. Flush the NG tube with 5mL of sterile water prior to administration D. Combine the medication with the formula in the feeding bag --------- Correct Answer -----------Flush the NG tube with 5mL of sterile water prior to administration A nurse is planning care for a client who has urinary incontinence. Which of the following interventions should the nurse include in the client's plan of care? a. Toilet the client every 4hr while the client is awake b. Apply a moisture barrier in a thick layer to vulnerable skin areas c. Cleanse the skin with antibacterial soap and hot water after each incontinence episode d. Reduce the clients daily fluid intake --------- Correct Answer -----------Apply a moisture barrier in a thick layer to vulnerable skin areas A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse administers a 500 mL IV bolus. Which of the following actions should the nurse take first? A. Complete an incident report B. Obtain the client's vital signs C. Document the fluid infusion in the client's chart D. Report the incident in to the unit manager --------- Correct Answer -----------Obtain the client's vital signs A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (SATA) a. I need to check my medications for expiration dates b. I will use the grab bars when getting in and out of the bathtub c. I need to have a fire escape plan with my family --------- Correct Answer -----------I need to check my medications for expiration dates - I will use the grab bars when getting in and out of the bathtub - I need to have a fire escape plan with my family A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, I trust my doctor, but I don't understand what is meant by resecting my intestine. Which of the following actions should the nurse take? a. notify the provider --------- Correct Answer -----------notify the provider A nurse is discussing the stages of general adaptation syndrome with a newly licensed nurse. The nurse should identify that which of the following manifestations occurs during the alarm reaction stage? A. Dilated pupils B. Physical exhaustion C. Bradycardia D. Depression --------- Correct Answer -----------Dilated pupils A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first? A. Unplug the pump B. obtain a replacement pump C. Notify the biomedical department to fix the pump D. Label the pump with a defective equipment sticker --------- Correct Answer ----------- Unplug the pump A nurse is caring for a client who is receiving a warm, moist compress to relieve lower back pain. Which of the following findings should indicate to the nurse that the compress has been effective? A. The client's skin on the lower back is intact without redness B. The client's laughing at a television show C. The client states that he is able to concentrate while eating D. The clients's vital signs are within the expected reference range --------- Correct Answer -----------The client states that he is able to concentrate while eating A nurse is preparing a sterile field to assist with suturing a clients laceration. Which of the following actions should the nurse plan to take? A. Pour the sterile solution with the bottle 20cm(8in) above the sterile bowl B. Hold the bottle of sterile solution so that the label is facing the palm of the hand C. Place the lid of the sterile solution bottle face down on the sterile drape D. Apply sterile gloves before opening the bottle of sterile solution --------- Correct Answer -----------Hold the bottle of sterile solution so that the label is facing the palm of the hand A nurse is caring for a client who is scheduled to have his alanine amino transferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse? A. This test will determine if your heart is performing properly B. This test will indicate if you are at risk for developing blood clots C. This test is used to check how your kidneys are working D. This test will provide information about the function of your liver --------- Correct Answer -----------This test will provide information about the function of your liver A nurse receives a new prescription over the telephone from a client's provider. Which of the following actions should the nurse take first? A. Ensure that the provider signs the prescription B. Write down the complete prescription. C. Read back the prescription to the Dr. d. Document the prescription as a telephone prescription in the medical record. --------- Correct Answer -----------Write it down, then read back the prescription to the Dr. A nurse is caring for a client who is on bed rest following abdominal surgery. Which of the following findings indicates the need to increase the frequency of position changes? A. Petechiae on the client's right anterior thigh B. Flat rash on the client's ankle C. Non-palpable macule on the client's left shoulder D. Non-blanching darkened area over the client's trochanter --------- Correct Answer ----- ------Non-blanching darkened area over the client's trochanter A nurse is providing teaching to a client who has a newly prescribed hearing aid. Which of the following statements by the client indicates an understanding of the teaching? A. After insert the hearing aid, i will turn it up as high as it will go B. I should leave the battery in the hearing aid when i take it out to sleep C. I will need to get a new hearing aide every year D. I should gradually increase the time that i wear the hearing aid --------- Correct Answer -----------I should gradually increase the time that i wear the hearing aid A nurse is preparing to collect a specimen from a client. Which of the following actions should the nurse take? a. Collect the sputum specimen in the morning --------- Correct Answer -----------Collect the sputum specimen in the morning A nurse is assessing a client who has diabetes mellitus prior to performing a blood glucose test. Which of the following findings should indicate to the nurse that the client has hyperglycemia? A. Thirst B. Confusion C. Cool skin D. Shakiness --------- Correct Answer -----------thirst A nurse is assessing an older adult client. Which of the following findings should the nurse expect? a. Decreased sense of balance --------- Correct Answer -----------Decreased sense of balance A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take? A. Report any discrepancy in the count total of the controlled substance after administration B. Place the assisted portion of the controlled substance in the sharps container C. Verify the count total of the controlled substance after removing the amount needed C. You need to realize that you have valuable skills to offer others D. Tell me about some hobbies you enjoy --------- Correct Answer -----------Tell me about some hobbies you enjoy A nurse is caring for a client who has an NG tube and has repeatedly pulled it out. The nurse should identify that which of the following findings indicates a need for restraints? A. The client's family is unable to stay with the client B. The client becomes confused at night C. The client gets out of bed to use the bathroom frequently D. The client is assigned a room near the nurses station --------- Correct Answer ---------- -The client is assigned a room near the nurses station A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrate correct documentation? A. No changes noted to the wound from previous nursing notes B. Client pre-medicated with MSO4 sunq prior to dressing change C. The wound seems clean and does not appear to be infected D. New dressing applied as prescribed, no drainage on old dressing --------- Correct Answer -----------Client pre-medicated with MSO4 sunq prior to dressing change a nurse is preparing to reposition a client who has a lower back injury. Which of the following actions should the nurse take? A. Place the clients arms at their sides B. Flex the client's knees C. Place the client at the side of the bed nearest the direction they will be turned D. Roll the client as one unit in a smooth continuous motion. --------- Correct Answer ----- ------Roll the client as one unit in a smooth continuous motion A nurse is caring for a client who has TB. which of the following precautions should the nurse plan to implement when working with the client? a. airborne --------- Correct Answer -----------airborne A nurse is implementing seizure precautions for a client who has a seizure disorder. Which of the following equipment should the nurse place at the client's bedside? --------- Correct Answer -----------Oral suction equipment, oral airway, and oxygen A nurse is providing teaching to the family of a client who is at the end stage of life. Which of the following client manifestations should the nurse instruct the family to expect? A. Increased periods of wakefulness B. Altered breathing patterns C. Increased salivation D. Warm and dry extremities --------- Correct Answer -----------Altered breathing patterns A nurse is preparing to obtain informed consent from a client who speaks a different language than the nurse and is scheduled for surgery. Which of the following actions should the nurse take? a. recommend an interpreter who is the same gender as the client. --------- Correct Answer -----------recommend an interpreter who is the same gender as the client A nurse is caring for a client who is receiving continuous enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take? a. Aspirate residual volume every 4 hr --------- Correct Answer -----------Aspirate residual volume every 4 hr A nurse is preparing to insert an IV catheter for a client following a right mastectomy. Which of the following veins should the nurse select when initiating IV therapy? a. The cephalic vein in the left distal forearm --------- Correct Answer -----------The cephalic vein in the left distal forearm A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full liquids. Which of the following foods should the nurse offer the client as a part of a full liquid diet? a. Plain yogurt --------- Correct Answer -----------plain yogurt A nurse is caring for a client following a bilateral mastectomy. The client is often tearful and avoids looking at her dressings. Which of the following actions should the nurse take first? A. Provide the client with a mirror to look at her mastectomy incisions B. refer the client to a breast cancer support group C. identify the impact of the mastectomy on the client's body image D. encourage the client to assist with her dressing change --------- Correct Answer ------- ----identify the impact of the mastectomy on the client's body image A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Place them in order of performance. Use all steps) - 1. Provide adequate lighting to inspect the abdomen - 2. Listen to the abdomen arteries using the bell of a stethoscope - 3. Percuss all four quadrants of the abdomen to measure sound quality - 4 Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm ( 1 to 3 in) into the abdomen - 5. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen --------- Correct Answer -----------3-Percuss all four quadrants of the abdomen to measure sound quality 1-Provide adequate lighting to inspect the abdomen 4-Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm ( 1 to 3 in) into the abdomen 2-Listen to the abdomen arteries using the bell of a stethoscope 5-Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen a nurse working on a medical surgical unit is making client assignments for an upcoming shift. Which of the following tasks should the nurse assign to an assistive personnel? a. assisting with ambulation for a client who has a pulmonary infection. --------- Correct Answer -----------assisting with ambulation for a client who has a pulmonary infection A nurse is mixing a short acting insulin and an intermediate insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should the nurse take first? a. Inject air into the short acting insulin vial. --------- Correct Answer -----------Inject air into the short acting insulin vial A nurse is caring for a client who has a new diagnosis of terminal cancer. Which of the following interventions is the priority? a. Develop a list of goals --------- Correct Answer -----------Develop a list of goals What do nurses use when preparing change-of-shift report? --------- Correct Answer ----- ------Standard handoff communication tools, such as Introduction, Situation, Background, Assessment, Recommendation (ISBAR) to facilitate transfers and discharges. When should discharge planning begin? --------- Correct Answer -----------On admission with every patient. Discharge documentation should include --------- Correct Answer -----------Type of discharge, date & time of discharge, who went with the client & transportation, where the client went, summary of clients current condition at discharge, description of any unresolved difficulties and disposition of valuables, medications brought from home & prescriptions. Documentation & abbreviations and symbols --------- Correct Answer -----------Being accurate & concise is an important element of documentation. Only abbreviations & symbols approved by The Joint Commission and the facility are acceptable. A nurse is discussing the HIPPA privacy rule with nurses during new employee orientation. Which of the following information should the nurse include? --------- Correct Answer -----------Family members should provide a code prior to receiving client health information Communication of a client can occur at the nurse's station A client can request a hard copy of their records Nurses may photocopy a client's medical record for transfer to another facility. A nurse is caring for a family experiencing a crisis. What approach should the nurse use when working with a family using an open structure for coping with crisis? --------- Correct Answer -----------Convening a family meeting. What should you do before administering any medications? --------- Correct Answer ------ -----Obtain a complete medication and allergy history. What does diphenhydramine treat in relation to allergic reactions? --------- Correct Answer -----------Mild rashes and hives What should you do after hand-washing with ostomy skin care? --------- Correct Answer -----------Apply gloves & inspect the stoma, use mild soap and water to cleanse, then dry it gently and completely. What are the steps to take when administering a large-volume enema? --------- Correct Answer -----------1. Position the client on the left side with right leg flexed forward. Put on gloves. Lubricate rectal tube or nozzle. (Also, warm to enema solution). 2. Slowly insert rectal tube (3 to 4 inches for an adult). Raise bag above anus, 18 inches (if client reports abd cramping, lower the enema fluid container) . Ask the client to retain the solution for prescribed amount of time, or until client is no longer able to retain it. 3. Discard bag. Assist the client to the appropriate position to defecate. Document results and the client's tolerance of the procedure. What should the nurse do to help prevent plantar flexion? --------- Correct Answer -------- ---Encourage active or provide passive ROM two or three times/day. Instruct clients to perform ROM while bathing, eating, grooming, and dressing. What should be done for a client to promote a proper sleep-wake cycle? --------- Correct Answer -----------Cluster care. ` Who is a fracture pan used for? --------- Correct Answer -----------Supine client and clients in body casts or leg casts. What should the nurse do for clients using a fracture pain? --------- Correct Answer ------- ----Raise the head of the bed to 30 degrees. If the client cannot lift his hips to get the bedpan under him, roll him onto one side, position the bedpan over his buttocks, and roll the client back onto the bedpan. Signs/symptoms of extracellular fluid volume deficit --------- Correct Answer -----------1. Hypothermia, tachycardia, thready pulse, orthostatic hypotension, decreased central venus pressure, tachypnea, and hypoxia. 2. Dizziness, syncope, confusion, weakness and fatigue. GI findings related to extracellular fluid volume deficit --------- Correct Answer ----------- Dry mucous membranes, dry furrowed tongue, nausea, vomiting, anorexia, and acute weight loss. The nurse should recognize which labs as a sign of dehydration? --------- Correct Answer ------------Hct 55% -Serum sodium 150 mEq/L -Urine specific gravity 1.035 What is a heart murmur? --------- Correct Answer -----------Audible when blood volume in the heart increased or its flow is impeded or altered. Using the bell of the stethoscope to hear the characteristic blowing or swishing sound. What are risk factors for pressure ulcers? --------- Correct Answer ------------Aging skin, immobility, incontinence, excessive moisture, skin friction, shearing. -Vascular disorders, obesity, inadequate nutrition, hydration, anemia, fever, dehydration. -Impaired circulation, edema, sensory deficits, impaired cognitive functioning, chronic diseases, sedation that impairs spontaneous repositioning. What should the nurse do if she were to find a surgical wound separated with viscera protruding? --------- Correct Answer -----------Cover the area with saline-soaked sterile dressing and position the client supine with his hips & knees bent. What is the expected reference range for ALT? --------- Correct Answer -----------4 to 36 units/L. Elevation occurs with hepatitis or cirrhosis. What are indications for ALT? --------- Correct Answer -----------Suspected liver, pancreatic, or billiary tract disorder. When do you use surgical asepsis for suctioning? --------- Correct Answer ----------- Surgical asepsis should be used for nasotracheal suctioning, but medical asepsis for the mouth. How long should the nurse suction for? --------- Correct Answer -----------No longer than 10 to 15 seconds to avoid hypoxemia and the vagal response. Limit total suctioning to 5 minutes. What position will promote draining of both lobes of the lungs in general? --------- Correct Answer -----------High Fowler's What position will promote draining of apical segments of both lobes? --------- Correct Answer -----------Sitting on the side of the bed What position will promote draining of both lower lobes of the lungs, anterior segments? --------- Correct Answer -----------Supine in Trendelenburg What position will promote draining of both lower lobes, posterior segments? --------- Correct Answer -----------Prone in Trendelenburg What should there nurse do when caring for a client who has a C. Diff infection? --------- Correct Answer -----------Implement contact precautions including gloves & a gown. Ensure the client has a private room & maintain a clean environment. Implement infection control measures including but not limited to hand washing, performing wound care measures, and encourage adequate rest and nutrition. A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile infection. Which of the following information should the nurse include in the teaching? a. assign the client to a room with a negative airflow system b. use alcohol-based hand sanitizer when leaving the client's room c. clean contaminated surfaces in the client's room with a phenol solution d. have family members wear a gown and gloves when visiting ---------- Correct Answer ---------- d. have family members wear a gown and gloves when visiting A client who has a Clostridium difficile infection requires a private room, but a negative airflow system is not necessary. Use alcohol-based hand sanitizer when leaving the client's room. The nurse should use soap and water for hand hygiene because alcohol-based hand sanitizer does not kill Clostridium difficile spores. Clean contaminated surfaces in the client's room with a phenol solution.The nurse should use a phenol solution to clean surfaces contaminated with bacteria and fungi. However, phenol does not kill Clostridium difficile spores. Chlorine bleach is an example of a disinfectant that kills spores. Have family members wear a gown and gloves when visiting.Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Staff must also wear gowns and gloves. A nurse is giving change of shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of info is the priority for the nurse to provide? a. admitting diagnosis b. breath sounds c. body temperature d. diagnostic test results ---------- Correct Answer ---------- b. breath sounds When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds. Knowing the client's admitting diagnosis is essential for planning care and following critical pathways; however, other information is the nurse's priority to provide. Body temperature Knowing the client's current body temperature is essential for planning care and following critical pathways; however, other information is the nurse's priority to provide. function of the device; therefore, the nurse should instruct the client to routinely check the condition of the cord.Keep the unit at least 1.2 m (4 feet) away from a gas stove is incorrect. Safe use of home oxygen equipment includes keeping the unit at least 3.05 m (10 feet) away from open flames, such as from a fireplace or a gas stove, and at least 2.4 m (8 feet) away from other heat sources.Consider purchasing a generator for power backup is correct. Loss of electricity prevents the oxygen concentrator from functioning and could deprive the client of necessary oxygen. The nurse should also instruct the family to have the client placed on their municipality's priority list for restoring power after an outage occurs.Observe for signs of hypoxia is correct. The nurse should instruct the family to observe for A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? a. 2 cups of soup b. 1 quart of water c. 8 oz of ice chips d. 6 oz of tea ---------- Correct Answer ---------- c. 8 oz of ice chips 2 cups of soup. The nurse should understand that 2 cups of soup are equivalent to 480 mL of fluid. 1 quart of water. The nurse should understand that 1 quart of water is equivalent to 960 to 1,000 mL of fluid. 8 oz of ice chips. The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid. 6 oz of tea. The nurse should understand that 6 oz of tea is equal to 180 mL of fluid. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (select all that apply) a. place the client in a room with negative airflow pressure b. wear gloves when assisting the client with oral care c. limit each visitor to 2 hr increments d. wear a surgical mask when providing client care e. use antimicrobial sanitizer for hand hygiene ---------- Correct Answer ---------- a,b,e 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? a. ask the client to consider a direct donation b. withhold the blood transfusion c. request a consultation with the ethics committee d. ask the client's family to intervene ---------- Correct Answer ---------- b. withhold the blood transfusion A direct donation still requires a blood transfusion and does not respect the client's wishes. Withhold the blood transfusion. The principle of autonomy ensures that a client who is competent has the right to refuse treatment. Request a consultation with the ethics committee.A client who is competent has the right to refuse treatment, regardless of the consequences. There is no need to involve the ethics committee. Ask the client's family to intervene.Clients who are competent have the right to consent to or refuse treatment. A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? a. "when descending the stairs, I will first shift my weight to my right leg" b. "I should place my crutches 12 inches in front and to the side of each foot" c. "As I sit down, I will hold one crutch in each hand" d. "I will make sure the shoulder rests are snug against my armpits" ---------- Correct Answer ---------- a. "when descending the stairs, I will first shift my weight to my right leg" To descend stairs, the client should first shift his body weight to his right, unaffected leg. "I should place my crutches 12 inches in front and to the side of each foot."The client should place his crutches 15 cm (6 in) in front and to the side of each foot. "As I sit down, I will hold one crutch in each hand."Just before sitting down, the client should hold both crutches by their hand bars in one hand. "I will make sure the shoulder rests are snug against my armpits." To avoid injury to the underlying nerves, the shoulder rests should be at least 2.5 to 5 cm (1 to 2 in) below the axillae. 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? a. .3 mg b. 0.3 mg c. 0.30 mg d. 3/10 mg ---------- Correct Answer ---------- b. 0.3 mg A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation? a. urine has an unusual odor b. urine specific gravity is 1.035 c. bladder scan shows 525 mL of urine d. urine is positive for ketones ---------- Correct Answer ---------- c. bladder scan shows 525 mL of urine Urine with an unusual odor can be a sign of infection; however, it is not an indication for irrigation. Urine specific gravity is 1.035.A urine specific gravity of 1.035 indicates that the urine is concentrated; however, it is not an indication for irrigation. Bladder scan shows 525 mL of urine. A client who has an indwelling urinary catheter should have a continuous urine flow without an accumulation of urine in the bladder; therefore, the nurse should irrigate the catheter to resolve any existing blockage. Urine is positive for ketones.Urine that is positive for ketones is a sign of diabetes mellitus with poor glucose control; however, it is not an indication for irrigation. A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene? a. erythema on pressure points b. lower-extremity pulse strength of 2+ c. fluid intake of 3,000 mL per day d. one bowel movement every other day ---------- Correct Answer ---------- a. erythema on pressure points Erythema on pressure pointsErythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from breakdown. Lower-extremity pulse strength of 2+A lower-extremity pulse strength of 2+ is an expected finding. Fluid intake of 3,000 mL per day. Clients should receive 2,000 to 3,000 mL of fluid per day. One bowel movement every other dayBowel movements less frequent than three times per week can indicate constipation and the need for intervention. However, a bowel movement every other day does not require intervention. 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? a. rinse the feeding bag with water between feedings b. tell the client to keep the head of the bed elevated at least 30 degrees c. make sure the enteral formula is at room temperature d. wipe the top of the formula can with alcohol ---------- Correct Answer ---------- b. tell the client to keep the head of the bed elevated at least 30 degrees The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula into the esophagus. The nurse should rinse the feeding bag with warm water to reduce the risk of bacterial growth; however, there is another action that is the priority. The nurse should make sure the enteral formula is at room temperature to prevent the cramping and discomfort that can result from instilling cold formula; however, there is another action that is the priority. The nurse should wipe the top of the formula can with alcohol to remove or disinfect any dirt or micro-organisms that could contaminate the formula; however, there is another action that is the priority. "You should receive a tetanus booster every 5 years."Older adults should receive a tetanus booster every 10 years. "You should receive a shingles vaccine when you are 70 years old."The nurse should instruct older adult clients to receive a shingles vaccine when they are 60 years old. "You should receive a pneumococcal vaccine when you are 65 years old." The nurse should instruct older adult clients to receive one of the two pneumococcal vaccines when they are 65 years old. The vaccines can be given to clients who are 19 years of age and older and have certain conditions, such as chronic heart, lung, or liver disease, diabetes mellitus, and alcohol disease, or to those who smoke cigarettes. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? a. neck vein distention b. urine specific gravity 1.010 c. rapid heart rate d. blood pressure 144/82 mmHg ---------- Correct Answer ---------- c. rapid heart rate Neck vein distension is a clinical manifestation of fluid volume excess. Urine specific gravity 1.010T ypically, a client's urine specific gravity is greater than 1.030 in the presence of fluid volume deficit. The expected reference range for urine specific gravity is 1.005 to 1.030. Rapid heart rate. Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days. Blood pressure 144/82 mm HgHypotension is an expected finding for a client who has fluid volume deficit. A nurse is caring for a client who is receiving pain medication through a patient- controlled analgesia(PCA) pump. Which of the following actions should the nurse take? a. instruct the family to refrain from pushing the button for the client while she is asleep b. inform the client that because she is on PCA, vital signs will be taken every 8 hours c. teach the client to avoid pushing the button until pain is above a 7 on a scale of 0-10 d. increase the basal rate and shorten the lock-out inter ---------- Correct Answer ---------- a. instruct the family to refrain from pushing the button for the client while she is asleep The nurse should instruct family members not to activate the button for the client while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain. Inform the client that because she is on PCA, vital signs will be taken every 8 hr.The nurse should monitor a client who is using a PCA pump every 1 to 2 hr during the first 12 hr. The client is at risk for respiratory depression as a result of opioid medication administration. Teach the client to avoid pushing the button until pain is above a 7 on a scale of 0 to 10.The nurse should instruct the client to activate the PCA pump when she needs it. It is inappropriate for the client to wait until pain escalates to any particular level of intensity before using the pump. Increase the basal rate and shorten the lock-out interval time if t A community health nurse is checking blood pressure for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension? a. a client who is 52 years old b. a client who smokes one pack of cigarettes each day c. a client who walks for 30 minutes every day d. a client who drinks one glass of wine 3 times per week ---------- Correct Answer -------- -- b. a client who smokes one pack of cigarettes each day A client who is 52 years oldClients who are 60 years of age or older are at an increased risk for hypertension. A client who smokes one pack of cigarettes each day. A client who smokes one pack of cigarettes each day is at an increased risk for hypertension. A client who walks for 30 min every dayRegular physical exercise lowers the risk for developing hypertension. A client who drinks one glass of wine three times per weekAlthough heavy alcohol consumption can increase the risk for hypertension, drinking one glass of wine three times per week is not considered heavy consumption. 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 routine screening. What does that involve?" Which of the following responses should the nurse make? a. "I'll get a blood sample from you and send it for a screening test." b. "beginning at age 60, you should have a colonoscopy" c. " you should have a fecal occult blood test every year" d. "the recommendation is to have a sigmoidoscopy every ---------- Correct Answer ------- --- c. " you should have a fecal occult blood test every year" Blood tests do not detect colorectal cancer. One option for screening is a double- contrast barium enema every 5 years. "Beginning at age 60, you should have a colonoscopy."Colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a colonoscopy every 10 years. "You should have a fecal occult blood test every year." Colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a fecal occult blood test annually. "The recommendation is to have a sigmoidoscopy every 10 years."One option for screening is a flexible sigmoidoscopy every 5 years. 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? a. insert an implanted port b. close a laceration with sutures c. place an endotracheal tube d. initiate an enteral feeding through a gastrostomy tube ---------- Correct Answer --------- - d. initiate an enteral feeding through a gastrostomy tube Implanted ports and other central venous access devices require insertion by a physician, a surgeon, or an advanced practice nurse. Close a laceration with sutures.Surgeons and other physicians close wounds with sutures. Place an endotracheal tube. Physicians and clinicians with special training insert endotracheal tubes. Initiate an enteral feeding through a gastrostomy tube.It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes. A nurse is caring for a client who has recently started using a behind the ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device? a. "this type of hearing aid does not allow for fine tuning of volume" b. "I shouldn't have trouble keeping the hearing aid in place during exercise c. "I expect to hear a whistling sound when I first insert the hearing aid" d. "I will be sure to remove my hearing a ---------- Correct Answer ---------- d. "I will be sure to remove my hearing aid before taking a shower" A behind-the-ear hearing aid allows for fine tuning of the volume of the device. It is useful for clients who have mild to severe hearing loss. "I shouldn't have trouble keeping the hearing aid in place during exercise."Physical activity can easily dislodge this type of hearing aid. "I expect to hear a whistling sound when I first insert the hearing aid."Whistling during insertion can be a sign that the hearing aid does not fit properly. A buildup of cerumen or fluid in the ear can also cause a whistling sound. "I will be sure to remove my hearing aid before taking a shower." Clients should remove any hearing devices before showering because exposure to water can damage them. A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? a. place a pillow under the client's knees b. position a trochanter toll under each of the client's hips c. advise the client to wear rubber-soled slippers d. apply an ankle-foot orthotic device to the client's feet ---------- Correct Answer ---------- d. apply an ankle-foot orthotic device to the client's feet The nurse should place a pillow under the client's lower legs to prevent pressure on the heels. Position a trochanter roll under each of the client's hips.The nurse should place a trochanter roll under the client's buttocks and alongside the hips to prevent external rotation of the hips while the client is supine. d. engaging in high-impact aerobics ---------- Correct Answer ---------- a. walking briskly Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy. Riding a bicycleCycling has no weight-bearing advantages; therefore, it does not help prevent osteoporosis. Performing isometric exercises Isometric exercises have no weight-bearing advantages; therefore, they do not help prevent osteoporosis. Engaging in high-impact aerobics High-impact aerobics can injure bones that have lost density; therefore, the nurse should not recommend these exercises for a client who is at risk for developing osteoporosis. A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make? a. "we can talk about advance directives, and I can also give you some brochures about them" b. "you should set up a time to talk with your provider about that" c. "let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better" d. "why do you ---------- Correct Answer ---------- a. "we can talk about advance directives, and I can also give you some brochures about them" "We can talk about advance directives, and I can also give you some brochures about them." With this statement, the nurse offers to provide the information the client needs in a direct and simple way. "You should set up a time to talk with your provider about that."The nurse is passing the responsibility of discussing this topic with the client to the provider, which dismisses the client's concerns. "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better."The nurse is rejecting the client's needs by postponing a discussion about what is important to the client. "Why do you want to discuss this without your partner here to plan this with you?"Clients might interpret "why" questions as accusatory, and they can provoke feelings of mistrust and resentment. A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? a. a client who has a history of physical abuse b. a client who has a permanent pacemaker c. a client who has ulcerative colitis d. a client who has asthma ---------- Correct Answer ---------- d. a client who has asthma Mental health issues that affect sensitivity to touch, such as previous physical abuse, are a contraindication for therapeutic touch, not aromatherapy. A client who has a permanent pacemakerHaving an implanted electrical device is a contraindication for magnet therapy, not aromatherapy. A client who has ulcerative colitisUlcerative colitis is a contraindication for colonic detoxification, not aromatherapy. A client who has asthma. Some essential oils can cause bronchospasm; therefore, the nurse should consult the client's provider before using this therapy for a client who has asthma. A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use? a."I can take echinacea to improve my immune system" b. "I can take feverfew to reduce my level of anxiety" c. "I can take ginger to improve my memory" d. "I can take ginkgo biloba to relieve nausea" ---------- Correct Answer ---------- a."I can take echinacea to improve my immune system" Echinacea is taken to promote immunity and reduce the risk of infection. "I can take feverfew to reduce my level of anxiety."Feverfew is taken to promote wound healing and decrease inflammation associated with arthritis. Valerian and chamomile can be taken to reduce anxiety. "I can take ginger to improve my memory."Ginger is taken to relieve nausea and vomiting and aid in digestion. Ginkgo biloba can be taken to improve memory and reduce stress. "I can take ginkgo biloba to relieve nausea."Ginkgo biloba is taken to improve memory and reduce stress. Ginger can be taken to relieve nausea and vomiting and aid in digestion. 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? a. gently shake the container of medication prior to administration b. transfer the medication to a medicine cup c. place the client in the semi-Fowler's position prior to medication administration d. verify the dosage by measuring the liquid before administering it ---------- Correct Answer ---------- a. gently shake the container of medication prior to administration The nurse should gently shake the liquid medication to ensure that the medication is mixed. Transfer the medication to a medicine cup.The nurse should not transfer prepackaged liquid medication to a medicine cup to reduce the risk of altering the premeasured dose. Place the client in a semi-Fowler's position prior to medication administration.The nurse should place the client in high-Fowler's position when administering an oral liquid medication to reduce the risk of aspiration. Verify the dosage by measuring the liquid before administering it.The nurse should not transfer prepackaged liquid medication to a measuring device to reduce the risk of altering the premeasured dose. A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as psychomotor approach to learning? a. role play b. group discussions c. question-answer meetings d. practice sessions ---------- Correct Answer ---------- d. practice sessions Role play is a technique that promotes cognitive and affective learning. Group discussionsGroup discussions assist adolescents with cognitive and affective learning. Question-answer meetingsQuestion-answer meetings promote cognitive learning. Practice sessionsPractice sessions require psychomotor skills when learning. 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? a. use resuscitation bag with 80% oxygen prior to the procedure b. select a suction catheter that is half the size of the lumen c. place the end of the suction catheter in water soluble lubricant d. adjust the wall suction apparatus to pressure of 170 mmHg ---------- Correct Answer -- -------- b. select a suction catheter that is half the size of the lumen The nurse should preoxygenate the client with 100% oxygen before suctioning to prevent hypoxemia. Select a suction catheter that is half the size of the lumen. The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa. Place the end of the suction catheter in water-soluble lubricant.The nurse should lubricate the end of the suction catheter with sterile water or 0.9% sodium chloride irrigation solution to decrease trauma to the mucosa. Adjust the wall suction apparatus to a pressure of 170 mm Hg.The nurse should adjust the suction pressure to approximately 120 mm Hg and no higher than 150 mm Hg to prevent hypoxemia and trauma to the mucosa. A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include? a. client flow sheet b. acuity ranges c. current medications d. incident reports ---------- Correct Answer ---------- c. current medications this response, the nurse is asking for an explanation instead of acknowledging the client's feelings. "People in middle adulthood often find satisfaction in nurturing and guiding young people." According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding? a. assign a staff member to feed the client b. provide small handled utensils for the client c. thicken liquids on the client's tray d. arrange food in a consistent pattern on the client's plate ---------- Correct Answer ------ ---- d. arrange food in a consistent pattern on the client's plate The nurse should allow the client to feed themself when possible. Assigning a staff member to feed a client who has vision loss impairs autonomy and can impede the client's ability to perform self-care. Provide small-handled utensils for the client.Large-handled, adaptive utensils are easier for the client to grip and allow for greater independence during meals for clients who have vision loss. Thicken liquids on the client's tray.Clients who have dysphagia, not vision loss, require thickening of liquids to facilitate swallowing without choking. Arrange food in a consistent pattern on the client's plate. Consistency in preparing the client's plate helps to facilitate self-feeding for clients who have vision loss. Staff can describe the location of the food on the plate by using a clock pattern, allowing the client to have greater independence during meals. A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? a. describe the procedure to the client b. witness the client's signature on the consent form c. inform the client of alternatives to the procedure d. tell the client which team members will assist with the procedure ---------- Correct Answer ---------- b. witness the client's signature on the consent form The provider who is performing the procedure is responsible for describing the procedure to the client. Witness the client's signature on the consent form. The nurse is responsible for witnessing the client sign the consent form. The nurse should confirm that the client appears competent to give consent and that the client understands the procedure. Inform the client of alternatives to the procedure.The provider who is performing the procedure is responsible for informing the client about potential alternatives. Tell the client which team members will assist with the procedure.The provider is responsible for informing the client of the names and roles of the team members who will assist in performing the procedure. A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client? a. gown b. N95 respirator c. shoe covers d. surgical cap ---------- Correct Answer ---------- b. N95 respirator A nurse is providing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, the nurse hears the following sound. This sound indicates which of the following. (click on the audio button to listen to the clip) a. Narrowed arterial lumen b. Distended jugular veins c. Impaired ventricular contraction d. Asynchronous closure of the aortic and pulmonic valves ---------- Correct Answer ------ ---- a. Narrowed arterial lumen Blowing sounds resulting from blood flowing through occluded or narrowed arteries are known as a bruit. Distended jugular veins Blood flowing through distended jugular veins does not produce a sound. Impaired ventricular contractionImpaired ventricular function produces extra heart sounds, either S3 or S4. These sounds are best heard over the aortic area of the heart. Asynchronous closure of the aortic and pulmonic valvesAsynchronous closure of the aortic and pulmonic valves is known as "splitting" of S2, so the nurse should hear two "dub" sounds during auscultation. This sound is best heard over the aortic area of the heart. A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration? a. purulent exudate b. warmth c. skin blanching d. bleeding ---------- Correct Answer ---------- c. skin blanching Purulent Exudate indicates infection, not infiltration. Warmth. Warmth indicates phlebitis, not infiltration. Skin blanching. Skin blanching, edema, and coolness at the IV site indicate infiltration. Bleeding. Bleeding can have a mechanical cause or can occur as the result of anticoagulation. It is not a sign of infiltration. A client who is non ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next? a. activate the emergency fire alarm b. extinguish the fire c. evacuate the client d. confine the fore ---------- Correct Answer ---------- c. evacuate the client Activate the emergency fire alarm.According to the RACE mnemonic, the second action in response to a fire is to activate the alarm. Extinguish the fire.According to the RACE mnemonic, the fourth action in response to a fire is to attempt to extinguish the fire. Evacuate the client. According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area. Confine the fire.According to the RACE mnemonic, the third action in response to a fire is to contain the fire by closing all the doors and windows in the area. The nurse should also turn off oxygen and electrical equipment in the area of the fire. A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next? a. rock the client up to a standing position b. pivot on the foot that is the farthest from the chair c. assess the client for orthostatic hypotension d. apply gait belt to the client ---------- Correct Answer ---------- c. assess the client for orthostatic hypotension The nurse should rock the client up to a standing position to generate momentum and reduce the nurse's workload in lifting the client up off the bed; however, there is another action that is the priority. Pivot on the foot that is the farthest from the chair.The nurse should pivot on the foot that is the farthest from the chair to give the client room to move; however, there is another action that is the priority. The nurse can also use their other knee to give the client's weak leg some support as the client moves to the chair. Assess the client for orthostatic hypotension.The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to 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? a. "I'm having mild pain" b. "the pain is like a dull ache in my stomach" c. "I notice that the pain gets worse after I eat" following the ethical principle of autonomy and is recognizing the client's right to refuse treatment. A client who has a do-not-resuscitate (DNR) order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family.A DNR order requires a request on the part of the client or the client's designated power of attorney for health care decisions. Enforcing a client's DNR order supports the ethical principle of autonomy by following the client's end-of-life wishes. A client who is about to undergo a painful procedure receives pain medicati 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? a. place the client in high-Fowler's position. b. increase the client's intake of carbohydrates c. massage reddened areas with unscented lotion d. have the client use a trapeze bar when changing position ---------- Correct Answer ---- ------ d. have the client use a trapeze bar when changing position Place the client in high-Fowler's position.High-Fowler's position places additional pressure on the sacrum and the heels, increasing the risk for skin breakdown. Increase the client's intake of carbohydrates.Increased protein intake helps with tissue repair. However, for prevention, the client should consume a balanced diet with adequate fluid intake. There is no need to increase carbohydrate intake. Massage reddened areas with unscented lotion. Massage can cause capillary breakdown in subcutaneous tissues. Have the client use a trapeze bar when changing position.By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-injury development. A nurse is preparing to obtain a lower extremity blood pressure and no longer palpates the popliteal pulse after 92 mmHg. Which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure? ---------- Correct Answer ---------- The nurse should inflate the blood pressure cuff 30 mm Hg beyond the point at which the nurse was last able to palpate the pulse. This image does not show the correct pressure reading. A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following action should the nurse plan to take? a. dissolve each medication in 5 mL of sterile water b. draw up medications together in the syringe c. push the syringe plunger gently when feeling resistance d. flush the tube with 15 mL of sterile water ---------- Correct Answer ---------- d. flush the tube with 15 mL of sterile water The caregiver is the client's financial power of attorney.Having a caregiver who is the client's financial power of attorney allows the caregiver to perform necessary financial transactions on the client's behalf. This it is not an indication of elder abuse. The client is in a wheelchair with the wheels locked.If the client uses a wheelchair, it is important to lock the wheels when the client is stationary to keep the client safe. Locking the wheels of a wheelchair is not an indication of elder abuse. The client reports receiving a full bath twice each week.Neglect is a form of abuse or mistreatment that is characterized by omission of necessary care. Although hygiene is an important part of care for all clients, a full bath is not necessary every day for older adults due to the adverse effects it can have on fragile skin. Therefore, a full bath twice each week is sufficient for effective care and is not an indication of neglect or elder a A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? a. "drink a cup of hot cocoa before bedtime" b. "maintain a consistent time to wake up each day" c. "exercise 1 hour before going to bed" d. "watch a television program in bed before going to sleep" ---------- Correct Answer ---- ------ b. "maintain a consistent time to wake up each day" Cocoa contains caffeine, which is a stimulant that can interfere with sleep. "Maintain a consistent time to wake up each day." The client should maintain a consistent time for waking up and going to sleep. This helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client. "Exercise 1 hour before going to bed."Exercising within 2 hr of bedtime can interfere with sleep. "Watch a television program in bed before going to sleep."The client should avoid watching television in bed before going to sleep to reduce stimulation in order to promote rest. A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? round to the nearest whole number ---------- Correct Answer ---------- 8 mL/hr A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess? a. hypotension b. weak, thready pulse c. slow capillary refill d. distended neck veins ---------- Correct Answer ---------- d. distended neck veins Hypotension is an indication of fluid volume deficit. Other indications of fluid volume deficit, or dehydration, are dry mucous membranes and sunken eyeballs. Weak, thready pulseA weak, thready pulse is an indication of fluid volume deficit. Other indications of fluid volume deficit, or dehydration, include an increased hematocrit and urine specific gravity. Slow capillary refillA decrease in capillary refill time is an indication of fluid volume deficit. Other indications of fluid volume deficit, or dehydration, include output of less than 30 mL/hr and dark yellow urine. Distended neck veins. Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure. 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? ---------- Correct Answer ---------- -the client holds the cane on the stronger side of her body the nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. when the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hours -which of the following actions should the nurse take first? ---------- Correct Answer ------- --- -check the IV tubing for obstruction 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? ------- --- Correct Answer ---------- -have the client take sips of water to promote insertion of the NG tube into the esophagus a nurse is reviewing a client's fluid and electrolyte status -which of the following findings should the nurse report to the provider? ---------- Correct Answer ---------- -potassium 5.4 mEq/L a nurse is providing discharge instruction to a client who will be using a walker -which of the following client statements indicates an understanding of the teaching? ---- ------ Correct Answer ---------- -"I will hire someone to trim the tree that hangs low over the stairs of my front porch" a nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia -which of the following tasks should the nurse assign to an assistive personnel (AP)? --- ------- Correct Answer ---------- -assist the client with a partial bed bath -measure the client's BP after the nurse administers an antihypertensive medication -use a communication board to ask what the client wants for lunch a nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer -which of the following actions should the nurse take? ---------- Correct Answer ---------- - reassure the client that this is an expected response to grief 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 this condition is a contraindication for which of the following therapies? ---------- Correct Answer ---------- -acupuncture 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? ------- --- Correct Answer ---------- -contact precautions a nurse is educating a client who has a terminal illness about declining resuscitation in a living will. the client asks, "what will happen if I arrive at the emergency department and I had difficulty breathing?" -which of the following responses should the nurse make? ---------- Correct Answer ------ ---- -"we would give you oxygen through a tube in your nose" a nurse is performing a skin assessment for a client who expresses concern about skin cancer -which of the following findings should the nurse identify as a potential indication of a skin malignancy? ---------- Correct Answer ---------- -a mole with an asymmetrical appearance a nurse is reviewing evidence based practice principles about administration of oxygen therapy with a newly licensed nurse -which of the following actions should the nurse include? ---------- Correct Answer -------- -- -regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min a nurse is performing a home safety assessment for a client who is receiving supplemental oxygen -which of the following observations should the nurse identify as a proper safety protocol? ---------- Correct Answer ---------- -the client uses non acetone nail polish remover a nurse is caring for a client who has a terminal illness and is at the end of life -the nurse should recognize that which of the following statements by the client's partner indicates effective coping? ---------- Correct Answer ---------- -"I am relying on support from our family during this time" a nurse is talking with an older client who is contemplating retirement. the client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire" -which of the following responses should the nurse make? ---------- Correct Answer ------ ---- -"let's talk about how the change in your job status will affect you" a nurse is caring for a group of clients -which of the following actions should the nurse take to prevent the spread of infection? ---------- Correct Answer ---------- -place a client who has tuberculosis in a room with negative pressure airflow a nurse is admitting a new client -which of the following actions should the nurse take while performing medication reconciliation? ---------- Correct Answer ---------- -compare the client's home medications with the provider's prescriptions a nurse is lifting a bedside cabinet to move it closer to client who is sitting in chair -to prevent self injury, which of the following actions should the nurse taken when lifting this object? ---------- Correct Answer ---------- -stand close to the cabinet when lifting it a nurse is talking with the partner of a client who has dementia. the client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner -the nurse should identify that the partner is experiencing which of the following types of role performance stress? ---------- Correct Answer ---------- -role overload a nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. the nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hour -which of the following actions should the nurse take next? ---------- Correct Answer ------ ---- -notify the nursing manager 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? ---------- Correct Answer ---------- -situation, background, assessment, recommendation (SBAR) 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? ---------- Correct Answer -- -------- -place the client's arm in a dependent position 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 actions is the nurse's priority? ---------- Correct Answer ---------- - determine the reasons why the client is refusing to use the incentive spirometer 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? ---------- Correct Answer ---------- -"use the complete name of the medication magnesium sulfate" 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? ---------- Correct Answer ------- --- -check the client for injuries a nurse on a medical surgical unit is caring for a client who has a new prescription for wrist restraints -which of the following actions should the nurse take? ---------- Correct Answer ---------- - pad the client's wrist before applying the restraints a home health nurse is performing a follow up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. the client has recently developed diarrhea -which of the following findings should the nurse identify as a possible cause of the diarrhea? ---------- Correct Answer ---------- -the client's caregiver washes out the feeding bag with warm water once every 24 hrs a nurse is caring for a client who is postoperative. when the nurse prepares to change her dressing, she says "Every time you change my bandage it hurts so much" -which of the following interventions is the nurse's priority action? ---------- Correct Answer ---------- -administer pain medication 45 min before changing the client's dressing a nurse is caring for a client who has diarrhea due to shigella -which of the following precautions should the nurse implement for this client? ---------- Correct Answer ---------- -wear a gown when caring for the client a nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit -which of the following changes should the nurse identify as an indication that the treatment was successful? ---------- Correct Answer ---------- -decrease in heart rate 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? ---------- Correct Answer ---------- - ask another nurse to observe the medication wastage a nurse is caring for a client who has a sodium level of 125 mEq/L -which of the following findings should the nurse expect? ---------- Correct Answer -------- -- -abdominal cramping a nurse is preparing an education program for staff about advocacy -which of the following information should the nurse include? ---------- Correct Answer --- ------- -advocacy ensures clients' safety, health and rights a nurse is caring for a client who has an aggressive form of prostate cancer. the provider briefly discusses treatment options and leaves the client's room. when the nurse asks if the client would like to discuss any concerns, the client declines False Imprisonment (International Tort) ---------- Correct Answer ---------- A person is confined or retained against his will. The nurses uses restraints on a competent client to prevent his leaving the health care facility. What should the nurse teach older clients about home safety? ---------- Correct Answer - --------- To place electrical cords & extension cords against a wall behind furniture and use a nonskid mat in the tub or shower & place a shower chair in the shower and a beside commode if needed. The client who has heat stroke will have what sign? ---------- Correct Answer ---------- Hypotension One of the nurse's responsibility for a client in restraints is to make sure... ---------- Correct Answer ---------- the restraints are loose enough for range of motion & that there is enough room to fit two fingers between the restraints & the client. What is the priority action for a patient with a history of falls? ---------- Correct Answer --- ------- Complete a fall risk assessment. What blood glucose level requires immediate action? ---------- Correct Answer ---------- 70 mg/dL of less What are manifestations of hypoglycemia? ---------- Correct Answer ---------- Mild shakiness, mental confusion, sweating, palpitations, headache, lack of coordination, blurred vision, seizures, and coma. What should clients with hypoglycemia do? ---------- Correct Answer ---------- Take 10 to 30 g of readily absorbed carbohydrate. Including two or three glucose tablets, six to ten hard candies, 1/2 cup of soda or juice, 1 tbsp honey or 4 tsp sugar. What should clients do when levels stabilize? ---------- Correct Answer ---------- Have the client take an additional carbohydrate and protein snack of small meal. What information should the nurse provide to a client with a new diagnosis of diabetes mellitus type 1? ---------- Correct Answer ---------- Usually occurs before the age 30, is treated with oral antiglycemic medications and regular exercise can reduce insulin requirements. What instructions should the nurse include when reinforcing dietary teaching to a client with type 2 diabetes mellitus? ---------- Correct Answer ---------- Carbohydrate intake should compromise of 55% of daily caloric intake, you can add table sugar to cereal, you can drink one alcoholic beverage with a meal and use the same portion size to exchange carbohydrates. What information should the nurse incorporate into the dietary plan for a client with type 2 diabetes mellitus? ---------- Correct Answer ---------- Weight management, lipid profile, cultural needs, and personal preferences. A nurse is caring for a family experiencing a crisis. What approach should the nurse use when working with a family using an open structure for coping with crisis? ---------- Correct Answer ---------- Convening a family meeting. What should you do before administering any medications? ---------- Correct Answer ----- ----- Obtain a complete medication and allergy history. What does diphenhydramine treat in relation to allergic reactions? ---------- Correct Answer ---------- Mild rashes and hives What should you do after hand-washing with ostomy skin care? ---------- Correct Answer ---------- Apply gloves & inspect the stoma, use mild soap and water to cleanse, then dry it gently and completely. What are the steps to take when administering a large-volume enema? ---------- Correct Answer ---------- 1. Position the client on the left side with right leg flexed forward. Put on gloves. Lubricate rectal tube or nozzle. (Also, warm to enema solution). 2. Slowly insert rectal tube (3 to 4 inches for an adult). Raise bag above anus, 18 inches (if client reports abd cramping, lower the enema fluid container) . Ask the client to retain the solution for prescribed amount of time, or until client is no longer able to retain it. 3. Discard bag. Assist the client to the appropriate position to defecate. Document results and the client's tolerance of the procedure. What should the nurse do to help prevent plantar flexion? ---------- Correct Answer ------- --- Encourage active or provide passive ROM two or three times/day. Instruct clients to perform ROM while bathing, eating, grooming, and dressing. What should be done for a client to promote a proper sleep-wake cycle? ---------- Correct Answer ---------- Cluster care. ` Who is a fracture pan used for? ---------- Correct Answer ---------- Supine client and clients in body casts or leg casts. What should the nurse do for clients using a fracture pain? ---------- Correct Answer ------ ---- Raise the head of the bed to 30 degrees. If the client cannot lift his hips to get the bedpan under him, roll him onto one side, position the bedpan over his buttocks, and roll the client back onto the bedpan. Signs/symptoms of extracellular fluid volume deficit ---------- Correct Answer ---------- 1. Hypothermia, tachycardia, thready pulse, orthostatic hypotension, decreased central venus pressure, tachypnea, and hypoxia. 2. Dizziness, syncope, confusion, weakness and fatigue. GI findings related to extracellular fluid volume deficit ---------- Correct Answer ---------- Dry mucous membranes, dry furrowed tongue, nausea, vomiting, anorexia, and acute weight loss. The nurse should recognize which labs as a sign of dehydration? ---------- Correct Answer ---------- -Hct 55% -Serum sodium 150 mEq/L -Urine specific gravity 1.035 What is a heart murmur? ---------- Correct Answer ---------- Audible when blood volume in the heart increased or its flow is impeded or altered. Using the bell of the stethoscope to hear the characteristic blowing or swishing sound. What are risk factors for pressure ulcers? ---------- Correct Answer ---------- -Aging skin, immobility, incontinence, excessive moisture, skin friction, shearing. -Vascular disorders, obesity, inadequate nutrition, hydration, anemia, fever, dehydration. -Impaired circulation, edema, sensory deficits, impaired cognitive functioning, chronic diseases, sedation that impairs spontaneous repositioning. What should the nurse do if she were to find a surgical wound separated with viscera protruding? ---------- Correct Answer ---------- Cover the area with saline-soaked sterile dressing and position the client supine with his hips & knees bent. What is the expected reference range for ALT? ---------- Correct Answer ---------- 4 to 36 units/L. Elevation occurs with hepatitis or cirrhosis. What are indications for ALT? ---------- Correct Answer ---------- Suspected liver, pancreatic, or billiary tract disorder. When do you use surgical asepsis for suctioning? ---------- Correct Answer ---------- Surgical asepsis should be used for nasotracheal suctioning, but medical asepsis for the mouth. How long should the nurse suction for? ---------- Correct Answer ---------- No longer than 10 to 15 seconds to avoid hypoxemia and the vagal response. Limit total suctioning to 5 minutes. What position will promote draining of both lobes of the lungs in general? ---------- Correct Answer ---------- High Fowler's What position will promote draining of apical segments of both lobes? ---------- Correct Answer ---------- Sitting on the side of the bed