ATI - Exam 1 fundamentals

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

"I flushed what I urinated at 7:00 AM and have saved all urine since."

A nurse is reviewing information about the health insurance Portability and accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates the need for further teaching

"Information about a client can be disclosed to family members at any time"

A nurse is teaching a client who left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indiction that the client understands the teaching?

"When descending the stairs, I will first shift my weight to my right leg"

A nurse is planning care for a client who requires precautions. Which of the following actions should the nurse take?

The nurse should wear an N95 respirator mask.

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

Walking Briskly

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 a psychomotor approach to learning?

Practice sessions

A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines?

A nurse asks a nurse from another unit to assist with documentation for a client

Q:A nurse is teaching a client who has been taking prednisone to treat asthma and has anew prescription to discontinue the medication. The nurse should explain to the client toreduce the dose gradually to prevent which of the following adverse effects?

A: Adrenocortical insufficiency.

A nurse has just inserted an NG for a client. Which of the following findings should the nurse expect to confirm correct tube placement?

An x-ray shows the end of the tube above the pylorus

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?

Apply 4-5 mL of liquid soap to the hands

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?

Apply an ankle foot orthotic device to the clients feet

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?

Arrange food in a consistent pattern on the client's plate

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to the chair. After securing a safe environment, which of the following actions should the nurse take next?

Assess the client for orthostatic hypotension

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full thickness wound with jagged edges and muscle tissue visible. The nurse should documents this as which of the following types of wounds?

Laceration

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?

Erythema on pressure points

A nurse is caring for ac client who reports difficulty falling asleep. Which of the following recommendations should the nurse?

Maintain a consistent time to wake up each day

A client who is non ambulatory notifies the nurse that his tracheostomy's can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

Evacuate the client

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

Flush the tube with 15 mL of sterile water

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?

Gently shake the container of medication prior to administration

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

Have the client stand with their arms at their sides and their feet together

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?

Have the client use a trapeze bar when changing position

A nurse is preparing an educational program for a group of newly licensed nurses about client confidentiality. The nurse should explain that curses may share a client's protected health information with which of the following groups?

Health care team members caring for the client

A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify with the provider?

Medication dose

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

N95 respirator

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?

People in middle adulthood often find satisfaction in nurturing and guiding young people

A nurse is caring for a client who has an infection. The nurses should use which of the following strategies to prevent the transmission of client's infection.

Performing hand hygiene before, during, and after direct contact with client

A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses' station?

A client who sustained a head injury and is having periods of confusion

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?

Rapid Heart Rate

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?

You should receive a pneumococcal immunization every 10 years.

The nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? Select all that apply.

- Check the cord routinely for frays or tearing - Consider purchasing a generator for power backup is correct - Observe for signs of hypoxia

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

- Place the client in a room with negative-pressure airflow - Wear gloves when assisting the client with oral care - Use antimicrobial sanitizer for hand hygiene

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. This is most likely an indication of which of the following conditions? a. Upper respiratory infection b. Pulmonary edema c. Atelectasis d. Delayed gastric emptying

b. Atelectasis Prolonged bedrest with few position changes and ineffective coughing are risk factors for atelectasis

a nurse is preparing to instill antibiotic ear drops into a toddler's ear. which of the following techniques should the nurse use when administering ear drops to this pt?

pull the auricle down and back to open the canal when administering ear drops.

A nurse is caring for a patient who has the following arterial blood gas results : HCO3 18mEq, PaCO2 28mm Hg, and pH 7.30. The nurse recognizes the client is experiencing which of the following acid base imbalances? metabolic acidosis, respiratory acidosis, metabolic alkalosis, respiratory alkalosis

metabolic acidosis

A nurse is admitting a client who has influenza and reporting numbness and tingling of fingers and toes. The nurse should recongize the client is experiencing which of the following acid-base imbalances?

metabolic alkalosis

A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching?

"I will take my medications at the first sign of an attack."

A nurse intercepts a messenger at the nurses' station who has a flower delivery for a client on the unit. As the nurse accepts the flowers, the messenger says. "I know Mrs. Welch from the neighborhood. What happened to her?" Which of the following responses should the nurse provide.

"It's my responsibility to remand you that we have to respect our clients privacy"

A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the clients' use of a cane?

"When the client moves, he should move the cane forward first"

A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? Select all that apply

1. check the position of the cannula frequently 2 Check the tops of the ears for skin breakdown. 3. post no smoking signs in a prominent location

a nurse is preparing to administer 0.9% sodium chloride 1200 ml IV to infuse over 24 hours the drop factor of the manual iv tubing is 15 gtt/ml. Round to the nearest whole number

13

A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive mantoux test. Room 208 is a private, negative-pressure airflow room, room 212 is a semi-private, positive-pressure airflow room; 214 is a negative-pressure, semi-private room; and room 216 is a private, positive-pressure airflow room. To which of the following rooms should the nurse assign the client?

208

A nurse is preparing a heparin infusion for a client who was admitted to the facility with sep-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

8 mL/hr

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?

8 oz of ice chips

A nurse is caring for a client who is postoperative following knee arthroplasty and has a new prescription for enoxaparin 1mg/kg/dose subcutaneous every 12 hr. The client weighs 185 lb. How many mg should the nurse administer per dose? (Round the answer to the nearest whole number/tenth. Use a leading zero if it applies/ Do not use a trailing zero.)

84.1 mg

A nurse is teaching a group a 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 client who has asthma

A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?

A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively

A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension?

A client who smokes one pack of cigarettes each day.

A nurse is 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?

Current medications

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 indiction of fluid volume excess?

Distended neck veins

a nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?

Remove the catheter and insert another into a different site. catheter could be up against a valve or against a nerve

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

Tell the client to keep the head of the bed elevated at least 30 degrees.

A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as potential of elder abuse?

The caregiver insists on remaining in the room

A charge nurse is observing a newly license nurse prepare a sterile field for a dressing change. Which of the following actions by the newly license nurse requires intervention by the charge nurse?

The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field

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?

The pain is like a dull ache in my stomach

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse?

The posterior tibial pulse is located on the innter ankle, one-third of the way along the line between the tip of the medial malleolus )end of the tibia) and the point of the heel. It is most easily palpated about 2.5 cm higher, where it runs behind the medial malleolus.

A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentation should thenurse include in the clients medical record?

The provider was notified

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?

We can talk about advance directives, and I can also give you some brochures about them

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

What could I have done to deserve this illness?

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurses responsibility?

Witness the clients signature on the consent form

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?

Wrap blankets around all four sides of the bed

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

Cleanse the would from the center outward

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

Compare prescriptions with medications the client received while at the facility.

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg. and temperature 36.8 decrees C (98.2 F). Which of the following actions should the nurse perform?

Complete a neurological check.

The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as likely explanation for the client''s behavior?

Confusion. Since the client was manifesting signs of confusion before coming to the emergency department and currently seems unable to understand or respond to speech the nurse should determine that the client has confusion.

A nurse is having difficulty reading the providers writing one transcribing a prescription for a clients medication. Which of the following actions should the nurse take?

Contact the provider to clarify the prescription.

.A nurse is working with a team of nursing personnel within a facility. Which of the following are necessary task performance roles that members of the group or the leader must perform?

Coordinator Evaluator Energizer

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect? A. Bradypnea B. Somnolence C. Pallor D. Tachycardia

D. Tachycardia

A nurse is preparing to perform wound irrigation on a client who has a puncture wound to the left leg. Identify the sequence of steps the nurse should take to perform the irrigation.Place a waterproof pad under the client's leg

Don clean gloves and remove the client's dressing Clean the wound using a circular motion Open a sterile dressing set and supplies Irrigate the wound until the solution becomes clear

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?

Droplet

The nurse is creating a discharge plan which of the following nursing statements indicates the nurse understands when discharge planning should be implemented?

Effective discharge planning must begin upon admission of the client to the facility.

A nurse is developing a plan of care for a client who has cellulitis of the leg. Which of the following interventions should the nurse include in the plan?

Elevate the affected leg on two pillows

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastronomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Elevate the head of the client's bed 30 to 45 degrees

A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the nurse delegate to the licensed practical nurse (LPN)?

Scheduling a diagnostic study for a client.

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Secure the restraints using a quick-release tie.

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?

Select a suction catheter that is half the size of the lumen

A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?

"Client found lying on floor"

A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the teaching?"I will use both medications immediately after exercising.""If my breathing begins to feel tight, I will use the cromolyn immediately.""I will be sure to take the albuterol before taking the cromolyn.""I will administer the medications 10 minutes apart."

"I will be sure to take the albuterol before taking the cromolyn."

A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. Which of the following images displayed the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure.

(picture with 122 mm Hg)

a nurse is preparing to use the z-track technique to administer medication to a client which of the following is is an appropriate action during this procedure quizlet

Aspirate for 5 to 10 seconds

A nurse is assessing a clients radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

Assess teh apical pulse for a full minute

A nurse is caring for a client who experienced a lacerated spleen and has been on bed rest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize realize that this finding is most likely and indication of which of the following conditions.

Atelectasis

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?

Auscultate lung sounds

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.

- Inject 10 units of air into the bottle of NPH insulin. - Inject 5 units of air into the bottle of regular insulin. - Withdraw the correct dose of regular insulin from the bottleWithdraw the correct dose of NPH insulin from the bottle

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?

0.3 mg

A nurse is completing a treatment on a client who has a stage 1 pressure ulcer. Which of the following dressings should the nurse apply? 1. Transparent dressing 2. Wet-to-dry dressing 3. Dry sterile dressing 4. Antimicrobial dressing

1. Transparent dressing

a provider prescribes dextrose 5% and water IV to infuse at 100 ml/hr. the drop Factor on the manual IV tubing is 60 gtt/ml. The nurse should set the iv flow rate to deliver how many gtt/min?

100 Formula: (Volume (mL)/Time (min))x Drop Factor (gtts/mL) = Y (Flow Rate in gtts/min) Example: Calculate the IV flow rate for 1200 mL of NS to be infused in 6 hours. The infusion set is calibrated for a drop factor of 15 gtts/mL. Volume (mL)Time (min) x Drop Factor (gtts/mL) = Y (Flow Rate in gtts/min) Convert 6 hours to minutes. min ← hr ( x by 60 ) 6 hr x 60 = 360 min 1200 mL360 min x 15 gtts/mL = 50 gtts/min Example: Calculate the IV flow rate for 200 mL of 0.9% NaCl IV over 120 minutes. Infusion set has drop factor of 20 gtts/mL. Volume (mL)Time (min) x Drop Factor (gtts/mL) = Y (Flow Rate in gtts/min) 200 mL120 min x 20 gtts/mL = 33 gtts/min

A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Which of the following precautions should the nurse include when creating a sigh to post outside the client's room?

A protective mask is correct A closed door is correct A puncture-proof sharps container is correct Hand hygiene is correct A gown is incorrect

A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions?

A. A client who has scabiesRationale:A client who has scabies requires contact precautions. B. A client who has pertussisRationale:A client who has pertussis requires droplet precautions. C. A client who has streptococcal pharyngitisRationale:A client who has streptococcal pharyngitis requires droplet precautions .D. A client who has measles Rationale:A client who has measles requires airborne precautions as well as a negative pressure room.

A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tests should the nurse delegate?

Ambulating a client who is postoperative

A nurse is planning to apply a transdermal analgesic cream prior to inserting an IV for a preschool-age child. Which of the following actions should the nurse plan to take? (Select all that apply.)

Apply to intact skin. Apply the medication an hour before the procedure begins. Use a visual pain rating scale to evaluate effectiveness of the treatment. Cleanse the skin prior to procedure.

a nurse is caring for a client who is receiving transfusion of packed red blood cells and suspects that the client is experiencing a hemolytic reaction Which of the following actions should the nurse take first? A. Inform the provider B. Stop the infusion of blood C. Notify the laboratory D. Obtain a urine specimen

B. Stop the infusion of blood The client is experiencing an acute intravascular hemolytic transfusion reaction. The greatest risk to this client is injury from receiving additional blood; therefore, the first action the nurse should take it to stop the infusion of blood.

An assistive personnel (AP) reports a clients vital signs as tympanic temperature of 37.1 degrees C (98.8 F), pulse 92/min, respiratory rate 18/min and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure

BP

During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer.

Basal cell carcinoma

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation?

Bladder scan shows 525 mL of urine

A nurse is caring for a client who has active pulmonary TB and is to be started on intravenous rifampin. The nurse should instruct the client that this medication can cause which of the following adverse effects?

Body sections turning a red orange color

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 information is the priority for the nurse to provide?

Breath Sounds

A nurse is preparing to administer medications to an older adult client who had a cerebrovacsular accident (CVA) and has difficulty swallowing medications. The client asks teh nurse if the prescribed enteric-coated aspirin (Ecotrin) can be crushed to make it easier to swallow. Which of the following would be an appropriate response by the nurse? A. "That would release all the medication at once, rather than over time." B. "I will crush it and mix it in some ice cream for you." C. "If I crush it you may experience a stomach ache or indigestion." D. "If I do that some of the medication will be inactivated by stomach acid."

C. "If I crush it you may experience a stomach ache or indigestion."

A nurse is assessing a clients cranial nerves as part of the neurological examination. Which of the following actions should the nurse take to assess cranial nerve III

Checking the papillary response to light

A nurse is caring for a client who refuses treatment and asked to be discharged from the hospital against medical advise. The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary, to keep her from leaving the hospital. The nurse understands taht restraining the client would be considered which type of civil action by the nurse?

False imprisonment

a nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. which of the following actions should the nurse plan to take? A. dissolve each medication in 5 mL of sterile water B. draw up medication together in the syringe C. push the syringe plunger gently when feeling resistance D. flush the tube with 15 mL of sterile water

Flush the tube with 15 mL of sterile water. The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication.

A nurse is preparing to exit the room of a client who had methicillin-resistant Staphylococcus aureus (MRSA) in a draining would, Identify the sequence the nurse should follow before leaving the client;s room. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps)

Gloves eye wear gown mask Perform hand hygiene

A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching?

Have family members wear a gown and gloves when visiting

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?

I can take echinacea to improve my immune system

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 indiction that the client understands the use of this assistive device?

I will be sure to remove my hearing aid before taking a shower

A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Which of the following of Erikson;s developmental stages should the nurse consider in planning

Industry vs inferiority

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?

Initiate an enteral feeding through a gastrostomy tube

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?

Instruct the family to refrain from pushing the button for the client while she is asleep.

A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client?

Kyphosis

A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion (select all that apply)

More difficulty seeing due to the greater sensitivity to glare Decreased cough reflex Decreased bladder capacity Dehydration of intervertebral disks

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurses priority?

Move any clients in the immediate vicinity.

A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?

Move teh client to a room closer to the nurses' station.

A nurse is performing 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?

Narrowed arterial lumen

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

Necrotic Subcutaneous tissue

A Nurse is caring for a client who has a Clostridium Difficile infection. Which of the following cleansing agents should the nurse use for hand hygiene

Non-antimicrobial soap

The nurse has completed an informed consent form with a client. The client then states, "I have changed my mind and do not want to have the procedure done."

Notify the surgeon that the client wishes to withdraw informed consent for the procedure

A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which of the following actions should the nurse take?

Perform the Heimlich maneuver

A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription

Repeat the order back to the provider. Questions any part of the order that is unclear or inappropriate Transcribe the order into the client's health record

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?

Withhold the blood transfusion

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

Wrap monitoring cords with stockinette and tape them in place

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

You should have a fecal occult blood test every year.

A nurse is performing a cardiac assessment. Identify where the nurses should place the stethoscope to auscultate the clients apical pulse.

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