ATI Fundamental Practice A

a nurse is caring for a client who asks about the purpose of advance directives. which of the following statements should the nurse make? "They allow the court to overrule an adult client's refusal of medical treatment." "They indicate the form of treatment a client is willing to accept in the event of a serious illness." "They permit a client to withhold medical information from health care personnel." "They allow health care personnel in the emergency department to stabilize a client's condition."

"They indicate the form of treatment a client is willing to accept in the event of a serious illness." Advance directives include a living will, which permits clients to direct the treatment they will receive in the event of a medical emergency or serious illness.

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? "Is your pain constant or intermittent?" "What would you rate your pain on a scale of 0 to 10?" "Does the pain radiate?" "Is your pain sharp or dull?"

"is your pain sharp or dull?"

a nurse in a long-term care facility is caring for a client who dies during the nurse's shift. identify the sequence in which the nurse should perform the following steps.

1. obtain the pronouncement of death from the provider 2. remove tubes and indwelling lines 3. wash the client's body 4. ask the client's family members if they would like to view the body 5. place a name tag on the body

a nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. the nurse should set the infusion pump to deliver how many mL/hr? (round the answer to the nearest whole number.)

107 mL/hr

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? - A lesion with uniform pigmentation - New appearance of petechiae - A mole with an asymmetrical appearance - The presence of a papule

A mole with an asymmetrical appearance An uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part.

a nurse is preparing to administer enoxaparin subcutaneously to a client. which of the following actions should the nurse take? Administer the medication with the needle at a 45° angle. Administer the medication into the client's nondominant arm. Pull the client's skin laterally or downward prior to administration. Massage the injection site after administration.

Administer the medication with the needle at a 45° angle. MY ANSWER The nurse should insert the needle at a 45° to 90° angle for a subcutaneous injection.

a nurse is caring for a client who has COPD E1 Nurses' Notes 1000:Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackles heard in left upper lobe and decreased breath sounds at bases bilaterally. E2 1000:Temperature 38.6° C (101.5° F)BP 114/56 mm HgHeart rate 99/minRespirations 32/minOxygen saturation 85% on room air E3: 1200:Chest x-ray shows lung hyperinflation and left upper lobe pneumonia. Select the 3 findings that require follow-up. Breath sounds Blood pressure Oxygen saturation Temperature Heart rate

Breath sounds is correct. Crackles are caused by mucous in the airways and are a manifestation of pneumonia. Decreased breath sounds indicate decreased ventilation and require follow-up by the nurse. Oxygen saturation is correct. The client's oxygen saturation is below the expected reference range of 95% to 100%, indicating hypoxia, and requires follow-up by the nurse. Temperature is correct. The client's temperature is greater than the expected reference range, indicating an infection, and requires follow-up by the nurse.

a nurse is admitting a new client. which of the following actions should the nurse take while performing medication reconciliation? Verify the client's name on their identification bracelet with the medication administration record. Call the pharmacy to determine whether the client's medications are available. Compare the client's home medications with the provider's prescriptions. Place the client's home medication bottles in a secure location.

Compare the client's home medications with the provider's prescriptions. The nurse should compare the client's home medications with the provider's prescriptions when performing medication reconciliation.

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the ED and I had a difficulty breathing?" Which of the following responses should the nurse make? "We would consult the person appointed by your health care proxy to make decisions." "We would give you oxygen through a tube in your nose." "You would be unable to change your previous wishes about your care." "We would insert a breathing tube while we evaluate your condition."

We would give you oxygen through a tube in your nose.

Nurse caring for client who has herpes zoster. Client asks about complementary and alternative therapies for pain control. Nurse should inform client that this condition is a contraindication for which of the following therapies? Biofeedback Aloe Feverfew Acupuncture

acupuncture The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk of further infection.

a nurse is providing discharge teaching to a client about self-adminsitering heparin. which of the following instructions should the nurse include in the teaching? Insert the needle at a 15° angle. Aspirate for blood return prior to administration. Administer the medication into the abdomen. Massage the site following the injection.

adminsiter the medication into the abdomen The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue.

a nurse is preparing an education program for staff about advocacy. which of the following information should the nurse include? Advocacy ensures clients' safety, health, and rights. Advocacy ensures that nurses are able to explain their own actions. Advocacy ensures that nurses follow through on their promises to clients. Advocacy ensures fairness in client care delivery and use of resources.

advocacy ensures client's safety, health, and rights

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? - Check the client for injuries. - Move hazardous objects away from the client. - Notify the provider - Ask the client to describe how she felt prior to the fall.

check the client for injuries

a nurse is adminsitering 1L 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? Increase in hematocrit Increase in respiratory rate Decrease in heart rate Decrease in capillary refill time

decrease in heart rate since FVD causes tachycardia. with correction of the imbalance, the heart rate should return to the expected range

a nursing is caring for a client who has pharynegeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? Contact Droplet Airborne Protective

droplet Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 1 m (3 feet) of the client who has a disorder requiring droplet precautions.

a nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. to prevent self-injury, which of the following actions should the nurse take when lifting this object? Bend at the waist. Keep his feet close together. Use his back muscles for lifting. Stand close to the cabinet when lifting it.

stand close to the cabinet when lifting it This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching.

a nurse is caring for a client who has a terminal illness and is approaching death. the client is SOB and has noisy respirations from secretions in their airway. which of the following actions should the nurse take? Turn the client every 2 hr. Administer an antiemetic every 6 hr. Hold oral care. Increase the room's temperature.

turn the client every 2 hr

a nurse is teaching a client and his family how to care for the client's tracheostomy at home. which of the following instructions should the nurse include in the teaching? Remove the outer cannula cautiously for routine cleaning. Use tracheostomy covers when outdoors. Use sterile technique when performing tracheostomy care at home. Cleanse irritated skin with full-strength hydrogen peroxide.

use tracheostomy covers when outdoors Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles.

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? Critical pathway Situation, background, assessment, and recommendation (SBAR) Transfer report Medication administration record (MAR)

SBAR situation, background, assessment, and recommendation SBAR is a communication tool nurses use to relate a client's status during a change-of-shift report. The nurse should use a transfer report when the client is moving from one health care area or facility to another. The nurse should use the MAR to document medication administration. A critical pathway is an interprofessional approach to planning all phases of client care.

a nurse is ausculatating the anterior chest of a client who has newly admitted to a medical-surgical unit.

normal breath sounds These are normal bronchovesicular breath sounds, characteristically of moderate intensity and sounding like blowing as air moves through the larger airways on inspiration and expiration. Friction rub is a scratching or squeaking sound that persists throughout the respiratory cycle. Rhonchi are dry, low-pitched, snore-like noises produced in the throat or bronchial tube due to a partial obstruction, such as by secretions. Unlike these breath sounds, crackles (also called rales) are discontinuous sounds heard primarily during inhalation and resulting from air bubbling through fluid or mucus in the airways.

a nurse is caring for a client who is postop 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 hr. which of the following actions should the nurse take next? --Document the provider's statement in the medical record. --Complete an incident report. --Consult the facility's risk manager. --Notify the nursing manager.

Notify the nursing manager. The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care.

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

Reassure the client that this is an expected response to grief.

A nurse is reviewing a evidence based practice principles about administration of oxygen therapy with a newly licensed nurse . Which of the following actions should the nurse include ? Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. Make sure the reservoir bag of a partial rebreathing mask remains deflated. Use petroleum jelly to lubricate the client's nares, face, and lips.

Regulate oxygen via nasal canal at a flow rate of no more then 6L/ min

A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?

The nurse should identify this image as assessing the client's patellar reflex. To elicit the expected response of lower leg extension, the nurse should allow the client's legs to hang freely over the side of the examination table while seated and quickly tap the patellar tendon just below the kneecap using a reflex hammer.

a nurse is caring for a client who is postoperative following abdominal surgery exhibit 1: 1100:Client received from PACU; initial vital signs recorded. Client drowsy but responds to verbal stimuli. Client is oriented to person, place, and time. Client can move all extremities. Hypoactive bowel sounds. Abdominal dressing intact with drainage noted and marked. Indwelling urinary catheter in place and draining yellow urine. Infusing lactated Ringer's at 100 mL/hr to the right forearm. Client positioned for comfort, side rails raised x 2, call light in the client's reach. 1115:Provider prescriptions reviewed. 1200:Upon waking, client reports nausea and rates pain as a 6 on a scale of 0 to 10. Abdominal dressing intact, no further drainage noted. Urine output of 15 mL since 1100. Morphine 4 mg IV bolus and metoclopramide 10 mg IV bolus administered. 1230:Client reports relief from nausea, but not pain. Client rates pain as an 8 on a scale of 0 to 10. No additional urine output since 1200. Repositioned client for comfort. exhibit 2: Medication Administration Record Morphine 4 mg IV bolus every 4 hr PRN painMetoclopramide 10 mg IV bolus every 6 hr PRN nausea and vomiting exhibit 3: 1100:Temperature 36.2° C (97.2° F)Heart rate 76/minRespirations 18/minBP 122/68 mm HgOxygen saturation 95% on room air 1200:Temperature 36.8° C (98.2° F)Heart rate 116/minRespirations 20/minBP 112/68 mm HgOxygen saturation 93% on room air Click to highlight the assessment findings below that the nurse should report to the provider. To deselect a finding, click on the finding again. Neurological assessment Incisional drainage Urinary output Reported pain level Gastrointestinal assessment Vital signs

Urinary output is correct. A client who has an indwelling urinary catheter should produce at least 30 to 50 mL/hr of urine. The client's output is less than the expected volume. The nurse should assess the catheter's placement and potential for blockage due to their reduced urine output. This finding should be reported to the provider. Reported pain level is correct. The client's pain has not been relieved with the administration of morphine. According to the client's report, their pain level is increasing. This finding should be reported to the provider. Vital signs is correct. The client's heart rate and respiratory rate have increased, and their blood pressure and oxygen saturation levels have decreased. These findings should be reported to the provider.

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. Which of the following statements should the nurse make? "I will return shortly after I document this in your record." "Most men live a long time with prostate cancer." "I am available to talk if you should change your mind." "I will make a referral to a cancer support group for you."

"I am available to talk if you should change your mind." When a client does not wish to share his feelings with the nurse, it is important for the nurse to convey a willingness to be available for the client.

a nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? Combine client care tasks when caring for multiple clients. Wait until the end of the shift to document client care. Use the planning step of the nursing process to prioritize client care delivery. Allow for interruptions in tasks to discuss client care issues with colleagues.

Use the planning step of the nursing process to prioritize client care delivery. Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management.

A nurse is admitting a client to a health care facility. exhibit 1: Client reports fever, chills, cough, and night sweats for past 2 weeks. Client has recently traveled outside of the country. Lethargic, but oriented to person, place, and time. Crackles heard in lower lobes of lungs upon auscultation. Cough is productive with small amounts of blood. Reports tightness in chest and pain when coughing. Reports losing 5 lb in the last week. Has no appetite and is nauseated. Obtained blood work, chest x-ray, and sputum culture as prescribed. exhibit 2: 1100:BP 138/72 mm HgHeart rate 80/min Respirations 22/min T emperature 38.3° C (101.1° F) Oxygen saturation 90% on room air exhibit 3 Diagnostic Results 1400:Chest x-ray positive for inflammation and infiltrates in upper lobesQuantiFERON-TB positive (negative)Tuberculosis culture positive (negative) The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply. Wear an N95 mask when caring for the client. Place a container for soiled linens inside the client's room. Place the client in a negative airflow room. Remove mask after exiting the client's room. Wear a sterile, water-resistant gown if within 3 feet of the client.

Wear an N95 mask when caring for the client is correct. The nurse should identify the client has tuberculosis, which requires airborne isolation. Therefore, the nurse should wear an N95 mask when caring for the client. Place a container for soiled linens inside the client's room is correct. The nurse should identify the client has tuberculosis, which requires airborne isolation. Therefore, the nurse should place a container for soiled linens inside the client's room to prevent transmission of the infection. Place the client in a negative airflow room is correct. The nurse should identify the client who has tuberculosis should be placed in a negative airflow pressure room that provides at least 6 to 12 air exchanges per hour through a HEPA filtration system. Remove mask after exiting the client's room is correct. The nurse should remove their mask after leaving the room of a client who is in airborne precautions for tuberculosis to prevent exposure to the infection.

a nurse is caring for a client who is posoperative and refuses to use an incentive spirometer following major abdominal surgery. which of the following actions is the nurse's priority? Request that a respiratory therapist discuss the technique for incentive spirometry with the client. Determine the reasons why the client is refusing to use the incentive spirometer. Document the client's refusal to participate in health restorative activities. Administer a pain medication to the client

determine the reasons why the client is refusing to use the incentive spirometer

a nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? During the admission process As soon as the client's condition is stable During the initial team conference After consulting with the client's family

during the admission process Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility.

a nurse is assessing four adult clients. which of the following physical assessment techniques should the nurse use? Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum. Palpate the client's abdomen before auscultating bowel sounds.

ensure the bladder of the bp cuff surrounds 80% of the client's arms

a nurse is caring for a child who has a prescription for blood transfusion. the child's parents have refused the treatment due to their religious beliefs. which of the following actions should the nurse take? Examine personal values about the issue. Tell the parents that this is a necessary procedure. Inform the parents that the staff does not require their consent. Contact a spiritual support person to explain the importance of the procedure.

examine personal values about the issue

Preparing to apply dressing to stage 2 pressure injury. Which type of dressing should the nurse use? Alginate Gauze Transparent Hydrocolloid

hydrocolloid Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed. Transparent dressings promote healing in stage 1 pressure injuries by preventing further friction and shearing. Moistened gauze promotes healing in stage 4 or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed. Alginate dressings are used to treat stage 3 and 4 pressure injuries to absorb drainage. Alginate forms a soft gel when it comes in contact with drainage.

a client who is postop is verbalizing pain as 2 on a pain scale of 0 to 10. which of the following statement should the nurse identify as an indication that the client understands the preoperative teaching she recieved about pain management? "I think I should take my pain medication more often, since it is not controlling my pain." "Breathing faster will help me keep my mind off of the pain." "It might help me to listen to music while I'm lying in bed." "I don't want to walk today because I have some pain."

it might help me to listen to music while i'm lying in bed

a nurse is initiating a protective envrionment for a client who has an allogeneic stem cell transplant. which of the following precautions should the nurse plan for this client? - Make sure the client's room has at least six air exchanges per hour. - Make sure the client wears a mask when outside her room if there is construction in the area. - Place the client in a private room with negative-pressure airflow. - Wear an N95 respirator when giving the client direct care.

make sure the client wears a mask when outside he room if there is construction in the area An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment.

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

place the client's arm in a dependent position since the veins will dilate due to gravity

a nurse is reviewing a client's fluid and electrolyte status. which of the following findings should the nurse is report to the provider. BUN 15 mg/dL Creatinine 0.8 mg/dL Sodium 143 mEq/L Potassium 5.4 mEq/L

potassium 5.4 mEq/L BUN 15 mg/dL This value is within the expected reference range of 10 to 20 mg/dL. Creatinine 0.8 mg/dL This value is within the expected reference range of 0.5 to 1.1 mg/dL for women 41 to 60 years of age and 0.6 to 1.3 mg/dL for men 41 to 60 years of age. Even for clients within younger and older age ranges (with the exception of newborn through 9 years of age), 0.8 mg/dL is within the expected reference range for creatinine. Sodium 143 mEq/L This value is within the expected reference range of 136 to 145 mEq/L. Potassium 5.4 mEq/L This value is above the expected reference range of 3.5 to 5 mEq/L, so the nurse should report this finding to the provider. This client is at risk for dysrhythmias.

Nurse is assessing an older adult for risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (select all that apply) Lacrimal apparatus Pupil clarity Appearance of bulbar conjunctivae Visual fields Visual acuity

pupil clarity visual fields visual acuity

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 reponsibilities while caring for their partner. the nurse should identify that the partner is experiencing which of the following types of role-performance stress? Role ambiguity Sick role Role overload Role conflict

role overload The partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage.

a nurse is evaluating a client's use of a crane. which of the following actions should the nurse identify as an indication of correct use? The top of the cane is parallel to the client's waist. When walking, the client moves the cane 46 cm (18 in) forward. The client holds the cane on the stronger side of her body. The client moves her stronger limb forward with the cane.

the client holds the crane on the stronger side of her body

a nurse is caring for a client who has dementia. which of the following interventions should the nurse take to minimize the risk for injury to client? Use a bed exit alarm system. Raise four side rails while the client is in bed. Apply one soft wrist restraint. Dim the lights in the client's room.

use a bed exit alarm system The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at a risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance.

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

"Use the complete name of the medication magnesium sulfate." The Institute for Safe Medication Practices designates that nurses and providers write the complete medication name for magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate.

a nurse is preparing an injection for opioid medication. Draws 1mL from 2mL vial, what should the nurse do? Ask another nurse to observe the medication wastage. Notify the pharmacy when wasting the medication. Lock the remaining medication in the controlled substances cabinet. Dispose of the vial with the remaining medication in a sharps container.

Ask another nurse to observe the medication wastage. A second nurse must witness the disposal of any portion of a dose of a controlled substance.

a nurse in an emergency department is caring for client. exhibit 1 Physical Examination 1200:Influenza with nausea, vomiting, and diarrhea for 3 days.Client is tachycardic, hypotensive, and tachypneic, with weak pulses, dry mucous membranes, poor turgor, and oliguria.Plan: Admit for IV fluids. exhibit 2 Vital Signs 1200:Temperature 38.4° C (101.1° F)Pulse rate 126/minRespirations 28/minBP 92/54 mm HgOxygen saturation 93% exhibit 3 Nurses' Notes 1900:Client is disoriented, confused. Client attempting to get out of bed without assistance and states, "I'm going home." Returned to bed, attempted to reorient to time, place, and circumstances. Call placed to client's family, no answer, message left. 1915:Client remains disoriented. Attempting to pull out IV line. Call was returned by client's family. Updated them on situation. exhibit 4 Medication Administration Record Dextrose 5% in 0.45% sodium chloride IV at 125 mL/hrPromethazine 25 mg IV bolus every 4 to 6 hr PRN nausea and vomitingDiphenoxylate 5 mg PO four times dailyAcetaminophen 625 mg PO every 6 hr PRN temperature greater than 38.6° C (101.5° F)

Complete the following sentence by using the list of options. The nurse should first review medications that might cause confusion followed by using other methods to keep the client safe Review medications that might be causing confusion is correct. Using the nursing process, the first step the nurse should take is to assess for a cause of the client's confusion. Using other methods to keep the client safe is correct. After assessing for the cause of the client's confusion, the nurse should attempt alternatives to the use of restraints, such as covering the client's IV lines or asking a family member to stay with the client. The use of restraints should be avoided if possible.

A nurse is providing discharge instructions to a client who will be using a walker. which of the following client statements indicates an understanding of the teaching? "I can place an extension cord across my living room to plug in my television." "I will hire someone to trim the tree that hangs low over the stairs of my front porch." "I will place my alarm clock on my bedroom dresser across the room." "I will replace the old throw rug in my kitchen with a new one."

"I will hire someone to trim the tree that hangs low over the stairs of my front porch." Clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls.

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? Protective environment Airborne precautions Droplet precautions Contact precautions

Contact precautions Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client. Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including tuberculosis and measles. Clients who have a compromised immune system require a protective environment.

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

Have the client take sips of water to promote insertion of the NG tube into the esophagus. Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea.

A nurse is caring for a client who has pancreatitis. Exhibit 1 Nurses' Notes 1000:Client states, "I am unable to eat anything without vomiting." Client reports pain in left upper quadrant of abdomen that radiates to their back. States that pain is a "7" on a 0 to 10 pain scale. Bruising noted on client's abdomen. Client is pale and diaphoretic. Provider prescribed blood work, abdominal CT, and NG tube insertion with low-intermittent decompression. IV fluids started and infusing in left peripheral IV site. Exhibit 2 Vital Signs 1000:BP 96/52 mm HgHeart rate 110/minRespirations 22/minTemperature 38.4° C (101.1° F)Oxygen saturation 92% on room air Exhibit 3 Prescriptions 1100:• CT of abdomen• NG tube to low wall suction• Serum amylase level Select the 3 tasks the nurse should delegate to an assistive personnel (AP). Document the client's vital signs. Measure the client's intake and output. Transfer the client from wheelchair to bed. Insert an NG tube for the client. Collect data about the client's pain level.

Select the 3 tasks the nurse should delegate to an assistive personnel (AP). Document the client's vital signs. Measure the client's intake and output. Transfer the client from wheelchair to bed.

A nurse in a provider's clinic is caring for a client who has diarrhea. Exhibit 1 Exhibit 2 Exhibit 3 Vital Signs Temperature 36.2° C (97.2° F)Pulse rate 116/minRespiratory rate 24/minBP 102/68 mm HgOxygen saturation 95%Weight 52.2 kg (115 lb) Nurses' Notes 1000: Client reports diarrhea for the past 5 days with approximately 8 liquid stools a day. Woke up this morning feeling dizzy. States, "I felt like I was going to pass out." Client was seen 7 days ago for sinus infection and was prescribed amoxicillin. Weight at previous visit was 56.2 kg (124 lb). Denies bloody or black stools. 1030: Blood collected for CBC, basic metabolic profile (BMP); stool collected for C. difficile; urine collected for urinalysis. 1100: Informed client that the office will call with results of laboratory findings; prescription for loperamide provided, instructed to discontinue amoxicillin; instructed to drink electrolyte solution; teaching provided for managing diarrhea.​ Physical Examination 1015: Oriented to person, place, and time; lethargic, reports headache Tachycardia, hypotension, thready pulse, dry mucous membranes, tenting present. Respirations slightly labored, chest clear. Bowel sounds x 4 quadrants hyperactive. Reports urine is dark, minimal amount. The nurse is providing teaching for the client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching. Increase intake of high-calcium foods. Eat probiotic foods, such as yogurt. Avoid alcohol while experiencing diarrhea. Eat raw vegetables. Eat three large meals a day. Avoid caffeine while experiencing diarrhea. Drink hot liquids several times a day. Drink carbonated beverages to replace lost fluids. Follow a low-fiber diet.

The nurse is providing teaching for the client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching. Eat probiotic foods, such as yogurt is correct. Probiotic foods, such as yogurt, contain live bacterial cultures, which can help to reduce diarrhea. Avoid alcohol while experiencing diarrhea is correct. Alcohol is a substance that stimulates gastrointestinal (GI) motility. Avoid caffeine while experiencing diarrhea is correct. Caffeine is a substance that stimulates GI motility. Follow a low-fiber diet is correct. Foods that are high in fiber stimulate GI motility and should be avoided while the client is experiencing diarrhea.

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? "I am not worried because I still have hope that he will be okay." "I am relying on support from our family during this time." "We can plan our family reunion once he recovers and comes home." "We don't see any reason to start discussing funeral arrangements right now."

"I am relying on support from our family during this time."

nurse is talking with an older adult 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? "You would have so much more time to spend with your family." "You should consider getting a part-time job or doing volunteer work." "Let's talk about how the change in your job status will affect you." "Why wouldn't you want to retire and relax?"

Let's talk about how the change in your hob status will affect you. This response is therapeutic because the nurse is encouraging the client to verbalize feelings about the life transition of retirement.

Nurse caring for postop client following knee arthroplasty and requires thigh high compression sleeves. What should the nurse do? Assist the client into a prone position. Place a sleeve over the top of each leg with the opening at the knee. Make sure two fingers can fit under the sleeves. Set the ankle pressure at 65 mm Hg.

Make sure two fingers can fit under the sleeve.

a nurse is caring for a client who has a peripheral IV inserted for fluid replacement Nurses' Notes Day 1:Lactated Ringer's at 100 mL/hr infusing into a 20-guage IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. Day 2:IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing. The nurse is assessing the client. Which of the following actions should the nurse take? Select all that apply. Stop the IV infusion. Elevate the client's left arm. Apply heat to the client's left hand. Place a pressure dressing over the IV site. Start a new IV in the client's left hand.

Stop the IV infusion is correct. The client has manifestations of IV infiltration. The nurse should stop the IV infusion and remove the IV catheter to reduce the risk for tissue damage. Elevate the client's left arm is correct. The nurse should elevate the client's left hand to decrease swelling and reduce the risk for tissue damage. Apply heat to the client's left hand is correct. The nurse should apply heat to the client's left hand to reduce swelling and promote comfort.

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? Place the client in a side-lying position. Instill 15 mL of irrigation fluid into the catheter with each flush. Subtract the amount of irrigant used from the client's urine output. Perform the irrigation using a 20-mL syringe.

Subtract the amount of irrigant used from the client's urine output. The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output.

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 proper safety protocol? The client uses a wool blanket on their bed. The client identifies the location of a fire extinguisher. The client stores an extra oxygen tank on its side under their bed. The client has a weekly inspection checklist for oxygen equipment.

The client identifies the location of a fire extinguisher. The client should be able to identify the location of fire extinguishers in the home and be aware of how to use them.

A nurse in a provider's clinic is caring for a client who has heart failure. Exhibit 1/Exhibit 2 Nurses' Notes First Clinic Visit: Client arrives to clinic with report of increasing shortness of breath, fatigue, and weakness. States they get short of breath with minimal activity. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus tachycardia. Pulses to lower extremities weak with +2 dependent edema present. Slightly labored respirations at rest. Chest with wheezes and crackles in the bases. Reports productive cough, especially during the overnight hours. Bowel sounds all present. Abdomen distended. Reports bowel movement this a.m. States voiding without difficulty, clear yellow urine. Teaching provided on nutrition therapy and adhering to a low-sodium diet, monitoring fluid intake, and lifestyle changes for heart failure. Provided medication teaching following provider's increase in furosemide dosage from 20 mg to 40 mg daily. Client to return in 2 weeks for follow-up. Second Clinic Visit: Client arrives for follow-up visit 2 weeks later. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus rhythm. Pulses to lower extremities weak. +1 dependent edema present. Respirations even. Chest clear. Reports less coughing. Bowel sounds all present. Abdomen slightly distended. Reports last bowel movement previous evening. States voiding without difficulty, clear yellow urine. States urination has increased with increased dose of furosemide. Vital Signs First Clinic Visit:Temperature 36.7° C (98° F)Heart rate 106/minRespirations 26/minBP 162/88 mm HgOxygen saturation 93% on room airWeight 83.9 kg (185 lb) Second Clinic Visit:Temperature 36.7° C (98° F)Heart rate 86/minRespirations 22/minBP 142/78 mm HgOxygen saturation 94% on room airWeight 81.6 kg (180 lb) A nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching? "I have been weighing myself every other morning." "I am trying to decrease my intake of foods with potassium." "I am limiting my sodium intake to 2 grams daily." "I am eating fewer potato chips and more fruit for snacks." "I lie down and rest after meals." "I know to call my doctor if I gain 3 pounds or more in 2 days."

A nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching? "I am limiting my sodium intake to 2 grams daily" is correct. Clients who have heart failure should maintain a sodium intake between 2 and 3 g daily. "I am eating fewer potato chips and more fruit for snacks" is correct. Chips are a processed snack food that contains high levels of sodium. Additionally, fruits contain electrolytes and fiber, both of which are important to controlling blood pressure and lipid levels. "I know to call my doctor if I gain 3 pounds or more in 2 days" is correct. The client should monitor weight on a daily basis and call the provider for a weight gain of 1.36 kg (3 lb) or more in 2 days to prevent an exacerbation of their heart failure.

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? - Pad the client's wrist before applying the restraints. - Evaluate the client's circulation every 8 hr after application. - Remove the restraints every 4 hr to evaluate the client's status. - Secure the restraint ties to the bed's side rails.

Pad the client's wrist before applying the restraints. The use of restraints without padding can abrade the client's skin, resulting in client injury.

A nurse is caring for a client who is receiving a unit of packed RBCs. Exhibit 1 Exhibit 2 Nurses' Notes 0800:Packed RBCs initiated by the charge nurse through an 18-guage peripheral IV to infuse over 2 hr. 0815:Client reports itching and anxiety. Client's face is flushed and has hives. Vital Signs 0800:BP 112/64 mm HgHeart rate 80/minRespirations 18/minTemperature 37.1° C (98.8° F)Oxygen saturation 97% on room air 0815:BP 106/54 mm HgHeart rate 100/minRespirations 22/minTemperature 37° C (98.6° F)Oxygen saturation 95% on room air Complete the following sentence by using the list of options. The client has manifestations of _______ as evidenced by the client's ___________.

The client has manifestations of allergic reaction as evidenced by the client's itching Allergic reaction is correct. The nurse should identify the client has manifestations of an allergic reaction as evidenced by itching, flushing of the face, anxiety, and urticaria. The nurse should stop the transfusion and notify the provider. Itching is correct. The nurse should identify that itching, flushing of the face, anxiety and urticaria are manifestations of an allergic reaction to the blood transfusion. The nurse should stop the transfusion and notify the provider.

A nurse is caring for a client who has a new diagnosis of seizure disorder. ex 1: 0800:Client awake, alert, oriented to person, place, and time. Preparing for discharge today. No seizure activity recorded during the night. Discharge teaching provided to client and partner regarding a new prescription for carbamazepine. Taught importance of taking medication twice daily as prescribed, not to miss a dose, and not to double a dose if one is missed. Advised client to avoid grapefruit and grapefruit juice while taking carbamazepine. Reminded client that follow-up laboratory tests and eye examinations will be necessary while on this medication. Client and partner verbalized understanding of all medication teaching. 0900:On entry into client's room with discharge papers, client was found on the floor seizing. Call button pressed to ask for additional help. ex 2: Medication Administration Record Carbamazepine ER 200 mg PO twice per dayLorazepam 4 mg IV bolus PRN seizure activity, may repeat after 10 to 15 min Complete the following sentence by using the list of options. The nurse should first address the client's _____________ followed by the client's ________________

The nurse should first address the client's physical safety followed by the client's positioning Physical safety is correct. The greatest risk to the client is injury from the seizure. Therefore, the first action the nurse should take is to ensure the client's physical safety by protecting the client's head. The nurse should cradle the client's head in their lap or place a pad underneath the head. Positioning is correct. The nurse should attempt to turn the client on their side with their head tilted slightly forward. This position will protect the client's airway from the aspiration of any secretions that may occur. Therefore, this is the second action the nurse should take.

A nurse is caring for a client who has pneumonia. Exhibit 1 Vital Signs 0800:Heart rate 109/minRespirations 26/minBP 125/65 mm HgTemperature 39.2° C (102.6° F)Oxygen saturation 95% 1200:Heart rate 94/minRespirations 18/minBP 115/65 mm HgTemperature 37.8° C (100° F)Oxygen saturation 96% Exhibit 2 Medication Administration Record 0.45% sodium chloride IV at 125 mL/hr Vancomycin 1 g intermittent IV bolus every 12 hr Acetaminophen 650 mg PO every 6 hr PRN temperature greater than 38.3° C (101° F) Codeine 20 mg PO every 4 hr PRN cough Exhibit 3 Nurses' Notes 0800: Oriented to person, place, and time. Appears fatigued. Diaphoretic, febrile. Reports not sleeping well last night due to "coughing a lot." Moves all extremities well. Tachycardia. All pulses palpable. Reports chest discomfort with coughing. Respirations 26/min, shallow. Auscultation reveals diminished breath sounds and bilateral crackles. Pulse oximetry 95% on O2 2 L via nasal cannula. Hypoactive bowel sounds present in all four quadrants. States tolerating diet with no nausea or vomiting but has no appetite. Client states voiding using the bedside commode with no difficulty. Output of 500 mL clear, yellow urine flushed. IV infusing to right arm, no noted redness or irritation at site. Acetaminophen administered for temperature. 1200: States feeling better following administration of acetaminophen. Vancomycin infusion started. Client voices no discomfort at this time. 1300: Client reports intense pain at IV catheter site. Area taut, blanched, cool to touch with edema present. IV vancomycin discontinued and catheter removed. Provider notified.

The nurse should identify that the client might be experiencing extravasation as evidenced by the client's iv catheter site. Extravasation is correct. The client's report of severe pain and the appearance of the IV catheter site are indications of extravasation. Vancomycin is a medication that carries the risk of extravasation. IV catheter site is correct. The appearance of the site is an indication of extravasation. Vancomycin is a medication that carries a risk of extravasation.