Foundations Content Review 1

The nurse is caring for a client who is on bed rest. After reviewing the image above, which is the most appropriate reason for the nurse to observe this client perform the activity? "This physical exercise only helps to promote blood flow to the extremities." "A client can perform this activity to prevent a permanent condition in the feet caused by bed rest." "It is important for the client to perform this exercise so the gluteal muscles do not shorten and cause one leg to be longer than the other." "The activity will help the client to build muscle mass in the calves."

"A client can perform this activity to prevent a permanent condition in the feet caused by bed rest." Assisting and observing the client perform dorsiflexion of the feet helps to reduce the risk of foot drop. Foot drop can occur if the toes of the feet are dropped downward for extended periods of time resulting in plantar flexion caused by changing the length of the muscles. Due to the gravitational pull, this position of the feet occurs naturally when the body is at rest and the toes are placed in a perpendicular position making heel-toe gait impossible. This results in altered mobility. Wearing shoes such as a high-top canvas sneaker could assist to minimize this complication of prolonged bed rest.

The nurse applies an alcohol-based hand rub upon entering the client's room. The client becomes upset stating, "You did not wash your hands!" Which response by the nurse is most appropriate? "We only wash our hands when they are visibly soiled." "I won't be touching you, so using the alcohol hand rub is the quickest method to perform hand hygiene." "Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin." "Washing the hands with soap and water is not necessary."

"Alcohol-based hand rub provides the greatest reduction in microbial counts on the skin."

A nurse is preparing to file a safety event report after a client experienced a fall. Which statement is correct regarding the filing of a safety event report? The nurse should record the incident in the client's medical record and fill out a safety event report separately. The nurse should await results of the x-ray before filing the report. The nurse should include a note on the client's chart that mentions the report. The nurse should make a copy of the safety event report and place it in the client's medical record.

"If I give this medication, the client probably will be sleepy."

A nurse manager is talking with a new nurse. The nurse manager determines that the new nurse is thinking critically based on which statement? "If I give this medication, the client probably will be sleepy." "If my client gets short of breath, I'm unclear about why." "I don't know if the client understands." "I'm not sure what to do here?"

"If I give this medication, the client probably will be sleepy."

The nurse is taking verbal medication prescriptions from the provider by hand to be documented in the clients eMAR for administration of medication. How should the nurse correctly document this information? Celecoxib 100 mg @ 0800 with applesauce, Jane Doe RN. 1200-Tramadol 50mg PO with OJ for pain rated 6 out of 10. Jane Doe RN. 0800-Amoxicillin 250mg PO with water. J. Doe, RN. Sertraline 100 mg per os HS 20:00. JD, RN.

0800-Amoxicillin 250mg PO with water. J. Doe, RN.

A nurse has administered 1 unit of glucose to the client as per order. What is the correct documentation of this information? 1 Unit of glucose 1U of glucose One U of glucose 1 bottle of glucose

1 Unit of glucose The nurse should write "1 Unit of glucose." The nurse cannot write "1 bottle" or "one U of glucose" because these are not the accepted standards. "1U" is an abbreviation that appears in the JCAHO "Do Not Use" list (see http://www.jcaho.com). It should be written as "1 Unit" instead of "1U" because "U" is sometimes misinterpreted as "zero" or "number 4" or "cc."

At 8:15 p.m., a client reports pain, and the nurse administers the prescribed analgesic. When documenting this intervention using military time, which time would the nurse use? 2015 0815 0945 1945

2015

The nurse is preparing to don sterile gloves for a procedure that requires surgical asepsis. Place the following steps in the order that the nurse should take when donning sterile gloves. Use all options. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. 2Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. 3Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. 4Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas.

3. Carefully open the inner package taking care not to touch the inner surface of the package or the gloves. 1. With the thumb and forefinger, grasp the folded cuff of the glove, insert fingers while pulling the glove over thee hand. 2. Place the fingers of the gloved hand inside the cuff of the remaining glove and insert the fingers while stretching it over the hand. 4. Adjust gloves on both hands if necessary, touching only sterile areas with other sterile areas.

The nurse prepares to give the change-of-shift report. The nurse provides the oncoming nurse with the intake and output record of the client for the shift, pictured above. What is the client's fluid balance in milliliters? Record your answer using a whole number. INTAKE breakfast- 120 meds- 60 lunch- 180 water- 240 IV fluids- 980 Output Urine- 200 175 320 400 1 Bowel Movement

485

A nurse is performing safety assessments in a health care facility. Which statements reflect considerations a nurse should keep in mind when assessing a client for safety? Select all that apply. A person with a history of falls is likely to fall again. Fires are responsible for most hospital incidents. Some people are more at risk for accidents than others. Between 15% and 25% of falls result in fractures or soft tissue injury. A medication regimen that includes diuretics or analgesics places an individual at risk for falls.

A person with a history of falls is likely to fall again. Some people are more at risk for accidents than others. A medication regimen that includes diuretics or analgesics places an individual at risk for falls.

A nurse is discussing care of her four clients with an unlicensed assistive personnel (UAP). The UAP is planning morning care and hygiene for the clients. Which client should the nurse instruct the UAP to offer hygiene measures to first? A client with body odor refusing to bathe. A pleasantly confused 86-year-old female requiring partial care being discharged today. A comatose 65-year-old man whose vital signs are: T: 98.7, P;60, R:9, B/P: 86/46. A 20-year-old man who is able to independently perform self-care and is recently medicated for pain.

A pleasantly confused 86-year-old female requiring partial care being discharged today.

A nurse has identified a nursing concern of altered nutrition based on the client's continued weight loss despite adequate intake. During the implementation phase of the nursing process, which activity(ies) is appropriate for the nurse to perform in care of this client? Select all that apply. Change the planned outcome to denote an increase in body weight. Ask the family to bring in a home-cooked meal. Gather subjective and objective data. Administer 100 ml of nutritional supplement as prescribed at bedtime. Contact a dietitian to perform a calorie count.

Administer 100 ml of nutritional supplement as prescribed at bedtime. Contact a dietitian to perform a calorie count Ask the family to bring in a home-cooked meal.

The nurse overhears an older adult client's son talking to her in a very aggressive and violent way. When the nurse walks into the room, the son changes and speaks kindly to his mother and the health care providers. What should the nurse do about this observation? Report the suspicions to the authorities. Ask to examine the client alone in order to speak to her privately. Document the observed behaviors in the client's chart. Nothing, as it is none of the nurse's concern.

Ask to examine the client alone in order to speak to her privately.

The nurse is caring for a new older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first? Apply a lap belt to assist with transfer Arrange furniture securely so that the client has something to hold on to. Assess the need for assistance with ambulation. Apply socks to the client's feet.

Assess the need for assistance with ambulation.

An older adult client recently suffered a stroke. The client is bedbound from the resultant paralysis of the right arm and right leg. Which intervention by the nurse is the best strategy to maintain skin integrity? Avoid hot water during bathing. Perform active and passive range-of-motion (ROM) four times daily. Provide a diet high in carbohydrates. Scoot the client up in bed with assistance.

Avoid hot water during bathing.

The nurse provides care for a female client who had a stroke 2 days ago. Which action(s) does the nurse take to facilitate health of the client's integumentary system? Select all that apply. Perform perineal care by cleansing the area from the anus toward the pubic area in one stroke Shampoo the hair with the client in bed using a tray to drain the water Bathe the client in bed to prevent unnecessary physical stress Perform back massage to promote circulation Provide hot water foot soaks to relax client

Bathe the client in bed to prevent unnecessary physical stress Shampoo the hair with the client in bed using a tray to drain the water Perform back massage to promote circulation

The nurse is caring for an older adult client. Which situational assessment findings establish the need for interventions? Select all that apply. Call light is at top of bed under the pillow. Bedside table with client's personal items is at the foot of the bed. Bed is in low position and brakes are in place. Oxygen by nasal cannula in place; tubing on floor; flow meter at ordered 3 L. Trash bag on side rail for used tissues.

Call light is at top of bed under the pillow. Bedside table with client's personal items is at the foot of the bed. Oxygen by nasal cannula in place; tubing on floor; flow meter at ordered 3 L.

Which statements accurately describe findings the nurse would document when performing a physical assessment of the oral cavity? Select all that apply. Oral malignancies may be present in the form of a dry oral mucosa. Hard deposits of tartar may be found on the teeth if plaque is allowed to build up. Gingivitis may be present involving the alveolar tissues. Caries may exist in the teeth, resulting from the failure to remove plaque. Stomatitis may be noted as an inflammation of the tongue. Cheilosis may present as reddened fissures at the angles of the mouth.

Caries may exist in the teeth, resulting from the failure to remove plaque. Hard deposits of tartar may be found on the teeth if plaque is allowed to build up. Cheilosis may present as reddened fissures at the angles of the mouth.

A nurse is applying restraints to a confused client who has threatened the safety of a roommate. Which actions would the nurse perform when properly applying restraints to a client? Select all that apply. Fasten the restraint to the side rail. For a restraint applied to an extremity, ensure that the restraint is tight enough that a finger cannot be inserted between the restraint and the client's wrist or ankle. Check agency policy for the application of restraints and secure a health care provider's order. Pad bony prominences. Remove the restraint at least every 2 hours or according to agency policy and client need. Choose the most restrictive type of device that allows the least amount of mobility.

Check agency policy for the application of restraints and secure a health care provider's order. Pad bony prominences. Remove the restraint at least every 2 hours or according to agency policy and client need.

A nurse is teaching a family member how to bathe the female bedbound client. What information should the nurse tell the client about perineal care? Clean the labia with flushing water then proceed to the anal area with a washcloth. Clean the perianal region with designated hospital grade disposable wipes. Clean the area surrounding the labia and anal area with washcloth before cleaning the labia and anus. Clean, using a washcloth, from the pubic area toward the anal area.

Clean, using a washcloth, from the pubic area toward the anal area

The older adult client is moving to another apartment. The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home? Use the stairs in the new home. Take walks outside. Change the older adult's routine. Clear clutter in the walkways of the new home.

Clear clutter in the walkways of the new home.

Which intervention(s) does the nurse initiate to assist a client in preventing corns on the feet? Select all that apply. Client will wear shoes that are straight and thin. Client will wear clean, dry socks. Client will wear shoes that are not tight around the toes. Client will wear shoes that have extra padding. Client will inspect feet daily.

Client will wear clean, dry socks. Client will wear shoes that are not tight around the toes. Client will wear shoes that have extra padding. Client will inspect feet daily.

Which group of terms best describes the nursing process? Family-centered, single point in time, intuitive Nursing goals, medical terminology, linear Client-centered, systematic, outcome-oriented Nurse-centered, single focus, blended skills

Client-centered, systematic, outcome-oriented

A client reports weakness following administration of insulin. The nurse decides to assess the client's blood glucose level and prepare a snack in case the level is low. Which action has the nurse implemented? Clinical reasoning Assessment Caring Reflection

Clinical reasoning

A new nursing graduate has made an error in documentation that led to an unexpected client outcome. When aiming to avoid future errors, which action should the nurse prioritize? Complete documentation as soon as possible after client interactions Prioritize subjectivity over objectivity in documentation Provide the greatest amount of detail possible in every charting entry Ensure charting entries are as concise as possible

Complete documentation as soon as possible after client interactions Documentation in a timely manner can help avoid errors. Accuracy is prioritized over brevity, and subjectivity is not a goal of documentation. It is necessary to provide sufficient detail but the goal is not to strive for the greatest amount of detail possible, which can compromise clarity.

A client with diabetes has been admitted to a long-term care facility. Upon assessment, the nurse noticed that the client's toenails are very thick, and pedal pulses are diminished. What nursing interventions are appropriate? Select all that apply. Use large clippers to clip toenails. Use orange stick to clean under toenails. Contact health care provider regarding diminished pedal pulses. Contact a podiatrist. Use emery board file to reduce toenail length.

Contact health care provider regarding diminished pedal pulses. Contact a podiatrist.

A client who has had abdominal surgery develops an infection in the wound while still hospitalized. Which precautions are implemented by the nurse to prevent the spread of infection? Airborne precautions Protective isolation precautions Droplet precautions Contact precautions

Contact precautions

A nurse is caring for a client who has been transported for a diagnostic test. The nurse is changing the client's bed linens and moves them to the location in the image. Which anticipated outcome is most plausible based on the nurse's actions? Contaminants can be transferred onto the furniture and spread microorganisms. The furniture will be tagged for removal from the hospital premise due to contamination. An incident report will be created and sent to risk management. Some hospital policies allow for temporary placement of soiled lines on furniture.

Contaminants can be transferred onto the furniture and spread microorganisms. Placing soiled linens on the floor or on furniture in a client's room is not appropriate. This action could further soil and contaminate the furniture because the floor is heavily contaminated. It is not an acceptable infection control practice for health care facilities to allow temporary placement of soiled lines on furniture and would not be noted in hospital policies. An incident report is not required, education and reinforcement of hospital procedures and infection control principles is warranted. It is not cost-effective for health care institutions to remove furniture that is soiled by linens. The furniture will be cleaned per hospital guidelines depending on the degree of contamination.

What is a systematic way to form and shape one's thinking? Critical thinking Trial and error Interpersonal values Intuitive thinking

Critical thinking

A client reports hearing voices in the head that tell the client to do bad things. When the nurse enters the client's room, the client is talking out loud to someone but there is nobody in the room. How should the nurse record this assessment? Do not document this assessment because the client could be using a wireless device to talk to family. Do not document this assessment because it is subjective. Document this assessment based on the client's behaviors. Document that the client is talking back to the voices in the client's head.

Document this assessment based on the client's behaviors.

The nurse is providing education to a group of healthy older adults. Which nursing recommendation best promotes client safety in an independent living environment? Suggest a high-fiber, low-fat diet Restrict consumption of liquids before bedtime Encourage exercise that improves balance and muscle strength Provide a pamphlet on maintaining healthy sleep habits

Encourage exercise that improves balance and muscle strength

A health care provider orders extremity restraints for a confused client who is at risk for injury by pulling out her central venous catheter. What is the nurse's most appropriate action when carrying out this order? Ensure that two fingers can be inserted between the restraint and the client's extremity. Use a quick-release knot to tie the restraint to the side rail. Apply restraints to the hands or wrists, never to the ankles. Remove the restraint at least every 4 hours, or according to facility policy.

Ensure that two fingers can be inserted between the restraint and the client's extremity.

Research has demonstrated that a common source of hospital-acquired infections in clients with intravenous (IV) infusions is the hub on the IV tubing. Which nursing practice competency is displayed when health care institutions recommend that health care providers always wash hands and wear gloves when accessing the hubs of IV tubing? Evidence-based practice Teamwork and collaboration Informatics Person-centered care

Evidence-based practice Evidence-based practice as defined by Quality and Safety Education for Nurses (QSEN) indicates the need to value evidence-based practice findings to ensure that the best clinical practice is provided for clients. When health care institutions change their policies based on research, this reflects the significance of this QSEN competency. Informatics is the use of technology to gather and use data to improve client health. Person-centered care is a model of client care based on holistic roots in which the nurse or other caregiver uses every clinical encounter to assess how the person is doing and to communicate respect, compassion, and care. Teamwork and collaboration are values in nursing that emphasize the benefits of health care team members working together to meet clients' needs rather than just individually.

A nurse is teaching a client about the beneficial effects of exercise on his body. Which education point would the nurse include in the plan? Select all that apply. Exercise decreases appetite. Exercise decreases rate of carbon dioxide excretion. Exercise increases intestinal tone. Exercise increases resting heart rate and blood pressure. Exercise increases efficiency of the metabolic system. Exercise increases blood flow to kidneys.

Exercise increases intestinal tone. Exercise increases efficiency of the metabolic system. Exercise increases blood flow to kidneys.

A client is receiving radiation treatments for thyroid cancer and has stomatitis. When planning care, the nurse identifies which priority nursing diagnosis? Risk for Infection Impaired Skin Integrity Imbalanced Nutrition: Less than Body Requirements Confusion

Imbalanced Nutrition: Less than Body Requirements

The unlicensed assistive personnel (UAP) is remaking the bed in a hospital room where the client was just discharged. The nurse observes the UAP performing the action pictured above. What initial instruction should the nurse provide to the UAP? Tell the UAP that it is best to do this with a partner. Remind the UAP that a gown and gloves should be worn. Inform the UAP that she should be wearing gloves. Teach the UAP about the chain of infection.

Inform the UAP that she should be wearing gloves.

The nurse has completed a bed bath on a client who is obese. The client asks the nurse to sprinkle baby powder in the perineal area. Which action is correct?' Apply a generous amount of baby powder to all areas where skin touches skin. Pour a small amount of powder into the hand and gently pat the perineal area while avoiding aerosolization of the powder. Inform the client that baby powder is not used because it may become a medium for bacterial growth. Carefully apply baby powder to skin folds only.

Inform the client that baby powder is not used because it may become a medium for bacterial growth. The nurse's best response is to inform the client that baby powder is not used because it may become a medium for bacterial growth. Baby powder should not be used on an infant.

Which are characteristics of critical thinking? Select all that apply. It requires a conscious and deliberate effort. It forms the basis for interdependent but not independent decision making. It is a habit that most nurses have learned in their education. It involves judgments based on evidence. It requires a systematic and logical approach

It requires a conscious and deliberate effort. It involves judgments based on evidence. It requires a systematic and logical approach

A nurse makes a medication error and reports it to the nurse manager, requesting assistance filling out the incident report. What guidance should the manager provide? Select all that apply. The nurse should document the suspected root causes of the incident It should include factual information about the incident. It should provide a clear, concise recording of the situation Completion of the incident report should be noted in the nurse's notes. The incident report should be placed with the client's health records.

It should provide a clear, concise recording of the situation It should include factual information about the incident.

A client will be transferred from the cardiovascular intensive care unit to the telemetry unit for continued care. Which documentation correctly demonstrates how the nurse would prepare information to be conveyed to the receiving nurse during a verbal handoff report? MR#12345, Alfred Jones, 76-year-old male 8 days post-op for RVEF. Transferring for monitoring for the next week. Braden score 13 and vitals are stable. IV fluids are currently being administered through R wrist with D51/2 NS + 20 mEq KCl at 125 ml/hr with orders to continue for 3 days. Pain at incision rated at 4 on a scale of 0-10 relieved with a combination of oxycodone and acetaminophen at 0845 with relief within 30 minutes. Mr. Alfred Jones, 76-year-old male, 8 days post-CABG to correct RVEF. Skin mostly warm and dry. Braden score 13. Vitals stable and documented in EHR. Client being transferred with D51/2 NS + 20 mEq KCl at 125 ml/hr in 18 gauge LFA PIV. Pain noted at 4 on the number scale. Oxycodone administered at 0800 with no relief reported. PRN acetaminophen administered at 0845 with pain decreased to 3 within 30 minutes. Alfred Jones, 76-year-old male-Transferring for monitoring for the next 7 days. Vitals are stable. IV fluids are currently being administered through R wrist with D51/2 NS + 20 mEq KCl at 125 ml/hr. Pain at incision relieved with a combination of oxycodone and acetaminophen at 0845. Mr. Alfred Jones, 8 days post-CABG to correct RVEF is being transferred to the telemetry unit. Vitals are BP 130/82, P 82 and irregular, R 21, T 99.2F (37.3C). Client is currently receiving D51/2 NS + 20 mEq KCl at 125 ml/hr in 18 gauge LFA PIV. Oxycodone pain medication administered at 0800 along with PRN acetaminophen.

Mr. Alfred Jones, 76-year-old male, 8 days post-CABG to correct RVEF. Skin mostly warm and dry. Braden score 13. Vitals stable and documented in EHR. Client being transferred with D51/2 NS + 20 mEq KCl at 125 ml/hr in 18 gauge LFA PIV. Pain noted at 4 on the number scale. Oxycodone administered at 0800 with no relief reported. PRN acetaminophen administered at 0845 with pain decreased to 3 within 30 minutes.

The nurse is completing a sterile dressing change on a confused client. During the procedure, the client reaches down and touches the contents of the open dressing kit. What is the nurse's next action? Wash the client's hands Restrain the client's hands Open a new sterile dressing kit Continue changing the dressing

Open a new sterile dressing kit The nurse's next action is to obtain a new sterile dressing kit before continuing with the dressing change procedure. Continuing the dressing change without obtaining a new kit would increase the client's risk for infection. The client's hands do not need to be cleansed after touching the contents of the kit, and it would be inappropriate to restrain the client's hands (unless the client is unaware of the event or has trouble remembering what is occurring).

What is the rationale for health care personnel to orient clients to rooms and equipment when they are admitted to the hospital? It allows time for the health care provider to write admission orders. Orienting clients to the surroundings decreases the potential for injury. It is hospital policy. It is part of the routine and is included on the admission checklist.

Orienting clients to the surroundings decreases the potential for injury.

Which abbreviation is correct for use in documentation? Sub q Per os PO BT

PO

A nurse is engaged in the assessment phase of the nursing process. When completing the physical exam, which techniques would the nurse likely use? Select all that apply. Percussing Auscultating Interviewing Inspecting Palpating

Percussing Auscultating Inspecting Palpating

A nurse makes an occupied bed that is stained with fecal matter. What should the nurse do with the dirty linens? Roll the linens into a ball and place them in a biohazard bag. Place the linens on the floor on top of a protective pad and roll them in the pad before placing in the linen hamper. Place them in a garbage bag and mark "disinfect" on the outside of the bag. Place a protective pad over and under the soiled linens to protect the clean linens.

Place a protective pad over and under the soiled linens to protect the clean linens. If linens are soiled with fecal matter, the nurse should obtain an extra towel or protective pad and place it under and over the soiled linens so that new linens will not be in contact with soiled linens. Linens are not placed in biohazard bags and destroyed, nor are they placed in garbage bags.

A client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure would be a priority recommendation for this client? Raising all the side rails of the bed Placing the client in a bed with a bed alarm Providing a bed that is elevated from the floor Using restraints on the client to prevent a fall

Placing the client in a bed with a bed alarm Raising all side rails on the bed would be a restraint, and may increase the client's risk of a fall if he or she climbs out of bed. Providing a bed that is elevated would put the client at a greater risk for a fall. Using restraints are not an option at this time, but placing the client in a bed with a bed alarm would help to prevent a fall.

The nurse performs personal hygiene, including bathing, for an immobile client. What benefit(s) is the client gaining? Select all that apply. Promotes relaxation and comfort Constricts blood vessels near the skin surface Reduces the risk of acquiring multidrug-resistant organisms Increases circulation Helps maintain muscle tone and joint mobility

Promotes relaxation and comfort Reduces the risk of acquiring multidrug-resistant organisms Increases circulation Helps maintain muscle tone and joint mobility

The client is to be discharged home with the wife providing some wound care. Which interventions can the wife perform at home? Select all that apply. Access IV site once a month and check for patency. Properly dispose of contaminated supplies. Monitor the wound for signs of infection. Take vital signs before giving medications. Provide basic hygiene care.

Properly dispose of contaminated supplies. Monitor the wound for signs of infection. Take vital signs before giving medications. Provide basic hygiene care.

A nurse is shaving a male client's face. Which should the nurse do? Let the skin hang loose and shave in long, downward strokes. Pull the skin taut and use short, upward strokes. Pull the skin taut and shave in the direction of hair growth using short strokes. Shave against the direction of hair growth, using short strokes.

Pull the skin taut and shave in the direction of hair growth using short strokes.

The emergency room triage nurse is assessing a client who may have been exposed to small pox. Which action would the nurse prioritize in the care of this client? Assessing medications that the client is taking Calling the client's emergency contact Notifying the appropriate agencies Quarantining the client and initiating isolation procedures

Quarantining the client and initiating isolation procedures

In SBAR, what does R stand for? Reinforcing data Recommendations Report Response

Recommendations

The nurse is planning to bathe a client who has thigh-high antiembolism stockings in place. Which action is correct? Leave the antiembolism stockings in place and spot-clean any soiled areas on the stockings. Remove the antiembolism stockings during the bath. Fold the antiembolism stockings halfway down to allow assessment of the popliteal pulse. Leave the antiembolism stockings in place, but be sure to remove all wrinkles.

Remove the antiembolism stockings during the bath.

The older adult client was admitted to the emergency department for accidentally overdosing on a prescribed medication. The client is prescribed several medications that have varying frequencies for administration. The nurse is providing tips to the client to prevent such an occurrence from happening again. What instructions would the nurse provide to the client? Select all that apply. Request large-print medication labels on each of the prescribed medication bottles. Maintain a list of medications with dosages and frequencies, and share it at each primary care provider visit. Place pills in a pill dispenser that provides for separate dosing throughout the day. Contact the pharmacist or primary care provider about questions regarding medications. Keep discontinued medications in case the health care provider prescribes the medication again.

Request large-print medication labels on each of the prescribed medication bottles. Maintain a list of medications with dosages and frequencies, and share it at each primary care provider visit. Place pills in a pill dispenser that provides for separate dosing throughout the day. Contact the pharmacist or primary care provider about questions regarding medications.

Upon hourly rounding, a nurse finds that a fire has broken out in a client's room. Which intervention is the priority? Confine the fire. Extinguish the fire. Raise an alarm. Rescue the client.

Rescue the client.

When assisting a client from the bed into a wheelchair, the nurse assesses the client on standing and notices the client is weak and unsteady. What would be the recommended nursing intervention in this situation? Use the call bell to summon the assistance of another nurse. Allow the client to keep standing for several minutes until balance returns. Place the client into the wheelchair. Return the client to the bed.

Return the client to the bed Once the client is standing, the nurse would assess the client's balance and leg strength. If the client is weak or unsteady, the nurse would return the client to the bed.

The nurse is using the nursing process to care for a client and is in the process of making a nursing diagnosis. Which condition best reflects a nursing diagnosis? Congestive heart failure Risk for falls Hypertension Pneumonia

Risk for falls

The nurse is caring for a client who has an elevated temperature. When calling the health care provider, the nurse should use which communication tools to ensure that communication is clear and concise? MAR SOAP SBAR PIE

SBAR

The nurse is assisting a client to ambulate following knee surgery. What is a key concern when assisting clients with activity? Confidentiality Privacy Nurse-client relationship Safety

Safety

What generalization can be made about safety in client care? Health care providers exclude safety as a client need. Although safety is a basic human need, it is provided by self-care. Safety is an important need, but not as important as self-actualization. Safety is a paramount concern underlying all nursing care.

Safety is a paramount concern underlying all nursing care.

After completing an assessment of a client, which finding should the nurse determine is the priority for care? Severe bleeding from a wound Diabetes Lack of family support History of asthma

Severe bleeding from a wound The client's problem is considered to be of high priority if it is life threatening, requires more intervention time, or has serious consequences. The severe bleeding from a wound would be the highest priority. The client's history of asthma, diabetes, and lack of family support may be important, but the bleeding is the priority.

The nurse begins a task and then realizes that personal protective equipment (PPE) is needed. What is the correct action by the nurse? Stop and obtain appropriate PPE. Ask a colleague to perform the task. Complete the task, then obtain PPE. Leave PPE in the room.

Stop and obtain appropriate PPE.

A client is to have an indwelling urinary catheter inserted. Which precaution is followed during this procedure? Medical asepsis technique Surgical asepsis technique Droplet precautions Strict reverse isolation

Surgical asepsis technique

The nurse is caring for an 80-year-old client who was admitted to the hospital in a confused and dehydrated state. After the client got out of bed and fell, restraints were applied. She began to fight and was rapidly becoming exhausted. She has black-and-blue marks on her wrists from the restraints. What would be the most appropriate nursing intervention for this client? Talk with the client's family about taking her home because she is out of control. Take the restraints off, stay with her, and talk gently to her. Sedate her with sleeping pills and leave the restraints on. Leave the restraints on and talk with her, explaining that she must calm down.

Take the restraints off, stay with her, and talk gently to her.

The nurse is caring for a client who has been physically restrained. Which observation(s) will the nurse include when documenting the client's care? Select all that apply. The client has redness around the ankles bilaterally. The client exhibits agitation and shouts at the nurse. The client's blood pressure is 135/82 mm Hg. The client participates in range-of-motion exercises. The client's skin turgor is normal.

The client has redness around the ankles bilaterally. The client exhibits agitation and shouts at the nurse. The client's blood pressure is 135/82 mm Hg. The client participates in range-of-motion exercises. The client's skin turgor is normal.

A nurse is caring for a client with a decreased level of consciousness (LOC). When performing mouth care, what action by the nurse will decrease complications of oral care? The client should remain in an upright position to avoid the tongue blocking the airway. The client should be placed in a side-lying position to prevent aspiration. The client should be placed in a position of comfort. The client should be placed in the lithotomy position.

The client should be placed in a side-lying position to prevent aspiration. Clients who are not alert are at risk for aspirating liquid into their lungs. Aspirated fluids predispose a client to pneumonia. The nurse should use special precautions to avoid getting fluid into the client's airways and lungs. Position the client on the side with the head slightly lowered. An upright position will not protect the airway from fluids entering. The lithotomy position is used for vaginal and anal exams and will not protect the airway from fluids and aspiration.

The nurse is preparing a care plan for a client with altered gas exchange in the lower airways. What short-term outcome is best for this client's care plan? The client will maintain a pulse oximeter reading of greater than 94% (0.94). The client will have clear breath sounds. The client will have decreased work of breathing. The client will maintain a respiratory rate between 12 and 20 breaths/min.

The client will maintain a pulse oximeter reading of greater than 94% (0.94). Outcomes can be short- or long-term, and short-term outcomes should describe a single, observable, and measurable behavior. Outcomes are created to specify a resolution to the identified nursing concern, such as altered gas exchange in the lower airways. Maintaining a pulse oximeter reading greater than 94% (0.94) specifies a resolution to this concern. Having clear breath sounds, decreased work of breathing, and a normal respiratory rate only assures that the airway is established but not that gas exchange is taking place to its fullest extent.

A client who is enrolled in Medicare and who has been recovering in the hospital from a stroke has developed a pressure injury on the coccyx, an event that the Centers for Medicare & Medicaid Services (CMS) has identified as a "never event." The nurse should recognize what implication of this CMS designation? CMS will bear the hospital's costs if the client chooses to sue the hospital. The hospital will be fined by CMS because the client developed a pressure injury. The hospital must bear any costs incurred for treating the client's injury. CMS may choose to divert clients to other health care facilities in the future.

The hospital must bear any costs incurred for treating the client's injury.

The nurse works at an agency that requires its employees to wear a face mask as long as the employee is in the building. Which activity(ies) performed by the nurse is correct? Select all that apply. The mask is positioned so that it covers both the nurse's nose and the mouth. The nurse puts on gloves prior to applying the mask. The nurse performs hand hygiene following removal of the their mask. The nurse touches only the strings of the mask when applying or removing the mask. The nurse does not touch the mask with their hands while wearing the mask.

The mask is positioned so that it covers both the nurse's nose and the mouth. The nurse performs hand hygiene following removal of the their mask. The nurse touches only the strings of the mask when applying or removing the mask. The nurse does not touch the mask with their hands while wearing the mask.

A nurse prefers to use an alcohol-based hand rub when providing care for clients. In which case is this practice contraindicated? The nurse is caring for a client with a C. difficile infection. The nurse finishes cleaning a client's table. The nurse finishes client care and hands are not visibly soiled. The nurse performs routine care and is moving to another client.

The nurse is caring for a client with a C. difficile infection.

What is the purpose of the diagnosis phase of the nursing process? To develop a prioritized list of client-centered problems To develop an individualized plan of client care To determine the client's health status To decide whether to continue, modify, or terminate client care

To develop a prioritized list of client-centered problems Diagnosing as part of the nursing process is meant to establish priorities of current and possible health problems of the client. Assessment is the process by which a nurse collects information from a database to determine a client's health status, self-care ability, and need for nursing health care. Outcome identification and planning specify the nursing diagnosis to the client's strengths, thereby individualizing the plan of care. Evaluation is used to determine the extent to which the client has met the outcome and drives the nurse to continue, modify, or terminate the plan of care.

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement regarding logrolling is correct? Use a drawsheet or a friction-reducing sheet to facilitate smooth movement. It is acceptable to twist the client's head, but not the hips, while logrolling. Logrolling can be performed by one experienced nurse. Logrolling will maintain straight alignment when the client is sitting in a chair.

Use a drawsheet or a friction-reducing sheet to facilitate smooth movement.

Which actions should the nurse perform to help prevent occupational safety hazards? Select all that apply. Twist or bend electric cords to make sure the cords are not dragging on the floor. Use three-pronged electric plugs whenever possible. Clean all equipment with soap and water after use. Use equipment only for the use for which it was intended. Only operate equipment the nurse is familiar with.

Use equipment only for the use for which it was intended. Only operate equipment the nurse is familiar with. Use three-pronged electric plugs whenever possible.

A client with cancer has been receiving chemotherapy for the past few weeks. The nurse is concerned about infection and is reviewing the white blood cell count (WBC) in the chart. Which result supports this concern? WBC of 10,500 mcL WBC of 25,000 mcL WBC of 5,500 mcL WBC of 7,500 mcL

WBC of 25,000 mcL Leukocytes, also called white blood cells (WBCs), and the inflammatory response make up the second line of defense to microbial invasion. A normal WBC count is 5,000 to 10,000 cells/mm3. A count above this range is indicative of infection.

The community nurse is educating a family about infection control measures. What teaching will the nurse include? Select all that apply. Wear personal protective equipment (PPE) when appropriate. Do not share drinking glasses with family members who are ill. Hand hygiene is not needed in the home environment. Standard precautions should be used when family members have active infections. Keep the entire living environment as clean as possible.

Wear personal protective equipment (PPE) when appropriate. Do not share drinking glasses with family members who are ill. Standard precautions should be used when family members have active infections. Keep the entire living environment as clean as possible.

A nurse is helping an older woman undress and notices the woman's knee-high hose have left deep indentations. The woman has diabetes. Does this pose a risk to the client? Yes, these are a safety hazard and should not be worn. No, knee-high hose are more comfortable. No, the indentations will go away. Yes, these can obstruct lower extremity circulation.

Yes, these can obstruct lower extremity circulation.

The nurse is caring for an older adult with pulmonary tuberculosis. Which precautions will the nurse begin? none contact droplet airborne

airborne

The nurse and an unlicensed assistive personnel (UAP) are transferring a client from a bed onto a stretcher. Prior to the move, where should the nurse position the stretcher? alongside the bed 1 in (2.5 cm) either lower or higher alongside the bed 2 in (5 cm) higher alongside the bed at the same height alongside the bed 2 in (5 cm) lower

alongside the bed at the same height

The nurse is caring for a client with right-sided weakness after having a cerebrovascular accident (CVA). While conducting the head-to-toe assessment, the nurse notices the client has redness around the right elbow. When developing the client's care plan, which problem-focused nursing concern will the nurse include? altered mobility due to cerebrovascular accident-related right-sided weakness as evidenced by elbow joint skin redness altered mobility risk due to pain from injury to elbow joint as evidenced by skin redness altered skin integrity of right elbow related to immobility due to right-sided weakness altered skin integrity risk related to immobility due to right-sided weakness

altered skin integrity of right elbow related to immobility due to right-sided weakness

An older adult client is being admitted to the hospital for treatment of a fractured hip. Which part of the nursing process would the nurse carry out first ? outcome planning evaluation assessment diagnosis

assessment

The correct progression of steps of the nursing process is: diagnosis, implementation, assessment, evaluation, and planning. implementation, planning, evaluation, assessment, and diagnosis. planning, assessment, diagnosis, evaluation, and implementation. assessment, diagnosis, planning, implementation, and evaluation.

assessment, diagnosis, planning, implementation, and evaluation.

Standard precautions apply to which items? Select all that apply. Intact skin Blood Mucous membranes Body fluid secretions Nonintact skin Sweat

blood body fluid secretions mucous membranes nonintact skin

What body system benefits the most from aerobic exercises? neurologic respiratory musculoskeletal cardiovascular

cardiovascular

The nurse is preparing to move a client from bed into a wheelchair to eat lunch. What client data would the nurse check to see if the assistance of another nurse is needed? client restrictions client food preferences client restraints client age

client restrictions When attempting to move a client, the nurse would first check the client's chart to see if the client has any physical limitations or restrictions. The nurse would also evaluate the client's condition and determine whether or not the client can help with positioning or understand directions. Last, the nurse would evaluate the client's body weight and his or her own strength. Age and food preferences would not affect movement. Clients with restraints still need to be moved and repositioned.

There have been an increase of needlestick injuries in the intensive care unit. When preparing to address this occurrence in a staff meeting, what should the nurse manager include in an education presentation to prevent needlestick injuries? Select all that apply. disposing of used needles in sharps container Using needleless adapters for medication administration using self-retracting safety needles wearing gloves for performing venipuncture recapping all needles after use

disposing of used needles in sharps container Using needleless adapters for medication administration using self-retracting safety needles

Which piece of personal protective equipment (PPE) should be removed first? Respirator Gloves Goggles Gown

gloves

When moving a client up in bed with the assistance of another caregiver, the nurse should: have the client fold the arms across the chest. elevate the head of the bed. ask another nurse about the plan of care. maintain a pillow under the client's head.

have the client fold the arms across the chest.

The nurse is caring for a client who has been on bed rest. The primary care provider has just written a new order for the client to sit in the chair 3 times per day. Which action will be most effective to transfer the client safely into the chair? having the client sit on the side of the bed for several minutes before moving to the chair infusing an intravenous fluid bolus 15 minutes before transferring the client into the chair obtaining a quad cane for the client to use as a transfer aid positioning a friction-reducing sheet under the client

having the client sit on the side of the bed for several minutes before moving to the chair Having the client sit at the side of the bed minimizes the risk for blood pressure changes (orthostatic hypotension) that can occur with position change.

A nurse is assessing a client's mobility status. What data would the nurse document as normal findings? Select all that apply. head, shoulders, and hips aligned in bed increased joint mobility scissors gait Fasciculations independent maintenance of correct alignment full range of motion

independent maintenance of correct alignment head, shoulders, and hips aligned in bed full range of motion Normal findings that the nurse would document regarding a client's mobility would include independent maintenance of correct alignment, full range of motion, and the alignment of the client's head, shoulders, and hips in bed. A fasciculation is a muscle twitch, which would not be a normal finding regarding a client's mobility. The documentation of a client having a scissors gait would not be a normal finding. Increased joint mobility would not be a normal finding regarding the client's mobility.

When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes: ensuring that abbreviations are understandable to clients who may seek access to their health records. limiting abbreviations to those approved for use by the institution. using only those abbreviations that are defined in full at another location in the client's chart. using only abbreviations whose meaning is self-evident to an educated health professional.

limiting abbreviations to those approved for use by the institution.

A nurse is about to enter the room of a client with a strain of influenza A. The nurse prepares to don PPE. Which would be appropriate? Select all that apply. respirator mask with face shield gloves gown

mask with face shield gloves gown

When assisting a client from the bed into a wheelchair, the nurse assesses the client for signs of dizziness. For what adverse condition is the nurse assessing in the client? circulatory alterations hypertension deep vein thrombosis orthostatic hypotension

orthostatic hypotension

The nurse is providing care to a client who had abdominal surgery yesterday. Click to highlight the items in the scenario that break the cycle of infection between the infectious agent and reservoir. The nurse enters the room, performs hand hygiene and confirms the client's identity . Using a scanner system the nurse accesses the medication adiministration record and hangs prescribed intravenous antibiotics . The nurse then prepares a sterile field on which sterile items are aseptically placed . The soiled dressing is removed and both the wound and the dressing are assessed. The nurse removes the soiled gloves and then dons sterile gloves to clean the wound and applies a new sterile dressing.

performs hand hygeine and hangs prescribed intravenous antibiotics prepares a sterile field on which sterile items are aseptically placed .

The nurse is providing oral care to a client who is unable to complete their own activities of daily living. While providing care, the nurse notices some bleeding. Following a full assessment and chart review, which potential cause(s) of oral bleeding will the nurse use to create a client-centered plan of care? Select all that apply. prescription for warfarin recent unwitnessed fall low platelet count prescription for carvedilol altered mental status dyspnea with exertion diagnosis of periodontitis current chemotherapy treatment

prescription for warfarin low platelet count diagnosis of periodontitis current chemotherapy treatment

The nurse is assisting the client who has dementia from the bed to the chair for mealtime. What actions by the nurse would facilitate cooperation from the client? Select all that apply. providing instructions one at a time using a forceful tone in the voice when providing instructions calling the client by the preferred name being positive in statements when providing instructions facing the client when speaking

providing instructions one at a time calling the client by the preferred name being positive in statements when providing instructions facing the client when speaking

A nursing student is donning sterile gloves to perform routine tracheostomy care for a client. Which behavior by the student would require immediate intervention from the instructor? washes hands for 20 seconds with soap and water reaches down to the bed to pick up a sterile drape picks up the glove at the folded edge with the thumb and forefinger stretches the glove over the hand without touching the unsterile area

reaches down to the bed to pick up a sterile drape The sterile gloves should always stay above waist level. Reaching down to the bed could create contamination to the sterile field and the student should be stopped and asked to don sterile gloves again. Washing the hands for 20 seconds with soap and water meets the expectation of 15 seconds. Picking up the folded edge of the glove is the appropriate step to get the glove on while maintaining sterility. The glove must be stretched over the hand carefully.

A client has an inguinal hernia repair and later develops a methicillin-resistant Staphylococcus aureus (MRSA) infection. What is the most important factor to prevent this infection? increased T cells surgical asepsis decreased antibiotics increased vitamin C

surgical asepsis Clients are at risk for health care-associated infections when the health care staff does not follow safety guidelines. Medical and surgical asepsis are the primary safety interventions for preventing disease in the health care environment.

Why is it important for the nurse to teach and role model proper body mechanics? to promote health and prevent illness to prevent unnecessary insurance claims to demonstrate knowledge and skills to ensure knowledgeable client care

to promote health and prevent illness

The nurse is caring for a 76-year-old client who has an unsteady gait. Which method is most appropriate to assist in transferring? transfer boards mechanical lift roller sheet transfer belt

transfer belt

A nurse is working with the case management model and using a collaborative pathway. The nurse notes that the client has not met an expected outcome and documents this using occurrence charting. When completing this documentation, what information would the nurse include? Select all that apply. Actions taken in response to the event Goals Incident report recording Cause of the event Unexpected event

unexpected event cause of the event actions taken in response to the event