Fundamental Practice 2/11

A nurse is caring for a client who is dehydrated. The nurse should expect that insensible fluid loss of approximately 500 to 600 mL occurs each day through which of the following organs? A. Kidney's B. Lungs C. Gastrointestinal Tract D. Skin

skin the skin can excrete approximately 500 to 600 mL of insensible fluid loss, this type of loss is continuous and can increase if the client is experiencing a fever or has had a recent burn to the skin

A nurse is caring for a client who is receiving dextrose 5% in water IV at 150 mL/hr and has ingested 4 oz of water and ½ pint of milk. What is the total 8-hr fluid intake in milliliters that the nurse should document for this client? (round to nearest whole number)

1560 150ml x 8 = 1200 + 4 x 30 = 1320 + 8 x 30 = 1560

A nurse is preparing to administer sotalol to a client with a prescription for 320 mg/day divided equally every 12 hr. The medication is available in 80 mg tablets. How many tablets should the nurse administer per dose? (nearest tenth)

2

After assessing a client, the nurse documents "1+ pedal edema bilaterally." This indicates that the nurse observed an indentation of which of the following depths after applying pressure? A. 2mm B. 4mm C. 6mm D. 8mm

2mm

A nurse is monitoring a client's fluid intake. For breakfast, the client consumed 8 oz of milk, 10 oz of water, 4 oz of flavored gelatin, 1 scrambled egg, 1 crisp piece of bacon, and 2 biscuits with jelly. How many mL should the nurse record as the client's fluid intake? (Nearest whole number)

660

A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask B. A client who has emphysema and is receiving oxygen at 3L/min via transtracheal oxygen cannula C. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar D. A client who has COPD and is receiving oxygen at 2L/min via nasal cannula

A client who has heart failure and is receiving 100% oxygen via partial rebreather mask

A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview? A. Previous illnesses and surgeries B. Clients level of comfort and ability to participate in the interview C. Events surrounding the client's recent illness D. Sociocultural history

Clients level of comfort and ability to participate in the interview

A new resident provider asks the charge nurse for an access code to review clients' online records. The resident is not scheduled to attend the facility's orientation computer class until next week. Which of the following actions should the nurse take? A. Explain that it is against policy to share access codes and refer the resident to his supervisor B. Access the clients' online data and monitor the resident as he reads them. C. Access the online system and allow the resident to locate clients' data. D. Ask each client to give permission for the resident to access medical records.

Explain that it is against policy to share access codes and refer the resident to his supervisor

A nurse is caring for an adult client who communicates an unmet spiritual need. Which of the following client statements should indicate to the nurse that the client is experiencing spiritual distress? A. "Life has its ups and downs" B. "I believe that I control my own destiny" C. "God is punishing me for something" D. "I like to keep my rosary beads in bed with me"

God is punishing me for something

A nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I'll limit pushing the button, so I don't get an overdose." B. "If I push the button and still have pain after 2 mins, I'll push it again." C. "I'll ask my niece to push the button when I am sleeping." D. "I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button."

I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button

A nurse is providing nutritional teaching to a group of clients. Which of the following definitions for the recommended dietary allowance (RDA) should the nurse include in the teaching? A. The RDA is a comprehensive term that includes various standards and scales. B. The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups C. The RDA defines the levels of nutrients that should not be exceeded to prevent adverse health effects. D. The RDA is the daily percentage of energy intake values for fat, carbohydrate, and protein.

The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups

A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? A. "There are times I should use soap and water rather than an alcohol-based rub to clean my hands." B. "I will use cold water when I wash my hands to protect my skin from becoming dry C. "I will apply friction for at least 10 seconds while washing my hands." D. "After washing my hands, I will dry them from the elbows down."

There are times I should use soap and water rather than alcohol-based rub to clean my hands

A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use? A. Deltoid B. Ventrogluteal C. Vastus lateralis D. Dorsogluteal

Vastus lateralis

A middle-aged adult client is discussing future plans with the nurse. Which of the following statements should the nurse identify as an indication that the client is having difficulty achieving Erikson's developmental task for this age group? A. "We miss our daughter so much that we are going to move closer to her." B. "I think this year I can plan on managing the funding at church." C. "I really wish I could lose some of this weight." D."I find I am spending more time at work now that my son is at college

We miss our daughter so much that we are going to move closer to her

A nurse in an urgent-care center is caring for a 15-year-old client whose symptoms suggest a sexually transmitted infection (STI). The client's parent is unavailable, but the client's grandmother accompanied the client to the clinic. Which of the following actions should the nurse take? A. Explain that the treatment can wait until the parent is available. B. Inform the grandmother that she may give consent for the treatment C. Invoke the principle of implied consent and prepare the client for treatment D. Ask the adolescent to sign the consent form

ask the adolescent to sign the consent form

A nurse on a medical-surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client's record first? A. Assessment B. Plan of Care C. Nursing interventions performed D. Evaluation of progress

assessment

A nurse documents the presence of clubbing of the fingernails for a client who has emphysema. Which of the following is the underlying cause of this finding? A. Trauma B. Severe infection C. Iron-deficiency anemia D. Chronic hypoxemia

chronic hypoxemia

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? A. Change the topic because the client is trying to divert attention from the illness. B. Encourage the client to express thoughts about death and dying C. Tell the client that religious beliefs are a personal matter. D. Offer to contact the client's minister or the facility's chaplain.

encourage the client to express thoughts about death and dying

A nurse is preparing to administer liquid medication from a bottle to a client. Which of the following actions should the nurse take first? A. Hold the medication bottle with the label against the palm of the hand when pouring B. Place the cap with the inside facing down on a hard surface C. Fill the cup until the medication is even with the edge of the dosage scale D. Pour any excess liquid back into the bottle after measuring

hold the medication bottle with the label against the palm of the hand when pouring

A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take? A. Hyper oxygenate the client before suctioning B. Insert the catheter during exhalation C. Apply suction during insertion of the catheter D. Apply suction for no more than 15 secs

hyper oxygenate the client before suctioning

A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first? A. Inspect both breasts simultaneously B. Squeeze the nipples C. Palpate the breast and tail of Spence D. Palpate the axillary lymph nodes

inspect both breast simultaneously

A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? A. "A lot of clients who are cared for at home have the same problem" B. "Don't worry about it. He will get a bath, and that will take care of the odor." C. "It must be difficult to care for someone who is confined to a bed." D. "When was the last time that he had a bath?"

it must be difficult to care for someone who is confined to a bed

A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the client's body? A. Heart B. Lungs C. Thyroid gland D. Skin

lungs percussion creates a vibration that helps the examiner determine the density of the underlying tissue

A nurse in a long-term care facility is in the dining room while residents are eating lunch. One resident begins to choke and is coughing strongly. Which of the following actions should the nurse take? A. Assist the client to the floor B. Perform an abdominal pain C. Open the airway with a head-chin tilt D. Observe the client closely

observe the client closely

A nurse on a medical unit is caring for a client who has difficulty sleeping. Which of the following actions should the nurse take to promote the client's ability to fall asleep? A. Encourage the client to ambulate in the hallway just before bedtime B. Allow the client to maintain the same bedtime routine as at home C. Keep the room temperature warm D. Offer the client a cup of hot chocolate before bedtime

allow the client to maintain the same bedtime routine as at home

A nurse in a provider's office is teaching a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching? (SATA) A. Canned peaches B. White rice C. Black beans D. Whole-grain bread E. Tomato juice

black beans Whole-grain bread

A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first? A. Document the client's food allergies in the medical record B. Ask the client to identify the specific food allergies C. Monitor the client for indications of anaphylaxis D. Have epinephrine available for administration

ask the client to identify the specific food allergies

A nurse is caring for a client who is postoperative following an abdominal surgery. Which of the following actions should the nurse perform first after discovering the client's wound has eviscerated? A. Cover the incision with a moist sterile dressing B. Have the client lie on his back with his knees flexed C. Call the client's surgeon D. Reassure the client

cover the incision with a moist sterile dressing

A nurse is caring for a client who requires fluid restriction and may drink only 1 oz of water with each oral medication. How many milliliters of water should the nurse document as intake for the 3 separate medications the client receives during 12-hour night shift? (round to the nearest whole number)

90 mL

A nurse is caring for a client who has injuries resulting from a motor-vehicle crash. Which of the following client statements should the nurse address first? A. "I'm afraid this injury will cause me to lose my job." B. "I can't sleep well because whenever I move in my sleep, the pain wakes me up." C. "I don't know what I will do if my car isn't safe or even drivable after the crash." D. "I wonder how I am going to be able to take care of my family."

I can't sleep well because whenever I move in my sleep, the pain wakes me up

A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? A. "My parents are retired, and they have come to help with our children." B. "I am going to ask my husband to go to counseling with me." C. "I keep having nightmares about my upcoming surgery." D. "My girlfriends bought me a nice wig."

I keep having nightmares about my upcoming surgery

A nurse is teaching a client how to perform range-of-motion exercises of the wrist. To perform adduction, which of the following instructions should the nurse include? A. "With your palm facing down. Move your wrist sideways toward your thumb." B. "Move your palm toward the inner part of your forearm." C. "With your palm facing down, move your wrist sideways toward your little finger." D. "Bring the back of your hand as far back toward the wrist as you can."

With your palm facing down, move you wrist sideways toward your thumb

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? A. Vitamin C and zinc B. Vitamin D C. Vitamin K and iron D. Calcium

vitamin C and zinc vitamin c and zinc help fight infection

A nurse is caring for a group of clients in a long-term care facility. One of the clients is walking along the hallway and bumping into walls and does not respond to his name. Which of the following actions should the nurse take first? A. Offer the client a nutritious snack B. Accompany the client back to his room C. Reorient the client to his surroundings D. Administer a PRN anti-anxiety medication

accompany the client back to his room

A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear? A. Air conduction is less than bone conduction in the left ear B. Air conduction is greater than bone conduction in the left ear. C. Sound is lateralizing to the right ear. D. Sound is lateralizing to the left ear.

air conduction is less than bone conduction in the left ear

A nurse is performing an abdominal assessment of a client. Which of the following positions should the nurse tell the client to assume for this examination? A. Lithotomy B. Lateral C. Supine D. Sims

supine

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis? A. "I'll wrap the old dressing in a paper bag and put it in the trash." B. "I'll wash my hands before I remove the old dressing and again before putting on the new one." C. "I'll need to take a pain pill 30 minutes before I change the dressing." D. "I'll wear sterile gloves when I apply the new dressing."

I'll wash my hands before I remove the old dressing and again before putting on the new one

A nurse is supervising a newly licensed nurse who is administering a controlled substance. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A. Placing an unused portion of the medication in a sharps box B. Asking another nurse to observe the disposal of an unused portion of the medication C. Counting the inventory of the available narcotic after administering the medication D. Ensuring that another nurse signs the control inventory form after disposal of an unused

asking another nurse to observe the disposal if an unused portion of the medication

A nurse discovers that a client received the wrong medication. Which of the following actions should the nurse take first? A. Complete a medication error report B. Notify the prescribing provider C. Assess the client D. Notify the charge nurse

assess the client

A nurse is planning weight-loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? A. Attempt to increase the client's self-motivation B. Keep detailed records of each client's progress C. Test client learning after each teaching session D. Avoid discussing topics that might increase client's anxiety

attempt to increase the client's self-motivation

An adolescent client in an outpatient mental health facility tells the nurse that he struggles to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make? A. "Don't worry; teenagers often have friends who give bad advice." B. "I think you should stop seeing those friends since they discourage you from following your treatment plan." C. "Tell me more about how your friends discourage you." D. "Where did you meet these friends?"

tell me more about how your friends discourage you

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room. The client states she no longer wants to have the surgery. Which of the following actions should the nurse take? A. Tell the client it is too late for her to change her mind because the surgery is already scheduled. B. Telephone the operating room and cancel the surgery. C. Inform the client's family about the situation. D. Notify the provider of the client's decision

Notify the provider of the clients decision

A nurse is administering medication to a client who asks the nurse to leave the medication at the bedside to be taken at a later time. Which of the following responses should the nurse make? A. "Call me when you are ready, and I will return with the medication." B. "Since you were taking this mediation at home, I will leave it for you to take." C. "I will come back in 30 mins to check that you took the medication so I can chart the time." D. "If you refuse to take the medication now, I can't give it again until your next scheduled time."

call me when you are ready, and I will return with the medication

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? A. Apply a fecal collection system B. Apply a barrier cream C. Cleanse and dry the area D. Check the client's perineum

check the client's perineum

A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take? A. Clean the incision from bottom to top B. Apply sterile gloves prior to opening dressing packages C. Remove the tape by pulling away from the wound D. Clean the drain site from the center outward

clean the drain site from the center outward

A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? (SATA) A. coat the tip of the tube with a water-soluble lubricant B. ask the client to swallow water while the tube enters the throat C. Place the coiled tube in ice chips prior to insertion D. tell the client to tilt their head backward as insertion begins E. Instruct the client to bear down during insertion

coat the tip of the tube with a water-soluble lubricant tell the client to tilt their head backward as insertion begins ask the client to swallow water while the tube enters the throat

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? A. Daily weight B. Blood Pressure C. Specific gravity D. Intake and Output

daily weight weighing the client daily provides the most accurate fluid status

A nurse is assessing a client's pulses of the lower extremities. The nurse should identify which of the following as the location of the most distal pulse? A. Popliteal B. Posterior Tibial C. Dorsalis Pedis D. Femoral

dorsalis pedis

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? A. Redness at the infusion site B. Edema at the infusion site C. Warmth at the infusion site D. Oozing of blood at the infusion site

edema at the infusion site

A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the client's risk of aspiration? A. Irrigate the tubing with 30 mL of sterile water B. Elevate the head of the bed to 30 or 40 degrees C. Suggest changing the feeding to lactose-free formula D. Warm the enteral formula to room temperature before feeding

elevate the head of the bed to 30 to 40 degrees

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? A. Maintain suction while removing the NG tube B. Instill 100 mL of air into the NG tube before removal C. Pinch the NG tube while removing the tube D. Instruct the client to breathe in and out during the removal of the NG tube

pinch the NG tube while removing the tube

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurse take? (SATA) A. Carefully reinsert the intestine through the opening in the wound B. Place the client in a supine position with the hips and knees flexed C. Leave the room to call the surgeon D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

place the client in a supine position with the hips and knees flexed cover the wound and intestine with a sterile, moistened dressing monitor the client for manifestations of shock

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? A. Place the client in the Trendelenburg position B. Perform percussions directly over the client's bare skin C. Use a flattened hand to perform percussions D. Remind the client that chest percussions can cause mild pain

place the client in the trendelenburg position

A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take? A. Deliver the formula at a slower rate B. Request a lower-fat formula C. Provide more water with feedings D. Instill a lactose-free formula

provide more water with feedings The elevation in the client's specific gravity indicates dehydration. The nurse should provide more fluids either by adding free water to feedings or by instilling water between feedings. Another strategy is to request a formula that contains less protein.

A nurse is inserting an NG tube into a client who begins to gag and cough. Which of the following actions should the nurse take? A. Remove the NG tube B. Advance the NG tube quickly C. Pull the NG tube back slightly D. Ask the client to tilt his head backward

pull the NG tube back slightly

A nurse is caring for a client who is receiving IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? A. Redness at the IV catheter entry site B. Palpable cord along the vein used for the infusion C. Taut skin around the IV catheter site that is cool to the touch D. Bleeding at the IV insertion site

taut skin around the IV catheter site that is cool to the touch

While in the hospital, a client who has a terminal illness tells the nurse, "I can't believe I'm dying. A lot of bad people in the world are healthy and here I am dying!" Which of the following responses should the nurse provide? A. "Everyone dies sometimes; some die sooner than others." B. "Who do you think deserves to die more than you?" C. "It does seem unfair, doesn't it?" D. "Tell me more about how you feel about dying?"

tell me more about how you feel about dying

A nurse is teaching a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching? A. The client holds the cane on the unaffected side B. The client walks by stepping with the unaffected leg before the affected leg. C. The client holds the cane directly next to the foot. D. The client holds the cane with a straight elbow.

the client holds the cane on the unaffected side

A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? A. "Does the medication you're taking relieve the pain?" B. "Can you point to where the pain is the worst?" C. "What do you think caused the onset of your pain?" D. "Changing positions makes your pain worse, right?"

what do you think caused the onset of your pain?

A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make? A. "You look just fine to me" B. "Nobody expects you to look beautiful in the hospital" C. "I understand how you feel. I would feel the same way." D. "Would you like to talk about how you feel?'

would you like to talk about how you feel?

A nurse is evaluating the development of a group of clients. According to Erikson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development? A. Middle adulthood B. Adolescence C. Childhood D. Young adulthood

young adulthood

A nurse is caring for a middle-aged adult client. The nurse should identify which of the following statements as an indication that the client has completed Erikson's developmental task for her age group? A. "I am comfortable with my decision to choose a lifelong partner." B. " I think I have done a good job with my children since they are all independent now." C. "As I look back over my life, I can see that I have achieved most of the goals I set for myself." D. "I love my work so much that it is difficult to think about retirement

I think I have done a good job with my children since they are all independent now

A nurse is caring for a client who has a terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first? A. Ask why the client is refusing the pain medication B. Administer a PRN antianxiety medication C. Help the client change positions D. Offer the client a heat or cold pack to place on painful areas

ask why the client is refusing the pain medication assess first

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? A. Evaluate pedal pulses B. Obtain a medical history C. Measure vital signs D. Assess for leg pain

evaluate pedal pulses

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? A. Encourage the client to drink fluids before swallowing food B. Offer the client tart or sour foods first C. Tilt the client's head backward when swallowing D. Turn on the television

offer the client tart or sour foods first

A nurse is caring for a client who has bilateral cats on her hands. Which of the following actions should the nurse take when assisting the client with feeding? A. Sit at the bedside when feeding the client B. Order pureed foods C. Make sure feedings are provided at room temperature D. Offer the client a drink of fluid after every bite

sit at the bedside when feeding the client sitting at the bedside provides the client with the nurse's full attention

A nurse is teaching ROM exercises to a client who has osteoarthritis. Which of the following client positions demonstrates an understanding of supination of the hand? A. The client holds the hand with the palm up B. The client holds the hand with the palm down C. The client points the fingers toward the floor D. The client points the fingers toward the ceiling

the client holds the hand with the palm up

A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? A. Sweeping the floor B. Shoveling snow C. Cleaning windows D. Washing dishes

washing dishes

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give to the dietary assistant? A. Don a gown before entering the room and remove it before exiting B. Wear a mask while in the client's room C. Don gloves when entering the room and use hand sanitizer when exiting D. Take no special precautions unless engaging in direct contact with the client

Don gloves when entering the room and use hand sanitizer when exiting

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of primary prevention? A. Teaching clients to perform self-examinations of breasts and testicles B. Educating clients about the recommended immunization schedule for adults C. Teaching clients who have type 1 diabetes mellitus about care of the feet D. Recommending that clients over the age of 50 have a fecal occult blood test annually

Educating clients about the recommended immunization schedule for adults

A nurse is caring for a client who reports not sleeping at night, which interferes with her ability to function during the day. Which of the following interventions should the nurse suggest to this client? A. Avoid beverages that contain caffeine B. Take a sleep medication regularly at bedtime C. Watch television for 30 minutes in bed to relax prior to falling asleep D. Advise the client to take several naps during the day

avoid beverages that contain caffeine

A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? A. Place an oxygen mask on the client B. Check the client's pulses C. Determine whether the client is able to breathe D. Wrap arms around the client from behind

determine whether the client is able to breath

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? A. Give the client a glass of water B. Assist the client into a sitting position C. Explain the procedure to the client D. Measure the length of tubing to be inserted

explain the procedure to the client

A nurse is planning an in-service training session about nutrition. Which of the following statements should the nurse include in the teaching? A. "Fats provide energy" B. "Carbohydrates repair body tissue" C. "Fats regulate fluid balance" D. "Carbohydrates prevent interstitial edema"

fats provide energy

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? A. Leave the bag in place for 45 mins B. Fill the bag 2/3 full with ice C. Place the ice bag uncovered on the client's ankle D. Tell the client numbness is expected when the ice bag is in place

fill the bag 2/3 full with ice

A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) items should the nurse don prior to providing client care? (SATA) A. Gown B. Gloves C. Mask D. Hair cover E. Goggles

gown gloves

A nurse is reviewing a client's 24 hr dietary recall. The client reports eating a slice of toasted white bread with butter, a banana, a glass of milk, and a cup of coffee for breakfast; grilled chicken, a baked potato, and a glass of milk for lunch; an apple and cheddar cheese for a snack; and 2 servings of chicken, 2 cups of steamed broccoli, and a glass of milk for dinner. This client's diet is deficient in which of the following food groups? A. Dairy B. Vegetables C. Fruits D. Grains

grains

A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein? A. Eggs B. Soybeans C. Lentils D. Yogurt

lentils Incomplete proteins are missing 1 or more of the essential amino acids necessary for the synthesis of protein in the body. Examples of incomplete proteins include lentils, vegetables, grains, nuts, and seeds.

A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family- centered care? A. "Social services can contact various community resources that will be helpful." B. "I will review the care plan to make the necessary changes." C. "Let's set up a meeting time with the doctor to discuss your options for home care." D. "I will make a list of things we need to do before discharge."

lets set up a meeting time with the doctor to discuss your options for home care

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (SATA) A. Set the suction machine at 120 mmHg B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown E. Apply petroleum jelly to the client's nares

provide oral hygiene frequently measure the amount of drainage from the NG tube every shift secure the NG tube to the client's gown

A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? A. Aim the hose at the base of the fire B. Squeeze the handle of the extinguisher C. Remove the safety pin from the extinguisher D. Sweep the hose from side to side to dispense material

remove the safety pin from the extinguisher

A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? A. Irrigate the tubing with sterile normal water once during each shift. B. Cleanse the opening with soap and water after emptying. C. Maintain the tubing above the level of the surgical incision. D. Collapse the device to remove air after emptying

collapse the device to remove air after emptying

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen? A. Collect the specimen when the client rises in the morning B. Force fluids during the day and collect the specimen in the evening C. Collect the specimen after antibiotics have been started D. Collect 2 mL of sputum before sending the specimen to the laboratory

collect the specimen when the client rises in the morning

A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief? A. Encourage the client to listen to soft music B. Instruct the client to practice tai chi C. Place a jasmine-scented air freshener in the client's room D. Offer the client ginger tea

encourage the client to listen to soft music

A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? A. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink. B. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back C. Press the skin above the ankle for 5 seconds, release it, and note the depth of the impression D. Measure the skinfold thickness on the upper arm using a pair of calibrated skinfold calipers

grasp a skin fold in the chest under the clavicle, release it, and note whether it springs back

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? A. Instruct the client to defecate into the toilet bowl B. Transfer the specimen to a sterile container C. Refrigerate the collected specimen D. Place the stool specimen collection container in a biohazard bag

place the stool specimen collection container in a biohazard bag

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? A. Stand toward the client's stronger side. B. Instruct the client to lean backward from the hips. C. Place the wheelchair at a 45-degree angle to the bed. D. Assume a narrow stance with the feet 15 cm (6 in) apart.

place the wheelchair at a 45-degree angle to the bed

A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the following functional classifications? A. Skeletal muscle relaxants B. Beta-adrenergic blockers C. Broad-spectrum anti-infective agents D. Plasma volume expanders

plasma volume expanders Dextran and albumin are plasma volume expanders that help correct hypovolemia in emergency situations, such as after hemorrhage or burns.

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? A. Secure the restraint with the buckle side next to the client's skin B. Renew the prescription for the use of restraints within 24 hours C. ensure 4 fingers can be inserted under the secured restraint D. Remove the restraint every 3 hours

renew the prescription for the use of restraints within 24 hours

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse perform first? A. Open all sterile supplies and solutions. B. Stabilize the tracheostomy tube. C. Put on sterile gloves D. Perform hand hygiene

perform hand hygiene

A nurse is preparing to administer a unit of packed RBC's to a client when she discovers that the IV line is no longer patent. The IV team informs her that someone can come to initiate a new line in 30 min. Which of the following actions should the nurse take? A. Return the blood to the laboratory B. Place the blood in the medication room C. Place the blood in the refrigerator D. Leave the blood at the client's bedside

return the blood to the laboratory

A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take? A. Establish client outcomes B. Collect information about past health problems C. Determine whether the client has met specific goals D. Identify the client's specific health problems

establish client outcomes The planning phase of the nursing process includes developing goals and outcomes that help the nurse create the client's plan of care.

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching? A. The wound edges are well-approximated B. The wound is closed at a later date C. A skin graft is placed over the wound bed D. Granulation tissue fills the wound during healing

granulation tissue fills the wound during healing

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires interventions? A. Obtaining hydrogen peroxide for tracheostomy care B. Obtaining cotton balls for tracheostomy care C. Obtaining sterile gloves for tracheostomy care D. Obtaining a sterile brush for tracheostomy care

obtaining cotton balls for tracheostomy care

A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. People who practice the Islamic faith pray over the deceased for a period of 5 days before burial. B. People who practice the Hindu faith bury the deceased with their head facing north. C. People who practice Judaism stay with body of the deceased until burial D. People who are practicing the Buddhist faith have the female family members prepare the body following death.

people who practice Judaism stay with the body of the deceased until burial In the Jewish faith, a family member often stays with the body until burial occurs.

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? A. Insert the rectal tube 15.2 cm (6 in) B. Wear sterile gloves to insert the tubing C. Position the client on his left side D. Hold the solution bag 91 cm (36 inch) above the client's rectum

position the client on his left side

A nurse is helping a client change his hospital gown. The client has an IV infusion via an infusion pump. Which of the following actions should the nurse take first? A. Remove the sleeve of the gown from the arm without the IV line B. Slow the infusion using a roller clamp C. Disconnect the IV line from the pump D. Bring the IV solution and tubing from the outside to the inside of the sleeve of the gown

remove the sleeve of the gown from the arm without the IV line

A nurse delegates the collection of a client's temperature to an AP. The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring? A. Right task B. Right circumstance C. Right person D. Right communication

right communication

A nurse is screening a client who has an S-shaped spinal column with unequal shoulder heights. The nurse should identify these findings as manifestations of which of the following abnormalities? A. Scoliosis B. Lordosis C. Torticollis D. Kyphosis

scoliosis

A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin discharge planning? A. One week prior to the client's discharge B. Upon the client's admission to the care facility C. Once the discharge date is identified D. When the client addresses the topic with the nurse

upon the client's admission to the care facility

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular-sized cuff for a client who is obese. Which of the following explanations should the nurse give the AP? A. "The reading will be inaudible if the cuff is too small for the client." B. "The width of the cuff bladder should be 75% of the circumference of the client's arm." C. "As long as the cuff will circle the arm, the reading will be accurate." D. "Using a cuff that is too small will result in an inaccurately high reading."

using a cuff that is too small will result in an inaccurately high reading

A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement? (SATA) A. Auscultate injected air B. Verify the initial X-Ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid E. Check the aspirated fluid for glucose

verify the initial x-ray examination Measure the length of the exposed tube Determine the pH of aspirated fluid