Fundamentals

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following pieces of information should the nurse include?

A 10 month old infant can pull up to a standing position

A nurse is using the I-SBAR communication tool to give a clients provider information about the client. The nurse should convey this client's pain status in which portion of the report?

Assessment

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?

Assessment

A nurse is performing an otoscopic examination of a client's right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding?

Document this as an expected finding

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus?

Bear down

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse have the client perform just before inserting the catheter?

Bear down gently

A nurse is teaching a client with lower extremity weakness how to use a 4 point crutch gait. Which of the following instructions should the nures include in the teaching?

Bear weight on both of your legs

A nurse is performing a focused assessment of a client's peripheral vascular system. In which of the following location should the nurse palate the posterior tibial pulse?

Below the medial malleolus

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 a client indicate an understanding of teaching?

Black beans, Whole grain bread

A nurse is caring for a client who requires ventilatory assistance with breathing following a motor vehicle crash. The nurse should suspect an injury to which of the following parts of the brain?

Brainstem

A nurse is replacing the surgical dressing on a client who had abdominal surgery Which of the following actions should the nurse take?

Don clean gloves to remove the old dressing

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 interview?

Client's level of comfort and ability to participate in the interview

A nurse is performing a mental status examination on the client who has manifestations of dementia. Which of the following directions should the nurse give the client when evaluating the client's ability to think abstractly?

Discuss the meaning of a common proverb

A nurse is caring for a client who is producing large amounts of urine. The nurse should documents this findings as which of the followings?

Diuresis

A nurse is teaching a middle aged female client about disease prevention and health maintenance. Which of the following diagnosis tests should the nurse recommend as part of this client's routine health screening?

Eye examination every 2 years

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?

Face the client when speaking

A nurse is planning an in service training session about nutrition. Which of the following statements should the nurse include in the teaching?

Fats provide energy

A nurse is communicating with a group of clients about what to expect during the postoperative phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as an evaluation of effective communication/

Feedback is provided

A nurse is called away for an emergency while concerning with a client who is concerned abut his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?

Fidelity

A nurse is caring for a client who has the head of his bed elevated to a 45 angle with his knees slightly flexed. Which of the following positions should the nurse document for the client?

Fowler's

A nurse is caring for a client who is having difficulty breathing. The nurse should assist the client into which of the following positions?

Fowler's

A nurse is caring for a client who is postoperative following vascular surgery on the left femoral artery. The nurse should identify that the surgical wound should be cleansed in which of the following directions?

From the wound toward the surrounding skin

A nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to assess which of the following

Gait

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. This manifestation is consistent with which of the following eye disorders?

Glaucoma

A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first?

Gloves

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?

God is punished me for something

A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique?

Keeping microorganisms from entering the wound

A nurse is presenting an in service training session about nutrition. Which of the following simple sugars should be the nurse identity as the carbohydrate found in milk?

Lactose

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?

Lentils

A charge nurse is observing a newly licensed nurse performing tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?

Obtaining cotton balls for tracheostomy care

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse tkae wehn assissting the client at mealtime?

Offer the client tart or sour foods first

A nurse is caring for a client who has a facial impaction. Before the digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces

Oil retention

A nurse in a provider's office is measuring a client and notes a loss in height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders?

Osteoporosis

A nurse is initiating seizure precautions for a client who has a seizure disorder. Which of the following pieces of equipment should the nurse have readily available at the client's bedside?

Oxygen equipment

A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use?

PC for after meals

A nurse is helping a client charge his hospital gown. The client has an IV infusion via an infusion pump. Which of the following actions should the nurse take first?

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

A nurse is caring for a client who is receiving continuous enteral feeding through an NG tube and develops diarrhea. Which of the following actions should the nurse take?

Request a prescription for an isotonic enteral nutrition formula

A nurse is preparing to administer a bolus feeding to a client through an NG tube and observes that the exit mark on the tube has moved since the last tube feeding. Which of the following actions should the nurse plan to take?

Request an X-ray of the client's abdomen

A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid base imbalances?

Respiratory alkalosis

A nurse is caring for a client who has breast cancer. The client has been receiving radiation therapy for several months and now refuses to undergo further treatment. Which of the following actions should the nurse take?

Support the client's decision

A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care the facilitates which of the following outcomes?

Supports self-determination

A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?

Tachycardia

A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an assistive personnel (AP). The nurse later observes the AP emptying the bag without wearing gloves. Which of the following actions should the nurse take?

Talk with the AP about the technique used

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?

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

A nurse is teaching a client who has urinary incontinence about bladder retraining. Which of the following instructions should the nurse include?

Try to blood the urge to urinate until the next scheduled time

A nurse is performing a straight urinary catheterization of a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique?

Wiping the labia minora in an anteroposterior direction

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?

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

A client has 1 L of dextrose 5% in 0.45% sodium chloride infusing IV at 125 mL/hr. How many hours will it take for the liter to infuse?

8

A nurse is witnessing a client sign an informed consent form for surgery. What is the nurse affirming by this action?

The signature on the preoperative consent form is the clients

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?

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

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

Tie the restraint with a quick release knot

A nurse is caring for a client who requires fluid restriction and may drink only 1 oz of water with each other medication. How many millimeters of water should the nurse document as intake for the 3 separate medications the client receives during a 12 hr night shift?

90

A nurse discovers that a client received the wrong medication. Which of the following actions should the nurse take first?

Assess the client

A nurse is assessing a client's nutritional status. The nurse determines the client is consuming 500 calories more per day than his energy level requires. If his dietary habits do not change, how long will it take the client to gain 4.5 kg (10lb)?

10 weeks

A nurse is measuring the blood pressure of several clients. Which of the following results in within the expected reference range for blood pressure?

116/70 mmHg

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 1/2 pint of milk. What is the total 8 hr fluid intake in millimeters that the nurse should document for this client?

1560

A nurse is assessing the pH of a client's gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect?

2

A nurse is teaching the parent of a child who is taking 10 mL of a liquid medication. The parent has to hollow medication spoon marks to indicate teaspoons and tablespoons. How many teaspoons should the nurse instruct the parent to give the child?

2

After assessing a client the nurse documents +1 pedal edema bilaterally. This indicates that the nurse observed an indention of which of the following depths after applying pressure?

2 mm

A nurse is calculating a client's intake for a 12 hr shift. The client had dextrose 5% in 0.45% sodium chloride infusing at 125 mg in 100 mL at 1400, famotidine 20 mg in 50 mL at 1000 and 1600, 250 mL of blood over 2 hr, and a nasogastric flush of 30 mL every 2 hr. What is the total intake in milliliters that the nurse should document for this client for this 12 hr period?

2130

A nurse is preparing to administer 700 mL of 0.9% sodium chloride IV to a child to infuse over 24 hr. The drop factor of the manual IV tubing is 60 ggt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

29

A nurse is preparing to administer 40 mL of 0.9% sodium chloride IV to infuse over 20 min. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min.

30

A nurse is calculating the protein needs of a young adult client who weights 132lbs. The RDA for protein for an adult who has no medical conditions is 0.8 g/kg. How many grams of protein per day should the nurse recommend for this client?

48

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?

660

A nurse is caring for a cleint whose intake and output flow sheets for 0700 to 1500 indicates the following: voided x3:350 mL, 200 mL, 150 mL; wound drainage 2 tsp: and emesis 2 oz. What total output in milliliters should the nurse document for this 8hr period?

770

A nurse is caring for a group of clients in a long term care facility. The nurse should understand that which of the following clients is eligible for hospice services at this time?

A client who has end-stage cirrhosis

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

A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative. Which of the following clients should the nurse see first?

A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag fill of bright red, blood drainage

A nurse in a provider's clinic is taking a client's age, height, weight, and vital signs. The nurse should identify this action is part of which of the following components of the nursing process?

Assessment

A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessment should the nurse expect?

Absent bowel sounds with distention

A nurse asks a client to explain the statement, A bird in the hand is worth two in the bush. Through this question the nurse evaluating the client's ability in which of the following intellectual functions?

Abstract reasoning

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?

Accompany the client back to his room

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

Administer analgesics to the child on a routine schedule throughout the day and night

A nurse is caring for a client who states that she does not want to go out beed due to pain from arthritis. Which of the following actions should the nurse take?

Advise the client to perform range of motion exercises while in bed

A nurse is assessing a client who has dysphagia at mealtimes. Which of the following actions should the nurse take?

Advise the client to tuck his chine downward

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?

Air conduction is less than bone conduction in the left ear

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

Airborne

A nurse is admitting a client who has tuberculosis. In addition to standard precautions, which of the following transmission-based precautions should the nurse add to the plan of care?

Airborne

A nurse on a surgical unit receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse take sure?

Airway

A nurse is caring for a client who is well hydrated and has no visible evidence of nutritional deficiencies. A laboratory result within the expected reference range for which of the following substances indicates adequate protein uptake and synthesis?

Albumin

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states, All this equipment is making me nervous. Which of the following responses should the nurse offer?

All of this equipment can be frightening

A nurse on the 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?

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

A nurse is teaching a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups is responsible for movement at the knee joint?

Antagonistic

A nurse is using a portable ultrasound bladder scanner to measure a client's post void residual volume. Which of the following actions should the nurse take?

Apply light pressure to the scanner head once it is in position

A nurse is preparing to administer eye drops for a client who has glaucoma. When installing the medication, which of the following actions should the nurse take?

Apply pressure to the puncta after installing the medication

During a client care staff meeting a nurse manager discusses potential problems with data security that affect confidential client information. Which of the following environments should the nurse manager identify as an acceptable place for discussing clients' information?

Areas with no public access

A nurse in an emergency department is caring for a client who reports developing sever right eye pain with sawing wood. Which of the following actions should the nurse take first?

Ask the client about first aid performed at the scene

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?

Ask the client to identify the specific food allergies

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?

Asking another nurse to observe the disposal of an unused portion of the medication

A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission based on precautions. Which of the following actions by the newly licensed nurse indicates an understanding of a droplet precautions?

Assigning another client with the same infection to share the room with the client

A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states, It's too late for me to quit. Which of the following actions should the nurse take?

Assist the client in finding local smoking cessation assistance programs

A nurse is beginning a therapeutic relationship with a client. Which of the following actions should the nurse take to convey empathy when using the therapeutic communication technique of active listening?

Assume an open position

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 clients' commitment to a long term goal weight loss?

Attempt to increase the clients' self motivation

A nurse is assessing a client who is undergoing a physical examination. Following the inspection which of the following techniques should the nurse use when assessing the client's abdomen?

Auscultation

A nurse is assessing a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries?

Auscultation of the arteries for bruits with the bell of the stethoscope

A nurse rates a clients' biceps reflex as 2+. Which of the following characteristics should the nurse document about the client's reflexes?

Average

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?

Avoid beverages that contain caffeine

A nurse is taking a client's vital signs. Which of the following findings should the nurse identify as outside the expected reference range?

BP 145/90 mmHg

A nurse is beginning her shift and reviewing the medication administration records (MARs) for her client. She notes a dosage of a medication above the safe range and see that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take?

Call the provider to clarify the dosage

A nurse is caring for a client who just received a diagnosis of cancer. The client states, I just don't know what I'm going to do now. Which of the following responses should the nurse make?

Can you explain the concerns you're having right now

During the completion of health history with a nurse, a client reports intermittent chest pain for the past week. Which of the following questions is the nurse's priority?

Can you tell me what the pain felt like and show me exactly where it was

A nurse is inserting an IV catheter for a client that results in a blood spills on her glove hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

Carefully remove the gloves and proceed with and hygiene

A nurse is caring for a middle aged adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks?

Ceasing to compare personal identity with others

A nurse is caring for a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect injury to which of the following area of the brain?

Cerebellum

A nurse is implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take?

Check capillary refill before applying an ice pack on the affected area

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?

Check the client's capillary blood glucose level every 4hr

A nurse is caring for a client who has a stage III pressure ulcer on the hell. When preparing to irrigate the wound, which of the following actions should the nurse take first?

Check the client's pain level

A nurse is preparing to administer oral phenytoin to a client who has a seizure disorder. Before administering the medication which of the following actions should the nurse take?

Check the medication dose and the client's identification

A nurse is caring for a postoperative client who has an indwelling urinary catheter for gravity drainage. The nurse notes no urine output in the past 2 hrs. Which of the following actions should the nurse take first?

Check to determine if the catheter tubing is kinked

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?

Chronic hypoxemia

A nurse is preparing to administer a tuberculin skin to a client. After performing hand hygiene, which of the following actions should the nurse take?

Circle the injection area with a pen

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?

Clamp the tubing below the collection port

A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse perform?

Cleanse the wound with 0.9% sodium chloride irrigation

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

Coat the tip of the tube with a water soluble lubricant - Ask the client to swallow water while the tube enter her throat - Tell the client to tilt her head backwards as insertion begins

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?

Collect the specimen when the client rises in the morning

A nurse is explaining Piaget's theory of cognitive development to a group of daycare providers for employees' children at an acute facility. Which of the following activities should the nurse include as an example of concrete operational thinking?

Collecting and trading game cards

A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client's bedside and perform which of the following verification procedures?

Compare the medical record number and name on the MAR with the client's identification band

A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first line in CPR?

Confirm unresponsiveness

A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to him. Which of the following actions should the nurse take?

Consult the medication reference book available on the unit

During a physical examination of a client, the nurse suspects strabismus. Which of the following test should the nurse use the collect additional data?

Corneal light reflex

A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test?

Cotton wisps

A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include?

Cough deeply after each use

A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take?

Count the apical pulse for 1 full min and describe the rhythm in the chart

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse perform first after discovering that the client's wound had eviscerated?

Cover the incision with a moist sterile dressing

A nurse is assessing a client who has fluid volume excess. Which of the following findings should the nurse expect?

Crackles in the lung fields

A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing?

Cranial nerve XII

A nurse is planning care for a young adult client who has a terminal illness. Which of the following concepts of death should the nurse consider for this client?

Death is viewed as an interruption of what might have been

A nurse is reviewing the laboratory values of a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect?

Decreased calcium

A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk for which of the following health alterations?

Decreased cardiac output

A nurse is caring for a client who has terminal cancer. The client is proceeding with plans to build a new home. The nurse should identify that this behavior typically indicates which of the following stages of grief?

Denial

A nurse is assessing a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect?

Depressed deep tendon reflexes

A nurse is caring for a client who is unstable and his vital signs measured every 15 minutes by an electrical blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals, and the readings are inconsistent. Which of the following actions should the nurse take?

Disconnect the machine and measure the blood pressure manually every 15 min

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?

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

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month and may require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse share with the client?

Donate autologous blood before the surgery

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?

Dorsalis pedis

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when installing eye drops?

Drop the eye medication into the lower conjunctival sac

A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment?

Dry, brittle hair - Edema - Poor wound healing

A nurse is admitting a client who is experiencing an exacerbation of heart failure. At which of the following time should the nurse initiate discharge planning?

During the admission process

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 the infiltration

Edema at the infusion site

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?

Educating clients about the recommended immunizations scheduled for adults

A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein?

Eggs

A nurse is teaching an assistive personal (AP) how to obtain a capillary finger stick blood sample. Which of the following actions by the AP requires the nurse to intervene

Elevating the finger about heart level

A nurse is teaching an assistive personnel (AP) how to obtain a capillary ringer stick blood sample. Which of the following actions by the AP requires the nurse to intervene?

Elevating the finger above heart level

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?

Encourage the client to express thoughts about death and dying

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?

Encourage the client to listen to soft music

A nurse is discussing fire safety with newly hired nurses. Which of the following actions is the priority if a fire occurs in the health care facility?

Evacuate clients from the unit

A nurse on a medical surgical unit observes smoke billowing from a client's room. Which of the following actions should the nurse take first?

Evacuate the client from the room

A nurse is admitting a client who has decreased circulation to his left leg. Which of the following actions should the nurse take first?

Evaluate pedal pulses

A nurse is caring for an older adult client who has an in the canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source of this sound?

Excessive wax in the ear canal

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?

Exert pressure on the bony prominences when holding the eyelids open

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?

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

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?

Explain the procedure to the client

A nurse is reviewing a client's 24 hr dietary recall. The client reports eating a slice of toasted white bread wit butter, a banana, a glass of milk, and a coup 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?

Grains

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?

Granulation tissues fills the wound during healing

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?

Grasp a skin fold on the chest under the clavicle, release it, and not whether it springs back

A nurse is assessing a client who is postoperative. Which of the following findings should the nurse identify as an indication that the client is experiencing pain?

Grimacing

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?

Halo erythema on the surrounding skin

A nurse is caring for a client with dehydration who is developing hypovolemic shock. Which of the following laboratory values should the nurse expect for this client?

Hct 55%

A nurse is teaching a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use to first help the client make a commitment to these lifestyle changes?

Help the client identify ways that these changes will result in positive personal outcomes

A nurse is caring for a client is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?

Hemolytic

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of information should the nurse include in the teaching?

Hold the breath for 5 sec after goal volume is reached

A nurse is preparing to administer an otic antibiotic to an adult client who has otitis media. Which of the following actions should the nurse plan to take?

Hold the dropper 1 cm (0.5 in) above the ear canal during administration

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse perform?

Hold the linens away from the body and clothing

As a nurse is preparing to administer liquid medication from a bottle to a client. Which of the following actions should the nurse take?

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

A nurse is teaching a client how to use an albuterol metered dose inhaler. After removing the cap from the inhaler and shaking the canister what sequence of instructions should the nurse give the client?

Hold the mouthpiece 1 to 2 inches in front of your mouth - Tilt your head back slightly and open your mouth wide - Depress the canister while taking a slow, deep breath - Hold your breath for 10 seconds

A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside. Which of the following actions should the nurse take?

Hold the sterile drape above the waist and away fro the body

A nurse is caring for a client who has a stage II pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer?

Hydrocolloid

A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur?

Hyperglycemia

A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should actions should the nurse take?

Hyperoxygenate the client before suctioning

A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, You are not putting that hose down my throat. Which of the following statements should the nurse make?

I can see that this is upsetting you

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?

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

A nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student should the nurse identify as a potential problem with achieving Erikson's developmental task for this age group?

I go home on the weekends to be with my family because I don't have any good friends here on campus.

A nurse is 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?

I keep having nightmares about my upcoming surgery

A nurse in a provider's office is talking with an older adult client who reports having trouble sleeping. Which of the following statements should the nurse identify as a possible cause of the client's sleeping difficulties?

I often have a cup of coffee with my dessert before going to bed

A nurse is teaching a group of older adults about expected age-related changes. Which of the following statements by a group member indicated that the teaching has been effective?

I should expect my heart rate to take longer to return to normal after exercise as I get older

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?

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

A charge nurse is providing teaching to a newly licensed nurse about removing sutures from a client's laceration. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

I will clip each suture close to the skin and pull it through from the other side

A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching?

I will put a night-light in the hallway

A nurse is teaching a client who has asthma about the proper use of an albuterol inhaler. Which of the following client statements indicates an understanding of the teaching?

I will shake the inhaler well right before I use it

A nurse is instructing a client about collecting a 24 hr urine specimen for creatinine clearance. Which of the following statements should the nurse identify as an indication that the client understands the procedure?

I'll make sure to keep the collection bottle in the container of ice they gave me

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?

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

A nurse is teaching a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching?

I'll wear nonsterile gloves

A nurse is caring for a client who requires a chest X-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?

Identify the client using 2 identifiers

A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP indicates that further teaching is required?

If the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself

A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?

Impaired peristalsis of the intestines

A nurse is caring for a toddler at a well child visit when the mother call, Help! My baby is choking on his food. Which of the following findings indicated the toddler has an airway obstruction?

Inability to cry or speak

A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect?

Increased blood pressure

A nurse is assessing a client who is experiencing stress following a near fall out of bed. Which of the following physiological responses should the nurse expect due to the fight or flight response?

Increased blood pressure

A nurse is teaching a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group?

Independent moral development

A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care associated infections (HAIs). Which of the following routes of infection should the manager identify as an iatrogenic HAI?

Infection acquired from a diagnostic procedure

A nurse is administering a cleaning enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?

Insert the tip of the tubing 8 cm (3.1 in)

A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first?

Inspection

A client who has glaucoma of the right eye self administrators timolol eye drops by looking at the ceiling instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process which of the following actions should the nurse take?

Instruct the client to apply pressure to the inside corner of the eye after instillation

A nurse in an acute care facility is planning care for a client who is alert but temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse plan to take to prevent a complication of immobility?

Instruct the client to perform foot and leg exercises every 1-2 hr while awake to prevent thrombophlebitis

A nurse is teaching a group of unit nurses about the experiences of clients who are having surgery. In which phase of care is the client transferred to the surgical suite table before being transferred to the PACU?

Intraoperative

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asked the nurse how a TENS unit helps relieve pain. Which of the following responses should the nurse make?

It modulates the transmission of the pain impulse

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nurse stimulation (TENS) for pain management. The clients ask the nurse how a TENS unit help to relieve pain. Which of the following responses should the nurse make?

It modulates the transmission of the pain impulse

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?

It must be difficult to care for someone who is confined to bed

A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying?

It sounds like your pain is intermittent

A nurse is caring for a client who has a temperature of 38.7 (101.7). Which of the following actions should the nurse take?

Keep the client's bed linens dry

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?

Let's set up a meeting time with the doctor to discuss your options for home care

A nurse is reviewing the client's laboratory results and notes a WBC of 3,600/mm^3. The nurse should identify this result as which of the following conditions?

Leukopenia

A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse include?

Limit drinking liquids with food

A nurse in a provider's office is collecting information from an older client who reports taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects?

Liver damage

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse perform to transfer the client from the stretcher to the bed?

Lock the wheels on the bed and stretcher

A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from a bed to a wheelchair. Which of the following indicates to the nurse that the AP understands how to perform this skill?

Locking the brakes on the bed and the wheelchair before moving the client

A nurse is caring for a client who begins having a tonic clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first?

Lower the client to the floor

A nurse is caring for a client who starts to experience a seizure while setting in a chair. Which of the following actions should the nurse take?

Lower the client to the floor and place a pad under the client's head

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?

Lungs

A nurse is admitting a client who has a hearing aid. Which of the following actions should the nurse take before beginning the interview process?

Make sure the device is functioning

A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift in which the client received atenolol instead of allopurinol. Which of the following interventions is the nurse's priority?

Measure the client's apical pulse

A nurse is measuring a client's vial signs. The client's resting radial pulse rate is 55/min. Which of the following actions should the nurse take next?

Measure the client's apical pulse rate

A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3 18. Which of the following acid base imbalances should the nurse identify and report to the provider?

Metabolic acidosis

A nurse is caring for a client who had a stroke and is at risk for fallings. Which of the following actions should the nurse take?

Monitor the client at least once every hour

A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take?

Monitor the client at least once every hour

A nurse is changing the dressing for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?

Montgomery straps

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastrostomy tube for enteral feedings. Which pieces of information are critical to communicate to the next nurse who will be caring for this client?

New prescriptions, Arterial blood gas results, Tracheal secretion characteristics

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 surgery. Which of the following actions should the nurse take?

Notify the provider of the client's decision

A nurse is using the Braden scale to predict the pressure risk of a client in a long term care facility. Using this scale, which of the following parameter should the nurse evaluate?

Nutrition

A client who reports shortness of breath requests the nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next?

Observe the rate, depth, and character of the client's respirations

During the insertion of a urinary catheter for a client the tip of the catheter brushes against the nurses's arm. Which of the following actions should the nurse take?

Obtain a new catheter and reattempt insertion

A nurse is caring for a client who has a dysrhythmia. Which of the following techniques should the nurse use to assess for pulse deficit?

Obtain the apical and radial rates simultaneously

A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks both the client's native language and the nurse's, arrives to drive the client home. Which of the following actions should the nurse take?

Obtain the serves of an interpreter

A nurse is collecting health history data from a client who is deaf and using American Sign Language (ASL) to communicate. The nurse will be working with a ASL interpreter. Which of the following actions should the nurse take when working with the interpreter?

Pace speech to allow time for the interpreter to convey the words

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?

People who practice Judaism stay with the body of the deceased until burial

A nurse is performing a physical assessment of a client. Which fo the following actions should the nurse take to assess the client's tissues perfusion?

Perform a blanch test

A nurse is assessing the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse auscultates a high pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?

Pericardial friction

A nurse is assessing a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings?

Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities

A nurse is employing a thorough, systematic method while obtaining objective data about a client. Through which of the following methods should the nurse collect this information?

Physical examination

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?

Pinch the NG tube while removing the tube

A nurse is leading an education session about disposing of biohazardous materials. Which of the following instructions should the nurse include in the teaching?

Place soiled linen in a single linen bag

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take?

Place the client in a lateral position with the head turned to the side before beginning the procedure

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 had eviscerated. Which of the following actions should the nurse take?

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?

Place the client in the Trendelenburg position

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?

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?

Plasma volume expanders

A nurse is preparing to perform postural drainage for a client. Which of the following actions should the nurse take?

Position the client for drainage of secretions by gravity

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take?

Position the client on his left side

A nurse is monitoring a client's laboratory results. Which of the following results should the nurse report to the provider?

Potassium 3.0 mEq/L

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing?

Provide a protein intake of 1.5 g/kg of body weight per day

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?

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 performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take?

Pull suction catheter back 1 cm (0.5 in) if the client starts coughing

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take?

Pull the NG tube back slightly

A nurse is changing the dressing for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing? The nurse should document this finding as which of the following types of drainage?

Purulent exudate

A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?

Raise the level of the bed

A nurse is preparing to insert of NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure?

Raise your index finger if you need to pause during the insertion

A nurse is preparing to administer a partial dose of a prefilled opioid analgesic parenterally to a client. Which of the following actions should the nurse plan to take?

Record the amount of medication wasted on the controlled substance inventory record

A nurse is caring for a client who has chronic kidney disease. This kidneys regulate body fluids as well as assisting with which of the following functions?

Regulation of acid base balance

A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take?

Remove the restraints at least every 2 hrs

A home health nurse is visiting an older adult client with severe dementia. The client's son, who serves as her primary caregiver, reports being exhausted from working part time and caring for his mother at home. Which of the following options should the nurse suggest to give the caregiver?

Respite care

A nurse is preparing to administer a unit of packed RBCs 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?

Return the blood back to the laboratory

A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring?

Right communication

A nurse is performing a neurological assessment of a client. To promote safety during the examination the nurse stands nearby as the client follows the instructions for which of the following test

Romberg

A nurse is performing a neurological assessment on a client. Which of the following examinations should the nurse use to check the client's balance?

Romberg test

A nurse is assessing a client's incision and observes the drainage to be blood tinged. Which of the following terms should the nurse use to document this finding?

Sanguineous

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?

Scoliosis

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a form of secondary prevention.

Screening groups of older adults in nursing care facilities for early influenza manifestations

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection.

Side hip between the iliac crest and anterior iliac spine

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?

Sit and hold the client's hand

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include the teaching?

Sit on the toilet 30 mins after eating a meal

A community health nurse is conducting a close about body mechanics for county office workers. Which of the following instructions should the nurse include?

Sit with your back supported - Keep your knees at hip level - Use an ergonomically designed computer keyboard

A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in which of the following positions for evaluation?

Sitting

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?

Skin

A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for the client?

Soak the inner cannula of the tracheostomy tube in normal saline

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume?

Sodium

A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion?

Sodium 123 mEq/L

A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider?

Sodium 150 mEq/L

A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following?

Stabilizing the position of the tube, Preventing aspiration of secretions, Preventing air leaks

A nurse is caring for a client who has xerostomia with a lack of saliva. Which of the following nutrients will be affected by the lack of salivary amylase?

Starch

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respiration, and is pulseless. Which of the following actions should the nurse take first?

Start chest compressions

As part of a neurological examination a nurse instructs a client to keep his eyes closed, places and object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique?

Stereognosis

A nurse on a medical surgical units is caring for a client who is at risk of experiencing seizures. Which of the following pieces of equipment must be available at the client's bedside at all times?

Suction equipment

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?

Supine

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?

Tell me more about how you feel about dying

An adolescent client in an outpatient mental health facility tells the nurse that he struggles to follow his treatment plants because his friends discourage him. Which of the following statements should the nurse make?

Tell me more about how your friends discourage you

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning how to self-inject insulin. Which of the following statements should the nurse make?

Tell me what I can do to help you overcome your fear of giving yourself injections

A nurse is planning to obtain the vital signs of a 2 year old child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the child's temperature?

Temporal

A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client?

Test for the presences of the client's gag reflex

An assistive personnel (AP) is helping a nurse care for a female client who has an indwelling catheter. Which of the following actions by the AP indicates a need for further teaching?

The AP hangs the collection bag at the level of the bladder

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?

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

A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indications safe usage of this equipment?

The client has slightly flexed elbows when ambulating with the crutches

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?

The client holds the care on the unaffected side

A nurse is teaching range of motion exercises to a client who has osteoarthritis. Which of the following client positions demonstrates an understanding of supination of the hand?

The client holds the hand with the palm up

A nurse is assisting a client who has right sided weakness while ambulating using a cane. Which of the following client actions should indicate to the nurse that the client understands the procedure of cane walking.

The client keeps 2 points of support on the group

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who is scheduled for emergy surgery for appendicitis. Which of the following statements indicated a lack of readiness to learn by the client?

The client reports sever pain

A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following enteries should the nurse enter into the client's medical record?

The client threw the medication on the floor

A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following entries should the nurse enter into the client's medical record

The client threw the medication on the floor

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following pieces of information must the nurse verify with another nurse prior to the administration?

The client's ID number, The client's name, ABO compatibility, Rh computability

A nurse is providing nutrition counseling to a middle aged adult client who has a sedentary job. Which of the following factors should the nurse consider?

The client's basal metabolic rate could decrease

A nurse is providing discharge teaching for a client who has type 2 diabetes mellitus and will be caring for herself at home. The client expresses concerns about preparing an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse offer?

The dietitian will help you choose foods that you are used to that also meet your health needs

A nurse is developing a plan of care for a client. Which of the following pieces of information should the nurse consider when planning care that is culturally congruent?

The meaning of disease can vary widely across cultures

A nurse on a medical surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical handwashing technique?

The nurse holds her hands higher than her elbows wile washing

A nurse is preparing to change a dressing on a client who is receiving negative pressure wound therapy. What sequence of actions should the nurse plan to take

Turn off the vacuum on the NPWT device and administer the prescribed analgesic, Remove the soiled dressing and perform hand hygiene, Apply sterile or clean gloves and irrigate the wound, Apply a skin protectant or a barrier film to the skin around the wound, Place prepared foam into the wound bed and cover with a transparent dressing, Connect the tubing to transparent film and turn on the NPWT unit

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?

Upon the client's admission to the care facility

A nurse is planning to administer pain mediation to a client following abdominal surgery. Which of the following actions should the nurse take first?

Use the pain scale to determine the client's pain level

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?

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

A nurse is administering an IM injection to a 5 month old infant. Which of the following injection sites should the nurse use?

Vastas lateralis

A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?

Ventrogluteal

A nurse is caring for a patient who reports using several herbal medicines. Which of the following actions should the nurse take?

Verify the herbal supplements do not interact with medications the provider has prescribed

A nurse is assessing a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields?

Vesicular

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?

Vitamin C and zinc

A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication of an infection?

WBC 15,000 mm^3

A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take?

Warm the irrigating solution to 37 (98.6)

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?

Washing dishes

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

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

A nurse is caring for a client who has methicillin resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse implement?

Wear a gown when in the client's room

A client is being discharged home with oxygen therapy delivered through a nasal cannula. Which of the following instructions should the nurse provide to the client and family members?

Wear cotton clothing to avoid static electricity

A nurse is caring for a client who has a Clostridium difficile infection and is in contact isolation. Which of the following actions should the nurse take?

Wear gloves when changing the client's gown

A nurse is caring for an older adult who becomes agitated when the nurse request to take the client's dentures be removed prior to surgery. Which of the following responses should the nurse provide?

What worries you about being without your teeth?

A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include?

When lifting an object, spread your feet apart to provide a wide base of support

A nurse is caring for a client who has a deficiency of vitamin D. Which of the following foods should the nurse recommend the client should include in his diet?

While milk

A nurse is obtaining a new capillary blood sample to determine a client's glucose level. The nurse prepares and punctures the client's finger from the procedure by does not obtain an adequate amount of blood. Which of the following actions should the nurse take next?

Wrap the client's finger in a warm washcloth