Fundamentals

30. A nurse is caring for a client following a laparoscopic cholecystectomy. The client has a prescription for ondansetron 4mg IV bolus every 6hr PRN for nausea and vomiting. Identify the sequence of steps the nurse should follow to administer the medication. ( Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

1. perform hand hygiene 2. select the injection port of the IV tubing closest to the client 3. cleanse the injection port with an antiseptic swab 4. aspirate for blood return 5. inject the medication

156. A nurse is preparing to administer gentamicin 2 mg/kg IV to a client who weighs 220Ib. How many mg should the nurse administer? (Round to the nearest whole number.Use a leading zero if it applies. Do not use trailing zero). DOSAGE CALCULATION

200 mg

172. A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Place them in order of performance. Use all steps) - 1. Provide adequate lighting to inspect the abdomen - 2. Listen to the abdomen arteries using the bell of a stethoscope - 3. Percuss all four quadrants of the abdomen to measure sound quality - 4 Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm ( 1 to 3 in) into the abdomen - 5. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen

3, 1, 4, 2, 5

17. A nurse is reviewing a client's intake and output and notes the following: 0.9% sodium chloride 600mL IV infusion, cefazolin 250 mg in dextrose 5% in water 100mL intermittent IV bolus, 200mL emesis, 40mL voided urine, and 20mL urine from straight catheterization. The nurse should record the client's net fluid intake as how many mL? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) DOSAGE CALCULATION

700 mL

21. A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who has difficulty swallowing pills. Available is diphenhydramine 12.5mg/5ml oral syrup. Which of the following images indicates the correct number of mL the nurse should administer? (round answer to the nearest whole number.) DOSAGE CALCULATION

8ml

118. A community health nurse is teaching a group of clients about kegel exercises to prevent urinary incontinence. Which of the following instructions should the nurse include?

A. Contract your pelvic muscle when performing the exercises

153. A nurse is caring for a client who is receiving continuous enteral feeding via NG tube. Which of the following is an unexpected finding?'

A. Diarrhea one time in a 24 hour period

5. A nurse is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the nurse plan to initiate?

A. Droplet

6. A nurse in a well-child clinic receives a telephone call from a parent who states that their child accidentally swallowed paint thinner. The child is awake and alert. Which of the following responses should the nurse make?

A. Have your child drink one large glass of water.

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

A. Place the client in a side-lying position.

3. A nurse is caring for a client who has influenza and isolation precautions in place. Which of the following actions should the nurse take to prevent the spread of infection?

A. Wear a mask when working within 3 feet of the client

119. A nurse is assessing the skin of a client who has worked outdoors for the past 20 years. Which of the following findings is the nurse's priority?

B. A change in appearance of a mole on the shoulder

7. A nurse is documenting a client's medical record. Which of the following entries should the nurse record.

B. Administered pain medication

10. A nurse is collecting a sputum specimen for culture from a client who has a respiratory infection. Which of the following actions should the nurse take?

B. Offer the client oral hygiene after the collection

120. A nurse is caring for a client who has a high fever. Which of the following actions should the nurse take?

C apply a bath blanket between the client and a cooling blanket

9. A nurse is collaborating with a risk management team about potential legal issues involving client care. The nurse should identify which of the following situations is an example of negligence?

C. A nurse begins a blood transfusion without obtaining consent.

4. A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG tube. Which of the following actions should the nurse take?

C. Allow room for two fingers to fit between the clients skin and the restraints

2. A nurse is conducting a health assessment for a client who takes herbal supplements. Which of the following statements by the client indicates an understanding of the use of the supplements?

C. I use ginger when I get car sick

152. A nurse who is documenting information in a clients electronic medical record is asked to assist with an emergency. Which of the following actions should the nurse take?

C. Move the computer to a secure place

111. A nurse is caring for a client who has a drainage evacuator. Which of the following is an appropriate action by the nurse?

Collapse the device of air after emptying.

122. A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse use?

D. Place the shallow end of the fracture pan under the clients buttocks.

113. A nurse in an acute care facility is preparing to transfer a client to a long-term facility. Which of the following information should be nurse include in the hand off report? a. Effectiveness of the last dose of pain medication

a

121. A nurse is caring for an infant who is to undergo surgery. The nurse should identify which of the following individuals should sign the consent form? A. The infants 17 year old mother B. The infants provider C. The infants grandmother D. The mother's 21 year old sibling

a

124. A nurse is caring for a client who requires airborne precautions. The nurse is preparing to leave the clients room following a dressing change. Which of the following pieces of personal protective equipment should the nurse remove first? A. Gloves B. Eyewear C. Gown D. Mask

a

129. A nurse is caring for a client who has wrist restraints after an episode of violent behavior. Which of the following actions should the nurse take? a. Remove one restraint at a time

a

134. A nurse is discussing the stages of general adaptation syndrome with a newly licensed nurse. The nurse should identify that which of the following manifestations occurs during the alarm reaction stage? A. Dilated pupils B. Physical exhaustion C. Bradycardia D. Depression

a

135. A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first? A. Unplug the pump B. obtain a replacement pump C. Notify the biomedical department to fix the pump D. Label the pump with a defective equipment sticker

a

142. A nurse is preparing to collect a specimen from a client. Which of the following actions should the nurse take? a. Collect the sputum specimen in the morning

a

143. A nurse is assessing a client who has diabetes mellitus prior to performing a blood glucose test. Which of the following findings should indicate to the nurse that the client has hyperglycemia? A. Thirst B. Confusion C. Coolskin D. Shakiness

a

144. A nurse is assessing an older adult client. Which of the following findings should the nurse expect? a. Decreased sense of balance

a

145. A nurse is preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take? A. Report any discrepancy in the court total of the controlled substance after administration B. Place the assisted portion of the controlled substance in the sharps container C. Verify the count total of the controlled substance after removing the amount needed D. Ask a second nurse to report her signature when wasting any unused portion of the controlled substance

a

146. A nurse is caring for a client who has colon cancer and is scheduled for a colon resection with a possible colostomy. Before the procedure, the client tells the nurse, i'm worried about the bag. Which of the following is an appropriate response by the nurse? A. You are worried about having to wear a colostomy bag? B. Have you ever known someone who has a colostomy C. Let's wait until after the surgery to discuss your concerns about your colostomy D. The surgeon will only place the colostomy if it is necessary

a

147. A nurse is preparing to administer medication to a client. Which of the following should the nurse use as a client identifier? A. Age B. Room number C. Photograph D. Bed number

a

148. A nurse is preparing to administer an injection to a client. Which of the following actions should the nurse plan to take after administering the injection? A. Discard the needle in a puncture proof container B. Place the needle on the bedside table C. Remove the needle from the syringe D. Recap the needle before disposal

a

161. A nurse is caring for a client who has TB. which of the following precautions should the nurse plan to implement when working with the client? a. airborne

a

162. A nurse is implementing seizure precautions for a client who has a seizure disorder. Which of the following equipment should the nurse place at the client's bedside? a. Oral suction equipment and oral airway.

a

164. A nurse is preparing to obtain informed consent from a client who speaks a different language than the nurse and is scheduled for surgery. Which of the following actions should the nurse take? a. recommend an interpreter who is the same gender as the client.

a

165. A nurse is caring for a client who is receiving continuous enteral feedings through a gastrostomy tube. Which of the following actions should the nurse take? a. Aspirate residual volume every 4 hr

a

166. A nurse is preparing to insert an IV catheter for a client following a right mastectomy. Which of the following veins should the nurse select when initiating IV therapy? a. The cephalic vein in the left distal forearm

a

167. A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full liquids. Which of the following foods should the nurse offer the client as a part of a full liquid diet? a. Plain yogurt

a

168. A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client's plan of care? a. Schedule the client as the first procedure

a

169. Type 2 diabetes mellitus patient with corns and calluses. a. I can apply lotion to soften calluses as long as i don't put lotion between my toes

a

170. A nurse is caring for a male client who has a prescription for intermittent catheterization with a coude catheter. Which of the following images show the type of catheter the nurse should use? a. The picture with the curled end of the catheter

a

133. A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (SATA) - I need to check my medications for expiration dates - I will use the grab bars when getting in and out of the bathtub - I need to have a fire escape plan with my family

a, b, c

50. A nurse is teaching a newly licensed nurse about the care of a client who has a methicillin resistant Staphylococcus aureus (MRSA) infection. Which of the following statements by newly licensed nurse indicates an understanding of the teaching?

a. " I will place the client in a Private room."

47. A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client's son tells the nurse, " I don't know what to tell my dad if he asks how he is going to die." Which of the following is an appropriate response by the nurse?

a. " Let's talk more about your dad's condition."

57. A nurse receives a telephone prescription from a provider for a client who is experiencing pain. Which of the following responses should the nurse make?

a. " Will you please spell the name of that medication for me?"

14. A nurse is teaching a client about home care equipment. Which of the following information should the nurse include in the teaching? (select all that apply) d. "Keep the oxygen delivery system 0.6 m (2 feet) from any heat source" Nope e. "Lay the oxygen tank flat when storing" Nope

a. "Avoid using wool blankets when receiving oxygen" b. check the O2 delivery rate at least once a day c. align the middle of the ball in the flow meter with the line of the prescribed flow rate

12. A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (select all that apply)

a. "Cut the opening of the pouch 1⁄8 of an inch larger than the stoma " YES b. "Place a piece a gauze over the stoma while changing the pouch" YES c. "Use povidone-iodine to clean around the stoma" YES d. "Empty the ostomy pouch when it becomes one-third full of contents" YES e. expect the stoma to turn a purple-blue color as its heals" NOPE

81. A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client's son tells the nurse "I don't know what to tell my dad if he asks how he is going to die". Which of the following is an appropriate response from the nurse?

a. "lets discuss your concerns about your father," or anything along those lines that is therapeutic.

18. A nurse is discussing incident reports with a group of newly licensed nurses. The nurse should include that which if the following requires the completion of an incident report?

a. A client's prescribed laboratory testing was not obtained

59. A Nurse is caring for client who has pneumonia. The nurse should recognize which of the following should be discarded in a biohazard bag?

a. An emesis basin filled with blood from severe coughing

34. A nurse is preparing to suction a client's tracheostomy tube. Which of the following actions should the nurse plan to take?

a. Apply intermittent suction during catheter insertion

96. A nurse on a medical unit is caring for a group of clients. For which of the following tasks should the nurse wear a face shield.

a. Changing the brief of an older client who has Clostridium difficile

60. A nurse is caring for a client who is receiving enteral feedings via NG tube. Which following actions should the nurse take prior to administering the formula?

a. Check for gastric residual volume

51. A nurse is planning care for a client who reports having a latex allergy. Which of the following interventions should the nurse include in the plan?

a. Cover the blood pressure cuff with a stockinette.

11. A nurse is assessing an older client. Which of the following findings should the nurse expect?

a. Decreased sense of balanced

175. A nurse is caring for a client who has a new diagnosis of terminal cancer. Which of the following interventions is the priority?

a. Develop a list of goals

99. A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend?

a. Eat a light carbohydrate snack before bedtime

101. A nurse is planning care for client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?

a. Ensure the client is free of metal objects

94. A nurse is caring for a client who is agitated and threatening to harm others. The nurse places the client in restraints but does not notify the provider or obtain a prescription for the restraints. The situation respects which of the following torts?

a. False imprisonment

112. A nurse is preparing to transfer a client who is partially weight bearing from the bed to a chair. Which of the following action should the nurse take?

a. Have the client bear weight on her stronger leg

82. a nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses toes. Which of the following statements by the client indicates understanding of the teaching?

a. I can apply lotion to soften the calluses as long as I don't put lotion between my toes

79. A nurse is caring for a client who recently received a diagnosis of terminal cancer. Which of the following statement by the client partner indicates maladaptive coping?

a. I don't know of if I will be able to meet his physical needs.

77. A home care nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (select all that apply) d. I will apply tape over frayed areas of electrical cords e. I need to set my hot water heater to 140 degrees Fahrenheit

a. I will use the bars when getting in and out of the bath tub b. I need to check my medications for expiration dates c. I need to have a fire escape plan with my family

58. During change of shift report, a nurse discovers she overlooked a prescription for a type and cross-match of a client who is to have surgery the next day. Which of the following actions should the nurse take first?

a. Inform the provider of the delay in obtaining the type and cross-match.

174. A nurse is mixing a short acting insulin and an intermediate insulin in the same syringe for a client who has diabetes mellitus. Which of the following actions should the nurse take first?

a. Inject air into the short acting insulin vial.

95. A nurse is conducting a Webber test on a client. Which of the following is an appropriate action for the nurse to take?

a. Place an activated tuning fork in the middle of the client's head

93. A nurse is planning care for a client who has a new prescription for parental nutrition in 20% dextrose and fat emulsion. Which of the following is the appropriate action to indicate in the plan of care?

a. Prepare the client for a central venous line

15. A nurse is planning care for a client who reports insomnia. Which of the following actions should the nurse perform shortly before bedtime?

a. Provide a late supper.

85. A nurse is planning care for a client who has latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the clients plan of care? a. Schedule the client as the first surgical procedure of the day b. Cleanse the stoppers with primidone iodine for withdrawing medication c. Remove the stop stocks from iv tubing d.Ensure the gloves in the surgical suite are powdered gloves

a. Schedule the client as the first surgical procedure of the day

109. A nurse in a long-term care facility is assessing a client. Which of the following findings should the nurse recognize as an indication of fecal impaction?

a. Seepage of liquid stool

32. A nurse is assessing the body temperature of an adult client using a temporal artery thermometer. Which of the following actions should the nurse take? (Select all that apply)

a. Slide the probe across the clients forehead c. Hold the client's hair aside while performing the procedure

49. A nurse is caring for a client who is prescribed a special diet. The client is concerned that he does not have the resources to purchase the food he needs to adhere to the diet at home. The nurse should notify which of the following members of the health care team.

a. Social worker

87. A nurse is teaching a client how to self-administer daily low dose heparin injections. Which of the following factors is most likely to increase the clients motivation to learn?

a. The client's belief that his needs will be met through education

107. A nurse is teaching about home safety with. Which of the following instructions should the nurse include?

a. Use electrical tape to secure extension cords next to base boards on the floor

39. A nurse is obtaining the medication history of a client who asks about taking ginkgo biloba. The nurse should identify which of the following medications can interact adversely with this supplement?

a. Warfarin

63. A nurse is caring for a client who reports a pain level of 5 on a scale from 0-10. The client informs the nurse that pain meds are not an option for managing pain. Which of the following is an appropriate response by the nurse?

a. Would you like to get you a back massage?

98. A nurse is caring for a client who has a new diagnosis of fibromyalgia. The client tells the nurse that she wants to use traditional Chinese medicine for treatment instead of the medication prescribed by her provider. Which of the following is an appropriate response by the nurse?

a. You should ask the provider if she recommend traditional Chinese medicine.

173. a nurse working on a medical surgical unit is making client assignments for an upcoming shift. Which of the following tasks should the nurse assign to an assistive personnel?

a. assisting with ambulation for a client who has a pulmonary infection.

86. A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. Which of the following action should the nurse take?

a. direct verbal discharge instruction to the interpreter

71. A nurse is teaching the assistive personnel about upper body mechanics to prevent injury. Which of the following actions by the AP demonstrate an understanding of the teaching?

a. holding the object close to the body

106. A nurse is delegating client's care to the assistive personnel. Which of the following tasks should the nurse delegate to the AP?

a. obtain input & output for the patient that was stable, ADLs, specimen collection, I&O, vital signs if stable

73. A nurse is planning care to prevent skin breakdown for a client who is immobile and has urinary incontinence. Which of the following actions should the nurse include in the plan of care.

a. request a prescription for an indwelling urinary cath

89. A nurse is caring for a client who has an incisional wound and a prescription for wound care. Which of the following answers indicates the proper method of cleaning a wound site?

a. use a different sterile swab for each stroke

102. A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include

a.Use full length side rales on the client's bed

116. A nurse is assessing a client's personal hygiene. Which of the following findings indicates that the client might have difficulty with routinely bruising their teeth? A. Theclientsmucosaismoist B. The client gums feel spongy C. The client has a missing tooth D. The Client's tongue is a dull red color

b

128. A nurse is teaching a client who is about to undergo a bowel resection about advance directives. Which of the following instructions should the nurse include in the teaching? A.Your partner must be present when you sign the advance directives B. You will receive written information about advance directives prior to signing C. You are required to sign advance directives prior to surgery D. Your provider must sign the advance directives before surgery

b

131. A nurse is planning care for a client who has urinary incontinence. Which of the following interventions should the nurse include in the client's plan of care? a. Toilet the client every 4hr while the client is awake b. Apply a moisture barrier in a thick layer to vulnerable skin areas c. Cleanse the skin with antibacterial soap and hot water after each incontinence episode d. Reduce the clients daily fluid intake

b

132. A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse administers a 500 mL IV bolus. Which of the following actions should the nurse take first? A. Complete an incident report B. Obtain the client's vital signs C. Document the fluid infusion in the client's chart D. Report the incident in to the unit manager

b

137. A nurse is preparing a sterile field to assist with suturing a clients laceration. Which of the following actions should the nurse plan to take? A. Pour the sterile solution with the bottle 20cm(8in) above the sterile bowl B. Hold the bottle of sterile solution so that the label is facing the palm of the hand C. Place the lid of the sterile solution bottle face down on the sterile drape D. Apply sterile gloves before opening the bottle of sterile solution

b

155. A nurse is reviewing the medical record for a newly admitted client. Which of thefollowing laboratory values should the nurse report to the provider? A. Sodium 140 B. Potassium 1.8 C. Magnesium 1.9 D. Calcium 6.5

b

159. A nurse is documenting a dressing change for a client who has a pressure injury. Which of the following entries by the nurse demonstrate correct documentation? A. No changes noted to the wound from previous nursing notes B. Client pre-medicated with MSO4 sunq prior to dressing change C. The wound seems clean and does not appear to be infected D. New dressing applied as prescribed, no drainage on old dressing

b

163. A nurse is providing teaching to the family of a client who is at the end stage of life. Which of the following client manifestations should the nurse instruct the family to expect? A. Increased periods of wakefulness B. Altered breathing patterns C. Increased salivation D. Warm and dry extremities

b

65. A nurse is caring for a client who is immunocompromised which of the following actions should the nurse take?

b. Cleanse hands with an alcohol based hand rub before client contact

33. A nurse is preparing to insert a peripheral IV catheter into the client's arm. Which of the following actions should the nurse take to help dilate the vein?

b. Dangle the client's arm over the edge of the bed

26. A nurse is speaking with a client who has recently received a diagnosis of a chronic illness. The client states, " The doctor must be wrong. I can't be that sick". The nurse should inform the client that their reaction is an example of which of the following expected responses to grief?

b. Denial

92. A nurse is preparing to insert an IV catheter for an older adult client who has fragile skin. Which of the following actions should the nurse take?

b. Engorge the vein by placing the arm in the dependent position

75. A nurse is caring for a client who is 2 days postoperative following bowel resection and reports sudden severe abdominal pain. Which of the following actions should the nurse take first?

b. Expose the client's abdomen to look for changes in appearance

97. An adult client tells a nurse about recent lack of sleep due to changing to a night shift job. Which of the following interventions should the nurse suggest?

b. Listen to soft music before lying down

62. A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse take to verify proper placement of the tube?

b. Measure the pH of the gastric

52. A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, " I trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take?

b. Notify the Provider.

64. a nurse is caring for a client who has an extracellular fluid volume deficit. Which of the following findings should the nurse expect?

b. Postural hypotension

55. A hospice nurse is caring for a client who has end stage cancer. Which of the following interventions should the nurse include to promote the client's dignity?

b. Refrain from discussing the client's prognosis

46. A nurse is preparing to obtain a health history from a client. Which of the following actions should the nurse take?

b. Tell the client the purpose for collecting the information.

66. Which of the following veins should the nurse select when initiating iv therapy?

b. The cephalic vein in the left distal forearm

61. A nurse is caring for a client immediately following the insertion of an NG tube. Which of the following should indicate to the nurse that the tube is placed incorrectly?

b. The client is coughing

103. A nurse is planning to obtain a blood sample from a client for capillary blood glucose posttest. Which of the following should the nurse take to obtain the sample?

b. The lateral aspect of the finger

80. A nurse is planning care for a client who has a stage 1 pressure ulcer on the right heel. The nurse should anticipate application of which of the following dressings?

b. Transparent

69. A nurse is teaching a client about the care and use of hearing aids. Which of the following instructions should the nurse include in the teaching?

b. Turn the hearing aid off and the volume down before insertion

84. A nurse is admitting a client who has a clostridium difficile infection. Which of the following actions should the nurse take? Select all that apply a. Use an N95 respirator while providing client care e. Ensure the client does not receive fresh fruits

b. wear a gown and gloves when providing client care c. assign the client to a private room with positive air flow d. wash hands with soap and water after contact with the client

114. A nurse is providing teaching to a client who is self-administer an ophthalmic solution. Which of the following statements by the client indicates understanding of the teaching? a. I will keep my eyes closed for 5 mins after inserting drops b. I will insert the drops in the center of the eye c. I will press the inner corner of my eye after insert drops d. I will raise my eye lid up while looking down and insert drops

c

125. A nurse is teaching a newly licensed nurse about the care of a client who has methicillin resistant staphylococcus aureus (MRSA) infection. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. I will wear an N95 respirator mask when caring for the client b. I will tell the clients visitors to wear a mask when they are within 3 feet of the client. c. I will place the client in a private room d. I will remove my gown before my gloves after providing client care.

c

130. A nurse is preparing to administer several medications via NG tube to a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take? A. Dilute each crushed medication with sterile water B. Mix the medication together in a single syringe C. Flush the NG tube with 5mL of sterile water prior to administration D. Combine the medication with the formula in the feeding bag

c

136. A nurse is caring for a client who is receiving a warm, moist compress to relieve lower back pain. Which of the following findings should indicate to the nurse that the compress has been effective? A. The client's skin on the lower back is intact without redness B. The client's laughing at a television show C. The client states that he is able to concentrate while eating D. The clients's vital signs are within the expected reference range

c

139. A nurse receives a new prescription over the telephone from a client's provider. Which of the following actions should the nurse take first? A. Ensure that the provider signs the prescription B. Write down the complete prescription C. Read back the prescription to the dr d. Document the prescription as a telephone prescription in the medical record

c

149. A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change. Which of the following actions should the nurse plan to take during this stage? A. Assist the client in setting goals to make the change B. Develop a plan for the client to integrate the change into her lifestyle C. Present information about the benefits of quitting smoking D. Recommend small changes for the client to make to change her behavior overtime

c

154. A nurse is planning care for a female client who has an indwelling urinary catheter.Which of the following actions should the nurse include in the plan? A. Tape the catheter to the lower abdomen B. Attach the drainage bag to the side rails of the bed C. Keep the drainage bag below the level of the bladder D. Empty the drainage bag when it is three quarters full

c

171. A nurse is caring for a client following a bilateral mastectomy. The client is often tearful and avoids looking at her dressings. Which of the following actions should the nurse take first? A. Provide the client with a mirror to look at her mastectomy incisions B. refer the client to a breast cancer support group C. identify the impact of the mastectomy on the client's body image D. encourage the client to assist with her dressing change

c

45. A nurse is caring for a client who begins to cry after receiving a diagnosis of cancer. Which of the following responses should the nurse make?

c " it must be difficult for you to receive this kind of news."

53. A nurse is documenting client care. Which of the following abbreviations should the nurse use?

c. "BRP" for bathroom privileges

25. A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include?

c. "Delirium has an abrupt onset."

36. A nurse is caring for a client who has been treated multiple times for STIs. Which of the following responses should the nurse take?

c. "Let's explore why this might be re-occuring"

13. A nurse is preparing to obtain informed consent from a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

c. "Offer written information in the client's language"

16. A nurse on a medical-surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first?

c. A client who has new onset of dyspnea 24hr after a total hip arthroplasty •

74. A nurse is teaching a client who had an enucleation about care of an artificial eye. Which of the following information should be included in the teaching? (select all that apply) a. Store the artificial eye in the label container filled with 0.9% sodium chloride irrigation b. Remove from the artificial eye by retracting the upper eyelid

c. Apply pressure just below artificial eye to break the suction d. Clear the artificial eye with hydrogen peroxide before storing e. Retract the upper and lower lids to reinsert the artificial eye

91. A nurse is caring for a client who refuses to follow the providers prescription for bed rest. The nurse over hears the assistive personnel tell the client that if she does not remain in bed he will place her in restraints. The nurse should identify that the AP is committing which of the following torts?

c. Assault

72. A nurse is assessing a client who is immobile and notices a red area over the client's coccyx. Which of the following actions should the nurse take?

c. Assess the red area for blanching

70. A nurse is teaching a client about the care and use of hearing aids. Which of the following should the nurse take?

c. Check the client's pupil reaction when focusing on distant and nearby objects

104. A nurse is planning to discharge a client who has diabetes and a new prescription for insulin which of the following actions should the nurse plan to complete first?

c. Determine whether the client can afford the insulin administration supplies

37. A nurse enters the room of a client who has a seizure disorder. The client is sitting in a chair and begins to experience a seizure. Which of the following actions should the nurse take first?

c. Help the client lie on the floor

108. A nurse is caring for a client who has restraints to each extremity. Which of the following assessment should the nurse perform first?

c. Peripheral pulses

38. A nurse is testing a client for conduction deafness by performing Weber's test. Which of the following actions should the nurse take when performing this test?

c. Place the base of a vibrating tuning fork on the top of the client's head

44. A nurse is performing a skin assessment on an older adult client. Which of the following findings should the nurse expect?

c. Reduced sweat production

83. A nurse is caring for a client who has wrists restraints after an episode of violent behavior. Which of the following actions should the nurse take?

c. Remove one restraint at a time

90. A nurse is teaching a client who requires maximum support about how to use a two wheeled walker. Which of the following actions by the client indicates an understanding of teaching?

c. The client stands with her elbows slightly flexed while holding the walker

54. A nurse is preparing to bathe a client who has dementia. Which of the following actions should the nurse take?

c. Use distractions when bathing the client.

78. A nurse in an emergency department is assessing a client who reports a right lower quadrant pain, nausea and vomiting for the past 48 hours? Which of the following actions should the nurse take first?

c.Auscultate bowel sounds

!60. A nurse is preparing to reposition a client who has a lower back injury. Which of the following actions should the nurse take? A. Place the clients arms at their sides B. Flex the client's knees C. Place the client at the side of the bed nearest the direction they will be turned D. Roll the client as one unit in a smooth continuous motion.

d

115. A nurse in a long-term care facility is planning care for 4 clients. Which of the following client's is at greatest risk of developing a pressure ulcer? a. A client who is incontinent of urine 1 to 2 times a day b. A client who is receiving enteral tube feedings c. Client who requires assistance to transfer from the bed to a chair d. Client who is unresponsive to pain stimuli

d

123. A nurse is reviewing the medical record of a client who asks about the use of a magnet therapy for pain relief. The nurse should identify which of the following findings is a contraindication for receiving this type of therapy? A. The client is allergic to penicillin B. The client has a prescription for metoprolol C. The client has a history of alcohol use disorder D. The client has an implanted defibrillator

d

127. A nurse is preparing to insert an IV catheter for an adult client. Which of the following actions should the nurse take? A.choose the most proximal site on the extremity selected B. apply a cool compress for several minutes before insertion of the IV catheter C. place the tourniquet below the proposed insertion site D. place the extremity in a dependent position

d

138. A nurse is caring for a client who is scheduled to have his alanine amino transferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse? A. This test will determine if your heart is performing properly B. This test will indicate if you are at risk for developing blood clots C. This test is used to check how your kidneys are working D. This test will provide information about the function of your liver

d

140. A nurse is caring for a client who is on bed rest following abdominal surgery. Which of the following findings indicates the need to increase the frequency of position changes? A. Petechiae on the client's right anterior thigh B. Flat rash on the client's ankle C. non-palpable macule on the client's left shoulder D. Non Blanching darkened area over the client's trochanter

d

141. A nurse is providing teaching to a client who has a newly prescribed hearing aid. Which of the following statements by the client indicates an understanding of the teaching? A. After insert the hearing aid, i will turn it up as high as it will go B. I should leave the battery in the hearing aid when i take it out to sleep C. I will need to get a new hearing aide every year D. I should gradually increase the time that i wear the hearing aid

d

150. A nurse is providing teaching to a client who is at risk for thrombus formation. Which of the following statements made by the client indicates an understanding of the teaching? A. I will keep my legs crossed while sitting B. I will perform exercises once every 4 hours while i am awake C. I should massage my legs when they hurt D. I should limit the time that i spend sitting in a chair

d

157. A nurse is caring for a client who tells the nurse, since I retired, I have a lot of time on my hands and nothing to do. I guess nobody needs me. Which of the following responses should the nurse make? A. If i were you, i would volunteer my time B. Do you have family members you can visit C. You need to realize that you have valuable skills to offer others D. Tell me about some hobbies you enjoy

d

158. A nurse is caring for a client who has an NG tube and has repeatedly pulled it out. The nurse should identify that which of the following findings indicates a need for restraints? A. The client's family is unable to stay with the client B. The client becomes confused at night C. The client gets out of bed to use the bathroom frequently D. The client is assigned a room near the nurses station

d

43. A nurse is preparing a client who has terminal cancer for discharge. Which of the following questions should the nurse ask when assessing the client's psychosocial history?

d. " What Techniques do you use to cope with stress?"

28. A nurse is teaching a client about performing breast self-examinations. Which of the following statements by the clients indicates an understanding of the teaching?

d. "I should make circular motions with my fingertips under my arms."

67. What interventions should the nurse take to prevent skin breakdown?

d. Apply a moisture barrier ointment after perineal hygiene

88. A nurse is caring for a client who is receiving continuous enteral feedings through gastrostomy tubes. Which of the following actions should the nurse take?

d. Aspirate residual volume every 4 hours (Every 4-8 hours is correct)

24. To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is the nurse manager functioning?

d. Client advocate

68. client tells the nurse" I am looking forward to seeing my grandchildren grow up." the nurse should identify the client is experiencing which of the following stages of grief?

d. Denial

40. A nurse is obtaining informed consent from a client who is scheduled for surgery. The client states, "I don't want to go through with the procedure." Which of the following actions should the nurse take?

d. Document the client's decision in the medical record

76. A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurses priority?

d. For the client explain the techniques of esophageal speech

29. A nurse is preparing to transfer a client who is partially weight bearing from the bed to the chair. Which of the following actions should the nurse take?

d. Have the client bear weight on her stronger leg

22. A nurse is admitting a client who is malnourished. The client states, "My wedding ring is loose and I'm worried I will lose it if it falls off."Which of the following is an appropriate response by the nurse?

d. I can put it in a locked storage unit for you

31. A nurse is teaching a client who has diabetes mellitus about mixing regular and NPH insulin. Which of the following statements made by the client indicates an understanding of the teaching

d. I should roll the vial of NPH insulin between my hands before drawing it up

20. A nurse is performing postural drainage with percussion and vibration for a client who has cystic fibrosis. Which of the following actions should the nurse take?

d. Perform percussion over the lower back

41. A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full to full liquids. Which of the following foods should the nurse offer the client as a part of a full liquid diet?

d. Plain Yogurt

56. A nurse is caring for a client who has a closed wound drainage system. Which of the following actions should the nurse take?

d. Press straight down on the container to create vacuum.

1. A nurse is planning care for a group of clients. Which of the following tasks should the nurse delegate to an assistive personnel?

d. Providing postmortem care to a client

35. A nurse is assessing a client who received morphine for severe pain 30 mins ago. Which of the following finding is the nurse's priority?

d. Respiratory rate 7/min

110. A nurse is caring for a client who has a tracheostomy which of the following actions should the nurse take?

d. Secure the tracheostomy ties to allow one finger to fit snuggly underneath

48. A Nurse is preparing to administer several medications to a client. Which of the following data should the nurse plan to use to confirm the client's identity?

d. The client's telephone number

19. A nurse is caring for a client who has a new prescription for negative-pressure therapy for a chronic wound. The nurse is unfamiliar with the procedure. Which of the following resources should the nurse consult to learn more about the intervention.

d. The policy and procedure manual

100. A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates understanding in the teaching?

d. The scale measures six elements

23. A charge nurse is teaching a group of newly licensed nurses about the use of restraints. In which of the following clinical situations should the nurse apply restraints?

d. When the client poses a threat to self

27. A Nurse on a medical-surgical unit is providing care for four clients. The nurse should identify which of the following situations as an ethical dilemma?

d. the family of a client who has a terminal illness asks the provider not to tell the client the diagnosis

42. A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching?

d." I will perform ankle and knee exercises every hour."