health + lab mods 4-7 PRACTICE

The nurse is preparing to administer medications to the client. The client sees the nurse double checking each medication and asks the nurse what is occurring. What is the nurse's best response?

"Checking the medication again to ensure the right medication is given to you."

The nurse is teaching a parent how to administer ear drops to a 3-year-old client with an ear infection. What instructions should the nurse give the parent?

"Have the child lie down with the affected ear facing the ceiling while administering the drops and then wait for 5 minutes after the drops are in."

The nurse teaches the client about home use of a transdermal medication patch for pain. The nurse evaluates the teaching as effective when the client makes which statement?

"I can't use my heating pad in the same area as the patch."

A home health nurse is visiting a client who was taught to crutch-walk in the hospital following a knee surgery. The client says, "My armpits are so sore." Which information does the nurse provide?

"I hear that a lot from clients."

The client overhears the nurse reviewing the rights of medication administration and asks, "Why are you saying, 'right medication, right client, right route, right dose'?" What is the nurse's best response?

"I review these to make sure your medications are accurate and correct."

An older adult client is transferring from a supine position to a sitting position in a chair. The client reports dizziness when transferring. Which teaching by the nurse is most appropriate?

"Move slowly and sit on the edge of the bed before transferring to the chair."

The nurse administers medication to a client. Which statement by the nurse is required to satisfy the three checks and rights of medication administration?

"Please tell me your name and date of birth."

The nurse is teaching a client with diabetes to withdraw insulin from a vial when the client and the client asks why it is recommended to recap the needle after withdrawing the medication. What is the best response by the nurse?

"Recapping the needle maintains sterility of the needle before injecting."

The nurse caring for a client has just inserted a rectal suppository. What is the best instruction by the nurse at this time?

"Remain in horizontal position for 10 to 20 minutes."

The nurse is preparing to administer a sublingual medication. Which instruction to the client is correct?

"Try not to swallow while the pill dissolves."

What instructions should the nurse give a client following the administration of prescribed eye drops?

- "Do not rub the medicated eye(s) - "Wash your hands before and after you use the eye drops." - "Damage may occur if you touch the dropper to the eye."

The nurse is administering medications to the client. What does the nurse explain to the client who asks about the checks of medication administration? Select all that apply.

- "I check the label of any medication before administering it to you." - "I check the label when taking medication from the storage area." - "I check the label before removing the medication from its container."

The nurse is splitting medications. After splitting the tablet and administering half to the client, what should the nurse do with the remaining half? Select all that apply.

- Dispose of medication per hospital protocol - If the medication is a narcotic, waste with another nurse present.

Which assessment findings will the nurse use to determine the stage of a client's pressure injury? Select all that apply.

- No bone, tendon, or muscle visible - Visible subcutaneous fat - Full-thickness tissue loss

The nurse needs half of a tablet of medication and is preparing to split the tablet but there is no score. What should the nurse do? Select all that apply.

- Refrain from splitting the tablet. - Call the health care provider.

The nurse splits a medication for client administration. What should the nurse do to assure safety and proper documentation?

- Take computer to the bedside - Take medication to bedside - Take medication package and label to bedside.

A nurse is distributing the 0900 medications to the client. What should the nurse do when removing a tablet from a multi-dose bottle? Select all that apply.

- Take the multi-dose bottle into the client's room - Put an extra tablet back into the bottle from cap - Use gloves for extra protection.

when performing hand hygiene, when is it necessary to use soap and water instead of an alcohol-based hand rub?

- after using the bathroom

The nurse is caring for a postsurgical client. The client asks the nurse why he needs to ambulate so soon after surgery. The nurse explains that the goals of ambulation include which factors? Select all that apply.

- aid GI motility - increase joint flexibility - improve respiratory function

the nurse is conducting a neurovascular assessment on a postoperative pt who experienced a total knee arthroplasty (TKA). what is the nurse's initial intervention when it appears that there is an absense of a pulse in the affected foot?

- assess the capillary refill in both longer extremities

which interventions help minimize the risk of infection postoperatively?

- assessing temp frequently - following aseptic technique when changing incision dressings - implementing standard precautions - maintaining hydration

Which recommendations should be included in a teaching plan for preventing falls in the home? Select all that apply.

- avoid climbing on a chair or table to reach items that are too high to reach - use a night light - keep electrical and telephone cords against the wall and out of walkways - remove clutter from walkways

a nurse is caring for a client who has been placed in physical restraints. which nursing action is appropriate?

- communicate with family regarding need for restraints - check circulation and skin condition frequently and regularly - offer opportunities for toileting frequently + regularly

The nurse has inadvertently administered medication ordered for Client A to Client B. What is the appropriate nursing action? Select all that apply. - contact the provider to report the error - tell client a that the wrong drugs were given to client b - do nothing as long as client b has no reaction - assess client b thoroughly - complete an incident report

- contact the provider to report the error - assess client b thoroughly - complete an incident report

The nurse is preparing to administer eye drops to a client. What purposes are commonly associated with instilling medications via eye drops?

- control of intraocular pressure - pupil dilation - infection treatment - pupil constriction

Which age-related change(s) increase the risk for complications after illness or injury in the older adult? (Select all that apply.)

- decreased muscle strength + bone demineralization - altered pain + pressure perception - fragile blood vessels - decreased skin elasticity

A client has requested assistance with tooth brushing. What necessary supplies will the nurse gather? Select all that apply.

- disposable gloves - toothbrush - toothpaste - towel - emesis basin

which interventions will the nurse implement when maintaining medical asepsis?

- do not place soiled bed linen on the floor - keep personal fingernails short - practice good hand hygiene - clean the least soiled areas first

A nurse has administered an intramuscular injection. What will the nurse do with the syringe and needle? - take off the needle + throw the syringe in the client's trash can - recap the needle; place it in a puncture-resistant container - do not recap the needle; place it in a puncture-resistant container - break off the needle, place it in the barrel, and throw it in the trash

- do not recap the needle; place it in a puncture-resistant container

A nurse is preparing an injection by withdrawing the solution from a multidose vial. What is necessary to facilitate withdrawing a medication from the vial? - first, inject an equal amount of air into the vial - insert a separate needle to equalize the pressure - withdraw the liquid and then inject an equal amount of air - insert the needle + slowly withdraw the liquid

- first, inject an equal amount of air into the vial

An older adult patient has been admitted for a hip fracture. The nurse is assessing fall risk with a fall risk tool. What essential elements should the tool assess? (Select all that apply.)

- high risk meds - symptoms of dizziness - altered elimination - mental + emotional status

which factors increase a postoperative pt's risk of infection?

- immunosuppression - age - presence of an incision - weight

which nursing interventions will have the greatest impact on minimizing the spread of MRSA among patients on a surgical unit?

- implementing standard precautions - using appropriate PPE - instituting meticulous handwashing technique

when considering a 40yo postoperative pt, which factor is likely to present the greatest risk for the development of an infection?

- invasive or indwelling medical procedures or devices

Which subjective questions by the nurse demonstrate a familiarity with commonly occurring disorders that can put an older patient at risk for unnecessary iatrogenesis? (Select all that apply.)

- is this the first time you have fallen? - have you had any difficulty eating? - how well do you usually sleep?

The nurse performs a focused musculoskeletal assessment on a patient with a hip fracture. Which should the nurse include for this type of assessment? (Select all that apply.)

- joint tenderness - muscle weakness - pain

when bathing a pt who requires contact + droplet precautions, which PPD will the nurse put on?

- mask - gloves - gown

mr. griffin is receiving enoxaparin sodium therapy. which assessment data would the nurse report to the pt's HCP to ensure his postoperative safety?

- moderate amount of gum bleeding after completing oral hygiene

what actions are appropriate when donning PPE for contact isolation?

- perform hand hygiene - put on gown, being sure to securely tie or fasten - don gloves

The nurse has finished a discussion with an older adult client about dangers in the home. The nurse recognizes that the instruction was effective when the client identifies which common risks in the home? Select all that apply.

- polypharmacy - extension cords - clutter

Which nursing interventions should a nurse anticipate for an older patient with a hip fracture? (Select all that apply.)

- prevent skin breakdown by frequent repositioning - maintain non-weight bearing status - reassess affected extremity - use logrolling techniques to turn the pt in bed

the nurse is conducting a neurovascular assessment on a postoperative knee replacement pt. which assessment data could be considered an initial indication of neurological impairment?

- pt reports "pins and needles" sensation below the incision site

when considering hand hygiene, which action will best remove a possible microorganism reservoir?

- removing any rings

The nurse is helping a client walk in the hallway when the client suddenly reaches for the handrail and states, "I feel so weak. I think I am going to pass out." Which initial actions are appropriate? Select all that apply.

- support the client's body against the nurse and gently slide the client onto the floor - firmly grasp the client's gait belt

The nurse is preparing to give a bad bath to a client. Which supplies would the nurse need to gather before entering the client's room? Select all that apply.

- towels - protective pads - gown - linen - bath blanket

An adult with diabetes receives 20 units of insulin each morning and evening. How will the nurse teach the client to administer the insulin? - use a 5mL syringe + give 0.4mL - use an insulin syringe + give 20 units - use a tuberculin syringe + give 4/10mL - use a 1mL syringe + give 0.4mL

- use an insulin syringe + give 20 units

A client has just been given a walker and the nurse is explaining to the client how to use it. Which instructions should the nurse give the client? Select all that apply.

- wear nonskid shoes/slippers - choose a walker with wheels on the front legs if you have a faster gait - check the walker for signs of damage, frame deformity, or loose or missing parts before use

The nurse has chosen the deltoid site to administer an intramuscular injection to an adult client. What size needle would the nurse use?

1 to 1 1/2 in (2.5 to 3.8 cm).

The nurse needs to prepare an insulin pen for injection of a prescribed dose of insulin. Place the following steps in the correct order. Use all options. - Watch for a drop of insulin at the needle tip. - Screw the correct needle onto the reservoir. - Verify the dose selector returned to "0." - Dial the dose selector to 2 units. - Clean the tip of the reservoir with alcohol. - Hold the pen upright and press the plunger firmly.

1)Clean the tip of the reservoir with alcohol. 2)Screw the correct needle onto the reservoir. 3)Dial the dose selector to 2 units. 4)Hold the pen upright and press the plunger firmly. 5)Watch for a drop of insulin at the needle tip. 6)Verify the dose selector returned to "0."

Place in order, from first to last, these actions the nurse will perform when providing wound care to a client with a pressure injury. Use all options.

1)Put on clean gloves. 2)Remove old dressing. 3)Assess the wound bed. 4)Open dressing materials. 5)Irrigate the wound bed. 6)Time and date the dressing.

The nurse is preparing to draw up a medication that is supplied in a glass ampule. Place in order, the steps the nurse will take. Use all options. - Attach the filter needle to the syringe. - Discard the filter needle. - Wrap a small gauze pad around the neck of the ampule. - Withdraw the medication. - Attach a sterile administration device to the syringe. - Break off the top of the ampule.

1)Wrap a small gauze pad around the neck of the ampule. 2)Break off the top of the ampule. 3)Attach the filter needle to the syringe. 4)Withdraw the medication. 5)Discard the filter needle. 6)Attach a sterile administration device to the syringe.

How quickly would the nurse inject solution into an intramuscular site?

10 sec/mL of medication.

A nurse is assisting a 72-year-old client with a tub bath. The nurse fills the tub halfway with water and checks the temperature of the bath water. Which temperature would the nurse identify as appropriate for this client?

100oF

A provider orders docusate sodium 100 mg, PO twice a day for an older patient. The pharmacy provides docusate sodium liquid 150 mg/15 mL. How much medication should the nurse administer?

10mL

The nurse is preparing to administer a subcutaneous injection for an adult client. The nurse knows that the volume of the injection is limited to how many milliliters of fluid?

1mL

The nurse is preparing to administer a rectal suppository to an adult client. How many inches (or centimeters) should the nurse plan to insert the suppository?

3"

The client is prescribed ear drops to be given in both ears. After administering the ear drops in one ear, how long would the nurse wait before administering the ear drops in the other ear?

5 minutes

The nurse is demonstrating to a client with diabetes how to properly self-inject insulin. Which injection site would be most appropriate to recommend to the client?

Abdomen

The nurse is preparing a medication from a vial and contaminates the plunger after the medication is drawn into the syringe. What should the nurse do next?

Administer the medication as prescribed

The nurse has just finished administering the 0800-prescribed 10 units regular insulin in the left arm using an insulin injection pen. What will the nurse include in the documentation?

Administered 10 units regular insulin subcutaneous at 0800 in the left arm.

The nurse is administering an intramuscular injection of cortisone to a client. What action would the nurse take immediately following the injection?

Apply gentle pressure with a dry gauze.

The nurse is preparing to administer a transdermal medication. How should the nurse proceed?

Apply the medication directly to the skin.

The nurse is assessing the pain of a neonate with altered respirations. Which pain assessment scale would be the best choice for this client?

CRIES pain scale

The nurse opens the multidose container of oxycodone. The nurse needs 1.5 tablets to deliver the as needed dose, and the tablets in the container are not scored. What action by the nurse is best?

Call the pharmacy to request a supply change.

The nurse is performing the third medication check for a medication administered from a multi-dose bottle. What should the nurse do?

Check the multi-dose bottle label after identifying the client and before administering the medication.

The nurse is to administer a medication to a client in isolation and the medication is in a multi-dose container. How will the nurse complete the third check of medication administration?

Check the multi-dose label before putting the container back in the drawer and label medicine cup with needed information.

The nurse has administered a client's medication. Which action would be most appropriate if the client vomits immediately, or soon after administration?

Check the vomit/emesis for pills or pill fragments and call the client's health care provider.

Prior to the nurse administering eye drops to the client, what should the nurse do?

Clean the eyelids of any loose eyelashes.

The nurse is preparing to administer an intramuscular injection to a client. Which statement accurately describes how to prepare the client's skin prior to the injection?

Cleanse the area around the injection site with an antimicrobial swab using firm, circular motions moving outward from the site.

The nurse is in the client's room to administer the client's morning oral medications. Which action should the nurse take first?

Confirm the client's identity.

The nurse is caring for a client who has a newly written prescription for "fluoxetine 20 mg by mouth daily for treatment of depression." The nurse is unfamiliar with this medication. Which action is most appropriate?

Consult a professional medication reference before preparing to administer the medication.

Which is true about giving medication using the intramuscular route?

Delivers medication into the muscle tissues.

A nurse is preparing to administer oral medications to a client. While opening the unit dose package, the medication inadvertently falls on the floor. Which action by the nurse would be most appropriate?

Discard the current unit-dose package and obtain a new one.

The nurse is holding the skin with the non-dominant hand prior to inserting the needle for an intramuscular injection. What is the recommended technique?

Displace the skin using the Z-track technique by pulling the skin to one side 1 inch.

The nurse is administering a client's medication and more tablets than needed fall into the bottle cap. What should the nurse do?

Drop extra tablets into bottle from bottle cap.

The instructor observes a nursing student who is preparing a liquid medication from a multi-dose bottle. Which action would concern the instructor if it were demonstrated by the student?

Holds the bottle of liquid medication with the label facing the medication cup.

The Z-track technique is utilized during drug administration by which route? - IM - subcutaneous - indradermal - IV

IM

The nurse administering a subcutaneous injection to a client avoids massaging the site after injecting the medication. Why is massaging the site contraindicated?

It can damage underlying tissue.

Which contains all the components of a valid order? - John Smith, atenolol 50mg, twice a day, by mouth - John Smith, warfarin, once a day, by mouth - John Smith, enoxaparin sodium 120mg, subcutaneously, periumbilical - John Smith, 70 units, b.i.d., SL

John Smith, atenolol 50mg, twice a day, by mouth

After reviewing the skills for administering different medications, a student nurse demonstrates the need for additional review when she does takes which action?

Leaves before verifying that the client has swallowed the medication.

The nurse is caring for an adult client by inserting a rectal suppository. Which action would be most appropriate by the nurse?

Lubricate the suppository and gloved finger.

A nurse is administering an intramuscular injection to a client. Which best describes the nurse's recommended hand movements?

Moves non-dominant hand to steady the lower end of the syringe, and dominant hand to the end of the plunger.

The nurse is preparing a medication form a vial and notices that a piece of the self-sealing stopper is floating in the medication in the syringe. What should the nurse do next?

Obtain a new vial, syringe and needle and start over

The nurse prepares the client's nightly medication doses and needs to administer an as needed dose of a hypnotic medication for sleep. The sleep medication is in a unit-dose package. What action does the nurse take?

Open the package after the client confirms the dose is wanted.

The nurse is preparing to administer a subcutaneous injection of insulin to a client. Which site would the nurse choose?

Outer aspect of the upper arm.

The nurse is administering an intramuscular injection of the hepatitis B vaccine to a client. At what angle would the nurse insert the needle?

Perpendicular to the skin.

After administering ear drops to a client, how does the nurse ensure the medication is delivered completely?

Place gentle pressure on the tragus after administration.

When pouring a liquid medication into a graduated liquid medication cup, which nursing action would be most appropriate?

Place the cup on a flat surface at eye level.

The nurse is administering an intramuscular injection to a client using the ventrogluteal site. How would the nurse locate the site?

Place the palm on the greater trochanter and the index finger on the anterior superior iliac spine.

The nurse is preparing to split medication for client administration. What method should the nurse use to split the medication?

Place the pill in the pill splitter and close

A nurse is preparing several oral medications for administration. One of the medications requires the nurse to obtain the client's apical pulse before administering it. Which action would be most appropriate?

Placing the medication requiring the assessment in a separate medication cup.

The nurse is distributing afternoon medications to the clients. When removing a tablet from a multi-dose bottle, what should the nurse do first?

Pour the tablet into the bottle cap.

A nurse has administered a pain medication to the client. What should the nurse do next?

Reassess the client.

What will the nurse do with the filter needle after withdrawing medication from an ampule?

Remove the filter needle and attach the administration needle.

The nurse is preparing to apply a new transdermal patch to a client's chest. What would the nurse do first?

Remove the old patch from the client's skin.

The nurse is administering an intramuscular injection in the deltoid site when the client pulls away from the needle before the medication is fully injected. What should the nurse do next?

Replace the needle on the syringe and administer the remaining medication in another site.

The nurse is withdrawing insulin from a vial to prepare an injection for a client. After removing the metal cap on the vial, what would be the nurse's next step in the procedure?

Swab the rubber top with an antimicrobial swab and allow it to dry.

The nurse is inserting a medication via a rectal suppository to a client. What would the nurse instruct the client to do?

Take slow, deep breaths.

The client tells the nurse that the medication in the cup is not the same as the medication he took the day before. The client is insistent that the medication is not the one prescribed. Which action by the nurse would be least appropriate?

Tell the client that he must take this medication because it is prescribed by the health care provider.

The nurse is teaching the student nurse where a subcutaneous injection is administered. How would the nurse describe the appropriate skin layer?

The adipose tissue layer, just below the epidermis and dermis.

The nurse is teaching a client how to prepare and administer liquid medications. The client has been on other types of medications for several years. What common error would be most appropriate for the nurse to include in teaching this client?

The client can use any type of measuring device.

The nurse is administering prescribed eye drops to a client. What action would cause the nurse to stop the administration?

The dropper touches the client's eyelid.

The nurse has just finished administering an insulin pen injection on a client and documents the administration in the electronic health record. Which is the correct information to document?

The fact that the medication was given, the dose and the time, and the site.

In an assessment for proper body alignment of a standing client, which finding is normal?

The weight of the body is distributed on the soles and heels.

The nurse is caring for a client with a pressure injury and is applying a saline-moistened dressing to the wound. What does the nurse understand to be the primary rationale for using a saline-moistened dressing?

To promote moist wound healing and protect the wound from contamination and trauma.

A client with a hip fracture is returning to the orthopedic unit, and the orders indicate that the client should be turned by logrolling. Which statement regarding logrolling is correct?

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

The nurse administering an intramuscular injection to a client divides the thigh into thirds, horizontally and vertically to locate the site. What injection site is the nurse using?

Vastus lateralis site.

The nurse has just finished injecting a medication intramuscularly, and needle is still in the client's arm. Which is the correct immediate next step?

Wait 10 seconds and then withdraw the needle

What is the best way for the nurse to remove air bubbles from the syringe after drawing up medication from an ampule?

Withdraw the needle from the ampule, tap the syringe, and push on the plunger.

What is the best method for opening an ampule of morphine for a prescribed IV push?

Wrap a small gauze pad around the neck and use a snapping motion to break the top at the scored line in the neck.

The new nurse places a transdermal medication patch on a client. The preceptor stops the new nurse for which action?

Writes date on medication patch.

36hrs after having surgery, a pt has a slightly elevated body temp and generalized malaise, as well as pain and redness at the surgical site. which intervention is most important to include in this pt's nursing care plan? a. document the findings and continue to monitor the pt b. administer antipyretics, as prescribed c. increase the frequency of assessment to every hour and notify the pt's PCP d. increase the frequency of wound care and contact the PCP for an antibiotic prescription

a

a nurse is administering a pain medication to a pt. in addition to checking his identification bracelet, the nurse correctly verifies the pt's identity by performing which action? a. asking the pt his name and birthdate b. reading the pt's name on the sign over the bed c. asking the pt's roommate to verify his name d. asking, "are you mr. brown?"

a

a nurse is administering phenytoin via a gastric tube to a pt who is receiving tube feedings. what would be an appropriate action of the nurse in this situation? a. discontinue the tube feeding and leave the tube clamped for required period of time before and after medication administration b. notify the PCP that medication cannot be given to the patient at this time via the gastric tube c. remove the tube in place and replace it with another tube prior to administering the medication d. flush the tube with 60mL of water prior to administering the medication

a

a nurse is assessing the following children. which child would the nurse identify as having the greatest risk for choking and suffocating? a. a toddler playing with his 9yo brother's construction set b. a 4yo eating yogurt for lunch c. an infant covered with a small blanket + asleep in a crib d. a 3yo drinking a glass of juice

a

a nurse is instructing a pt who is recovering from a stroke how to use a cane. which step would the nurse include in the teaching plan for this pt? a. support weight on stronger leg and cane and advance weaker foot forward b. hold the cane in the same hand of the leg with the most severe deficit c. stand with as much weight distributed on the cane as possible d. do not use the cane to rise from a sitting position, as this is unsafe

a

a nurse is measuring the depth of a pt's puncture wound. which technique is recommended? a. moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90 degree angle with the tip down b. draw the shape of the wound and describe how deep it appears in cm c. gently insert a sterile applicator into the wound and move it in a clockwise direction d. insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker

a

a nurse is removing rigid gas-permeable (RGP) contact lenses from the eyes of a pt who is unable to assist with removal. the nurse notices that one of the lenses is not centered over the cornea. what would be the nurse's first action in this procedure? a. apply gentle pressure on the lower eyelid to center the lens prior to removing it b. move the eyelids toward one another to cause the lens to slide out between the eyelids c. do not attempt to remove the lens as it should only be removed by an eyecare specialist d. have the pt look forward, retract the lower lid, and move the lens down on the sclera

a

a nurse is teaching parents in a parenting class about the use of car seats + restraints for infants and children. which information is accurate + should be included in the teaching plan? a. booster seats should be used for children until they are 4'9" tall and weigh between 80 and 100lbs b. most US states mandate the use of infant car seats + carriers when transporting a child in a motor vehicle c. infants + toddlers up to 2yo (or up to the maximum height and weight for the seat) should be in a front-facing safety seat d. children older than 6yo may be restrained using a car seat belt in the back seat

a

a nurse working in a long-term care facility uses proper pt care ergonomics when handling and transferring pts to avoid back injury. which action should be the focus of these preventive measures? a. carefully assessing the pt care environment b. using two nurses to lift a pt who cannot assist c. wearing a back belt to perform routine duties d. properly documenting the pt lift

a

when a fire occurs in a pt's room, what would be the nurse's priority action? a. rescue the pt b. extinguish the fire c. sound the alarm d. run for help

a

which statement best defines a human infection?

a disease state that is a result of pathogens in/on the body

a nurse caring for pts in a critical care unit know that providing good oral hygiene is an essential part of nursing care. what are some of the benefits of providing this care? a. it promotes the pt's sense of well-being b. it prevents deterioration of the oral cavity c. it contributes to decreased incidence of aspiration pneumonia d. it eliminates the need for flossing e. it decreases oropharyngeal secretions f. it helps to compensate for an inadequate diet

a, b, c

a nurse caring for pts in the PACU teaches a novice nurse how to assess and document wound drainage. which statements accurately describe a characteristic of wound drainage? a. serous drainage is composed of the clear portion of the blood and serous membranes b. bright-red sanguineous drainage indicates a large number of RBCs and looks like blood c. bright-red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding d. purulent drainage is composed of WBCs, dead tissue, and bacteria e. purulent drainage is thin, cloudy, and watery and may have a musty or foul odor f. serosanguineous drainage can be dark yellow or green depending on the causative organism

a, b, c, d

a nurse is preparing medications for pts in the ICU. the nurse is aware that there are pt variables that may affect the absorption of these medications. which statements accurately describe these variables? select all that apply. a. pts in certain ethnic groups obtain therapeutic responses at lower doses or higher doses than those usually prescribed b. some people experience the same response with a placebo as with the active drug used in studies c. people with liver disease metabolize drugs more quickly than people with normal liver functioning d. a pt who receives a pain medication in a noisy environment may not receive full benefit from the medication's effects e. oral meds should not be given with food as the food may delay the absorption of the meds f. circadian rhythms and cycles may influence drug action

a, b, d, f

the nurse is cleaning an open abdominal wound that has unapproximated edges. what are accurate steps in this procedure? a. use standard precautions or transmission-based precautions when indicated b. moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution c. clean the wound in full or half circles beginning on the outside and working toward the center d. work outward from the incision in lines that are parallel to it from the dirty area to the clean area e. clean to at least 1" beyond the end of the new dressing if one is being applied f. clean to at least 3" beyond the wound if a new dressing is not being applied

a, b, e

a nurse is providing foot care for pts in a long-term care facility. which actions are recommended guidelines for this procedure? a. bathe the feet thoroughly in a mild soap and tepid water solution b. soak the feet in warm water and bath oil c. dry feet thoroughly, including the area between the toes d. use an alcohol rub if the feet are dry e. use an antifungal foot power if necessary to prevent fungal infections f. cut the toenails at the lateral corners when trimming the nail

a, c, e

a nurse is teaching a pt how to use a meter-dosed inhaler to control asthma. what are appropriate guidelines for this procedure? select all that apply. a. shake the inhaler well and remove the mouthpiece covers from the MDI and spacer b. take shallow breaths when breathing through the spacer c. depress the canister releasing one puff into the spacer and inhale slowly and deeply d. after inhaling, exhale quickly through pursed lips e. wait 1-5 minutes as prescribed before administering the next puff f. gargle and rinse with salt water after using the MDI

a, c, e

a nurse who is changing dressings of post-op pts in the hospital documents various phases of wound healing on the pt charts. which statements accurately describe these stages? a. hemostasis occurs immediately after the initial injury b. a liquid called exudate is formed during the proliferation phase c. WBCs move to the wound in the inflammatory phase d. granulation tissue forms in the inflammatory phase e. during the inflammatory phase, the pt has generalized body response f. a scar forms during the proliferation phase

a, c, e

a nurse is providing range-of-motion exercises for a pt who is recovering from a stroke. during the session, the pt complains that she is "too tired to go on." what would be priority nursing actions for this pt? a. stop performing the exercises b. decrease the number of repetitions performed c. reevaluate the nursing care plan d. move to the pt's other side to perform exercises e. encourage the pt to finish the exercises and then rest f. assess the pt for other symptoms

a, c, f

nurses performing skin assessments on pts must pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and lesions. which guidelines should nurses follow when performing these assessments? a. compare bilateral parts for symmetry b. proceed in a toe-to-head systemic manner c. use standard terminology to report + record findings d. do not allow data from the nursing history to direct the assessment e. document only skin abnormalities on the pt record f. perform the appropriate skin assessment when risk factors are identified

a, c, f

a nurse is preparing an exercise program for a pt who has COPD. which instructions would the nurse include in a teaching plan for this pt? a. instruct the pt to avoid sudden position changes that may cause dizziness b. recommend that the pt restrict fluid until after exercising is finished c. instruct the pt to push a little further beyond fatigue each session d. instruct the pt to avoid exercising in very cold or very hot temperatures e. encourage the pt to modify exercise if weak or ill f. recommend that the pt consume a high-carb, low-protein diet

a, d

a nurse is teaching a student nurse how to cleanse the perineal area of both male and female pts. what are accurate guidelines when performing this procedure? a. for male and female pts, wash the groin area with a small amount of soap + water and rinse b. for a female pt, spread the labia and move the washcloth from the anal area toward the pubic area c. for male and female pts, always proceed from the most contaminated area to the least contaminated area d. for male and female pts, use a clean portion of the washcloth for each stroke e. for a male pt, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward f. in an uncircumcised male pt, do not retract the foreskin while washing the penis

a, d, e

a nurse who is administering medications to pts in an acute care setting studies the pharmacokinetics of the drugs being administered. which statements accurately describe these mechanisms of action? select all that apply a. distribution occurs after a drug has been absorbed into the bloodstream and is made available to body fluids and tissues b. metabolism is the process by which a drug is transferred from its site of entry into the body to the bloodstream c. absorption is the change of a drug from its original form to a new form, usually occuring in the liver d. during first-pass effect, drugs move from the intestinal lumen to the liver by way of the portal vein instead of going into the system's circulation e. the GI tract, as well as sweat, salivary, and mammary glands, are routes of drug absorption f. excretion is the process of removing a drug, or its metabolites, from the body

a, d, f

a nurse is caring for an adolescent with severe acne. which recommendations would be most appropriate to include in the teaching plan for this pt? a. wash the skin twice a day with a mild cleanser and warm water b. use cosmetics liberally to cover blackheads c. use emollients on the area d. squeeze blackheads as they appear e. keep hair off the face and wash hair daily f. avoid sun-tanning booth exposure and use sunscreen

a, e, f

The nurse observes a client independently move all the joints through their normal motions. Which range of motion has the client demonstrated?

active range of motion

Which client would be at greatest risk for developing a pressure injury?

adult client who is comatose

A client who is taking an oral opioid for pain relief tells the nurse he is constipated. What is this common response to opioids called? - adverse effect - therapeutic effect - toxic effect - idiosyncratic effect

adverse effect

The client has recently been instructed on use of a walker, and the nurse observes the client ambulate using a walker. The client is unsteady and is not performing the task as instructed. What is the best response by the nurse?

allow me to show you how to use your walker again

A nurse is assisting an older, continent client with dry skin who is hospitalized. Which approach to hygiene should the nurse take with this client?

alternate between a full bed bath on one day and use of skin lotion or bath oil on the next

The nurse is caring for a postoperative client after gallbladder surgery. The client asks the nurse why he or she needs to ambulate in halls three times a day. What is the correct response by the nurse?

ambulation helps prevent thromboelmbolism

A client tells the nurse that the heartburn she is experiencing is worse when she eats spicy foods. What would the spicy food be considered?

an aggravating factor

The nurse is performing perineal care on an adult male client who was incontinent of stool. After cleansing the perineal area, what is the most appropriate intervention by the nurse?

apply a thin barrier of skin protectant to the perineal area

A client is shaving and calls for the nurse when he cuts his face and is bleeding. What is the best action by the nurse?

apply pressure with a gauze pad for 2-3 minutes

After assisting a bed-bound client with oral care, what action does the nurse take?

assist the client to a comfortable position in the bed

The nurse, assessing a client's pain, asks the client if there are any other factors that consistently relate to the pain. What characteristic of the pain is the nurse assessing with this question?

associated phenomena

The nurse is preparing to administer 10 units regular insulin via insulin injection pen to a client with a body mass index (BMI) equal to 40. How will the nurse best administer this medication?

at 90-degree angle using a 5/8-in (1.6-cm) needle

a health care provider orders a pain med for a postoperative pt that is a PRN order. when would the nurse administer this medication? a. a single dose during the postoperative period b. doses administered as needed for pain relief c. one dose administered immediately d. doses routinely administered as a standing order

b

a nurse assisting with a pt bed bath observes that an older female adult has dry skin. the pt states that her skin is always "itchy". which nursing action would be the nurse's best response? a. bathe the pt more frequently b. use an emollient on the dry skin c. massage the skin with alcohol d. discourage fluid intake

b

a nurse caring for pts in a pediatrician's office assesses infants and toddlers for physical developmental milestones. which pt would the nurse refer to a specialist based on failure to achieve these milestones? a. a 4mo infant who is unable to roll over b. a 6mo infant who is unable to hold his head up himself c. an 11mo infant who cannot walk unassisted d. an 18mo toddler who cannot jump

b

a nurse is caring for a 25yo male pt who is comatose following a head injury. the pt has several piercings in his ears and nose. the piercing in his nose appears to be new and is crusted and slightly inflamed. which action would be appropriate when caring for this pt's piercings? a. do not remove/wash the piercings without permission from the client b. rinse the sites with warm water and remove crusts with a cotton swab c. wash the sites with alcohol and apply an antibiotic ointment d. remove the jewelry and allow the sites to heal over

b

a nurse is caring for a pt in a long-term care facility who has had 2 UTIs in the past year related to immobility. which finding would the nurse expect in this pt? a. improved renal blood supply to the kidneys b. urinary stasis c. decreased urinary calcium d. acidic urine formation

b

a nurse is caring for a pt who is on bed rest following a spinal injury. in which position would the nurse place the pt's feet to prevent footdrop? a. supination b. dorsiflexion c. hyperextension d. abduction

b

a nurse is scheduling hygiene for pts on the unit. what is the priority consideration when planning a pt's personal hygiene? a. when the pt has his/her most recent bath b. the pt's usual hygiene practices + preferences c. where the bathing fits in the nurse's schedule d. the time that is convenient for the pt care assistant

b

a nurse is using the katz index of independence in activities of daily living (ADLs) to assess the mobility of a hospitalized pt. during the pt interview, the nurse documents the following pt data: "patient bathes self completely but needs help with dressing. pt toilets independently and is continent. pt needs help moving from bed to chair. patient follows directions and can feed self." Based on this data, which score would the pt receive on the katz index? a. 2 b. 4 c. 5 d. 6

b

a pt has a fractured left leg, which has been casted. following teaching from the physical therapist for using crutches, the nurse reinforces which teaching point with the pt? a. use the axillae to bear body weight b. keep elbows close to the sides of the body c. when rising, extend the uninjured leg to prevent weight bearing d. to climb stairs, place weight on affected leg first

b

a pt requires 40 units of NPH insulin and 10 units of regular insulin daily subcutaneously. what is the correct sequence when mixing insulins? a. inject air into the regular insulin vial and withdraw 10 units; then, using the same syringe, inject air into the NPH vial and withdraw 40 units of NPH insulin b. inject air into the NPH insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the regular insulin vial and withdraw 10 units; then, withdraw 40 units of NPH insulin c. inject air into the regular insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the NPH insulin vial and withdraw 40 units; then, withdraw 10 units of regular insulin d. inject air into the NPH insulin vial and withdraw 40 units; then, using the same syringe, inject air into the regular insulin vial and withdraw 10 units of regular insulin

b

after an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. according to recognized staging systems, this pressure injury would be classified as: a. stage 1 b. stage 2 c. stage 3 d. stage 4

b

ms. hall has an order for hydromorphone, 2mg, intravenously, q 4hrs PRN pain. the nurse notes that according to ms. hall's chart, she is allergic to hydromorphone. the order for medication was signed by dr. long. what would be the correct procedure for the nurse to follow in this situation? a. administer the medication; the doctor is responsible for medication administration b. call dr. long and ask that the medication be changed c. ask the supervisor to administer the medication d. ask the pharmacist to provide a medication to take the place of hydromorphone

b

the joint commission issues guidelines regarding the use of restraints. in which case is a restraint properly used? a. the nurse positions a pt in a supine position prior to applying wrist restraints b. the nurse ensures that two fingers can be inserted between the restraint and the pt's ankle c. the nurse applies a cloth restraint to the left hand of a pt with an IV catheter in the right wrist d. the nurse ties an elbow restraint to the raised side rail of a pt's bed

b

the nurse uses the RYB wound classification system to assess the wound of a pt whose arm was cut on a factory machine. the nurse documents the wound as "red." what would be the priority nursing intervention for this type of wound? a. irrigate the wound b. provide gentle cleansing of the wound c. debride the wound d. change the dressing frequently

b

a nurse caring for pts in a skilled nursing facility performs risk assessments on the pts for foot + nail problems. which pts would be at a higher risk? a. a pt who is taking antibiotics for chronic bronchitis b. a pt diagnosed with type II diabetes c. a pt who is obese d. a pt who has a nervous habit of biting his nails e. a pt diagnosed with prostate cancer f. a pt whose job involves frequent handwashing

b, c, d, f

a nurse is developing a care plan for an 86yo pt who has been admitted for right hip arthroplasty. which assessment findings indicate a high risk for pressure injury for this pt? a. the pt takes time to think about responses to questions b. the pt is 86yo c. the pt reports inability to control urine d. the pt is scheduled for a hip arthroplasty e. lab findings include BUN 12 (older adult normal 8-23mg/dL) and creatinine 0.9 (adult female normal 0.61-1mg/dL) f. the pt reports increased pain in right hip when repositioning in bed or chair

b, c, d, f

a nurse is assisting a post-op pt with conditioning exercises to prepare for ambulation. which instructions from the nurse are appropriate for this pt? a. do full-body push-ups in bed six-to-eight times daily b. breath in and out smoothly during quadriceps drills c. place the bed in the lowest position or use a foot stool for dangling d. dangle on the side of the bed for 30-60 minutes e. allow the nurse to bathe the pt completely to prevent fatigue f. perform quadriceps 2-3 times per hour, 4-6 times a day

b, c, f

the nurse caring for pts in a long-term care facility knows that there are factors that place certain pts at a higher risk for falls. which pts would that nurse consider to be in this category? a. a pt who is older than 50 b. a pt who has already fallen twice c. a pt who is taking antibiotics d. a pt who experiences postural hypotension e. a pt who is experiencing nausea from chemo f. a 70yo pt who is transferred to long-term care

b, d, f

a medication order reads: "K-Dur, 20 mEq po BID." When and how does the nurse correctly give this drug? a. daily at bedtime by subcutaneous route b. every other day by mouth c. twice a day by the oral route d. once a week by transdermal patch

c

a nurse administers a dose of an oral medication for HTN to a pt who immediately vomits after swallowing the pill. what would be the appropriate initial reaction of the nurse in this situation? a. readminister the medication and notify the PCP b. readminister the pill in a liquid form if possible c. assess the vomit, looking for the pill d. notify the PCP

c

a nurse discovers that a medication error occurred. what should be the nurse's first response? a. record the error on the medication sheet b. notify the physician regarding course of action c. check the pt's condition to note any possible effect of the error d. complete an incident report, explaining how the mistake was made

c

a nurse is about to bathe a female pt who has an intravenous access in place in her forearm. the patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. what is the appropriate nursing action? a. temporarily disconnect the IV tubing at a point close to the pt and threat it through the gown sleeve b. cut the gown with scissors to allow arm movement c. thread the bag and tubing through the gown d. temporarily disconnect the tubing from the IV container, threading it through the gown

c

a nurse is administering heparin subcutaneously to a pt. what is the correct technique for this procedure? a. aspirate before giving and gently massage after the injection b. do not aspirate; massage the site for 1 minute c. do not aspirate before or massage after the injection d. massage the site of the injection; aspiration is not necessary but will do no harm

c

a nurse is assisting a pt who is 2 days post-op from a c-section to sit in a chair. after assisting the pt to the side of the bed and to stand up, the pt's knees buckle and she tells the nurse she feels faint. what is the appropriate nursing action? a. wait a few minutes and then continue the move to the chair b. call for assistance and continue the move with the help of another nurse c. lower the pt back to the side of the bed and pivot her back into bed d. have the pt sit down on the bed and dangle her feet before moving

c

a nurse is assisting a pt with dementia with bathing. which guideline is recommended in this procedure? a. shift the focus of the interaction to the "process of bathing" b. wash the face and hair at the beginning of the bath c. consider using music to soothe anxiety and agitation d. do not perform towel baths or alternate forms of bathing with which the pt is unfamiliar

c

a nurse is assisting an older adult with an unsteady gait with a tub bath. which action is recommended in this procedure? a. add bath oil to the water to prevent dry skin b. allow the pt to lock the door to guarantee privacy c. assist the pt in and out of the tub to prevent falling d. keep the water temperature very warm because older adults chill easily

c

a nurse is caring for a pt who has been hospitalized for a spinal cord injury following a motor vehicle accident. which action would the nurse perform when logrolling the pt to reposition him on his side? a. have the pt extend his arms outward and cross his legs on top of a pillow b. stand at the side of the bed in which the pt will be turned while another nurse gently pushes the pt from the other side c. have the pt cross his arms on his chest and place a pillow between his knees d. place a cervical collar on the pt's neck and gently roll him to the other side of the bed

c

a nurse is caring for a pt who is hospitalized with pneumonia and is experiencing some difficulty breathing. the nurse most appropriately assists him into which position to promote maximal breathing in the thoracic cavity? a. dorsal recumbent position b. lateral position c. fowler's position d. sims' position

c

a nurse is explaining to a pt the anticipated effect of the application of cold to an injured area. what response indicates that the pt understands the explanation? a. "I can expect to have more discomfort in the area where the cold is applied." b. "I should expect more drainage from the incision after the ice has been in place." c. "I should see less swelling and redness with the cold treatment." d. "My incision may bleed more when the ice is first applied"

c

a nurse is providing pt teaching regarding the use of negative pressure would therapy. which explanation provides the most accurate information to the pt? a. the therapy is used to collect excess blood loss and prevent the formation of a scab b. the therapy will prevent infection, ensuring that the wound heals with less scar tissue c. the therapy provides a moist environment and stimulates blood flow to the wound d. the therapy irrigates the wound to keep it free from debris and excess wound fluid

c

a nurse who gives subcutaneous and IM injections to pts in a hospital setting attempts to reduce discomfort for the pts receiving the injections. which technique is recommended? a. the nurse selects a needle of the largest gauge that is appropriate for the site and solution to be injected b. the nurse injects the medication into contracted muscles to reduce pressure and discomfort at the site c. the nurse uses the z-track technique for IM injections to prevent leakage of medication into the needle track d. the nurse applies vigorous pressure in a circular motion after the injection to distribute the medication to the intended area

c

a pt was in an automobile accident and received a wound across the nose and cheek. after surgery to repair the wound, the pt says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate? a. pain b. impaired skin integrity c. disturbed body image d. disturbed thought processes

c

while discussing home safety with a nurse, a pt admits that she always smokes a cig in bed before falling asleep at night. which nursing diagnosis would be the priority for this pt? a. impaired gas exchange related to cig smoking b. anxiety related to inability to stop smoking c. risk for suffocation related to unfamiliarity with fire prevention guidelines d. deficient knowledge related to lack of follow-through of recommendation to stop smoking

c

a pt who has a large abdominal wound suddenly calls out for help because the pt feels as though something is falling out of her incision. inspection reveals a gaping open wound with tissue bulging outward. in which order should the nurse perform the following interventions? arrange from first to last. a. notify the health care provider of the situation b. cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution c. place the pt in the low fowler's position

c, b, a

a school nurse is teaching parents about home safety + fires. what info would be accurate to include in the teaching plan? a. sixty percent of US fire deaths occur in the home b. most fatal fires occur when people are cooking c. most people who die in fires die of smoke inhalation d. fire-related injury + death have declined due to the availability + use of smoke alarms e. fires are more likely to occur in homes without electricity or gas f. fires are less likely to spread if bedroom doors are kept open when sleeping

c, d, e

the nurse is administering a medication to a pt via an enteral feeding tube. which are accurate guidelines related to this procedure? select all that apply. a. crush the enteric-coated pill for mixing in a liquid b. flush open the tube with 60mL of very warm water c. use the recommended procedure for checking tube placement in the stomach or intestine d. give each medication separately and flush with water between each drug e. lower the head of the bed to prevent reflux f. adjust the amount of water used if patient's fluid intake is restricted

c, d, f

the nurse assesses the wound of a pt who was cut on the upper thigh with a chain saw. the nurse documents the presence of biofilms in the wound. what is the effect of this condition on the wound? a. enhanced healing due to the presence of sugars and proteins b. delayed healing due to dead tissue present in the wound c. decreased effectiveness of antibiotics against the bacteria d. impaired skin integrity due to overhydration of the cells of the wound e. delayed healing due to cells dehydrating and dying f. decreased effectiveness of the pt's normal immune process

c, f

a nurse is ambulating a pt for the first time following surgery for a knee replacement. shortly after beginning to walk, the pt tells the nurse that she is dizzy and feels like she might fall. place these nursing actions in the order in which the nurse should perform them to protect the pt: a. grasp the gait belt b. stay with the pt and call for help c. place feet wide apart with one foot in front d. gently slide pt down to the floor, protecting her head e. pull the weight of the pt backward against your body f. rock your pelvis out on the side of the pt

c, f ,a, e, d, b

The acute care nurse is preparing to bathe a client and notices that the client is wearing a regular hospital gown and has continuous intravenous (IV) fluids infusing. Which action by the nurse is appropriate?

carefully thread the IV bag and tubing through the arm of the regular gown, and then replace it with a snap-arm gown at the end of the bath

the poison control nurse receives a call from a caregiver of a young school-age child who may have ingested a poisonous substance. which is the priority response by the nurse?

check breathing + HR

The older adult client is moving to another apartment. The nurse should encourage the client's family to take which action to reduce the older adult's risk of falling in the new home?

clear clutter in the walkways of the new home

The nurse is demonstrating proper ambulation technique with a walker to a hospitalized older adult with a diagnosis of weakness. What is the priority nursing assessment?

cognitive function level

A nurse is counseling an older adult client on fall prevention in the home before the client is discharged from the hospital. Which action should the nurse recommend to the client?

consult with your health care provider about beginning an exercise program

a medication order reads: "hydromorphone, 2mg IV every 3-4 hours PRN pain." the prefilled cartridge is available with a label reading "hydromorphone 2mg/1mL." the cartridge contains 1.2mL of hydromorphone. what should the nurse do? a. give all the medication in the cartridge because it expanded when it was mixed and this is what the pharmacy sent b. call the pharmacy and request the proper dose c. refuse to give the medication and document refusal in the EHR d. dispose of 0.2mL before administering the drug; verify te waste with another nurse

d

a nurse is developing a care plan related to prevention of pressure injuries for residents in a long-term care facility. which action accurately describes a priority intervention in preventing a pt from developing a pressure injury? a. keeping the head of the bed elevated as often as possible b. massaging over bony prominences c. repositioning bed-bound pts every 4hrs d. using a mild cleansing agent when cleaning the skin

d

a nurse is filing a safety event report for a confused pt who fell when getting out of bed. what action is performed appropriately? a. the nurse includes suggestions on how to prevent the incident from recurring b. the nurse provides minimal info about the incident c. the nurse discusses the details with the pt before documenting them d. the nurse records the circumstances and effect on the pt in the medical record

d

a nurse is performing oral care on a pt who is in traction. the nurse notes that the mouth is extremely dry with crusts remaining after the oral care. what should be the nurse's next action? a. make a recommendation for the pt to see an oral surgeon b. report the condition to the PCP c. gently scrape the oral cavity with a tongue depressor d. increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa

d

a nurse orients an older adult to the safety features in her hospital room. what is a priority component of this admission routine? a. explain how to use the telephone b. introduce the pt to her roommate c. review the hospital policy on visiting hours d. explain how to operate the call bell

d

a nurse working a in a pediatrician's office receives calls from parents whose children have ingested toxins. what would be the nurse's best response? a. administer activated charcoal in tablet form + take child to the ED b. administer syrup of ipecac + take child to the ED c. bring the child to the PCP for gastric lavage d. call the PCC immediately before attempting any home remedy

d

a pt has an eye infection with a moderate amount of discharge. which action is an appropriate step for the nurse to perform when cleaning this pt's eyes? a. use hydrogen-peroxide on a clean washcloth to wipe the eyes b. wipe the eye from the outer canthus to the inner canthus c. position the pt on the opposite side of the eye to be cleaned d. cleanse the eye using a different section of the cleaning cloth for each stroke until clean

d

a pt is admitted with a nonhealing surgical wound. which nursing action is most effective in prevent a wound infection? a. using sterile dressing supplies b. suggesting dietary supplements c. applying antibiotic ointment d. performing careful hand hygiene

d

a pt who injured the spine in a motorcycle accident is receiving rehabilitation services in a short-term rehab center. the nurse caring for the pt correctly tells the aide not to place the pt in which position? a. side-laying b. fowler's c. sims' d. prone

d

an older resident who is disoriented likes to wander the halls of his long-term care facility. which action would be most appropriate for the nurse to use as an alternative to restraints? a. sitting him in a geriatric chair near the nurse's station b. using the sheets to secure him snugly in his bed c. keeping the bed in the high position d. identifying his door with his picture and a balloon

d

based on the statistics for the leading cause of hospital admission for trauma in older adults, what would be the nurse's priority intervention to prevent trauma when caring for older adults in a nursing home? a. checking to make sure fire alarms are working properly b. preventing exposure to temperature extremes c. screening for partner or elder abuse d. making sure patient rooms are decluttered

d

what consideration should the nurse keep in mind regarding the use of side rails for a pt who is confused? a. they prevent confused pts from wandering b. a history of a previous fall from a bed with raised side rails is insignificant c. alternative measures are ineffective to prevent wandering d. a person of small stature is at increased risk for injury from entrapment

d

when discussing emergency preparedness with a group of first responders, what info would be important to include about preparation for a terrorist attack? a. posttraumatic stress disorders can be expected in most survivors of a terrorist attack b. the FDA has collaborated with drug companies to create stockpiles of emergency drugs c. even small doses of radiation result in bone marrow depression + cancer d. BLI is a serious consequence following detonation of an explosive device

d

which intervention ordered for mr. griffin poses the greatest risk for injury?

daily complete blood count (CBC)

The nurse is providing oral care to a hospitalized client. Which outcome of this intervention is the priority?

decreasing the incidence of hospital-acquired pneumonia

When assessing a client's skin, the nurse observes an area of deep purple discoloration on the client's heel. The skin in that area is intact. How will the nurse document this finding?

deep tissue injury

The nurse is assessing a cancer client's pain. The client is unable to point to a specific area of pain; rather, the client moves a hand over the abdomen to indicate the pain. What type of pain is this client experiencing?

diffuse

A nurse is preparing a medication from a glass ampule. After breaking the ampule, the nurse notes blood on the gauze pad. What should the nurse do first?

discard the ampule and medication

Which question, used for a pain assessment, would assess a client for the perception of pain?

do you find any meaning in your pain?

The nurse is preparing to administer ear drops to a 2-year-old client. The nurse would pull the pinna in which direction?

down and backward

Which type of drug preparation is a medication in a clear liquid containing water, alcohol, sweeteners, and flavor? - elixir - solution - suspension - syrup

elixir

a nurse is planning hygiene care for a client with a self-care bathing deficit related to weakness. which nursing intervention is appropriate?

encourage client to wash own face + hands

How much air does the nurse inject into a vial prior to withdrawing the medication?

equal to the amount of the medication dosage

A nurse is caring for a client at risk for falls who does not have access to an activated bed or chair alarm. How often should the nurse assess this client?

every 60mins

Tell whether the following statement is true or false. Only pain medications may be given to patients without a medication order from a licensed practitioner.

false

The nurse, assessing a client for pain, looks for behavioral responses to the pain. Which is an example of a behavioral response?

grimacing

The nurse has documented that a client has an unstageable pressure injury. Which statement best describes this type of wound? The wound:

has black brown eschar covering the top

The nurse is preparing to bathe a client using a self-contained bathing system that has premoistened, disposable washcloths. Which method for warming the premoistened cloths is correct?

heat the entire package in the microwave, following the manufacturer's recommendation

The nurse is teaching a client about shaving the face. Which statement made by the client indicates a need for additional teaching?

i will pull the skin taut to reduce the risk for ingrown hairs

when following the proper procedure for removing gloves that are a part of contact precautions, where should the first removed inverted glove be stored while the second glove is being removed?

in the palm of the gloved hand

When assessing a client's pain, what characteristic of pain does the nurse assess using a pain rating scale?

intensity

A client with allergies has been advised to have an allergy test. The nurse needs to administer an injection to the client for allergy testing. Which injection route is most suitable for allergy testing? - intradermal - IV - IM - subcutaneous

intradermal

The nurse is performing perineal care for a female client when the client asks the nurse to use baby powder to help keep her perineum dry. What is the best response by the nurse?

it is recommended to avoid the use of baby powder in the perineal area because it creates a place for bacteria to grow

The acute care nurse is talking with a client who just finished performing oral care. The client states, "I have some whitish-yellow patches on my tongue. Should I be concerned?" Which response by the nurse is most appropriate?

let me assess the patches. they may indicate the development of a fungal infection

The nurse is administering eye drops to a client. Where should the nurse place the drops?

lower conjunctival sac

The nurse assesses the client and checks the medication prescription prior to administering an intramuscular injection. Which factor affects the choice of an intramuscular site?

medication volume

The nurse observes a staff member performing perineal care on a female client. The staff member washes the client's rectal area and then washes the client's urinary meatus. What is the most useful instruction for the nurse to give the staff member?

microbial contamination can occur when cleaning the anal area first

A client rates pain on a numeric pain scale at a "5" out of 10. What type of pain is this client experiencing?

moderate

When assessing a client, the nurse may identify which physiologic response to pain?

muscle tension and rigidity

a nurse is teaching a UAP about fire safety. which UAP statement requires immediate nursing intervention?

only certain members of the health care team can extinguish a fire

Which route of medication administration is most commonly prescribed?

oral

what is the final step in removing PPE when caring for a pt requiring droplet precautions?

perform hand hygiene

The nurse observes a client using a walker for ambulation. The client lifts the walker, places the rear feet on the ground ahead of him, steps forward with the right leg, then the left leg, and then sets the front two feet of the walker on the ground. What further instruction does the client need?

place all four feet of the walker on the ground before stepping forward

The nurse is administering routine medications to a postsurgical client and the client asks, "Could I have something for pain?" The nurse checks the medication administration record (MAR) and notes that the medication is an opioid. What should the nurse do?

place the opioid into a separate cup

mr griffin's surgical care includes anticoagulation therapy. which diagnostic blood count indicates a risk for spontaneous bleeding and should be reported to his HCP immediately?

platelet of <50,000/muL

the nurse is preparing to administer a transdermal medication. Which placement is appropriate?

posteriorly on the shoulder

The client requests powder to be applied to the genitalia after perineal care. Which explanation from the nurse to the client is best?

powder in the genital area can create a medium for bacterial growth

in which stage of the development of an infection does the pt present the greatest risk to others?

prodromal

A nurse is shaving a male client's face. Which should the nurse do?

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

When administering medications to a client, what information should the nurse know about the medication?

purpose, safe dose range, adverse effects, action

The nurse is assessing a client's pain and asks the client, "What words would you use to describe your pain?" What characteristic of pain is the nurse assessing with this question?

quality

The nurse is planning to bathe a client who has thigh-high antiembolism stockings in place. Which action is correct?

remove the antiembolism stockings before the bath

An older adult is admitted for a hip fracture and is confined to bed. What is the priority action by the nurse to decrease the risk of pressure ulcer?

reposition the pt every 2hrs

which piece of PPE should be removed only after leaving the pt's room?

respiratory mask

The nurse is providing perineal care for an uncircumcised adult male client. What is a recommended guideline for this action?

retract the foreskin when washing the prepuce of adolescents and older

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. What is the correct technique for cleaning the penis?

retract the foreskin while washing the penis; then, immediately pull the foreskin back into place

The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. Which technique for cleaning the penis is correct?

retract the foreskin while washing the penis; then, immediately pull the foreskin back into place

When performing perineal care for the male client, the nurse should be particularly gentle and avoid pressure when cleansing which area?

scrotum

The nurse administers the client's scheduled morning medications. The previous dose of antihypertensive was held due to a blood pressure that was too low according the health care provider's parameters. What does the nurse do with this scheduled unit-dose packaged antihypertensive medication?

set the antihypertensive dose aside pending assessment

When administering a rectal suppository, in which position would the nurse position the client?

side-lying

The nurse is preparing to administer a vaccination to an adult in the deltoid site. In what position would the nurse place the client?

sitting

The nurse is assisting a hospitalized client with oral care. How will the nurse position the client?

sitting at the edge of the bed

The nurse observes a reddened area with intact skin over the client's coccyx. When gentle pressure is applied, the area does not blanch. How will the nurse document this finding?

stage 1 pressure injury

A nurse is preparing to give a bed bath to a client. What approach should the nurse take?

start with the cleanest areas and end with the most soiled areas

In which of the following medication supply systems are large quantities of medications kept on the nursing unit making them immediately available to the nurse? - unit dose system - individual supply - stock supply - bar-coded med cart

stock supply

The nurse is caring for a client with a pressure injury on the heel of the foot. The injury is covered with stable black eschar. What is the best nursing intervention at this time?

teach the client ways to relieve the pressure on the heel

What would be most important to document after shaving a client?

that the chin was nicked with the razor

An unlicensed assistive personal (UAP) is performing perineal care for a female client. Which action by the UAP requires intervention by the nurse?

the UAP begins cleansing from the anus toward the pubic bone

A nurse is measuring a liquid medication in a graduated liquid medication cup. The nurse determines the correct amount by reading:

the bottom of the meniscus.

A female nurse is assisting an older man who has dementia with a bath in his hospital room. Which approach should the nurse take?

the client should be allowed to complete as much of the bath as he can

A nurse is delegating shaving of a client who is prescribed anticoagulant therapy to the unlicensed assistive personnel (UAP). What information is most important for the nurse to include for this client?

the client should use an electric razor

The nurse is performing perineal care for a male client. What part of the perineum would the nurse clean first?

tip of the penis

Devices such as pillows, trapeze bars, special mattresses, and trochanter rolls are used for what primary purpose?

to alleviate pressure + maintain proper body alignment

If the nurse is the only caregiver assisting a client with gait belt ambulation, where should the nurse be positioned?

to either side and slightly behind the client with near hand on gait belt

The nurse applies a gait belt to a client prior to ambulation. For what reason might the nurse use a gait belt when ambulating certain clients?

to improve grasp and help provide more stability and balance

The nurse is teaching a client's caregiver about ways to help prevent skin breakdown. What would the nurse teach as an important intervention to prevent pressure injury development?

turn and reposition the client every 2hrs

A nurse is performing perineal care for a female client. Which action would most be important to maintain the client's privacy?

uncover only the area being cleaned

The nurse is providing a bed bath for a female client who is unconscious. The nurse should pay special attention to cleaning which areas of the body?

underneath the breasts and in between skin folds

The nurse is preparing to administer ear drops to an adult client. In what direction would the nurse position the pinna?

up and back

The acute care nurse is talking with an older adult client who had a complete bed bath earlier in the day. The client states, "I like to be scrubbed clean during my bath, and the person who bathed me today didn't even use soap and water and barely rubbed my skin to dry it." Which response by the nurse is most appropriate?

use of special bathing products and avoidance of scrubbing help keep your skin intact

Which modification to bathing should be implemented for a client who is incontinent?

use special perineal skin cleansers and moisture barriers

The nurse cares for a client who is postoperative after an abdominal surgery. Which is the most important statement for the nurse to use in teaching this client?

use the call bell for any needs and wear nonslip footwear

a nursing student is caring for a client with dentures. which action by the nursing student would require intervention by the nurse?

using ungloved hands to remove an unconscious client's dentures

The charge nurse is observing a new nurse care for a client who is at high risk for falls. Which actions by the new nurse would require the charge nurse to intervene?

waiting outside of the closed bathroom door while the client uses the toilet

The nurse assists the client back to bed from the bathroom utilizing a walker. What action by the nurse will decrease the spread of microorganisms?

wiping down the handles of the walker once the client has returned to bed

The medical chart of a newly admitted client notes a penicillin allergy, yet the physician has just written an order for an antibiotic in the same drug family after reviewing the client's wound culture and sensitivity. How should the nurse respond to this situation? - withhold the medication until the potential drug allergy has been addressed by the care team - substitute an antibiotic with similar action, but one that is from a different drug family - administer the medication and increase the frequency of assessments in the hours that follow - discuss the severity, signs, and symptoms of the drug allergy with the client in order to ascertain the risks of administration

withhold the medication until the potential drug allergy has been addressed by the care team