Lab quizzes

The nurse uses the Rinne test to asses: Hearing Vision Pupil reaction Reflexes

Hearing

Arterial Problems

Lower extremity pale and cool with decreased pulse

A nurse is teaching a client who has a prescription of a nasogastric tube (NG) to treat a pyloric obstruction (gastric outlet obstruction). Which of the following rationales for the use of the nasogastric tube should the nurse include in the teaching? Determine the pH of the gastric secretions. Supply nutrients via tube feedings. Decompress the stomach. Administer medications.

Decompress the stomach A pyloric obstruction, also called gastric outlet obstruction, is caused by edema, scarring, or spasm, often the result of gastritis or peptic ulcer disease The nurse should inform the client that because the stomach is dilated and may contain undigested food, it must be decompressed, necessitating the placement of an NG tube

A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following? Delivers a constant rate of a specific concentration of oxygen Delivers a high concentration of oxygen Delivers a low concentration of oxygen Restricts the client's ability to eat, speak, or drink

Delivers a low concentration of oxygen A nasal cannula delivers a relatively low concentration of oxygen (24% to 44%).

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material? Discard the dressing in the bedside trash receptacle. Dispose of the dressing in a biohazardous waste container. Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle. Double-bag the dressing in clear bags and label it "biohazard".

Dispose of the dressing in a biohazardous waste container

A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse? Symmetrical convex sphere shape Concave umbilicus Bilateral bowel sounds in lower quadrants Ecchymosis

Ecchymosis It is a finding outside of the expected reference range for an abdominal assessment and would require the nurse to further investigate for potential injury, bleeding disorder, or physical abuse.

A nurse is developing a teaching plan for a client who has an ileostomy and will require stoma care. Which of the following information should the nurse include? Empty the pouch when it is 1/2 full. Hold pressure on the skin barrier for 10 to 15 sec to secure the seal. Clean the peristomal skin four times a day. Expect firm fecal content.

Empty the pouch when it is 1/2 full

The Glasgow Coma Scale assesses: Speech, Pupil response, Level of consciousness, and Motor movement Eye opening, Verbal response, and Motor response Pupil response, Level of consciousness, and Motor response

Eye opening, Verbal response, and Motor response eye opening (1-4 scale), verbal response (1-5 scale), and motor response (1-6 scale).

After assessing the client's respiratory system, the nurse listens to his apical pulse. What location is used to listen to his apical pulse? Fifth intercostal space at left midclavicular line Fifth intercostal space at midsternal line Fourth intercostal space midsternal line

Fifth intercostal space at left midclavicular line This is the location of the mitral valve and is known as the point of maximal impulse, so sound is best heard at this location.

When assessing range of motion of a client's wrists, the client states they have pain when they rotate their hand from palm down to palm up. This is an example of moving the joint: From extension to flexion From flexion to extension From pronation to supination From supination to pronation

From pronation to supination

nurse is assisting an older adult client who sometimes loses her balance while walking. Which of the following devices should the nurse use when helping the client ambulate? Gait belt Jacket harness Four-wheel walker

Gait belt

Which of the following statements about the use of a gait belt is true? The gait belt should be applied to the patient while lying down to assist the patient with sitting at the bedside. The gait belt should encircle the patient's chest snuggly with 2 fingers able to fit under the belt. Gait belts should not be used for patients who do not have balance when standing. Gait belts may be applied over wounds with a dressing in place.

Gait belts should not be used for patients who do not have balance when standing

Which technique does the nurse use to assess the triceps reflex? Holds the knee in a slightly flexed position while stroking the sole of the foot with a dull object Holds the patient's relaxed forearm with the hand pronated while striking the appropriate tendon with the reflex hammer Holds the patient's relaxed arm with the elbow flexed at a 90-degree angle, places a thumb over the appropriate tendon and strikes the thumb with the pointed end of the reflex hammer Holds the patient's relaxed arm with the elbow flexed at a 90-degree angle in one hand and striking the appropriate tendon just above the elbow with the reflex hammer

Holds the patient's relaxed arm with the elbow flexed at a 90-degree angle in one hand and striking the appropriate tendon just above the elbow with the reflex hammer

A nurse is preparing to administer ampicillin and gentamicin sulfate via IV infusion. Which of the following resources should the nurse consult first regarding medication compatibility? Nurse manager Hospital pharmacist Health care provider

Hospital pharmacist

A nurse teaches the patient about the prescribed buccal medication. Which statement by the patient indicates teaching by the nurse is successful? "I should let the medication dissolve completely." "I will place the medication in the same location." "I can only drink water, not juice, with this medication." "I better chew my medication first for faster distribution."

I should let the medication dissolve completely

A nurse is assessing an older adult client who has experienced some loss of bone density. The nurse observes a "hunchback" curvature of the client's spine. The nurse should expect the provider to document which of the following disorders? Scoliosis Kyphosis Lordosis

Kyphosis

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take? Place the wheelchair at a 90° angle to the bed. Lock the wheels of the bed and the wheelchair. Acquire the help of several people to lift the client. Elevate the bed to a position of comfort for the nurse.

Lock the wheels of the bed and the wheelchair

A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort? Lower the height of the solution container. Encourage the client to bear down. Allow the client to expel some fluid before continuing. Stop the enema and document that the client did not tolerate the procedure.

Lower the height of the solution container

A charge nurse is observing a newly-licensed nurse insert an indwelling urinary catheter for a male client. Which of the following actions by the newly-licensed nurse requires intervention by the charge nurse? Lubricates the first 2.5 to 5 cm (2 in) of the catheter. Dons sterile gloves before cleaning the client's meatus. Secures the tubing to the client's upper thigh. Pulls gently on the catheter to check for resistance after inflating the balloon.

Lubricates the first 2.5 to 5 cm (2 in) of the catheter. The nurse should lubricate the first 2.5 to 5 cm (1 to 2 in) of the catheter when inserting a catheter into a female client. The nurse should lubricate the first 15 to 17.5 cm (6 to 7 in) when inserting a catheter into a male client.

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following findings should indicate to the nurse the client's peristalsis is returning? Hypoactive bowel sounds in two quadrants Request for a cup of tea and some toast Passage of flatus Abdominal distention

Passage of flatus Passing flatus and belching indicate the return of peristaltic activity. Hypoactive bowel sounds are an expected finding postoperatively and do not indicate peristalsis has returned. The client's request for fluid and food does not indicate peristalsis has returned. Abdominal distention is more likely to indicate the absence rather than the return of peristalsis.

A nurse is assessing a client who has ataxia (impaired coordination). Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate? Observe for the presence of Kernig's sign. Perform a Romberg's test. Check the function of cranial nerve V. Inspect for the presence of clubbing.

Perform a Romberg's test

A client requests help to get up and go to the bathroom using his walker. As they are walking to the bathroom, the nurse notices that the client is using the walker by putting the two back legs on the floor and then rocking to the front two legs. What should the nurse tell the client about his walker usage? Pick the walker up and set the four legs down together. He is doing a good job adjusting to the walker. Put the right side down first followed by the left side.

Pick the walker up and set the four legs down together.

A confused client's spouse asks about alternatives to use of restraints to prevent falls. Which of the following are acceptable alternatives to prevent use of restraints for a client at risk for falls? (Select all that apply.) Four bed side rails in up position when alone in room. Place client in a room close to the nurses' station. Provide visual reminders in room to call for assistance. Set a toileting every 2 hours schedule for the client. Evaluate and medicate for pain on regular schedule.

Place client in a room close to the nurses' station. Provide visual reminders in room to call for assistance. Set a toileting every 2 hours schedule for the client. Evaluate and medicate for pain on regular schedule.

Which nursing intervention is the highest priority for a client at risk for falls in a hospital setting? Keep all the side rails up Review prescribed medications Place the bed in the lowest position Keep the room door open

Place the bed in the lowest position

A nurse is assisting with a routine physical examination of an adolescent. The provider observes a lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders? Scoliosis Kyphosis Lordosis Torticollis

Scoliosis

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? Serous Purulent Sanguineous Serosanguineous

Serosanguineous

A nurse is providing discharge teaching to a client has a new prescription for a metered dose inhaler (MDI). Which of the following instructions should the nurse include in the teaching? Shake the inhaler for 3 to 5 seconds. Rinse the mouth with mouthwash after inhaling the medication. Wait 2 min between inhalations. Press down twice on the MDI canister.

Shake the inhaler for 3 to 5 seconds

The nurse is caring for a patient receiving continuous enteral feedings. What is the first action of the nurse if she suspects aspiration of the feeding? Obtain a chest x-ray Initiate oxygen therapy Stop the feeding Auscultate breath sounds.

Stop the feeding

To assess muscle strength in a client's biceps, the nurse: Tells the client to try to flex the arm while the nurse is pulling the forearm down. Tells the client to straighten while the nurse is pushing the forearm toward the upper arm. Tells the client to shrug their shoulders while the nurse pushes the shoulders down. Tells the client pull their leg back as the nurse pushes the leg forward.

Tells the client to try to flex the arm while the nurse is pulling the forearm down

The nurse suspects a dark-skinned patient is cyanotic. The nurse should assess: The palms of the hands bilaterally The mucus membranes of the mouth Sclera of both eyes

The mucus membranes of the mouth Cyanosis can be difficult to assess in a dark-skinned patient. Signs of cyanosis are an ashen-gray color of the conjunctiva of the eye, oral mucus membranes, and nail beds for patients with dark skin

The charge nurse is observing a novice nurse administer an intramuscular injection in the deltoid muscle of a well-developed adult. Which observation would cause the charge nurse to intervene? The novice nurse measures three finger widths from the acromion process to mark injection site The novice nurse asks the patient to remove their arm from their sweatshirt for the injection The novice nurse asks the patient to relax the arm and cleans the site in a circular motion The novice nurse has 3 mL of the medication in a 3 mL syringe with a 1 ½ inch needle

The novice nurse has 3 mL of the medication in a 3 mL syringe with a 1 ½ inch needle Rationale: The charge nurse would need to intervene because of the 3 mL of medication. The maximum amount of medication in the deltoid is 2 mL for an adult.

The nurse knows that the use of technology is beneficial for sharing patient information with the treatment team quickly. Which of the following is a HIPAA (Health Insurance Portability and Accountability Act) violation related to the use of technology? The emergency room nurse faxes report to the medical unit before transferring a patient to the unit The nurse contacts a patient's insurance company for pre-approval for surgery with patient consent The nurse logs in to the computer at the patient's bedside to administer medication with family in the room The nurse faxes the patient's lab results to the dietary department instead of the primary care provider

The nurse faxes the patient's lab results to the dietary department instead of the primary care provider

The nurse is using palpation to assess respiratory function. Which action by the nurse requires more education regarding palpation? The nurse asks the client to repeat "ninety-nine" while placing both hands on the chest wall bilaterally. The nurse listens for dull sounds over the chest wall while striking the middle finger of the opposite hand. The nurse places both hands with thumbs touching on the client's back and asked them to take a deep breath. The nurse uses the thumbs of both hands to determine if the trachea is midline.

The nurse listens for dull sounds over the chest wall while striking the middle finger of the opposite hand The nurse listening for sounds while striking the middle finger is assessing by percussion not palpation.

Which of the following actions by the student nurse is a HIPAA (Health Insurance Portability and Accountability Act) violation? The student nurse shares patient history information with peers during instructor led post-conference discussion at the clinical site The student nurse shares on her social media page that she had the best clinical day watching the delivery of triplets The student nurse reviews a patient's electronic health record to gather information for writing a care plan for class The student nurse shares with the clinical staff concerns about the patient verbalizations about wanting to die

The student nurse shares on her social media page that she had the best clinical day watching the delivery of triplets

The primary nurse asks a student nurse to take a new post-op client an incentive spirometer and teach her what it is and how to use it properly. What is the primary goal of incentive spirometer use? To measure exhalation force after surgery To measure client oxygenation To cause the client post-op pain to help waken from anesthesia To force deep breaths to keep lungs expanded

To force deep breaths to keep lungs expanded

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? To confirm the placement of the NG tube To remove gastric acid that might cause dyspepsia To determine the client's electrolyte balance To identify delayed gastric emptying

To identify delayed gastric emptying

A nurse is observing the unlicensed assistive personnel (UAP) obtain a blood pressure. The patient's arm is lifted above shoulder level. The nurse expects that the blood pressure reading will be: Too high Too low Systolic reading low and diastolic reading high Systolic reading high and diastolic reading low

Too low Having the arm above the level of the heart will cause an erroneously low BP

Which of the following would be an inappropriate indication for placement of an indwelling foley catheter? Urinary incontinence Pre-operational intervention for abdominal surgery Urethral blockage Need for accurate output monitoring

Urinary incontinence

A nurse is auscultating different areas on an adult patient. Which technique should the nurse use during an assessment? Uses the bell to listen for lung sounds. Uses the diaphragm to listen for bruits. Uses the diaphragm to listen for bowel sounds. Uses the bell to listen for high-pitched murmurs.

Uses the diaphragm to listen for bowel sounds. the diaphragm is best for listening to high-pitched sounds such as bowel and lung sounds and high-pitched murmurs.

A new nurse in orientation is approached by a surveyor from the department of health and is asked, "What is the best means to prevent the spread of infection?" What is the best answer for the nurse to provide? "Let me get my preceptor." "Wash your hands before and after any patient care." "Clean all instruments and work surfaces with an approved disinfectant." "Ensure proper disposal of all items contaminated with blood or body fluids."

Wash your hands before and after any patient care

A nurse is teaching a client's adult son about how to position the client when administering enteral feedings at home. Which of the following statements by the son indicates an understanding of the teaching? "I will allow him to be in the position where he is most comfortable during the feeding." "I will elevate the head of the bed 10 degrees during the feeding." "I will turn him on his left side during the feeding." "I will have him sit in his chair during the feeding."

"I will have him sit in his chair during the feeding."

A nurse is caring for a client who had IV fluids initiated at 0330. The IV fluids are infusing at 120 mL/hr. The nurse should record how many mL of IV fluids on the intake record at 0600?

300 mL The time span in question is 2.5 hr. 120 + 120 + 60 = 300 mL infused. 120 mL/hr X 2.5 hr = 300 mL

A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions. (Place the steps in the correct order of performance. All steps must be used. Use 1, 2, 3, 4, 5 format.) 1) Elevate the extremity. 2) Remove the IV catheter. 3) Apply warm or cold compresses. 4) Stop the infusion. 5) Apply a sterile dressing.

4, 2, 5, 1, 3

The nursing student is calculating the output for their patient over the last four (4) hours. The patient had voided 250 mL clear urine and had a large formed stool the first time the student assisted him to the bathroom. The next time the student entered the room, they dumped 150 mL of clear urine from the urinal. The student has refilled the patient's water three times for 350 mL each. How many mL of output would the student calculate?

400 mL 250 mL + 150 mL = 400 mL, the stool and the fluid intake are not part of the output calculation.

A nurse is preparing to insert an NG tube for a client who requires gastric suctioning. Place the following steps in the appropriate order. (Place the steps of NG tube placement in the correct order of performance. All steps must be used. Use 1, 2, 3, 4, 5, 6 format.) 1) Measure the NG tube. 2) Instruct the client to flex the head forward. 3) Instruct the client to extend the neck backward. 4) Connect the tube to the suction device. 5) Prepare equipment at the bedside. 6) Obtain an x-ray.

5, 1, 3, 2, 6, 4

A nurse is preparing to perform a capillary blood glucose test. Identify the sequence of steps the nurse should follow. (Place steps in 1, 2, 3, 4, 5, 6 format.) 1) Document results. 2) Perform a quality control test. 3) Apply blood sample onto test strip. 4) Cleanse puncture site. 5) Perform hand hygiene. 6) Check expiration date on test strips.

6,2,5,4,3,1

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III? Testing visual acuity Observing for facial symmetry Eliciting the gag reflex Checking the pupillary response to light

Checking the pupillary response to light

The nurse completed assessments on several patients. Which assessment finding will the nurse record as normal? Pulse strength 3 1+ pitting edema Constricting pupils when directly illuminated Hyperactive bowel sounds in all four quadrants

Constricting pupils when directly illuminated

Myopia

nearsightedness

Tinnitus

ringing in the ears

Patients who fall, even when uninjured, are at risk for falling again. True false

true

When auscultating the abdomen, the nurse should report which finding to the primary care provider? Bruit over the aorta Absence of bowel sounds for 90 seconds Continuous bowel sounds over the ileocecal valve Completely irregular pattern of bowel sounds

Bruit over the aorta

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first? Administer oxygen at 2 L/min. Administer prescribed analgesic medication. Encourage coughing and deep breathing. Raise the head of the bed.

Raise the head of the bed Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head and neck can be extended, which promotes a patent airway.

To palpate lymph nodes, the nurse uses which technique? Compress the nodes between the index fingers of both hands. Use the pads of two or three fingers in a circular motion. Use the back of the hand to feel for temperature differences from the right and left sides. Use all four fingers in a vertical and then side-to-side motion.

Use the pads of two or three fingers in a circular motion Rationale: Use the pads of two or three fingers and a gentle rotating motion over the nodes. None of the other options are proper palpation of lymph nodes.

A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect? 6.0 4.0 7.0 8.0

4 4.0 is an acidic pH, which is consistent with gastric drainage. This indicates that the NG tube is correctly placed

The nurse is assessing an adult patient's patellar reflex. Which finding will the nurse record as normal? 1+ 2+ 3+ 4+

2+

A nurse is caring for a client who is postoperative following abdominal surgery. The nurse discovers a loop of bowel through an opening in the surgical incision. Which of the following actions should the nurse take? Place the head of the client's bed in the flat position. Gently reinsert the bowel back into the client's wound. Apply moistened sterile gauze to the site. Position the client on his left side.

Apply moistened sterile gauze to the site

Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use? Ask the client's full name and date of birth. Verify the client's room number. Check the client's name on the medication administration record (MAR). Ask a family member to verify the client's identity.

Ask the client's full name and date of birth

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? Assess the apical pulse for a full minute. Assess the apical pulse with a Doppler device. Assess the pedal pulses for a full minute. Assess the pedal pulses with a Doppler device.

Assess the apical pulse for a full minute.

A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first? Call the client's provider. Assess the client. Notify the nurse manager. Complete an incident report.

Assess the client

To increase stability during patient transfer, the nurse increases the base of support by performing which action? Leaning slightly backward Spacing the feet farther apart Tensing the abdominal muscles Bending the knees

Spacing the feet farther apart

A nurse is caring for a client who requires a medication that is packaged in a single dose glass ampule. Which of the following techniques should the nurse use when opening the glass ampule? Wear sterile gloves and break off the neck of the glass ampule with a single snap to the right side. Wear sterile gloves and break off the neck of the glass ampule with a single snap in a downward motion. Tap the bottom of the ampule, place a gauze pad around the ampule neck, and break off the bottom with a forward motion away from the body. Tap the top of the ampule, place a sterile gauze pad around the ampule neck, and break off the top by bending it toward the body.

Tap the top of the ampule, place a sterile gauze pad around the ampule neck, and break off the top by bending it toward the body.

A nurse is teaching a client about crutch walking using the three-point gait. Which of the following statements by the nurse should be included in the teaching? "Look down at your feet before moving the crutches." "Place one crutch forward with the opposite foot and then place the second crutch forward followed by the second foot." "Move both crutches forward while standing on the unaffected leg, then lift and swing your body past the crutches."

"Move both crutches forward while standing on the unaffected leg, then lift and swing your body past the crutches."

A nurse is caring for a client who is receiving heparin 3,800 units subcutaneous daily. Available is heparin 5,000 units/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth.)

0.8 mL STEP 1: What is the unit of measurement to calculate? units STEP 2: What is the dose needed? Dose needed = Desired. 3,800 units STEP 3: What is the dose available? Dose available = Have. 5,000 units STEP 4: Should the nurse convert the units of measurement? No STEP 5: What is the quantity of the dose available? 5,000 mL STEP 6: Set up an equation and solve for X.Have/Quantity = Desired/X5,000 units/1 mL = 3,800 units/xX = 0.76 mL STEP 7: Round if necessary.X= 0.8 mL STEP 8: Reassess to determine whether the amount to give makes sense. If there are 5,000 units/mL and the amount prescribed is 3,800 units, it makes sense to administer 0.8 mL. The nurse should administer heparin 0.8 mL subcutaneous daily.

A nurse is providing discharge teaching to the parent of a child who is prescribed diphenhydramine 25 mg elixir every 4 hr as needed. The amount available is diphenhydramine elixir 12.5 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

10 mL 25 mg x 5 mL/12.5 mg = X mL 10 = X

A nurse at a health fair is assessing the weight status of four clients. Which of the following clients are classified as overweight? A female client who has a body mass index of 24 male client who has a body mass index of 29 A female client who has a waist circumference of 101.6 cm (40 in)

A male client who has a body mass index of 29

Assessment of which body system requires the nurse to auscultate before palpation? Head and neck Lungs Abdomen

Abdomen By auscultating the abdomen before palpation, the chance of altering the frequency and intensity of bowel sounds is decreased.

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? Creatine kinase Troponin Total bilirubin Albumin

Albumin A low albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time

A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take? Use the tablet's packaging to pick it up from the counter. Wash the tablet off with alcohol and place it in a clean medication cup. Discard the tablet and obtain another dose of medication.

Discard the tablet and obtain another dose of medication

A male student comes to the college health clinic. He hesitantly describes that he found something wrong with his testis when taking a shower. Which assessment finding will alert the nurse to possible testicular cancer? Hard, pea-sized testicular lump Rubbery texture of testes Painful enlarged testis Prolonged diuretic use

Hard, pea-sized testicular lump

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status? Measure the circumference of the thigh. Palpate the femoral pulse. Monitor the client's calf for edema. Instruct the client to wiggle his toes.

Instruct the client to wiggle his toes.

A patient is being admitted to acute care from home. The patient spouse (caregiver) states the patient is only comfortable laying in the left side. What areas are a priority to assess for skin breakdown? (Select all that apply.) Right iliac crest Left ear Sacrum Left knee Right medial thigh

Left ear Left knee

A nurse is caring for a patient with ordered bilateral soft wrist restraints. The patient is confused and had pulled out her IV line twice and continuously tried to get out of bed. Which action(s) by the nurse are appropriate? (Select all that apply) Orient the patient. Assess the tightness of the restraints. Ensure that the restraints are tied to the side rails. Provide range-of-motion exercises when the restraints are removed. Document the behavior(s) that require the continued use of restraints.

Orient the patient Assess the tightness of the restraints Provide range-of-motion exercises when the restraints are removed Document the behavior(s) that require the continued use of restraints

The nurse has an order for acetaminophen rectal suppository for a patient with a fever. What would be a contraindication for this medication order? Patient reports vomiting for 2 days Patient reports allergy to ibuprofen Patient reports bleeding from the bowel Patient reports constipation for 1 week

Patient reports bleeding from the bowel

A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first? Deflate the catheter balloon using a sterile syringe. Measure and document the urine in the drainage bag. Remove the tape or device securing the catheter to the client's thigh. Position the client supine.

Position the client supine

A nurse requires a pen light when assessing which areas? (Select all that apply.) Pupil reaction Middle ear Nares of the nose Lips Pharynx

Pupil reaction Nares of the nose Pharynx

A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider? Stoma oozing red drainage Shiny, moist stoma Purplish-colored stoma

Purplish-colored stoma

Upon auscultation of the heart, the nurse recognizes which as an expected finding for an adult? A low-pitched blowing sound heard over the abdominal aorta. A high-pitched vibration is heard over the base of the heart. The S1 heart sound is louder at the apex of the heart.

The S1 heart sound is louder at the apex of the heart.

Jugular Vein Distention

Vein visible when sitting

An older-adult patient needs an intramuscular (IM) injection of antibiotic. Which site is best for the nurse to use? Deltoid Dorsal gluteal Ventrogluteal

Ventrogluteal

Order: Glucophage 1000 mg PO BID (fill in the blank) Available: Glucophage 500 mg tablets How many tablet(s) should be administered per dose?

2 tablets

An advanced practice nurse is preparing to assess the external genitalia of a 25-year-old woman of Chinese descent. Which action will the nurse do first? Place the patient in the lithotomy position. Drape the patient to enhance patient comfort. Assess the patient's feelings about the examination. Ask the patient if she would like her mother to be present in the room.

Assess the patient's feelings about the examination

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 5 L/min via nasal cannula. Which of the following actions should the nurse take? Attach a humidifier bottle to the base of the flow meter. Remove the nasal cannula while the client eats. Secure the oxygen tubing to the bed sheet near the client's head. Apply petroleum jelly to the nares as needed to soothe mucous membranes.

Attach a humidifier bottle to the base of the flow meter Oxygen therapy can dry the mucous membranes. The nurse should attach humidification for a client receiving oxygen greater than 4 L/min via nasal cannula

The nurse is discussing strategies with the unlicensed assistive personnel (UAP) for bathing a client with dementia. Which strategies would be appropriate for the client? (Select all that apply.) Be organized Sing or talk to the client Offer choices and follow personal preferences Expect the client to protest, finish quickly Cover the client as much as possible

Be organized Sing or talk to the client Offer choices and follow personal preferences Cover the client as much as possible

A novice nurse is preparing to remove a stained dressing from a wound to perform wound irrigation. The charge nurse would question which of the following actions? Placing a biohazard bag on the foot of the bed Preparing syringe with irrigation solution Donning goggles/eye protection Donning sterile gloves

Donning sterile gloves All the actions listed are normal for removing a stained dressing in preparation for wound irrigation except the sterile gloves. They are not required as removing a stained dressing is a clean rather than a sterile procedure.

A registered nurse interprets that a scribbled medication prescription reads 25 mg. The nurse administers 25 mg of the medication to a patient and then discovers that the dose was incorrectly interpreted and should have been 15 mg. Who is ultimately responsible for the error? Health care provider Pharmacist Hospital Nurse

Nurse

A nurse on a medical-surgical unit is providing care for a group of clients. The nurse should delegate collection of which of the following specimens to the assistive personnel (AP)? Wound drainage for culture Urine from an indwelling catheter Blood for PaCO2 Random stool specimen

Random stool specimen

A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take? Insert the needle into the needless port at a 60° angle. Withdraw 3 to 5 mL of urine from the port. Wipe the area of needleless port with sterile water.

Withdraw 3 to 5 mL of urine from the port

Which assessment finding by the nurse would best determine if the goal of "Demonstrate adequate tissue perfusion" is being met? Symmetrical chest expansion Activity intolerance Brisk capillary refill

Brisk capillary refill Rationale: Capillary refill is an assessment of capillary blood flow thus tissue perfusion

Which statement by the student nurse demonstrates understanding of expected findings during the assessment of the musculoskeletal system? "By comparing the patient's assessment with expected findings for his age group, I can identify any limitations." "By comparing the patient's assessment with expected findings for his gender, I can identify any limitations." "By comparing the patient's assessment with expected findings of his race, I can identify any limitations." "By comparing the patient's left side with his right side, I can identify any limitations."

By comparing the patient's left side with his right side, I can identify any limitations

A nurse is providing education to a 15 year-old female and her mother during a well child office visit. The mother asks about when her daughter should start seeing a gynecologist for gynecological exams. The nurse's best response is: "Your daughter is too young to discuss that yet." "We encourage all teens to start their yearly gynecological exam when they begin having menses." "At this age, your daughter only needs to see a gynecologist if she is pregnant or has a STI." "Females should be seen by a gynecologist every year if they are sexually active or beginning at age 21."

"Females should be seen by a gynecologist every year if they are sexually active or beginning at age 21."

A nurse is reinforcing teaching with a client about using transdermal patches at home. Which of the following statements should the nurse identify as an indication that the client understands the teaching? "I will remove the old patch and apply a new one in the same location." "I will press the patch securely in place on my forearm." "I will clean and dry the area before applying the patch." "I will use lotion on irritated skin before applying a new patch in that area."

"I will clean and dry the area before applying the patch."

A nurse is preparing an in-service program about preventing medication errors when transcribing a prescription. The nurse is using a dosage example of two tenths of a milligram. Which of the following examples should the nurse use to show appropriate transcription of this dosage? .2 mg 0.2 mg 0.20 mg 2.0 mg

0.2 mg A zero should precede a decimal point, but should not follow a decimal point unless a whole number follows the zero, as in 1.05 mg.

The nurse is using a Snellen chart to determine visual acuity. The patient should stand how far away from the chart for an accurate assessment? 5 feet 10 feet 20 feet

20 feet

The nurse is preparing to administer an injection into the deltoid muscle of an adult patient weighing approximately 160 lb. Which needle size and length will the nurse choose? 18 gauge × 1 1/2 inch 23 gauge × 1/2 inch 25 gauge × 1 inch 27 gauge × 5/8 inch

25 gauge × 1 inch

A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed ½ cup of juice, 3 oz gelatin, 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?

260 ½ cup of juice: 1 cup = 8 oz ½ cup (8 oz ÷ 2) = 4 oz 1 oz = 30 mL 4 oz x 30 = 120 mL ½ cup = 120 mL 3 oz gelatin: 1 oz = 30 mL 3 oz x 30 = 90 mL 1 oz ice pop: 1 oz = 30 mL 20 mL of ginger ale Then, the nurse should total the amounts: 120 mL + 90 mL + 30 mL + 20 mL = 260 mL

Which are appropriate interventions for a patient complaining of dry mouth with an NPO order (Select all that apply): The patient may have sips of water, no more than 50 ml/hr The patient may have ice chips only The patient may use moistened swaps as needed The nurse offers oral care frequently The patient may swish and spit water or mouthwash as needed

Correct! The patient may use moistened swaps as needed Correct! The nurse offers oral care frequently Correct! The patient may swish and spit water or mouthwash as needed

During auscultation of breath sounds on the posterior thorax, the nurse hears high-pitched, fine, short sounds during inspiration. This is most likely what kind of breath sounds? Wheezes Crackles Stridor Rhonchi

Crackles

Venous Problems

Lower extremity swollen and warm with normal pulse

After applying an elastic bandage to a wrist, it is important for the nurse to assess: (Select all that apply): Wrinkles in the bandage Looseness of the bandage Palpate proximal pulses to the bandaged site Skin pallor or cyanosis distal to bandage Joint mobility

Wrinkles in the bandage Looseness of the bandage Skin pallor or cyanosis distal to bandage Joint mobility Assess the degree of tightness of the bandage and the presence of wrinkles, looseness, and drainage to identify any pressure areas that may cause tissue injury. Assess distal extremity circulation by observing for skin pallor or cyanosis and palpating skin warmth and compare to the opposite extremity to identify diminished blood flow. Palpate pulses distal to the bandage to assess circulation. Observe for joint mobility to determine if joint immobilization is attained. (Skill 48.6)