Midterm Rationales

A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"I will wear synthetic clothing and woolen socks when using my oxygen."

A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the client's partner should indicate to the nurse that the teaching was effective?

"My partner should tilt their head forward when swallowing."

A nurse is orienting a newly licensed nurse about receiving telephone prescriptions. Which of the following statements by the newly licensed nurse should indicate a need for further teaching?

"Telephone prescriptions are transcribed into the nurse's notes."

A nurse is caring for a client who has heart failure and a prescription for digoxin 125 mcg PO daily. Available isdigoxin PO 0.25 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to thenearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.5 tabs

A nurse is preparing to administer oral medications to a client. Which of the following should the nurse recognize as an acceptable client identifier? (Select all that apply.)

A. Client's full name E. Facility-assigned identification number

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select all that apply.)

B. Teach the client to use the call light. C. Keep the client's bed in the lowest position. D. Place a fall-risk identification band on the client's wrist.

A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make?

I will cover the catheter so he cannot see it."

A nurse is teaching a client who has left hemiparesis how to use a cane. Which of the following instructions should the nurse include?

Review

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene?

The nurse allows the client to rest in a supine position during feeding.

A nurse is caring for a client who is to receive liquid medications via a gastrostomy tube. The client is prescribed phenytoin 250 mg. The amount available is phenytoin oral solution 25 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

50 mL

A nurse is preparing to administer amoxicillin 350 mg PO. Available is amoxicillin 250 mg/5 mL. How many mL should the nurse administer? (Round to the nearest whole number.)

7 ml

A nurse is caring for four clients. Which of the following clients should the nurse identify as having the highest risk for aspiration?

A client receiving continuous enteral feeding through NG tube

A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses' station?

A client who sustained a head injury and is having periods of confusion

A nurse is caring for a group of clients. Which of the following clients does the nurse identify as having an increased risk of aspiration? Select all that apply.

A. A client in a rehab facility after experiencing a CVA B. A 94-year-old client with dysphagia C. A client who is receiving enteral feedings through a small bore NG tube D. A client who passed the speech therapy evaluation and has a straw restriction

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (Select all that apply.)

A. Contractures of the extremities D. Crackles in the lungs E. Pressure ulcers

A nurse is preparing to teach the community about the effects of long-term or prolonged immobility on the metabolic system. Which of the following does the nurse prepare to teach? Select all that apply

A. Decreased appetite and altered nutritional intake B. Decreased muscle mass C. Loss of weight D. Resorption of calcium from the bones

A client is receiving tube feeding through an NG tube and has had 6 episodes of diarrhea in the last 24 hours. The nurse understands the client may not be tolerating the tube feed and performs which of the following actions? Select all that apply)

A. Slows the instillation rate B. Notifies the provider D. Collaborates with the dietician

A nurse is preparing to teach the community about the effects of long-term or prolonged immobility on the metabolic system. Which of the following does the nurse prepare to teach? Select all that apply

A. The elderly client who takes furosemide/Lasix at 1900 B. A client who takes opiates around the clock

The student nurse is helping to care for a client who is on a clear liquid diet. The nurse correctly explains to the precepting nurse that clear liquid diets are prescribed for which of the following? Select all that apply.

A. To rest the GI tract B. Post-operatively D. Acute large amounts of vomiting (hyperemesis), nausea, and diarrhea

A nurse is preparing a teaching plan for a client who speaks limited English and is scheduled for a surgical procedure. Which of the following guidelines should the nurse plan to use when selecting written educational materials for the client? (Select all that apply.)

A. Use culturally diverse materials. B. Use pictures. D. Use materials written in the client's spoken language. E. Provide a variety of educational materials.

A provider prescribes a sublingual medication for a client who has an NG tube in place. Which of the following actions should the nurse take?

Administer the medication under the client's tongue.

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?

Albumin

A nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet?

B Vitamin B is found in animal products and is commonly lacking in vegan diets

A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)

B. Assist the client with toileting at frequent intervals. C. Use an electronic position-sensitive device. D. Provide diversionary activities for the client. E. Involve the family in the client's care.

A nurse is teaching a client who has chronic kidney disease about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply.)

B. Tomatoes C. Bananas E. Raisins

A nurse notices an assistive personnel (AP) preparing to deliver a food tray to a client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?

Call the dietary department and ask for a kosher tray

A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort ,and a feeling of bloating. Which of the following actions is the nurse's priority?

Check to see if the suction equipment is working.

A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take?

Cleanse the top of the can of formula with an alcohol wipe.

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray?

Cranberry juice

A nurse prepares to replace the nearly empty container of total parenteral nutrition (TPN) for a client when she finds that there has been a delay in receiving the new container of solution from the pharmacy. Which of the following solutions should the nurse infuse until the next container of TPN solution becomes available?

Dextrose 10% in water

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?

Footboard

A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?

Gown

A nurse is preparing to administer morphine 4 mg IV bolus to a client who reports pain. Available is morphine 10mg/mL. Which of the following actions should the nurse take when disposing the remainder of the medication?

Have another nurse witness the disposal of the extra medication.

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?

Have the client wear a mask.

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

Increase dietary intake of raw vegetables.

A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care?

Instruct the client to tighten muscle groups for a short period, and then relax.

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?

Leave a nightlight on in the client's room.

A nurse is caring for a client who has pertussis. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray?

Mask

A nurse is caring for a client who has a Clostridium difficile infection. Which of the following cleansing agents should the nurse use for hand hygiene?

Nonantimicrobial soap

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection?

Performing hand hygiene before, during, and after direct contact with the client

A nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first?

Place a seat alarm in the client's chair

A nurse is developing a plan of care for a client who practices Islam. Which of the following actions should the nurse include in the plan?

Request a meal tray without pork.

A nurse enters a client's room and sees that ashes from a cigarette are beginning to ignite trash in the wastebasket. Which of the following actions should the nurse take first?

Rescue the client from immediate danger

A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the clients' use of a cane?

Review

A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?

Review

A nurse is assessing a client's ability to ambulate with crutches using a three-point gait. Which of the following actions should the nurse identify as a risk to the client's safety?

The client places partial weight on the affected leg.

A nurse manager is observing an AP applying wrist restraints for a client. Which of the following actions should the nurse identify as an indication that the AP understands the procedure?

The padding of the restraints is against the client's bony prominences.

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 identify delayed gastric emptying

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Turn the client's head to the side.

A nurse administers an incorrect medication to a client. Following an assessment of the client, the nurse determines that the client has experienced no untoward effects as a result of the medication. The nurse does not complete an incident report because no harm came to the client. Which of the following ethical principles did the nurse violate?

Veracity