NUR-Fundamental

A nurse is caring for a client who has a new diagnosis of chronic kidney disease. Which statement should the nurse identify as an indication of anticipatory grieving?

I just cant believe that this dialysis is going to ruin my whole life.

A nurse is instructing to a young adult client about healthful sleep habits. which statement should the nurse identify as an indication that the client needs further teaching?

I watch television until I fall asleep at night.

A nurse is conducting a health promotion class for patients and their children about sun protection. The nurse should identify which patient responses as an indication that the teaching was effective.

I will avoid sitting in the sun between 10 am. and 3 pm.

A nurse Is reinforcing teaching with a patient about using transdermal patches at home. Which statement should the nurse identify as an indication that the patient understands the teaching?

I will clean and dry before applying the patch.

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

I will cover the catheter so he cannot see it. Using stockinette or clothing to cover the IV insertion site is an appropriate distraction technique and might steer the clients attention away from the catheter.

A nurse is teaching a patient who reports insomnia about promoting rest ans sleep. Which statement should the nurse identify as an indication that the patient understands the instructions?

I will no longer have a glass of wine before bedtime.

A nurse is caring a client who has metastatic bone cancer. The client states. " I want to go home to die". The family is concerned about meeting the clients care needs at home. Which action should the nurse take?

Discuss initiating a hospice care with the client and family.

A nurse is preparing a sterile field. which action should the nurse perform when opening the sterile pack?

Reach around the pack and the top flat away from the body. Place the pack on the clean work surface.

A nurse is assessing a patient for pitting edema and notes an indentation of 6 mm (0.25) at the point of pressure. Which notation should the nurse use to document the severity of the patient edema.

3+ Pitting edema of 5-7 mm as 3+

A nurse is measuring a patient oral temperature. The patient telling the nurse that she just eaten some ice chips. Which action should the nurse take?

Wait 30 minutes and return to measure the oral temperature.

A nurse is teaching a client who has a new diagnosis of atopic dermatitis. Which statements should the nurse include in the teaching?

Your provider may recommend a daily antihistamine to help control your symptoms.

A nurse is assessing a clients radial pulse and determines that the pulse is irregular. Which action should the nurse take?

Assess the Apical pulse for a full minute. This help to determine the regularity or irregularity of the heart.

A patient receives a wrong medication. The nurse who made the medication error should take which of the actions first?

Assess the patient.

A nurse is admitting a patient who has a partial hearing loss. Which is the priority action by the nurse?

Determine is the patient uses hearing aids.

A nurse is caring for a client who requests prescription pain medication. Which action should the nurse perform first?

Determine the location of the pain. First action the nurse should take using process is to assess the client. By determining the location of the pain, the nurse can take the necessary step to alleviate the clients pain.

A nurse is providing postmortem care for an adult patient. Which actions should the nurse take?

Determine whether the client will have an autopsy is correct. Cover the body with a clean sheet and place the arms outside the sheet. Give the patient personal belongings ti the family.

A nurse is preparing a client evening dose of risperidone when the tablet falls on the countertop. Which action the nurse should take?

Discard the tablet and obtain another dose of medication.

A nurse is admitting a patient who is dehydrated. Which BUN levels should the nurse expect the client to have upon admission?

35 mg/dL. Patient who have dehydration can have decreased blood flow, which leads to decrease renal excretion of BUN.

A nurse is completing an 8-hr I&O record for a client who consumed 4 oz juice, 6 oz tea, a 100mL, cup full of ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record.?

740 mL. 120(juice)+180(tea)+50(ice-chips)+100(ml ice chips)+50(fluid volume)+150(IV)+240(broth)= 740 mL.

A nurse is caring for a patient who is cognitively impaired and repeatedly pulls on his NG tube. Which action should the nurse take?

Assist the patient with toileting at frequent intervals. Use an electronic position-sensitive device. Provide diversionary activities for the patient. Involve the family patient in the care.

A nurse is preparing to administer a pre-packaged oral medication to a client and complete the final medication check, At which time or places should the nurse perform this final check?

At the clients bedside before administration.

A nurse is caring for a patient who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultated decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which condition

Atelectasis.

A nurse is caring for a client who is immobile. Which action is the priority for the nurse to include in the patient care plan

Auscultate breath sounds at least every two hours.

A nurse is ready to insert an indwelling urinary catheter for female client. Which instructions should the nurse give the client as the catheter is inserted?

Bear down

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. the nurse recognizes this finding can be a manifestation of which urinary alterations?

Bladder infection. The nurse should recognize that hematuria, or blood-tinged urine, can be a manifestation of a bladder or kidney infection.

A nurse is caring a patient who ingested a poison and is now expecting a seizure. Which is the priority action the nurse should take?

Check the patency of the patient airway. Using the airway, breathing, circulation, approach to client care is checking the patent airway.

A nurse is assisting with the admission of a patient to an inpatient unit. Which sources of information should the nurse rely on for accurate information about the client.

Client concerns.

A nurse is preparing to administer oral medication to a client. Which of the following should the nurse recognize as an acceptable client identifier?

Client full name. Facility- assigned identification number.

A nurse is assessing a patient who has a chronic respiratory insufficiency. Which finding should the nurse expect as result of the long-term inadequate oxygenation?

Clubbing of the fingers.

A nurse is planning for a hospitalized patient who is immobile and in a continuous mitten restraint. Which interventions should be included in the patient care plan?

Document restraint check and Patient status every 2hr. Educate the patient family about restraint use. Implement passive range of motion exercises.

A nurse is caring for a client who has pressure injury. Client has a 2cm stage 3 pressure injury on the left heal. No drainage or redness noted. Hydrocolloid dressing applied to the wound.

Documentation on the medical records that requires further action by the nurse: Increase redness at the wound borders and purulent drainage note. Temperature 38.9 (102.F) WBC 12,000/mm (5,000 - 10,000)

A nurse is admitting a patient who has pertussis. Which type of transmission-based precautions should the nurse initiate?

Droplet

A nurse is teaching a patient who has constipation. which findings the nurse discuss as causes of constipation?

Excessive laxative use. Ignoring the urge to defecate. inadequate fluid intake.

A nurse is caring for a client whose family is in a state of disagreement over the care of their family member. The nurse should report the situation to which of the facility personnel?

Hospital Ethic commitee.

A nurse is teaching a client about carbon monoxide poisoning. Which statement should the nurse identify as an indication that the client needs further instructions?

I can detect the presence of carbon monoxide by a metallic odor.

A nurse is reviewing information about the health insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which statement by the newly licensed nurse indicates a need for further teaching?

Information about a client can be disclosed to family members as any time.

A nurse is reviewing a providers prescription for four patients. Which prescription is outside the legal scope of practice for the nurse?

Inserte a tunneled central venous catheter for a client.

A nurse receives a client care assignment from the charge nurse that he believes is unfair. The nurse voices his concern to the charge nurse. The nurse is using which level of communication at this point?

Interpersonal communication.

A nurse is adhering to standard precautions while

Irrigating a client abdominal wound. Suctioning a client new tracheostomy tube.

A nurse intercepts a messenger at the nurse station who has a flower delivery for a client on the unit. As the nurse accepts the flowers, the messenger says. "I know Mrs. Welch from the neighborhood. What happened to her" Which responses should the nurse provide?

It's my responsibility to remind you that we have to respect our clients privacy. Provides clarification to the messenger that the hospital staff cannot disclose information about clients.

A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive device. The nurse initiate a referral with which of the members of the interprofessional health care team.

Occupational therapist.

A nurse on mental health unit is caring for a client whose plan of care includes learning work-related skills. Which of the members of the interprofessional team is appropriate for this patient.

Occupational therapist.

A nurse in a long-term care facility enters the day room and finds the window on fire. Clients are panicking and the room is filling with smoke. Indicate the emergency action the nurse must take.

Remove the clients from the room. Active the fire alarm. Close the door. Extinguish the fire.

A nurse is receiving a provider prescription for a client via telephone. Which of the action should the nurse take to ensure the accuracy of the telephone prescription?

Repeat the order back to the provider. Question any part of the order that is unclear or inappropriate. Transcribe the order into the clients health record.

A nurse finds an open vial of morphine lying on the top of the cabinet in the patient room. Which action should the nurse take?

Report the discrepancy immediately.

A nurse is preparing to administer an intramuscular (IM) injection of meperidine to a patient. Which is the priority assessment the nurse should complete?

Respiration rate.

A nurse is preforming a pain assessment for a client who is alert. The nurse should that which measures is the most reliable indicator of pain?

Self- report of pain.

A nurse is providing discharge teaching to a patient has a new prescription for metered dose inhaler (MDI). Which of the instructions should the nurse include in the teaching?

Shake the inhaler for 3 to 5 seconds.

A nurse is orienting a newly licensed nurse about receiving telephone prescriptions. Which statement by the newly LN. , should indicate a need further teaching?

Telephone Prescription are transcribed into the nurse notes.

A nurse is administering a nasal decongestant drops for a patient. Which actions should the nurse take?

Tell the patient to blow her/his nose gently before the installation. This action will help to remove any secretions or crust the could interfere with the distribution of the medication.

A nurse is reviewing the medical record for a client who has health care-associated infection (HAI). The nurse should identify which of the findings as a risk factor for acquiring an HAI.?

The client 71-year-old. Clients older than 70 Yrs. of age are at an increased risk of acquiring HAI. Decreased immune system function increases the susceptibility to infection.

A nurse provides a back massage as a palliative care measure to the client who is unconscious, grimacing, and restless. Which findings should the nurse identify as indicating a therapeutic response?

The shoulders droop. The facial muscles relax. The pulse is within the expected range. The

A nurse is teaching the parents of a child who is start using a ,etered-dose inhaler (MDI) to treat asthma. Which information should the nurse include in the teaching?

The spacer increases the amount of medication that reaches the lungs.

A nurse is providing care for a patient who is immobile. Which action should the nurse take?

Turn the patient on his side before starting oral care. This action helps fluids run out of patients mouth by gravity, thus preventing aspiration and chocking.

A nurse is planning to perform a sterile dressing change fo a patient. Which action should the nurse plan to take?

Use sterile forceps to move the sterile items on the sterile field.

A nurse at the nurse facility is instructing a newly nurse about patient use of assistive devices during ambulation. Which instruction should the nurse instructor include about the patient uses of cane?

When the patient moves, he should move the cane forward first. He should first move the cane forward 30.5 cm (12 in) then, move the weak leg even with the cane.

A nurse is preparing an older patient for a physical examination the provider is about to perform, Which action should the nurse take?

explain to the patient what is about to happen.

A nurse is working with a team of nursing personnel within a facility. Which necessary task performance role that members of the group pf the leader must perform?

Coordinator Evaluator. Energizer.

A Patient smoking in the bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which action is the nurse priotity?

Move any client in the immediate vicinity.

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask a client potential allergies during which phase of the nursing process?

Assessment. This phase includes asking the patient about health history, physical concerns, and healthcare expectations.

A nurse is implementing direct nursing care for a group of patients in an acute care setting. Which action by the nurse is considered an indirect care activity?

Assigning tasks to an assistive personnel.

A nurse is giving change of shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury. Which information should the nurse include in the background segment of SBAR?

Code Status

A nurse in the ER. is caring for a patient who collapsed after playing football on a hot day. After reviewing the admission Labs. findings, the nurse recognizes that these findings are consistent with which condition?

Dehydration. Hypernatremic (hypertonic) dehydration occurs whith excessive fluid losses due to perspitarion, respiration, and inadequate fluid intake.

A nurse is preparing to initiate a continues enteral feeding through an open system to a client. Which action should the nurse take?

Discard unused formula after 8hrs. Unused formula after 8-12 hr. reconstitution reduce the risk for bacterial growth.

A nurse is assessing a client who has insomnia. which question is the highest priority for the nurse to ask the client?

Do you have difficulty staying awake when you are driving.

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

Nonantimicrobial soap. CDC, recommended htat hands should washed with nonantimicrobial soap and water if in contact with spore-forming organisms such as Cdiff., Bacillus anthracis.

A nurse in a clinic is caring a patient who reports pain, crepitus and a popping sound in his temporomandibular joint. Based on the findings, to which provider should the nurse request a referral to the patient.

Oral surgeon. The clinical manifestations of pain, crepitus and a popping sound require further evaluation and assessment.

Nurse admitted a patient in the ER. Patient alert and oriented. Breath sound are clear and present throughout. Denies tobacco use. Patient reports they just returned from an 8 hr. car trip. Patient eats a high fiber diet and drinks 1800 ml. of fluid/day. 2.5 cmx2.5 (1 inx 1 in.) reddened area noted on patients left calf.

Patient is at an increased risk for developing Deep vein thrombosis due to recent car ride.

A nurse is reviewing an admitting prescription for a client, the nurse notes that the dose of the medication is three times the usual dose of the medication. Which actions should the nurse take?

Contact the provider to question the dosage.

A nurse is caring for patient who requires removal of surgical sutures. Which action should the nurse take?

Cut the suture as close to the skin as possible.

A nurse is caring for a patient who, two hr. earlier, severed the tip of a finger in an accident. During the assessment the nurse detects a strong smell of alcohol from the client breath. Which finding should the nurse assess first?

Date of the patient last tetanus immunization.

A nurse is developing a teaching plan for a patient who has a ew diagnosis of type 2 diabetes mellitus. Which action should the nurse plans to take first?

Determine what the patient knows about managing diabetes.

A nurse is caring for a patient who has an infected wound removes a dressing saturates with blood and purulent drainage. how should the nurse dispose of the material?

Dispose of the dressing in a biohazardous waste container.

A nurse is completing the initial admission assessment and history for patient. Which is the priority action for the nurse to take?

Document the client's allergies in the electronic medical record.

A nurse is teaching a newly licensed nurses about documentation of patient information in the electronic health record. Which statement by the newly licensed nurse indicates understanding of the information

Documentation is a communication tool for the interprofessional health care team.

A nurse is completing a patient assessment for admission. Which abdominal assessment findings require further investigation by the nurse?

Ecchymosis.

A home health nurse is conducting a home safety assessment for an older adult client. Which of the followings should the nurse identify as a safety risk for the client?

Electric cords behind the furniture, the nurse should make sure all electrical cords are secure against the walls or baseboards. Water heater temperature 54.4 (130F). Recommend setting the water temperature no higher than 49.0C (120F)

A nurse is presenting information to the public about preventing measures to reduce the risk for contracting West Nile virus. Which instructions should the nurse include.

Encourage the use of mosquito repellant.

A nurse is caring dor a patient who refuses treatment and asks to be discharged from the hospital against the medical advice. The nurse notifies the patient provider, who tells the nurse to restrain the client, if necessary, to keep her from leaving the hospital. The nurse understands that restraining this patient would be considered which type of civil>

False imprisonment

A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which action should the nurse should take?

Perform the Heimlich maneuver.

The nurse has just finished teaching a hypertensive patient about the newly prescribed drug, ramipril (Altace). Which patient statement indicates that more teaching is needed? a. "The medication may not work well if I take aspirin." b. "I can expect some swelling around my lips and face." c. "The doctor may order a blood potassium level occasionally." d. "I will call the doctor if I notice that I have a frequent cough."

"I can expect some swelling around my lips and face."

A nurse is caring a patient who has hypernatremia and requires IV fluid therapy due to her NPO status. which solutions should the nurse prepare to infuse this patient

0.45% sodium chloride

A nurse calculated a patient fluid output for a 12hr-period. Include Jackson-pratt (JP) drainage 35ml, suction 120 ml, and incontinence pads weighing 24og, 275g, 310g, and 270 g. The dry weight of the incontinence pads is 90g. The nurse should record how many ml. of output on the clients record.

35 (JP draining)+ 120 ml (suction)+ 240 (-90)+275 (-90) + 310 (-90)+ 270(-90)= 890 ML (35+120+150+185+220+180+

A nurse is preparing to administer an IV fluid of 500 ml. 0.9% sodium chorine over 60 min. The drop factor of the manual IV tubing is 10 gtt/ml. The nurse should set the manual IV infusion to deliver how many gtt/min.

83 gtt/min 500/60x 10=83.33333. nearest whole number= 83. gtt/minn

A charge nurse is anticipating the admission of four patients and planning their room assignments. Which client should the nurse assign to the room closest to the nurse station?

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

A nurse has received

A client who was admitted for chest pain and reporting a new onset of indigestion.

A nurse is caring a group of patients. Which clients should the nurse identify as having an increase risk of aspiration while eating?

A patient who has had radiation therapy for head and neck cancer. A patient who has had a cerebrovascular accident. A patient who is 4hr. postoperative following a leg amputation with anesthesia.

A nurse is caring a patient who requires isolation for active Tuberculosis. Which precautions should the nurse include when creating a sign to post outside of the clients room?

A protective mask N-95. Close door all the time. A gown. Hand hygiene. A puncture- proof sharps container.

A nurse assumes a variety of roles while working with patients. Which describes the nursing role of protecting the patient and supporting the patient decision making process?

Advocate.

A nurse on the medical-surgical floor is conducting a fall risk assessment for four patients. The nurse should identify that which patient is the greatest risk for fall?

An older adult patient who is confused and urinary frequency.

A nurse is at the orthopedic unit caring a group of patient. Which patient should the nurse identify as being at greatest risk for skin breakdown

An older adult who has a hip fracture and is in Bucks traction.

A nurse is preparing to perform hand hygiene. which action should the nurse take?

Apply 4 - 5 mL of liquid soap to the hands.

A nurses is providing teaching to a group of assistive personnel, about hand hygiene,. Which statement by one of the AP's indicates a "need for further teaching".

As long as I change gloves between clients, it is not necessary to wash my hands.

A nurse is caring for a patient who has mental health disorder. The patient ask about his medication and their effects. The nurse ask the patient the reason that he needs to know this. Which nontherapeutic communication techniques the nurse using?

Asking for explanation.

A nurse is caring for a client within the intimate zone of the patient space. The nurse should perform which activities in this space.

Auscultating heart sound. Changing a dreassing.

An assistive personnel (AP) reports a patient VS- as tympanic temperature- 37.1C (98.8F) BP-98/58, pulse 91/min., respiration 17/min. Which vital signs should the nurse re-measure?

BP (blood pressure)

A nurse in a medical unit, assessing a patient as part of a routine physical examination. Patient BP-142/88, body mass index (BMI) 31 and he is a current smoker. The nurse should identify that this client has multiple risk factors for which disorder?

Cardiovascular Disease.

A nurse is providing hygiene care for patient who is immobile. which actions should the nurse take?

Check for personal items when changing the bed linens Keep the bath water temperature between 43.3C - 46.1 C ( 110F - 115 F) Shave the patient hair in the direction of the hair growth.

A nurse is caring a patient who is postoperative and has a prescription for anti-embolic stockings. which action should the nurse take?

Check the stockings for wrinkles. Apply the stockings before patient gets out of the bed. Remove the stocking ones per shift to assess the client skin integrity. Measure the circumference of the patient calf and thigh at the widest point before obtaining.

A nurse is providing nail care for a patient. Which action should the nurse take?

Clean under the nail with an orange stick.

The nurse is receiving report a group of patients. The nurse anticipates which activities first in delivering patient care using the nursing process?

Collect and organized client data.

A nurse on medical unit is caring a patient who suddenly becomes confused and drowsy. Additional data includes pulse 100/min., respirations 24/mn. BP- 132/76, Temp-36.8 (98.2) Which action should the nurse perform?

Complete neurological check.

An older adult patient family member brings her to the ER, after finding her wandering outside. During the initial assessment, the nurse notes that the patient flinches when she palpates her abdomen yet responds to the questions only to questions by nodding and smiling. Which factors should the nurse identify as a likely explanation for the clients behavior.?

Confusion.

A nurse is discussing the norming stage of the group development process with a student nurse. Which statement by the student indicates understanding of the discussion/

Consensus evolves in this stage.

A nurse is admitting a client who has a wound infected with vancomycin-resistance enterocossi (VRE) which type of precautions should the nurse plan to initiate?

Contact precaution.

A nurse is transcribing a client medication prescriptions and is having difficulty reading a written prescription by the provider. Which nursing action should the nurse take?

Contact the provider to clarify the prescription.

A nurse is caring a patient who reports difficulty sleeping while in the hospital. Which action taken by the assistive personnel (AP) while the client is sleeping should the prompt the nurse to intervene?

Flushes the patient toilet after emptying the urinary catheter drainage bag.

A nurse has just finished a wound care visit for patient who requires contact precautions. Which pieces of the personal protective equipment (PPE) should the nurse remove first.

Gloves

A nurse is caring a patient who has a prescription for clear liquid diet. Which food should the nurse allow the patient to have?

Grape juice. Apple juice. broth. black coffee.

A nurse withdraws morphine 2 mg from a vial that contains 4 mg/mL to inject IM for a client. Which actions should the nurse take for wasting the excess medication?

Have a second nurse witness the disposal of the medication.

A nurse is preparing to administer a cleansing enema to a patient. Which action should the nurse take?

Hold the container solution 30 cm. (12 in) above the anus.

A nurse is preparing to administer ophthalmic solution to a patient. which action should the nurse take?

Hold the ophthalmic solution 2 cm (3/4 in) above the lower conjunctival sac.

A Nurse is discharging a patient who came to the outpatient clinic with an ankle sprain. Which statement should the nurse identify as an indication that the client understands the discharge instructions?

I 'll apply ice to my ankle today and tomorrow.

A nurse is caring for a patient who has cancer and is receiving palliative care. Which statement by the patient indicates they understand this type of care?

I am hoping this will limit my comfort.

A nurse is rehearsing

I decline the opportunity at this time.

A n urse is administering an oral medication to an older patient. The patient States "The pill i always take is green. I dont take an orange pill". Which responses should the nurse make?

I will check your medication order again.

A nurse is teaching a patient about how to use her new hearing aids. Which statement should identify as an indication that the patient needs further instruction.

I will clean the hearing aids with alcohol wipes.

A nurse is teaching a patient who has a history of falls about home safety. Which statement should the nurse identify as an indication that the patient understands the instructions

I will place a bath seat in my shower to use when i bathe. I will remove the rugs at the entry of my bathroom. I will install a nightlight instead the fluorescent lighting. I keep my walker at the side of my bed.

A nurse is instruct the patient who has a new diagnosis of Raynaud's disease about preventing the onset of manifestation. Which statement should indicate to the nurse the need for additional teaching?

I will take my medication at the first sign of an attack.

An nurse is providing discharge teaching to a patinet who was recently diagnosed with a latex allergy. Which client statement indicates an understanding of the information.

I will use ink pens for writing.

A nurse identifies a pressure ulcer after a patient had a long-extensive recovery following a surgical procedure. When completing an incident report about the pressure ulcer, the nurse should take which action?

Include any relevant statements the client made about the ulcer.

A nurse is teaching an older adult patient who report constipation> which instructions should the nurse include in the teaching?

Increase dietary intake of raw vegetables. Drink at least 6 - 8 glasses of water each day. Increasing activity.

A nurse is planning to administer an IM injection to a patient deltoid muscle. which action should the nurse take?

Inject the medication at 90 angle.

A nurse is assessing a patient who has experiences some loss of bone density. The nurse observe a "Hunchback" curvature of the patient spine. The nurse should expect the provider to document which disorder?

Kyphosis.

A nurse i preparing medication for a client when AP call for an emergency. Which action should the nurse take?

Lock the medication in the room and finish preparing it after returning form the emergency.

A nurse is providing postmortem care for a patient. Which steps the nurse should take to perform this procedure?

Make sure the provider has certified the client's death. Verify the patient organs and tissues donation status. Remove medical equipment's from the patient. Cleanse the body while adhering to body- fluid precautions. Attach identification tags to the body.

A nurse is measuring a client for Knee-high antiembolic stocking to help prevent venous stasis. Which action should the nurse take?

Measure from the heel to the popliteal space.

A nurse is caring for a patient who has arterial blood gas results: HCO3-18mEq, PaCO2-28mm-Hg and pH 7.30. The nurse recognized the patient is experiencing which acid base imbalance.

Metabolic acidosis.

A nurse is teaching a newly licensed nurse about transcribing prescriptions. Which of the examples should the nurse include in the instructions/

Metformin 500mg. 1 tablet, PO, daily.

A nurse is completing a patient history and physical examination. Which information should the nurse consider subjective data?

Nausea

A nurse plans to leave her schedules shift and hour early without permission or notification of the charge nurse. The patient in the nurse assignment are stable. Which legal act torts applies to this situation?

Negligence.

A nurse has completed an informed consent form with a client. The client states " I have changed my mind and do not want to have the procedure done." Which action should the nurse take

Notify the surgeon that the client wishes to withdraw informed consent for the procedure.

A nurse is caring a patient who has schizophrenia an having difficulty with performing ADL's. The nurse should consult with which of the interdisciplinary team to assist the client?

Occupational therapist.

Nurse is caring for a patient on medical unit. Patient had been working outside all day in a sun and 36.7C (98.0F) heat. Approximately 1 hr. prior to arrival the patient complained of dizziness and fainted, staying on the ground for several minutes prior to being able to get up. BP-92/58, Respiration-26, HR-116/min., temp- 28.6 C (102.5F) O2- 95% RA.

Patient is at risk for developing HYPERNATREMIA due to CONFUSION

A nurse is caring for a group of patients. Which patient should the nurse refer to the social worker?

Patient who requires placement in an assisted living facility. Patient who requests to secure an emergency notification system in the home. Patient who request to get school assignments while hospitalized on pediatric unit.

a nurse is planning care for a patient who is postoperative. Which statements about pain management should the nurse consider when implementing care?

Patietn-controlled analgesia (PCA) offers a constant level of opioids with therapeutic range. The patient will express the feeling of pain both verbally and nonverbally. Each client expression of pain may be different and individualized.

A nurse is assisting a provider with a sterile procedure and prepares to pour solution onto a piece of sterile gauze. which steps the nurse perform when pouring the sterile solution .

Perform hand hygiene. Remove the bottle cap. Place the bottle cap face-up on the clean surface. pick the bottle with the label facing toward the palm. pour 1- 2 ml. into a receptacle. Pour the solution onto the gauze.

A nurse is preparing a sterile field prior to inserting a urinary catheter for a patient. Which sequence of steps the nurse should plan to take?

Performance hand hygiene. Place the package on the work surface. Open the outermost flap away from self. Open the side flap, pulling to the side. Open innermost flap, toward self. Use inner surface of package as sterile field.

A nurse is teaching a group of assistant personnel (AP) about infection control measures on the unit. It is crucial for the nurse to remind the APs that which is the most effective way to prevent spread pathogens during patient care?

Performing hand hygiene frequently and constantly throughout the day.

A nurse is caring for a patient who refusing life-saving treatment due to their religious beliefs. The nurse should identify that this situation is an example of which consideration of the public health code of ethics?

Permissibility. The nurse demonstrating the ethical consideration of permissibility. It is considered is ethically wrong even if it were to have a good outcome.

A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability insurance. Which statement should the preceptor provide?

Personal liability coverage is not mandatory, but you should consider purchasing your own coverage.

A nurse is caring a patient who is a risk for falls. which actions should the nurse take?

Place a falls-risk identification band on the patients wrist. Teach the patient to use the call ight. Keep the client bed in the lower position.

A nurse is preparing to administer the Hepatitis B vaccine to a client. Which of the techniques should the nurse use to locate the deltoid muscle?

Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm.

A nurse is teaching a patient partner about how to obtain a blood pressure reading. Which action by the partner indicates a need further teaching?

Places the patient's arm above the level of the patient arm.

A nurse is observing an assistant personnel (AP) changing the linen for a patient who has fecal incontinence. Which actions indicates that the AP understands the principles of infection control?

Plece clean linen that touched the floor in the soiled linen bag.

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which findings should the nurse expect?

Poor skin turgor. Hypotension. Tachycardia. Flat neck veins. Dark yellow urine (concentrate)

A nurse manager is observing an AP applying wrist restraints for a client. which action should the nurse identify as an indication that the AP understands the procedure?

The padding of the restraints is against the patient bony prominences.

A hospice nurse is reviewing the prescriptions for a patient who is receiving palliative care. which prescription should the nurse expecte?

Provide skin care with moisture barrier. Administer artificial tears PRN. Perform mouth care every hour. Administer oxygen 2 L/ml via nasal cannula.

Remove a protective equipment after provided care.

Remove gloves. remove eyewear. Remove gown. Remove mask. Perform hand hygiene.

A nurse is caring a patient who is experiencing prostatic hypertrophy. Which findings associated with urinary retention should the nurse expect?

Report os feeling pressure. Tenderness over the symphysis pubis. Distended bladder. Voiding 30 ml. frequent.ly

A nurse is planning the discharge of a patient who has sleep apnea and requires bi-level positive airway pressure. (BiPAP) The nurse plan to consult with which of the health team care members to help educate the client.

Respiratoty therapist.

A nurse is teaching a new group of assistant personnel (AP) about the importance of hand hygiene. Which statement should the nurse include.

Rub all surfaces of your hands. with alcohol rub for 20-30 seconds.

A nurse is admitting a patient who has hepatitis C. Which precautions should the nurse implement

Standar precautions.

A nurse is receiving shift report about a group of patients. Which patient the nurse should plan to take first?

Suction the tracheostomy of a patient who has copious seretions.

A nurse is developing a plan of care for an older adult patient who is at risk for fall. Which actions should the nurse plan to include in the plan.

Teach balance and strengthening exercises. Provide information about home safety checks. Locks beds and wheelchairs when not providing care. Place the bedside table within the patient.

A patient on the medical unit unit, after transfer to ER following self-administration of an overdose of medication. The patient looks down at the floor and mumbles. "Hello". Which responses should the nurse make?

Tell me a little more about what happened.

A nurse caring for a patient who has a urinary tract infection. Hypertension. Furosemide 40 mg. po. bid., Trimothoprim/sulfamethoxazole 160mg/800 mg. po. q-12 hr. Client reports frequent watery diarrhea.

The client is at an increased risk for developing HUPOKALEMIA due to FLUID VOLUME DEFICIT.

A nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which action should prompt the nurse to intervene

The nurse allow the patient to rest in supine position during feefing.

A nurse is preparing an educational presentation about organ donation for a newly group of licensed nurses. Which information should the nurse include?

The nurse may serve as a witness to informed consent for organs donation

A nurse is providing preoperative teaching a client who will undergo surgery. The nurse explains that the client will wear antiembolism stockings during and the procedure. When the patient asks what the stockings do.

They improve your circulation to keep blood form pooling in your legs.

A nurse in outpatient clinic is caring for a patient who has a new diagnosis of plantar warts. which teaching plan of care the nurse include for this patient.

They may be painful whit ambulation.

A nurse on the long-term care facility is teaching a group os AP's about handling patients bed linens safety. Which instructions should the nurse include?

Tie the bags securely at the top. Any linen in the clients room, whether is clean or soiled, requires laundering before using for another patient.

A nurse is caring for a patient ans observes that the patient is dark amber, cloud, and has an unpleasant odor. The nurse should recognize that the patient are experiencing?

Urinary tract infection (UTI)

A nurse admisnister an incorrect medication to a patient. Following an assessment, of the patient the nurse determine that the patient has experienced no untoward effects as a result of the medication. The nurse does not complete an incident repport because no harm came to the patient. Which ethical principle sis the nurse ciolate?

Veracity

A nurse is assisting and older adult patient who is sedentary plan a new exercise regimen. Which Activities should the nurse recommend?

Walking

A nurse is talking with a patient who is beginning a program of moderate exercise. The patient ask the nurse why warm-up exercises are necessary. Which responses should the nurse make?

Warm-up exercises reduce the risk of injury.

A nurse is administering 1 mg hydromorphone IV to the client. The available dose is 2mg/1mL. What should the nurse do with the remaining medication.?

Waste the medication in the presence of another nurse. Immediately following administration, the nurse should as another nurse to witness the disposal of the medication. if paper records are used, each nurse should sign.

A nurse is preparing to collect health history data during a patient admission. Which question should the nurse use to promote this discussion?

What brought you to the hospital?

A nurse is caring for a patient whose partner ask to talk to the nurse. Tha partner relates her concerns about her spouse abusing alcohol and having difficulty maintaining employment. which responses should the nurse make?

What have you done in the past to cope with this issue.

A nurse is observing a newly licensed nurse performing a mantoux tuberculin skin test on a patient. Which action should the nurse intervene to the licensed nurse?

Withdrawing the needle and massaging the site gently.

A nurse is caring for a client who is scheduled for an elective surgical procedure. Which action the nurse take regarding informed consent?

Witness the client signature.

A nurse is providing home safety information for an older patient who uses a cane. Which statement should the nurse include in the teaching?

You should advance your weak leg forward to the cane. then move your strong leg. Hold the cane on the strong side of the body. Advance the cane 6-10 inches (15-25 cm.) when walking.

An older patient is scheduled to have an elective surgical procedure and informs the nurse that she wants to be designated as a do not resuscitate (DNR) case. Which responses should thenurse provide?

Your provider needs to talk with you concerning request.

A nurse on a medical unit is planning care for several patients. Which client should benefit most from the nurse acting as advocate?

an older adult patient who has no family and is uncertain about moving to assisted living.

A nurse is documenting a in a patient medical record. Which abbreviations is appropriate for the nurse to use?

bid. PRN - Q.O.D. - 30ml. -DNR. - NPO.

A nurse is teaching a client who has a new second degree ankle sprain. Which instructions should the nurse include in the teaching?

Elevate the affected ankle above the level of the heart. Apply heating pad intermittently to the affected ankle after 48 hr. Wrap the affected ankle with an elasticized compression bandage. Apply intermittent ice to the affected ankle for the first 48 hr.

A nurse is preparing to administer 3 liquid medications to a client who has an NG feeding tube with continues enteral feedings. which action should the nurse take?

Flush the NG feeding tube with 30 mL of water immediately following medication administration.

A nurse is preparing an educational program for a group of newly licensed nurses about client confidentiality. The nurse should explain that nurses nay share patient protected information with which group?

Health care team members caring for the patient.

A nurse is caring for a patient who has not voided for 8 hr. following the removal of an indwelling urinary catheter. Which action should the nurse take first?

Perform a bladder scan. Take using the nursing process is to assess the patient. Assess the post void residual (PVR) using a bladder scanner.

A nurse is preparing to insert an NG tube for patient that requires gastric suctioning. Which steps the nurse takes to perform this procedure?

Prepare the equipment at bedside. Measure the NG tube. Instruct the client to extend the neck backward. instruct the client to flex his neck forward. Obtain an x-ray. Connect the tube to suction device.

A nurse is administering several medications via a Patient gastrostomy tube. At which time should the nurse instill 15-30 mL of water?

Prior to administering each medication. After each medication. After giving multiple medications.

A nurse accidentally administers the wrong medication to a patient, which resulted in a severe allergic reaction and prolongs the patient hospitalization. The patient could rightfully sue the nurse for which of the ethical principals?

Malpractice.

As part of annual physical examination, a nurse is preparing a client to undergo a chest X-ray. Which instructions should the nurse give the patient prior to the procedure?

Remove all metal necklaces. Metal objects block visualization of the body structures and tissues, thus the client must remove them.

A nurse is wearing personal protective equipment and is preparing to leave a clients room after providing care. which action should the nurse take to remove the equipment?

Remove gloves. Remove the protective eyewear. remove the gown. Remove the mask.

A nurse is giving a presentation about patient confidentiality to a group of newly licensed nurses. which action is an example of a violation of confidentiality?

Reporting laboratory findings to a member of the family.

A nurse is developing a plan of care for a patient who practices Islam. Which action should the nurse include in the plan?

Request a meal tray without pork.

A nurse is documenting information in a computerized health record. Which of the nursing actions jeopardizes clients confidentiality?

Sharing computer passwords with coworkers.

A nurse is assessing a patient who has narcolepsy. Which findings should the nurse expect?

Sudden attacks of sleep. Hallucinations at the onset of sleep

A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the health care providers is responsible for obtaining informed consent form the client for the procedure?

Surgeon

A nurse is filling out an incident report after finding a client lying on the floor, Which information should the nurse include?

The client was lying on the floor next to his bed. The nurse should only document what she actually witnessed, along with date, time, place, and any other actual facts about the incident.

A nurse is caring a patient in the ER. Patient reports three days history of nausea, vomiting, and diarrhea. The patient states that they have been to Keep water down for the last 24 hr.

The nurse should First Initiate Oxygen followed by Administer a fluid bolus.