Practice Assessment

A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

breath sounds

A nurse is administering 1L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

decrease in heart rate

A nurse is auscultating the anterior chest wall of a client newly admitted to a medical-surgical unit. Identify the type of breath sounds.

normal breath sounds

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?

wrap blankets around all four side rails

A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?

"Are you able to help with your hygiene care?"

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?

"I am available to talk if you should change your mind."

A nurse is assessing a client's readiness to learn about insulin administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?

"I can concentrate best in the morning."

A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?

"I flushed what I urinated at 7:00 a.m. and have saved all urine since."

A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?

"I'll check the wires and cables on my TV to make sure they are in good working order."

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?

"Is your pain sharp or dull?"

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?

"It might help me to listen to music while im lying in bed."

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?

"People in middle adulthood often find satisfaction in nurturing and guiding young people."

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

"The pain is like a dull ache in my stomach."

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make?

"They indicate the form of treatment a client is willing to accept in the event of a serious illness."

A nurse is caring for a client who is terminally ill. Which of the following statements should the nurse identify as an indication that the client's family member is coping effectively with the situation?

"This is a difficult time, but we are helping each other through this."

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?

"Use the complete name of the medication magnesium sulfate."

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

"We can talk about advance directives, and I can also give you some brochures about them."

A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give to the client?

"We need to document the exact medication you were taking because you might be allergic to it."

A nurse is educating a client who has a terminal illness about her request to decline resuscitation in her living will. The client asks what would happen if she arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide?

"We will apply oxygen through a tube in your nose"

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have routine screening. What does that involve?" Which of the following responses should the nurse make?

"You should have a fecal occult blood test every year."

A nurse enters a client's room ad finds her on the floor. The client's roommate reports that the client fell getting out of bed. Which of the following statements should the nurse document?

"client was found lying on floor."

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

"when descending stair, I will first shift my weight to my right leg."

A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?

(fried egg)

A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

0.3 mg

A nurse working in the ED is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following signatures may the nurse legally witness?

1. A 16 yo client who is married 2. a 27 yo who has schizophrenia 3. an adoptive parent who brings in his 8 yo son 4. a 17 yo mother who brings in her toddler.

A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hours. The nurse should set the pump to deliver how many mL/Hr?

107mL/hr

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.

?

A nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. In what order should the nurse take the following actions to assist the client?

?

A nurse is providing care to four clients. Which of the following situations requires the nurse the complete an incident report?

A client who has an IV infusion pump receives an additional 250 mL of IV fluid.

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies?

Acupuncture

A nurse is admitting a client who has varicella. Which of the following types of transmission precautions should the nurse initiate?

Airborne

A nurse has just inserted an NG tube for a client. Which of the following assessment findings should the nurse expect to confirm correct tube placement?

An x-ray shows the end of the tube above the pylorus

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?

Apply intermittent suction when withdrawing the catheter.

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?

Ask another nurse to observe the medication wastage.

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions should the nurse take first?

Assist the client to an upright position.

A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects?

Auscultate lung sounds

A nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following foods should the nurse suggest that the client ass to his diet?

Avocados

A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?

Calf swelling

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?

Check the client for injuries

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

Cleanse the wound from the center outward.

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

Contact precautions

A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention?

Erythema on pressure points

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?

Flush the tube with 15 mL of sterile water.

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

Gently shake the container of medication prior to administration.

A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile infection. Which of the following information should the nurse include in the teaching?

Have family members wear a gown and gloves when visiting.

A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use?

Have the client stand with her arms at her side and her feet together.

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube?

Have the client take sips of water to promote insertion of the NG tube into the esophagus.

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

Have the client use a trapeze bar when changing position.

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?

Initiate an enteral feeding through a gastrostomy tube.

A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take?

Insert the IV catheter without using a tourniquet

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

Make sure the client wears a mask when outside her room if there is construction in the area?

A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. Which of the following actions should the nurse take?

Make sure two fingers can fit under the sleeves.

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following?

Narrowed arterial lumen

A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minute and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?

Notify the nursing manager

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

Pad the client's wrist before applying the restraints.

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

Place the client in a room with negative-pressure airflow. Wear gloves when assisting the client with oral care. Use antimicrobial sanitizer for hand hygiene.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

Place the client's arm in a dependent position.

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?

Potassium 5.4 meq/L

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear?

Pressing gently on the tragus of the client's ear.

A nurse is assessing an older client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs?

Pupil clarity Visual fields Visual acuity

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect?

Rapid heart rate

A nurse is caring for a client who is expressing anger over his diagnosis of colorectal cancer. Which of the following actions should the nurse take?

Reassure the client that this is an expected response to grief.

A nurse is caring for a client who requires bed rest and has a prescription for antiembolic stockings. Which of the following actions should the nurse take?

Remove the stockings at least once per shift.

A nurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress?

Role overload

A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the following locations should the nurse place the bell of the stethoscope?

Second intercostal space at the left sternal boarder

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?

Select a suction catheter that is half the size of the lumen.

A nurse is assisting a client who is post operative with the use of an incentive spirometer. Into which of the following positions should the nurse place the client?

Semi-fowler's

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?

Situation, background, assessment, and recommendation (SBAR)

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30 degrees.

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use?

The client holds the cane on the stronger side of her body.

A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field?

The nurse opens the sterile field on a wet surface

A nurse is planning care to improve self-feeding for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care?

Use a clock pattern to describe food on the client's plate.

A nurse is caring for a client who is reporting difficulty falling asleep. Which of the following measures would the nurse recommend?

Use progressive relaxation techniques at bedtime.

A nurse is teaching an older client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?

Walking briskly

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

Withhold the blood transfusion.

A nurse in a surgical suite notes documentation on a client's medical record he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

Wrap monitoring cords with stockinette and tape them in place.

A nurse is caring for a client who has a sodium level of 125mEq/L. Which of the following findings should the nurse expect?

abdominal cramping

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

1. Assist the client with a partial bed bath 2. Measure the client's BP after the nurse administers an antihypertensive medication 3. use a communication board to ask what the client wants for lunch

A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?

A client unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.

A nurse manager is overseeing the care on a unit. Which of the following situations should the nurse manager identify as a violation of HIPAA guidelines?

A nurse asks a nurse from another unit to assist with her documentation.

A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first?

Check the IV tubing for obstruction

A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?

Clean sutures along the incision site.

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action?

Determine the reasons why the client is refusing to use the incentive spirometer.

A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?

Skin blanching

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object?

Stand close to the cabinet when lifting it.

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

Subtract the amount of irrigant used from the client's urine output.

A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?

The family member washed out the feeding bag with warm water once every 24 hours.

A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy?

a client who has asthma

A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing she says, "Every time you change my bandage, it hurts so much" which of the following interventions is the nurse's priority action?

administer pain medication 45 min before changing the client's dressing

A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the nurse expect?

albumin level of 3g/dL

A nurse is performing a skin assessment of a client who has a lesion on his anterior thigh and expresses concern about skin cancer. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy?

an uneven shape

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?

bladder scan shows 525mL of urine

A nurse is caring for a client who has a pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate?

droplet

A nurse is caring for a client who has a terminal illness and is approaching death. The client's respirations are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take?

elevate the head of the client's bed

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next?

evacuate the client

A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?

evaluate electrolytes

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

regulate oxygen via nasal cannula at a flow rate no more than 6l/min

A nurse is caring for a patient with behind the ear hearing aid.

remove before shower

A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?

tap just bellow the kneecap

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?

use tracheostomy covers when outdoors

a nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take?

wash her hands before and after contact with the client

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?

"What could I have done to deserve this illness?"

A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family?

1. Check the cord routinely for frays or tearing 2. consider purchasing a generator for power backup 3. observe for signs of hypoxia

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.

1. obtain the pronouncement of death from the provider 2. remove tubes and indwelling lines 3. wash the client's body 4. ask the client's family members if they would like to view the body 5. place a name tag on the body

A nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (round)

8 mL/hr

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

8 oz ice chips

A nurse is planning an deduction session for an older adult client who has just learned that she has type 2 diabetes mellitus. Which of the following strategies should the nurse plan to use with this client?

Allow extra time for the client to respond to questions.

A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein?

Cheddar cheese

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?

Compare prescriptions with medications the client received during hospitalization.

A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. After which of the following observations should the nurse remove the IV catheter

Swelling and coolness are observed at the IV site

A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day. "Which of the following components of the prescription should the nurse question?

The dose

A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection?

Thread the IV catheter so that the hub rests at the insertion site.

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

administer the medication with the needle at a 45 degree angle

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?

assess the client for orthostatic hypotension

a nurse is completing an admission assessment of an older adult client. Which of the following findings should the nurse identify as a potential indication of abuse?

bruises on the arms in various stages of healing

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

during the admission process

A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take?

examine personal values about the issue

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?

place a client who has tuberculosis in a room with negative-pressure airflow.

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?

practice sessions

A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of the following actions should the nurse take?

talk directly to the client, instead of the interpreter, when speaking