Practice Final ATI

A nurse is planning care for a client who has manifestations of C. diff infection. Which of the following actions should the nurse plan to take? a. Place a surgical mask on the client during transport. b. Place the client on contact precautions. c. Use an alcohol-based agent to perform hand hygiene when caring for the patient. d. Obtain a blood specimen to test for C. diff.

b. Place the client on contact precautions.

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 client's use of a cane? a. "When the client moves, he should move the can forward first." b. "The client should hold the can on the weak side of his body." c. "The grip should be level with the client's waist." d. "The client should first move the strong leg, then the weak one."

a. "When the client moves, he should move the can forward first."

A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall? a. An older adult client who is confused and has urinary frequency. b. A client with diabetes mellitus who has a leg ulcer. c. A client who is 1 day postoperative and has a nursing assistant helping him out. d. An adolescent client who has a leg fracture and has been using crutches for the past 2 days.

a. An older adult client who is confused and has urinary frequency.

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? a. Apply a moisture barrier ointment to the client's skin. b. Clean the client's skin and perineum with hot water after each episode of incontinence. c. Clean the client's skin every 8 hours for signs of breakdown. d. Request a prescription for the insertion of an indwelling urinary catheter.

a. Apply a moisture barrier ointment to the client's skin.

A nurse is preparing to administer a pre-packaged oral medication to a client and complete the final medication check. At which of the following times or places should the nurse perform this final check? a. At the client's bedside before administration b. In the area where the nurse obtained the medication c. At the time of documentation d. At the nurses' station while reviewing the provider's prescription

a. At the client's bedside before administration

A nurse is assessing a client who is 2 days postoperative and auscultates bilateral breath sounds, but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications? a. Atelectasis b. Pneumonia c. Pulmonary embolism d. Arterial thrombus

a. Atelectasis

A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care? a. Auscultate breath sounds at least every 2 hour. b. Perform range-or-motion (ROM) exercises at least two to three times daily. c. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day. d. Apply antiembolic stockings.

a. Auscultate breath sounds at least every 2 hour.

A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take? (Select all that apply.) a. Check for personal items when changing the bed linens. b. Place a clean gown on the strongest arm first. c. Keep the bath water temperature between 43.3 degrees and 46.1 degrees d. Shave the client's hair in the direction of the hair growth. e. Wash the client's extremities from proximal to distal.

a. Check for personal items when changing the bed linens. c. Keep the bath water temperature between 43.3 degrees and 46.1 degrees d. Shave the client's hair in the direction of the hair growth.

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 b. Polyuria c. Diarrhea d. Crackles in the lungs e. Pressure ulcers

a. Contractures of the extremities d. Crackles in the lungs e. Pressure ulcers

A nurse is teaching a client who constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply): a. Excessive laxative use b. Ignoring the urge to defecate c. Inadequate fluid intake d. Increased fiber in the diet e. Increased activity

a. Excessive laxative use b. Ignoring the urge to defecate c. Inadequate fluid intake

A 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? a. Gait belt b. Jacket harness c. Four-wheel walker d. Cane

a. Gait belt

A nurse is planning to administer an IM injection into a client's deltoid muscle. Which of the following actions should the nurse take? a. Inject the medication at a 90 degree angle. b. Inject a volume of less than 2 mL. c. Inject the medication 12.7 cm (5 in) below the client's acromion process. d. Use a 21-gauge needle for the injection.

a. Inject the medication at a 90 degree angle.

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing action should the nurse take to promote he client's comfort. a. Obtain a pair of slipper-socks for the client. b. Rub the client's feet briskly for several minutes. c. Increase the client's oral fluid intake. d. Place a moist heating pad under the client's feet.

a. Obtain a pair of slipper-socks for the client.

A nurse is assessing a client who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply): a. Poor skin turgor b. Bradycardia c. Hypotension d. Pale yellow urine e. Flat neck veins

a. Poor skin turgor c. Hypotension e. Flat neck veins

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

a. Shake the inhaler for 3 to 5 seconds.

A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers. a. The left second intercostal space. b. The right second intercostal space. c. The left fifth intercostal space. d. The left fifth intercostal space at the midclavicular line.

a. The left second intercostal space.

A nurse is engaging in relationship counseling with a male client. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship? a. They are more direct when discussing issues. b. They are likely to wait for others to initiate the conversation. c. They tend to use more verbal communication d. They disclose more personal information.

a. They are more direct when discussing issues.

A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following? a. Urinary tract infection b. Urinary incontinence c. Urinary frequency d. Urinary retention

a. Urinary tract infection

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? a. Use a transfer device to lift the client up in bed. b. Apply cornstarch to keep sensitive skin areas dry. c. Massage the skin over the client's bony prominences. d. Elevate the head of the bed no more than 45 degrees.

a. Use a transfer device to lift the client up in bed.

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. c. Use materials written at an eighth-grade level. d. Use materials written in the client's spoken language. e. Provide a variety of educational materials.

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 nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take? a. Wait 30 min and return to measure the oral temperature. b. Provide the client a sip of warm water, wait 5 min, and measure the temperature c. Document that the nurse was unable to measure the client's temperature. d. Proceed to measure the oral temperature.

a. Wait 30 min and return to measure the oral temperature.

A nurse is teaching a client about foods that are included on a clear liquid diet. Which of the following food choices made by the client indicates the need for further teaching? a. Yogurt b. Popsicle c. Gelatin d. Broth

a. Yogurt

A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply): a. Repeat the order back to the provider. b. Question any part of the order that is unclear or inappropriate. c. Transcribe the order into the client's medical record. d. Obtain the provider's signature within 24 hours. e. Implement a recorded order message if the nurse can hear and understand it clearly.

a. repeat the order back to the provider b. question any part of the order that is unclear or inappropriate c. transcribe the order into the client's medical record d. Obtain the provider's signature within 24 hours.

A nurse is caring for a patient who is postoperative and has a prescription for antiembolic stockings. Which of the following actions should the nurse take? a. Apply the stockings while the client is sitting in a chair. b. Remove the stockings once each day. c. Check the stockings for wrinkles. d. Measure the size of the client's foot.

c. Check the stockings for wrinkles.

A nurse is providing teaching to an assistive personnel (AP) about caring for clients with restraints. Which of the following statements by the AP indicates an understanding of the teaching? a. "I will tie the restraints in double knots." b. "I will tie a restrain to the portion of the bed that moves when the head of the bed is moved." c. "I will ensure that restraints fit tightly against the client." d. "I will put four side rails up if a client is confused."

b. "I will tie a restrain to the portion of the bed that moves when the head of the bed is moved."

A nurse is teaching an assistive personnel (AP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions? a. "I will wear gloves whenever I am in contact with clients." b. "I will wear gloves and a gown when bathing a client who has open skin lesions." c. "I will wear gloves to minimize the number of times I have to wash my hands." d. "I will wear gloves when measuring a client's blood pressure."

b. "I will wear gloves and a gown when bathing a client who has open skin lesions."

A nurse is assessing a client for pitting edema and notes an indentation of 6 mm (0.25in) at the point of pressure. Which of the following notations should the nurse use to document the severity of the client's edema? a. 4+ b. 3+ c. 2+ d. 1+

b. 3+

A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment. a. Inspect the abdomen for skin integrity. b. Ask the client about having a history of abdominal pain. c. Percuss the abdomen in each of the four quadrants. d. Auscultate the abdomen for bowel sounds. e. Palpate the abdomen lightly for tenderness.

b. Ask the client about having a history of abdominal pain. a. Inspect the abdomen for skin integrity. d. Auscultate the abdomen for bowel sounds. c. Percuss the abdomen in each of the four quadrants. e. Palpate the abdomen lightly for tenderness.

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

b. Assess the client.

A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following should the nurse include in the teaching? (Select all that apply): a. Verify the oxygen flow rate every other day. b. Check the cannula position on a regular basis. c. Check the tops of the ears for skin breakdown. d. Post "no smoking" signs in a prominent location in the home. e. Apply petroleum ointment to nares if they become dry and irritated.

b. Check the cannula position on a regular basis. c. Check the tops of the ears for skin breakdown. d. Post "no smoking" signs in a prominent location in the home.

A nurse is developing the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include? a. Make sure a family member is present to interpret for the staff. b. Determine the client's level of fluency in his primary language. c. Speak directly to he interpreter when teaching the client. d. Encourage the client to. nod to indicate understanding.

b. Determine the client's level of fluency in his primary language.

A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations? a. Finger b. Earlobe c. Toe d. Skin fold

b. Earlobe

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? a. Gown b. Gloves c. Face shield d. Mask

b. Gloves

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? a. Ask the x-ray technician to come to the client's room to obtain a portable x-ray. b. Have the client wear a mask. c. Notify the x-ray department that the client requires airborne precautions. d. Wear a filtration mask and gloves during transportation.

b. Have the client wear a mask.

A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demonstration? a. Place her hands on the sides of her rib cage. b. Inhale slowly and evenly through her nose. c. Hold her breath for at least 10 seconds. d. Exhale forcefully through the nose.

b. Inhale slowly and evenly through her nose.

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

b. Lock the wheels of the bed and the wheelchair.

A nurse is caring for an older client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs? a. Call the family and ask them to stay with the client. b. Move the client to a room closer to the nurses' station. c. Apply wrist and leg restraints to the client. d. Administer medication to sedate the client.

b. Move the client to a room closer to the nurses' station.

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? a. Pinnae of the ears b. Dorsal surface of the hand c. Conjunctivae d. Dorsal surface of the foot

c. Conjunctivae

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction? a. Wraps the blood pressure cuff snugly around the client's arm b. Places the client's arm above the level of the client's heart c. Checks the instrument gauge to ensure the reading starts at zero d. Centers the cuff bladder over the client's brachial artery

b. Places the client's arm above the level of the client's heart

A nurse in a long-term care facility enters the day room and finds the window curtains on fire. Clients are panicking and the room is filling with smoke. Indicate the emergency actions the nurse must take. a. Activate the fire alarm. b. Remove the clients from the room. c. Extinguish the fire. d. Close the door.

b. Remove the clients from the room. a. Activate the fire alarm. d. Close the door. c. Extinguish the fire.

A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan? a. Apply a heat lamp twice a day. b. Reposition the client at least every 2 hours. c. Clean the wound with hydrogen peroxide solution. d. Massage reddened areas with dressing changes.

b. Reposition the client at least every 2 hours.

A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad? a. Set the pad's temperature o 42.2 degrees C (108 degrees F). b. Stop the treatment if the client's skin becomes red. c. Leave the pad in place for at least 40 minutes. d. Use safety pins to keep the pad in place.

b. Stop the treatment if the client's skin becomes red.

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.): a. Keep the client's room dark at night. 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. e. Assess the client every 4 hr.

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 is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pain? a. Vital sign measurement b. The client's self-report of pain severity c. Visual observation for nonverbal signs of pain d. The nature and invasiveness of the surgical procedure

b. The client's self-report of pain severity

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first? a. Report the incident to the charge nurse. b. Wash the area of the puncture thoroughly with soap and water. c. Complete an incident report. d. Go to employee health services.

b. Wash the area of the puncture thoroughly with soap and water.

A nurse is planning care for a client who requires airborne precautions which of the following actions should the nurse take? a. Provide a positive-pressure airflow room. b. Wear a N95 respirator mask. c. Allow the client to ambulate in the hall. d. Stand 1.8 m (6 feet) from the client.

b. Wear a N95 respirator mask.

A charge nurse is observing a nurse performing a Mantoux tuberculin skin test for a client. Which of the following actions should prompt the charge nurse to intervene? a. Creating a 6 mm (1/4 in) bleb in the intradermal space of the forearm b. Withdrawing the needle and massaging the site gently c. Stretching the skin tightly before injection d. Visualizing the tip of the needle under the skin

b. Withdrawing the needle and massaging the site gently

A nurse finds an open vial of morphine lying on top of the cabinet in a client's room. Which of the following actions should the nurse take? a. Return the medication to the unit's stock for future use. b. Report the discrepancy immediately. c. Administer he medication to other clients to avoid waste. d. Independently dispose of the remaining medication.

b. report the discrepancy immediately

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? a. "I will remove the old patch and apply a new one in the same location." b. "I will press the patch securely in place on my forearm." c. "I will clean and dry the area before applying the patch." d. "I will use lotion on irritated skin before applying a new patch in that area."

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

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? a. "My partner should cough while swallowing food." b. "My partner should place their food on the weaker side of their mouth when eating." c. "My partner should tilt their head forward when swallowing." d. "My partner should sit at a 30 degree angle while eating their meals."

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

A nurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear antiembolism stockings during and after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make? a. "They protect your legs and heels from skin breakdown." b. "They help keep you warm after surgery." c. "They improve your circulation to keep blood from pooling in your legs." d. "They make it easier for you to do leg exercises after your surgery."

c. "They improve your circulation to keep blood from pooling in your legs."

A nurse is caring for four client. Which of the following clients should the nurse identify as having the highest risk for aspiration? a. A client who has a chest tube following a fall from a ladder b. A client who had a hemi-colectomy and placement of a colostomy c. A client receiving continuous enteral feeding through NG tube d. A client with Crohn's disease and has an ileostomy

c. A client receiving continuous enteral feeding through NG tube

A nurse is caring for a client who experienced a lacerated spleen and has been bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions? a. An upper respiratory infection b. Pulmonary edema c. Atelectasis d. Delayed gastric emptying

c. Atelectasis

When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take? a. Contact the pharmacy and confirm that the dosage is safe to administer. b. Ask another nurse to verify that the dosage is appropriate for the client. c. Contact the provider to question the dosage. d. Inform the charge nurse and administer the dose of the medication the provider prescribed.

c. Contact the provider to question the dosage.

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first? a. Reposition the client. b. Administer the medication. c. Determine the location of the pain. d. Review the effects of the pain medication.

c. Determine the location of the pain.

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? a. Encourage the client to ambulate frequently. b. Encourage coughing and deep breathing. c. Encourage the client to increase fluid intake. d. Encourage regular use of the incentive spirometer.

c. Encourage the client to increase fluid intake.

A nurse is preparing to administer ophthalmic solution to a client. Which of the following actions should the nurse take? a. Instill the drops into the inner canthus. b. Approach the client's eye from below it. c. Hold the opthalmic solution 2 cm (3/4 in) above the lower conjunctival sac. d. Ask the client to look down when instilling the solution.

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

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching? a. Bear down hard when defecating. b. Drink four to five glasses of water daily. c. Increase dietary intake of raw veggies. d. Limit activity.

c. Increase dietary intake of raw veggies.

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? a. Limit the client's fluid intake in the evening. b. Obtain a bedside commode for the client's use. c. Leave a nightlight on in the client's room. d. Put side rails up and tell the client to call the nurse before voiding.

c. Leave a nightlight on in the client's room.

A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take? a. Provide support by holding the client's arm. b. Lean the client toward the wall. c. Lower the client to the floor. d. Assume a narrow base of support.

c. Lower the client to the floor.

A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take? a. Measure from heel to the gluteal fold. b. Measure the length of the feet. c. Measure from the heel to the popliteal space. d. Measure the ankle circumference.

c. Measure from the heel to the popliteal space.

A client smoking in his bathroom has dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority? a. Close the fire doors on the unit. b. Activate the fire alarm. c. Move any clients in the immediate vicinity. d. Use a fire extinguisher to put out the fire.

c. Move any clients in the immediate vicinity.

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take? a. Use a stiff toothbrush to clean the client's teeth. b. Use the thumb and index finger to keep the client's mouth open. c. Turn the client on his side before starting oral care. d. Apply petroleum jelly to the client's lips after oral care.

c. Turn the client on his side before starting oral care.

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take? a. Wear an N95 respirator mask. b. Wear sterile gloves. c. Wear clean gloves. d. Wear protective eyewear.

c. Wear clean gloves.

A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record? a. "There were no injuries sustained." b. "An incident report was completed." c. "An incident report was forwarded to risk management." d. "The provider was notified."

d. "The provider was notified."

A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection into the client's ventrogluteal muscle. a. 45 degrees b. 60 degrees c. 75 degrees d. 90 degrees

d. 90 degrees

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? a. Request a prescription for an oral formulation of the medication. b. Administer the crushed medication through the NG tube. c. Dissolve the medication in water and give it through the NG tube. d. Administer the medication under the client's tongue.

d. Administer the medication under the client's tongue.

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength? a. Ask the client how strong she feels today. b. Ask the client to touch her finger to her nose. c. Palpate the client's pedal pulses. d. Ask the client to push her feet against the nurse's palms.

d. Ask the client to push her feet against the nurse's palms.

A nurse is teaching a client has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include? a. Relax her abdominal muscles when she lifts an object. b. Twist at the waist when she moves an object to one side. c. Hold an object away from her body as she lifts it. d. Bend at knees when picking up an object.

d. Bend at knees when picking up an object.

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 manifestation of which of the following urinary alterations? a. Pernicious anemia b. Dehydration c. Prostate enlargement d. Bladder infection

d. Bladder infection

A nurse is having difficulty reading the provider's writing when transcribing a prescription for a client's medication. Which of the following actions should the nurse take? a. Clarify the type of medication with the family. b. Review the medication history on the admission record. c. Send the prescription to the pharmacist to clarify. d. Contact the provider to clarify the prescription.

d. Contact the provider to clarify the prescription.

A nurse is transcribing a client's medication prescriptions and is having difficulty reading a written prescription by the provider. Which of the following nursing actions should the nurse take? a. Clarify the prescription with the client's family. b. Interpret the prescription based on the client's health history. c. Ask the pharmacist for clarification of the prescription. d. Contact the provider to clarify the prescription.

d. Contact the provider to clarify the prescription.

A nurse is admitting a client who has partial hearing loss. Which of the following is the priority action by the nurse? a. Speak using his usual tone of voice. b. Stand directly in front of the client. c. Rephrase statements the client does not hear. d. Determine if the client uses hearing aids.

d. Determine if the client uses hearing aids.

A nurse is administering an IM injection to a client who has hepatitis C . Before placing the syringe and needle in a puncture-resistant container, which of the following actions should the nurse take? a. Recap the needle b. Place the cap on the bedside table and slide the needle into the cap. c. Wrap the needle with gauze. d. Dispose of the needle uncapped.

d. Dispose of the needle uncapped.

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? a. Symmetrical convex sphere shape. b. Concave umbilicus. c. Bilateral bowel sounds in lower quadrants. d. Ecchymosis

d. Ecchymosis

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? a. Trochanter roll b. Sheepskin heel pad c. Abduction pillow d. Footboard

d. Footboard

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer? a. Exposed bone b. Blood filled blisters c. Partial-thickness skin loss d. Necrotic subcutaneous tissue

d. Necrotic subcutaneous tissue

A nurse is preparing to administer the hepatitis B vaccine to a client. Which of the following techniques should the nurse use to locate the deltoid muscle? a. Locate the center of the arm between the elbow and the shoulder. b. Find the catheter of the anterior aspect of the thigh. c. Locate the middle third of thee anterior thigh between the greater trochanter of the femur and the lateral femoral condyle. d. 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.

d. 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 assessing a client who has hypoxia. Which of the following findings should the nurse expect? a. Bradypnea b. Somnolence c. Pallor d. Tachycardia

d. Tachycardia

A nurse in a long-term care facility is assisting a client with eating during meal time and recognizes another client indicating he is choking. Which of the following situations requires the nurse to perform the Heimlich maneuver? a. The client has a high-pitched inspiratory stridor. b. The client is able to whisper. c. The client is coughing only. d. The client is not making any sounds.

d. The client is not making any sounds.

A nurse is preparing to move a client who is only partially able to assist in bed. Which of the following methods should the nurse plan to use? a. One nurse lifting as the client pushes with his feet b. Two nurses lifting the client under the shoulders c. One nurse lifting the client's legs as the client uses a trapeze bar d. Two nurses using a friction-reducing device

d. Two nurses using a friction-reducing device

A nurse is reviewing the lab results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following lab values as an indication that the client has developed an infection? a. BUN b. Potassium c. RBC count d. WBC count

d. WBC count

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds? a. Crackles b. Rhonchi c. Stridor d. Wheezes

d. Wheezes