unit 1 ATI modules

A nurse is assisting with teaching a newly licensed nurse about surgical asepsis. Which of the following statements should the nurse make?

"Remove nail polish on your fingernails if it is chipped."

A nurse is preparing to administer acetaminophen 320 mg oral solution to a school-age child. The amount available is acetaminophen oral solution 160 mg/5 mL. How many mL should the nurse administer? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

10

A nurse is assisting with teaching a newly licensed nurse about hand hygiene for surgical asepsis. Which of the following instructions should the nurse include?

Apply chlorhexidine and ethanol to the hands.

A nurse is caring for adolescents in a school-based health clinic. Which of the following client statements should the nurse recognize as an indication that the client is experiencing Erikson's stage of identity versus role confusion? A. "I'm coaching a little league team." B. "I think I might be gay." C. "I can't seem to do anything right from my parents." D. "Why would someone want to help me? What's in it for them?"

B. "I think I might be gay."

A nurse is assisting with teaching a group of nurses on processes that can trigger an inflammatory response in the body. The nurse should include that which of the following is an infectious trigger?

Bacteria

A nurse is caring for a client who states, "I am feeling so much better. My fever is gone, and I have a good appetite." The nurse should identify the client is likely in which of the following stages of infection?

Convalescence

A nurse is caring for a client who had a stroke and reports having difficulty with proprioception. The nurse should plan to assess the client for which of the following?

Diminished awareness of body position and balance

A nurse is assisting with teaching a newly licensed nurse about infectious agents. The nurse should include in the teaching that pertussis is transmitted by which of the following modes of transmission?

Droplet

A nurse is caring for a client who has influenza. The client asks how they acquired the infectious agent. The nurse should inform the client that influenza is transmitted by which of the following modes?

Droplet

A nurse is providing teaching for a client who has kyphosis. Which of the following information should the nurse include?

Kyphosis is a rounded upper back with the pelvis tilted forward

A nurse is discussing macronutrients with a client. Which of the following statements should the nurse make?

Macronutrients include carbohydrates, proteins, and fats, which make up the majority of a person's diet."

A nurse is preparing a poster presentation about the musculoskeletal system. The nurse should include that which of the following is responsible for body posture?

Muscles

A nurse is caring for a client who has acquired an infection from a visitor. The client is an example of which of the following links in the chain of infection?

Susceptible host

A nurse is assisting with implementing an infection control bundle for clients at risk for catheter-associated urinary tract infections (CAUTIs). Which of the following interventions should the nurse include in the bundle?

Try to use alternatives before inserting indwelling urinary catheters.

A nurse is caring for an older adult client whose caregiver reports that the client is resistant to bathing at home. Which of the following statements should the nurse make?

"Give the client choices regarding their bathing preferences to encourage them to bathe."

A nurse is caring for a client who states, "I only eat a diet high in protein and carbohydrates." Which of the following responses should the nurse make?

"Make sure to get enough servings of red meat in your diet daily." "Your diet is varied but should also be high in calorie intake." "A varied diet should be high in protein and carbohydrate consumption." "A nutritious diet should include carbohydrates, protein, fiber, and healthy fats."

A nurse is caring for a client who is prescribed a low glycemic index diet. The client states, "I don't understand what this means." Which of the following responses should the nurse make? (Select all that apply.)

"The glycemic index of a food relates to its ability to increase the blood glucose level." "You should eat foods such as whole grains, fruits, and vegetables." "Try to limit or avoid potatoes due to their high glycemic index." "Foods with a high glycemic index will cause your blood glucose to increase rapidly."

A nurse is teaching a client about the function of mucous membranes in protecting the body from pathogens. Which of the following statements should the nurse include?

"The mucous membranes in the nose contain cilia that trap particles, preventing them from invading the body."

A nurse is teaching a client who has a new diagnosis of a skin infection about the function of the skin in the body. Which of the following statements should the nurse include?

"The skin contains Langerhans cells that kill pathogens."

A nurse is caring for a client who has a new prescription for parenteral nutrition. The client states, "I am scared that I will be on this therapy for the rest of my life." Which of the following responses should the nurse make?

"This type of nutrition can be lifelong, but it can also be temporary depending on how your nutritional needs change."

A nurse is caring for a client who has a high phosphorus level. Which of the following instructions regarding food should the nurse provide?

"You should eat white bread."

A nurse is caring for a client whose provider prescribed a heart-healthy diet. Which of the following information should the nurse include for the client regarding heart-healthy diets? (Select all that apply.)

"You should limit saturated fats in your diet." "Eat foods with whole grains in your new diet." "It's important to eat larger portions of fruits and vegetables." "Limiting high-calorie food intake will promote adherence to your new diet."

A nurse is a caring for a client who has a new prescription for a clear liquid diet. The client asks the nurse, "How long will I have to be on this type of diet?" Which of the following responses should the nurse make?

"You should not be on this diet for more than a few days."

A nurse is discussing proper body mechanics with a group of assistive personnel. Which of the following information should the nurse include?

1. A stable center of gravity increases stability and balance 2. A wide base lowers the center of gravity 3. Proper body alignment involves tightening the abdomen

A nurse is preparing to lift a heavy object off the floor. In which order should the nurse perform the following steps to demonstrate the proper use of body mechanics?

1. Stand as close to the object as possible 2. Keep abdominal muscles contracted and lower the back straight 3. Look straight ahead with shoulders raised up 4. Bend hips slightly and squat 5. Push up from the knees when lifting the object

A nurse is preparing to administer an intradermal injection to a client. At which of the following degree angles should the nurse insert the needle?

10° angle

A nurse is preparing to administer phenytoin suspension 300 mg PO, twice per day. The amount available is phenytoin suspension 125 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

12

A nurse is preparing to administer clindamycin 0.3 g IM to a client. Available is clindamycin 150 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2

A nurse is preparing to administer amikacin 7 mg/kg/day IM to a client who weighs 165 pounds. Available is amikacin 250 mg/mL solution for injection. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2.1

A nurse is helping a client calculate how many net carbohydrates they consumed in their last meal. The client's food had a total of 72 g of carbohydrates and 9 g of fiber. How many net carbohydrates did the client consume?

63

A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at the greatest risk of developing medication toxicity?

A client who has impaired kidney function

A nurse is reviewing oral hygiene practices with an assistive personnel. Which of the following should the nurse include? (Select all that apply.)

A fluoride mouthwash should be used to promote oral health. The teeth should be brushed twice daily for 2 min. Poor oral hygiene can lead to gingivitis. Use a soft-bristled toothbrush for brushing the teeth.

A nurse is caring for a client during a prenatal visit. The client states, "now that I'm pregnant. I drink wine with dinner. I've given up hard alcohol. Which of the following responses should the nurse make? A. "Avoiding alcohol, even wine, is advised during pregnancy since it can cause harm to your baby." B. "Since you've stopped drinking hard liquor, your baby will be fine." C. "You can drink two glasses of wine each day and not cause harm to your baby." D. "You should consume wine with food to minimize its effect on your baby."

A. "Avoiding alcohol, even wine, is advised during pregnancy since it can cause harm to your baby."

A nurse is discussing climacteric changes that occur during middle adulthood with a newly licensed nurse. Which of the following statments by the newly licensd nurse indicates an understanding of the concept? (Select all that apply) A. "Both males and females experience a change of life referred to as climacteric." B. "Climacteric in females is referred to as menopause." C. "Climacteric in males means they are no longer able to fertilize a female egg." D. "Climacteric changes in males occur gradually over a number of years." E. "Climacteric in females can manifest as heart palpitations."

A. "Both males and females experience a change of life referred to as climacteric." B. "Climacteric in females is referred to as menopause." D. "Climacteric changes in males occur gradually over a number of years." E. "Climacteric in females can manifest as heart palpitations."

A nurse is providing an educatinal session on cognitive development at a community event. Which of the following statements by the nurse are consistent with Piaget's theory of cognitive development? (Select all that apply) A. "Individuals acquire knowledge, intellect and cognition over time." B. "Intelligence is a natural ability that develops as a child grows and adapts to their environment." C. "Children construct knowledge that evolves and changes over time." D. "Children construct knowledge in new ways at critical points during development." E. "Adolescents achieve formal operational thought by 16 years of age."

A. "Individuals acquire knowledge, intellect and cognition over time." B. "Intelligence is a natural ability that develops as a child grows and adapts to their environment." C. "Children construct knowledge that evolves and changes over time." D. "Children construct knowledge in new ways at critical points during development."

A nurese is planning an educational session about human growth and development for a group of clients who are pregnant. Which of the following universal principles should the nurse include in the discussion? (Select all that apply) A. Cephalocaudal principle B. Equifinality principle C. Simple to complex D. Continuous process E. Individual rates

A. Cephalocaudal principle C. Simple to complex D. Continuous process E. Individual rates

A nurse is assessing an adolescent who reports feeling "very depressed". The nurse should recognize that which of the following are signs of increased risk for suicide? (Select all that apply) A. Expressing feelings of gloom and helplessness B. Expressing loss of interest in activities once considered important C. Making threats of self-harm D. Having access to weapons E. Purchasing valued possessions

A. Expressing feelings of gloom and helplessness B. Expressing loss of interest in activities once considered important C. Making threats of self-harm D. Having access to weapons

A nurse is providing discharge teaching to parents of a preschooler who was admitted due to a severe asthma exacerbation. Which of the following instructions should the nurse include? (Select all that apply) A. Instruct on the use of a metered-dose inhaler (MDI). B. Have family memebers smoke tobacco products outside of the house. C. Make changes in the home environment to reduce dust mites. D. Share the plan for managin gan asthma attack with the child's preschool teachers. E. Decreased fluid intake to prevent an exacerbation of asthma.

A. Instruct on the use of a metered-dose inhaler (MDI). B. Have family memebers smoke tobacco products outside of the house. C. Make changes in the home environment to reduce dust mites. D. Share the plan for managin gan asthma attack with the child's preschool teachers.

A home health nurse is planning care for an older adult client who has hypertension and is living alone. Which of the following health promotion topics should the nurse include in the client's plan of care? (Select all that apply) A. Maintaing functional capacity B. Encouraging the use of free-weight exercises C. Participating in social functions D. Installing grab bars in the shower E. Preparing for age-related diminished cognition

A. Maintaing functional capacity B. Encouraging the use of free-weight exercises C. Participating in social functions D. Installing grab bars in the shower

A nurse is planning a health class at a local middle school about puberty during adolescence. Which of the following pieces of information should the nurse include in the discussion? (Select all that apply) A. Primary sex organs mature during puberty. B. Puberty begins with a growth spurt in height and weight. C. Onset of puberty is influenced by genetics, environment factors, and gender. D. Secondary sex characteristics emerge during puberty . E. Maturation during puberty occurs at the same rate for everyone.

A. Primary sex organs mature during puberty. B. Puberty begins with a growth spurt in height and weight. C. Onset of puberty is influenced by genetics, environment factors, and gender. D. Secondary sex characteristics emerge during puberty .

A school nurese asks a first grader about rules at school. The child responds, "we need to wash our hands before lunch, be respectful to the teacher, and pay attention in class. If we don't we'll get into big trouble." The nurse should recognize that the child is in which of the following of Kohlberg's stages of moral development? A. Punishment and obedience B. Good Boy---Nice Girl C. Social contract D. Law and order

A. Punishment and obedience

A nurse is planning discharge teaching for a client who is newly diagnosed with type 2 diabetes mellitus. Which of the following topics should the nurse include in the teaching? (Select all that apply) A. Weight management B. Low-protein diet C. Glucose testing D. Daily exercise E. Foot care

A. Weight management C. Glucose testing D. Daily exercise E. Foot care

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

Administer the medication to the client in a liquid form.

A nurse has received a prescription to administer a medication STAT to a client. Which of the following actions should the nurse take?

Administer the medication within 30 min of the health care provider prescribing the medication.

A nurse is preparing to administer medications to a client. The nurse should identify that which of the following factors contributes to medication errors? (Select all that apply.)

Administering medication outside of prescribed time intervals Failing to administer a medication Incorrect dose of the prescribed medication administered to the client

A nurse is wearing gloves while caring for a client. In which of the following situations should the nurse obtain a new pair of gloves?

After changing a dressing on the client and before documenting findings on a computer

A nurse is reviewing the pharmacokinetics of medications with a newly licensed nurse. The nurse should include that which of the following factors can affect the rate of absorption? (Select all that apply.)

Age of the client Lipid solubility of a medication Route of administration

A nurse is assisting in providing an in-service about infectious agents to a group of nurses. The nurse should include in the teaching that tuberculosis is transmitted by which of the following modes of transmission?

Airborne

A nurse is assisting with teaching a newly licensed nurse about infection control. The nurse should include in the teaching that which of the following types of precautions requires the use of an N95 mask?

Airborne

A nurse is planning to use the teach-back method to educate a client about a new antihypertensive medication. Which of the following should the nurse include to demonstrate this method?

Ask the client to explain the information using their own words.

A nurse is assisting with teaching a client who has a new prescription for a nitroglycerin patch. Which of the following actions should the nurse take? (Select all that apply)

Ask the client what they know about the nitroglycerin patch. Determine the client's ability to apply the patch. Check the client's reading comprehension level.

A nurse is caring for a client who has bariatric care needs and has a rash between skinfolds. Which of the following actions should the nurse take?

Assist the client as needed to ensure proper hygiene is performed.

A nurse in a long term facility is caring for an older adult client and notes their muscles have become smaller and weaker. Which of the following should the nurse suspect the client is experiencing?

Atrophy

During a wellness visit for a 4-year-old preschooler, a parent explains that their child enjoys playing games on a computer and asks the nurse about an acceptable amount of screen time for their child. Which of the following responses should the nurse make? A. "If the child is learning, there are no screen time limits." B. "An acceptable amount of screen time is 1 hour per day." C. "If the child is content, there is no protocol for screen time." D. "Acceptable screen time is 4 hours per day."

B. "An acceptable amount of screen time is 1 hour per day."

A nurse is preparing an educational session about school-age children to a group of caregivers. Which of the following characteristics should the nurse include in the teaching? (Select all that apply) A. Attributes feelings an dmotives to objects B. Egocentrism decreases C. Begins to understand reversibility D. Understands evens can be interpreted in different ways E. Deductive reasoning develops

B. Egocentrism decreases C. Begins to understand reversibility D. Understands evens can be interpreted in different ways

A nurse is providing prenatal education to a client who is in the first trimester of pregnancy. Which of the following teratogens should the nurse instruct the client to avoid during pregnancy due to the risk to fetal development? (Select all that apply) A. Chamomile tea B. Hyperthermia C. Uncontrolled glucose levels D. Rubella E. Smoking

B. Hyperthermia C. Uncontrolled glucose levels D. Rubella E. Smoking

A nurse is assisting with teaching a newly licensed nurse about laboratory tests that can indicate generalized inflammation. The nurse should include which of the following laboratory tests?

C-reactive protein

A nurse is scheduled to administer a medication to a client who is currently in the bathroom. Which of the following actions should the nurse plan to take?

Come back in a few minutes to administer the medication.

A nurse is admitting a client who has vancomycin-resistant enterococcus (VRE) of the urine. The nurse should place the client on which of the following precautions?

Contact

A nurse is caring for a 10-year-old child who is newely diagnosed with diabetes mellitus. Which of the following actions by the child should the nurse recognize as characteristic of Erikson's stage of industry versus inferiority? A. Becomes frustrated when their caregiver fills out the child's menu. B. Apologizes to their caregiver for wanting to manage their insulin administration independently. C. States frustration that diabetes mellitus will make them different from everyone else. D. Expresses confidence in their ability to self-administer insulin.

D. Expresses confidence in their ability to self-administer insulin.

A nurse is performing a skin assessment on a client who has a wound on their heel that is blistered and lighter in color than the client's skin tone. The nurse should identify that the wound is in which of the following stages of damage?

Damage into the skin layer

A nurse is caring for a client who had stroke and is immobile. The nurse should identify that the client is at risk for which of the following conditions?

Deep vein thrombosis

A nurse is caring for a client who practices a religion the nurse is not familiar with. Which of the following actions should the nurse take

Discuss with the client their individual perspective on health and illness.

A nurse is planning to admit a client who has respiratory syncytial virus. Which of the following precautions should the nurse plan to implement?

Droplet

A nurse is discussing the role of tooth enamel with a client. Which of the following information should the nurse include in the discussion?

Enamel protects the teeth from pathogens.

A nurse is providing discharge teaching to a client. Which of the following strategies should the nurse include?

Encourage the client to ask questions.

A nurse is assessing a client's mobility and notes one of the client's feet drags behind them when ambulating. Which of the following conditions should the nurse suspect the client is experiencing?

Foot drop

A nurse is assisting with teaching a newly licensed nurse about removing personal protective equipment (PPE). Which of the following items should the nurse instruct to remove first?

Gloves

A nurse is assisting with teaching about personal protective equipment with a newly licensed nurse. Which of the following instructions should the nurse include?

Gloves should be removed from the inside out.

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

Have a second nurse confirm the insulin dose.

A nurse is preparing to administer medications to a client who is not wearing an identification bracelet. Which of the following actions should the nurse take before administering the medications?

Have the client confirm their name and date of birth.

A nurse is assisting with teaching a client about self-administration of insulin. Which of the following actions should the nurse take?

Have the client perform a return demonstration of the procedure.

A nurse is discussing health promotion programs with a client. Which of the following information should the nurse include?

Health promotion programs emphasize behavior changes in relation to prevention of illness.

A nurse is performing a focused assessment to an older adult client's mobility. Which of the following findings should indicate to the nurse that the client is experiencing and age-related change to their musculoskeletal system?

Increased curvature of the thoracic spine

A nurse is caring for client who reports having daily constipation. Which of the following information should the nurse provide to the client regarding fiber intake?

Increasing daily fiber intake can help alleviate the issue of constipation. Eating more whole grains can promote regular bowel movements.

A nurse is caring for a client who is receiving tube feedings via PEG. Which of the following actions should the nurse implement in order to help prevent the client from aspirating?

Keep the client's head elevated to at least 30° for a minimum of 1 hr after a feeding.

A nurse is preparing to transfer a client from a bed to a wheel chair. Which of the following actions by the nurse demonstrates proper use of body mechanics?

Looking at the client face-to-face when transferring the client

A nurse is participating in a committee to reduce medication errors on a medical unit. Which of the following interventions should the nurse recommend? (Select all that apply.)

Mark the area around the automated medication dispensing system. Provide the nurse administering medications with a vest. Double check dosages of high-alert medications.

A nurse is preparing to measure a nasogastric tube for insertion. The nurse recalls that the client's xyphoid process should be used as the last place of measurement. Which of the following landmarks should the nurse measure before the xyphoid process?

Measure from the tip of the nose to the earlobe.

A nurse is caring for a client who requires total assistance with mobility. When using the Mobility Assessment Tool (MAT), which of the following pieces of equipment should the nurse use to transfer the client?

Mechanical lift

A nurse is preparing a presentation about muscle function for a group of newly licensed nurses. Which of the following information should the nurse plan to include?

Muscles assist with thermoregulation in the body

A nurse is assessing a client who is experiencing digestive issues. Which of the following findings should the nurse expect? (Select all that apply).

Nausea Abdominal pain Diarrhea Reports of bloating

A nurse is caring for a client who requires assistance with ADLs. Which of the following referrals should the nurse recommend for this client?

Occupational Therapist

A nurse is setting up a sterile field to perform a dressing change on a client. Which of the following actions should the nurse take?

Open the first flap on the sterile package away from their body.

A charge nurse is reviewing routes of medication administration with a newly licensed nurse when providing care to a client. Which of the following routes of administration should the charge nurse include as having the slowest onset of action?

Oral

A nurse is performing a medication reconciliation for a client who is being transferred to a long-term care facility. Which of the following actions should the nurse take? (Select all that apply.)

Place the medication reconciliation form with the client's transfer documents. Reinforce teaching about the medications to the client upon discharge. Include over-the-counter medications in the medication reconciliation. Compare the client's home medications with prescribed discharge medications.

A nurse in a clinic is caring for a client who reports generalized aches and fever for the past 12 hr. The nurse suspects the client has acquired an infection. Which of the following stages of infection is the client likely experiencing?

Prodromal

A nurse is caring for a client who has pneumonia. In which of the following positions should the nurse place the client to promote postural drainage?

Prone

A nurse is caring for a nondiabetic client who has a new prescription for a fasting blood glucose check. The nurse checks the client's blood glucose and it is 67 mg/dL. Which of the following actions should the nurse take next?

Provide the client with a 15-g carbohydrate snack.

A nurse is caring for a client who is at risk for developing atelectasis. Which of the following actions should the nurse take?

Remind the client to use incentive spirometer

A nurse is assisting with teaching a newly licensed nurse about needlestick injuries. Which of the following instructions should the nurse include?

Report needlestick injuries to the nursing supervisor.

A nurse is caring for a client who acquired an infection after touching a faucet that an infected person had touched. Which of the following links in the chain of infection does the faucet represent?

Reservoir

A nurse is completing the Mobility Assessment Tool (MAT) for a client and determines that the client is at a Level 1 Mobility. The nurse should identify that the client is unable to perform which of the following tasks?

Sit on the edge of the bed for 1 min

A nurse is caring for a client who requires maximum assistance to transfer from the bed to a chair. Which of the following pieces of equipment should the nurse use?

Slide board

A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following hand hygiene methods should the nurse use?

Soap and water

A nurse is collecting data on a client who is receiving vancomycin IV. The nurse observes the client has a rash on their neck, chest, and back. Which of the following actions should the nurse take first?

Stop the infusion of the vancomycin.

A nurse is performing a throat culture on a client. Which of the following actions should the nurse take?

Swab the back of the client's pharyngeal wall.

A nurse is providing teaching for a client who injured their ankle. Which of the following information should the nurse include?

Tendons connect muscle to bone

A nurse is assessing a client's hair and notes that it is brittle. Which of the following should the nurse determine about the client's nutritional intake?

The client has insufficient protein in their diet.

A nurse is evaluating a client who has a broken leg and is using crutches. Which of the following actions by the client demonstrates proper use of the crutches?

The client has the crutches resting 5 cm (2 in) below their axilla

A nurse is reviewing information about the structure and function of the nails with a client. Which of the following information should the nurse include?

The cuticle of the nail forms a barrier to prevent infections.

A nurse is preparing to administer medications to a preschooler. Which of the following information should the nurse keep in mind when administering medications to this client?

The deltoid muscle can be used to administer intramuscular injections.

A nurse is assisting with teaching a newly licensed nurse about airborne infection isolation rooms (AIIR). Which of the following information should the nurse include?

The door to the AIIR should remain closed.

A nurse is reviewing the anatomy of the skin with a newly licensed nurse. Which of the following information should the nurse include as a characteristic of the epidermis?

The epidermis consists of squamous epithelial cells.

A charge nurse is reviewing oral care and hygiene practices with another nurse for a client who has glaucoma. Which of the following information should the charge nurse include?

The nurse should educate the client and caregivers about the importance of routine dental visits to maintain oral health.

A nurse is caring for a client who has right-sided hemiplegia following a stroke. Which of the following should the nurse consider when caring for this client?

The nurse should have the client remove clothing from the unaffected side first.

A nurse is reviewing a list of client care tasks with another nurse. In which of the following scenarios should the nurse plan to use soap and water to perform hand hygiene? (Select all that apply.)

The nurse's hands become visibly soiled. The nurse removes the meal tray of a client who has infectious diarrhea. The nurse empties the urinal of a client who has Clostridium difficile.

A nurse is teaching a client who has an unsteady gait about how to use a walker. Which of the following instructions should the nurse include?

The top of the walker should be at the level of your wrist

A nurse is teaching an in-service about the use of ergonomics to a group of staff members. Which of the following information should the nurse include?

The use of ergonomics increases job satisfactions

A nurse is reviewing measurement systems to perform dosage calculations with a newly licensed nurse. Which of the following instructions should the nurse include?

To convert g to mg, move the decimal point 3 places to the right.

A nurse is teaching a newly hired assistive personnel (AP) about working with clients who require assistance with ADLs. Which of the following activities should the nurse include as an ADL?

Toileting

A nurse is performing nail hygiene on a client. Which of the following actions should the nurse take?

Trim the nails straight across.

A nurse is supervising a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Turns off the faucet with a towel

A nurse is planning care for a client who has incontinence. Which of the following information should the nurse consider when providing skin care for the client?

Urinary incontinence can cause a yeast infection.

A nurse is performing foot care for a client. Which of the following actions should the nurse take?

Use a towel to completely dry between the toes.

A nurse is performing a bed bath for a client. Which of the following should the nurse remember when preparing to bathe the client?

Washing the client in bed is less effective than taking a shower.

A nurse is assisting with teaching a class about hospital-acquired injuries. The nurse should include which of the following? Select all that apply a) blood transfusion incompatibility b) wrong-site surgery c) ineffective insulin usage d) dysphagia following a stroke e) dehydration due to diarrhea

a) blood transfusion incompatibility b) wrong-site surgery c) ineffective insulin usage

A nurse is preparing to conduct a fall risk screening on a client. Which of the following variables will the nurse use to evaluate the client? Select all that apply a) fall history b) medical diagnosis c) use of assistive devices d) mental status e) do-not-resuscitate status

a) fall history b) medical diagnosis c) use of assistive devices d) mental status

A nurse is assisting with teaching a newly licensed nurse about using a lift device to transfer a client. Which of the following actions by the nurse indicates an understanding of the teaching? Select all that apply a) locks the brakes on the client's bed b) checks the max weight on the lift before using it c) places the client on the edge of the sling d) uses the lift without assistance from another team member e) performs a safety check before lifting the client

a) locks the brakes on the client's bed b) checks the max weight on the lift before using it e) performs a safety check before lifting the client

A nurse is checking a client's allergy bracelet before administering a medication and finds the client is allergic to that medication. The nurse does not administer the medication to the client. This is an example of which of the following unexpected events? a) near-miss event b) client safety event c) adverse event d) sentinel event

a) near-miss event

A nurse is caring for a client who is at risk for suicide. Which of the following actions should the nurse take? Select all that apply a) place the client on round-the-clock surveillance b) remove the objects from the room that the client could use to arm themselves c) search items brought into the client's room by visitors d) refrain from asking the client if they intend to harm themselves e) screen the client for suicide ideation

a) place the client on round-the-clock surveillance b) remove the objects from the room that the client could use to arm themselves c) search items brought into the client's room by visitors e) screen the client for suicide ideation

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? a) record the time and length of the seizure b) restrain the client's extremities c) place the client in the prone position d) monitor the client's hemoglobin level

a) record the time and length of the seizure

A nurse is assisting with emergency care of a client who has been exposed to a chemical toxin, Which of the following actions should the nurse take? a) rinse the client's skin with water b) remove the client's clothing by pulling it over their head c) dispose of the client's clothing in a single biohazard bag d) prepare to administer potassium iodide to the client

a) rinse the client's skin with water

A nurse is preparing to administer medications to a client. Which of the following information should the nurse use to identify the client? Select all that apply a) the client's full name b) the client's DOB c) the client's telephone number d) the client's diagnosis e) the client's room number

a) the client's full name b) the client's DOB c) the client's telephone number

A nurse is preparing to administer a premixed medication to a client. The nurse should check the label for which of the following information? Select all that apply a) the date the med was mixed b) the client's age c) the client's room number d) the dose of the mixed med e) the time the medication was mixed

a) the date the med was mixed d) the dose of the mixed med e) the time the medication was mixed

A nurse is assisting with teaching a class about evidence-based protocols established by the CDC to prevent healthcare-associated infections (HAIs). Which of the following infections should the nurse include? Select all that apply a) influenza infection b) catheter-associated urinary tract infection c) Mycobacterium tuberculosis infection d) central line-associated bloodstream infection e) surgical site infection

b) catheter-associated urinary tract infection d) central line-associated bloodstream infection e) surgical site infection

A nurse is caring for a client who has a prescription for wrist restraints. Which of the following actions should the nurse take? a) tie the restraints to the siderails on the client's bed b) remove the restraints with each vital sign check c) use the square knot to secure the restraints d) make sure one finger can fit under the restraints

b) remove the restraints with each vital sign check

A nurse is assisting with conducting a home hazard assessment for a client who has dementia. Which of the following findings indicates an understanding of home safety? a) an extension cord is secured under a rug b) the edges of stairs are marked with brightly colored tape c) a toaster is plugged in when not in use d) the water heater is set to 55 degrees C

b) the edges of stairs are marked with brightly colored tape

A nurse is caring for a client who has an indwelling urinary catheter in place. Which of the following actions is the priority for the nurse to take to reduce the client's risk of developing a healthcare-associated infection? a) wipe down the client's bedside table with an antiseptic wipe b) conduct informal audits of medical records to identify the number of healthcare-associated infections c) perform hand hygiene d) instruct the client on ways to reduce the risk for infection

c) perform hand hygiene

A nurse is planning to use the identify, situation, background, assessment, recommendation, read-back (ISBARR) tool to communicate with a provider about a client. Which of the following information is included in the assessment component of ISBARR? a) the client's admitting diagnosis b) the client's medical history c) the client's lab test results d) the client's response to treatment

c) the client's lab test results

a nurse is planning to implement the Transforming Care at the Bedside plan on a med-surg unit. Which of the following interventions should the nurse include in the plan? a) require nurses to spend 50% of their time at the bedside of the clients b) perform change-of-shift report at the nurses' station c) complete the client rounds every 4 hours d) use a standardized communication tool

d) use a standardized communication tool

A nurse is caring for a client who states, "I feel like I don't have to eat a varied diet when I take my multivitamin." Which of the following responses should the nurse make?

"A multivitamin should not be used in place of a nutritious diet."

A nurse is caring for a client who states, "I only eat a diet high in protein and carbohydrates." Which of the following responses should the nurse make?

"A nutritious diet should include carbohydrates, protein, fiber, and healthy fats."

A nurse is reviewing information about performing oral hygiene with an assistive personnel (AP). Which of the following information should the nurse include?

"Clean the tongue with the toothbrush or tongue scraper during oral hygiene."

A nurse is caring for a client who states, "I have been getting a lot of cavities lately, but I don't know what is causing them." Which of the following responses should the nurse make?

"Drinking sugary beverages can make you prone to cavities."

A nurse is teaching the importance of handwashing to a client. Which of the following statements should the nurse make about hand hygiene in a health care setting?

"Effective handwashing can decrease hospital infection rates."

A nurse is reinforcing teaching with a client who has a new prescription for an antibiotic to treat a urinary tract infection. Which of the following statements should the nurse make?

"Finish the entire course of the prescription."

A nurse is caring for a client who has renal disease and must limit potassium intake. Which of the following foods should the nurse instruct the client to avoid because they are high in potassium?

Bananas Dried beans Spinach Tomatoes

A nurse is preparing to assist with feeding a client who is at risk for aspiration. Which of the following actions should the nurse take?

Cut the client's food into small bites.

A nurse is planning care for a client who is postoperative. In which of the following positions should the nurse place the client to prevent atelectasis?

Fowler's

A nurse is caring for a client who is on contact precautions. Which of the following actions should the nurse take?

Place the client in a private room.

A nurse is caring for a client who routinely eats a regular diet and is scheduled to have surgery with sedation in the morning. The nurse receives a new NPO diet prescription for the client. Which of the following should the nurse identify as the rationale for the provider's prescription?

The client is at risk for aspiration due to the upcoming surgery.

A nurse is reviewing a client's medical record and notes that their BMI is 25.5. How should the nurse interpret this finding?

The client is overweight.

A nurse is preparing a presentation for a group of clients who are scheduled for joint replacement surgery. Which of the following information should the nurse plan to include regarding flexion of a joint?

The contraction of a muscle results in flexion of a joint

A nurse is assisting with teaching a newly licensed nurse about administering a transdermal nitroglycerin patch to a client. Which of the following instructions should the nurse include?

Wear clean gloves to apply the transdermal medication.

A nurse is reviewing handwashing skills with a newly licensed nurse. In which order should the nurse plan to perform this task using soap and water? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Wet hands with warm water is the first step. Apply the amount of soap recommended by the manufacture Rub hands together vigorously for at least 15 seconds is the third step. Rinse hands with water Use a disposable towel to dry Use a towel to turn off the faucet

A nurse is assisting with teaching a class about events that require an occurrence report. Which of the following events should the nurse include? Select all that apply a) a client's visitor falls in the hallway b) a nurse forgets their computer password c) a client develops an unexpected reaction to a medication d) a client's dentures are lost e) an antibiotic was administered to a client 30 min after the scheduled time

a) a client's visitor falls in the hallway c) a client develops an unexpected reaction to a medication d) a client's dentures are lost

A nurse is assisting with teaching a newly licensed nurse about electrical safety. Which of the following actions by the newly licensed nurse indicated an understanding of the teaching? a) the nurse plugs in a sequential compression device with wet hands b) the nurse holds onto the plug to unplug a client's electronic bp machine c) the nurse rolls the client's bed over an electrical cord d) the nurse uses an extension cord to plug in a client's smart infusion pump

b) the nurse holds onto the plug to unplug a client's electronic bp machine

A nurse is preparing a poster about fire safety for a community health fair. The nurse should include on the poster that which of the following components contains needed elements for a fire to occur? Select all that apply a) CO2 b) Nitrogen c) cooking oil d) oxygen e) heat

c) cooking oil d) oxygen e) heat

A nurse discovers a small fire in a client's room. After removing the client to safety, which of the following actions should the nurse take next? a) extinguish the fire b) close the windows in the client's room c) close the client's door d) activate the fire alarm

d) activate the fire alarm

A nurse is assisting with teaching about warning signs from a co-worker that might indicate future workplace violence. Which of the following behaviors should the nurse include? a) legitimate absenteeism b) strict adherence to facility policies c) consistent adequate work performance d) frequent reports of not being treated fairly

d) frequent reports of not being treated fairly