2050 iClicker and Practice questions

Your patient is NPO and is receiving continuous tube feeding via PEG tube. All of the following are appropriate nursing actions EXCEPT A. Check blood sugar AC/HS B. Keep the bead of bed at or above a 30-degree angle C. Place feeding on hold when placing patient in a supine position D. Checking residual every 4 hours

A. Check blood sugar AC/HS

The nurse is counseling the family of a terminally ill client about palliative care. The nurse identifies which goals as being those of palliative care? Select all that apply A)The delay of the impending death B)Offering a caring support system C)Providing measure focused on pain management D)Introduction of interventions that enhance the quality of life E)Expanding the focus of care to both the client and the family F)Addressing the expressed spiritual needs of the client and the family

B)Offering a caring support system C)Providing measure focused on pain management D)Introduction of interventions that enhance the quality of life E)Expanding the focus of care to both the client and the family F)Addressing the expressed spiritual needs of the client and the family

A client has been receiving total parenteral nutrition (TPN) for the last 5 days. Before discontinuing the infusion, the infusion rate is slowed. What complication of TPN infusion should the nurse assess the client for as the infusion is discontinued? A)Essential fatty acid deficiency B)Dehydration C)Rebound hypoglycemia D)Malnutrition

C)Rebound hypoglycemia

The nurse assesses the daily lab reports for a patient with a long history of cirrhosis with acute hepatic encephalopathy. Which of the following findings would indicate to the nurse that the patient is improving? A. The patient's fasting blood sugar decreased from 100 to 90 mg/dL. B. The patient's prothrombin time (PT) increased from 20 to 25 seconds. C. The patient's ammonia level decreased from 160 to 120 mg/dL. D. The patient's AST (SGOT) increased from 24 to 30 units.

C. The patient's ammonia level decreased from 160 to 120 mg/dL.

The wife of an older adult who has been admitted to the hospital with kidney failure tells the nurse, "I know he doesn't want to die in a hospital, but it's so hard for me to take care of him at home. He said he doesn't want any more treatment, but I'm not ready to let him go. We have so many arrangements to decide before he dies." Which statement by the nurse to the client's wife would be most appropriate? Select all that apply. 1. "He's not going to die that soon judging by his current symptoms." 2. "What are your fears about your husband dying?" 3. "I can imagine that it's hard for you to care for him at home." 4. "What do you and your husband know about advance directives?" 5. "We can discuss types of hospice and home care options available." 6."What kind of arrangements do you think need to be made before he dies?"

3. "I can imagine that it's hard for you to care for him at home." 4. "What do you and your husband know about advance directives?" 5. "We can discuss types of hospice and home care options available." 6."What kind of arrangements do you think need to be made before he dies?"

The nurse has admitted a client to the postoperative unit following a bowel resection and is providing postoperative health education on coughing and deep breathing. What does the nurse explain to the client about why these actions are important? A) If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia. B) If you continue to breathe shallowly or cough ineffectively, this can lead to deep vein thrombosis (DVT) by preventing poor oxygen exchange in the cardiac and peripheral circulatory system. C) If you continue to breathe shallowly or cough ineffectively, this can lead to dizziness, falling, or an inability to ambulate because of shortness of breath. D. If you continue to breathe shallowly or cough ineffectively, this can lead to respiratory obstructive disease

A) If you continue to breathe shallowly or cough ineffectively, this can lead to atelectasis and pneumonia.

After an episode of severe pain, a client says to the nurse, "The pain really frightened me. I thought I was going to die." Which statement is the most appropriate response from the nurse? A)"I understand that pain can be a frightening experience." B)"Why were you frightened? You've had pain before." C)"There's no need to be frightened of pain." D)"Pain can't cause you to die. Try to relax."

A)"I understand that pain can be a frightening experience."

The nurse is preparing a client for surgery and notices that the client looks sad. The client says, "I am scared of having cancer. It is so horrible, and I brought it on myself. I should have quit smoking years ago." What would be the nurse's best response to the client? A)"It's okay to be scared. What is it about cancer that you are afraid of?" B)"It's normal to be scared. I would be, too. We will help you through it." C)"Don't be so hard on yourself. You don't know if your smoking caused the cancer." D)"Do you feel guilty because you smoked?"

A)"It's okay to be scared. What is it about cancer that you are afraid of?"

The nurse gave the client the wrong medication. It is 2 hours later when the nurse realizes the error. What should the nurse do first? A)Assess the client's condition. B)Notify the health care provider (HCP) of the error. C)Complete an incident report. D)Report the error to the unit manager.

A)Assess the client's condition.

A client is receiving opioid epidural analgesia. The nurse should notify the health care provider (HCP) if the client has which findings? Select all that apply. A)Blood pressure of 80/40 mm Hg and baseline blood pressure of 110/60 mm Hg B)Respiratory rate of 14 breaths/min and baseline respiratory rate of 18 breaths/min C)Report of crushing headache D)Minimal clear drainage on the dressing E)Pain rating of 3 on a scale of 1 to 10

A)Blood pressure of 80/40 mm Hg and baseline blood pressure of 110/60 mm Hg C)Report of crushing headache D)Minimal clear drainage on the dressing

A client is receiving opioid epidural analgesia. The nurse should notify the health care provider (HCP) if the client has which findings? Select all that apply. A. Blood pressure of 80/40 mm Hg and baseline blood pressure of 110/60 mmHg B. Respiratory rate of 14 breaths/min and baseline respiratory rate of 18breaths/min C. Report of crushing headache D. Minimal clear drainage on the dressing

A)Blood pressure of 80/40 mm Hg and baseline blood pressure of 110/60 mm Hg C)Report of crushing headache D)Minimal clear drainage on the dressing

When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, and then a couple of small breaths, then 10 to 20 seconds of no breaths. How should the nurse record the breathing pattern? A)Cheyne-Stokes respiration B)Hyperventilation C)Obstructive sleep apnea D)Biot's respiration

A)Cheyne-Stokes respiration

When the nurse assesses the incision of a client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible. Which of these actions should the nurse take FIRST? A)Cover the open area with sterile gauze soaked in normal saline. B)Reapply a sterile dressing after cleaning the incision with peroxide. C)Pack the opened area with sterile 3⁄4-inch gauze soaked in normal saline. D)Apply Neosporin ointment and cover the incision with Tegaderm dressing

A)Cover the open area with sterile gauze soaked in normal saline.

When the nurse is developing a plan of care to manage a client's pain from cancer, what should the nurse plan to do? A)Individualize the pain medication regimen for the client. B)Select medications that are least likely to lead to addiction. C)Administer pain medication as soon as the client requests it. D)Change pain medications periodically to avoid drug tolerance

A)Individualize the pain medication regimen for the client.

A client with cancer of the throat had a tracheostomy tube inserted 2 days ago. The client has moderate secretions and can take deep breaths without pain. When suctioning a client's tracheostomy tube, what should the nurse do? A)Oxygenate the client before suctioning. B)Insert the suction catheter about 2 inches (5 cm) into the cannula. C)Use a bolus of sterile water to stimulate cough. D)Use clean gloves during the procedure.

A)Oxygenate the client before suctioning.

The nurse cares for a client after a thyroidectomy. The nurse would be MOST concerned if which of the following was observed? A)Tension and muscle spasm of the hand when a blood pressure cuff is applied to the arm and inflated. B)Absence of facial movement when the muscles of the facial nerve or branches of the nerve are tapped. C)Pain in the neck when pulling self to a sitting position or with sudden head movements. D)Blood pressure readings that remain 10 points below the preoperative readings.

A)Tension and muscle spasm of the hand when a blood pressure cuff is applied to the arm and inflated.

Which of the following indicates to the nurse a need for further teaching for a postoperative client using the incentive spirometer? A)The client exhales with the spirometer in his mouth. B)The client inhales with the spirometer in his mouth. C)The client splints his incision before using the spirometer. D)The client raises the head of his bed before using the spirometer

A)The client exhales with the spirometer in his mouth.

A client has the following arterial blood gas values: pH 7.52; PaO2 50 mm Hg (6.7 kPa); PaCO2 28 mm Hg (3.72 kPa); HCO3− 24 mEq/L (24 mmol/L). Based upon the client's PaO2, which nursing clinical judgment should the nurse make? A)The client is severely hypoxic. B)The oxygen level is low but poses no risk for the client. C)The client's PaO2 level is within normal range. D)The client requires oxygen therapy with very low oxygen concentrations

A)The client is severely hypoxic.

A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as prescribed. Which statement is true concerning oxygen administration to a client with COPD? A)High oxygen concentrations will cause coughing and dyspnea. B)High oxygen concentrations may inhibit the hypoxic stimulus to breathe. C)Increased oxygen use will cause the client to become dependent on the oxygen. D)Administration of oxygen is contraindicated in clients who are using bronchodilators.

B)High oxygen concentrations may inhibit the hypoxic stimulus to breathe.

Which rationale should a nurse use to explain the reason for oxygen being bubbled through a humidifier to a client receiving 4 liters of oxygen by nasal cannula? A)Prevents the burning sensation of direction oxygen B)Prevents drying of the nasal passage C)Prevents a chemical reaction between the tubing and oxygen D)Prevents contamination with environmental gasses

B)Prevents drying of the nasal passage

The nurse is preparing to administer a soapsuds enema to a preoperative client. In which position should the nurse place the client to administer the enema? A)Lateral B)Sims C) dorsal recumbent D) Prone

B)Sims

After abdominal surgery 3 days ago the client continues to have pain every 4 to 6 hours ranging from 3 to 7 on a 10-point scale. The client has prescriptions for morphine 10 mg IM every 3 to 4 hours and acetaminophen with codeine 30 mg every 3 to 4 hours as needed for pain. The client has been taking the morphine every 4 hours for the past 3 days but tells the nurse that the morphine is no longer lasting 4 hours and wants to receive pain medication every 3 hours. The nurse reviews the progress notes that indicate the client has obtained pain relief for 5 to 6 hours after receiving the morphine. What should the nurse do to help the client manage the pain? A)Administer the morphine every 3 hours. B)Suggest that the client take the acetaminophen with codeine every 3 hours. C)Continue to administer the morphine every 4 hours. D)Encourage the client to ambulate more frequently.

B)Suggest that the client take the acetaminophen with codeine every 3 hours.

The nurse finds the client who has had an colostomy crying. The client explains to the nurse ,"I'm upset because I know I won't be able to have children now that I have an ileostomy."Which response by the nurse is best? A. "Many women with colostomies decide to adopt. Perhaps you could consider that option?" B. "Having an colostomy doesn't necessarily mean that you can't bear children. Let's talk about your concerns." C. "I can understand your reasons for being upset. Having children must be important to you." D. "I'm sure you will adjust to this situation with time. Try not to be too upset."

B. "Having an colostomy doesn't necessarily mean that you can't bear children. Let's talk about your concerns."

Total parenteral nutrition (TPN) is prescribed for a client who has recently had a small and large bowel resection and who is currently not taking anything by mouth. What should the nurse do to safely administer the TPN? A. Administer TPN through a nasogastric or gastrostomy tube. B. Handle TPN using strict aseptic technique. C. Auscultate for the presence of bowel sounds prior to administering TPN. D. Designate a peripheral IV site for TPN administration

B. Handle TPN using strict aseptic technique.

A client has a patient-controlled analgesia (PCA) infusion to manage postoperative pain. In spite of receiving a dose of pain medication, the client rates the pain at 8 on a 0 to 10 pain scale. What should the nurse do first? A. Check the patient-controlled analgesia (PCA) pump function. B. Inspect the infusion site. C. Assess vital signs. D. Notify the health care provider (HCP).

B. Inspect the infusion site.

How should the nurse determine the length of the nasogastric tube to be inserted? A. Insert the tube until resistance is felt .B. Measure from the nose to the earlobe to the xiphoid process. C. Insert the tube nasally until the patient feels discomfort. D. Have the patient to swallow some water, and insert the tube to the third premarkedline.57

B. Measure from the nose to the earlobe to the xiphoid process.

The nurse teaches the client with chronic cancer pain about optimal pain control. Which recommendation is most effective for pain control? A. Get used to some pain, and use a little less medication than needed to keep from being addicted. B. Take prescribed analgesics on an around-the-clock schedule to prevent recurrent pain. C. Take analgesics only when pain returns. D. Take enough analgesics around the clock so that you can sleep 12 to 16 hours a day to block the pain.

B. Take prescribed analgesics on an around-the-clock schedule to prevent recurrent pain.

A client is receiving morphine sulfate by a patient-controlled analgesia (PCA) system after a left lower lobectomy 4 hours ago. The client reports moderately severe pain in the left thorax that worsens when coughing. What should the nurse do first? A)Reassure the client that the PCA system is working and will relieve pain. B)Request a prescription for a cough suppressant. C)Assess the pain using a pain scale and compare to the previous assessment. D)Encourage the client to take deep breaths and expectorate the mucous that is stimulating the cough.

C)Assess the pain using a pain scale and compare to the previous assessment.

The nurse is planning care for an 80-year-old client with a stage 1 pressure ulcer. The nurse should do which of the following to prevent further advancement of this pressure injury? Select all that apply. A)Elevate the head of the bed to 50 degrees. B)Obtain daily wound cultures C)Cover with protective dressing D)Reposition the client every 2 hours E)Place pillows on bony prominence F)Use barrier cream to the affected area G)Massage the area to increase comfort H)Inspect skin daily

C)Cover with protective dressing D)Reposition the client every 2 hours E)Place pillows on bony prominence F)Use barrier cream to the affected area H)Inspect skin daily

Which instruction is most important for the nurse to include when teaching a post- operative patient with limited mobility strategies to prevent venous thrombosis? A)Perform cough and deep breathing exercises hourly. B)Turn from side to side in bed at least every 2 hours. C)Dorsiflex and plantarflex the feet 10 times each hour. D)Use the incentive spirometer 10 times each hour

C)Dorsiflex and plantarflex the feet 10 times each hour.

When the nurse asks the client who is having abdominal surgery today if the client understands the procedure, the client replies, "No, not really; I talked about several different things with my surgeon, and I'm just not sure." What should the nurse do next? A)Teach the client all the details of the planned procedure. B)Utilize a second witness when the client signs for consent. C)Notify the surgeon of the client's expressed lack of understanding. D)Administer the prescribed preoperative narcotics and/or sedative

C)Notify the surgeon of the client's expressed lack of understanding.

After teaching the client how to use the patient-controlled analgesia (PCA) pump, the nurse determines that the client understands the use of the PCA when the client makes which statement? A)"It's OK for my family to press the button for me if I'm too tired to do it myself." B)"I should wait until the pain is really bad before I push the button to get more pain medicine." C)The machine will only give me the prescribed amount of pain medication even if I push the button too soon." D)I have to be careful about pushing the button too many times or I will overdose myself."

C)The machine will only give me the prescribed amount of pain medication even if I push the button too soon."

After teaching the client how to use the patient-controlled analgesia(PCA) pump, the nurse determines that the client understands the use of the PCA when the client makes which statement? A. "It's OK for my family to press the button for me if I'm too tired todo it myself." B. "I should wait until the pain is really bad before I push the button to get more pain medicine." C. "The machine will only give me the prescribed amount of pain medication even if I push the button too soon." D. "I have to be careful about pushing the button too many times or I will overdose myself."

C. "The machine will only give me the prescribed amount of pain medication even if I push the button too soon."

The maximum amount of any medication that can be given in one site for a subcutaneous injection is: A. 5 mL. B. 3 mL. C. 1 mL. D. 0.5 mL.

C. 1 mL.

A nurse discovers that she made a medication error. What should be the nurse's FIRST response? A. Record the error in the EMR B. Notify the primary care provider C. Asses the patient for any possible side effects of the error D. Complete an incident report explaining how the error was made.

C. Asses the patient for any possible side effects of the error

A client with pancreatic cancer has been receiving morphine via a subcutaneous pump for 2 weeks. The client is requiring an increased dose of the morphine to manage the pain. How should the nurse document this finding? A. Tolerating the medication well B. Showing addiction to morphine C. Developing a tolerance for the medication D. Experiencing physical dependence

C. Developing a tolerance for the medication

The nurse is planning to assist the health care provider with a thoracentesis for a client who has a pleural effusion. Which position for the client would be appropriate for this procedure? A. Lying supine with the arms extended B. Lying prone with the head supported by the arms C. Sitting upright and leaning on an overbed table D. Side lying with the knees drawn up to the abdomen

C. Sitting upright and leaning on an overbed table

A nurse is caring for a client with acute kidney injury who is receiving a protein-restricted diet. The client asks why this diet is necessary. Which information should the nurse include in a response to the client's questions? A. A high-protein intake ensures an adequate daily supply of amino acids to compensate for losses. B. Essential and nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis. C. This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys .D. Urea nitrogen cannot be used to synthesize amino acids in the body, so the nitrogen for amino acid synthesis must come from the dietary protein.

C. This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys

A client had a Mantoux test result of an 8-mm induration. When should the nurse interpret the test as positive? When the client: A.Lives in a long-term care facility. B.Has no known risk factors. C.Is immunocompromised. D.Works as a health care provider in a hospital.

C.Is immunocompromised.

The equipment (syringe, needle) you choose for injections are based on: 1. Quantity of solution 2. Route to be administered 3. Type of medication 4. Body size 5. Viscosity of solution A. 1, 2, 3 B. 2, 3, 4 C. 3, 5 D. All the above

D. All the above

On assessment of a patient with a colostomy, you note the stoma is located on the right lower quadrant. Due to its location, this is known as what type of colostomy? A. Descending Colostomy B. Transverse C. Ileostomy D. Ascending Colostomy

D. Ascending Colostomy

A Jackson Pratt (JP) drain in a post surgical patient is filled with clear pink drainage that is a mix of clear fluid and blood. The nurse knows documents this drainage as? A. Serous drainage B. Sanguineous drainage C. Purulent drainage D. Seriosanguineous drainage

D. Seriosanguineous drainage

The nurse is administering a medication by intravenous bolus when the client reports pain and burning at the IV site. What is the next action by the nurse? A. Encourage the client to take deep breaths during the administration to minimize pain. B. Place a warm pack on the IV site and continue to administer the medication. C. Flush the site with normal saline to verify patency of the IV site. D. Stop the infusion and assess for signs of infiltration.

D. Stop the infusion and assess for signs of infiltration.

A client was discharged from the hospital for cancer-related pain. While in the hospital the pain was well controlled on patient-controlled administration (PCA) of IV morphine, and on discharge 2 days ago was taking oral morphine. The client now reports pain as an 8 on a 10-pointscale and is asking the nurse about using PCA for the morphine at home. Which explanation is the most likely for the client's reports of inadequate pain control? The client is: A. Addicted to the IV morphine. B. Going through withdrawal from the IV opioid. C. Physically dependent on the IV morphine. D. Undermedicated on the oral opioid.

D. Undermedicated on the oral opioid.

Before administering an intermittent enteral feeding through a nasogastric tube, the nurse assesses for gastric residual. The nurse understands that this procedure is important to accomplish which purpose? A. To relieve gastric pressure B. Assess fluid and electrolyte status. C. Evaluate absorption of the last feeding. D. Confirm proper nasogastric tube placement

D.Confirm proper nasogastric tube placement

The amount of oxygen that can be delivered via a nasal cannula 10-15 L/min 8-10 L/min 6-8 L/min 1-6 L/min

1-6 L/min

The nurse is assessing for stoma prolapse in a client with a colostomy. What should the nurse observe if stoma prolapse occurs? 1. Protruding stoma 2. Sunken and hidden stoma 3. Narrowed and flattened stoma 4. Dark- and bluish-colored stoma

1. Protruding stoma

During the last 8 hours, a nurse cared for a client who had a transurethral prostatectomy. The client has continuous bladder irrigation (CBI) infusing. At the end of the 8 hours, a nurse determines that the client received 3,050 mL of irrigation fluid and that 4,030 mL of fluid was emptied from the urinary drainage bag. The nurse calculates the actual urine output for 8 hours to be _______ mL.

980ml

8. As a nurse, which statement is INCORRECT regarding an informed consent signed by a patient? A) The nurse is responsible for obtaining the consent for surgery B) Patients under 18 years of age may need a parent or legal guardian to sign a consent form C) The nurse can witness the client signing the consent form D)It is the nurse's responsibility to ensure the patient has been educated by the physician

A) The nurse is responsible for obtaining the consent for surgery

he nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents and checks the gastric pH. The nurse verifies correct tube placement if which pH value is noted? A)3.5 B)6.5 C)7.35 D)8.0

A)3.5

The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). The results are as follows: pH 7.35; Pco2 62 (8.25 kPa); Po2 70 (9.31 kPa); HCO3 34 mEq/L (34 mmol/L). What should the nurse do first? A)Apply a 100% nonrebreather mask. B)Assess the vital signs. C)Reposition the client. D)Prepare for intubation.

A)Apply a 100% nonrebreather mask.

Thinking back to the patient in the previous question, what type of stool would you expect the stoma to be excreting? A. Liquid stool B. Lose to partly formed stool C. Similar to normal stool D. Semi-solid stool

A. Liquid stool

The implementation of diagnosis-related groups (DRGs) by Medicare in 1983 affected hospitals in which way? A. Medicare pays only the amount of money preassigned to a treatment for a diagnosis. B. This reimbursement method focuses on preventing illness through screening and health promotion. C. It decreased in hospital admission rates significantly

A. Medicare pays only the amount of money preassigned to a treatment for a diagnosis.

Sitz baths are prescribed for a client with an inflamed painful hemorrhoid . How do the sitz baths aid the healing process? A. Promoting vasodilation B. Cleansing perineal tissue C. Softening the incision site D. Tightening the rectal sphincter

A. Promoting vasodilation

A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? A. This is a normal, expected event. B. The client is experiencing early signs of ischemic bowel. C. The client should not have the nasogastric tube removed. D. This indicates inadequate preoperative bowel preparation

A. This is a normal, expected event.

A patient has had colon surgery as a result of an intestinal obstruction. Which is a method of delivering nutrition that avoids the gut? A. Total parenteral nutrition (TPN) B. Puree diet with thickened liquids C. Tube feeding per gastrostomy tube D. Tube feeding per nasogastric (NG) tube

A. Total parenteral nutrition (TPN)

You are giving a community presentation on Medicare Part D. Medicare Part D: A)Pays for over-the-counter medications. B) Pays a portion of prescription drug costs. C) Pays for physical therapy. D)Pays for laboratory work needed for medication monitoring

B) Pays a portion of prescription drug costs.

A client says to a nurse, "I wish my family would let me die in peace. I get so angry that my family keeps hovering over me as if I have given up. The doctor told me I have terminal lung cancer and there is no cure!" Which is the best therapeutic response by the nurse? A)"Your family is hovering over you? I can ask them to leave if you wish." B)"You are angry because your family thinks that you have given up hope for a cure?" C)"Have you talked to your family about your feelings?" D)"You shouldn't feel angry. Your family is just trying to show that they love and care for you."

B)"You are angry because your family thinks that you have given up hope for a cure?"

A 6-month survival rate has been established. The patient refuses to accept the diagnosis and denies the conversation ever took place. Which stage of grief is the patient experiencing? A)Anger B)Denial C)Depression D)Acceptance

B)Denial

The physician orders hydromorphone hydrochloride (Dilaudid) 15 mg IM for a 56-year- old woman. Side effects of this medication that the nurse should observe the patient for include- A)Photosensitivity and constipation. B)Hypotension and respiratory depression. C)Tardive dyskinesia and diplopia. D)Dry mouth and tinnitus.

B)Hypotension and respiratory depression.

A client is one day post-op following a transverse loop colostomy. Which assessment finding would be indicative of a complication? A. Hypoactive bowel sounds B. A dusky color to the stoma C. Soft stool measuring 200 mL D. Scant bleeding at the stoma site

B. A dusky color to the stoma

A client has a positive reaction to the Mantoux test. How should the nurse interpret this reaction. The client has: A. Active tuberculosis. B. Been exposed to Mycobacterium tuberculosis. C. Developed a resistance to tubercle bacilli. D. Developed passive immunity to tuberculosis

B. Been exposed to Mycobacterium tuberculosis.

Mrs. D returns from surgery with a new colostomy. The nurse assesses the stoma and notes that it is red and edematous. What is the best nursing action based on this finding? A. Place patient in a prone position B. Document the findings C. Apply ice immediately D. Call the health care provider

B. Document the findings

Total parenteral nutrition (TPN) is prescribed for a client who has recently had a small and large bowel resection and who is currently not taking anything by mouth. What should the nurse do to safely administer the TPN? A. Administer TPN through a nasogastric or gastrostomy tube. B. Handle TPN using aseptic technique. C. Auscultate for the presence of bowel sounds prior to administering TPN. D. Designate a peripheral IV site for TPN administration

B. Handle TPN using aseptic technique.

A client states to a hospice nurse, "If I could live until my grandson's wedding in 2 months, then I would be ready to die." Based on this statement, the nurse should interpret that the client is in which stage of grief? A)Denial B)Depression C)Bargaining D)Acceptance

Bargaining

A nurse is using a pulse oximeter to measure the arterial oxyhemoglobin saturation (SaO2 or SpO2) of a client's arterial blood. What range is considered a normal value for SpO2? A) 70-80 % B) 80-87% C) 95-100% D) 75-85%

C) 95-100%

In completing a client's preoperative routine, the nurse finds that the informed consent is not signed. The client begins to ask more questions about the surgical procedure. What action should the nurse take next? A)Obtain the client's signature to the consent B)Answer the client's questions about the surgery C) Inform the surgeon the informed is not signed and the client has questions about the surgery. D)Reassure the client that the surgeon will answer any questions right before the anesthesia is administered

C) Inform the surgeon the informed is not signed and the client has questions about the surgery.

Mrs. Redor, age 55 years, was hospitalized. She takes 5 medications. She isbeing discharged home. In preparing her discharge, which of the following is least likely to be helpful? A) Assess her knowledge about the medications B) Explain to her how she should take the medications C) Leave medication brochures by her bed D) Explore her feelings about her medications and diagnoses

C) Leave medication brochures by her bed

The nurse empties a Jackson-Pratt drainage bulb. Which nursing action ensures correct functioning of the drain? A)Irrigating it with normal saline B)Connecting it to low intermittent suction C)Compressing it and then plugging it to establish suction D)Connecting it to a drainage bag and clamping it off

C)Compressing it and then plugging it to establish suction

The nurse is preparing a client for surgery. Although the client can speak English, English is the client's second language. The client has completed high-school level education. When the nurse asks the client what type of surgery is scheduled, the client is unable to provide an answer. What should the nurse do next? A)Explain the procedure in detail to the client, and assess the client's understanding. B)Continue to follow the preoperative procedures required to prepare the client for surgery. C)Notify the health care provider that the client cannot explain the scheduled surgery. C)Document the client's response in the electronic medical record.

C)Notify the health care provider that the client cannot explain the scheduled surgery.

A client has requested to have patient-controlled analgesia (PCA)after surgery? When is it appropriate for a client to receive PCA?A. A family member is able to assist with self-dosing. B. There are advanced directives in place. C. The client has the ability to self-administer. D. There is a nurse to assist with self-administration.

C. The client has the ability to self-administer.

While a client is receiving TPN, it is MOST important for the nurse to monitor A. vital signs and level of consciousness. B. arterial blood gases and liver enzymes. C. serum glucose and electrolytes. D. skin turgor and daily weights.111

C. serum glucose and electrolytes.

The hospital readmission reduction program looks at: A) The illness level of all patients admitted to that hospital for the past year .B) The infection rates within the hospital correlated with readmission rates. C) The number of prescriptions the patient filled 30 days prior to readmission. D) Readmission rates of patients during a 30-day period after discharge

D) Readmission rates of patients during a 30-day period after discharge

Following abdominal surgery, a client refuses to deep breathe and cough every 2 hours as prescribed. What should the nurse do first? A)Ask the client's wife to insist that the client take the deep breaths every 2 hours. B)Respect the client's wishes, and turn the client from side to side more frequently. C)Suggest that the client increase the daily fluid intake to at least 2,500 mL. D)Explain the risks of not expanding the lungs and why the exercise is important.

D)Explain the risks of not expanding the lungs and why the exercise is important.

This mask prevents the patient from rebreathing exhaled air. The reservoir bag filled with oxygen enters the mask on inspiration. Exhaled air escapes through the side vent. This mask delivers the highest concentration of oxygen. A)Simple face mask B)Venturi mask C)Partial rebreather mask D)Non-rebreather mask

D)Non-rebreather mask

A client who underwent a left lower lobectomy has been out of surgery for 48 hours. The client is receiving morphine sulfate via a patient-controlled analgesia (PCA) system and reports having pain in the left thorax that worsens when coughing. After checking the PCA system, what should the nurse do next? A)Let the client rest so the client is not stimulated to cough. B)Encourage the client to take deep breaths to help control the pain. C)Reassure the client that the machine is working and will administer medication to relieve the pain. D)Obtain a more detailed assessment of the client's pain using a pain scale.

D)Obtain a more detailed assessment of the client's pain using a pain scale.

A client is receiving total parenteral nutrition (TPN). The nurse notices that the bag of TPN solution has been infusing for 24 hours but has 300 mL of solution left. What should the nurse do? A. Continue the infusion until the remaining 300 mL is infused. B. Change the filter on the tubing, and continue with the infusion. C. Notify the health care provider (HCP), and obtain prescriptions to alter the flow rate of the solution. D. Discontinue the current solution, change the tubing, and hang a new bag of TPN solution

D. Discontinue the current solution, change the tubing, and hang a new bag of TPN solution

The nurse has emptied the drainage from a Hemovac drain. How will the nurse re- establish the suction? A. Turn the suction back on the wall outlet B. Milk and then clamp the drain tubing. C. Recap the drain and keep the tubing to gravity. D. Fully compress the drain and reapply the cap

D. Fully compress the drain and reapply the cap

A 19-year-old college student has a Mantoux test performed at the college health clinic. The result is positive. The clinic nurse should- A)Refer the student to an appropriate center for further testing. B)Restrict the student's activity until his parents can be notified. C)Notify the local Public Health Department. D) Place the student in an isolation room in the college infirmary.

Refer the student to an appropriate center for further testing.

After pelvic surgery, the client reports pain in the calf. Which action should the nurse take first? a.Ask the client to walk and observe the gait b.Check the client's calf for temperature, color, and size. c.Lightly massage the calf area to relieve the muscle pain. d.Administer as-needed morphine as prescribed.

b.Check the client's calf for temperature, color, and size.