ATI Fundamental

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with newly licensed nurse. Which of the following actions should the nurse include? 1. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. 2. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. 3. Make sure the reservoir bag of a partial rebreathing mask remains deflated. 4. Use petroleum jelly to lubricate the client's nares, face, and lips.

Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min

A nurse is caring for a client who is receiving a unit of packed RBCs. Nurses' notes: 0800:Packed RBCs initiated by the charge nurse through an 18-guage peripheral IV to infuse over 2 hr. 0815:Client reports itching and anxiety. Client's face is flushed and has hives. Vital Signs: 0800:BP 112/64 mm HgHeart rate 80/minRespirations 18/minTemperature 37.1° C (98.8° F)Oxygen saturation 97% on room air 0815:BP 106/54 mm HgHeart rate 100/minRespirations 22/minTemperature 37° C (98.6° F)Oxygen saturation 95% on room air

The client has manifestations of "allergic reaction" as evidenced by the client's "itching"

A nurse is caring for a client who has pneumonia. Vital Signs: 0800:Heart rate 109/minRespirations 26/minBP 125/65 mm HgTemperature 39.2° C (102.6° F)Oxygen saturation 95% 1200:Heart rate 94/minRespirations 18/minBP 115/65 mm HgTemperature 37.8° C (100° F)Oxygen saturation 96% Medication Administration Record: 0.45% sodium chloride IV at 125 mL/hr Vancomycin 1 g intermittent IV bolus every 12 hr Acetaminophen 650 mg PO every 6 hr PRN temperature greater than 38.3° C (101° F) Codeine 20 mg PO every 4 hr PRN cough Nurses' Notes 0800: Oriented to person, place, and time. Appears fatigued. Diaphoretic, febrile. Reports not sleeping well last night due to "coughing a lot." Moves all extremities well. Tachycardia. All pulses palpable. Reports chest discomfort with coughing. Respirations 26/min, shallow. Auscultation reveals diminished breath sounds and bilateral crackles. Pulse oximetry 95% on O2 2 L via nasal cannula. Hypoactive bowel sounds present in all four quadrants. States tolerating diet with no nausea or vomiting but has no appetite. Client states voiding using the bedside commode with no difficulty. Output of 500 mL clear, yellow urine flushed. IV infusing to right arm, no noted redness or irritation at site. Acetaminophen administered for temperature. 1200: States feeling better following administration of acetaminophen. Vancomycin infusion started. Client voices no discomfort at this time. 1300: Client reports intense pain at IV catheter site. Area taut, blanched, cool to touch with edema present. IV vancomycin discontinued and catheter removed. Provider notified. Complete the following sentence by using the list of options. The nurse should identify that the client might be experiencing Select... as evidenced by the client's Select... .

The nurse should identify that the client might be experiencing "Extravasation" as evidenced by the client's "IV catheter site" 1. Extravasation is correct. The client's report of severe pain and the appearance of the IV catheter site are indications of extravasation. Vancomycin is a medication that carries the risk of extravasation. 2. IV catheter site is correct. The appearance of the site is an indication of extravasation. Vancomycin is a medication that carries a risk of extravasation.

A nurse is caring for a child who has a prescription for blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take? 1. Examine personal values about the issue. 2. Tell the parents that this is a necessary procedure. 3. Inform the parents that the staff does not require their consent. 4. Contact a spiritual support person to explain the importance of the procedure.

1. Examine personal values about the issue.

A nurse is caring for a client who has COPD. Nurses' Notes: 1000: Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackles heard in left upper lobe and decreased breath sounds at bases bilaterally. Vital Signs: 1000:Temperature 38.6° C (101.5° F)BP 114/56 mm HgHeart rate 99/minRespirations 32/minOxygen saturation 85% on room air Diagnostic Results: 1200:Chest x-ray shows lung hyperinflation and left upper lobe pneumonia. Select the 3 findings that require follow-up. 1. Breath sounds 2. Blood pressure 3. Oxygen saturation 4. Temperature 5. Heart rate

1. Breath sounds 3. Oxygen saturation 4. Temperature

A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take? 1. Instruct the family to refrain from pushing the button for the client while she is asleep. 2. Inform the client that because she is on PCA, vital signs will be taken every 8 hr. 3. Teach the client to avoid pushing the button until pain is above a 7 on a scale of 0 to 10. 4. Increase the basal rate and shorten the lock-out interval time if the client's pain level is too high.

1. Instruct the family to refrain from pushing the button for the client while she is asleep. - The nurse should instruct family members not to activate the button for the client while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain.

A nurse is admitting a client. Nurses' notes: 0930:Client reports a sore throat, productive cough, shortness of breath, and fever for the past 4 days. 1030:Client has swollen lymph nodes of the neck upon palpation. Client reports chills and coughs up yellow-colored mucus. Client's face is flushed and diaphoretic. States lack of appetite. Chest x-ray obtained and positive for pneumonia. Vital Signs: 1030:Blood pressure 110/68 mm HgHeart rate 110/minRespiratory rate 24/minTemperature 38.6° C (101.5° F)Oxygen saturation 91% on room air The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? 1. Place the client on droplet isolation precautions. 2. Apply oxygen at 2 L/min via nasal cannula. 3. Request a prescription for an antipyretic medication. 4. Wear an N-95 mask when providing care to the client. 5. Request a prescription for an antihypertensive medication. 6. Remain 1 m (3 feet) from the client.

1. Place the client on droplet isolation precautions. 2. Apply oxygen at 2 L/min via nasal cannula. 3. Request a prescription for an antipyretic medication. 6. Remain 1 m (3 feet) from the client.

A nurse is planing care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client? 1. Gown 2. N95 respirator 3. Shoe covers 4. Surgical cap

2. N95 respirator - The nurse should wear an N95 respirator when providing care for a client who requires droplet precautions as a result of tuberculosis to prevent the transmission of bacteria.

A nurse is caring for a client who has an NG tube and is receiving intermittent feeding through an open system. Which of the following actions should the nurse take first? 1. Rinse the feeding bag with water between feedings. 2. Tell the client to keep the head of the bed elevated at least 30°. 3. Make sure the enteral formula is at room temperature. 4. Wipe the top of the formula can with alcohol.

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

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following action is the nurse's responsibility? 1. Describe the procedure to the client. 2. Witness the client's signature on the consent form. 3. Inform the client of alternatives to the procedure. 4. Tell the client which team members will assist with the procedure.

2. Witness the client's signature on the consent form.

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? 1. A client who has a history of physical abuse 2. A client who has a permanent pacemaker 3. A client who has ulcerative colitis 4. A client who has asthma

4. A client who has asthma - some essential oils can cause bronchospasm; therefore, the nurse should consult the client's provider before using this therapy for a client who has asthma

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? 1. Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube. 2. Remove the NG tube if the client begins to gag or choke. 3. Apply suction to the NG tube prior to insertion. 4. Have the client take sips of water to promote insertion of the NG tube into the esophagus.

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

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? 1. Discuss the risk factors for colon cancer. 2. Focus teaching on what the client will need to do in the future to manage his illness. 3. Provide the client with written information about the phases of loss and grief. 4. Reassure the client that this is an expected response to grief.

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

A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse? 1. The caregiver is the client's financial power of attorney. 2. The client is in a wheelchair with the wheels locked. 3. The client reports receiving a full bath twice each week. 4. The caregiver insists on remaining in the room.

4. The caregiver insists on remaining in the room. - A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment.

A nurse is planning a educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include? 1. "You should have an eye examination every 2 years." 2. "You should receive a tetanus booster every 5 years." 3."You should receive a shingles vaccine when you are 70 years old." 4."You should receive a pneumococcal vaccine when you are 65 years old."

4."You should receive a pneumococcal vaccine when you are 65 years old." - The nurse should instruct older adult clients to receive one of the two pneumococcal vaccines when they are 65 years old. The vaccines can be given to clients who are 19 years of age and older and have certain conditions, such as chronic heart, lung, or liver disease, diabetes mellitus, and alcohol disease, or to those who smoke cigarettes. 1. "You should have an eye examination every 2 years." - every year. 2. "You should receive a tetanus booster every 5 years." - every 10 years. 3."You should receive a shingles vaccine when you are 70 years old." - 60 years old.

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precaution should the nurse initiate? 1. Contact precaution 2. Droplet precaution 3. Airborne precaution 4. Protective precaution

Fhydor2. Droplet precaution 1. Contact precaution - Contact precautions are a requirement for clients who have infections that spread via direct contact or from environmental contact. Examples are vancomycin-resistant enterococci and herpes simplex infections. 2. Droplet precaution - Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 1 m (3 feet) of the client who has a disorder requiring droplet precautions. 3. Airborne precaution - Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles. 4. Protective precaution - Clients who have a compromised immune system, such as those who have received an allogeneic stem cell transplant, require a protective environment. This precaution keeps them from acquiring infections from others.

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

The nurse should first inject air into the vial of NPH insulin without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding? 1. Assign a staff member to feed the client. 2. Provide small-handled utensils for the client. 3. Thicken liquids on the client's tray. 4. Arrange food in a consistent pattern on the client's plate.

4. Arrange food in a consistent pattern on the client's plate.

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

The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer.

A nurse in an emergency department is caring for a client. Physical Examination: 1200:Influenza with nausea, vomiting, and diarrhea for 3 days. Client is tachycardic, hypotensive, and tachypneic, with weak pulses, dry mucous membranes, poor turgor, and oliguria. Plan: Admit for IV fluids. Vital Signs: 1200:Temperature 38.4° C (101.1° F)Pulse rate 126/minRespirations 28/minBP 92/54 mm HgOxygen saturation 93% Nurses' notes: 1900: Client is disoriented, confused. Client attempting to get out of bed without assistance and states, "I'm going home." Returned to bed, attempted to reorient to time, place, and circumstances. Call placed to client's family, no answer, message left. 1915: Client remains disoriented. Attempting to pull out IV line. Call was returned by client's family. Updated them on situation.

The nurse should first " medications that might be causing confusion is correct" followed by "using other methods to keep the client safe"

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? 1. Walking briskly 2. Riding a bicycle 3. Performing isometric exercises 4. Engaging in high-impact aerobics

1. Walking briskly - Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy.

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? 1. Place the client in a side-lying position. 2. Instill 15 mL of irrigation fluid into the catheter with each flush. 3. Subtract the amount of irrigant used from the client's urine output. 4. Perform the irrigation using a 20-mL syringe.

3. Subtract the amount of irrigant used from the client's urine output - The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output.

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? 1. Advocacy ensures clients' safety, health, and rights. 2. Advocacy ensures that nurses are able to explain their own actions. 3. Advocacy ensures that nurses follow through on their promises to clients. 4. Advocacy ensures fairness in client care delivery and use of resources.

1. Advocacy ensures clients' safety, health, and rights - Advocacy is a key component of professional nurses' code of ethics. As a client advocate, the nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care.

A nurse is auscultating the anterior chest of a client who was newly admitted to a medical-surgical unit. 1. Crackles 2. Rhonchi 3. Friction rub 4. Normal breath sounds

4. Normal breath sounds

A charge nurse is observing a newly licensed nurse prepare a sterile field for dressing change. Which of the following actions by the newly licensed nurse required intervention by the charge nurse? 1. The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field. 2. The newly licensed nurse places sterile objects 2.5 cm (1 inch) within the border of the field. 3. The newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring. 4. The sterile field is positioned at the level of the newly licensed nurse's waist.

1. The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field.

A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping? 1. "I am not worried because I still have hope that he will be okay." 2. "I am relying on support from our family during this time." 3. "We can plan our family reunion once he recovers and comes home." 4. "We don't see any reason to start discussing funeral arrangements right now."

2. "I am relying on support from our family during this time." 1. False hope 3. Denial feelings 4. Yes, it's right that not a good time to talk about funeral arrangement but it is not effective coping to patient

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? 1. Protective environment 2. Airborne precautions 3. Droplet precautions 4. Contact precautions

4. Contact precautions

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? 1. Insert an implanted port. 2. Close a laceration with sutures. 3. Place an endotracheal tube. 4. Initiate an enteral feeding through a gastrostomy tube.

4. Initiate an enteral feeding through a gastrostomy tube. - It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes.

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use? 1. Alginate 2. Gauze 3. Transparent 4. Hydrocolloid

Hydrocolloid - dressings promote healing in stage 2 pressure injuries by creating a moist wound bed. 1. Alginate - dressing are used to treat stage 3 and 4 pressure injuries to absorb drainage. Alginate forms a soft gel when it comes in contact with drainage. 2. Gauze - moistened gauze promotes healing in stage 4 or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed. 3. Transparent - dressings promote healing in stage 1 pressure injuries by preventing further friction and shearing. 4. Hydrocolloid - dressings promote healing in stage 2 pressure injuries by creating a moist wound bed.

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

Lower leg extension

A nurse is caring for a client who has a newly placed ileostomy. Nurses' notes: 0800:Client is 2 days postoperative following an ileostomy. Pouch is one-fourth full of stool. Stoma is red. Abdomen is soft and nontender. Bowel sounds present in all quadrants. 1200:Stoma site appears dark purple with blistering on the skin around the stoma. Pouch is slightly leaking and is three-fourths full of brown, liquid stool. Diagnostic Results: 1200:Hgb 19 g/dL (12 to 16 g/dL)Hct 46% (37% to 47%) Complete the following sentence by using the lists of options. Diagnostic Results 1200:Hgb 19 g/dL (12 to 16 g/dL)Hct 46% (37% to 47%) Complete the following sentence by using the lists of options. The nurse should first address the Select... followed by the Select....

The nurse should first address the "stoma color" followed by the "skin around the stoma"

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? 1. Remove the outer cannula cautiously for routine cleaning. 2. Use tracheostomy covers when outdoors 3. Use sterile technique when performing tracheostomy care at home. 4. Cleanse irritated skin with full-strength hydrogen peroxide.

Use tracheostomy covers when outdoors - tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles.

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? 1. Check the client for injuries. 2. Move hazardous objects away from the client. 3. Notify the provider. 4. Ask the client to describe how she felt prior to the fall.

1. Check the client for injuries - The first action the nurse should take when using the nursing process is to assess the client for injuries.

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? 1. The client uses a wool blanket on their bed. 2. The client identifies the location of a fire extinguisher. 3. The client stores an extra oxygen tank on its side under their bed. 4. The client has a weekly inspection checklist for oxygen equipment.

2. The client identifies the location of a fire extinguisher - The client should be able to identify the location of fire extinguishers in the home and be aware of how to use them.

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? 1. "I'm having mild pain." 2. "The pain is like a dull ache in my stomach." 3. "I notice that the pain gets worse after I eat." 4. "The pain makes me feel nauseous."

2. "The pain is like a dull ache in my stomach." - The client is describing the quality of the pain, which is how the pain feels in the client's own words.

A nurse is caring for a client who asks about the purpose of advance directives. which of the following statements should the nurse make? 1. "They allow the court to overrule an adult client's refusal of medical treatment." 2. "They indicate the form of treatment a client is willing to accept in the event of a serious illness." 3. "They permit a client to withhold medical information from health care personnel." 4. "They allow health care personnel in the emergency department to stabilize a client's condition."

2. "They indicate the form of treatment a client is willing to accept in the event of a serious illness." Advance directives include a living will, which permits clients to direct the treatment they will receive in the event of a medical emergency or serious illness.

A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPPA guideline? 1. A nurse who is caring for a client reviews the client's medical chart with a nursing student who is working with the nurse. 2. A nurse asks a nurse from another unit to assist with documentation for a client. 3. A nurse who is caring for a client returns a call to the person appointed in the health care proxy to discuss the client's care. 4. A nurse discusses a client's status with the physical therapist who is caring for the client.

2. A nurse asks a nurse from another unit to assist with documentation for a client.

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? 1. Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain. 2. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. 3. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum. 4. Palpate the client's abdomen before auscultating bowel sounds.

2. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? 1. Insert the catheter at a 45° angle. 2. Place the client's arm in a dependent position. 3. Shave excess hair from the insertion site. 4. Initiate IV therapy in the veins of the hand.

2. Place the client's arm in a dependent position - The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity.

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. which of the following actions should the nurse take? 1. Ask the client to consider a direct donation. 2. Withhold the blood transfusion. 3. Request a consultation with the ethics committee. 4. Ask the client's family to intervene.

2. Withhold the blood transfusion. - The principle of autonomy ensures that a client who is competent has the right to refuse treatment.

A nurse is calculating a client's fluid intake over the past 8 hour. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid? 1. 2 cups of soup 2. 1 quart of water 3. 8 oz of ice chips 4. 6 oz of tea

3. 8 oz of ice chips - The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid.

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment. Which of the following actions should the nurse take next? 1. Rock the client up to a standing position. 2. Pivot on the foot that is the farthest from the chair. 3. Assess the client for orthostatic hypotension. 4. Apply a gait belt to the client.

3. Assess the client for orthostatic hypotension. - The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair.

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? 1. Verify the client's name on their identification bracelet with the medication administration record. 2. Call the pharmacy to determine whether the client's medications are available. 3. Compare the client's home medications with the provider's prescriptions. 4. Place the client's home medication bottles in a secure location.

3. Compare the client's home medications with the provider's prescriptions.

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which the following actions should the nurse take? 1. Assist the client into a prone position. 2. Place a sleeve over the top of each leg with the opening at the knee. 3. Make sure two fingers can fit under the sleeves. 4. Set the ankle pressure at 65 mm Hg.

3. Make sure two fingers can fit under the sleeves.

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? 1. "Is your pain constant or intermittent?" 2. "What would you rate your pain on a scale of 0 to 10?" 3. "Does the pain radiate?" 4. "Is your pain sharp or dull?"

4. "Is your pain sharp or dull?" - Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain.

A nurse is preparing to administer multiple medications to a client who has enteral feeding tube. Which of the following actions should the nurse plan to take? 1. Dissolve each medication in 5 mL of sterile water. 2. Draw up medications together in the syringe. 3. Push the syringe plunger gently when feeling resistance. 4. Flush the tube with 15 mL of sterile water.

4. Flush the tube with 15 mL of sterile water.

A nurse is preparing a heparin infusion for a client who was admitted to the facility with a deep vein thrombosis. The prescription reads: 25000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump?

8 mL/hr

A nurse is caring for a client who has a new diagnosis of seizure disorder. Nurse Notes 0800:Client awake, alert, oriented to person, place, and time. Preparing for discharge today. No seizure activity recorded during the night. Discharge teaching provided to client and partner regarding a new prescription for carbamazepine. Taught importance of taking medication twice daily as prescribed, not to miss a dose, and not to double a dose if one is missed. Advised client to avoid grapefruit and grapefruit juice while taking carbamazepine. Reminded client that follow-up laboratory tests and eye examinations will be necessary while on this medication. Client and partner verbalized understanding of all medication teaching. 0900:On entry into client's room with discharge papers, client was found on the floor seizing. Call button pressed to ask for additional help. Medication Administration Record: Carbamazepine ER 200 mg PO twice per dayLorazepam 4 mg IV bolus PRN seizure activity, may repeat after 10 to 15 min

The nurse should first address the client's "physical safety", followed by the client's "positioning"

A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use? 1. Touch the face with a cotton ball. 2. Apply a vibrating tuning fork to the client's forehead. 3. Have the client stand with their arms at their sides and their feet together. 4. Perform direct percussion over the area of the kidneys.

3. Have the client stand with their arms at their sides and their feet together. - A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance.

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make? 1. "Most people are happy when their children grow up and leave home." 2. "You should be proud that your children are becoming independent." 3. "Maybe you should consider why you are feeling useless." 4. "People in middle adulthood often find satisfaction in nurturing and guiding young people."

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

A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mmHg. Which of the following images displays the measurement in mmHg to which the nurse should inflate the cuff when obtaining the blood pressure?

To obtain an accurate blood pressure measurement, the nurse should inflate the cuff 30 mm Hg beyond the point at which the nurse was last able to palpate the pulse. If the nurse last palpated the pulse at 92 mm Hg, then this would be the correct pressure to which the nurse should inflate the cuff.

A nurse manager is preparing to review medication documentation with a group a newly licensed nursing. Which of the following statements should the nurse manager plan to include in the teaching? 1. "Use the complete name of the medication magnesium sulfate." 2. "Delete the space between the numerical dose and the unit of measure." 3. "Write the letter U when noting the dosage of insulin." 4. "Use the abbreviation SC when indicating an injection."

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

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "what would happen if I arrived at the emergency department and I had difficulty breathing?" which of the following response should the nurse take? 1. "We would consult the person appointed by your health care proxy to make decisions." 2. "We would give you oxygen through a tube in your nose." 3. "You would be unable to change your previous wishes about your care." 4. "We would insert a breathing tube while we evaluate your condition."

2. "We would give you oxygen through a tube in your nose."

A nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? 1. .3 mg 2. 0.3 mg 3. 0.30 mg 4. 3/10 mg

2. 0.3 mg

A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risks for hypertension? 1. A client who is 52 years old 2. A client who smokes one pack of cigarettes each day 3. A client who walks for 30 min every day 4. A client who drinks one glass of wine three times per week

2. A client who smokes one pack of cigarettes each day

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? 1. Combine client care tasks when caring for multiple clients. 2. Wait until the end of the shift to document client care. 3. Use the planning step of the nursing process to prioritize client care delivery. 4. Allow for interruptions in tasks to discuss client care issues with colleagues.

3. Use the planning step of the nursing process to prioritize client care delivery - Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management.

A nurse in the emergency department (ED) is caring for a client. Nurses' notes: 1100: Client arrives to ED and reports nausea, vomiting, and diarrhea for 3 days. Client is febrile. 1110: Provider at bedside; prescriptions received. 1115:IV initiated to right arm with 20-gauge catheter. Acetaminophen and metoclopramide administered. 1200: Client appears fatigued, with no energy. Hair is thin and sparse. Cachectic, with flaccid muscle tone. Oriented x 3, able to move all extremities. Tachycardia, edema to lower extremities. Respirations unlabored, chest clear. Bowel sounds x 4 hyperactive, abdomen distended. Reports no difficulty with urination. Skin dry and scaly with bruises on extremities. Medication Administration Record: 1115: Acetaminophen 650 mg rectal every 6 hr PRN temperature greater than 38.3° C (101° F)Metoclopramide 10 mg IV every 6 hr PRN nausea/vomiting Vital Signs: 1100: Temperature 39.2° C (102.6° F)Pulse rate 118/minRespiratory rate 18/minBlood pressure 92/68 mm HgOxygen saturation 95%Weight 44.9 kg (99 lb)BMI 17 Click to highlight the findings that indicate the client is malnourished. To deselect a finding, click on the finding again. 1. Cachectic, with flaccid muscle tone. 2. Skin dry and scaly with bruises on extremities. 3. Oriented x 3, able to move all extremities. 4. Pulse rate 118/min 5. Respiratory rate 18/min 6. Abdomen distended Temperature 39.2° C (102.6° F) 7. BMI 17

1. Cachectic, with flaccid muscle tone. 2. Skin dry and scaly with bruises on extremities. 4. Pulse rate 118/min 6. Abdomen distended 7. BMI 17

A nurse in the emergency department (ED) is caring for a client who reports abdominal pain Nurses' notes: 1200: Client arrives to ED and reports abdominal pain and no bowel movement for the past 7 days. Client is undergoing chemotherapy for pancreatic cancer and has been taking 40 mg oxycodone extended-release tablets daily for the past 3 months. Client states they have attempted to relieve constipation for the last 7 days with bisacodyl suppositories and magnesium citrate oral suspension. Client reports that neither therapy initiated defecation. 1230:Client transported for abdominal x-ray. 1245:Client returned from x-ray. Provider prescribes a hypertonic cleansing enema. 1300:Procedure explained to client who verbalized understanding. Based on the client's clinical findings, which of the following actions should the nurse take? 1. Assist the client to a left side-lying position with the right knee flexed. 2. Prepare the client for a chest x-ray. 3. Administer a cleansing enema. 4.Auscultate the client's bowel sounds. 5. Perform a manual digital examination of the client's rectum. 6. Administer oxycodone extended-release tablets. 7. Prepare the client for NG tube placement. Diagnostic Results: 1245: Abdominal x-ray indicates a large amount of fecal material throughout the colon. No evidence of gastrointestinal obstruction observed. Based on the client's clinical findings, which of the following actions should the nurse take? 1. Assist the client to a left side-lying position with the right knee flexed. 2. Prepare the client for a chest x-ray. 3. Administer a cleansing enema. 4. Auscultate the client's bowel sounds. 5. Perform a manual digital examination of the client's rectum. 6. Administer oxycodone extended-release tablets. 7. Prepare the client for NG tube placement.

1. Assist the client to a left side-lying position with the right knee flexed. 3. Administer a cleansing enema. 4. Auscultate the client's bowel sounds. 5. Perform a manual digital examination of the client's rectum.

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? 1. During the admission process 2. As soon as the client's condition is stable 3. During the initial team conference 4. After consulting with the client's family

1. During the admission process - Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility.

A nurse is preparing to administer 0.5 ml of oral single dose liquid medication to a client. Which of the following actions should the nurse take? 1. Gently shake the container of medication prior to administration. 2. Transfer the medication to a medicine cup. 3. Place the client in a semi-Fowler's position prior to medication administration. 4. Verify the dosage by measuring the liquid before administering it.

1. Gently shake the container of medication prior to administration. *do not transfer if it is originated like that

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, the nurse hears the following sound. 1. Narrowed arterial lumen 2. Distended jugular veins 3. Impaired ventricular contraction 4. Asynchronous closure of the aortic and pulmonic valves

1. Narrowed arterial lumen - blowing sounds resulting from blood flowing through occluded or narrowed arteries are known as a bruit.

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? 1. "I can place an extension cord across my living room to plug in my television." 2. "I will hire someone to trim the tree that hangs low over the stairs of my front porch." 3. "I will place my alarm clock on my bedroom dresser across the room." 4. "I will replace the old throw rug in my kitchen with a new one."

2. "I will hire someone to trim the tree that hangs low over the stairs of my front porch."

A nurse is caring for a client who is postoperative and refused to use an incentive spirometer following major abdominal surgery. which of the following actions is the nurse's priority? 1. Request that a respiratory therapist discuss the technique for incentive spirometry with the client. 2. Determine the reasons why the client is refusing to use the incentive spirometer. 3. Document the client's refusal to participate in health restorative activities. 4. Administer a pain medication to the client.

2. Determine the reasons why the client is refusing to use the incentive spirometer - The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action for the nurse to take is to determine why the client is refusing the treatment.

A nurse in a provider's clinic is caring for a client who has diarrhea. Vital Signs: Temperature 36.2° C (97.2° F)Pulse rate 116/minRespiratory rate 24/minBP 102/68 mm HgOxygen saturation 95%Weight 52.2 kg (115 lb) Nurse's note: 1000: Client reports diarrhea for the past 5 days with approximately 8 liquid stools a day. Woke up this morning feeling dizzy. States, "I felt like I was going to pass out." Client was seen 7 days ago for sinus infection and was prescribed amoxicillin. Weight at previous visit was 56.2 kg (124 lb). Denies bloody or black stools. 1030: Blood collected for CBC, basic metabolic profile (BMP); stool collected for C. difficile; urine collected for urinalysis. 1100: Informed client that the office will call with results of laboratory findings; prescription for loperamide provided, instructed to discontinue amoxicillin; instructed to drink electrolyte solution; teaching provided for managing diarrhea.​ Physical Examination: 1015:Oriented to person, place, and time; lethargic, reports headache Tachycardia, hypotension, thready pulse, dry mucous membranes, tenting present. Respirations slightly labored, chest clear. Bowel sounds x 4 quadrants hyperactive. Reports urine is dark, minimal amount. The nurse is providing teaching for the client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching. 1. Increase intake of high-calcium foods. 2. Eat probiotic foods, such as yogurt. 3. Avoid alcohol while experiencing diarrhea. 4. Eat raw vegetables. 5. Eat three large meals a day. 6. Avoid caffeine while experiencing diarrhea. 7. Drink hot liquids several times a day. 8. Drink carbonated beverages to replace lost fluids. 9. Follow a low-fiber diet.

2. Eat probiotic foods, such as yogurt. 3. Avoid alcohol while experiencing diarrhea. 6. Avoid caffeine while experiencing diarrhea. 9. Follow a low-fiber diet.

A nurse is taking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I am not sure I want to retire." which of the following responses should the nurse make? 1. "You would have so much more time to spend with your family." 2. "You should consider getting a part-time job or doing volunteer work." 3. "Let's talk about how the change in your job status will affect you." 4. "Why wouldn't you want to retire and relax?"

3. "Let's talk about how the change in your job status will affect you."

A nurse in a clinic is caring for middle adult who states, "the doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" which of the following responses should the nurse make? 1. "I'll get a blood sample from you and send it for a screening test." 2. "Beginning at age 60, you should have a colonoscopy." 3. "You should have a fecal occult blood test every year." 4."The recommendation is to have a sigmoidoscopy every 10 years."

3. "You should have a fecal occult blood test every year." - colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a fecal occult blood test annually.

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? 1. A lesion with uniform pigmentation 2. New appearance of petechiae 3. A mole with an asymmetrical appearance 4. The presence of a papule

3. A mole with an asymmetrical appearance - An uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part.

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? 1. Insert the needle at a 15° angle. 2. Aspirate for blood return prior to administration. 3. Administer the medication into the abdomen. 4. Massage the site following the injection.

3. Administer the medication into the abdomen - The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue.

A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include? 1. Client flow sheet 2. Acuity ratings 3. Current medications 4. Incident reports

3. Current medications - The nurse should include the client's medications in the discharge summary to ensure client safety and continuity of care. 50% - Client flow sheet - It is not necessary to include the client's flow sheet in the discharge summary. Flow sheets contain routine client data recorded by the nurse.

A nurse is administering 1L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? 1. Increase in hematocrit 2. Increase in respiratory rate 3. Decrease in heart rate 4. Decrease in capillary refill time

3. Decrease in heart rate - Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range.

A nurse is reviewing a client's mediation prescription that reads, "digoxin 0.25 by mouth everyday." which of the following components of the prescription should the nurse verify with the provider? 1. Medication name 2. Route of administration 3. Medication dose 4. Frequency of administration

3. Medication dose - In the prescription, the medication dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? 1. Neck vein distention 2. Urine specific gravity 1.010 3. Rapid heart rate 4. Blood pressure 144/82 mm Hg

3. Rapid heart rate - Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.

A nurse is taking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress? 1. Role ambiguity 2. Sick role 3. Role overload 3. Role conflict

3. Role overload - The partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage.

A nurse is caring for a client who has pancreatitis. Nurses' notes: 1000: Client states, "I am unable to eat anything without vomiting." Client reports pain in left upper quadrant of abdomen that radiates to their back. States that pain is a "7" on a 0 to 10 pain scale. Bruising noted on client's abdomen. Client is pale and diaphoretic. Provider prescribed blood work, abdominal CT, and NG tube insertion with low-intermittent decompression. IV fluids started and infusing in left peripheral IV site. Vital Signs 1000:BP 96/52 mm HgHeart rate 110/minRespirations 22/minTemperature 38.4° C (101.1° F)Oxygen saturation 92% on room air Prescriptions 1100:• CT of abdomen• NG tube to low wall suction• Serum amylase level 1. Collect data about the client's pain level. 2. Insert an NG tube for the client. 3. Transfer the client from wheelchair to bed. 4. Measure the client's intake and output. 5. Document the client's vital signs.

3. Transfer the client from wheelchair to bed. 4. Measure the client's intake and output. 5. Document the client's vital signs

A nurse is caring for a client who is postoperative following abdominal surgery. Nurses' notes: 1100: Client received from PACU; initial vital signs recorded. Client drowsy but responds to verbal stimuli. Client is oriented to person, place, and time. Client can move all extremities. Hypoactive bowel sounds. Abdominal dressing intact with drainage noted and marked. Indwelling urinary catheter in place and draining yellow urine. Infusing lactated Ringer's at 100 mL/hr to the right forearm. Client positioned for comfort, side rails raised x 2, call light in the client's reach. 1115: Provider prescriptions reviewed. 1200:Upon waking, client reports nausea and rates pain as a 6 on a scale of 0 to 10. Abdominal dressing intact, no further drainage noted. Urine output of 15 mL since 1100. Morphine 4 mg IV bolus and metoclopramide 10 mg IV bolus administered. 1230: Client reports relief from nausea, but not pain. Client rates pain as an 8 on a scale of 0 to 10. No additional urine output since 1200. Repositioned client for comfort. Medication Administration Record: Morphine 4 mg IV bolus every 4 hr PRN painMetoclopramide 10 mg IV bolus every 6 hr PRN nausea and vomiting Vital Signs 1100: Temperature 36.2° C (97.2° F)Heart rate 76/minRespirations 18/minBP 122/68 mm HgOxygen saturation 95% on room air 1200: Temperature 36.8° C (98.2° F)Heart rate 116/minRespirations 20/minBP 112/68 mm HgOxygen saturation 93% on room air Click to highlight the assessment findings below that the nurse should report to the provider. To deselect a finding, click on the finding again. 1. Neurological assessment 2. Incisional drainage 3. Urinary output 4. Reported pain level 5. Gastrointestinal assessment 6. Vital signs

3. Urinary output 4. Reported pain level 6. Vital signs

A nurse is caring for a client who has herpes zoster and ask the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies? 1. Biofeedback 2. Aloe 3. Feverfew 4. Acupuncture

4. Acupuncture - The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk of further infection.

A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? 1. Place a pillow under the client's knees. 2. Position a trochanter roll under each of the client's hips. 3. Advise the client to wear rubber-soled slippers. 4. Apply an ankle-foot orthotic device to the client's feet.

4. Apply an ankle-foot orthotic device to the client's feet. - The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress. 50% - Place a pillow under the client's knees. - The nurse should place a pillow under the client's lower legs to prevent pressure on the heels.

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions the nurse take as part of the medication reconciliation process? 1. Seal unused medications from the facility in a plastic bag. 2. Evaluate the client's ability to self-administer medications. 3. Report an identified discrepancy to The Joint Commission. 4. Compare prescriptions with medications the client received while at the facility.

4. Compare prescriptions with medications the client received while at the facility.

A charge nurse is discussing the responsibility of nurse caring for clients who have a C.Diff infection. Which of the following information should the nurse include in the teaching? 1. Assign the client to a room with a negative airflow system. 2. Use alcohol-based hand sanitizer when leaving the client's room. 3. Clean contaminated surfaces in the client's room with a phenol solution. 4. Have family members wear a gown and gloves when visiting.

4. Have family members wear a gown and gloves when visiting. 50% - 2. Use alcohol-based hand sanitizer when leaving the client's room. - The nurse should use soap and water for hand hygiene because alcohol-based hand sanitizer does not kill Clostridium difficile spores.

A nurse is planing teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? 1. Role play 2. Group discussions 3. Question-answer meetings 4. Practice sessions

4. Practice sessions - Practice sessions require psychomotor skills when learning.

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse makes? 1. "We can talk about advance directives, and I can also give you some brochures about them." 2. "You should set up a time to talk with your provider about that." 3. "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better." 4. "Why do you want to discuss this without your partner here to plan this with you?"

1. "We can talk about advance directives, and I can also give you some brochures about them." - With this statement, the nurse offers to provide the information the client needs in a direct and simple way.

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understand the teaching? 1. "When descending stairs, I will first shift my weight to my right leg." 2. "I should place my crutches 12 inches in front and to the side of each foot." 3 "As I sit down, I will hold one crutch in each hand." 4 "I will make sure the shoulder rests are snug against my armpits."

1. "When descending stairs, I will first shift my weight to my right leg." - To descend stairs, the client should first shift his body weight to his right, unaffected leg.

A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity? 1. A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. 2. A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes. 3. A client who has a do-not-resuscitate (DNR) order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family. 4. A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse previously promised to administer.

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

A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate? 1. Ambulating a client who is postoperative 2. Inserting an indwelling urinary catheter for a client 3. Demonstrating the use of an incentive spirometer to a client 4. Confirming that a client's pain has decreased after receiving an analgesic

1. Ambulating a client who is postoperative - ambulating a client is within the range of function of an AP. The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching.

A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instruction should the nurse provide to the client and his family? 1. Check the cord routinely for frays or tearing. 2. Keep the unit at least 1.2 m (4 feet) away from a gas stove. 3. Consider purchasing a generator for power backup. 4. Observe for signs of hypoxia. 5. Select synthetic clothing and bedding.

1. Check the cord routinely for frays or tearing. 3. Consider purchasing a generator for power backup. 4. Observe for signs of hypoxia.

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse takes? 1. Pad the client's wrist before applying the restraints. 2. Evaluate the client's circulation every 8 hr after application. 3. Remove the restraints every 4 hr to evaluate the client's status. 4. Secure the restraint ties to the bed's side rails.

1. Pad the client's wrist before applying the restraints - The use of restraints without padding can abrade the client's skin, resulting in client injury. 2. Evaluate the client's circulation every 8 hr after application. - The nurse should evaluate the client's circulation, range of motion, vital signs, and overall status every 15 min after initial application of restraints

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? 1. Place the client in a room with negative-pressure airflow. 2. Wear gloves when assisting the client with oral care. 3. Limit each visitor to 2-hr increments. 4. Wear a surgical mask when providing client care. 5. Use antimicrobial sanitizer for hand hygiene.

1. Place the client in a room with negative-pressure airflow. 2. Wear gloves when assisting the client with oral care. 5. Use antimicrobial sanitizer for hand hygiene.

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respiration from secretions in their airway. Which of the following actions should the nurse take? 1. Turn the client every 2 hr. 2. Administer an antiemetic every 6 hr. 3. Hold oral care. 4. Increase the room's temperature.

1. Turn the client every 2 hr - The nurse should turn the client at least once every 2 hr to break up the secretions in the client's lungs and prevent noisy respirations.

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk of injury to the client? 1. Use a bed exit alarm system. 2. Raise four side rails while the client is in bed. 3. Apply one soft wrist restraint. 4. Dim the lights in the client's room.

1. Use a bed exit alarm system.

A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide? 1. Admitting diagnosis 2. Breath sounds 3. Body temperature 4. Diagnostic test results

2. Breath sounds

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? 1. Make sure the client's room has at least six air exchanges per hour. 2. Make sure the client wears a mask when outside her room if there is construction in the area. 3. Place the client in a private room with negative-pressure airflow. 4. Wear an N95 respirator when giving the client direct care.

2. Make sure the client wears a mask when outside her room if there is construction in the area - protect patient from risk for infection from environment. 1. 12 air exchanges not 6 3. private room yes, but positive pressure airflow. 4. The nurse should wear an N95 respirator mask when caring for clients who require airborne precautions, not a protective environment.

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plane to take? 1. Use a resuscitation bag with 80% oxygen prior to the procedure. 2. Select a suction catheter that is half the size of the lumen. 3. Place the end of the suction catheter in water-soluble lubricant. 4. Adjust the wall suction apparatus to a pressure of 170 mm Hg.

2. Select a suction catheter that is half the size of the lumen - The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? 1. Critical pathway 2. Situation, background, assessment, and recommendation (SBAR) 3. Transfer report 4. Medication administration record (MAR)

2. Situation, background, assessment, and recommendation (SBAR)

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? 1. Ensure sterilization of nondisposable items with ethylene oxide. 2. Wrap monitoring cords with stockinette and tape them in place. 3. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication. 4. Wear hypoallergenic latex gloves that contain powder.

2. Wrap monitoring cords with stockinette and tape them in place.

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? 1. "Drink a cup of hot cocoa before bedtime." 2."Maintain a consistent time to wake up each day." 3. "Exercise 1 hour before going to bed." 4. "Watch a television program in bed before going to sleep."

2."Maintain a consistent time to wake up each day."

A client who is non ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? 1. Activate the emergency fire alarm. 2. Extinguish the fire. 3. Evacuate the client. 4. Confine the fire.

3. Evacuate the client - According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area.

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV sites should the nurse identify as indicating infiltration? 1. Purulent exudate 2. Warmth 3. Skin blanching 4. Bleeding

3. Skin blanching - Skin blanching, edema, and coolness at the IV site indicate infiltration.

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? 1. The top of the cane is parallel to the client's waist. 2. When walking, the client moves the cane 46 cm (18 in) forward. 3. The client holds the cane on the stronger side of her body. 4. The client moves her stronger limb forward with the cane.

3. The client holds the cane on the stronger side of her body. 1. The top of the cane should be parallel to the client's greater trochanter. 2. To maintain balance, the client should advance the cane about 15 to 30 cm (6 to 12 in) at a time. 4. The client should move her weaker leg forward with the cane.

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next? 1. Document the provider's statement in the medical record. 2. Complete an incident report. 3. Consult the facility's risk manager. 4. Notify the nursing manager.

4. Notify the nursing manager

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? 1. BUN 15 mg/dL 2. Creatinine 0.8 mg/dL 3. Sodium 143 mEq/L 4. Potassium 5.4 mEq/L

4. Potassium 5.4 mEq/L

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? 1. Bend at the waist. 2. Keep his feet close together. 3. Use his back muscles for lifting. 4. Stand close to the cabinet when lifting it.

4. Stand close to the cabinet when lifting it.

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use? 1. "I can take echinacea to improve my immune system." 2. "I can take feverfew to reduce my level of anxiety." 3. "I can take ginger to improve my memory." 4."I can take ginkgo biloba to relieve nausea."

1. "I can take echinacea to improve my immune system." - Echinacea is taken to promote immunity and reduce the risk of infection.

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? 1. "What could I have done to deserve this illness?" 2. "I blame medical science for not curing me." 3. "Where is my daughter at a time like this?" 4. "Will I ever begin to feel in charge of my life again?"

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

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 ml of the medication form a 2 ml vial. Which of the follwing action should the nurse take? 1. Ask another nurse to observe the medication wastage. 2. Notify the pharmacy when wasting the medication. 3. Lock the remaining medication in the controlled substances cabinet. 4. Dispose of the vial with the remaining medication in a sharps container.

1. Ask another nurse to observe the medication wastage - A second nurse must witness the disposal of any portion of a dose of a controlled substance.

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority? 1. Auscultation lung sounds. 2. Measure urine output. 3. Monitor blood pressure readings. 4. Monitor electrolyte levels.

1. Auscultation lung sounds. 50% - 3. Monitor blood pressure readings. - The nurse should monitor blood pressure readings to evaluate the hemodynamic stability of a client who is receiving IV fluids; however, it is not the priority assessment.

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess? 1. Hypotension 2. Weak, thready pulse 3. Slow capillary refill 4. Distended neck veins

4. Distended neck veins - indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.

A nurse in a medical-surgical unit is caring for six clients. Nurses' notes: 0800: Client 1: Client is admitted with a new diagnosis of rheumatoid arthritis. Client 2: Client has a history of hyperlipidemia. Atorvastatin 20 mg PO administered as prescribed. Client 3: Client is 1 day postoperative. Reports pain as 8 on a scale of 0 to 10. Morphine 5 mg subcutaneous administered as prescribed. Client 4: Client is admitted with a new diagnosis of heart failure. Client 5: Client has a stage 2 pressure injury on the left heel. Client 6: Client is admitted with a new diagnosis of diabetes mellitus. Complete the following sentence by using the lists of options. The first client the nurse should assess is Select... followed by Select...

The first client the nurse should assess is "client 3" followed by "client 4"

A nurse is admitting a client who reports experiencing a sore throat, productive cough, and fever for the past 3 days. Nurses' notes: 1000: Client reports sore throat, productive cough with yellow-colored mucus, and fever for the past 3 days. Client has swollen lymph nodes. Client also reports headache that, "won't go away." Client's face is flushed and diaphoretic. Throat culture and blood work obtained as prescribed. Vital Signs: 1000: Blood pressure 132/68 mm HgHeart rate 99/minRespiratory rate 20/minTemperature 38.3° C (101° F)Oxygen saturation 96% on room air Diagnostic Results: 1100: Positive throat culture for streptococci bacteria. The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? 1. Request a prescription for an antibiotic medication. 2. Apply oxygen at 2 L/min via nasal cannula. 3. Initiate droplet precautions. 4. Wear a mask within 1 m (3 feet) of the client. 5. Place the client in a negative airflow room. 6. Apply a mask on the client when they leave their room.

1. Request a prescription for an antibiotic medication. 3. Initiate droplet precautions. 4. Wear a mask within 1 m (3 feet) of the client. 6. Apply a mask on the client when they leave their room.

A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. Nurses' notes: Day 1:Lactated Ringer's at 100 mL/hr infusing into a 20-guage IV catheter in left hand. IV dressing dry and intact. IV site without redness or swelling. IV fluid infusing well. Day 2:IV site edematous. Skin surrounding catheter site taut, blanched, and cool to touch. IV fluid not infusing.​​ The nurse is assessing the client. Which of the following actions should the nurse take? 1. Stop the IV infusion. 2. Elevate the client's left arm. 3. Apply heat to the client's left hand. 4. Place a pressure dressing over the IV site. 5. Start a new IV in the client's left hand.

1. Stop the IV infusion. 2. Elevate the client's left arm. 3. Apply heat to the client's left hand.

A nurse is caring for a client who has a pressure injury. Nurses' notes: Day 1: Client is alert and oriented to person, place, and time. Client has stage 2 pressure injury on coccyx. Wound tissue is pink with no drainage. Lungs clear on auscultation. Heart sounds are regular. +2 peripheral pulses and no presence of edema in lower extremities. Bowel sounds active x 4 quadrants. Client ate 50% of breakfast. Client reports pain to pressure injury as 2 on a scale of 0 to 10. Client repositioned every 2 hr while in bed. Day 4:Client has stage 2 pressure injury on coccyx. Wound tissue is yellow with purulent drainage. Wound has foul odor. Client ate 75% of breakfast. Client reports pain to pressure injury as 6 on a scale of 0 to 10. Client repositioned every 2 hr while in bed. Vital Signs: Day 4:Temperature 38.3° C (101° F)Pulse rate 80/minRespiratory rate 20/minBlood pressure 128/64 mm HgOxygen saturation 93% on room air Diagnostic Results: Day 4:Potassium 4.2 mEq/L (3.5 to 5 mEq/L)Hgb 13 g/dL (12 to 16 g/dL)Hct 38% (37% to 47%)WBC count 12,000/mm3 (5,000 to 10,000/mm3)Prealbumin12 mg/dL (15 to 36 mg/dL) Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again. 1. Temperature 2. WBC count 3. Prealbumin level 4. Hemoglobin level 5. Blood pressure 6. Pain level 7. Odor of wound 8. Bowel sounds

1. Temperature 2. WBC count 3. Prealbumin level 6. Pain level 7. Odor of wound

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? 1. Administer the medication with the needle at a 45° angle. 2. Administer the medication into the client's nondominant arm. 3. Pull the client's skin laterally or downward prior to administration. 4. Massage the injection site after administration.

1. The nurse should insert the needle at a 45° to 90° angle for a subcutaneous injection. 2. AThe nurse should administer enoxaparin into the abdomen, at least 5 cm (2 in) from the umbilicus. 3. The Z-track technique involves displacing the skin laterally or downward prior to administration of an IM injection. 4. The nurse should not massage the injection site following the injection of an anticoagulant due to the risk for bruising.

A nurse is admitting a client to a health care facility. Nurses' notes: 1100: Client reports fever, chills, cough, and night sweats for past 2 weeks. Client has recently traveled outside of the country. Lethargic, but oriented to person, place, and time. Crackles heard in lower lobes of lungs upon auscultation. Cough is productive with small amounts of blood. Reports tightness in chest and pain when coughing. Reports losing 5 lb in the last week. Has no appetite and is nauseated. Obtained blood work, chest x-ray, and sputum culture as prescribed. Vital Signs: 1100:BP 138/72 mm HgHeart rate 80/minRespirations 22/minTemperature 38.3° C (101.1° F)Oxygen saturation 90% on room air Diagnostic Results: 1400:Chest x-ray positive for inflammation and infiltrates in upper lobesQuantiFERON-TB positive (negative)Tuberculosis culture positive (negative) The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? 1. Wear an N95 mask when caring for the client. 2. Place a container for soiled linens inside the client's room. 3. Place the client in a negative airflow room. 4. Remove mask after exiting the client's room. 5. Wear a sterile, water-resistant gown if within 3 feet of the client.

1. Wear an N95 mask when caring for the client. 2. Place a container for soiled linens inside the client's room. 3. Place the client in a negative airflow room. 4. Remove mask after exiting the client's room.

A nurse is preparing to administer 0.9% sodium chloride 750 ml IV to infuse over 7 hour. The nurse should set the infusion pump to deliver how many mL/hr?

107 ml/hr

A nurse is caring for a client who had a spinal cord injury and has paraplegia. Nurses' Notes Day 1: Client is alert and oriented.Client is repositioned every 2 hr.Passive range-of-motion exercises to lower extremities performed once each day. Day 5: Client is alert and oriented.Client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities performed once each day.Feet warm. Pedal pulses 2+ bilaterally.Plantar flexion contractures noted bilaterally.Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact. The nurse is reviewing the client's medical record. Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding again. 1. Client is repositioned every 2 hr. 2. Passive range-of-motion exercises to lower extremities performed once each day. 3. Feet warm. Pedal pulses 2+ bilaterally. 4. Plantar flexion contractures noted bilaterally. 5. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact.

2. Passive range-of-motion exercises to lower extremities performed once each day. 4. Plantar flexion contractures noted bilaterally. 5. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact.

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse to identify the client's safety needs? (Select all that apply) 1. Lacrimal apparatus 2. Pupil clarity 3. Appearance of bulbar conjunctivae 4. Visual fields 5. Visual acuity

2. Pupil clarity 4. Visual fields (finger test) 5. Visual acuity (Snellen chart) 1. Lacrimal apparatus - If clients have an impairment in the ability to produce tears, it should not affect their fall risk. 3. Appearance of bulbar conjunctivae

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the clients would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? 1. I will return shortly after I document this in your record." 2. "Most men live a long time with prostate cancer." 3. "I am available to talk if you should change your mind." 4. "I will make a referral to a cancer support group for you."

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

A nurse in a provider's clinic is caring for a client who has heart failure. Nurses' notes: First Clinic Visit: Client arrives to clinic with report of increasing shortness of breath, fatigue, and weakness. States they get short of breath with minimal activity. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus tachycardia. Pulses to lower extremities weak with +2 dependent edema present. Slightly labored respirations at rest. Chest with wheezes and crackles in the bases. Reports productive cough, especially during the overnight hours. Bowel sounds all present. Abdomen distended. Reports bowel movement this a.m. States voiding without difficulty, clear yellow urine. Teaching provided on nutrition therapy and adhering to a low-sodium diet, monitoring fluid intake, and lifestyle changes for heart failure. Provided medication teaching following provider's increase in furosemide dosage from 20 mg to 40 mg daily. Client to return in 2 weeks for follow-up. Second Clinic Visit: Client arrives for follow-up visit 2 weeks later. Client is alert and oriented to person, place, and time. Moves all extremities well, follows simple commands. Sinus rhythm. Pulses to lower extremities weak. +1 dependent edema present. Respirations even. Chest clear. Reports less coughing. Bowel sounds all present. Abdomen slightly distended. Reports last bowel movement previous evening. States voiding without difficulty, clear yellow urine. States urination has increased with increased dose of furosemide. Vital Signs: First Clinic Visit: Temperature 36.7° C (98° F)Heart rate 106/minRespirations 26/minBP 162/88 mm HgOxygen saturation 93% on room airWeight 83.9 kg (185 lb) Second Clinic Visit: Temperature 36.7° C (98° F)Heart rate 86/minRespirations 22/minBP 142/78 mm HgOxygen saturation 94% on room airWeight 81.6 kg (180 lb) A nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching? 1. "I have been weighing myself every other morning." 2. "I am trying to decrease my intake of foods with potassium." 3. "I am limiting my sodium intake to 2 grams daily." 4."I am eating fewer potato chips and more fruit for snacks." 5. "I lie down and rest after meals." 6. "I know to call my doctor if I gain 3 pounds or more in 2 days."

3. "I am limiting my sodium intake to 2 grams daily." 4."I am eating fewer potato chips and more fruit for snacks." 6. "I know to call my doctor if I gain 3 pounds or more in 2 days."

A nurse is caring for a client who requires a 24 hour urine collection. Which of the following statements by the client indicates an understanding of the teaching? 1. "I had a bowel movement, but I was able to save the urine." 2. "I have a specimen in the bathroom from about 30 minutes ago." 3. "I flushed what I urinated at 7:00 a.m. and have saved all urine since." 4. "I drink a lot, so I will fill up the bottle and complete the test quickly."

3. "I flushed what I urinated at 7:00 a.m. and have saved all urine since." - For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings.

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? 1. "I think I should take my pain medication more often, since it is not controlling my pain." 2. "Breathing faster will help me keep my mind off of the pain." 3. "It might help me to listen to music while I'm lying in bed." 4. "I don't want to walk today because I have some pain."

3. "It might help me to listen to music while I'm lying in bed."

A nurse is caring for a client: Medical History: Client is receiving chemotherapy for treatment of breast cancer. Diagnostic Results: Week 1: Hct 42% (37% to 47%)Hgb 15 g/dL (12 g/dL to 16 g/dL)WBC count 8,000/mm3 (5,000 to 10,000/mm3)Platelet count 350,000/mm3 (150,000 to 400,000/mm3)Potassium 3.7 mEq/L (3.5 to 5 mEq/L) Week 2: Hct 37% (37% to 47%)Hgb 12 g/dL (12 g/dL to 16 g/dL)WBC count 6,000/mm3 (5,000 to 10,000/mm3)Platelet count 100,000/mm3 (150,000 to 400,000/mm3)Potassium 3.6 mEq/L (3.5 to 5 mEq/L) Complete the following sentence by using the lists of options. The client is at risk for infection (______) as evidenced by the client's (______)

The client is at risk for infection "bleeding" as evidenced by the client's "platelet"