ATI Fundamentals

A nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student should the nurse identify as a potential problem with achieving Erikson's developmental task for this age group? A. "I am in no hurry to get married. I think I'll enjoy single life for a while." B. "I go home on the weekends to be with my family because I do not have any good friends here on campus." C. "I am interested in politics and may consider becoming an elected official." D. "I am looking forward to finishing school and going to work for my family's business."

"I go home on the weekends to be with my family because I do not have any good friends here on campus."

A client is scheduled for a lumbar puncture to rule out bacterial meningitis. She tells the nurse that she is fearful of becoming paralyzed from the needle placement in her spinal column. Which of the following responses should the nurse offer? A. "Let's not focus on the negative. Let's focus on getting better." B. "Why are you feeling so anxious about this procedure?" C. "The needle is inserted below the third lumbar vertebrae, which is well below the point at which the spinal cord ends." D. "Your doctor is very skilled at this procedure. Everything will be all right."

"The needle is inserted below the third lumbar vertebrae, which is well below the point at which the spinal cord ends."

A nurse is caring for a client who is receiving dextrose 5% in water IV at 150 mL/hr and has ingested 4 oz of water and ½ pint of milk. What is the total 8-hr fluid intake in milliliters that the nurse should document for this client? (Round the answer to the nearest whole number and fill in the blank with the numeric value only.)

1560

A nurse is preparing to administer sotalol to a client with a prescription for 320 mg/day divided equally every 12 hr. The medication is available in 80 mg tablets. How many tablets should the nurse administer per dose? (Fill in the blank with the numeric value only, round the answer to the nearest tenth, and use a leading zero if applicable. Do not use a trailing zero.)

2

A nurse is teaching the parent of a child who is to take 10 mL of a liquid medication. The parent has a hollow medication spoon with marks to indicate teaspoons and tablespoons. How many teaspoons should the nurse instruct the parent to give the child? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

2

A nurse is calculating a client's intake for a 12-hr shift. The client had dextrose 5% in 0.45% sodium chloride infusing at 125 mL/hr, gentamicin 150 mg in 100 mL at 1400, famotidine 20 mg in 50 mL at 1000 and 1600, 250 mL of blood over 2 hr, and a nasogastric flush of 30 mL every 2 hr. What is the total intake in milliliters that the nurse should document for this client for this 12-hr period? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2130

A nurse is preparing to administer 700 mL of 0.9% sodium chloride IV to a child to infuse over 24 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

29

A nurse is calculating the protein needs of a young adult client who weighs 132 lb. The RDA for protein for an adult who has no medical conditions is 0.8 g/kg. How many grams of protein per day should the nurse recommend for this client? (Fill in the blank with the numeric value only.)

48

A nurse is caring for a client whose intake and output flow sheet for 0700 to 1500 indicates the following: voided x3: 350 mL, 200 mL, 150 mL; wound drainage 2 tsp; and emesis 2 oz. What total output in milliliters should the nurse document for this 8 hr period? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.) Fill in the blank

770

A nurse in the emergency department is assessing a client who has pancreatitis. In which of the following laboratory results should the nurse expect to see an elevation? A. Amylase B. Potassium C. Calcium D. Hematocrit

A. Amylase

A nurse is planning care for a client who is receiving chemotherapy and has a protein deficiency. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Mix powdered skim milk into liquid milk B. Add a raw egg to fruit smoothies C. Add a slice of cheese to hot vegetables D. Add honey to hot tea E. Mix yogurt into fresh fruit

A. Mix powdered skim milk into liquid milk C. Add a slice of cheese to hot vegetables E. Mix yogurt into fresh fruit

A nurse is caring for a client who is undergoing a diagnostic evaluation following an episode of chest pain. The client tells the nurse, "I am not sick, and I want to go home!" Which of the following responses should the nurse make? A. "Am I correct in understanding that you feel well?" B. "People aren't admitted to hospitals unless they are sick." C. "Why do you feel that way?" D. "If you're fine, then why is your heart beating irregularly?"

A. "Am I correct in understanding that you feel well?"

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus? A. "Bear down." B. "Perform Kegel exercises." C. "Hold your breath." D. "Raise your head off of the pillow."

A. "Bear down."

A nurse is talking with a client who states, "The nurses around here are incompetent." Which of the following responses should the nurse make? A. "Could you tell me about a specific example of a nurse being incompetent?" B. "Let's talk about the progress you have made today and not about the nurses." C. "The nurses and doctors at this facility are highly experienced and do an excellent job." D. "I am doing the best I can to take care of these very ill clients."

A. "Could you tell me about a specific example of a nurse being incompetent?"

A nurse is providing teaching for a client who has a prescription for a low-sodium diet to manage hypertension. Which of the following statements by the client indicates an understanding of the teaching? A. "I can snack on fresh fruit." B. "I can continue to eat lunchmeat sandwiches." C. "I can have cottage cheese with my meals." D. "Canned soup is a good lunch option."

A. "I can snack on fresh fruit."

A nurse is providing teaching for a client who has a prescription for a low-sodium diet to manage hypertension. Which of the following statements by the client indicates an understanding of the teaching? A."I can snack on fresh fruit." B."I can continue to eat lunchmeat sandwiches." C."I can have cottage cheese with my meals." D."Canned soup is a good lunch option."

A. "I can snack on fresh fruit."

A nurse is teaching a client with heart disease about a low-cholesterol diet. Which of the following client statements indicates the teaching was effective? A. "I should remove the skin from poultry before eating it." B. "I will eat seafood once per week." C. "I should use margarine when preparing meals." D. "I can use whole milk in my oatmeal."

A. "I should remove the skin from poultry before eating it."

A nurse is teaching a client who has a cast on his left arm to treat a forearm fracture. Which of the following statements indicates that the client understands the teaching? A."I'll call the doctor's office if my fingers get colder on the arm with the cast." B."If I have any itching under the cast, I'll try to reach the area with a cotton swab." C."If my fingers swell, I should put a heating pad on them and rest." D."If I have any tingling under my cast, I'll know I need to move my fingers more."

A. "I'll call the doctor's office if my fingers get colder on the arm with the cast."

A nurse is caring for an older adult client who dies during the night while his partner is at his side. The next morning, the partner says, "I can't believe he's gone." Which of the following responses should the nurse make? A. "It must be hard to accept that this has happened." B. "His suffering is over now, and he is in a better place." C. "Would you like to take his personal items home with you?" D. "He lived a long and full life."

A. "It must be hard to accept that this has happened."

A nurse is caring for a client who has type 1 diabetes mellitus and is scheduled to receive hemodialysis. The client says, "I don't even know why I'm doing this. There is no cure." Which of the following statements should the nurse make? A. "It sounds as though you have given up." B. "Dialysis will help you live longer." C. "You shouldn't complain. You are fortunate to have this option available to you." D. "Let's talk about what you are going to do after dialysis today."

A. "It sounds as though you have given up."

An emergency department nurse takes a telephone call from a client who states, "I have just taken 100 amitriptyline tablets to kill myself." The client is crying and says, "I want to die. I have no reason to live." Which of the following responses should the nurse make? A. "Please stay on the phone with me so we can talk about your feelings." B. "Why do you think you have no reason to live?" C. "How do you feel about what you have just done?" D. "I'm sure things are not as bad as they seem to you right now."

A. "Please stay on the phone with me so we can talk about your feelings."

A middle-aged adult client is discussing future plans with the nurse. Which of the following statements should the nurse identify as an indication that the client is having difficulty achieving Erikson's developmental task for this age group? A. "We miss our daughter so much that we are going to move closer to her." B. "I think this year I can plan on managing the funding at church." C. "I really wish I could lose some of this weight." D. "I find I am spending more time at work now that my son is at college."

A. "We miss our daughter so much that we are going to move closer to her."

A nurse is caring for a client following a myocardial infarction. The client tells the nurse that she doubts her ability to remain on a low-cholesterol diet. Which of the following responses should the nurse make? A. "What about the low-cholesterol diet concerns you?" B. "If you don't follow the diet, you will probably have another heart attack." C. "I've been on this diet for the last 5 years. You will learn to change your eating habits after a while." D. "I will have the dietitian talk to you to provide some guidance."

A. "What about the low-cholesterol diet concerns you?"

A nurse is teaching a client who has human immunodeficiency virus (HIV) about the early manifestations of acquired immune deficiency syndrome (AIDS). Which of the following statements should the nurse include in the teaching? A."You can expect a persistent fever and swollen glands." B."You can expect an elevated white blood cell count." C."You can expect increased blood pressure and edema." D."You can expect weight gain."

A. "You can expect a persistent fever and swollen glands."

A nurse is providing dietary teaching for a client with AIDS who has stomatitis of the mouth. Which of the following instructions should the nurse include in the teaching? A. "You can suck on popsicles to numb your mouth." B. "Season food with spices instead of salt." C. "Avoid the use of a straw to drink liquids." D. "Eat foods at hot temperatures."

A. "You can suck on popsicles to numb your mouth."

After assessing a client, the nurse documents "1+ pedal edema bilaterally." This indicates that the nurse observed an indentation of which of the following depths after applying pressure? A. 2 mm B. 4 mm C. 6 mm D. 8 mm

A. 2 mm

A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask B. A client who has emphysema and is receiving oxygen at 3L/min via transtracheal oxygen cannula C. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar D. A client who has COPD and is receiving oxygen at 2 L/min via nasal cannula

A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask

A nurse is caring for a client who is well-hydrated and has no visible evidence of nutritional deficiencies. A laboratory result within the expected reference range for which of the following substances indicates adequate protein uptake and synthesis? A. Albumin B. Calcium C. Sodium D. Potassium

A. Albumin

A nurse on a medical-surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client's record first? A. Assessment B. Plan of care C. Nursing interventions performed D. Evaluation of progress

A. Assessment

A nurse is beginning a therapeutic relationship with a client. Which of the following actions should the nurse take to convey empathy when using the therapeutic communication technique of active listening? A. Assume an open position B. Sit upright and lean back into the chair C. Avoid direct eye contact until the client initiates it D. Sit next to the client

A. Assume an open position

A nurse is planning weight-loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients' commitment to a long-term goal of weight loss? A. Attempt to increase the clients' self-motivation B. Keep detailed records of each client's progress C. Test client learning after each teaching session D. Avoid discussing topics that might increase clients' anxiety

A. Attempt to increase the clients' self-motivation

A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse use next when assessing the client's abdomen? A. Auscultation B. Light palpation C. Percussion D. Deep palpation

A. Auscultation

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen? A. Collect the specimen when the client rises in the morning B. Force fluids during the day and collect the specimen in the evening C. Collect the specimen after antibiotics have been started D. Collect 2 mL of sputum before sending the specimen to the laboratory

A. Collect the specimen when the client rises in the morning

A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to him. Which of the following actions should the nurse take? A. Consult the medication reference book available on the unit B. Ask a more experienced nurse for information about the medication C. Call the client's provider and verify the prescription D. Ask the client if she takes this medication at home

A. Consult the medication reference book available on the unit

A nurse is teaching the parent of a school-age child who has celiac disease. Which of the following foods selected by the parent indicates an understanding of the teaching? A. Corn tortilla with black beans B. Pizza C. Canned soup D. Hot dogs

A. Corn tortilla with black beans

A nurse is planning care for a client who has acute systemic lupus erythematosus (SLE) and is scheduled to begin treatment for systemic manifestations. Which of the following types of medications should the nurse plan to administer? A.Corticosteroids B.Antimalarials C.Antidepressants D.Opioids

A. Corticosteroids

A nurse is reviewing the laboratory findings of a client who has protein-calorie malnutrition. Which of the following findings should the nurse expect? A. Decreased albumin B. Elevated hemoglobin C. Elevated lymphocytes D. Decreased cortisol

A. Decreased albumin

A nurse is reviewing the laboratory values of a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? A. Decreased calcium B. Decreased potassium C. Increased potassium D. Increased calcium

A. Decreased calcium

A nurse is teaching a middle-aged adult client about health promotion and disease prevention. The nurse should inform the client that which of the following changes could occur? A.Decreased estrogen and testosterone production B.Increased tone of the large intestines C.Increased percentage of the body's muscle mass D.Decreased incidence of chronic illnesses

A. Decreased estrogen and testosterone production

A nurse is admitting a client who is experiencing an exacerbation of heart failure. At which of the following times should the nurse initiate discharge planning? A. During the admission process B. As soon as the client's condition is stable C. During the initial team conference D. On the day prior to discharge

A. During the admission process

A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger-stick blood sample. Which of the following actions by the AP requires the nurse to intervene? A. Elevating the finger above heart level B. Rubbing the fingertip with an alcohol pad C. Puncturing the side of the fingertip D. Wrapping the finger in a warm cloth

A. Elevating the finger above heart level

A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief? A. Encourage the client to listen to soft music B. Instruct the client to practice tai chi C. Place a jasmine-scented air freshener in the client's room D. Offer the client ginger tea

A. Encourage the client to listen to soft music

A nurse is developing a therapeutic relationship with a client who reports depression. Which of the following activities should the nurse initiate during the orientation phase of the therapeutic relationship? A. Encouraging the client to state the problems she is having B. Talking about alternative behavioral approaches the client could try C. Identifying assumptions that keep the client from reaching her potential D. Planning the incorporation of new strategies into the client's daily life

A. Encouraging the client to state the problems she is having

A nurse is reviewing the laboratory results of a client who has end-stage renal disease and reports fatigue. The client's hemoglobin level is 8 g/dL. The nurse should expect a prescription for which of the following medications? A. Erythropoietin B. Erythromycin C. Filgrastim D. Calcitriol

A. Erythropoietin

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? A. Evaluate pedal pulses B. Obtain a medical history C. Measure vital signs D. Assess for leg pain

A. Evaluate pedal pulses

A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first? A. Gloves B. Gown C. Eyewear D. Mask

A. Gloves

As a nurse is preparing to administer liquid medication from a bottle to a client. Which of the following actions should the nurse take? A. Hold the medication bottle with the label against the palm of the hand when pouring B. Place the cap with the inside facing down on a hard surface C. Fill the cup until the medication is even with the edge of the dosage scale D. Pour any excess liquid back into the bottle after measuring

A. Hold the medication bottle with the label against the palm of the hand when pouring

A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur? A. Hyperglycemia B. Hypotension C. Heightened immune response D. Bleeding tendencies

A. Hyperglycemia

A nurse is teaching a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group? A. Independent moral development B. Acceptance of body changes C. Strengthening ties with the family of origin D. Development of concrete reasoning

A. Independent moral development

A nurse is providing nutritional counseling for a client who is pregnant. Which of the following nutrients should the nurse instruct the client to increase in her daily diet? A. Iron B. Calcium C. Vitamin E D. Vitamin K

A. Iron

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse perform to transfer the client from the stretcher to the bed? A. Lock the wheels on the bed and stretcher. B. Instruct the client to raise his arms above his head. C. Elevate the stretcher 2.5 cm (1 in) above the height of the bed. D. Log-roll the client.

A. Lock the wheels on the bed and stretcher.

A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift in which the client received atenolol instead of allopurinol. Which of the following interventions is the nurse's priority? A. Measure the client's apical pulse B. Administer the allopurinol to the client C. Inform the nurse manager D. Complete an incident report

A. Measure the client's apical pulse

A nurse is caring for a client who has a dysrhythmia. Which of the following techniques should the nurse to use to assess for a pulse deficit? A. Obtain the apical and radial rates simultaneously B. Check the blood pressure in the left and right arms C. Compare the pulse strength in the upper extremities D. Palpate the pulses in the lower extremities

A. Obtain the apical and radial rates simultaneously

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? A. Place the client in a lateral position with the head turned to the side before beginning the procedure B. Use the thumb and index finger to keep the client's mouth open C. Rinse the client's mouth with an alcohol-based mouthwash following the procedure D. Cleanse the client's mucous membranes with lemon-glycerin sponges

A. Place the client in a lateral position with the head turned to the side before beginning the procedure

A nurse is caring for an older adult client who has dementia, gets up frequently to pace during meals, and eats sparingly. Which of the following actions should the nurse take? A. Provide finger foods for the client B. Offer food at fewer times each day to promote hunger C. Administer a benzodiazepine medication to the client before meals D. Assist the client to sit still during meals using soft restraints

A. Provide finger foods for the client

A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances? A. Respiratory alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Metabolic alkalosis

A. Respiratory alkalosis

A nurse is preparing to administer a unit of packed RBCs to a client when she discovers that the IV line is no longer patent. The IV team informs her that someone can come to initiate a new line in 30 min. Which of the following actions should the nurse take? A. Return the blood to the laboratory B. Place the blood in the medication room C. Place the blood in the refrigerator D. Leave the blood at the client's bedside

A. Return the blood to the laboratory

A nurse is assessing a client's incision and observes the drainage to be blood-tinged. Which of the following terms should the nurse use to document this finding? A. Sanguineous B. Purulent C. Serous D. Hyperemia

A. Sanguineous

A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? A. Sit at the bedside while feeding the client B. Order pureed foods C. Make sure feedings are provided at room temperature D. Offer the client a drink of fluid after every bite

A. Sit at the bedside while feeding the client

A nurse in a pediatric clinic is talking with the parent of a toddler who states that her child will not sit at the table to eat with the family. She asks the nurse for recommendations for "finger foods" for her child. Which of the following foods should the nurse suggest? A. Slices of ripe banana B. Popcorn C. Slices of hot dogs D. Raw carrots

A. Slices of ripe banana

A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion? A. Sodium 123 mEq/L B. Blood glucose 100 mg/dL C. Potassium 3.5 mEq/L D. Hemoglobin 13 g/dL

A. Sodium 123 mEq/L

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first? A. Start chest compressions B. Provide breaths with a manual resuscitation bag C. Administer oxygen D. Establish an airway

A. Start chest compressions

A nurse is preparing to administer a medication to a client. Which of the following administration schedules should the nurse identify as a prescription to administer the medication once and as soon as possible? A. Stat prescription B. PRN prescription C. Standing prescription D. Single prescription

A. Stat prescription

A nurse is teaching range-of-motion exercises to a client who has osteoarthritis. Which of the following client positions demonstrates an understanding of supination of the hand? A. The client holds the hand with the palm up. B. The client holds the hand with the palm down. C. The client points the fingers toward the floor. D. The client points the fingers toward the ceiling.

A. The client holds the hand with the palm up.

A nurse is preparing to assist an older adult client with ambulation following bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall? A. Use a gait belt during ambulation B. Ensure the client is wearing socks before ambulating C. Instruct the client to sit on the edge of the bed for 15 sec before ambulating D. Walk 2 ft behind the client during ambulation

A. Use a gait belt during ambulation

A nurse is caring for a client who has a deficiency of vitamin D. Which of the following foods should the nurse recommend the client include in his diet? A. Whole milk B. Chicken C. Oranges D. Dried peas

A. Whole milk

A nurse is planning an in-service training session about nutrition. Which of the following statements should the nurse include in the teaching? A."Fats provide energy." B."Carbohydrates repair body tissue." C."Fats regulate fluid balance." D."Carbohydrates prevent interstitial edema."

A. "Fats provide energy."

A nurse is caring for a client who had a spontaneous miscarriage at 9 weeks gestation. The nurse walks into the client's room and finds her crying uncontrollably. Which of the following statements should the nurse make? A. "It is hard to deal with the loss of a pregnancy. Here is the number of a local support group that you can attend." B. "When a pregnancy ends spontaneously, there is often something wrong with the fetus." C. "You are young and will have other children." D. "The best thing for you to do is to go home and relax."

A. "It is hard to deal with the loss of a pregnancy. Here is the number of a local support group that you can attend."

A home health nurse is assessing a toddler who is scheduled to begin receiving hospice care for a terminal illness. The child's parent tells the nurse, "This is all my fault, and I wish I could trade places with my child." Which of the following responses should the nurse make? A. "Tell me more about what you are feeling." B. "I understand how you are feeling." C. "Let's talk about hospice care for your child." D. "Try to focus more on positive things."

A. "Tell me more about what you are feeling."

A nurse is reviewing the laboratory reports of a client and notes an elevated thyroid-stimulating hormone (TSH) level. Which of the following findings should the nurse expect? A. Bradycardia B. Tremors C. Low-grade fever D. Diaphoresis

A. Bradycardia

A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview? A. Client's level of comfort and ability to participate in the interview B. Previous illnesses and surgeries C. Events surrounding the client's recent illness D. Sociocultural history

A. Client's level of comfort and ability to participate in the interview

A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger- stick blood sample. Which of the following actions by the AP requires the nurse to intervene? A.Elevating the finger above heart level B.Rubbing the fingertip with an alcohol pad C.Puncturing the side of the fingertip D.Wrapping the finger in a warm cloth

A. Elevating the finger above heart level

A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take? A. Hyperoxygenate the client before suctioning B. Insert the catheter during exhalation C. Apply suction during insertion of the catheter D. Apply suction for no more than 15 sec

A. Hyperoxygenate the client before suctioning

A nurse is teaching a client about the manifestations of an allergic reaction. The release of histamine causes which of the following reactions? A.Increased mucus secretion B.Bronchial dilation C.Bradycardia D.Vertigo

A. Increased mucus secretion

A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client's insomnia? A.The client watches television in her bed during the day. B.The client drinks warm milk before bedtime. C.The client goes to bed at 2200 every night. D.The client gets up to use the bathroom once during the night

A. The client watches television in her bed during the day.

A nurse in a provider's office is reviewing the medical records of a group of clients. Which of the following clients is at risk for iron deficiency? (Select all that apply.) A. A client who is postmenopausal B. A client who is a vegetarian C. A middle adult male client D. A client who is pregnant E. A toddler who is overweight

B. A client who is a vegetarian D. A client who is pregnant E. A toddler who is overweight

A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment? (Select all that apply.) A. Gingivitis B. Dry, brittle hair C. Edema D. Spoon-shaped nails E. Poor wound healing

B. Dry, brittle hair C. Edema E. Poor wound healing

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurse take? (Select all that apply.) A. Carefully reinsert the intestine through the opening in the wound B. Place the client in a supine position with the hips and knees flexed C. Leave the room to call the surgeon D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

B. Place the client in a supine position with the hips and knees flexed D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Set the suction machine at 120 mmHg B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown E. Apply petroleum jelly to the client's nares

B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown

A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following? (Select all that apply.) A. Allowing the client to speak B. Stabilizing the position of the tube C. Preventing aspiration of secretions D. Preventing air leaks E. Preventing tracheal injury

B. Stabilizing the position of the tube C. Preventing aspiration of secretions D. Preventing air leaks

A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement? (Select all that apply.) A. Auscultate injected air B. Verify the initial X-ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid E. Check the aspirated fluid for glucose

B. Verify the initial X-ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states, "All this equipment is making me nervous." Which of the following responses should the nurse offer? A."You won't need the equipment for very long." B."All of this equipment can be frightening." C."Why does the equipment bother you?" D."Let me tell you about what each machine does."

B. "All of this equipment can be frightening."

A nurse is caring for a client who is a sexual assault survivor. The client says, "I feel so humiliated. I don't want anyone to know what happened to me." Which of the following responses should the nurse make? A."You will be just fine. You'll see." B."Are you saying that you are fearful of what others will think?" C."This is a normal feeling after what happened to you." D."The best thing for you to do is to put this event out of your mind and think positive thoughts."

B. "Are you saying that you are fearful of what others will think?"

A nurse is completing dietary teaching with a client who has heart failure and is prescribed a 2 g sodium diet. Which of the following statements by the client indicates an understanding of the teaching? A. "I should use salt sparingly while cooking." B. "I can have yogurt as a dessert." C. "I should use baking soda when I bake." D. "I should use canned vegetables instead of frozen."

B. "I can have yogurt as a dessert."

A nurse in a provider's office is talking with an older adult client who reports having trouble sleeping. Which of the following statements should the nurse identify as a possible cause of the client's sleeping difficulties? A. "I take a warm shower when getting ready for bed." B. "I often have a cup of coffee with my dessert before going to bed." C. "I usually read a chapter in a book before I go to bed." D. "I make sure I do my exercises in the morning."

B. "I often have a cup of coffee with my dessert before going to bed."

A nurse is caring for a middle-aged adult client. The nurse should identify which of the following statements as an indication that the client has completed Erikson's developmental task for her age group? A. "I am comfortable with my decision to choose a lifelong partner." B. "I think I have done a good job with my children since they are all independent now." C. "As I look back over my life, I can see that I have achieved most of the goals I set for myself." D. "I love my work so much that it is difficult to think about retirement."

B. "I think I have done a good job with my children since they are all independent now."

A nurse is providing teaching to a client who has COPD about maintaining proper nutrition. Which of the following statements by the client indicates an understanding of the teaching? A. "I will increase my fluid intake when I eat a meal." B. "I will eat more cold foods at meals rather than hot foods." C. "I will avoid high-fat foods like butter and gravies." D. "I will cook my meals instead of eating convenience foods."

B. "I will eat more cold foods at meals rather than hot foods."

A nurse is caring for a client who has major depressive disorder. The client tells the nurse, "Don't bother me. Find someone else to talk with. I don't have anything to say that's worth sharing." Which of the following statements should the nurse make? A. "Surely you can't think I don't want to talk to you." B. "I would like to sit quietly with you for a while." C. "I'm assigned to take care of you, so I intend to spend time with you." D. "Let's talk about what you would like for lunch today."

B. "I would like to sit quietly with you for a while."

A nurse is instructing a client about collecting a 24-hr urine specimen for creatinine clearance. Which of the following statements should the nurse identify as an indication that the client understands the procedure? A. "The next time I urinate will be the first specimen of the collection." B. "I'll make sure to keep the collection bottle in the container of ice they gave me." C. "Once the container is half full, I no longer have to add any more urine." D. "It's okay if a piece of toilet paper gets in the bottle. The lab people will remove it when they do the test."

B. "I'll make sure to keep the collection bottle in the container of ice they gave me."

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis? A. "I'll wrap the old dressing in a paper bag and put it in the trash." B. "I'll wash my hands before I remove the old dressing and again before putting on the new one." C. "I'll need to take a pain pill 30 minutes before I change the dressing." D. "I'll wear sterile gloves when I apply the new dressing."

B. "I'll wash my hands before I remove the old dressing and again before putting on the new one."

A nurse is teaching a client who is postoperative about the importance of turning, coughing, and breathing deeply. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "If I do this often, I won't experience muscle wasting." B. "If I do this often, I won't get pneumonia." C. "If I do this often, I won't get constipation." D. "If I do this often, I won't have a fast heartbeat."

B. "If I do this often, I won't get pneumonia."

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps relieve pain. Which of the following responses should the nurse make? A. "It provides a distraction from the pain." B. "It modulates the transmission of the pain impulse." C. "It promotes increased circulation to the painful area." D. "It elicits a relaxation response."

B. "It modulates the transmission of the pain impulse."

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps relieve pain. Which of the following responses should the nurse make? A. "It provides a distraction from the pain." B. "It modulates the transmission of the pain impulse." C. "It promotes increased circulation to the painful area." D. "It elicits a relaxation response."

B. "It modulates the transmission of the pain impulse."

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps to relieve pain. Which of the following responses should the nurse make? A. "It provides a distraction from the pain." B. "It modulates the transmission of the pain impulse." C. "It promotes increased circulation to the painful area." D. "It elicits a relaxation response."

B. "It modulates the transmission of the pain impulse."

A nurse is providing teaching about crutches to a client who has a fracture of the right foot. Which of the following instructions should the nurse include? A. "When you go up a flight of stairs, place your right foot on the first step." B. "Keep the rubber crutch tips securely in place." C. "When standing, keep the crutches 12 inches in front of you and 12 inches to the side." D. "Place your weight on the crutch pads at your armpits."

B. "Keep the rubber crutch tips securely in place."

A nurse is caring for a client who states that she is sure her partner is about to leave her because they missed some house payments and their house will soon be in foreclosure. Which of the following responses should the nurse offer? A. "I think you should come up with a creative solution for making those payments." B. "Please explain how you think your financial situation will result in separation." C. "I don't believe that your long-term partner would walk out at a time like this." D. "Why do you think your partner is getting ready to leave you?"

B. "Please explain how you think your financial situation will result in separation."

A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure? A. "Inhale forcefully during insertion." B. "Raise your index finger if you need to pause during the insertion." C. "Bear down during insertion." D. "Avoid making any swallowing motions during the insertion."

B. "Raise your index finger if you need to pause during the insertion."

A nurse is caring for an adolescent client who is overweight. The adolescent tells the nurse that classmates tease him about his weight. Which of the following responses should the nurse make? A. "You shouldn't worry about what other people say." B. "Tell me how you feel when your classmates tease you." C. "Your friends will learn to like you for who you are inside, not what you look like." D. "It is important to begin to eat healthier so you can look the way you want to look."

B. "Tell me how you feel when your classmates tease you."

A nurse is caring for a client who has a new diagnosis of breast cancer. The client becomes quiet and withdrawn and says to the nurse, "What do you think people will say about me when I'm gone?" Which of the following responses should the nurse make? A. "What are you worried they will say about you?" B. "The thought of having breast cancer may seem hopeless." C. "Maintaining a positive attitude can influence your recovery." D. "You will be remembered as a kind person."

B. "The thought of having breast cancer may seem hopeless."

A nurse is caring for a client who recently found out that she is pregnant. The client says, "I don't think I should tell my partner about the pregnancy." Which of the following responses should the nurse provide? A. "Why wouldn't you want to tell your partner?" B. "You seem uncertain about telling your partner." C. "I am sure he will be happy when you tell him about the pregnancy." D. "You are in disbelief. You should be thrilled."

B. "You seem uncertain about telling your partner."

A nurse is teaching a client who is beginning a vegan diet and is concerned about maintaining an adequate protein intake. Which of the following food servings should the nurse recommend due to the high amount of protein? A. 1/2 cup tomato soup B. 1/2 cup of hummus C. 2 tablespoons of peanut butter D. 1 cup penne pasta

B. 1/2 cup of hummus

A nurse is assessing the pH of a client's gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect? A.6 B.2 C.10 D.8

B. 2

A nurse is caring for a group of clients in a long-term care facility. The nurse should understand that which of the following clients is eligible for hospice services at this time? A. A client who has multiple sclerosis and uses a wheelchair B. A client who has end-stage cirrhosis C. A client who has hemiplegia due to a stroke D. A client who has cancer and receives weekly radiation therapy

B. A client who has end-stage cirrhosis

A nurse is caring for a group of clients in a long-term care facility. One of the clients is walking along the hallway and bumping into walls and does not respond to his name. Which of the following actions should the nurse take first? A. Offer the client a nutritious snack B. Accompany the client back to his room C. Reorient the client to his surroundings D. Administer a PRN antianxiety medication

B. Accompany the client back to his room

A nurse on a medical unit is caring for a client who has difficulty sleeping. Which of the following actions should the nurse take to promote the client's ability to fall asleep? A. Encourage the client to ambulate in the hallway just before bedtime B. Allow the client to maintain the same bedtime routine as at home C. Keep the room temperature warm D. Offer the client a cup of hot chocolate before bedtime

B. Allow the client to maintain the same bedtime routine as at home

A nurse is teaching a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups is responsible for movement at the knee joint? A.Antigravity B.Antagonistic C.Synergistic D.Skeletal

B. Antagonistic

A nurse is planning dietary teaching for a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first? A. Obtain sample menus from the dietitian to give to the client B. Ask the client to identify the types of foods she prefers C. Identify the recommended range of the client's blood glucose level D. Discuss long-term complications that can result from non-adherence to the dietary plan

B. Ask the client to identify the types of foods she prefers

A nurse is implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take? A.Apply a cold pack to the edematous area B.Check capillary refill before applying an ice pack to the affected area C.Half-fill an ice pack with crushed ice D.Apply an ice pack for 60 min intervals

B. Check capillary refill before applying an ice pack to the affected area

A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. The client states she slipped while getting out of bed. Which of the following actions should the nurse take first? A. Complete an incident report B. Check the client for injuries C. Make sure the client has skid-free footwear D. Remind the client to ask for help when getting out of bed

B. Check the client for injuries

A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. Which of the following actions should the nurse perform immediately following the transfer? A. Administer pain medication B. Check the client's vital signs C. Instruct the client to use the incentive spirometer every 1 hr D. Provide ice chips as per provider prescription

B. Check the client's vital signs

A nurse is teaching an assistive personnel (AP) about dietary restrictions for a client who is taking phenelzine to treat depression. The AP's selection of which of the following foods for the client's lunch indicates an understanding of the teaching? A. Bologna on wheat bread B. Chicken salad C. Cheddar cheese and crackers D. Pizza with pepperoni

B. Chicken salad

A nurse is providing teaching about proper care to a client who has a new colostomy. Which of the following pieces of information should the nurse include in the teaching? A. Change the colostomy bag following breakfast B. Cleanse the skin around the stoma with warm water C. Change the pouch every day D. Place an aspirin in the ostomy pouch to decrease odor

B. Cleanse the skin around the stoma with warm water

A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse perform? A. Wear sterile gloves when collecting the specimen B. Cleanse the wound with 0.9% sodium chloride irrigation C. Allow the collection swab to absorb old exudate D. Rotate the collection swab over the edges of the wound

B. Cleanse the wound with 0.9% sodium chloride irrigation

A nurse is teaching a newly licensed nurse about pain management in clients age 65 and older. Which of the following pieces of information should the nurse include in the teaching? A. Clients who are age 65 or older experience a decreased ability to perceive pain compared to young adult clients. B. Clients who are age 65 or older are reluctant to report pain. C. Clients who are age 65 or older should not receive opioid narcotics. D. Clients who are age 65 or older experience a shorter duration of action with medications than young adult clients.

B. Clients who are age 65 or older are reluctant to report pain.

A nurse is preparing to administer a feeding via a gastrostomy tube to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding? A. Warm the feeding in a microwave oven B. Elevate the head of the client's bed C. Flush the tube with 0.9% sodium chloride for irrigation D. Verify that the client's gastric pH is above 4

B. Elevate the head of the client's bed

A nurse is planning care for a client who is postoperative following a gastrectomy. Which of the following strategies should the nurse include to help prevent dumping syndrome? A. Have the client drink plenty of water with meals B. Eliminate simple sugars and sugar alcohols from the client's diet C. Limit the client's intake to 2 meals per day D. Offer the client meals that are low in protein or protein-free

B. Eliminate simple sugars and sugar alcohols from the client's diet

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? A. Change the topic because the client is trying to divert attention from the illness B. Encourage the client to express thoughts about death and dying C. Tell the client that religious beliefs are a personal matter D. Offer to contact the client's minister or the facility's chaplain

B. Encourage the client to express thoughts about death and dying

A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source for this sound? A. Low battery power B. Excessive wax in the ear canal C. A volume setting that is too low D. A crack in the ear tube

B. Excessive wax in the ear canal

A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of impaired skin integrity? A. 3+ Achilles reflex B. Faint pedal pulses C. Feet warm to the touch bilaterally D. Capillary refill of <2 sec

B. Faint pedal pulses

A nurse is communicating with a group of clients about what to expect during the postoperative phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as an evaluation of effective communication? A. The motivation for communication is evident. B. Feedback is provided. C. A message is communicated to the group of clients. D. Multiple channels are used by the sender.

B. Feedback is provided.

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? A. Leave the bag in place for 45 min B. Fill the bag 2/3 full with ice C. Place the ice bag uncovered on the client's ankle D. Tell the client that numbness is expected when the ice bag is in place

B. Fill the bag 2/3 full with ice

A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? A. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink B. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back C. Press the skin above the ankle for 5 seconds, release it, and note the depth of the impression D. Measure the skinfold thickness on the upper arm using a pair of calibrated skinfold calipers

B. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of information should the nurse include in the teaching? A. Exhale slowly to reach the goal volume B. Hold the breath for 5 sec after goal volume is reached C. Continue to breathe deeply between each cycle D. Limit the repeat pattern of breathing to 5 breaths

B. Hold the breath for 5 sec after goal volume is reached

A nurse is caring for a toddler at a well-child visit when the mother calls, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction? A. Flushing of the skin B. Inability to cry or speak C. Presence of nausea and mild emesis D. Capillary refill time of 1.5 sec

B. Inability to cry or speak

A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? A. Decreased urine specific gravity B. Increased heart rate C. Decreased hematocrit D. Increased skin turgor

B. Increased heart rate

A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the client's body? A. Heart B. Lungs C. Thyroid gland D. Skin

B. Lungs

A nurse is changing the dressings for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? A. Abdominal binder B. Montgomery straps C. Hypoallergenic tape D. Plastic tape

B. Montgomery straps

A client who reports shortness of breath requests the nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? A. Encourage the client to take deep breaths B. Observe the rate, depth, and character of the client's respirations C. Prepare to administer oxygen D. Give the client a back rub to promote relaxation

B. Observe the rate, depth, and character of the client's respirations

A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse prioritize when using the nursing process? A. Identify goals for client care B. Obtain client information C. Document nursing care needs D. Evaluate the effectiveness of care

B. Obtain client information

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? A. Encourage the client to drink fluids before swallowing food B. Offer the client tart or sour foods first C. Tilt the client's head backward when swallowing D. Turn on the television

B. Offer the client tart or sour foods first

A nurse is preparing to perform postural drainage for a client. Which of the following actions should the nurse take? A. Give the client a bronchodilator immediately after the procedure B. Position the client for drainage of secretions by gravity C. Schedule postural drainage following meals D. Instruct the client regarding the importance of fluid restrictions

B. Position the client for drainage of secretions by gravity

A nurse is planning an in-service training session about nutrition. Which of the following pieces of information should the nurse include? A. Fat breaks down into amino acids. B. Protein serves as an energy source when other sources are inadequate. C. Glucose breaks down into ammonia. D. Carbohydrates provide 9 cal/g of energy.

B. Protein serves as an energy source when other sources are inadequate.

A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider? A. Calcium 9.5 mg/dL B. Sodium 150 mEq/L C. Potassium 4 mEq/L D. Magnesium 1.5 mEq/L

B. Sodium 150 mEq/L

A nurse is providing nutrition counseling to a middle-aged adult client who has a sedentary job. Which of the following factors should the nurse consider? A. The risk of eating disorders increases at this age. B. The client's basal metabolic rate could decrease. C. Daily vitamins will be become necessary to meet nutritional needs. D. Limiting the intake of fish to once per week reduces cardiovascular risks.

B. The client's basal metabolic rate could decrease.

A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? A. Fasten the ties on the restraint to the side rails of the bed. B. Tie the restraint with a quick-release knot. C. Allow a fingerbreadth between the restraint and the client's chest. D. Place the restraint under the client's clothing.

B. Tie the restraint with a quick-release knot.

A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin discharge planning? A. One week prior to the client's discharge B. Upon the client's admission to the care facility C. Once the discharge date is identified D. When the client addresses the topic with the nurse

B. Upon the client's admission to the care facility

A nurse is preparing a 24-hr urine specimen for a client who is suspected to have pheochromocytoma. Which of the following laboratory tests from the 24-hr urine specimen should the nurse use to determine the client's condition? A.Creatinine clearance B.Vanillylmandelic acid (VMA) C.17-hydroxycorticosteroids (17-OHCS) D.Protein

B. Vanillylmandelic acid (VMA)

A nurse on a medical-surgical unit observes smoke billowing from a client's room. Which of the following actions should the nurse take first? A.Close the door to the client's room. B.Evacuate the client from the room. C.Sound the fire alarm. D.Activate the fire extinguisher.

B. Evacuate the client from the room.

A nurse is teaching a client about preventing the transmission of hepatitis A. The nurse should identify that hepatitis A is transmitted by which of the following routes? A. Maternal-fetal B. Fecal-oral contamination C. Genital sexual contact D. Blood to blood

B. Fecal-oral contamination

A nurse is providing dietary teaching to a client who has chronic renal failure. Which of the following food choices by the client indicates an understanding of the teaching? A. Canned soup B. Grilled fish C. Pastrami D. Peanut butter

B. Grilled fish

A nurse is conducting a home visit for an older adult client who has diabetes mellitus and takes regular insulin subcutaneously before each meal. The client appears disoriented and weak and has slurred speech. Which of the following conditions should the nurse consider first when responding to these manifestations? A. Dementia B. Hypoglycemia C. Infection D. Transient ischemic attack

B. Hypoglycemia

A nurse is admitting a client who has a hearing aid. Which of the following actions should the nurse take before beginning the interview process? A. Sit beside the client during the interview B. Make sure the device is functioning C. Make sure lighting in the room is soft D. Provide a lengthy interview process to allow adequate time to answer questions

B. Make sure the device is functioning

A nurse on a medical-surgical unit is talking with a client who pauses while discussing his feelings about being in the facility. The nurse replies, "Please go on." Which of the following communication techniques is the nurse using? A. Reflecting B. Providing a general lead C. Focusing D. Seeking clarification

B. Providing a general lead

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? A.Lower medial quadrant of the buttock near the coccyx B.Side hip between the iliac crest and anterior iliac spine C.Tissue of the posterior upper arm D.Lower inner thigh 4 finger-widths above the patella

B. Side hip between the iliac crest and anterior iliac spine

A nurse is planning care for a client who has syndrome of inappropriate antidiuretic hormone secretion (SIADH) with mild manifestations. The nurse should expect the provider to prescribe which of the following medications? A. Chlorpropamide B. Tolvaptan C. Vasopressin D. Desmopressin

B. Tolvaptan

A nurse is caring for a client with Clostridium difficile who has contact-isolation precautions in place. Which of the following actions should the nurse perform? A. Instruct visitors to maintain a distance of at least 1 m (3 ft) from the client. B. Wash hands with antimicrobial soap after leaving the client's room. C. Use dedicated equipment for the client. D. Keep the doors to the client's room closed at all times.

C. Use dedicated equipment for the client.

A nurse is caring for an adult client who communicates an unmet spiritual need. Which of the following client statements should indicate to the nurse that the client is experiencing spiritual distress? A. "Life has its ups and downs." B. "I believe that I control my own destiny." C. "God is punishing me for something." D. "I like to keep my rosary beads in bed with me."

C. "God is punishing me for something."

A nurse in a mental health clinic is beginning a counseling session with a client who is having difficulties in a personal relationship. The client states that she does not want to talk at all today. Which of the following responses should the nurse make? A. "Why don't you want to talk today? We have talked several times before." B. "I think you should take a moment to collect your thoughts. Then, you need to talk." C. "How about I just spend some time with you instead? We don't have to talk." D. "I don't believe that you don't want to talk to me. You know it can be helpful."

C. "How about I just spend some time with you instead? We don't have to talk."

A home health nurse is performing an assessment on a client who is 1 week postoperative following a total knee replacement. Which of the following statements by the client indicates an understanding of the teaching? A."I will discontinue the blood thinner my doctor prescribed once I am at home." B."I will keep a pillow under my knee when I am in bed." C."I plan to use a walker to help me get around." D."I will discontinue using the CPM machine when I get home."

C. "I plan to use a walker to help me get around."

A nurse is teaching a client who has asthma about the proper use of an albuterol inhaler. Which of the following client statements indicates an understanding of the teaching? A. "I should rinse my mouth out right before I use the inhaler." B. "After the first puff, I will wait 10 seconds before taking the second puff." C. "I will shake the inhaler well right before I use it." D. "I will tilt my head forward while inhaling the medication."

C. "I will shake the inhaler well right before I use it."

A nurse is providing teaching about nutritious diets to a group of adult women. Which of the following statements should the nurse include? A. "Include at least 3 g of sodium in your daily diet." B. "Limit wine consumption to 230 mL daily." C. "Include 2.5 cups of vegetables in your daily diet." D. "Limit water intake to 1.5 L each day."

C. "Include 2.5 cups of vegetables in your daily diet."

At the start of a counseling session with the nurse, the client states, "We're wasting time with these meetings. I can't trust anyone with what's really bothering me about things I've done." Which of the following responses should the nurse provide? A. "What makes you think that?" B. "These sessions are for your own good. We need to continue them." C. "Is it because you feel like no one would understand what you are experiencing?" D. "Perhaps you'd rather talk about that visit you had with your sister."

C. "Is it because you feel like no one would understand what you are experiencing?"

A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying? A. "Now that we have talked about your medications, let's talk about your pain." B. "Are you having other symptoms?" C. "It sounds like your pain is intermittent." D. "It seems as though you have really had a rough time these past few weeks."

C. "It sounds like your pain is intermittent."

A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make? A. "During this phase, feed your child anything that she will eat." B. "Increase the amount of calories and water your child consumes." C. "Keep a diary of the foods your child eats each day." D. "Provide a large variety of fruit juices for your child to choose from."

C. "Keep a diary of the foods your child eats each day."

A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care? A. "Social services can contact various community resources that will be helpful." B. "I will review the care plan to make the necessary changes." C. "Let's set up a meeting time with the doctor to discuss your options for home care." D. "I will make a list of things we need to do before discharge."

C. "Let's set up a meeting time with the doctor to discuss your options for home care."

A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? A. "Does the medication you're taking relieve the pain?" B. "Can you point to where the pain is the worst?" C. "What do you think caused the onset of your pain?" D. "Changing positions makes your pain worse, right?"

C. "What do you think caused the onset of your pain?"

A nurse is teaching a client how to perform personal ileostomy care prior to discharge. The client says, "I don't think that I am going to be able to take care of this myself." Which of the following responses should the nurse make? A. "In time, you will become better at this than I am." B. "Don't worry about it. Most clients feel like that at first." C. "What part of the ileostomy care are you having trouble with?" D. "I agree. This is a difficult process."

C. "What part of the ileostomy care are you having trouble with?"

The adult child of a client arrives to take his parent home from the facility following a colon resection. The client's son tells the nurse, "I don't know how I am going to take care of my mom now." Which of the following responses should the nurse make? A."A home health nurse will be stopping by tomorrow. If you have any questions, you can ask the nurse." B."Your mother has been taught to care for the colostomy independently." C."What part of your mother's care are you concerned about?" D." Your job is quite simple. I'll make sure that the colostomy bag is clean before your mother leaves."

C. "What part of your mother's care are you concerned about?"

A nurse is admitting a client who is scheduled to undergo a cardiac catheterization. The client says, "My coworker died last week from a heart attack." Which of the following responses should the nurse offer? A. "Your provider will not let that happen because she knows how to treat your condition." B. "Do you think the same thing might happen to you?" C. "You appear to be feeling anxious." D. "Has anyone in your family had a heart attack?"

C. "You appear to be feeling anxious."

An assistive personnel is bathing a client who is unconscious and is talking to him about current events and the weather. The client's partner asks the nurse, "Why does the assistive personnel talk to my husband? He's unconscious." Which of the following responses should the nurse provide? A. "I'll speak to the assistive personnel about it. Your husband should not be stimulated like that." B. "Why do you care if the assistive personnel talks with your husband?" C. "Your husband is unconscious but might still be able to hear." D. "The assistive personnel must not realize that your husband cannot hear."

C. "Your husband is unconscious but might still be able to hear."

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? A. Encourage the child to cough frequently to clear congestion from anesthesia. B. Place a heating pad on the child's neck for comfort. C. Administer analgesics to the child on a routine schedule throughout the day and night. D. Provide the child with ice cream when oral intake is initiated.

C. Administer analgesics to the child on a routine schedule throughout the day and night.

A nurse is assisting a client who has dysphagia at mealtimes. Which of the following actions should the nurse take? A. Assist the client into a semi-sitting position B. Have the client lean slightly backward C. Advise the client to tuck his chin downward D. Instruct the client to tilt his head slightly backward

C. Advise the client to tuck his chin downward

A nurse is assisting a client who has dysphagia with eating meals. Which of the following actions should the nurse take? A. Add water to soups for a thinner consistency B. Encourage using water to clear the client's mouth C. Ask the client to think of a food that produces salivation D. Remind the client to rest after meals

C. Ask the client to think of a food that produces salivation

A nurse discovers that a client received the wrong medication. Which of the following actions should the nurse take first? A. Complete a medication error report. B. Notify the prescribing provider. C. Assess the client. D. Notify the charge nurse.

C. Assess the client.

A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions? A. Shaking soiled linen before putting it in a hamper B. Removing a face mask when standing 0.5 m (1.6 ft) from the client C. Assigning another client with the same infection to share the room with the client D. Allowing the client to visit a family member in the lobby of the facility

C. Assigning another client with the same infection to share the room with the client

A nurse is reviewing the laboratory reports of a client who is receiving enteral feedings. Which of the following values indicates a complication of enteral feeding that the nurse should report to the provider? A. Sodium 143 mEq/L B. Potassium 4.2 mEq/L C. BUN 25 mg/dL D. Glucose 185 mg/dL

C. BUN 25 mg/dL

A nurse is caring for a client who requires ventilatory assistance with breathing following a motor vehicle crash. The nurse should suspect an injury to which of the following parts of the brain? A. Hypothalamus B. Cerebral cortex C. Brainstem D. Cerebellum

C. Brainstem

A nurse is assessing a client who has Addison's disease. Which of the following skin manifestations should the nurse expect to find? A.Purple striae on the chest and abdomen B.Butterfly rash across the bridge of the nose C.Bronze pigmentation of the skin D.Jaundice of the face and sclera

C. Bronze pigmentation of the skin

A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following sites should the nurse select? A. Select a vein in the client's dominant arm B. Choose the most proximal vein in the extremity C. Choose a vein that is soft on palpation D. Select a site distal to previous venipuncture attempts

C. Choose a vein that is soft on palpation

A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? A. Call for assistance. B. Begin chest compressions. C. Confirm unresponsiveness. D. Give rescue breaths.

C. Confirm unresponsiveness.

A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test? A.Sugar B.Coffee C.Cotton wisps D.Snellen chart

C. Cotton wisps

A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take? A. Measure the pulse using a Doppler ultrasound stethoscope B. Check the client's pedal pulses C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart D. Take the pulse at each peripheral site and count the rate for 30 sec

C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart

A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take? A.Measure the pulse using a Doppler ultrasound stethoscope B.Check the client's pedal pulses C.Count the apical pulse rate for 1 full min and describe the rhythm in the chart D.Take the pulse at each peripheral site and count the rate for 30 sec

C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart

A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations? A. Increased intestinal motility B. Respiratory alkalosis C. Decreased cardiac output D. Hypocalcemia

C. Decreased cardiac output

A nurse is caring for a client who has a BMI of 29 and expresses a desire to lose weight. Which of the following actions should the nurse take first? A. Refer the client to a nutritionist B. Discuss eating strategies with the client C. Determine the client's intention to change current eating habits D. Instruct the client to perform 30 min of vigorous exercise daily

C. Determine the client's intention to change current eating habits

A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? A. Place an oxygen mask on the client B. Check the client's pulse C. Determine whether the client is able to breathe D. Wrap arms around the client from behind

C. Determine whether the client is able to breathe

A nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following? A. Retention B. Oliguria C. Diuresis D. Dysuria

C. Diuresis

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give to the dietary assistant? A. Don a gown before entering the room and remove it before exiting. B. Wear a mask while in the client's room. C. Don gloves when entering the room and use hand sanitizer when exiting. D. Take no special precautions unless engaging in direct contact with the client.

C. Don gloves when entering the room and use hand sanitizer when exiting.

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give to the dietary assistant? A.Don a gown before entering the room and remove it before exiting. B.Wear a mask while in the client's room. C.Don gloves when entering the room and use hand sanitizer when exiting. D.Take no special precautions unless engaging in direct contact with the client.

C. Don gloves when entering the room and use hand sanitizer when exiting.

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? A. Auscultate bowel sounds after each feeding B. Ensure the formula is cold before administering C. Elevate the head of the client's bed to 45° before the feeding D. Flush the tubing with 15 mL of water after the enteral feeding

C. Elevate the head of the client's bed to 45° before the feeding

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? A. Hold the irrigator 1.25 cm (0.5 in) above the eye B. Direct the irrigation solution up toward the upper eyelid C. Exert pressure on the bony prominences when holding the eyelids open D. Direct the irrigation from the outer canthus to the inner canthus of the eye

C. Exert pressure on the bony prominences when holding the eyelids open

A nurse in a same-day procedure unit is caring for several clients who are undergoing different types of procedures. The nurse should anticipate that the client who has which of the following devices can safely undergo magnetic resonance imaging (MRI)? A. Coronary artery stents B. Aneurysm clip C. Hearing aids D. Automated internal defibrillator

C. Hearing aids

A nurse is assessing a client who is experiencing stress following a near fall out of bed. Which of the following physiological responses should the nurse expect due to the fight-or-flight response? A. Decreased respiratory rate B. Pinpoint pupils C. Increased blood pressure D. Bronchiolar construction

C. Increased blood pressure

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? A.Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube B.Position the client on the right side C.Insert the tip of the tubing 8 cm (3.1 in) D.Hold the enema container 61 cm (24 in) above the rectum

C. Insert the tip of the tubing 8 cm (3.1 in)

A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein? A. Eggs B. Soybeans C. Lentils D. Yogurt

C. Lentils

A nurse is caring for an infant who has gastroenteritis and is dehydrated. Which of the following characteristics places the infant at a higher risk of electrolyte imbalances compared to an adult client? A. Less extracellular fluid B. Reduced body surface area C. Longer intestinal tract D. Decreased rate of metabolism

C. Longer intestinal tract

A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take? A. Assign the client to a private room B. Keep 4 side rails up while the client is in bed C. Monitor the client at least once every hour D. Request a PRN prescription for restraints

C. Monitor the client at least once every hour

A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks both the client's native language and the nurse's, arrives to drive the client home. Which of the following actions should the nurse take? A. Ask the client's neighbor to call a family member to interpret. B. Ask the client's neighbor to translate the information. C. Obtain the services of an interpreter. D. Document the inability to provide discharge instructions.

C. Obtain the services of an interpreter.

A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A.People who practice the Islamic faith pray over the deceased for a period of 5 days before burial. B.People who practice the Hindu faith bury the deceased with their head facing north. C.People who practice Judaism stay with the body of the deceased until burial. D.People who are practicing the Buddhist faith have the female family members prepare the body following death.

C. People who practice Judaism stay with the body of the deceased until burial.

A nurse is assessing a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings? A. Peripheral pulses equal bilaterally at a rate of 60/min B. Radial, brachial, and pedal pulses bilaterally weak C. Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities D. Brachial, radial, popliteal, and dorsalis pedis pulses regular, 58, and bilaterally palpable

C. Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? A. Maintain suction while removing the NG tube B. Instill 100 mL of air into the NG tube before removal C. Pinch the NG tube while removing the tube D. Instruct the client to breathe in and out during the removal of the NG tube

C. Pinch the NG tube while removing the tube

A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take? A. Raise the enema bag if the client experiences cramping B. Lubricate 2.54 cm (1 in) of the tip of the rectal tube prior to insertion C. Place the client in a left Sims' position D. Don sterile gloves prior to the procedure

C. Place the client in a left Sims' position

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? A. Stand toward the client's stronger side. B. Instruct the client to lean backward from the hips. C. Place the wheelchair at a 45-degree angle to the bed. D. Assume a narrow stance with the feet 15 cm (6 in) apart.

C. Place the wheelchair at a 45-degree angle to the bed.

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? A. Insert the rectal tube 15.2 cm (6 in) B. Wear sterile gloves to insert the tubing C. Position the client on his left side D. Hold the solution bag 91 cm (36 in) above the client's rectum

C. Position the client on his left side

A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? A. Aim the hose at the base of the fire. B. Squeeze the handle of the extinguisher. C. Remove the safety pin from the extinguisher. D. Sweep the hose from side to side to dispense material.

C. Remove the safety pin from the extinguisher.

A nurse is caring for a client and asks, "How are you?" The client responds, "My leg still hurts." Which of the following communication techniques should the nurse use first? A. Offer information B. Share hope C. Seek clarification D. Summarize

C. Seek clarification

A nurse is caring for a client who has breast cancer. The client has been receiving radiation therapy for several months and now refuses to undergo further treatment. Which of the following actions should the nurse take? A. Suggest the client talk with someone who has survived breast cancer B. Encourage the client not to give up C. Support the client's decision D. Refer the client to a counselor

C. Support the client's decision

A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2°C (102.6°F), a heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority? A. Heart rate of 105/min B. Soft nontender abdomen C. Temperature D. Overdue menses

C. Temperature

An assistive personnel (AP) is helping a nurse care for a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? A. The AP uses soap and water to clean the perineal area. B. The AP tapes the catheter to the client's inner thigh. C. The AP hangs the collection bag at the level of the bladder. D. The AP ensures there are no kinks in the drainage tubing.

C. The AP hangs the collection bag at the level of the bladder.

A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors increases the client's risk of developing complicated grief? A. The deceased was a close friend. B. The client lived far from the deceased. C. The death was sudden. D. The client has not visited the deceased in a long time.

C. The death was sudden.

A nurse is preparing to instill a vaginal medication in suppository form to a client. Which of the following actions should the nurse take during this procedure? A. Don sterile gloves B. Use the dominant hand to retract the labia C. Use the index finger to insert the suppository D. Ease the suppository along the anterior vaginal wall

C. Use the index finger to insert the suppository

A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use? A.Deltoid B.Ventrogluteal C.Vastus lateralis D.Dorsogluteal

C. Vastus lateralis

A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take? A. Use a 10 mL syringe B. Attach a 22-gauge catheter to the syringe C. Warm the irrigating solution to 37°C (98.6°F) D. Administer an analgesic 10 min before the irrigation

C. Warm the irrigating solution to 37°C (98.6°F)

A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight? A. Calibrate the scales weekly B. Use a different scale each time C. Weigh the client on arising D. Weigh the client without clothing

C. Weigh the client on arising

A nurse is teaching a client who has tuberculosis about a new prescription for rifampin. Which of the following statements by the client indicates an understanding of the teaching? A."I should take this medication with food." B."I need to take a B-complex vitamin while using this medication." C."I can expect this medication to turn my skin orange." D."I can expect this medication to make my vision blurry."

C. "I can expect this medication to turn my skin orange."

A nurse is providing teaching to a client who has a diagnosis of hepatitis A. Which of the following statements by the client indicates an understanding of the teaching? A."I am unable to donate blood." B."I will need to get a booster shot of immune serum globulin every year." C."I should stop eating raw clams." D."I can develop this disease by getting a tattoo."

C. "I should stop eating raw clams."

A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? A."A lot of clients who are cared for at home have the same problem." B."Don't worry about it. He will get a bath, and that will take care of the odor." C."It must be difficult to care for someone who is confined to bed." D."When was the last time that he had a bath?"

C. "It must be difficult to care for someone who is confined to bed."

A nurse is teaching a client who has urinary incontinence about bladder retraining. Which of the following instructions should the nurse include? A."Wake up every 2 hr to urinate during the night." B."Drink citrus juices throughout the day." C."Try to block the urge to urinate until the next scheduled time." D."Limit fluids to no more than 1 L (34 oz) during waking hours."

C. "Try to block the urge to urinate until the next scheduled time."

A nurse is caring for a client who states, "No one in the world actually cares about me." Which of the following responses should the nurse offer? A. "Your family visits you often, so they must care." B. "I don't really believe that no one cares about you." C. "You are feeling totally alone and without support?" D. "Why do you feel this way?"

C. "You are feeling totally alone and without support?"

A nurse is reviewing the medical record of a client who has a prescription for probenecid to treat gout. The nurse should identify that which of the following medications can interact with probenecid? A. Colchicine B. Naproxen C. Aspirin D. Prednisone

C. Aspirin

A nurse is teaching a group of unit nurses about the experiences of clients who are having surgery. In which phase of care is the client transferred to the surgical suite table before being transferred to the PACU? A. Preoperative B. Postoperative C. Intraoperative D. Admission

C. Intraoperative

A nurse is initiating seizure precautions for a client who has a seizure disorder. Which of the following pieces of equipment should the nurse have readily available at the client's bedside? A. Vest restraint B. Tongue blade C. Oxygen equipment D. Neck brace

C. Oxygen equipment

A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. The nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. Which of the following actions should the nurse take? A. Change the infusion tubing B. Flush the IV catheter C. Remove the IV catheter D. Apply a cool compress to the site

C. Remove the IV catheter

A nurse is caring for a client who has scurvy. Which of the following vitamin deficiencies should the nurse identify as the cause of this disease? A. Vitamin A B. Vitamin B3 C. Vitamin C D. Vitamin D

C. Vitamin C

A nurse is caring for a client following a fetal demise. The client is crying and says, "I tried to get pregnant for so long. My partner and I wanted this baby so much. Now, what will we do?" Which of the following responses should the nurse provide? A. "Why do you think this happened to you?" B. "You can have another baby soon." C. "I think you should look into adoption." D. "Are you feeling overwhelmed?"

D. "Are you feeling overwhelmed?"

A nurse is caring for a client who just received a diagnosis of cancer. The client states, "I just don't know what I'm going to do now." Which of the following responses should the nurse make? A. "In time you'll know the right thing to do." B. "I am sorry. Would you like me to call someone for you?" C. "There are multiple treatment options for you to consider." D. "Can you explain the concerns you're having right now?"

D. "Can you explain the concerns you're having right now?"

A nurse is caring for a client who just received a diagnosis of cancer. The client states, "I just don't know what I'm going to do now." Which of the following responses should the nurse make? A."In time you'll know the right thing to do." B."I am sorry. Would you like me to call someone for you?" C."There are multiple treatment options for you to consider." D."Can you explain the concerns you're having right now?"

D. "Can you explain the concerns you're having right now?"

During the completion of a health history with a nurse, a client reports intermittent chest pain for the past week. Which of the following questions is the nurse's priority? A. "Did you report the chest pain episodes to your physician?" B. "Is there a history of heart disease in your family?" C. "Have you had this pain before?" D. "Can you tell me what the pain felt like and show me exactly where it was?"

D. "Can you tell me what the pain felt like and show me exactly where it was?"

A nurse is caring for a client who has schizophrenia. The client tells the nurse that he's hearing voices in his head telling him to purchase a knife today. He states that he knows purchasing the knife will make him "do something bad." Which of the following responses should the nurse make? A. "Why do you think the voices want you to buy a knife?" B. "Do you already own any knives?" C. "When the voices speak, do you always do what they say?" D. "I don't hear any voices, just yours and mine. But, I understand that you are fearful."

D. "I don't hear any voices, just yours and mine. But, I understand that you are fearful."

A nurse is assessing a 66-year-old client during a routine physical examination. This is the client's first clinic visit, and she does not have her medical records. When the nurse asks if she has received the pneumococcal immunization, the client replies, "I am not sure, but it's been at least 5 years since I've had any immunizations." Which of the following responses should the nurse provide? A."In case you had the immunization before, we can't give you another one." B."You'll need a series of 3 injections." C."This immunization is unsafe for people over the age of 65 years old." D."Let's go ahead and give you this immunization."

D. "Let's go ahead and give you this immunization."

A nurse is admitting a client who has major depressive disorder. The client states, "This has been the worst day of my life." Which of the following responses should the nurse offer? A."You should focus on positive things rather than negative things." B."We all have a bad day from time to time." C."Why would someone with so much to live for say that?" D."Please take a seat and talk to me about your feelings."

D. "Please take a seat and talk to me about your feelings."

A nurse at a skilled nursing facility is admitting a client who has Alzheimer's disease. While speaking with the nurse, the client's partner begins to cry and says, "I never thought it would come to this. I feel so guilty about bringing my husband here." Which of the following responses should the nurse offer? A. "If he understood what was happening, I'm sure he would forgive you." B. "We will take good care of your husband here." C. "Admitting your husband was the right decision." D. "This has been a difficult time for you."

D. "This has been a difficult time for you."

A nurse is caring for an adolescent client who gave birth to a stillborn preterm baby. The client is crying and asks the nurse, "Why did this happen to me?" Which of the following responses should the nurse provide? A. "I understand how you feel." B. "You are young and can have healthy babies when you are older." C. "Sometimes, this is just nature's way." D. "This must be so difficult for you."

D. "This must be so difficult for you."

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular-sized cuff for a client who is obese. Which of the following explanations should the nurse give the AP? A. "The reading will be inaudible if the cuff is too small for the client." B. "The width of the cuff bladder should be 75% of the circumference of the client's arm." C. "As long as the cuff will circle the arm, the reading will be accurate." D. "Using a cuff that is too small will result in an inaccurately high reading."

D. "Using a cuff that is too small will result in an inaccurately high reading."

A nurse is caring for a client who has been recently diagnosed with cancer. The client says, "I would rather be dead than go through the treatment for cancer." Which of the following responses should the nurse make? A. "That wouldn't be fair to your family, would it?" B. "How can you feel that way when you have so much to live for?" C. "Why don't we talk about the successes you have in your life?" D. "What concerns you about the cancer treatment?"

D. "What concerns you about the cancer treatment?"

A nurse is performing a spiritual assessment of a client. Which of the following questions should the nurse ask? A. "When did you start to believe in your faith?" B. "How often do you perform religious rituals?" C. "Which church do you regularly attend?" D. "What is your source of strength and hope?"

D. "What is your source of strength and hope?"

A nurse is performing a spiritual assessment of a client. Which of the following questions should the nurse ask? A."When did you start to believe in your faith?" B."How often do you perform religious rituals?" C."Which church do you regularly attend?" D."What is your source of strength and hope?"

D. "What is your source of strength and hope?"

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse provide? A. "It's for your safety. Dentures can slip and block your airway during surgery." B. "You wouldn't want your teeth to be lost or broken during surgery, would you?" C. "The anesthesiologist requires all clients to remove their dentures." D. "What worries you about being without your teeth?"

D. "What worries you about being without your teeth?"

A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make? A. "You look just fine to me." B. "Nobody expects you to look beautiful in the hospital." C. "I understand how you feel. I would feel the same way." D. "Would you like to talk about how you feel?"

D. "Would you like to talk about how you feel?"

A nurse is caring for a client who is preparing to perform a return demonstration of a subcutaneous injection of medication for the second time. The client hesitates and says, "I'm not sure I can do this." Which of the following responses should the nurse make? A. "Why are you so nervous? Do you need help?" B. "You need to talk to your doctor about prescribing an oral medication." C. "I know it's new. You'll get the hang of it soon." D. "You did great last time. Give it a try."

D. "You did great last time. Give it a try."

A nurse is caring for a client who is preparing to perform a return demonstration of a subcutaneous injection of medication for the second time. The client hesitates and says, "I'm not sure I can do this." Which of the following responses should the nurse make? A."Why are you so nervous? Do you need help?" B."You need to talk to your doctor about prescribing an oral medication." C."I know it's new. You'll get the hang of it soon." D."You did great last time. Give it a try."

D. "You did great last time. Give it a try."

A nurse is caring for a client when the client's son enters the room and states, "You people can't do anything right. Ever since my father was admitted, we've seen one mistake after another. I'm taking him out of here." Which of the following responses should the nurse make? A. "Your father hasn't complained about his care. Why do you feel this way?" B. "We have the best intentions for all of the clients." C. "Let's not discuss this now. Tell me more about the rest of your family." D. "You feel that your father is not receiving appropriate care?"

D. "You feel that your father is not receiving appropriate care?"

A nurse is caring for an adolescent client who has a positive human chorionic gonadotropin (hCG) test. She tells the nurse, "I don't think I can tell my parents that I am pregnant." Which of the following responses should the nurse make? A. "Do you think you might terminate the pregnancy?" B. "Give them a chance. Your parents will understand." C. "You must tell your parents as soon as possible." D. "You seem frightened to tell your parents."

D. "You seem frightened to tell your parents."

A nurse asks a client to explain the statement, "A bird in the hand is worth two in the bush." Through this question, the nurse is evaluating the client's ability in which of the following intellectual functions? A. Judgment B. Short-term memory C. Attention span D. Abstract reasoning

D. Abstract reasoning

A nurse in an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first? A. Instill proparacaine hydrochloride eye drops B. Perform ocular irrigation of the right eye C. Place the client in a supine position with the head turned toward the affected side D. Ask the client about first aid performed at the scene

D. Ask the client about first aid performed at the scene

A nurse in an employee assistance program is counseling a client who states, "I just feel completely lost at work these days." The nurse replies, "You must feel like you are not getting things done." Which of the following therapeutic communication techniques is the nurse using? A. Presenting reality B. Encouraging comparison C. Offering general leads D. Attempting to translate words into feelings

D. Attempting to translate words into feelings

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse have the client perform just before inserting the catheter? A. Swallow water B. Prepare for a painful sensation C. Hold her breath D. Bear down gently

D. Bear down gently

A nurse is preparing to administer oral phenytoin to a client who has a seizure disorder. Before administering the medication, which of the following actions should the nurse take? A.Document the administration of the medication B.Count the amount of available medication on hand and sign for it C.Measure the client's respiratory rate D.Check the medication dose and the client's identification

D. Check the medication dose and the client's identification

A nurse documents the presence of clubbing of the fingernails for a client who has emphysema. Which of the following is the underlying cause of this finding? A. Trauma B. Severe infection C. Iron-deficiency anemia D. Chronic hypoxemia

D. Chronic hypoxemia

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? A. Withdraw the specimen from the drainage bag B. Cleanse the collection port with soap and water C. Place the specimen in a clean specimen cup D. Clamp the tubing below the collection port

D. Clamp the tubing below the collection port

A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? A. Irrigate the tubing with sterile normal water once during each shift B. Cleanse the opening with soap and water after emptying C. Maintain the tubing above the level of the surgical incision D. Collapse the device to remove air after emptying

D. Collapse the device to remove air after emptying

A nurse is caring for a client who has terminal cancer. The client is proceeding with plans to build a new home. The nurse should identify that this behavior typically indicates which of the following stages of grief? A. Acceptance B. Bargaining C. Anger D. Denial

D. Denial

A nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to assess which of the following? A. Liver size B. Pedal edema C. Skin texture D. Gait

D. Gait

A nurse is creating a plan of care for a client who adheres to Kosher dietary laws. Which of the following food selections should the nurse recommend? A. Baked pork chop B. Cheeseburger C. Ham and cheese omelet D. Grilled salmon

D. Grilled salmon

A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first? A. Provide oxygen B. Place the client in a side-lying position C. Provide privacy D. Lower the client to the floor

D. Lower the client to the floor

A nurse is providing dietary teaching to a client who has dumping syndrome following gastric bypass surgery 4 days ago. Which of the following recommendations should the nurse include in the teaching? A. Avoid foods containing protein B. Drink liquids during each meal C. Eat foods that contain simple sugars D. Maintain a supine position after meals

D. Maintain a supine position after meals

A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider? A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis

D. Metabolic acidosis

A nurse is caring for a client who is receiving radiation therapy for breast cancer and reports a metallic taste in the mouth. Which of the following dietary recommendations should the nurse share with the client? A. Eat with metal utensils B. Limit coffee C. Avoid citrus foods D. Offer mints

D. Offer mints

A nurse is planning an in-service training session for a group of nurses regarding the role of enzymes in digestion. Which of the following enzymes plays a role in the digestion of protein? A. Amylase B. Lipase C. Steapsin D. Pepsin

D. Pepsin

A nurse is assessing the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? A. Audible click B. Murmur C. Third heart sound D. Pericardial friction rub

D. Pericardial friction rub

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? A. Instruct the client to defecate into the toilet bowl B. Transfer the specimen to a sterile container C. Refrigerate the collected specimen D. Place the stool specimen collection container in a biohazard bag

D. Place the stool specimen collection container in a biohazard bag

A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take? A. Tie a secure knot with the restraint straps B. Attach the restraints' straps to the bedside rails C. Make sure 3 fingers fit beneath the restraints D. Remove the restraints at least every 2 hr

D. Remove the restraints at least every 2 hr

A client in a clinic setting tells the nurse, "I haven't seen my son for 2 weeks." The nurse replies, "Your son has not come to see you for 2 weeks?" This is an example of the nurse using which of the following therapeutic communication techniques? A. Reflecting B. Questioning C. Focusing D. Restating

D. Restating

A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? A. 2-point discrimination test B. Glasgow coma scale C. Babinski reflex D. Romberg test

D. Romberg test

A nurse is caring for a client who is dehydrated. The nurse should expect that insensible fluid loss of approximately 500 to 600 mL occurs each day through which of the following organs? A.Kidneys B.Lungs C.Gastrointestinal tract D.Skin

D. Skin

A nurse is caring for a client who has just learned that he has a terminal illness. He states, "I'll deal with this after my wife and I take that cruise we've always dreamed about." The nurse should identify that the client is demonstrating which of the following defense mechanisms? A. Displacement B. Sublimation C. Conversion D. Suppression

D. Suppression

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the child's temperature? A.Rectal B.Tympanic C.Oral D.Temporal

D. Temporal

A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment? A. The client places a crutch on each side when assuming a sitting position. B. The client moves the unaffected leg onto a step first when descending stairs. C. The client places weight on the axillae when walking. D. The client has slightly flexed elbows when ambulating with the crutches.

D. The client has slightly flexed elbows when ambulating with the crutches.

A nurse is accepting a transfer from the postanesthesia care unit (PACU) of a client who has had a subtotal thyroidectomy. Which of the following pieces of equipment should the nurse have available at the bedside for this client? A.Cardiac monitor B.Defibrillator C.Thoracotomy tray D.Tracheostomy tray

D. Tracheostomy tray

A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? A. Sweeping the floor B. Shoveling snow C. Cleaning windows D. Washing dishes

D. Washing dishes

A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include? A. Stand 3 feet from the client when assisting with lifting. B. Lock your knees when standing for long periods. C. Lift up to 22.6 kg (50 lb) without the use of assistive devices. D. When lifting an object, spread your feet apart to provide a wide base of support.

D. When lifting an object, spread your feet apart to provide a wide base of support.

A nurse is obtaining a capillary blood sample to determine a client's blood glucose level. The nurse prepares and punctures the client's finger for the procedure but does not obtain an adequate amount of blood. Which of the following actions should the nurse take next? A. Smear the small amount of blood onto the testing strip B. Hold the finger above heart level C. Massage the client's fingertip D. Wrap the client's finger in a warm washcloth

D. Wrap the client's finger in a warm washcloth

A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. Which of the following actions should the nurse take? A. Tell the client the provider does not want her to remain in bed B. Allow the client to remain in bed until her pain subsides C. Instruct the family to perform ADLs for the client D. Advise the client to perform range-of-motion exercises while in bed

D. Advise the client to perform range-of-motion exercises while in bed

A nurse is performing a preoperative assessment of a client about to undergo a cholecystectomy. The nurse should identify a risk for a latex allergy when the client reports an allergy to which of the following foods? A. Cabbage B. Oatmeal C. Milk D. Bananas

D. Bananas

A nurse is caring for a middle-aged adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks? A. Managing a home B. Establishing a sense of self in the adult world C. Forming new friendships D. Ceasing to compare personal identity with others

D. Ceasing to compare personal identity with others

A nurse is performing a mental-status examination on a client who has manifestations of dementia. Which of the following directions should the nurse give the client when evaluating the client's ability to think abstractly? A. Subtract by 7 serially, starting at 100 B. Describe a previous illness C. Explain what to do if a fire happened in his bedroom D. Discuss the meaning of a common proverb

D. Discuss the meaning of a common proverb

A nurse is updating the plan of care for a client who has dumping syndrome. Which of the following instructions should the nurse include? A. Consume beverages with meals B. Eat 3 large meals per day C. Include high-fiber foods in the diet D. Eat a source of protein with each meal

D. Eat a source of protein with each meal

A nurse is caring for a client who requires a chest X-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? A. Explain the X-ray procedure to the client. B. Help the client into a wheelchair before the transporter arrives. C. Ask if the client has any questions. D. Identify the client using 2 identifiers.

D. Identify the client using 2 identifiers.

A nurse is performing a physical examination for a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques? A. Percussion B. Auscultation C. Inspection D. Palpation

D. Palpation

A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring? A. Right task B. Right circumstance C. Right person D. Right communication

D. Right communication

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) through a central line. Which of the following actions should the nurse perform? A. Change the tubing every 12 hr B. Check the client's blood glucose every 8 hr C. Apply a new dressing to the IV site every 76 hr D. Weigh the client daily

D. Weigh the client daily

A new resident provider asks the charge nurse for an access code to review clients' online records. The resident is not scheduled to attend the facility's orientation computer class until next week. Which of the following actions should the nurse take? A. Explain that it is against policy to share access codes and refer the resident to his supervisor. B. Access the clients' online data and monitor the resident as he reads them. C. Access the online system and allow the resident to locate clients' data. D. Ask each client to give permission for the resident to access medical records.

Explain that it is against policy to share access codes and refer the resident to his supervisor.

A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? A.Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink B.Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back C.Press the skin above the ankle for 5 seconds, release it, and note the depth of the impression D.Measure the skinfold thickness on the upper arm using a pair of calibrated skinfold calipers

Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back

A nurse is providing nutritional teaching to a group of clients. Which of the following definitions for the recommended dietary allowance (RDA) should the nurse include in the teaching? A. The RDA is a comprehensive term that includes various dietary standards and scales. B. The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups. C. The RDA defines the levels of nutrients that should not be exceeded to prevent adverse health effects. D. The RDA is the daily percentage of energy intake values for fat, carbohydrate, and protein.

The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups.