ATI Fundamentals

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphasia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply) A. Assist the client with a partial bed bath B. Measure the client's BP after the nurse administers an antihypertensive medication C. Test the clients swallowing ability by providing thickened liquids D. Use a communication board to ask what the client wants for lunch E. Irrigate the client's indwelling urinary catheter

ABD

A nurse is caring for a client who has TB. Which of the following actions should the nurse take? (Select all that apply) A. Place the client in a room with negative-pressure airflow B. Wear gloves when assisting the client with oral care C. Limit each visitor to 2 hour increment D. Wear a surgical mask when providing client care E. Use antimicrobial sanitize for hand hygiene

ABE

A community health nurse is checking bp for a group of clients at a community health screening. Which of the following clients is at an increased risk for HTN? A. a client who is 52 years old B. a client who smokes one pack of cigarettes each day C. a client who walks for 30 min every day D. A client who drinks one glass of wine three times per week

B

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

B

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

D

A nurse is admitting a client who has rubella. Which of the following type of transmission-based precautions should the nurse initiate? A. Droplet B. Airborne C. Contact D. Protective environment

A

A nurse has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement? A. The tube aspirate has pH of 7 B. An x-ray shows the end of the tube above the pylorus C. Bowel sounds are present on auscultation D. The client reports relief of nausea

B

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

B

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

D

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use a psychomotor approach to learning? A. Role play B. Group discussion C. Question-answer meetings D. Practice sessions

D

A nurse is preparing to apply a dressing for a client who has stage 2 pressure injury. Which of the following types of dressing should the nurse use? A. Alginate B. Gauze C. Transplant D. Hydrocolloid

D

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

B

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? A. Activate the emergency fire alarm B. Extinguish the fire C. Evacuate the client D. Confine the fire

C

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

D

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

B

A nurse is initiating a protective environment for a client who has had a allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? A. Make sure the client's room has at least 6 air exchanges per hours B. Make sure the client wears a mask when outside her room if there is construction in the area C. Place the client in a private room with negative-pressure airflow D. Wear an N95 respiratory when giving the client direct care

B

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

B

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. A. Place a name tag on the body B. Obtain the pronouncement of death from the provider C. Remove tubes and indwelling lines D. Wash the client's body E. Ask the client's family members if they would like to view the body

BCDEA

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration? A. Purulent exudate B. Warmth C. Skin blanching D. Bleeding

C

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

A

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? A. Numbness of the extremities B. Bradycardia C. Positive Chvostek's sign D. Abdominal cramping

D

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

D

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

A

A nurse is caring for a client who requires a 24-hour urine collection. Which of the following statements by the client indicates an understanding of the teaching? A. "I had a bowel movement, but I was able to save the urine B. "I have a specimen in the bathroom from about 30 minutes ago" C. "I flushed what I urinated at 0700 and have saved all urine since" D. "I drink a lot, so I will fill up the bottle and complete the test quickly"

C

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? A. neck vein distention B. Urine specific gravity 1.010 C. Rapid heart rate D. BP 144/82 mmHg

C

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

D

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

D

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

A

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? A. Contact B. Droplet C. Airborne D. Protective

B

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

C

A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? A. Bladder distention B. Decreased blood pressure C. Calf swelling D. Diminished bowel sounds

C

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

C

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

D

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation? A. Urine has an unusual odor B. Urine specific gravity is 1.035 C. Bladder scan shows 525 mL of urine D. Urine is positive for ketones

C

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

D

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

A

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

A

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

A

A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea? A. The client is receiving formula at room temperature B. The feeding infuse at a slow, continuous drip over 8 hour each night C. The client's caregiver washes out the feeding bag with water once every 24 hours D. The client's caregiver flushes the tubing with water before and after administering medications

C

A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident? A. "Incident report completed" B. "Client climbed over the side rails" C. "Client found lying on the floor" D. "Client was trying to get out of bed"

C

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

C

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

A

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

B

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

C

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

D

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

D

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

B

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? A. Insert the suction catheter while the client is swallowing B. Apply intermittent suction when withdrawing the catheter C. Place the catheter in a location that is clean and dry for later use D. Hold the suction catheter with her clean, nondominant hand

B

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

B

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

D

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

D

A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene? A. Erythema on pressure points B. Lower-extremity pulse strength of 2+ C. Fluid intake of 3,000 mL per day D. One bowel movement every other day

A

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority? A. Auscultate lung sounds B. Measure the urine output C. Monitor bp reading D. Monitor electrolyte levels

A

A nurse is administering an optic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? A. Press gently on the tragues of the client's ear B. Pack a small piece of cotton deep into the client's ear canal C. Move the client auricle down and back toward her head D. Tilt the client's head backward for 5 min.

A

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care? A. Wrap blanket around all four sides of the bed B. Apply restraints during seizure activity C. Place the client in a supine position during seizure activity D. Have a tongue depressor at the client's bedside

A

A nurse is admitting a client who is having an exacerbation of HF. In planning this client's care, when 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. After consulting with the client's family

A

A nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. "I can concentrate best in the morning" B. "It is difficult to read the instruction because my glasses are at home" C. "I'm wondering why I need to learn this" D. "You will have to talk to my wife about this"

A

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

A

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

A

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

A

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

A

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

A

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

A

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? A. Ask another nurse to observe the medication wastage B. Notify the pharmacy when wasting the medication C. Lock the remaining medication in the controlled substance cabinet D. Dispose of the vial with the remaining medication in a sharps container

A

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? A. check the client for injuries B. move hazardous objects away from the client C. notify the provider D. ask the client to describe how she felt prior to the fall

A

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

A

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

A

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? A. "Use the complete name of the medication Magnesium Sulfate" B. "Delete the space between the numerical dose and the unit of measure" C. " Write the letter U when noting the dosage of insulin" D. "Use the abbreviation SC when indicating an injection"

A

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

A

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

ACD

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

B

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

B

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

B

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

B

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

B

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

B

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? A. Carry a client's soiled linens out of the room in a mesh linen bag B. Place a client who has TB in a room with a negative-pressure airflow C. Provide disposable plates and utensils for a client who is HIV positive D. Dispose of a client's bloods saturated dressing in a trash bag inside a second trash bag

B

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

B

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

B

A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client? A. Gown B. N95 respirator C. Shoe cover D. Surgical cap

B

A nurse is planning to insert a peripheral IV catheter for an older adult client. which of the following actions should the nurse plan to take? A. Insert the catheter at a 45 angle B. Place the client's arm in a dependent position C. Shave excessive hair from the insertion site D. Initiate IV therapy in the veins of the hand

B

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse sue to communicate continuity of care? A. Critical pathway B. Situation, background, assessment, and recommendation (SBAR) C. Transfer report D. Medication Administration Record (MAR)

B

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

B

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

B

A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines? A. A nurse who is caring for a client review the client's medical chart with a nursing student who is working with the nurse B. A nurse asks a nurse from another unit to assist with documentation for a client C. A nurse who is caring for a client returns a call to the person appointed in the health care proxy to discuss the client's care D. A nurse discusses a client's status with the PT who is caring for the client

B

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

BDE

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

C

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

C

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

C

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

C

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

C

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? A. Wear sterile gloves when removing the old dressing B. Warm the irrigation solution to 40.5 C (105F) C. Cleanse the wound from the center outward D. Use a 20 mL syringe to irrigate the wound

C

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

C

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

C

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

C

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

C

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

C

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

C

A nurse is reviewing a client's medication prescription that reads, "Digoxin 0.25 by mouth everyday." Which of the following components of the prescription should the nurse verify with the provider? A. Medication name B. Route of administration C. Medication dose D. Frequency of administration

C

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

C

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

C

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. A. Inject 5 units of air into the bottle of regular insulin B. Withdraw the correct dose of NPH insulin from the bottle C. Inject 10 units of air into the bottle of NPH insulin D. Withdraw the correct dose of regular insulin from the bottle

CADB

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

D

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

D

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

D

A nurse is caring for a client who ahs recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understand the use of this assistive device? A. "This type of hearing aid does not allow for fine tuning of volume" B. "I shouldn't have trouble keeping the hearing aid in place during exercise" C. "I expect to hear a whistling sound when I first insert the hearing aid" D. "I will be sure to remove my hearing aid before taking a shower"

D

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client? A. Have the client wear a mask when receiving visitors B. Limit the client's time with visitors to no more than 30 minutes per day C. Assign the client to a room with negative-pressure airflow exchange D. Wear a gown when caring for the client

D

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies? A. Biofeedback B. Aloe C. Feverfew D. Acupunture

D

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? A. Place the client in high-Fowler position B. Increase the client's intake of carbohydrates C. Massage reddened areas with unscented lotion D. Have the client use a trapeze bar when changing positions

D

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

D

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

D

A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action? A. Encourage the client to relax and take deep breaths during the dressing change B. Educate the client about the importance of the dressing change to prevent infection C. Assist the client to a comfortable position for the dressing change D. Administer pain medication 45 minutes before changing the client's dressing

D

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

D

A nurse receives a report on a client who is receiving 0.9% sodium chloride at 125 mL/hr. When the nurse performs the initial assessment she notes that the client has received 80 mL for the last 2 hrs. Which of the following actions should the nurse first take? A. Reposition the client B. Document the client's IV intake in the medical record C. Request a new IV fluid prescription D. Check the IV tubing for obstruction

D