ATI Fundamentals
A nurse is teaching a client how to use an albuterol metered-does inhaler. After removing the cap from the inhaler and shaking the canister, what sequence of instructions should the nurse give the client? -Hold your breath for 10 seconds. -Tilt your head back slightly and open your mouth wide -Depress the canister while taking a slow, deep breath -Hold the mouthpiece 1 to 2 inches in front of your mouth
-Hold the mouthpiece 1 to 2 inches in front of your mouth -Tilt your head back slightly and open your mouth wide -Depress the canister while taking a slow, deep breath -Hold your breath for 10 seconds
A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate? A. Airborne B. Droplet C. Contact D. Protective environment
A. Airborne
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse perform first after discovering that the client's wound has eviscerated? A. Cover the incision with a moist sterile dressing B. Have the client lie on his back with his knees flexed C. Call the client's surgeon D. Reassure the client
A. Cover the incision with a moist sterile dressing
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 admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take? A. Establish client outcomes B. Collect information about past health problems C. Determine whether the client has met specific goals D. Identify the client's specific health problems
A. Establish client outcomes The planning phase of the nursing process includes developing goals and outcomes that help the nurse create the client's plan of care.
A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment items should the nurse don prior to providing client care? (select all that apply) A. Gown B. Gloves C. Mask D. Hair cover E. Goggles
A. Gown B. Gloves
A nurse is caring for a client who has a stage II pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer? A. Hydrocolloid B. Collagen C. Calcium alginate D. Proteolytic enzyme
A. Hydrocolloid This dressing is applied to absorb exudate and to produce a moist environment that will facilitate healing.
A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? A. Loss B. Trust C. Self-disclosure D. Risk-taking
A. Loss At the close of a relationship, even when planned, loss is an expected feeling for both the client and the nurse.
A nurse is preparing to administer medication to a client who has a 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 in a provider's office is measuring a client and notes a loss in height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders? A. Osteoporosis B. Scoliosis C. Kyphosis D. Lordosis
A. Osteoporosis
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 the lemon-glycerin sponges
A. Place the client in a lateral position with the head turned to the side before beginning the procedure This position reduces the risk of aspiration.
A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? A. Place the client in the Trendelenburg position B. Perform percussions directly over the client's bare skin C. Use a flattened hand to perform percussions D. Remind the client that chest percussions can cause mild pain
A. Place the client in the Trendelenburg position This position promotes drainage from the client's left lower lobe.
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 everyday D. Place an aspiring 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 client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? A. Blow into the spirometer to elevate the balls in the device B. Cough deeply after each use C. Clean the mouthpiece with an alcohol swab after each use D. Use the spirometer every 8 hr
B. Cough deeply after each use Proper use of the incentive spirometer loosens secretions in the client's lungs.
A nurse is performing an otoscopic examination of a client's right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding? A. Obtain an audiology referral B. Document this as an expected finding C. Irrigate the ear with warm water D. Document mild inflammation
B. Document this as an expected finding
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 This can indicate poor circulation and tissue perfusion.
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 measuring a client's vital signs. The client's resting radial pulse rate is 55/min. Which of the following actions should the nurse take next? A. Document the finding B. Measure the client's apical pulse rate C. Talk with the client about factors that can affect the pulse rate D. Notify the provider about the client's radial pulse rate
B. Measure the client's apical pulse rate
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 charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? A. Obtaining hydrogen peroxide for tracheostomy care B. Obtaining cotton balls for tracheostomy care C. Obtaining sterile gloves for tracheostomy care D. Obtaining a sterile brush for tracheostomy care
B. Obtaining cotton balls for tracheostomy care These can be aspirated in the opening.
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 This will help stimulate saliva production, which aids chewing and swallowing.
A nurse is caring for a client in a long-term care facility. Which of the following findings should alert the nurse to the possibility that the client has developed delirium? A. Gradual memory loss B. Reduced level of consciousness C. Difficulty with abstract thought D. Verbalized feelings of hopelessness
B. Reduced level of consciousness
A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who is scheduled for emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? A. The client asks the nurse to repeat the instructions before attempting the exercises B. The client reports severe pain C. The client asks the nurse how often deep breathing should be done after surgery D. The client tells the nurse that this exercise will probably be painful after surgery
B. The client reports severe pain
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 take? 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 a 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 a bed."
A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take? A. Instruct the client to blink several times after instilling the medication B. Ask the client to look straight ahead during instillation of the medication C. Apply pressure to the puncta after instilling the medication D. Place each drop of the medication directly onto the client's cornea
C. Apply pressure to the puncta after instilling the medication
A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record to the client's bedside and perform which of the following verification procedures? A. Check the client's name and medical record number on the MAR against the room and bed number B. Call the client by name and check the name on her identification band against the MAR C. Compare the medical record number and name on the MAR with the client's identification band D. Ask the client's visitor to identify the client by name and to state the client's birth date
C. Compare the medical record number and name on the MAR with the client's identification band
A nurse is planning care for a young adult client who has a terminal illness. Which of the following concepts of death should the nurse consider for this client? A. Death is unacceptable under any circumstances B. Magical thinking helps avoid thoughts of death C. Death is viewed as an interruption of what might have been D. Death is a natural consequence of a deteriorating body
C. Death is viewed as an interruption of what might have been
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 the current eating habits D. Instruct the client to perform 30 min of vigorous exercise daily
C. Determine the client's intention to change the current eating habits
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 Diuresis or polyuria is the excretion of a high volume of urine.
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 degrees 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 degrees 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 the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client's HIV infection status. Which of the following actions should the nurse take? A. Inform the guard that the warden must request this information B. Ask the guard to sign a release of information form C. Instruct the guard to ask the inmate D. Complete an incident report
C. Instruct the guard to ask the inmate The nurse is not able to supply this information to the guard. In order to obtain this information, the client must offer the information freely.
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 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 Incomplete proteins are missing 1 or more of the essential amino acids necessary for the synthesis of protein in the body. Other examples are vegetables, grains, nuts, and seeds.
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 lost 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 planning to document care provided for a client. Which of the following abbreviations should the nurse use? A. BT for bedtime B. SC for subcutaneously C. PC for after meals D. HS for half-strength
C. PC for after meals
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 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?
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 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 caring for a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect injury to which of the following areas of the brain? A. Hypothalamus B. Cerebral cortex C. Pituitary D. Cerebellum
D. Cerebellum The nurse should suspect an injury to the cerebellum if the client is experiencing difficulty controlling balance and coordination.
A nurse is teaching a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes? A. Identify the risks of nonadherence B. Schedule learning sessions to demonstrate the psychomotor skills the client will need C. Provide clearly written and easy-to-understand materials D. Help the client identify ways that these changes will result in positive personal outcomes
D. Help the client identify ways that these changes will result in positive personal outcomes
A client who has glaucoma of the right eye self administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following actions should the nurse take? A. Confirm that the client performed the procedure correctly B. Instruct the client to look at the floor while instilling the eye drop C. Remind the client to avoid using a facial tissue after installation D. Instruct the client to apply pressure to the inside corner of the eye after installation
D. Instruct the client to apply pressure to the inside corner of the eye after installation
A nurse is reviewing a client's laboratory results and notes a WBC count of 3600/mm^3. The nurse should identify this result as which of the following conditions? A. Leukoplakia B. Leukemia C. Leukocytosis D. Leukopenia
D. Leukopenia Occurs when there is a decrease in the production of WBCs.
A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse include? A. Serve foods at warm or got temperatures B. Offer the client low-density foods C. Make sure the client lies supine after meals D. Limit drinking liquids with foods
D. Limit drinking liquids with foods Drinking beverages with food leads to early satiety and bloating, which results in the client consuming fewer calories.
A nurse is leading an education session about disposing of biohazard materials. Which of the following instructions should the nurse include in the teaching? A. Use isopropyl alcohol to clean blood spills B. Discard empty blood bags in a bedside trash can C. Break used needles before discarding D. Place soiled linen in a single linen bag
D. Place soiled linen in a single linen bag
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? A. Auscultate the blood pressure at the dorsalis pedis artery B. Measure the blood pressure with the client sitting on the side of the bed C. Place the cuff at 7.6 cm (3 in) above the popliteal artery D. Place the bladder of the cuff over the posterior aspect of the thigh
D. Place the bladder of the cuff over the posterior aspect of the thigh
A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the following functional classifications? A. Skeletal muscle relaxants B. Beta-adrenergic blockers C. Broad-spectrum anti-infective agents D. Plasma volume expanders
D. Plasma volume expanders They help correct hypovolemia in emergency situations.
While in the hospital, a client who has a terminal illness tells the nurse, "I can't believe I'm dying. A lot of people in the world are healthy, and here I am dying!" Which of the following responses should the nurse provide? A. Everyone dies sometimes; some die sooner than others B. Who do you think deserves to die more than you? C. It does seem unfair, doesn't it? D. Tell me more about how you feel about dying
D. Tell me more about how you feel about dying
A nurse is preparing to administer an afternoon does of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following entries should the nurse enter into the client's medical record? A. The client refused to take the medication today B. The client stated, "I will not take this pill" C. The client seemed angry and hostile D. The client threw the medication on the floor
D. The client threw the medication on the floor
A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client? A. Vastus lateralis B. Dorsogluteal C. Deltoid D. Ventrogluteal
D. Ventrogluteal This is the safest injection site for all adults because it contains thick gluteal muscles and does not contain major nerves or blood vessels.
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 using the I-SBAR communication tool to give a client's provider information about the client. The nurse should convey the client's pain status in which portion of the report? A. Assessment B. Background C. Situation D. Recommendation
A. Assessment
A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states, "It's too late for me to quit." Which of the following actions should the nurse take? A. Assist the client in finding local smoking-cessation assistance programs B. Tell the client that she will be all right after receiving medical care C. Inform the client that she must stop smoking or the provider will not be able to care for her D. Advocate for the client by supporting her statement about not quitting
A. Assist the client in finding local smoking-cessation assistance programs
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 The nurse should listen for bowel sounds before palpating.
A nurse is caring for a postoperative client who has an indwelling urinary catheter for gravity drainage. The nurse notes no urine output in the past 2 hrs. Which of the following actions should the nurse take first? A. Check to determine if the catheter tubing is kinked B. Palpate the bladder C. Obtain a prescription to irrigate the catheter with 0.9% sodium chloride D. Encourage the client to drink more fluids
A. Check to determine if the catheter tubing is kinked
A nurse is caring for a group of clients. Which of the following tasks should the nurse assign to an assistive personnel? A. Provide oral care to a client who cannot take oral fluids B. Check a client's IV insertion site for manifestations of infiltration C. Assess a client's ability to ambulate D. Demonstrate the use of a glucometer to a client who has diabetes mellitus
A. Provide oral care to a client who cannot take oral fluids
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 This prevents contaminating the label with spilled medication.
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 Stress causes an increased secretion of cortisol, which can lead to hypertension and hyperglycemia.
A nurse in a rehabilitation facility is observing an assistive personnel help a client transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse that the AP understands how to perform this task? A. Locking the brakes on the bed and the wheelchair before moving the client B. Lowering the footplates of the wheelchair before the transfer C. Placing the wheelchair perpendicular to the bed D. Placing the wheelchair on the client's weaker side prior to the transfer
A. Locking the brakes on the bed and the wheelchair before moving the client
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 mins. 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 bedisde
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 This type of drainage contains large amounts of red blood cells, indicating that damaged capillaries are allowing the escape of red blood cells from the plasma.
A nurse is screening a client who has an S-shaped spinal column with unequal shoulder heights. The nurse should identify these findings as manifestations of which of the following abnormalities? A. Scoliosis B. Lordosis C. Torticollis D. Kyphosis
A. Scoliosis
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 is assessing a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields? A. Vesicular B. Bronchial C. Rhonchi D. Bronchovesicular
A. Vesicular These sounds are soft and low-pitched.
A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? A. Vitamin C and zinc B. Vitamin D C. Vitamin K and iron D. Calcium
A. Vitamin C and zinc
A nurse is caring for a client who has a Clostridium difficile infection and is in contact isolation. Which of the following actions should the nurse take? A. Wear gloves when changing the client's gown B. Use alcohol-based sanitizer to cleanse the hands C. Wear a mask when assisting the client with his meal tray D. Place the client on complete bed rest
A. Wear gloves when changing the client's gown
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 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 anti-anxiety medication
B. Accompany the client back to his room
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 this equipment bother you? D. Let me tell you about what each machine does
B. All of this equipment can be frightening
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 performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first? A. Document the client's food allergies in the medical record B. Ask the client to identify the specific food allergies C. Monitor the client for indications of anaphylaxis D. Have epinephrine available for administration
B. Ask the client to identify the specific food allergies
A nurse is assessing a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries? A. Palpation of both carotid arteries simultaneously B. Auscultation of the arteries for bruits with the bell of the stethoscope C. Palpation of the arteries for murmurs bilaterally D. Auscultation of the arteries for thrills with the diaphragm of the stethoscope
B. Auscultation of the arteries for bruits with the bell of the stethoscope
A nurse is caring for a client who is recieving total parenteral nutrition. Which of the following actions should the nurse take? A. Administer 0.9% sodium chloride until TPN is available from the pharmacy B. Check the client's capillary blood glucose level every 4 hrs C. Obtain the client's weight weekly D. Change the IV tubing every 3 days
B. Check the client's capillary blood glucose level every 4 hrs This should be done due to the client's risk of hyperglycemia while receiving TPN.
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 hour D. Provide ice chips as per provider prescription
B. Check the client's vital signs
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 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 communication 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 changing the bed lines for a client who is on bed rest. Which of the following actions should the nurse perform? A. Place the soiled linens on the chair while making the bed B. Hold the linens away from the body and clothing C. Place the linens on the floor until a linen bag is available D. Shake the clean linens to unfold
B. Hold the linens away from the body and clothing
A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription states "clear liquids; advance diet as tolerated". Which of the following responses should the nurse make? A. Lunch trays should be here within the hour B. I am going to listen to your abdomen C. I'll get you some water to drink D. Let's wait a bit so you don't feel sick
B. I am going to listen to your abdomen A common reason clients experience nausea and vomiting after surgery is delayed gastric emptying time or decreased peristalsis. Nurse should determine the presence of bowel sounds before clear liquids can be given.
A nurse in a provider's office is teaching a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching? (select all that apply) A. Canned peaches B. White rice C. Black beans D. Whole-grain bread E. Tomato juice
C. Black beans D. Whole-grain bread
A nurse is teaching a middle-aged female client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of this client's routine health screening? A. Annual Papanicolaou (Pap) testing B. Mammogram every 2 years C. Eye examination every 2 years D. Annual colonoscopy
C. Eye examination every 2 years
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 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 caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? A. Tie the restraints to the side rails B. Perform range-of-motion exercises to the wrists every 3 hrs C. Remove the restraints one at a time D. Obtain a PRN prescription for the restraints
C. Remove the restraints one at a time
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 providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? A. Drink a minimum of 1000 mL of fluid daily B. Increase your intake of refined-fiber foods C. Sit on the toilet 30 min after eating a meal D. Take a laxative every day to maintain regularity
C. Sit on the toilet 30 min after eating a meal
A nurse is performing an abdominal assessment of a client. Which of the following positions should the nurse tell the client to assume for this examination? A. Lithotomy B. Lateral C. Supine D. Sims'
C. Supine
A nurse in an urgent-care center is caring for a 15-year old client whose symptoms suggest a sexually transmitted infection. The client's parent is unavailable, but the client's grandmother accompanied the client to the clinic. Which of the following actions should the nurse take? A. Explain that the treatment can wait until the parent is available B. Inform the grandmother that she may give consent for the treatment C. Invoke the principle of implied consent and prepare the client for treatment D. Ask the adolescent to sign the consent form
D. Ask the adolescent to sign the consent form
A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings is another clinical manifestation of fluid volume excess? A. Sunken eyeballs B. Hypotension C. Poor skin turgor D. Bounding pulse
D. Bounding pulse
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 caring for a client who requires a dressing change. Which of the following actions should the nurse take? A. Clean the incision from bottom to top B. Apply sterile gloves prior to opening dressing packages C. Remove the tape by pulling away from the wound D. Clean the drain site from the center outward
D. Clean the drain site from the center outward
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 providing preoperative teaching to a client who is scheduled for arthroplasty in the next month and may require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse share with the client? A. Ask your provider to prescribe epoetin before the surgery B. You should ask your provider about taking iron supplements prior to the surgery C. Ask a family member to donate blood for you D. Donate autologous blood before the surgery
D. Donate autologous blood before the surgery Autologous blood is the safest form of blood transfusion because exclusive use of a client's own blood eliminates exposure to a transfusion-transmitted infection.
While admitting a client to the medical unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able." The nurse should identify that the client if referring to which of the following documents? A. Informed consent form B. Living will document C. Do not-resuscitate (DNR) directive D. Durable power of attorney document
D. Durable power of attorney document
A nurse is discussing fire safety with newly hired nurses. Which of the following actions is the priority if a fire occurs in the health care facility? A. Close the fire doors on the unit B. Use a fire extinguisher on the fire C. Pull the nearest fire alarm D. Evacuate clients from the unit
D. Evacuate clients from the unit
A nurse in a long-term care facility is in the dining room while residents are eating lunch. One resident begins to choke and is coughing strongly. Which of the following actions should the nurse take? A. Assist the client to the floor B. Perform an abdominal thrust C. Open the airway with a head-chin tilt D. Observe the client closely
D. Observe the client closely As long as the client is able to cough strongly, the nurse does not need to intervene.
During the insertion of a urinary catheter for a client, the tip of the catheter brushed against the nurse's arm. Which of the following actions should the nurse take? A. Wipe the catheter with povidone-iodine and continue the catheter insertion B. Soak the catheter in chlorhexidine for 15 mins and then reattempt insertion C. Continue with the catheter insertion D. Obtain a new catheter and reattempt insertion
D. Obtain a new catheter and reattempt insertion
