ATI- Fundamentals

A nurse is admitting a client who has decreased circulation in his left leg. which of the following actions should the nurse take first? -evaluate pedal pulses -obtain a medical history -measure vital signs -assess for leg pain

evaluate pedal pulses --it's essential to determine if there is adequate blood supply to the foot

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? -press gently on the tragus of the client's ear -pack a small piece of cotton deep into the client's ear canal -move the client's auricle down and back toward her head -tilt the client's head backward for 5 min.

press gently on the trigs of the client's ear --this will help the medication get into the inner ear

A nurse is evaluating the development of a group of clients. According to Erikson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development? -middle adulthood -adolescence -childhood -young adulthood

young adulthood

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

"Try to block the urge to urinate until the next scheduled time." --The client is set to follow a schedule of voiding intervals. Instruct him to take slow, deep breaths and try 5-6 pelvis exercises to help reduce the urge.

A middle aged 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? -"We miss our daughter so much that we are going to move closer to her." -"I really wish I could lose some of this weight." -"I think this year I can plan on managing the funding at church" -"I find I am spending more time at work now that my son is at college."

"We miss our daughter so much that we are going to move closer to her." --the stage of development for older adults is generatively vs. stagnation. accepting the independence of your children is part of this developmental stage.

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? -"It's for your safety. Dentures can slip and block your airway during surgery" -"You wouldn't want your teeth to be lost or broken during surgery, would you?" -"The anesthesiologist requires all clients to remove their dentures." -"what worries you about being without your teeth?"

"what worries you about being without your teeth?"

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? -The client holds the hand with the palm up -the client holds the hand with the palm down -the client points the fingers toward the floor -the client points the fingers towards the ceiling

-the client holds the hand with the palm up

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? -Numbness of the extremeties -bradycardia -positive chvostek's sign -abdominal cramping

Abdominal cramping --manifestations of hyponatremia include abdominal cramping, weakness, confusion, lethargy, headache, and nausea

A nurse is preparing to administer enoxaparin subcutaneously to a client. which of the following actions should the nurse take? -Administer the medication with he needle at a 45 degree angle -administer the medication into the client's nondominant arm -pull the client's skin laterally or downward prior to administration -massage the injection site after administration

Administer the medication with the needle at a 45 degree angle --should be administered at a 45-90 degree angle

A nurse is supervising a newly licensed nurse who is suctioning a client's tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? -Using clean technique to perform the procedure -Applying suction while inserting the catheter -lubricating the suction catheter with an oil-based lubricating jelly -Administering high-flow O2 prior to the procedure

Administering high-flow O2 prior to the procedure --Administer 3-4 breaths of 100% O2 prior to suctioning the client to reduce the risk of hypoxia

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

Advocacy ensures client's safety, health, and rights --advocacy is. key component of a professional nurses' code of ethics.

A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate? -Airborne -Droplet -Contact -Protective environment

Airborne --Airborne precautions are for infections that spread via droplet nuclei, and include varicella, tuberculosis, pneumonia, and measles

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 -Assist the client with a partial bed bath -measure the clients BP after the nurse administers an antihypertensive medication -test the client's swallowing ability by providing thickened liquids -use a communication board to ask what the client wants for lunch -irrigate the client's indwelling urinary catheter

Assist the client with a partial bed bath, measure the client's BP after the nurse administers an antihypertensive medication, and use a communication board to ask what the client wants for lunch

A nurse in a provider's office is assessing 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. -Sunken eyeballs -hypotension -poor skin turgor -bounding pulse

Bounding pulse

A nurse is caring for a client who requires ventilatory assistance with breathing following a MVA. The nurse should suspect an injury to which of the following parts of the brain? -Brainstem -Cerebral cortex -Cerebellum -hypothalamus

Braintstem --injury to the medulla and pons of the brainstem result in difficulty breathing.

A nurse is caring for a client who is having difficulty with muscle coordination following a head injury. The nurse should expect injury to which of the following areas of the brain? -hypothalamus -cerebral cortex -pituitary -cerebellum

Cerebellum --the client is experiencing difficulty with balance and coordination

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? -Change the colostomy bag following breakfast -cleanse the skin around the stoma with warm water -change the much every day -place aspirin in the ostomy pouch to decrease odor

Cleanse the skin around the stoma with warm water --Using soap can leave a residue on the skin and cause poor adherence of the pouch

A nurse is conducting an admission interview with a client. which of the following pieces of assessment information -A client's level of comfort and ability to participate in the interview -Previous illnesses and surgeries -events surrounding the client's recent illness -sociocultural history

Client's level of comfort and ability to participate in the interview --the nurse should establish rapport and ensure comfort during the orientation phase of admission

A nurse is teaching a client who is post-op how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? -Blow into the spirometer to elevate the balls in the device -cough deeply after each use -clean the mouthpiece with an alcohol swab after each use -use the spirometer every 8 hr.

Cough deeply after each use

A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing? -CN XII -CN X -CN VIII -CN V

Cranial nerve X --the hypoglossal nerve innervates the tongue

A nurse is auscultation a client's lungs and identifies rhonchi over the trachea and bronchi. Which of the following actions should the nurse take? -Limit the client's fluid intake -Assist the client into a supine position -Administer O2 at 2 L/min -Encourage the client to cough

Encourage the client to cough

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? -change the topic because the client is trying to divert attention from the illness -encourage the client to express thoughts about death and dying -tell the client that religious beliefs are a personal matter -offer to contact the clients minister or the facility's chaplain

Encourage the client to express thoughts about death and dying --allowing the client to reflect on their own thoughts and feelings of death and dying represents the therapeutic technique of reflecting.

A nurse is working with the facility's language interpreter to explain a wound-care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when describing the procedure to the client. -Make eye contact with the interpreter -break sentences into shorter segments to allow time for interpretation -ensure the interpreter and the client speak the same dialect -speak in a loud tone of voice

Ensure the interpreter and the client speak the same dialect.

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? -autonomy -fidelity -nonmaleficence -justice

Fidelity --fidelity was met by keeping a promise that was made

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. This manifestation is consistent with which of the following eye disorders? -Retinopathy -Glaucoma -Cataracts -Macular Degeneration

Glaucoma --an obstruction to the nitrous humor leads to an increase in intraocular pressure that results in irreversible damage to the eye

A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside. Which of the following actions should the nurse take? -Hold the sterile drape above the waist and away from the body -drop sterile objects toward the edges of the sterile field -Hold packaged supplies 7.6 cm above the sterile field -Hold sterile objects over the field before setting them down on the field

Hold the sterile drape above the waist and away from the body --the sterile field is considered contaminated if any object falls below waist level or if you touch anything other than a sterile object

A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care-associated infections (HAI). Which of the following routes of infection should the manager identify as an iatrogenic HAI? -Infection acquired from improper hand washing -infection acquired by drug resistance -infection acquired by inappropriate waste disposal -infection acquired from a diagnostic procedure

Infection acquired from a diagnostic procedure.

A nurse who 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? -it provides a distraction from the pain -it modulates the transmission of the pain impulse -it promotes increased circulation to the painful area -it elicits a relaxation response

It modulates the transmission of the pain impulse -- TENS can also cause a release of endorphins to assist in pain relief

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? -"When you go up a flight of stairs, place your right foot on the first step." -"Keep the rubber crutch tips securely in place" -"When standing, keep the crutches 12 inches in front of you and 12 inches to the side." -"Place your weight on the crutch pads at your armpits."

Keep the rubber crutch tips securely in place. --Crutches should never be used without a rubber cap.

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 responses should the nurse make? -"you would have so much more time to spend with your family" -"You should consider getting a part-time job or doing volunteer work." -"Let's talk about how the change in your job status will affect you." -"Why wouldn't you want to retire and relax?"

Let's talk about how the change in your job status will affect you --this is a therapeutic response, encouraging the client to verbalize feelings about their life

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? -Loss -Trust -Self-disclosure -risk-taking

Loss --even when planned, loss is an expected feeling for both the nurse and the client. It's important to close the relationship without feelings of guilt or anxiety

A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the clients body? -Heart -Lungs -Thyroid gland -Skin

Lungs --auscultation, palpation, and percussion are all used to evaluate hollow organs such as the lungs

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

Make sure that the client wears a mask when outside her room if there is construction in the area --an allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in environmental pathogens

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? -document the finding -measure the client's apical pulse rate -talk with the client about factors that can affect the pulse rate -notify the provider about the radial pulse rate

Measure the client's apical pulse rate --while this pulse rate is within normal limits, it's important for the nurse to assess both the radial pulse and the apical pulse to measure if there is a pulse deficit.

A nurse is caring for a child who is post-op following a tonsillectomy. Which of the following actions should the nurse take? -encourage the child to cough frequently to clear congestion from anesthesia -place a heating pad on the Child's neck for comfort -administer analgesics to the child on a routine schedule throughput the day and night -provide the child with ice cream when oral intake is initiated

Minister analgesics to the child on a routine schedule throughout the day and night --pain medication should be administered regularly to sooth throat pain.

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? -Assign the client to a private room -Keep 4 side rails up while the client is in bed -Monitor the client at least once every hour -Request a PRN prescription for restraints

Monitor the client at least once every hour --other interventions could include putting the bed in a low position, creating toileting schedules, and using a gait belt and assistive devices when walking

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

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

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? -insert the catheter at a 45 degree angle -place the client's are in a dependent position -shave the excess hair from the insertion site -initiate IV therapy in the veins of the hand

Place the client's arm in a dependent position --this will cause the veins to dilate due to gravity

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take? -Remove the NG tube -Advance the NG tube quickly -Pull the NG tube back slightly -Ask the client to tilt his head back

Pull the NG tube back slightly --the nurse should pull the tube back and instruct them to breathe slowly. Once relaxed, the nurse should gently advance the tube as they swallow.

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? -Change the infusion tubing -flush the IV catheter -remove the IV catheter -apply a cool compress to the site

Remove the IV catheter --the manifestations suggest phlebitis. the IV should be removed and then apply a warm compress to the site.

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? -Renew the prescription for the use of restraints within 24 hours -Secure the restraint with the buckle side next to the client's skin -Ensure 4 fingers can be inserted under the secured restraint -Remove the restraint every 3 hr.

Renew the prescription for the use of restraints within 24 hr. --Only two fingers should be able to fit underneath restraints, and they should be removed every 2 hr to check skin condition and to toilet or exercise

A nurse delegates the collection of a client's temperature to an assistive personal (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 happening? -Right task -Right circumstance -Right person -Right communication

Right communication --the nurse was not concise about the specific type of vitals that were required for this patient.

A nurse is performing a neurological assessment of a client. to promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests? -Romberg -Kinesthetic sensation -2-point discrimination -Weber

Romberg --the Romberg test evaluates standing balance, the nurse should remain nearby in case the client fails the test

A nurse is preparing a change-of-shift report. which of the following tools or documents should the nurse use to communicate continuity of care? -critical pathway -situation, background, assessment, and recommendation (SBAR) -transfer report -medication administration record (MAR)

Situation, background, assessment, and recommendation (SBAR)

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? -The client uses a wool blanket on the bed -the client identifies the location of a fire extinguisher -the client stores an extra oxygen tank on its side under the bed -the client has a weekly inspection checklist for oxygen equipment

The client identifies the location of a fire extinguisher

A nurse is preparing to administer an afternoon dose 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? -the client refused to take medication today -the client stated "I will not take this pill" -the client seemed angry and hostile -the client threw the medication on the floor

The client threw the medication on the floor --the nurse should document exactly what took place to provide a factual account of the events

An at home health nurse us 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? -The client is receiving formula to room temperature -The feedings infuse at a slow, continuous drip over 8hr each night -The client's caregiver washes out the feeding bag with warm water once every 24 hours. -The client's caregiver flushes the tubing with water before and after administering medications

The client's caregiver washes out the feeding bag with warm water once every 24 hours --feeding bags should be washed out after EVERY feeding, and replaced with a new bag every 24 hours.

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? -The deceased was a close friend -the client lived far from the deceased -the death was sudden -the client has not visited the de ceased in a long time

The death was sudden

A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? -fasten the ties on the restraint to the side rails of the bed -tie the restraint with a quick-release knot -allow a finger breadth between the restraint and the client's chest -place the restraint under the client's clothing

Tie the restraint with a quick-release knot --this knot can be released quickly in case the client's wellbeing requires that they be removed quickly

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? -use a bed exit alarm system -raise four side rails while the client is in bed -apply one soft wrist restraint -dim the lights in the client's room

Use a bed exit alarm system --the nurse should identify that a client with dementia requires assistance when exiting their bed and might be unable to remember to ask for help.

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? -combine client care tasks when caring for multiple patients -wait until the end of the shift to document client care -use the planning step of the nursing process to prioritize client care delivery -allow for interruptions in tasks to discuss client care issues with colleagues

Use the planning step of the nursing process to prioritize client care delivery --Setting up a list of goals and tasks for clients can help the nurse set care priorities and plan tasks accordingly.

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions would the use include in the teaching? -remove the outer cannula cautiously for routine cleaning -use tracheostomy covers when outdoors -use sterile technique when performing tracheostomy care at home. -cleanse irritated skin with full-strength hydrogen peroxide

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

A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use? -Deltoid -ventrogluteal -vastus lateralis -dorsogluteal

Vastus lateralis --anterior thigh is used for IM injections in infants and children

A nurse is caring for a middle-aged 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? -"Am I comfortable with my decision to choose a lifelong partner." -"I think I have done a good job with my children since they are all independent now" -"As I look back over my life, I can see that I have achieved most of the goals I set for myself." -"I love my work so much that it's difficult to think about retirement."

"I think I have done a good job with my children since they are all independent now" --the developmental task for the middle adult is generatively vs. stagnation. Helping their children gain independence indicates that the client has completed this task.

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

"I will hire someone to train the tree that hangs low over the stairs of my front porch" --clearing objects from the clients path that might trip them will decrease the risk of falls

A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP indicates that further teaching is required? -"I should not leave all 4 side rails cup unless there is a prescription for restraints." -"An alert client will be safest If I raise the 2 upper side rails at the head of the bed." -"If the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself." -"If a client is sedated, I should raise all 4 side rails to prevent a fall out of bed."

"If the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself."

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

"Is your pain sharp or dull?" --sharp, dull, crushing, throbbing, aching, burning, shooting, are all good words to describe the quality of pain

A nurse is preparing to administer 40 mL of 0.9% sodium chloride IV to infuse over 20 min. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round to the nearest whole number)

30 gtt/min

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 2oz. What total output in mL should the nurse document for this 8 hr period? (round to the nearest whole number)

770

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following pieces of information should the nurse include? -A 2-month-old infant can turn from his abdomen to his back -A 10-month-old infant can pull up to a standing position -A 4-mont-old infant can sit up without support -A 6-month-old infant can crawl on his hands and knees

A 10-month-old infant can pull up to a standing position

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

A mole with an asymmetrical appearance --uneven or asymmetrical shape is an indication of skin malignancy and should always be reported

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? -insert the suction catheter while the client is swallowing -apply intermittent suction when withdrawing the catheter -place the catheter in a location that is clean and dry for later use -hold the suction catheter with her clean, non dominant hand

Apply intermittent suction when withdrawing the catheter --prevents injury to the mucosa, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise

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? -Assist the client in finding local smoking-cessation assistance programs -tell the client that she will be all right after receiving medical care -inform the client that she must stop smoking or the provider will not be able to care for her -advocate for the client by supporting her statement about not quitting

Assist the client in finding local smoking-cessation assistance programs

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? -Attempt to increase the client's self-motivation -Keep detailed records of each client's progress. -Test client learning after each teaching session -Avoid discussing topics that might increase client's anxiety

Attempt to increase the client's self-motivation

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? -Retention -Oliguria -Diuresis -Dysuria

Diuresis

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? -Independent moral development -acceptance of body changes -strengthening ties with the family of origin -development of concrete reasoning

Independent moral development

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? -Eggs -Soybeans -Lentils -Yogurt

Lentils --incomplete proteins are missing 1 or more of the essential amino acids required for the synthesis of protein in the body. These include lentils, veggies, grains, nuts, and seeds

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? -Assist the client to the floor -perform an abdominal thrust -open the airway with a head-chin tilt -observe the client closely

Observe the client closely --as long as the client is able to cough strongly, the nurse does not need to intervene

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? -Encourage the client to drink fluids before swallowing food -Offer the client tart or sour foods first -tilt the client's head backwards when swallowing -Turn on the TV

Offer the client tart or sour foods first -- tart and sour foods stimulate saliva production

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? -pad the client's wrist before applying the restraints -evaluate the client's circulation every 8hr after application -remove the restraints every 4hr to evaluate the client's status -secure the restraint ties to the bed's side rails

Pad the client's wrist before applying the restraints --the use of restraints without padding can abrade the client's skin and result in injury

A nurse is monitoring a client's lab results. Which of the following results should the nurse report to the provider? -Sodium 140 mEq/L -Potassium 3.0 mEq/L -Chloride 100 mEq/L -Magnesium 2.0 mEq/L

Potassium 3.0 mEq/L

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? -discuss the risk factors for colon cancer -focus teaching on what the client will need to do in the future to manage his illness -provide the client with written information about the phases of loss and grief reassure the client that this is an expected response to grief

Reassure the client that this is an expected response to grief --the nurse should support the client and explain that anger is an expected reaction in the stages of grief related to his cancer diagnosis

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? -offer the client a nutritious snack -accompany the client back to his room -reorient the client to his surroundings -administer a PRN anti anxiety medication

accompany the client back to his room --it's the nurses priority to prevent harm to the patient by directing him back to his room to prevent the risk of injury due to wandering

A nurse is assessing a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries? -Palpation of both carotid arteries simultaneously -auscultation of the arteries for bruits with the bell of the stethoscope -palpation of the arteries for murmurs bilaterally -auscultation of the arteries for thrills with the diaphragm of the stethoscope

auscultation of the arteries for bruits with the bell of the stethoscope --the bell of the stethoscope is more effective than the diaphragm in transmitting blowing or swishing sounds that come from turbulence in the blood vessels.

A nurse is reviewing the lab values of a client who has a positive chvostek's sign. Which of the following lab findings should the nurse expect? -Decreased calcium -decreased potassium -increased potassium -increased calcium

decreased calcium --calcium is necessary for nerve conduction and muscle contractions. with a low calcium, muscle spasms and tetany might occur

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? -Tenderness when touched -pink, shiny tissue with a granular appearance -serosanguineous drainage -halo of erythema on the surrounding skin

halo of erythema on the surrounding skin --a ring of redness around the skin could indicate an underlying infection

A nurse is planning to perform PROM exercises for a client. Which of the following actions should the nurse take? -repeat each joint motion 5 times during each session -move the joint to the point of considerable resistance -sit approx. 2ft from the side of the bed closest to the joint being exercised -exercise the smaller joints first

repeat each joint motion 5 times during each session.

A nurse is caring fore 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? -start chest compressions -provide breaths with a manual resuscitation bag -administer oxygen -establish an airway

start chest compressions --check your ABC's! maintaining blood flow is essential to oxygenation of the body.

A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take? -Continue the teaching, but check afterward with the surgeon about informed consent -stop the teaching and check with the surgeon about informed consent -Stop the teaching and ask the client to sign an informed consent form. -Continue the teaching and check the client's medical record afterward for a signed consent

stop the teaching and check with the surgeon about informed consent

A nurse is applying antiembolitic stockings for a client who has a history of DVT's. Which of the following actions should the nurse take when applying the stockings? -Roll the stocking partially down if too long -Remove the stocking once per day -bunch and pull the stocking halfway up the calf -turn the sticking inside out up to the heel before applying

turn the sticking inside out up to the heel before applying