ATI PN Fundamentals Online Practice 2020 B with NGN

A nurse is documenting client care in a client's electronic health record. Which of the following entries should the nurse include in the documentation? a. complained about having incisional pain b. voided adequate amounts through the shift c. became short of breath when ambulating d. appeared to be sleeping while in bed

"Became short of breath when ambulating." The nurse should include objective and significant information about the client when documenting client data in the electronic health record. -The nurse should avoid using words that reflect personal judgment about the client's behavior, such as "complained." -The nurse should avoid including subjective information when documenting client data in the electronic health record. -The nurse should avoid including nonessential information or vague terminology when documenting client data in the electronic health record.

A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that they are afraid to go to sleep, fearing they will not wake up. Which of the following therapeutic response the nurse should make? a. "I will have the nursing staff check on you frequently during the night shift" b. "You are right to be afraid. This place is new to you" c. "I will give you your prescribed sleep medication to help you fall asleep" d. "describe your concerns about sle

"Describe your concerns about sleeping to me." This statement is open-ended and allows for further communication. This addresses the client's concerns and builds trust.

A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify the client's religious preferences? a. "do you receive holy communion?" b. "do you follow a kosher diet?" c. "do you consume pork products? d. "do you oppose receiving a blood transfusion if it is needed?"

"Do you consume pork products?" Some clients who practice Islam do not consume pork or alcohol.

A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask? a. "what types of foods have you been eating?" b. "are you using stool softeners or laxatives?" c. "have you been passing gas?" d. "have you had small liquid stools?"

"Have you had small liquid stools." Using the nursing process, the first action the nurse should take is to collect data from the client to determine if the client has any findings consistent with a fecal impaction. Therefore, the first question for the nurse to ask is if the client has had any small liquid stools, which can indicate that there is seepage of liquid feces around the impacted mass. -Flatus can be present even if the client has an impaction; however, there is another question the nurse should ask first. -The nurse should know what treatments the client might be using at home; however, there is another question the nurse should ask first. -The nurse should know what foods the client is eating to determine if they need to modify their diet; however, there is another question the nurse should ask first.

A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching? a. "I know that i can change my advance directives if I need to in the future." b. "my health care surrogate will make my healthcare decisions as soon as I have signed the power of attorney." c. "my family can overrule the decisions made by my health care surrogate" d. "advance directives from one state are v

"I know that I can change my advance directives if i need to in the future." The client can change their advance directives at their discretion. The client's health care surrogate will only make health care decisions when the client is unable to do so. The individual named as health care surrogate for a client has the legal authority to make decisions on the client's behalf and cannot be overruled by the client's family. The nurse should inform the client that laws regarding advance directives vary among different states. The nurse should be familiar with the laws regarding advance directives in the state of practice.

A nurse in a providers clinic is caring for a client who has heart failure. The nurse is evaluating the client's understanding of the teaching. Select three client statements that indicate an understanding of the teaching: a. "I know to call my doctor if I gain 3 pounds or more in 2 days" b. "I am eating fewer potato chips and more fruit for snacks" c. "I am limiting my sodium intake to 2 grams daily" d. "I am trying to decrease my intake of foods with potassium" e. "I have been weighing myself

"I know to call my doctor if I gain 3 pounds or more in 2 days" is correct. The client should monitor their weight daily and call their provider for a weight gain of 3 lb or greater in 2 days to prevent an exacerbation of their heart failure. "I am eating fewer potato chips and more fruit for snacks" is correct. Chips are a processed snack food that contain increased amounts of sodium. Additionally, fruits contain electrolytes and fiber, both of which are important in controlling blood pressure and lipid levels. "I am limiting my sodium intake to 2 grams daily" is correct. Clients who have heart failure should maintain a sodium intake of between 2 to 3 g daily.

A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure their blood pressure daily. Which of the following client statements indicates an understanding of the teaching? a. "I will wait 15 minutes after drinking coffee to measure my blood pressure." b. "I will measure my blood pressure while my arm is elevated above my heart." c. "I should remove constrictive clothing prior to measuring my blood pressure." d. "I should measure my blood pressure immediatel

"I should remove constrictive clothing prior to measuring my blood pressure." The nurse should instruct the client to remove constrictive clothing prior to measuring their blood pressure because constrictive clothing can cause falsely elevated blood pressure readings.

A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. Which of the following instructions should the nurse include in the teaching? a. you will need to sign a consent form before we begin the procedure b. I will place a gel pad directly above your pubic area before I place the probe c. you will need to hold your urine for 1 hour prior to the procedure d. you will receive a contrast dye through an IV catheter prior to the scan

"I will place a gel pad directly above your pubic area before I place the probe." The nurse should use a gel pad, which promotes ultrasound transmission and accurate measurement. The correct placement of the ultrasound device is just above the symphysis pubis.

A nurse is reinforcing teaching with a new parent who is concerned about sudden infant death syndrome (SIDS). Which of the following statements by the client indicates an understanding of the teaching? a. "I will place my baby on her side to sleep" b. "I should avoid giving my baby a pacifier" c. "I will remove all stuffed animals from my baby's crib" d. "I will cover my baby with a light blanket when she is sleeping"

"I will remove all stuffed animals from my baby's crib." The nurse should reinforce the need to remove all stuffed animals and toys when the infant is sleeping to reduce the risk for SIDS.

A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make? a. "It must be difficult facing this type of surgery." b. "other clients who have had this surgery have done just fine" c. "this facility is known for providing excellent care for people who need this type of surgery" d. "I can request a sleeping pill if you think that will help"

"It must be difficult facing this type of surgery." Stating that it must be difficult to be in this position is an open-ended and nonjudgmental statement that allows the client to talk about their fears.

A nurse is caring for a client who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment ? a. "perform muscle relaxation before bedtime." b. "exercise vigorously 1 hour prior going to bed" c. "drink a cup of hot chocolate at bedtime" d. "change the time you go to sleep each day"

"Perform muscle relaxation before bedtime." The nurse should encourage the client to perform muscle relaxation to reduce anxiety and induce sleep.

A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following clients statements presents an ethical dilemma? a. "I might file a lawsuit because of how my surgery went" b. "please don't tell my doctor, but I am taking my partner's oxycodone" c. "please don't get me out of bed this morning. It hurts too much" d. "I don't want to take my medicine. It makes me sick to my stomach"

"Please don't tell my doctor, but I am taking my partner's oxycodone." This situation poses an ethical dilemma for the nurse because there is a conflict between what the client is asking of the nurse and the nurse's responsibility to protect the client from harm during hospitalization.

A nurse is reinforcing teaching with the caregiver of a client who is near death. Which of the following instructions should the nurse provide? a. encourage meals at least three times daily b. keeping the room warm will help the breathe easier c. help them onto their left side if they are experiencing nausea d. provide mouth care to them at least every 2 hours.

"Provide mouth care to them at least every 2 hours." Providing oral care as needed to a client who is near death will help reduce discomfort from dehydration, nausea, and dry mucous membranes.

A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed? a. "keep your feet close together" b. "tighten your stomach muscles" c. "straighten your knees" d. "bend at your waist"

"Tighten your stomach muscles." The nurse should instruct the client's partner to tighten the abdominal and gluteal muscles to help protect their back.

A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops. Which of the following instructions should the nurse include? a. "you will need to look to the side when putting drops in your eye" b. "you should put the drops directly in the center of your eyeball" c. "you should cleanse your eye form the inner to the outer edge prior to putting in the drops" d. "you should avoid pressing on the tear duct after putting the drops in your eye

"You should cleanse your eye from the inner to the outer edge prior to putting in the drops." The nurse should instruct the client to cleanse the eye from the inner to the outer canthus to prevent contamination of the lacrimal duct. The nurse should instruct the client to look up during instillation of the medication to help protect the cornea and to reduce blinking. The nurse should instruct the client to place the drops on the lower conjunctival sac to protect the cornea. The nurse should instruct the client to press on the nasolacrimal duct for 30 seconds after instillation to prevent systemic absorption of the medication.

choose the findings that indicate the client might be malnourished. -Client is cachectic with flaccid muscle tone. -Skin is dry and scaly with bruises on extremities. -Oriented to person, place, and time. -Client is able to move all extremities. -Pulse rate 118/min -Respiratory rate 18/min -Abdomen is distended -Temperature 39.2° C (102.5° F) -BMI 17

-Client is cachectic with flaccid muscle tone is correct. The client's lack of energy, flaccid muscle tone, and wasting appearance can be an indication of malnutrition. -Skin is dry and scaly with bruises on extremities is correct. The client's dry, scaly, and bruised skin can be an indication of malnutrition. -Pulse rate 118/min is correct. The client's tachycardia can be an indication of malnutrition. -Abdomen is distended is correct. The client's abdominal distention can be an indication of malnutrition. -BMI 17 is correct. A BMI of 17 is considered underweight and can be an indication of malnutrition.

A nurse is caring for a client who had a spinal cord injury and has paraplegia. Nurses Notes -Day 1:Client is alert and oriented to person, place, and time. Client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities performed once daily. -Day 5:Client is alert and oriented to person, place, and time. Client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities performed once daily. Feet are warm. Pedal pulses 2 + bilaterally. Plantar fl

-Passive range-of-motion exercises to lower extremities performed once daily is correct. The nurse should perform passive range-of-motion exercises to the client's lower extremities two to three times daily to reduce the risk for contractures. -Plantar flexion contractures noted bilaterally is correct. The nurse should place a foot board at the end of the client's bed or apply foot boots to the client's feet to protect the client's heels and decrease the contracture. -Left heel has 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema; skin is intact is correct. The client has a stage 1 pressure injury on their left heel. The nurse should apply foot boots to the client's feet to protect the client's heels and promote healing.

A nurse is admitting a client. The nurse is reviewing the client's medical record. Nurses Notes: -0930:Client reports a sore throat, productive cough, shortness of breath, and fever for the past 4 days. -1030:Client has swollen cervical lymph nodes on palpation. Client reports chills and coughs up yellow-colored mucus. Client's face is flushed and is diaphoretic. Reports poor appetite. Chest x-ray obtained and positive for pneumonia. Blood pressure 110/68 mm Hg Heart rate 110/min Respiratory rat

-Place the client in droplet isolation precautions is correct. The nurse should identify that the client has pneumonia, which is transmitted through droplets that are greater than 5 microns in the air. Therefore, the nurse should place the client in droplet isolation. -Apply oxygen at 2 L/min via nasal cannula is correct. The nurse should identify that the client's oxygen saturation is less than 95% on room air, indicating a decrease in oxygen in the client's blood, which can lead to hypoxia. Therefore, the nurse should apply oxygen at 2 L/min via nasal cannula to the client. -Request a prescription for an antipyretic medication is correct. The nurse should identify that the client has temperature that is greater than 38° C (100.4° F), indicating a fever. Therefore, the nurse should request an antipyretic medication to treat the client's fever. -Stay at least 0.9 m (3 feet) away from the client when possible is correct. The nurse should identify that droplet precautions include weari

A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. Nurses Notes Day 1:Lactated Ringer's at 100 mL/hr infusing into a 20-gauge IV catheter in left hand. IV dressing is dry and intact. IV site is without redness or swelling. IV fluid is infusing well. Day 2:IV site is edematous. Skin surrounding catheter site is taut, blanched, and cool to touch. IV fluid is not infusing. A nurse is collecting data from the client. Which of the following actions should the nurse

-Stop the IV infusion is correct. The client has manifestations of IV infiltration. The nurse should stop the IV infusion and remove the IV catheter to reduce the risk for tissue damage. -Elevate the client's left arm is correct. The nurse should elevate the client's left hand to decrease swelling and reduce the risk for tissue damage. -Apply heat to the client's left hand is correct. The nurse should apply heat to the client's left hand to reduce swelling and promote comfort.

A nurse is providing oral hygiene for a client who is unconscious. Identify the sequence of the steps the nurse should take. -Cleanse the client's mouth using a toothbrush. -Place a towel under the client's head with an emesis basin under their chin. -Assess the client's gag reflex. -Position the client on their side with their head turned to the side. -Separate the client's upper and lower teeth with an oral airway device.

1. Assess the client's gag reflex. 2. Position the client on their side with their head turned to the side. 3. Place a towel under the client's head with an emesis basin under their chin. 4. Separate the client's upper and lower teeth with an oral airway device. 5. Cleanse the client's mouth using a toothbrush.

A nurse is preparing to administer a medication to a preschooler and must convert the child's weight from pounds to kilograms. The child weighs 30 lb. How many kilograms does the child weigh?

13.6 Kg 30 lb | x/2.2 =30/2.2 =13.6363

A nurse is preparing to document information about a client's lower legs, which are swollen with 6mm edema. Which of the following information should the nurse document. a. 1+ pitting edema b. 2+ pitting edema c. 3+ pitting edema d. 4+ pitting edema

3+ pitting edema The nurse should document 3+ pitting edema when there is deep indentation of the tissue, which is about 6mm.

A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic communication technique of silence? a. a client who plans to leave the facility against medical advice b. a client that informs the nurse that they have made their funeral arrangements c. a client who tells the nurse that the night shift nurse did not bring their medication d. a client who has just experienced the death of their child

A client who has just experienced the death of their child. Silence is a therapeutic communication technique to use when a client is grieving. It demonstrates caring and patience and allows the client to speak when they are ready to do so.

A nurse is contributing to the plan of care for four patients. For which of the following clients should the nurse initiate airborne precations? a. a client who has pneumonia b. a client who has measles c. a client who has pertussis d. a client who has methicillin-resistant Staphylococcus aureus (MRSA)

A client who has measles. The nurse should initiate airborne precautions for a client who has measles. -The nurse should initiate droplet precautions for a client who has pneumonia -The nurse should initiate droplet precautions for a client who has pertussis. -The nurse should initiate contact precautions for a client who has MRSA.

A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. A nurse can disclose health information without the client's written permission to which of the following entities? a. an insurance agency offering a life insurance policy b. a family member who requests the client's diagnosis c. a physical therapist who is involved in the client's care d. an employer completing a pre-employment screening

A physical therapist who is involved in the client's care. According to HIPAA guidelines, a nurse is allowed to disclose personal health information to members of the health care team involved in the client's care.

A nurse is preparing to perform a wound irrigation for a client who has a stage 3 pressure injury. Which of the following supplies should the nurse plan to use? a. a piston syringe b. barrier ointment c. chilled irrigation solution d. sterile cotton balls

A piston syringe. The nurse should use an irrigation or piston syringe with an angiocatheter attached to irrigate wounds because it provides a gentle flow of solution to flush exudate and debris from the wound. -A barrier ointment is useful for protecting the skin of clients who have urinary incontinence. The nurse should not use a barrier ointment on an exudative wound, because it is a lubricant that could block the effects of the irrigating solution. -The nurse should plan to use an irrigation solution that is warmed to body temperature. -The nurse should not use sterile cotton balls, because fibers from the cotton can shed onto the wound's surface and adhere to its tissue. The nurse should use gauze to dry the edges of the wound after the irrigation procedure.

A nurse is caring for a client who has been vomiting and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit? a. BUN 18mg/dl b. a thready pulse c. hemoglobin 15 g/dl d. prominent neck veins

A thready pulse A client who has fluid volume deficit will have thready peripheral pulses. -A BUN above 20 mg/dL indicates an extracellular fluid volume deficit. This finding is within the expected reference range of 10 to 20 mg/dL. -The nurse should identify that a hemoglobin level of 15 g/dL is within the expected reference range of 14 to 18 g/dL for males and 12 to 16 g/dL for females. An increased hemoglobin level indicates that the client can be experiencing dehydration, congenital heart disease, or COPD, while decreased levels can indicate anemia, cirrhosis, or hemorrhage. -With a fluid volume deficit, the client's neck veins are flat. With a fluid volume excess, they are full and visible when the client is in a sitting position.

A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make? a. "stand with your feet together and your arms at the sides" b. "after I place the tuning fork, tell me when you no longer hear the sound" c. "I'm going to stroke the lateral side of the bottom of your foot" d. "Touch each fingertip as quickly as possible with your thumb"

A. "Stand with your feet and your arms at the sides." A. The Romberg test measures stability with and without the eyes closed. The nurse should instruct the client to stand with their feet together and their arms at their sides. B. The nurse should instruct the client to indicate when they no longer hear the sound of the tuning fork for a Rinne test. C. The nurse should stroke the lateral side of the bottom of the client's foot to test for the presence of a Babinski reflex. D. The nurse should instruct the client to touch their thumb to each fingertip as quickly as possible to evaluate their fine motor skills.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? a. clean the perineal area at least once a day b. empty the drainage bag when it is three/fourths full c. flush the catheter with sterile water daily d. disconnect the drainage bag when emptying and measuring urine

A. Clean the perineal area at least once a day. The nurse should clean the perineal area at least once a day to reduce the risk for infection.

A nurse is caring for a client who is postoperative following a mastectomy. The client states, "I can barely look at myself in the mirror." The nurse should identify that the client is experiencing which of the following? a. complicated grief b. maturational loss c. disenfranchised grief d. actual loss

Actual loss The nurse should identify that the client's comments indicate an actual loss, which is a loss that occurs when the person can no longer feel, see, hear, or know an object, another person, or a part of themselves, such as the loss of a body part. -Complicated grief results when the usual stages of grieving do not take place. -Maturational loss results from a developmental process, such as the growth of a child into an adult. -Disenfranchised grief results when clients have a loss they are unable to share publicly and that society might view as controversial. An example is the death of a partner who had a spouse.

A nurse is reinforcing teaching about carbohydrates counting with a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first? a. use pictures of different food groups to help the client plan a daily menu b. ask the client what they already know about meal planning c. give the client a brochure with sample menus for all meals d. involve the family in the discussion of the client's meal plan

Ask the client what they already know about meal planning. The first action the nurse should take using the nursing process is to collect data to determine the client's current level of knowledge. Then, the nurse can plan education to meet the client's needs.

A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via simple face mask. Which of the following actions should the nurse take ensure client safety? a. keep the side holes of the mask closed b. ensure the reservoir bag is inflated on expiration c. apply petroleum jelly to the client's nostrils d. attach a humidifier to the base of the flow meter

Attach a humidifier to the base of the flow meter. The nurse should attach a humidifier at the base of the flow meter to moisten the air for the client. This action will prevent drying mucous membranes when the client is receiving oxygen at a rate greater than 4 L/min.

A nurse in a long-term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take? a. sit beside the client b. speak slowly and loudly to the client c. dim the lights on the client's room d. choose a private room for the interview

Choose a private room for the interview. The nurse should use a private room, which will minimize background noise so the client is able to hear what the nurse is saying.

A nurse is caring for a client who reports itching 30 min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record? a. client is itching from medication b. client states, "I started to itch after taking that medication." c. it appears the client has a rash from the medication d. rash from medication noted

Client states, "I started to itch after taking that medication." The nurse should document information using an objective description, putting the client's exact words in quotation marks.

A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take? a. count the client's radial and apical pulses simultaneously with another nurse. b. calculate the client's pulse for 30 seconds then multiply by 2 c. assist the client to a side-lying position d. auscultate the area of the client's chest over the Erb's point

Count the client's radial and apical pulses simultaneously with another nurse. The nurse should have another nurse count the radial pulse as they count the apical pulse. A pulse deficit occurs when there are differences between the radial and apical pulse rates.

A nurse is assisting with caring for a client who has a newly placed ileostomy. Nurses Notes: 0800 - Client is 2 days postoperative following an ileostomy. Pouch is one-fourth full of stool. Stoma is red. Abdomen is soft and nontender. Bowel sounds are present in all quadrants. 1200 - Stoma site appears dark purple with blistering on the skin around the stoma. Slight leakage of the stool noted underneath the wafer. Pouch is three-fourths full of brown, liquid stool. Complete the following sente

Dropdown 1 Color of the stoma is correct. The nurse should identify that the color of the stoma indicates the client is at greatest risk for necrosis of the bowel. The nurse should notify the charge nurse immediately. Client's hemoglobin level is incorrect. The nurse should report the client's hemoglobin level because it is greater than the expected reference range. However, there is another finding that the nurse should address first. Leakage underneath the wafer is incorrect. The nurse should address the leakage underneath the wafer because it can cause irritation to the skin surrounding the stoma. However, there is another finding that the nurse should address first. Dropdown 2 Ostomy pouch seal is incorrect. The nurse should address the ostomy pouch seal because it can cause irritation to the skin surrounding the stoma. However, there is another finding that the nurse should address next. Skin condition around the stoma is correct. The nurse should identify that the skin condition

A nurse working in a community clinic is talking with an older adult client who states that their life has no purpose. The nurse should identify that the client is in which of the following stages of Erikson's Theory of Psychosocial Development. a. ego integrity vs. despair b. generativity vs. self-absorption c. identity vs. role confusion d. intimacy vs. isolation

Ego integrity vs. despair The nurse should identify that this client is experiencing the ego integrity vs. despair stage of Erikson's Theory of Psychosocial Development, which occurs in the older adult population. The nurse should assist the client to reflect on past accomplishments and find pleasure in life rather than focusing on health problems and limitations. Supporting the client's ego integrity will help the client cope with the challenges of aging. -The nurse should identify that middle adults are in the generativity vs. self-absorption and stagnation stage of Erikson's Theory of Psychosocial Development. In this stage, the client works to contribute to the welfare of future generations through activities such as parenthood, teaching, mentoring, and work within the community. -The nurse should identify that adolescents are in the identity vs. role confusion stage of Erikson's Theory of Psychosocial Development. In this stage, the client works to establish a sense of identity

A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following as a potential adverse effect of this procedure? a. fluid overload b. diarrhea c. headache d. difficulty voiding

Headache The nurse should identify that a headache can be an adverse effect following a lumbar puncture. To minimize the client's discomfort, the nurse should administer analgesics, offer fluids, and maintain the client in a dorsal recumbent position for the length of time prescribed by the provider.

A nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the client? a. offer the client a straw to drink liquids b. place food toward the back of the client's mouth c. encourage the client to lie down and rest for 30 minutes after meals. d. instruct the client to tilt their head forward while eating

Instruct the client to tilt their head forward while eating. A client who has dysphagia following a stroke should sit upright with their head tilted forward to facilitate swallowing and to prevent aspiration. -A client who has dysphagia following a stroke should not drink with a straw. This can increase the risk for aspiration. -Placing food toward the back of the mouth of a client who has dysphagia following a stroke increases the risk for choking and aspiration. Food should be placed on the unaffected side of the client's mouth to decrease this risk. -A client who has dysphagia following a stroke should sit upright for at least 1 hr after meals to decrease the risk for aspiration.

A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that they have numerous allergies. Which of the following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy? a. eggs b. latex c. seafood d. bee stings

Latex Nurses use products containing latex, including gloves, tourniquets, and IV tubing, to deliver IV therapy. Clients who have an allergic reaction to latex can have a wide range of manifestations, such as itching and hives, or a more serious reaction, such as dyspnea or laryngospasm.

A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the first action the nurse should take? a. measure the client's gastric residual before each feeding b. change the bag and tubing every 24 hr. c. document intake and output d. flush the tubing with 30 ml of water after each feeding

Measure the client's gastric residual before each feeding. When using the nursing process, the first action the nurse should take is assessment. Therefore, obtaining gastric residual volume is the priority action for the nurse to take.

A client who is scheduled to undergo surgery tells the nurse that they do not understand the procedure and are reconsidering their decision to have it. Which of the following actions should the nurse take? a. offer information about alternative therapies to the procedure b. contact a family member to convince the client to change their mind c. tell the client the benefits of the surgery d. notify the charge nurse of the client's concerns

Notify the charge nurse of the client's concerns. The nurse should notify the charge nurse of the client's concerns. The charge nurse can then inform the provider that the client requires further explanation of the procedure.

A nurse is assisting with the admission of a client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished? a. heart rate 89/min b. pink mucous membranes c. pallor with scaly skin d. body mass index 23

Pallor with scaly skin. The nurse should identify that pallor along with scaly skin can indicate malnutrition. The skin should be smooth and have the same hue as other areas of sun-exposed skin in clients who are well-nourished. -A heart rate of 89/min is within the expected reference range of 60 to 100/min for an adult client. This finding does not indicate malnutrition. -Red, swollen, and inflamed gums are an indication of malnutrition. Pink mucous membranes are an expected finding in well-nourished clients. -A body mass index below 18.5 indicates malnutrition.

A nurse is planning to perform intermittent urinary catheterization for a client who is unable to urinate. Which of the following actions should the nurse take first? a. perform a bladder scan b. cleanse the meatus c. provide perineal care d. lubricate the catheter

Perform a bladder scan The first action the nurse should take when using the nursing process is to collect data from the client. Therefore, the nurse should evaluate the bladder contents before performing an invasive procedure. A bladder scan determines the amount of urine in the bladder and helps the nurse avoid unnecessary catheterizations.

A nurse is planning care for a group of clients. The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures? a. administration of an enema b. performance of a paracentesis. c. insertion of an indwelling urinary catheter. d. placement of an NG tube

Performance of a paracentesis. The nurse should expect to witness the informed consent for a client prior to an invasive diagnostic procedure, such as a paracentesis. Paracentesis is a procedure that removes fluid (peritoneal fluid) from the abdomen through a slender needle.

A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions by the nurse maintains the client's confidentiality? a. sharing the client's prognosis with a member of the client's family b. discussing the client's status with a member of the spiritual support team c. collaborating with a nurse form another unit about the client's care d. Providing client information to another nurse at change of shift.

Providing client information to another nurse at change of shift. The nurse can share information with other staff who are caring for the client because it is essential to maintaining continuity of care, and does not violate the client's confidentiality. The nurse should only share information about the client with those directly involved in the client's care.

A nurse in an acute care setting is documenting postmortem care in a client's medical record. Which of the following information should the nurse include in the documentation? a. completion of an incident report b. name of the nurse certifying the client's death c. release of personal belonging form d. one client identifier at the client's time of death

Release of personal belongings form. The nurse should document the release of the client's personal belongings form and the articles the nurse gave to the family. -The nurse should not document the completion of an incident report in the client's medical record. -The nurse should document the name of the provider who certified the death of the client. -The nurse should document the identification of the client using two identifiers at the time of death and compare these with the identifiers in the client's medical record.

A nurse is planning to administer medication to a client who has Clostridium difficile infection. Which of the following actions should the nurse plan to take to prevent the transmission of this infection to others? a. clean hands with an alcohol-based hand rub immediately after removing gloves b. remove the cover gown in the client's room after providing care c. place the client in a room with negative-pressure airflow d. wear a mask when administering oral medications to the client

Remove the cover gown in the client's room after providing care. The nurse should initiate contact precautions for clients who have a C. difficile infection. Contact precautions include the removal of the cover gown and other personal protective equipment inside the client's room to prevent the spread of infection. -Alcohol-based hand rubs are not effective against C. difficile; therefore, the nurse should use soap and water to clean hands after providing care. -Clients who have a C. difficile infection require contact precautions. A negative-pressure environment is a requirement for clients who are placed in airborne precautions. -Clients who have a C. difficile infection require contact precautions. Therefore, the nurse should wear gloves and a gown when giving direct care to the client. A mask is a requirement when caring for clients who are placed in droplet precautions.

A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take? a. lift the staple remover when squeezing the handle b. avoid completely closing the handle after squeezing c. expect the staples to bend at each outer side of the staple d. remove the staple from the skin after both sides are visible

Remove the staple from the skin after both sides are visible. The nurse should remove the staple from the skin after both sides of the staple are visible, which indicates proper dislodgement of the staple and prevents pulling on the skin around the incision, which can cause needless discomfort.

A nurse and an assistive personnel (AP) are providing postmortem care for a deceased client prior to visitation by the family. Which of the following actions by the AP requires intervention by the nurse? a. gathering the client's personal belongings b. removing the client's dentures c. placing absorbent pads under the client's buttocks d. closing the client's eyes

Removing the client's dentures. The client's dentures should remain in place in order to give the face a natural appearance. -The nurse should determine what items need to remain with the client's body. All other belongings should be gathered and given to the client's family. -Absorbent pads are placed under the buttocks to absorb feces and urine released because of relaxation of the sphincter muscles. -The deceased client's eyes should be closed by holding them gently shut for a few seconds.

A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following interventions should the nurse recommend to include in the plan? a. flex the client's feet using pillows b. support the client's feet with foot boots c. place a hand roll under the client's heels d. remove ankle-foot orthotic devices at bedtime

Support the client's feet with foot boots. The nurse should support the feet in dorsiflexion with foot boots to prevent foot drop. -The nurse should flex the client's feet. However, pillows will not provide enough pressure to prevent foot drop. -The nurse should place a hand roll in the palm of the client's immobile hand to maintain a functional position and prevent contractures. -The nurse should have the client alternate wearing the ankle-foot orthotic devices for 2 hr and removing them for 2 hr.

A nurse in a provider's office is providing care for a client who has minimal exposure to sunlight. Which of the following interventions should the nurse recommend? a. reduce intake of calcium-rich foods b. use sunscreen with skin protection factor (SPF) of 8 c. take vitamin D supplements d. use tanning bed 2 hr weekly

Take Vitamin D supplements . The human body requires sunlight exposure to synthesize vitamin D. Therefore, the nurse should recommend that a client who has minimal sunlight exposure take supplemental vitamin D.

A nurse working in a hospital overhears the following conversation between two other nurses on the elevator. Which of the following actions should the nurse take? "I heard that the wound on Mr. Jones' leg is from his neighbor's dog biting him..." a. inform the nurses that the neighbors dog did not cause the wound b. tell the nurses to change the topic of conversation c. complete an incident report upon returning to the unit d. report the nurses' conversation to the client's provider

Tell the nurses to change the topic of conversation. The nurse has the responsibility to protect the client's right to confidentiality and should intervene on the client's behalf. A breach of client confidentiality can result in liability for those involved.

A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider? a. the client reports incisional pain as 7 on a scale of 0 to 10 b. the client reports increased nausea and chills c. the client has an oral temperature of 38.5 degrees Celsius (101.3 Fahrenheit) d. the client has tenderness and warmth in their calf

The client has tenderness and warmth in their calf. When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding to report is tenderness and warmth in the client's calf, which can indicate the presence of a thrombus. If it moves from the vein to the heart, brain, or lungs, it can cause life-threatening complications.

A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority to report to the provider? a. client reports voiding three times during the night b. client reports burning and discomfort with urination c. client's WBC is 11,000/mm3 d. the client's output was 60 ml for the past 3 hours

The client's output was 60 mL for the past 3 hours. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is a urinary output of 60 mL over 3 hr. This finding represents oliguria and can indicate a decrease in kidney perfusion or function.

A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off their right leg. Which of the following is the proper crutch for this client? a. four-point b. three-point c. two-point d. swing-through

Three-point The nurse should identify that the client needs to be able to bear weight on the unaffected leg; therefore, a three-point gait provides at least two points of support at all times.

A nurse is preparing to obtain a client's vital signs. Which of the following actions should the nurse take when washing their hands? a. rinse their forearms with running water before applying soap b. hold their hands above elbow level when washing and rinsing c. generate lather by rubbing their hands together vigorously for 5 seconds d. turn off the faucet with a clean paper towel after drying hands.

Turn off the faucet with a clean paper towel after drying hands. If the nurse's hands are wet or the paper towel is wet when they turn off the faucet, they increase the risk of transferring micro-organisms from the faucet back to their hands. The nurse should wash their hands using ample lather and friction for at least 15 seconds to allow for sufficient removal of dirt and pathogens. The nurse should keep their hands and forearms below elbow level while washing and rinsing them to allow water to wash micro-organisms away without recontaminating clean areas. For routine care procedures, the nurse does not have to rinse their forearms, just their hands and wrists. In health care, the hands of staff members are a major source of transmission of infection and are more contaminated than forearms are.

A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity? a. use warm water when bathing the client. b. place a donut shaped cushion in the client's chair c. massage reddened areas over bony prominences d. maintain the client in the high fowler's position

Use warm water when bathing the client. The nurse should use warm water to bathe the client because hot water can dry and damage the skin. The nurse should use a gel, foam, or air cushion to redistribute weight away from the ischial areas. Rigid and donut-shaped cushions are contraindicated because they reduce blood supply to the area.

A nurse is assisting in the care of a client who has pancreatitis. Select three tasks the nurse should delegate to the assistive personnel. a. transfer the client from a wheelchair to the bed b. measure the client's intake and output c. collect data about the client's pain level d. insert an NG tube for the client e. document the client's vital signs

a. transfer the client from a wheelchair to the bed b. measure the client's intake and output e. document the client's vital signs

A nurse is caring for a group of clients in a long-term care facility. Which of the following actions should the nurse take to prevent health care-associated infections for these clients? a. place immunocompromised clients in the same room b. wash hands after removing gloves c. use antimicrobial hand gel after refilling a client's water pitcher d. clean the stethoscope with an antimicrobial wipe after obtaining vital signs e. administer a prophylactic dose of antibiotics prior to discharge.

b. wash hands after removing gloves. c. use antimicrobial hand gel after refilling a client's water pitcher. d. clean the stethoscope with an antimicrobial wipe after obtaining vital signs. The nurse should perform hand hygiene after removing gloves to prevent the transmission of micro-organisms from one setting or client to another. The nurse should perform hand hygiene after touching a client's supplies to prevent the transmission of micro-organisms. The nurse should wipe all equipment used for multiple clients with an antimicrobial wipe to prevent the transmission of micro-organisms from one client to another.