ATI practice A Fundamentals
A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? A. "Drink a cup of hot cocoa before bedtime." B. "Maintain a consistent time to wake up each day." C. "Exercise 1 hour before going to bed." D. "Watch a television program in bed before going to sleep."
"Drink a cup of hot cocoa before bedtime." INCORRECT Cocoa contains caffeine, which is a stimulant that can interfere with sleep. "Maintain a consistent time to wake up each day." CORRECT The client should maintain a consistent time for waking up and going to sleep. This helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client. "Exercise 1 hour before going to bed." INCORRECT Exercising within 2 hr of bedtime can interfere with sleep. "Watch a television program in bed before going to sleep." INCORRECT The client should avoid watching television in bed before going to sleep to reduce stimulation in order to promote rest.
A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? A. "Is your pain constant or intermittent?" B. "What would you rate your pain on a scale of 0 to 10?" C. "Does the pain radiate?" D. "Is your pain sharp or dull?"
"Is your pain constant or intermittent?" INCORRECT Asking the client whether the pain is constant or intermittent determines the onset, duration, and pattern of the pain. "What would you rate your pain on a scale of 0 to 10?" INCORRECT Asking the client to rate the pain using the pain scale determines the intensity of the pain. "Does the pain radiate?" INCORRECT Asking the client whether the pain radiates determines the pain's location. "Is your pain sharp or dull?" CORRECT Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain.
A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests info about advance directives. Which of the following responses should the nurse make? A. "We can talk about advance directives, and I can also give you some brochures about them." B. "You should set up a time to talk with your provider about that." C. "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better." D. "Why do you want to discuss this without your partner here to plan this with you?"
"We can talk about advance directives, and I can also give you some brochures about them." CORRECT With this statement, the nurse offers to provide the information the client needs in a direct and simple way. "You should set up a time to talk with your provider about that." INCORRECT The nurse is passing the responsibility of discussing this topic with the client to the provider, which dismisses the client's concerns. "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better." INCORRECT The nurse is rejecting the client's needs by postponing a discussion about what is important to the client. "Why do you want to discuss this without your partner here to plan this with you?" INCORRECT Clients might interpret "why" questions as accusatory, and they can provoke feelings of mistrust and resentment.
A nurse is planning an educational program for a group of older adults at a senior living facility. Which of the following recommendations should the nurse include? A. "You should have an eye examination every 2 years." B. "You should receive a tetanus booster every 5 years." C. "You should receive a shingles vaccine when you are 70 years old." D. "You should receive a pneumococcal vaccine when you are 65 years old."
"You should have an eye examination every 2 years." INCORRECT Older adults should have an eye examination every year. "You should receive a tetanus booster every 5 years." INCORRECT Older adults should receive a tetanus booster every 10 years. "You should receive a shingles vaccine when you are 70 years old." INCORRECT The nurse should instruct older adult clients to receive a shingles vaccine when they are 60 years old. "You should receive a pneumococcal vaccine when you are 65 years old." CORRECT The nurse should instruct older adult clients to receive one of the two pneumococcal vaccines when they are 65 years old. The vaccines can be given to clients who are 19 years of age and older and have certain conditions, such as chronic heart, lung, or liver disease, diabetes mellitus, and alcohol disease, or to those who smoke cigarettes.
A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round to the nearest whole number. Use a leading zero if if applies. Do not use a trailing zero.)
107 mL/hr
A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use? A. Alginate B. Gauze C. Transparent D. Hydrocolloid
Alginate INCORRECT Alginate dressings are used to treat stage 3 and 4 pressure injuries to absorb drainage. Alginate forms a soft gel when it comes in contact with drainage. Gauze INCORRECT Moistened gauze promotes healing in stage 4 or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed. Transparent INCORRECT Transparent dressings promote healing in stage 1 pressure injuries by preventing further friction and shearing. Hydrocolloid CORRECT Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed.
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? A. Ask the client to consider a direct donation. B. Withhold the blood transfusion C. Request a consultation with the ethics committee D. Ask the client's family to intervene.
Ask the client to consider a direct donation. INCORRECT A direct donation still requires a blood transfusion and does not respect the client's wishes. Withhold the blood transfusion. CORRECT The principle of autonomy ensures that a client who is competent has the right to refuse treatment. Request a consultation with the ethics committee. INCORRECT A client who is competent has the right to refuse treatment, regardless of the consequences. There is no need to involve the ethics committee. Ask the client's family to intervene. INCORRECT Clients who are competent have the right to consent to or refuse treatment.
A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? A. Bend at the waist. B. Stand close to the cabinet when lifting it. C. Use the back muscles for lifting. D. Keep the feet close together.
Bend at the waist. INCORRECT The nurse should bend the knees when lifting the cabinet. Stand close to the cabinet when lifting it. CORRECT This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching. Use the back muscles for lifting. INCORRECT The nurse should use the arm and leg muscles when lifting the cabinet because they are generally stronger than back muscles. Keep the feet close together. INCORRECT The nurse should spread the feet wide apart to create a broad base of support. This promotes stability while lifting the cabinet.
A nurse is caring for a client who is postop and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and report back in 1hr. Which of the following actions should the nurse take next. A. Document the provider's statement in the medical record. B. Complete an incident report. C. Consult the facility's risk manager. D. Notify the nursing manager.
Document the provider's statement in the medical record. INCORRECT The nurse should document the provider's directions in the medical record for later reference; however, another action is the nurse's priority. Complete an incident report. INCORRECT The nurse should prepare an incident report detailing the delay in treatment for later review and action for prevention of future occurrences; however, another action is the nurse's priority. Consult the facility's risk manager. INCORRECT The nurse should discuss the situation with the facility's risk management department to help determine the need for preventive actions; however, another action is the nurse's priority. Notify the nursing manager. CORRECT The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care.
A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? A. Ensure sterilization of non-disposable items with ethylene oxide. B. Wrap monitoring cords with stockinette and tape them in place. C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication. D. Wear hypoallergenic latex gloves that contain powder.
Ensure sterilization of non-disposable items with ethylene oxide. INCORRECT Ethylene oxide can cause an allergic reaction in clients who have a latex allergy. The nurse should rinse any items that received this type of sterilization before use. Wrap monitoring cords with stockinette and tape them in place. CORRECT Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication. INCORRECT The nurse should use a stopcock for injecting medication. Cleansing a latex item will not remove the latex protein. Wear hypoallergenic latex gloves that contain powder. INCORRECT Hypoallergenic latex gloves contain latex and can still provoke an allergic response. Powder is especially harmful because it contains the latex protein. The nurse should make sure all members of the client-care staff wear nonlatex gloves.
A nurse is planning care of an adolescent who is postop following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care? A. Limit the adolescent's visitors B. Select the food choices for the adolescent C. Allow the adolescent to make decisions regarding their daily routine. D. Encourage the adolescent's guardian to assist with personal hygiene
Limit the adolescent's visitors. INCORRECT An adolescent interacts with others to gain a sense of identity. Therefore, the nurse should encourage the adolescent to have visitors. Select the food choices for the adolescent. INCORRECT The nurse should allow the adolescent to make decisions regarding their food choices to promote independence. Allow the adolescent to make decisions regarding their daily routine. CORRECT The nurse should allow the adolescent to make decisions regarding their daily routine in order to give them a sense of control. Encourage the adolescent's guardian to assist with personal hygiene. INCORRECT The nurse should encourage the adolescent to perform their own personal hygiene in order to maintain a level of independence.
A nurse is using an open irrigation technique to irrigate a client's indwelling catheter. which of the following actions should the nurse take? A. Place the client in a side-lying position. B. Instill 15 mL of irrigation fluid into the catheter with each flush C. Subtract the amount of irrigant used from the client's urine output D. Perform the irrigation using a 20-mL syringe.
Place the client in a side-lying position. INCORRECT For a catheter irrigation, the nurse should place the client in a supine or dorsal recumbent position for maximal access to the catheter. Instill 15 mL of irrigation fluid into the catheter with each flush INCORRECT Open irrigation technique requires instilling 30 to 40 mL of irrigation fluid. Subtract the amount of irrigant used from the client's urine output. CORRECT The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output. Perform the irrigation using a 20-mL syringe. INCORRECT The nurse should use a 30- to 50-mL syringe to perform open irrigation.
A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? A. Rinse the feeding bag with water between feedings. B. Tell the client to keep the head of the bed elevated at least 30° C. Make sure the enteral formula is at room temperature. D. Wipe the top of the formula can with alcohol.
Rinse the feeding bag with water between feedings. INCORRECT The nurse should rinse the feeding bag with warm water to reduce the risk of bacterial growth; however, there is another action that is the priority. Tell the client to keep the head of the bed elevated at least 30°. CORRECT The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula into the esophagus. Make sure the enteral formula is at room temperature. INCORRECT The nurse should make sure the enteral formula is at room temperature to prevent the cramping and discomfort that can result from instilling cold formula; however, there is another action that is the priority. Wipe the top of the formula can with alcohol. INCORRECT The nurse should wipe the top of the formula can with alcohol to remove or disinfect any dirt or micro-organisms that could contaminate the formula; however, there is another action that is the priority.
A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps.
The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer.
A nurse is caring for a client who has a pressure injury. Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again. A. Temperature B. WBC count C. Prealbumin level D. Hemoglobin level E. Blood pressure F. Pain lvl G. Odor of wound H. Bowel sounds
Temperature is CORRECT. The nurse should identify that the client has a fever, which is a manifestation of an infection. Therefore, the nurse should report this finding to the provider. WBC count is CORRECT. The nurse should identify that the client has a WBC count that is greater than the expected reference range, which is a manifestation of an infection. Therefore, the nurse should report this finding to the provider. Prealbumin level is CORRECT. The nurse should identify that the client has a prealbumin level that is lower than the expected reference range. This is a manifestation of malnutrition, which contributes to delayed wound healing. Therefore, the nurse should report this finding to the provider. Hemoglobin level is INCORRECT. The client's hemoglobin is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider. Blood pressure is INCORRECT. The client's blood pressure is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider. Pain level is CORRECT. The nurse should identify that the client's pain level has increased over 3 days and is an indication of complications associated with wound healing. Therefore, the nurse should report this finding to the provider. Odor of wound is CORRECT. The nurse should identify that a foul odor of a wound is a manifestation of an infection. Therefore, the nurse should report this finding to the provider. Bowel sounds is INCORRECT. The client's bowel sounds are present in all four quadrants. Therefore, the nurse does not need to report this finding to the provider.
A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? A. Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain. B. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. C. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum. D. Palpate the client's abdomen before auscultating bowel sounds.
Use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain. INCORRECT The nurse should use an age-appropriate pain-rating scale, such as the visual analog or numerical scale, when assessing the pain level of an adult. The FLACC pain rating scale is used for clients aged from 2 months to 7 years old. Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm. CORRECT The nurse should use a blood pressure cuff with a bladder that surrounds 80% of the client's arm circumference to give an accurate reading. Obtain an apical heart rate by auscultating at the third intercostal space left of the sternum. INCORRECT The nurse should place the stethoscope at the point of maximal impulse, which is at the fifth intercostal space at the midclavicular line left of the sternum. Palpate the client's abdomen before auscultating bowel sounds. INCORRECT When assessing an adult client's abdomen, the nurse should auscultate bowel sounds before performing palpation in order not to change the character of the sounds.
A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care? A. Wrap blankets around all four sides of the bed. B. Apply restraints during seizure activity. C. Place the client in a supine position during seizure activity. D. Have a tongue depressor at the client's bedside
Wrap blankets around all four sides of the bed. CORRECT The nurse should affix linens or blankets around the head, foot, and side rails of the bed to pad them and prevent injury for a client who has been having frequent tonic-clonic seizures. Apply restraints during seizure activity. INCORRECT Restraining a client who is having a seizure increases their risk for injury. Place the client in a supine position during seizure activity. INCORRECT The nurse should turn the client to the side so that the tongue does not occlude the airway and so that secretions can flow out of the side of the client's mouth. Have a tongue depressor at the client's bedside. INCORRECT Inserting any object into the mouth of a client who is having a seizure increases the risk for injury to the mucous membranes in the mouth and damage to the teeth.
A nurse is caring for a client who requires 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? A. "I had a bowel movement, but I was able to save the urine." B. "I have a specimen in the bathroom from about 30 minutes ago." C. "I flushed what I urinated at 7:00 a.m. and have saved all urine since." D. "I drink a lot, so I will fill up the bottle and complete the test quickly."
"I had a bowel movement, but I was able to save the urine." INCORRECT For a 24-hr urine collection, the client should collect urine that is free of feces. "I have a specimen in the bathroom from about 30 minutes ago." INCORRECT For a 24-hr urine collection, the client should place any urine in the container immediately and keep it on ice or in a refrigerator. "I flushed what I urinated at 7:00 a.m. and have saved all urine since." CORRECT For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings. "I drink a lot, so I will fill up the bottle and complete the test quickly." INCORRECT For a 24-hr urine collection, there is no specified amount. The collection takes place over a 24-hr period regardless of the total volume of urine collected.
A nurse is evaluating teaching for a client who has heart failure. Which of the following 3 statements by the client indicates an understanding of the teaching? A. "I have been weighing myself every other morning" B. "I am trying to decrease my intake of foods with potassium" C. "I am limiting my sodium intake to 2 grams daily" D. "I am eating fewer potato chips and more fruit for snacks" E. "I lie down and rest after meals" F. "I know to call my doctor if I gain 3 pounds or more in 2 days"
"I have been weighing myself every other morning" is INCORRECT. The client should weigh in every day to monitor for fluid retention. "I am trying to decrease my intake of foods with potassium" is INCORRECT. The client's furosemide dosage was increased, which can lead to increased elimination of potassium. Increasing potassium intake is a lifestyle modification that is important in controlling hypertension. "I am limiting my sodium intake to 2 grams daily" is CORRECT. Clients who have heart failure should maintain a sodium intake between 2 and 3 g daily. "I am eating fewer potato chips and more fruit for snacks" is CORRECT. Chips are a processed snack food that contains high levels of sodium. Additionally, fruits contain electrolytes and fiber, both of which are important to controlling blood pressure and lipid levels. "I lie down and rest after meals" is INCORRECT. The client should be taught to lie down and rest before meals as eating requires energy and oxygen consumption. The client should also be instructed to eat small, frequent meals rather than large meals to help relieve shortness of breath and fatigue. "I know to call my doctor if I gain 3 pounds or more in 2 days" is CORRECT. The client should monitor weight on a daily basis and call the provider for a weight gain of 1.36 kg (3 lb) or more in 2 days to prevent an exacerbation of their heart failure.
A nurse enters a client's room and finds them on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident? A. "Incident report completed." B. "Client climbed over the side rails." C. "Client found lying on floor." D. "Client was trying to get out of bed."
"Incident report completed." INCORRECT An incident report is an internal document that is part of a facility's risk management system. The nurse should not document completion of an incident report in the client's medical record for the facility's protection in the event of litigation. "Client climbed over the side rails." INCORRECT Unless the nurse witnessed the client climbing over the bed's side rails, this statement is not an objective account of the nurse's findings. "Client found lying on floor." CORRECT The nurse should include documentation of information that is descriptive and objective concerning what the nurse actually observed, without including any opinions or judgments about motives or cause. "Client was trying to get out of bed." INCORRECT Unless the nurse witnessed the client trying to get out of bed, this statement is not an objective account of the nurse's findings.
A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make? A. "Most people are happy when their children grow up and leave home." B. "You should be proud that your children are becoming independent." C. "Maybe you should consider why you are feeling useless." D. "People in middle adulthood often find satisfaction in nurturing and guiding young people."
"Most people are happy when their children grow up and leave home." INCORRECT This is an automatic or stereotypical response that minimizes the client's feelings by implying that the client should respond like everyone else. "You should be proud that your children are becoming independent." INCORRECT This response conveys the nurse's approval of people who are proud of their children's independence, which implies that this is the only acceptable behavior in this situation. "Maybe you should consider why you are feeling useless." INCORRECT Clients might interpret "why" questions as accusatory, and they can elicit feelings of mistrust and resentment. With this response, the nurse is asking for an explanation instead of acknowledging the client's feelings. "People in middle adulthood often find satisfaction in nurturing and guiding young people." CORRECT According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore opportunities for mastering the developmental tasks of this stage with the client, such as volunteering and mentoring young people.
A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? A. "Use the complete name of the medication magnesium sulfate." B. "Delete the space between the numerical dose and the unit of measure." C. "Write the letter U when noting the dosage of insulin." D. "Use the abbreviation SC when indicating an injection."
"Use the complete name of the medication magnesium sulfate." CORRECT The Institute for Safe Medication Practices designates that nurses and providers write the complete medication name for magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate. "Delete the space between the numerical dose and the unit of measure." INCORRECT The Institute for Safe Medication Practices recommends including a space between the dose and the unit of measure, such as in 10 mg, to avoid confusion when documenting medication dosages. "Write the letter U when noting the dosage of insulin." INCORRECT The Institute for Safe Medication Practices designates "unit(s)" as the correct term for use in medication documentation. "Use the abbreviation SC when indicating an injection." INCORRECT The Institute for Safe Medication Practices designates either "subcut" or "subcutaneously" as the correct terms for use in medication documentation.
A nurse is preparing to delegate client care tasks to an AP. Which of the following tasks should the nurse delegate? A. Ambulating a client who is postoperative. B. Inserting an indwelling urinary catheter for a client C. Demonstrating the use of an incentive spirometer to a client D. Confirming that a client's pain has decreased after receiving an analgesic
Ambulating a client who is postoperative. CORRECT Ambulating a client is within the range of function of an AP. The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching. Inserting an indwelling urinary catheter for a client INCORRECT Indwelling urinary catheter insertion requires advanced nursing judgment and sterile technique. This task is outside the range of function of an AP. Demonstrating the use of an incentive spirometer to a client INCORRECT Client education requires advanced nursing knowledge and is outside the range of function of an AP. Confirming that a client's pain has decreased after receiving an analgesic INCORRECT Evaluating a client's pain level requires advanced nursing judgment and is outside the range of function of an AP.
A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding? A. Assign a staff member to feed the client. B. Provide small-handled utensils for the client. C. Thicken liquids on the client's tray. D. Arrange food in a consistent pattern on the client's plate.
Assign a staff member to feed the client. INCORRECT The nurse should allow the client to feed themself when possible. Assigning a staff member to feed a client who has vision loss impairs autonomy and can impede the client's ability to perform self-care. Provide small-handled utensils for the client. INCORRECT Large-handled, adaptive utensils are easier for the client to grip and allow for greater independence during meals for clients who have vision loss. Thicken liquids on the client's tray. INCORRECT Clients who have dysphagia, not vision loss, require thickening of liquids to facilitate swallowing without choking. Arrange food in a consistent pattern on the client's plate. CORRECT Consistency in preparing the client's plate helps to facilitate self-feeding for clients who have vision loss. Staff can describe the location of the food on the plate by using a clock pattern, allowing the client to have greater independence during meals.
A nurse in the emergency department (ED) is caring for a client. Click to highlight the findings that indicate the client is malnourished. To deselect a finding, click on the finding again. A. Cachectic, with flaccid muscle tone B. Skin dry and scaly with bruises on extremities C. Oriented x 3, able to move all extremities D. Pulse rate 118/min E. Respiratory rate 18/min F. Abdomen distended G. Temperature 39.2° C H. BMI 17
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 dry and scaly with bruises on extremities is CORRECT. The client's dry, scaly, and bruised skin can be an indication of malnutrition. Oriented x 3, able to move all extremities is INCORRECT. The client's neurological status is within expected parameters. Pulse rate 118/min is CORRECT. The client's tachycardia can be an indication of malnutrition. Respiratory rate 18/min is INCORRECT. The client's respiratory rate is within the expected reference range. Abdomen distended is CORRECT. The client's abdominal distention can be an indication of malnutrition. Temperature 39.2° C (102.6° F) is INCORRECT. An elevated temperature is not 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 admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate? A. Droplet B. Airborne C. Contact D. Protective environment
Droplet CORRECT Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis. Airborne INCORRECT Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles. Contact INCORRECT Contact precautions are a requirement for clients who have infections that spread via direct contact with another person or contact with the environment, including vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and scabies. Protective environment INCORRECT Clients who have a compromised immune system, such as those who have had an allogeneic hematopoietic stem cell transplant, require a protective environment.
A nurse is admitting a client who is having an exacerbation of heart failure. In planning the client's care, when should the nurse initiate discharge planning? A. During the admission process B. As soon as the client's condition is stable C. During the initial team conference D. After consulting with the client's family
During the admission process CORRECT Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility. As soon as the client's condition is stable INCORRECT Although it is appropriate to defer client teaching until the client is stable and receptive to learning, the initiation of discharge planning does not depend on the client's physiological stability. During the initial team conference INCORRECT Team conferences facilitate discharge planning, but they are not essential for initiating the planning process. After consulting with the client's family INCORRECT The nurse should only consult with the client's family if the client gives the nurse permission to share that information. In the case of a client who has an exacerbation of heart failure, delaying discharge planning until this time could result in overlooking essential care needs.
A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client? A. Have the client wear a mask when receiving visitors B. Wear a gown when caring for the client. C. Assign the client to a room with negative-pressure airflow exchange. D. Limit the client's time with visitors to no more than 30 min per day.
Have the client wear a mask when receiving visitors. INCORRECT The client does not need to wear a mask to prevent the spread of the infection because shigella does not require airborne or droplet precautions. Wear a gown when caring for the client. CORRECT The nurse should implement contact precautions for a client who has shigella to prevent the transmission of the bacteria. The nurse should wear a gown when providing care for a client who requires contact precautions due to the risk of contact with bodily fluids and contaminated surfaces. Assign the client to a room with negative-pressure airflow exchange. INCORRECT The nurse should assign a client who has shigella to a private room; however, negative-pressure airflow is not necessary because shigella is not airborne. Limit the client's time with visitors to no more than 30 min per day. INCORRECT Limit the client's time with visitors to no more than 30 min per day. Limiting the client's time with visitors will not decrease the risk of spreading shigella. Clients who require isolation precautions are at risk for depression and loneliness; therefore, the nurse should encourage visitation.
A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? A. Increase in hematocrit B. Increase in respiratory rate C. Decrease in heart rate D. Decrease in capillary refill time
Increase in hematocrit INCORRECT Fluid volume deficit causes an increase in hematocrit level due to depletion of extracellular fluid. With correction of the imbalance, the hematocrit level should decrease. Increase in respiratory rate INCORRECT Fluid volume deficit causes an increase in respiratory rate. With correction of the imbalance, the respiratory rate should return to the expected range. Decrease in heart rate CORRECT Fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range. Decrease in capillary refill time INCORRECT Fluid volume deficit slows capillary refill. With correction of the imbalance, capillary refill time should return to the expected range.
A nurse is caring for a client who is receiving pain medication through PCA pump. which of the following actions should the nurse take? A. Instruct the family to refrain from pushing the button for the client while the client is asleep. B. Inform the client that because they are on a PCA pump, vital signs will be taken every 8 hr. C. Teach the client to avoid pushing the button until pain is above a 7 on a scale of 0 to 10. D. Increase the basal rate and shorten the lock-out interval time if the client's pain level is too high.
Instruct the family to refrain from pushing the button for the client while the client is asleep. CORRECT The nurse should instruct family members not to activate the button for the client while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain. Inform the client that because they are on a PCA pump, vital signs will be taken every 8 hr. INCORRECT The nurse should monitor a client who is using a PCA pump every 1 to 2 hr during the first 12 hr. The client is at risk for respiratory depression as a result of opioid medication administration. Teach the client to avoid pushing the button until pain is above a 7 on a scale of 0 to 10. INCORRECT The nurse should instruct the client to activate the PCA pump when they need it. It is inappropriate for the client to wait until pain escalates to any particular level of intensity before using the pump. Increase the basal rate and shorten the lock-out interval time if the client's pain level is too high. INCORRECT It is not within the scope of practice for the nurse to prescribe the rate and lock-out interval.
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? A. Make sure the client's room has at least six air exchanges per hour. B. Make sure the client wears a mask when outside their room if there is construction in the area. C. Place the client in a private room with negative-pressure airflow D. Wear an N95 respirator when giving the client direct care.
Make sure the client's room has at least six air exchanges per hour. INCORRECT A protective environment requires at least 12 air exchanges per hour. Make sure the client wears a mask when outside their room if there is construction in the area. CORRECT 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 any pathogens in the environment. Place the client in a private room with negative-pressure airflow INCORRECT The nurse should place the client in a private room that provides positive-pressure airflow. Wear an N95 respirator when giving the client direct care. INCORRECT The nurse should wear an N95 respirator mask when caring for clients who require airborne precautions, not a protective environment.
A nurse is completing an admission for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? A. Neck vein distention B. Urine specific gravity 0.99 (1.01 to 1.025) C. Rapid heart rate D. Blood pressure 144/82 mm Hg
Neck vein distention INCORRECT Neck vein distension is a clinical manifestation of fluid volume excess. Urine specific gravity 0.99 (1.01 to 1.025) INCORRECT The urine specific gravity is expected to be greater than 1.025 for a client who has a potential fluid volume deficit. A decrease urine specific gravity may indicate overhydration or excess of fluid volume. Rapid heart rate CORRECT Tachycardia is manifestation of fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days. Blood pressure 144/82 mm Hg INCORRECT Hypotension is an expected finding for a client who has fluid volume deficit.
A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? A. Numbness of the extremities B. Bradycardia C. Positive Chvostek's sign D. Abdominal cramping
Numbness of the extremities INCORRECT Numbness of the extremities is a manifestation of hyperkalemia. Bradycardia INCORRECT Tachycardia is a manifestation of hyponatremia along with hypovolemia. Positive Chvostek's sign INCORRECT A positive Chvostek's sign is a manifestation of hypomagnesemia and hypocalcemia. Abdominal cramping CORRECT This client has hyponatremia, which is a low sodium level. Manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea.
A nurse on a med-surg unit is caring for a patient who has a new prescription for wrist restraints. Which of the following actions should the nurse take? A. Pad the client's wrist before applying the restraints B. Evaluate the client's circulation every 8 hr after application C. Remove the restraints every 4 hr to evaluate the client's status. D. Secure the restraint ties to the bed's side rails.
Pad the client's wrist before applying the restraints. CORRECT The use of restraints without padding can abrade the client's skin, resulting in client injury. Evaluate the client's circulation every 8 hr after application. INCORRECT The nurse should evaluate the client's circulation, range of motion, vital signs, and overall status every 15 min after initial application of restraints. Remove the restraints every 4 hr to evaluate the client's status. INCORRECT The nurse should remove the restraints at least every 2 hr to reposition the client and assess needs for hygiene and toileting. Secure the restraint ties to the bed's side rails. INCORRECT The nurse should secure the restraint ties to a part of the bed frame that moves with the client to reduce the risk of injury.
A nurse is admitting a client. The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply. A. Place the client on droplet isolation precautions B. Apply oxygen at 2 L/min via nasal cannula C. Request a prescription for an antipyretic medication D. Wear an N95 mask when providing care to the client E. Request a prescription for an antihypertensive medication F. Remain 1 m (3 feet) from the client
Place the client on droplet isolation precautions is CORRECT. The nurse should identify that the client has pneumonia, which is transmitted through droplets greater than 5 microns in the air. Therefore, the nurse should place the client on droplet isolation precautions. 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 a temperature of 38.6° C (101.5° F), indicating a fever. Therefore, the nurse should request an antipyretic medication to treat the client's fever. Wear an N95 mask when providing care to the client is INCORRECT. The nurse should wear an N95 mask when providing care to clients who have an airborne infection and are in a negative air pressure room. Request a prescription for an antihypertensive medication is INCORRECT. The client's blood pressure is within the expected reference range. Therefore, a request for a prescription for an antihypertensive medication is not indicated. Remain 1 m (3 feet) from the client is CORRECT. The nurse should identify that the client has pneumonia. Therefore, the nurse should wear a sterile mask and remain within 1 m (3 feet) from the client.
A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? A. Protective environment B. Airborne precautions C. Droplet precautions D. Contact precautions
Protective environment INCORRECT Clients who have a compromised immune system require a protective environment. Airborne precautions INCORRECT Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including tuberculosis and measles. Droplet precautions INCORRECT Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. Contact precautions CORRECT Major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client.
A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress? A. Role ambiguity B. Sick role C. Role overload D. Role conflict
Role ambiguity INCORRECT Role ambiguity occurs when people are unclear about the expectations of their role in a given situation. Sick role INCORRECT Sick role refers to the expectations placed on the individual who has the alteration in health, rather than the caregiver. Role overload CORRECT The partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage. Role conflict INCORRECT Role conflict develops when a person must assume multiple roles that have opposing expectations.
A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? A. The client uses a wool blanket on their bed. B. The client identifies the location of a fire extinguisher. C. The client stores an extra oxygen tank on its side under their bed. D. The client has a weekly inspection checklist for oxygen equipment.
The client uses a wool blanket on their bed. INCORRECT The client should use a cotton blanket instead of a wool blanket to avoid generating static electricity that could ignite the oxygen. The client identifies the location of a fire extinguisher. CORRECT The client should be able to identify the location of fire extinguishers in the home and be aware of how to use them. The client stores an extra oxygen tank on its side under their bed. INCORRECT The client should store extra oxygen tanks in an upright position to maintain safety. The client has a weekly inspection checklist for oxygen equipment. INCORRECT The client or caregiver should inspect oxygen equipment daily.
A nurse has just inserted a NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement. A. The tube aspirate has a pH of 7 (less than 5) B. An x-ray shows the end of the tube above the pylorus C. Bowel sounds are present on auscultation D. The client reports relief of nausea
The tube aspirate has a pH of 7 (less than 5) INCORRECT Gastric aspirate from a client who has been fasting for several hours should have a pH of 5 or less. Intestinal fluid or fluid from the client's airway usually has a pH higher than 6. Therefore, a pH of 7 does not indicate gastric placement of an NG tube. An x-ray shows the end of the tube above the pylorus. CORRECT An abdominal x-ray showing the end of the tube above the pylorus indicates gastric placement. Bowel sounds are present on auscultation. INCORRECT The presence of bowel sounds on auscultation reflects gastric motility, not gastric placement of the tube. The client reports relief of nausea. INCORRECT Correct placement of an NG tube can help relieve nausea, especially if the tube is intended for gastric decompression. However, this finding alone is not enough to confirm gastric placement.
A nurse is caring for a client with a diagnosis of terminal cancer. Which of the following statements by the client should indicate to the nurse that the client is ready to hear information regarding palliative care? A. "I am ready to learn about chemotherapy to help cure my cancer." B. "I just want you to give me something to get this over with soon." C. "I know that many people have recovered fully from cancer, and so will I." D. "I want you to tell me about measures available to keep me comfortable."
"I am ready to learn about chemotherapy to help cure my cancer." INCORRECT This statement would indicate that the client has not accepted that their diagnosis is terminal and is still hoping for a cure, which is not the goal of palliative care. "I just want you to give me something to get this over with soon." INCORRECT This statement would indicate that the client has accepted that their diagnosis is terminal but is overwhelmed and experiencing exaggerated grief. "I know that many people have recovered fully from cancer, and so will I." INCORRECT This statement would indicate that the client has not accepted that their diagnosis is terminal and is still hoping for a cure, which is not the goal of palliative care. "I want you to tell me about measures available to keep me comfortable." CORRECT This statement would indicate that the client has accepted that their diagnosis is terminal and is focusing on the goals of palliative care, which are comfort and manifestation control.
A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate? A. "The transfer of your family member is being done because the provider knows what's best." B. "Would you like it if we discussed the transfer with your family member?" C. "Why are you so concerned about this transfer?" D. "I know how you feel. My parent had to be transferred to a long-term care facility."
"The transfer of your family member is being done because the provider knows what's best." INCORRECT This is a defensive response which can hinder further communication. "Would you like it if we discussed the transfer with your family member?" CORRECT This response facilitates therapeutic communication and provides general leads while maintaining client confidentiality. "Why are you so concerned about this transfer?" INCORRECT Asking a why question can make the recipient defensive which can hinder further communication. "I know how you feel. My parent had to be transferred to a long-term care facility." INCORRECT This is a sympathetic response, which can interfere with a therapeutic relationship.
A client who is nonambulatory notifies the nurse that their trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? A. Activate the emergency fire alarm B. Extinguish the fire C. Evacuate the client. D. Confine the fire
Activate the emergency fire alarm. INCORRECT According to the RACE mnemonic, the second action in response to a fire is to activate the alarm. Extinguish the fire. INCORRECT According to the RACE mnemonic, the fourth action in response to a fire is to attempt to extinguish the fire. Evacuate the client. CORRECT According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area. Confine the fire. INCORRECT According to the RACE mnemonic, the third action in response to a fire is to contain the fire by closing all the doors and windows in the area. The nurse should also turn off oxygen and electrical equipment in the area of the fire.
A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile infection. Which of the following information should the nurse include in the teaching? A. Assign the client to a room with a negative airflow system. B. Use alcohol-based hand sanitizer when leaving the client's room. C. Clean contaminated surfaces in the client's room with a phenol solution. D. Have family members wear a gown and gloves when visiting.
Assign the client to a room with a negative airflow system. INCORRECT A client who has a Clostridium difficile infection requires a private room, but a negative airflow system is not necessary. Use alcohol-based hand sanitizer when leaving the client's room. INCORRECT The nurse should use soap and water for hand hygiene because alcohol-based hand sanitizer does not kill Clostridium difficile spores. Clean contaminated surfaces in the client's room with a phenol solution. INCORRECT The nurse should use a phenol solution to clean surfaces contaminated with bacteria and fungi. However, phenol does not kill Clostridium difficile spores. Chlorine bleach is an example of a disinfectant that kills spores. Have family members wear a gown and gloves when visiting. CORRECT Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Staff must also wear gowns and gloves.
A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.) A. Assist the client with a partial bed bath B. Measure the client's BP after the nurse administers an antihypertensive medication C. Test the client's swallowing ability by providing thickened liquids D. Use a communication board to ask what the client wants for lunch E. Irrigate the client's indwelling urinary catheter
Assist the client with a partial bed bath is CORRECT. Assisting a client with a bed bath poses minimal risk to the client and is within the AP's range of function. Measure the client's BP after the nurse administers an antihypertensive medication is CORRECT. Measuring a client's BP poses minimal risk to the client and is within the AP's range of function. Test the client's swallowing ability by providing thickened liquids is INCORRECT. Assessing the client's swallowing ability places the client at risk for aspiration and is not within the AP's range of function. Nurses perform tasks that require assessment. Use a communication board to ask what the client wants for lunch is CORRECT. Using a communication board poses minimal risk to the client and is within the AP's range of function. Irrigate the client's indwelling urinary catheter is INCORRECT. Irrigating the client's indwelling urinary catheter is an invasive procedure and is not within the AP's range of function.
A nurse is caring for a client who is postoperative. When the nurse prepares to change the client's dressing, they say, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse priority action? A. Encourage the client to relax and take deep breaths during the dressing change. B. Educate the client about the importance of the dressing change to prevent infection C. Assist the client to a comfortable position for the dressing change. D. Administer pain medication 45 min before changing the client's dressing
Encourage the client to relax and take deep breaths during the dressing change. INCORRECT Encouraging the client to relax and take deep breaths during the postoperative period is important because relaxation can help reduce the client's anxiety about the procedure. However, there is another intervention that is the priority. Educate the client about the importance of the dressing change to prevent infection. INCORRECT Encouraging the client to relax and take deep breaths during the postoperative period is important because relaxation can help reduce the client's anxiety about the procedure. However, there is another intervention that is the priority. Assist the client to a comfortable position for the dressing change. INCORRECT Assist the client to a comfortable position for the dressing change. Moving the client to a comfortable position for the dressing change is important because it can help the client relax and can also reduce strain on the wound. However, there is another intervention that is the priority. Administer pain medication 45 min before changing the client's dressing. CORRECT The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's physiological need for comfort and pain relief. Therefore, the priority intervention is to administer an analgesic 30 to 60 min before changing the client's dressing.
A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess? A. Hypotension B. Weak, thready pulse C. Slow capillary refill D. Distended neck veins
Hypotension INCORRECT Hypotension is an indication of fluid volume deficit. Other indications of fluid volume deficit, or dehydration, are dry mucous membranes and sunken eyeballs. Weak, thready pulse INCORRECT A weak, thready pulse is an indication of fluid volume deficit. Other indications of fluid volume deficit, or dehydration, include an increased hematocrit and urine specific gravity. Slow capillary refill INCORRECT A decrease in capillary refill time is an indication of fluid volume deficit. Other indications of fluid volume deficit, or dehydration, include output of less than 30 mL/hr and dark yellow urine. Distended neck veins CORRECT Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.
A nurse in a provider's clinic is caring for a client who has diarrhea. The nurse is providing teaching for the client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching. A. Increase intake of high-calcium foods B. Eat probiotic foods, such as yogurt C. Avoid alcohol while experiencing diarrhea D. Eat raw vegetables E. Eat three large meals a day F. Avoid caffeine while experiencing diarrhea G. Drink hot liquids several times a day H. Drink carbonated beverages to replace lost fluids I. Follow a low-fiber diet
Increase intake of high-calcium foods is INCORRECT. The nurse should instruct the client to increase intake of high-potassium foods. Eat probiotic foods, such as yogurt is CORRECT. Probiotic foods, such as yogurt, contain live bacterial cultures, which can help to reduce diarrhea. Avoid alcohol while experiencing diarrhea is CORRECT. Alcohol is a substance that stimulates gastrointestinal (GI) motility. Eat raw vegetables is INCORRECT. Raw vegetables contain fiber. The nurse should instruct the client to eat vegetables that are well-cooked and do not have skins or seeds. Eat three large meals a day is INCORRECT. The nurse should instruct the client to eat small meals throughout the day to manage diarrhea. Avoid caffeine while experiencing diarrhea is CORRECT. Caffeine is a substance that stimulates GI motility. Drink hot liquids several times a day is INCORRECT. Hot liquids can stimulate peristalsis and should be avoided while the client is experiencing diarrhea. Drink carbonated beverages to replace lost fluids is INCORRECT. Items such as milk, fruit, and carbonated beverages can contain simple sugars that stimulate GI motility. Follow a low-fiber diet is CORRECT. Foods that are high in fiber stimulate GI motility and should be avoided while the client is experiencing diarrhea.
A nurse is caring for a client who is postoperative following abdominal surgery. Click to highlight the assessment findings below that the nurse should report to the provider. To deselect a finding, click on the finding again. A. Neuro Assessment B. Incisional drainage C. Urinary output D. Reported pain lvl E. GI Assessment F. Vital Signs
Neurological assessment is INCORRECT. The client is oriented to person, place, and time. They are able to move all extremities and have no obvious indication of neurological compromise. Incisional drainage is INCORRECT. While the initial assessment indicated drainage on the dressing, there has been no further drainage since that time. A small amount of drainage following abdominal surgery is an expected finding and does not need to be reported to the provider unless drainage continues or increases over time. Urinary output is CORRECT. A client who has an indwelling urinary catheter should produce at least 30 to 50 mL/hr of urine. The client's output is less than the expected volume. The nurse should assess the catheter's placement and potential for blockage due to their reduced urine output. This finding should be reported to the provider. Reported pain level is CORRECT. The client's pain has not been relieved with the administration of morphine. According to the client's report, their pain level is increasing. This finding should be reported to the provider. Gastrointestinal assessment is INCORRECT. While nausea and hypoactive bowel sounds were initially noted, the client reports relief after the administration of metoclopramide. Vital signs is CORRECT. The client's heart rate and respiratory rate have increased, and their blood pressure and oxygen saturation levels have decreased. These findings should be reported to the provider.
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.) A. Place the client in a room with negative-pressure airflow B. Wear gloves when assisting the client with oral care C. Limit each visitor to 2-hr increments D. Wear a surgical mask when providing client care E. Use antimicrobial sanitizer for hand hygiene
Place the client in a room with negative-pressure airflow is CORRECT. The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions. Wear gloves when assisting the client with oral care is CORRECT. The nurse should wear gloves when assisting the client with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever their hands might come in contact with a client's bodily fluids, such as saliva, and the mucous membranes in the mouth. Limit each visitor to 2-hr increments is INCORRECT. The nurse does not need to limit the client's visitors. However, the nurse should limit the client's presence outside the room and the client should wear a surgical mask when outside of the room. Wear a surgical mask when providing client care is INCORRECT. The nurse should wear an N95 respirator during client care to meet the requirements of airborne precautions. Use antimicrobial sanitizer for hand hygiene is CORRECT. The nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. Nurses should also wash their hands with soap and water when their hands are visibly soiled.
A nurse is caring for a client who has limited mobility in their lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? A. Place the client in high-Fowler's position. B. Have the client use a trapeze bar when changing position. C. Massage areas of skin that are darker than the surrounding skin tissue with unscented lotion. D. Increase the client's intake of carbohydrates.
Place the client in high-Fowler's position. INCORRECT High-Fowler's position places additional pressure on the sacrum and the heels, increasing the risk for skin breakdown. Have the client use a trapeze bar when changing position. CORRECT By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-injury development. Massage areas of skin that are darker than the surrounding skin tissue with unscented lotion. INCORRECT Massaging pressure point that have a change in color of skin tissue can cause further capillary breakdown in subcutaneous tissues. Increase the client's intake of carbohydrates. INCORRECT Increased protein intake helps with tissue repair. However, for prevention, the client should consume a balanced diet with adequate fluid intake. There is no need to increase carbohydrate intake.
A nurse is caring for a client who is having difficulty breathing. The client is supine and is receiving supplemental oxygen via nasal cannula. Which of the following interventions should the nurse take 1st? A. Suction the client's airway. B. Instruct the client to perform incentive spirometry every hour. C. Humidify the client's supplemental oxygen. D. Assist the client to an upright position.
Suction the client's airway. INCORRECT The use of suction to remove pulmonary secretions can help to ease the client's breathing. However, evidence-based practice indicates that there is another intervention that the nurse should implement first. Instruct the client to perform incentive spirometry every hour. INCORRECT The use of incentive spirometry can help to ease the client's breathing by expanding the smaller airways and alveoli. However, evidence-based practice indicates that there is another intervention that the nurse should implement first. Humidify the client's supplemental oxygen. INCORRECT The use of humidity with supplemental oxygen can help to thin secretions that can limit airflow. However, evidence-based practice indicates that there is another intervention that the nurse should implement first. Assist the client to an upright position. CORRECT According to evidence-based practice the nurse should assist the client to an upright position. This assists with chest expansion and increases the effectiveness of the existing supplemental oxygen. The nurse should elevate the head of the client's bed to the semi-Fowler's or high-Fowler's position to facilitate maximal chest expansion. Sitting upright improves gas exchange and prevents pressure on the diaphragm from abdominal organs.
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation? A. Urine has an unusual odor B. Urine specific gravity is 1.035 (1.01 to 1.025) C. Bladder scan shows 525 mL of urine D. Urine is positive for ketones
Urine has an unusual odor. INCORRECT Urine with an unusual odor can be a sign of infection; however, it is not an indication for irrigation. Urine specific gravity is 1.035 (1.01 to 1.025). INCORRECT A urine specific gravity of 1.035 indicates that the urine is concentrated; however, it is not an indication for irrigation. Bladder scan shows 525 mL of urine. CORRECT A client who has an indwelling urinary catheter should have a continuous urine flow without an accumulation of urine in the bladder; therefore, the nurse should irrigate the catheter to resolve any existing blockage. Urine is positive for ketones. INCORRECT Urine that is positive for ketones is a sign of diabetes mellitus with poor glucose control; however, it is not an indication for irrigation.
A nurse is admitting a new client. Which of the following actions should the nurse take while performing med reconciliation. A. Verify the client's name on their identification bracelet with the medication administration record. B. Call the pharmacy to determine whether the client's medications are available. C. Compare the client's home medications with the provider's prescriptions. D. Place the client's home medication bottles in a secure location.
Verify the client's name on their identification bracelet with the medication administration record. INCORRECT The nurse should verify the client's name on their identification bracelet when administering medication; however, this action is not a part of performing medication reconciliation. Call the pharmacy to determine whether the client's medications are available. INCORRECT The nurse should call the pharmacy if the client's medications are not available to administer at the appropriate time; however, this action is not a part of performing medication reconciliation. Compare the client's home medications with the provider's prescriptions. CORRECT The nurse should compare the client's home medications with the provider's prescriptions when performing medication reconciliation. Place the client's home medication bottles in a secure location. INCORRECT The nurse should place the client's home medications in a secure location to ensure safe handling of prescribed medications; however, this action is not a part of performing medication reconciliation.
A nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. "I can concentrate best in the morning." B. "It is difficult to read the instructions because my glasses are at home." C. "I'm wondering why I need to learn this." D. "You will have to talk to my partner about this."
"I can concentrate best in the morning." CORRECT The client's statement indicates a readiness to learn because they are verbalizing the best time for them to learn. "It is difficult to read the instructions because my glasses are at home." INCORRECT The client's statement indicates the client is not ready to learn. The client has to have the tools they need to learn and comprehend the information. "I'm wondering why I need to learn this." INCORRECT The client's statement indicates a reluctance to learn information they think they might not need to know. "You will have to talk to my partner about this." INCORRECT With this statement, the client is redirecting the nurse's attempt to teach toward someone else, indicating that they are not ready to learn.
A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statement indicates an understanding of herbal supplement use? A. "I can take echinacea to improve my immune system." B. "I can take feverfew to reduce my level of anxiety." C. "I can take ginger to improve my memory." D. "I can take ginkgo biloba to relieve nausea."
"I can take echinacea to improve my immune system." CORRECT Echinacea is taken to promote immunity and reduce the risk of infection. "I can take feverfew to reduce my level of anxiety." INCORRECT Feverfew is taken to promote wound healing and decrease inflammation associated with arthritis. Valerian and chamomile can be taken to reduce anxiety. "I can take ginger to improve my memory." INCORRECT Ginger is taken to relieve nausea and vomiting and aid in digestion. Ginkgo biloba can be taken to improve memory and reduce stress. "I can take ginkgo biloba to relieve nausea." INCORRECT Ginkgo biloba is taken to improve memory and reduce stress. Ginger can be taken to relieve nausea and vomiting and aid in digestion.
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? A. "I think I should take my pain medication more often, since it is not controlling my pain." B. "Breathing faster will help me keep my mind off of the pain." C. "It might help me to listen to music while I'm lying in bed." D. "I don't want to walk today because I have some pain."
"I think I should take my pain medication more often, since it is not controlling my pain." INCORRECT As a 2 on a scale of 0 to 10, this client's pain is mild. Additional analgesic medication is unnecessary at this time. "Breathing faster will help me keep my mind off of the pain." INCORRECT Rapid breathing can lead to hyperventilation, while slow, focused breathing helps induce relaxation, which can help with managing pain. "It might help me to listen to music while I'm lying in bed." CORRECT Listening to music is an effective nonpharmacological intervention for the management of mild pain. "I don't want to walk today because I have some pain." INCORRECT Postoperative clients need to ambulate even if they are having mild pain.
A nurse is reviewing the laboratory results of a female client who has hypovolemia. Which of the following laboratory result would be a priority for the nurse to report to the provider? A. BUN 21 mg/dL (10 to 20 mg/dL) B. Creatinine 1.4 mg/dL (0.5 to 1.1 mg/dL) C. Sodium 142 mEq/L (136 to 145 mEq/L) D. Potassium 5.8 mEq/L (3.5 to 5 mEq/L)
BUN 21 mg/dL (10 to 20 mg/dL) INCORRECT This BUN level is slightly above the expected reference range and is an expected non-urgent finding for a client who has hypovolemia; therefore, there is another laboratory result that is a priority for the nurse to report to the provider. Creatinine 1.4 mg/dL (0.5 to 1.1 mg/dL) INCORRECT This creatinine level is slightly above the expected reference range and is an expected non-urgent finding for a client who has hypovolemia; therefore, there is another laboratory result that is a a priority for the nurse to report to the provider. Sodium 142 mEq/L (136 to 145 mEq/L) INCORRECT This sodium level is slightly below the expected reference range and is an expected non-urgent finding for a client who has hypovolemia; therefore, there is another laboratory result that is a priority for the nurse to report to the provider. Potassium 5.8 mEq/L (3.5 to 5 mEq/L) CORRECT When using the urgent versus nonurgent approach to client care, the nurse should determine that this potassium level is above the expected reference range and should be reported to the provider. Potassium affects the contractility of the heart and this client would be at risk for developing dysrhythmias.
