ATI RN Fundamentals Online Practice 2023 B
A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump?
8 mL/hr
A nurse is caring for a client who is receiving a unit of packed RBC's. Complete the following sentence by using the lis of options. The client has manifestations of _____ as evidenced by the client's ______.
Correct Answer (1): Allergic Reaction The nurse should identify that itching, flushing of the face, anxiety and urticaria are manifestations of an allergic reaction to the blood transfusion. The nurse should stop the transfusion and notify the provider. Correct Answer (2): Itching The nurse should identify that itching, flushing of the face, anxiety and urticaria are manifestations of an allergic reaction to the blood transfusion. The nurse should stop the transfusion and notify the provider. Incorrect Answer (1): Febrile reaction is incorrect. A febrile reaction has manifestations of fever, chills, headache, flushing of the face, and muscle pain. Fluid overload is incorrect. Fluid overload has manifestations of cough, crackles heard in bases of the client's lungs, shortness of breath, and distended neck veins. Incorrect Answer (2): Temperature is incorrect. The client's temperature is within the expected reference range. An increase in temperature is a manifestation of febrile or hemolytic reaction to blood administration. Oxygen saturation is incorrect. The client's oxygen saturation is within the expected reference range.
A nurse is caring for a female client. Complete the following sentence by using the lists of options. The client is at risk for _____ as evidenced by the client's _____.
Correct Answer (1): Bleeding The client's platelet count is less than the expected reference range. Therefore, the client is at risk for bleeding. Correct Answer (2): Platelet count The client's platelet count is less than the expected reference range. Therefore, the client is at risk for bleeding. Incorrect Answer (1): Dysrhythmias is incorrect. The client's potassium level is within the expected reference range. Therefore, the client is not at an increased risk for dysrhythmias. Infection is incorrect. The client's WBC count is within the expected reference range. Therefore, the client is not at an increased risk for infection. Incorrect Answer (2) WBC count is incorrect. The client's WBC count is within the expected reference range. Therefore, the client is not at an increased risk for infection. Potassium level is incorrect. The client's potassium level is within the expected reference range. Therefore, the client is not at an increased risk for dysrhythmias.
A nurse in a medical-surgical unit is caring for six clients. Complete the following sentence by using the list of options. The first client the nurse should assess is _____ followed by _____. Client 1: Client is admitted with a new diagnosis of rheumatoid arthritis.Client 2: Client has a history of hyperlipidemia. Atorvastatin 20 mg PO administered as prescribed.Client 3: Client is 1 day postoperative. Reports pain as 8 on a scale of 0 to 10. Morphine 5 mg subcutaneous administered as prescribed.Client 4: Client is admitted with a new diagnosis of heart failure.Client 5: Client has a stage 2 pressure injury on the left heel.Client 6: Client is admitted with a new diagnosis of diabetes mellitus.
Correct Answer (1): Client 3 When using the airway, breathing, circulation approach to client care, the nurse should determine that this client is the priority client to assess. The client has an oxygen saturation that is less than the expected reference range, which is an indication of hypoxia. Correct Answer (2): Client 4 When using the airway, breathing, circulation approach to client care, the nurse should determine that this client is the next priority client to assess. The client has a potassium level that is less than the expected reference range, which places the client at risk for dysrhythmias. Incorrect Answers (1): Client 1 is incorrect. The nurse should assess this client because the client's C-reactive protein is greater than the expected reference range, which is an indication of inflammation. However, there is another client the nurse should assess first. Client 2 is incorrect. The nurse should assess this client because the client's cholesterol level is greater than the expected reference range, which places them at risk for coronary heart disease. However, there is another client the nurse should assess first. Incorrect Answers (2): Client 5 is incorrect. The nurse should assess this client because their prealbumin level is less than the expected reference range, which places them at risk for delayed wound healing. However, this client is not the next priority client to assess. Client 6 is incorrect. The nurse should assess this client because their glycosylated hemoglobin level is greater than the expected reference range, which indicates poor diabetic control. However, this client is not the next priority client to assess.
A nurse is caring for a client in a medical surgical unit. Click to highlight the findings that indicate an improvement in the client's condition. To deselect a finding, click on the finding again. 0830: At client's beside for dressing change. S1 and S2 auscultated, rate 76/min. Respirations even and regular at 16/min. Negative pressure wound therapy dressing removed. Granulation tissue covers the wound bed. Slight erythema at wound edges. The surrounding tissue is warm to touch. No odor present. Pressure injury is 8.75 cm (3.5 in) in diameter and 2.5 cm (1 in) at the deepest point. Two tunnels measuring 5 cm (2 in) and 3 cm (1.2 in). Dressing reapplied and sealed, intermittent pressure setting at 125 mm Hg. Client reports pain as a 2 on a scale from 0 to 10, tolerated procedure well.
Correct Answer: When evaluating outcomes, the nurse should identify that the assessment findings of granulation tissue covering the wound bed, no odor present, increased comfort level, and the decrease in size of the wound bed and tunneling indicate an improvement of the client's condition. Granulation tissue is comprised of new blood vessels, a lack of odor indicates infection is not suspected, and the decrease in the wound bed size and length of tunneling are associated with healing of the client's pressure injury.
A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device? "This type of hearing aid does not allow for fine tuning of volume." "I shouldn't have trouble keeping the hearing aid in place during exercise." "I expect to hear a whistling sound when I first insert the hearing aid." "I will be sure to remove my hearing aid before taking a shower."
Correct Answer: "I will be sure to remove my hearing aid before taking a shower." Clients should remove any hearing devices before showering because exposure to water can damage them. Incorrect Answer: "This type of hearing aid does not allow for fine tuning of volume." A behind-the-ear hearing aid allows for fine tuning of the volume of the device. It is useful for clients who have mild to severe hearing loss. "I shouldn't have trouble keeping the hearing aid in place during exercise." Physical activity can easily dislodge this type of hearing aid. "I expect to hear a whistling sound when I first insert the hearing aid." Whistling during insertion can be a sign that the hearing aid does not fit properly. A buildup of cerumen or fluid in the ear can also cause a whistling sound.
A nurse is providing discharge instructions to a client who will be using a walker. Which of the following statements by the client indicates the teaching has been effective? "I will use an extension cord so I can watch television in the living room." "I will hire someone to trim the tree that overhangs the front porch stairs." "I will place my alarm clock on my bedroom dresser." "I will replace the old throw rug in the kitchen with a new one."
Correct Answer: "I will hire someone to trim the tree that overhangs the front porch stairs." Clearing stairwells of any object that could cause the client to trip or the need to bend over will decrease the risk for falls. Incorrect Answer: "I will use an extension cord so I can watch television in the living room." Extension cords should only be used when necessary and not on a daily basis due to the risk of the client tripping over the cord. "I will place my alarm clock on my bedroom dresser." Placing frequently used items such as an alarm clock, glasses, or tissues should be placed on the client's night stand within reach to prevent the client from falling in the night. "I will replace the old throw rug in the kitchen with a new one." Using throw rugs increases the client's risk for falls, as it creates a tripping and slipping hazard for the client.
A nurse is providing teaching to a client who is on protective isolation precautions. Which of the following client statements indicates understanding of the teaching? "I can shower up to three times a week." "I will inform my friends and family to visit when I'm feeling well." "I can take a plane to visit my grandchildren." "I will wear a face mask when leaving my hospital room."
Correct Answer: "I will wear a face mask when leaving my hospital room." The client is encouraged to wear a face mask because of increased risk for exposure to micro-organisms. Incorrect Answer: "I can shower up to three times a week." The client should be encouraged to bathe daily with an antimicrobial soap. "I will inform my friends and family to visit when I'm feeling well." The client is encouraged to limit visitors as much as possible, even when feeling well, because of increased risk for exposure to micro-organisms. "I can take a plane to visit my grandchildren." The client should avoid crowds and contact with people who might be ill.
A client demonstrates anger when the nurse does not respond within 5 min of ringing for the nurse. Which of the following is an appropriate response by the nurse? "I'm sorry, but another client needed my attention." "I could not arrive any sooner. What can I do for you?" "We had an emergency on the unit and that was a priority, but now I'm here." "That must be frustrating for you. How can I help you right now?"
Correct Answer: "That must be frustrating for you. How can I help you right now?" This response is therapeutic because the nurse is acknowledging the client's feelings and offering help. Incorrect Answer: "I'm sorry, but another client needed my attention." This response is nontherapeutic because the nurse is responding defensively. "I could not arrive any sooner. What can I do for you?" This response is nontherapeutic because the nurse is responding defensively. "We had an emergency on the unit and that was a priority, but now I'm here." This response is nontherapeutic because the nurse is responding defensively.
A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? "I'm having mild pain." "The pain is like a dull ache in my stomach." "I notice that the pain gets worse after I eat." "The pain makes me feel nauseous."
Correct Answer: "The pain is like a dull ache in my stomach." The client is describing the quality of the pain, which is how the pain feels in the client's own words. Incorrect Answer: "I'm having mild pain." The client is describing the severity of the pain, not the quality of the pain. The nurse should use a pain scale to specify the intensity of the client's pain. "I notice that the pain gets worse after I eat." The client is describing a factor that aggravates the pain, not the quality of the pain. "The pain makes me feel nauseous." The client is describing a manifestation that accompanies the pain, not the quality of the pain.
A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? "They allow the court to overrule an adult client's refusal of medical treatment." "They indicate the form of treatment a client is willing to accept in the event of a serious illness." "They permit a client to withhold medical information from health care personnel." "They allow health care personnel in the emergency department to stabilize a client's condition."
Correct Answer: "They indicate the form of treatment a client is willing to accept in the event of a serious illness." Advance directives include a living will, which permits clients to direct the treatment they will receive in the event of a medical emergency or serious illness. Incorrect Answer: "They allow the court to overrule an adult client's refusal of medical treatment." A court can only overrule an adult client's refusal of medical treatment if the client is legally incompetent. "They permit a client to withhold medical information from health care personnel." The Americans with Disabilities Act, not advance directives, protects the privacy of a client who chooses not to disclose a medical disability. "They allow health care personnel in the emergency department to stabilize a client's condition." The Emergency Medical Treatment and Active Labor Act, not advance directives, directs emergency personnel to provide screening and stabilizing care before discharging or transferring clients to another facility.
A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make? "We would consult the person appointed by your health care proxy to make decisions." "We would give you oxygen through a tube in your nose." "You would be unable to change your previous wishes about your care." "We would insert a breathing tube while we evaluate your condition."
Correct Answer: "We would give you oxygen through a tube in your nose." Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula. Incorrect Answer: "We would consult the person appointed by your health care proxy to make decisions." The staff must honor the client's wishes as stated in their living will; therefore, it would not be necessary to consult the person appointed by the client's health care proxy to make decisions about the client's care. "You would be unable to change your previous wishes about your care." Clients determine advance directives ahead of time to guide decision-making at the time of an emergency event. If the client initiates a change, the staff must honor it. Otherwise, staff must honor the decisions the client has documented in the advance directives. "We would insert a breathing tube while we evaluate your condition." Intubation is a resuscitative measure. The staff should not implement this intervention for a client who declines resuscitation in their living will.
A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? "What could I have done to deserve this illness?" "I blame medical science for not curing me." "Where is my daughter at a time like this?" "Will I ever begin to feel in charge of my life again?"
Correct Answer: "What could I have done to deserve this illness?" The client's terminal illness might prompt the client to review their life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to them. Incorrect Answer: "I blame medical science for not curing me." The basis of medicine is science, not spirituality. This statement does not reflect the client's conflict with spiritual beliefs. "Where is my daughter at a time like this?" This statement reflects conflict in family relationships, not with the client's spiritual beliefs. "Will I ever begin to feel in charge of my life again?" This statement reflects the client's feelings of powerlessness but does not indicate a conflict of a spiritual nature.
A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? "When descending stairs, I will first shift my weight to my right leg." "I should place my crutches 12 inches in front and to the side of each foot." "As I sit down, I will hold one crutch in each hand." "I will make sure the shoulder rests are snug against my armpits."
Correct Answer: "When descending stairs, I will first shift my weight to my right leg." To descend stairs, the client should first shift their body weight to their right, unaffected leg. Incorrect Answer: "I should place my crutches 12 inches in front and to the side of each foot." The client should place their crutches 15 cm (6 in) in front and to the side of each foot. "As I sit down, I will hold one crutch in each hand." Just before sitting down, the client should hold both crutches by their hand bars in one hand. "I will make sure the shoulder rests are snug against my armpits." To avoid injury to the underlying nerves, the shoulder rests should be at least 2.5 to 5 cm (1 to 2 in) below the axillae.
A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make? "I'll get a blood sample from you and send it for a screening test." "Beginning at age 60, you should have a colonoscopy." "You should have a fecal occult blood test every year." "The recommendation is to have a sigmoidoscopy every 10 years."
Correct Answer: "You should have a fecal occult blood test every year." Colorectal cancer screening for clients who are at average risk begins at age 45. One option for screening is a fecal occult blood test annually. Incorrect Answer: "I'll get a blood sample from you and send it for a screening test." Blood tests do not detect colorectal cancer. One option for screening is a double-contrast barium enema every 5 years. "Beginning at age 60, you should have a colonoscopy." Colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a colonoscopy every 10 years. "The recommendation is to have a sigmoidoscopy every 10 years." One option for screening is a flexible sigmoidoscopy every 5 years.
A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid? 2 cups of soup 1 quart of water 8 oz of ice chips 6 oz of tea
Correct Answer: 8 oz of ice chips The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid. Incorrect Answer: 2 cups of soup The nurse should understand that 2 cups of soup are equivalent to 480 mL of fluid. 1 quart of water The nurse should understand that 1 quart of water is equivalent to 960 to 1,000 mL of fluid. 6 oz of tea The nurse should understand that 6 oz of tea is equal to 180 mL of fluid.
A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity? A client who is unaware of their recent cancer diagnosis asks the nurse if they have cancer, and the nurse responds affirmatively. A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes. A client who has a do-not-resuscitate (DNR) order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family. A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse previously promised to administer.
Correct Answer: A client who is unaware of their recent cancer diagnosis asks the nurse if they have cancer, and the nurse responds affirmatively. Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others. Incorrect Answer: A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes. When stopping a procedure that the client refuses, the nurse is following the ethical principle of autonomy and is recognizing the client's right to refuse treatment. A client who has a do-not-resuscitate (DNR) order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family. A DNR order requires a request on the part of the client or the client's designated power of attorney for health care decisions. Enforcing a client's DNR order supports the ethical principle of autonomy by following the client's end-of-life wishes. A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse previously promised to administer. This is an example of the ethical principle of fidelity, which means keeping promises.
A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? A lesion with uniform pigmentation New appearance of petechiae A mole with an asymmetrical appearance The presence of a papule
Correct Answer: A mole with an asymmetrical appearance An uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part. Incorrect Answer: A lesion with uniform pigmentation Variations in pigmentation are a possible indication of a skin malignancy. A lesion with uniform pigmentation is not an expected indication of a skin malignancy. New appearance of petechiae Petechiae are capillaries that have burst under the skin and appear as small spots on the skin. Although they can be indications of other conditions, petechiae are not an expected indication of a skin malignancy. The presence of a papule Papules are solid elevations that are palpable in the skin and are less than 1 cm (0.39 in) in size. They are not an expected indication of a skin malignancy.
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies? Biofeedback Aloe Feverfew Acupuncture
Correct Answer: Acupuncture The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk of further infection. Incorrect Answer: Biofeedback Biofeedback is a complementary and alternative therapy to assist clients with stroke recovery, smoking cessation, headaches, and many other disorders. Herpes zoster is not a contraindication for the use of this mind-body technique. Aloe Aloe is a complementary and alternative therapy that can help improve disorders and can have wound healing effects. Herpes zoster is not a contraindication for the use of this type of therapy. Feverfew Acupuncture The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk of further infection.
A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? Insert the needle at a 15° angle. Aspirate for blood return prior to administration. Administer the medication into the abdomen. Massage the site following the injection.
Correct Answer: Administer the medication into the abdomen. The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue. Incorrect Answer: Insert the needle at a 15° angle. The nurse should instruct the client to insert the needle at a 45° to 90° angle to administer the medication into the subcutaneous tissue. Aspirate for blood return prior to administration. The nurse should instruct the client not to aspirate for blood return because this can cause tissue damage and bruising. Massage the site following the injection. The nurse should instruct the client not to massage the site because this can cause tissue damage and bruising.
A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? Place a pillow under the client's knees. Position a trochanter roll under each of the client's hips. Advise the client to wear rubber-soled slippers. Apply an ankle-foot orthotic device to the client's feet.
Correct Answer: Apply an ankle-foot orthotic device to the client's feet. The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress. Incorrect Answer: Place a pillow under the client's knees. The nurse should place a pillow under the client's lower legs to prevent pressure on the heels. Position a trochanter roll under each of the client's hips. The nurse should place a trochanter roll under the client's buttocks and alongside the hips to prevent external rotation of the hips while the client is supine. Advise the client to wear rubber-soled slippers. The soles of the client's slippers have no impact on the alignment of the feet while in bed.
A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? Insert the suction catheter while the client is swallowing. Apply intermittent suction when withdrawing the catheter. Place the catheter in a location that is clean and dry for later use. Hold the suction catheter with their clean, nondominant hand.
Correct Answer: Apply intermittent suction when withdrawing the catheter. The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise. Incorrect Answer: Insert the suction catheter while the client is swallowing. The nurse should insert the suction catheter while the client is inhaling to avoid inserting the catheter into the esophagus. Place the catheter in a location that is clean and dry for later use. The nurse should discard the suction catheter after use to eliminate the risk of reintroducing pathogens into the respiratory tract. Hold the suction catheter with their clean, nondominant hand. The nurse should hold the suction catheter with their dominant hand after donning a sterile glove.
A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection? Apply transparent dressing over the IV insertion site and securement device. Shave excess hair from around the IV insertion site. Cleanse the site with hydrogen peroxide before IV catheter insertion. Palpate the site carefully just before inserting the IV catheter.
Correct Answer: Apply transparent dressing over the IV insertion site and securement device. Transparent dressing prevents infection by protecting the IV site. Incorrect Answer: Shave excess hair from around the IV insertion site. Shaving can increase the risk for microabrasions and infection. Cleanse the site with hydrogen peroxide before IV catheter insertion. The nurse should use chlorhexidine or povidone-iodine, per facility protocol, as the cleansing agent for IV catheter insertion. Palpate the site carefully just before inserting the IV catheter. Unless nurses use sterile technique, they should not palpate the site after cleansing, because this can introduce micro-organisms and lead to infection.
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? Ask another nurse to observe the medication wastage. Notify the pharmacy when wasting the medication. Lock the remaining medication in the controlled substances cabinet. Dispose of the vial with the remaining medication in a sharps container.
Correct Answer: Ask another nurse to observe the medication wastage. A second nurse must witness the disposal of any portion of a dose of a controlled substance. Incorrect Answer: Notify the pharmacy when wasting the medication. Pharmacies do not require notification of the disposal of a portion of a dose of a controlled substance. Lock the remaining medication in the controlled substances cabinet. The nurse should not lock the remaining controlled substance in the cabinet because this is a violation of the Controlled Substances Act. Dispose of the vial with the remaining medication in a sharps container. The nurse should not dispose of the remaining controlled substance in the sharps container because this is a violation of the Controlled Substances Act.
A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next? Rock the client up to a standing position. Pivot on the foot that is the farthest from the chair. Assess the client for orthostatic hypotension. Apply a gait belt to the client.
Correct Answer: Assess the client for orthostatic hypotension. The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair. Incorrect Answer: Rock the client up to a standing position. The nurse should rock the client up to a standing position to generate momentum and reduce the nurse's workload in lifting the client up off the bed; however, there is another action that is the priority. Pivot on the foot that is the farthest from the chair. The nurse should pivot on the foot that is the farthest from the chair to give the client room to move; however, there is another action that is the priority. The nurse can also use their other knee to give the client's weak leg some support as the client moves to the chair. Apply a gait belt to the client. The nurse should use a gait belt to help maintain the client's stability; however, there is another action that is the priority.
A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene? Erythema on pressure points Lower-extremity pulse strength of 2+ Fluid intake of 3,000 mL per day One bowel movement every other day
Correct Answer: Erythema on pressure points Erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from breakdown. Incorrect Answer: Lower-extremity pulse strength of 2+ A lower-extremity pulse strength of 2+ is an expected finding. Fluid intake of 3,000 mL per day Clients should receive 2,000 to 3,000 mL of fluid per day. One bowel movement every other day Bowel movements less frequent than three times per week can indicate constipation and the need for intervention. However, a bowel movement every other day does not require intervention.
A nurse in the emergency department (ED) is caring for a client who reports abdominal pain. Based on the client's clinical findings, which of the following actions should the nurse take? Select all that apply. Assist the client to a left side-lying position with the right knee flexed. Prepare the client for a chest x-ray. Administer a cleansing enema. Auscultate the client's bowel sounds. Perform a manual digital examination of the client's rectum. Administer oxycodone extended-release tablets. Prepare the client for NG tube placement.
Correct Answer: Assist the client to a left side-lying position with the right knee flexed The nurse should place the client in a left side-lying position with the right knee flexed prior to administering an enema. Because the provider prescribed a cleansing enema for the client, the nurse should prepare the client for the procedure. Administer a cleansing enema The nurse should administer a cleansing enema for the client as a result of the provider's prescription. A cleansing enema is intended to assist with bowel elimination and remove any impacted fecal matter indicated by the abdominal x-ray. Auscultate the client's bowel sounds The nurse should auscultate the client's bowel sounds to determine the status of the client's peristalsis. This is a necessary part of determining the presence of bowel sounds, which are an indication of the status of the client's gastrointestinal tract. Perform a manual digital examination of the client's rectum The nurse should perform a manual digital examination of the client's rectum to determine if impacted stool is present. This is a part of the necessary evaluation of the status of the client's gastrointestinal tract. Incorrect Answer: Prepare the client for a chest x-ray is incorrect. A chest x-ray is typically performed for a client who has an impairment of the upper thorax or lungs, not the abdomen. The client has already received an abdominal x-ray; therefore, a chest x-ray is not necessary. Prepare the client for NG tube placement is incorrect. The nurse should not prepare the client for placement of an NG tube because there is no indication or prescription to do so. Placement of an NG tube is required when there is an obstruction of the gastrointestinal tract and peristalsis is absent.
A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority? Auscultate lung sounds. Measure urine output. Monitor blood pressure readings. Monitor electrolyte levels.
Correct Answer: Auscultate lung sounds. The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and shortness of breath. Incorrect Answer: Measure urine output. The nurse should measure urine output to monitor the renal function of a client who is receiving IV fluid; however, it is not the priority assessment. Monitor blood pressure readings. The nurse should monitor blood pressure readings to evaluate the hemodynamic stability of a client who is receiving IV fluids; however, it is not the priority assessment. Monitor electrolyte levels. The nurse should monitor electrolyte levels, especially sodium, to guide the planning of interventions to correct any imbalances in a client who is receiving IV fluids; however, it is not the priority assessment.
A nurse is caring for a client who is at risk for hypokalemia. Which of the following foods should be included in the client's diet. Cucumbers Corn Asparagus Avocados
Correct Answer: Avocados The nurse should suggest the client eat avocados, which are an excellent dietary source of potassium. Incorrect Answer: Cucumbers This food is low in potassium. Corn This food is low in potassium. Asparagus This food is low in potassium.
A nurse is caring for a client who has COPD. Select the 3 findings that require follow-up. Breath sounds Blood pressure Oxygen saturation Temperature Heart rate
Correct Answer: Breath Sounds Crackles are caused by mucous in the airways and are a manifestation of pneumonia. Decreased breath sounds indicate decreased ventilation and require follow-up by the nurse. Oxygen Saturation The client's oxygen saturation is below the expected reference range of 95% to 100%, indicating hypoxia, and requires follow-up by the nurse. Temperature The client's temperature is greater than the expected reference range, indicating an infection, and requires follow-up by the nurse. Incorrect Answer: Blood pressure is incorrect. The client's blood pressure is within the expected reference range and does not require follow-up by the nurse. Heart rate is incorrect. The client's heart rate is within the expected reference range of 60 to 100/min and does not require follow-up by the nurse.
A nurse is giving a change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide? Admitting diagnosis Breath sounds Body temperature Diagnostic test results
Correct Answer: Breath sounds When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds. Incorrect Answer: Admitting diagnosis Knowing the client's admitting diagnosis is essential for planning care and following critical pathways; however, other information is the nurse's priority to provide. Body temperature Knowing the client's current body temperature is essential for planning care and following critical pathways; however, other information is the nurse's priority to provide. Diagnostic test results Knowing diagnostic test results is essential for planning care and following critical pathways; however, other information is the nurse's priority to provide.
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? Check the client for injuries. Move hazardous objects away from the client. Notify the provider. Ask the client to describe how they felt prior to the fall.
Correct Answer: Check the client for injuries. The first action the nurse should take when using the nursing process is to assess the client for injuries. Incorrect Answer: Move hazardous objects away from the client. Moving hazardous objects away from the client can prevent further injury; however, there is another action the nurse should take first. Notify the provider. The nurse should notify the provider of the client's fall; however, there is another action the nurse should take first. Ask the client to describe how they felt prior to the fall. Determining the facts that surrounded the fall is important to help prevent subsequent falls; however, there is another action the nurse should take first.
A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use? Touch the face with a cotton ball. Apply a vibrating tuning fork to the client's forehead. Have the client stand with their arms at their sides and their feet together. Perform direct percussion over the area of the kidneys.
Correct Answer: Have the client stand with their arms at their sides and their feet together. A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance. Incorrect Answer: Touch the face with a cotton ball. The nurse should touch the client's corneas with a wisp of cotton and measure light touch and pain across the client's face to test cranial nerve V, the trigeminal nerve. Apply a vibrating tuning fork to the client's forehead. The nurse should apply a vibrating tuning fork to the client's head to perform the Weber test to identify sound lateralization when assessing hearing. Perform direct percussion over the area of the kidneys. The nurse should perform direct percussion over the area of the kidneys to evaluate them for inflammation.
A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and their family. Check the cord routinely for frays or tearing. Keep the unit at least 1.2 m (4 ft) away from a gas stove. Consider purchasing a generator for power backup. Observe for signs of hypoxia. Select synthetic clothing and bedding.
Correct Answer: Check the cord routinely for frays or tearing. Oxygen concentrators require electrical power. Safe use of this delivery system includes assessing the electrical function of the device; therefore, the nurse should instruct the client to routinely check the condition of the cord. Consider purchasing a generator for power backup. Loss of electricity prevents the oxygen concentrator from functioning and could deprive the client of necessary oxygen. The nurse should also instruct the family to have the client placed on their municipality's priority list for restoring power after an outage occurs. Observe for signs of hypoxia. The nurse should instruct the family to observe for and report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and respirations, pallor, and cyanosis. Even with supplemental oxygen, the client's status can worsen, resulting in the development of hypoxia. Incorrect Answer: Keep the unit at least 1.2 m (4 ft) away from a gas stove. Safe use of home oxygen equipment includes keeping the unit at least 3.05 m (10 feet) away from open flames, such as from a fireplace or a gas stove, and at least 2.4 m (8 feet) away from other heat sources. Select synthetic clothing and bedding. Safe use of oxygen therapy includes choosing clothing and bedding made from material that does not generate static electricity; therefore, the nurse should instruct the client to select materials made from cotton.
A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? Wear sterile gloves when removing the old dressing. Warm the irrigation solution to 40.5° C (105° F). Cleanse the wound from the center outward. Use a 20-mL syringe to irrigate the wound.
Correct Answer: Cleanse the wound from the center outward. The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface. Incorrect Answer: Wear sterile gloves when removing the old dressing. The nurse should wear clean gloves to remove the old dressing. Warm the irrigation solution to 40.5° C (105° F). The nurse should warm the irrigation solution to body temperature. Use a 20-mL syringe to irrigate the wound. The nurse should use a 35-mL syringe to irrigate the wound. Syringes that hold 30 to 60 mL of fluid create a safe but effective amount of pressure for wound irrigation.
A nurse is caring for a client who had a spinal cord injury and has paraplegia. The nurse is reviewing the client's medical record. Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding again. Client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities performed once each day. Feet warm. Pedal pulses 2+ bilaterally. Plantar flexion contractures noted bilaterally. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact.
Correct Answer: Client is repositioned every 2 hr The nurse should reposition the client every 2 hr to reduce the risk for skin breakdown. Therefore, this finding does not require intervention at this time. Passive range-of-motion exercises to lower extremities performed once each day The nurse should perform passive range-of-motion exercises to the client's lower extremities two to three times each day to reduce the risk for contractures. Plantar flexion contractures noted bilaterally The nurse should place a footboard 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 contractures. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact The client has a stage 1 pressure injury on the heel. The nurse should apply foot boots to the client's feet to protect the client's heels and promote healing. Incorrect Answer: Feet warm. Pedal pulses 2+ bilaterally is incorrect. The nurse should identify that the client has adequate circulation to their feet. Therefore, this finding does not require intervention at this time.
A nurse is planning teaching for a client who has a new diagnosis of type 1 diabetes mellitus about insulin self-administration. Which of the following actions should the nurse take first? Encourage the client to include a support person in the teaching. Schedule a series of teaching sessions. Provide written directions for the client to use. Determine the client's learning style.
Correct Answer: Determine the client's learning style. Using the nursing process, the first action the nurse should take is to assess the client's learning style. Incorrect Answer: Encourage the client to include a support person in the teaching. The nurse should encourage the client to include a support person in the teaching to provide support. However, this is not the first action the nurse should take. Schedule a series of teaching sessions. The nurse should schedule a series of teaching sessions to reinforce learning. However, this is not the first action the nurse should take. Provide written directions for the client to use. The nurse should provide written directions for future reference. However, this is not the first action the nurse should take.
A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority? Request that a respiratory therapist discuss the technique for incentive spirometry with the client. Determine the reasons why the client is refusing to use the incentive spirometer. Document the client's refusal to participate in health restorative activities. Administer a pain medication to the client.
Correct Answer: Determine the reasons why the client is refusing to use the incentive spirometer. The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action for the nurse to take is to determine why the client is refusing the treatment. Incorrect Answer: Request that a respiratory therapist discuss the technique for incentive spirometry with the client. The nurse can request that another team member discuss the use of the incentive spirometer with the client to encourage the client to use it; however, this is not the priority action for the nurse to take. Document the client's refusal to participate in health restorative activities. If other interventions to promote the client's use of the incentive spirometer are unsuccessful, the nurse must document the client's refusal; however, this is not the priority action for the nurse to take. Administer a pain medication to the client. Pain or incisional complications might make the client refuse spirometry; however, administering medication is not the priority action for the nurse to take.
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube. Remove the NG tube if the client begins to gag or choke. Apply suction to the NG tube prior to insertion. Have the client take sips of water to promote insertion of the NG tube into the esophagus.
Correct Answer: Have the client take sips of water to promote insertion of the NG tube into the esophagus. Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea. Incorrect Answer: Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube. The client should be sitting in high-Fowler's position with the head of the bed elevated to 90° to reduce the risk for aspiration. Remove the NG tube if the client begins to gag or choke. The nurse should withdraw the NG tube slightly, not remove it, if the client gags or chokes to reduce the risk of injury to the client. Apply suction to the NG tube prior to insertion. The nurse should not apply suction until the NG tube is in place with x-ray verification of its position in order to reduce the risk of injury to the client.
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. Inject 5 units of air into the bottle of regular insulin Withdraw the correct dose of NPH insulin from the bottle Inject 10 units of air into the bottle of NPH insulin Withdraw the correct dose of regular insulin from the bottle
Correct Answer: Inject 10 units of air into the bottle of NPH insulin Inject 5 units of air into the bottle of regular insulin Withdraw the correct dose of regular insulin from the bottle Withdraw the correct dose of NPH insulin from the bottle The nurse should first inject air into the vial of NPH insulin without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.
A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take? Assist the client into a prone position. Place a sleeve over the top of each leg with the opening at the knee. Make sure two fingers can fit under the sleeves. Set the ankle pressure at 65 mm Hg.
Correct Answer: Make sure two fingers can fit under the sleeves. The nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate. Incorrect Answer: Assist the client into a prone position. The nurse should place the client in a dorsal recumbent or semi-Fowler's position to facilitate application of the sleeves. Place a sleeve over the top of each leg with the opening at the knee. The nurse should place the sleeve under each leg with the opening at the knee and then wrap the sleeve around the leg so that it is secure. Set the ankle pressure at 65 mm Hg. The nurse should set the ankle pressure between 35 and 55 mm Hg to achieve a therapeutic effect while also preventing damage to the client's skin and circulatory impairment.
A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify with the provider? Medication name Route of administration Medication dose Frequency of administration
Correct Answer: Medication dose In the prescription, the medication dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer. Incorrect Answer: Medication name The prescription states that the medication name is digoxin; therefore, this component of the prescription does not require verification. Route of administration In the prescription, the medication dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer. Frequency of administration The prescription states that the frequency of administration is every day; therefore, this component of the prescription does not require verification.
A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? Carry a client's soiled linens out of the room in a mesh linen bag. Place a client who has tuberculosis in a room with negative-pressure airflow. Provide disposable plates and utensils for a client who is HIV-positive. Dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag.
Correct Answer: Place a client who has tuberculosis in a room with negative-pressure airflow. A client who has tuberculosis requires airborne precautions, which include placing the client in a room that has negative-pressure airflow to reduce the risk of infection transmission. Incorrect Answer: Carry a client's soiled linens out of the room in a mesh linen bag. The nurse should place soiled linens in a fluid-resistant bag to reduce the risk of infection transmission. Provide disposable plates and utensils for a client who is HIV-positive. People transmit HIV mainly by blood and sexual activity; therefore, a client who is HIV-positive does not require disposable plates and utensils. Standard precautions are sufficient. Dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag. The nurse should dispose of items that have a large amount of blood in a biohazard bag that is impervious to micro-organisms.
A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? Insert the catheter at a 45° angle. Place the client's arm in a dependent position. Shave excess hair from the insertion site. Initiate IV therapy in the veins of the hand.
Correct Answer: Place the client's arm in a dependent position. The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity. Incorrect Answer: Insert the catheter at a 45° angle. Generally, the nurse should insert the catheter at a 10° to 30° angle. However, for an older adult client, an angle of 10° to 15° is preferable because veins are closer to the skin surface as aging diminishes subcutaneous tissue. Shave excess hair from the insertion site. The nurse should clip excess hair from the IV insertion site and avoid shaving the area because shaving can cause breaks and cuts in the skin that could place the client at risk for infection. Initiate IV therapy in the veins of the hand. The nurse should avoid using the fragile veins of an older adult's hands because the loss of subcutaneous tissue can allow those veins to roll away from the needle. Also, having an IV catheter in the client's hand can interfere with the client's performance of activities of daily living and can diminish an older adult's sense of independence and mobility.
A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? Role play Group discussions Question-answer meetings Practice sessions
Correct Answer: Practice sessions Practice sessions require psychomotor skills when learning. Incorrect Answer: Role play Role play is a technique that promotes cognitive and affective learning. Group discussions Group discussions assist adolescents with cognitive and affective learning. Question-answer meetings Question-answer meetings promote cognitive learning.
A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches in the inner ear? Press gently on the tragus of the client's ear. Pack a small piece of cotton deep into the client's ear canal. Move the client's auricle down and back toward their head. Tilt the client's head backward for 5 min.
Correct Answer: Press gently on the tragus of the client's ear. Pressing gently on the tragus of the ear will help the medication get into the inner ear. Incorrect Answer: Pack a small piece of cotton deep into the client's ear canal. Inserting a piece of cotton into the meatus of the canal could damage the ear. If cotton is necessary, the nurse should place it into the outer portion of the ear canal and not push it inward. Move the client's auricle down and back toward their head. For an adult client, the nurse should move the auricle upward and backward or upward and outward to straighten the ear canal. Tilt the client's head backward for 5 min. The client should lie on one side with the ear that received the instillation facing upward for 2 to 5 min.
A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.) Lacrimal apparatus Pupil clarity Appearance of bulbar conjunctivae Visual fields Visual acuity
Correct Answer: Pupil clarity Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly. Visual fields The nurse should use a finger to test the client's peripheral vision by moving the finger out of range and then back into the visual field to determine when the client sees the finger. Clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall. Visual acuity The nurse should use a Snellen chart to assess distance vision and a handheld card to assess near vision. Clients who wear eyeglasses should wear them during the assessments. Clients who have impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall. Incorrect Answer: Lacrimal apparatus is incorrect. If clients have an impairment in the ability to produce tears, it should not affect their fall risk. The nurse tests this by palpating the tear duct at the lower eyelid to see if any tears emerge. Appearance of bulbar conjunctivae is incorrect. The nurse should examine the bulbar conjunctivae by gently retracting the lower and upper lids to evaluate color and texture and assess for the presence of infection. However, the condition of the conjunctivae will not impede the client's safety.
A nurse is caring for a client who is expressing anger about their diagnosis of colorectal cancer. Which of the following actions should the nurse take? Discuss the risk factors for colon cancer. Focus teaching on what the client will need to do in the future to manage their illness. Provide the client with written information about the phases of loss and grief. Reassure the client that this is an expected response to grief.
Correct Answer: Reassure the client that this is an expected response to grief. During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis. Incorrect Answer: Discuss the risk factors for colon cancer. The client might perceive this as challenging or argumentative and react defensively. Instead, the nurse should listen to the client's concerns and should avoid challenging them. Focus teaching on what the client will need to do in the future to manage their illness. During the anger stage of the client's psychosocial adaptation to illness, the nurse should focus teaching on the present. The client is not yet ready to face the future. Provide the client with written information about the phases of loss and grief. Unless the client requests reading materials about loss, this is not an optimal time to provide them. At this stage, the client needs to express their feelings without any expectations for learning.
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. Make sure the reservoir bag of a partial rebreathing mask remains deflated. Use petroleum jelly to lubricate the client's nares, face, and lips.
Correct Answer: Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min have a drying effect and force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2). Incorrect Answer: Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. The nurse should regulate the oxygen flow rate by aligning the rate on the flow meter with the middle of the silver ball inside the meter. Make sure the reservoir bag of a partial rebreathing mask remains deflated. The reservoir bag should inflate by one-third to one-half with inspiration. If it remains deflated, it indicates that clients are breathing in too much of the carbon dioxide they exhale. Use petroleum jelly to lubricate the client's nares, face, and lips. Evidence-based practice supports the use of a water-soluble lubricant to protect the client's skin from the drying effects of oxygen.
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? Use a resuscitation bag with 80% oxygen prior to the procedure. Select a suction catheter that is half the size of the lumen. Place the end of the suction catheter in water-soluble lubricant. Adjust the wall suction apparatus to a pressure of 170 mm Hg.
Correct Answer: Select a suction catheter that is half the size of the lumen. The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa. Incorrect Answer: Use a resuscitation bag with 80% oxygen prior to the procedure. The nurse should preoxygenate the client with 100% oxygen before suctioning to prevent hypoxemia. Place the end of the suction catheter in water-soluble lubricant. The nurse should lubricate the end of the suction catheter with sterile water or 0.9% sodium chloride irrigation solution to decrease trauma to the mucosa. Adjust the wall suction apparatus to a pressure of 170 mm Hg. The nurse should adjust the suction pressure to approximately 120 mm Hg and no higher than 150 mm Hg to prevent hypoxemia and trauma to the mucosa.
A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration? Purulent exudate Warmth Skin blanching Bleeding
Correct Answer: Skin Blanching Skin blanching, edema, and coolness at the IV site indicate infiltration. Incorrect Answer: Purulent exudate Exudate indicates infection, not infiltration. Warmth Warmth indicates phlebitis, not infiltration. Bleeding can have a mechanical cause or can occur as the result of anticoagulation. It is not a sign of infiltration.
A nurse is caring for a client who has a peripheral IV inserted for fluid replacement. The nurse is assessing the client. Which of the following actions should the nurse take? Select all that apply. Stop the IV infusion. Elevate the client's left arm. Apply heat to the client's left hand. Place a pressure dressing over the IV site. Start a new IV in the client's left hand.
Correct Answer: Stop the IV infusion. 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. 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. The nurse should apply heat to the client's left hand to reduce swelling and promote comfort. Incorrect Answer: Place a pressure dressing over the IV site. The nurse should not apply pressure to the IV site, because this can cause tissue damage. Start a new IV in the client's left hand. The nurse should start a new IV in a different extremity to reduce the risk of tissue damage.
A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as potential indications of elder abuse? The caregiver is the client's financial power of attorney. The client is in a wheelchair with the wheels locked. The client reports receiving a full bath twice each week. The caregiver insists on remaining in the room.
Correct Answer: The caregiver insists on remaining in the room. A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment. Incorrect Answer: The caregiver is the client's financial power of attorney. Having a caregiver who is the client's financial power of attorney allows the caregiver to perform necessary financial transactions on the client's behalf. This it is not an indication of elder abuse. The client is in a wheelchair with the wheels locked. If the client uses a wheelchair, it is important to lock the wheels when the client is stationary to keep the client safe. Locking the wheels of a wheelchair is not an indication of elder abuse. The client reports receiving a full bath twice each week. Neglect is a form of abuse or mistreatment that is characterized by omission of necessary care. Although hygiene is an important part of care for all clients, a full bath is not necessary every day for older adults due to the adverse effects it can have on fragile skin. Therefore, a full bath twice each week is sufficient for effective care and is not an indication of neglect or elder abuse.
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? The top of the cane is parallel to the client's waist. When walking, the client moves the cane 46 cm (18 in) forward. The client holds the cane on the stronger side of their body. The client moves their stronger limb forward with the cane.
Correct Answer: The client holds the cane on the stronger side of their body. The client should hold the cane on the stronger side of their body to increase support and maintain alignment. Incorrect Answer: The top of the cane is parallel to the client's waist. The top of the cane should be parallel to the client's greater trochanter. When walking, the client moves the cane 46 cm (18 in) forward. To maintain balance, the client should advance the cane about 15 to 30 cm (6 to 12 in) at a time. The client moves their stronger limb forward with the cane. The client should move their weaker leg forward with the cane. This divides the client's body weight between the cane and the stronger leg.
A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse? The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field. The newly licensed nurse places sterile objects 2.5 cm (1 in) within the border of the field. The newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring. The sterile field is positioned at the level of the newly licensed nurse's waist.
Correct Answer: The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field. The newly licensed nurse should place the cap with the sterile side up on a clean surface because the outer edges are unsterile and will contaminate the sterile field. Incorrect Answer: The newly licensed nurse places sterile objects 2.5 cm (1 in) within the border of the field. The edges of the sterile field are considered contaminated. Therefore, the nurse should place all sterile items inside the 2.5 cm (1 in) border of the field. The newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring. The newly licensed nurse should hold the bottle of sterile saline outside the edge of the field when pouring to prevent contaminating the field. The sterile field is positioned at the level of the newly licensed nurse's waist. An object that is below waist level is considered nonsterile. Positioning the table at waist level does not require intervention.
A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? Use a bed exit alarm system. Raise four side rails while the client is in bed. Apply one soft wrist restraint. Dim the lights in the client's room.
Correct Answer: Use a bed exit alarm system. The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at a risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance. Incorrect Answer: Raise four side rails while the client is in bed. Raising four side rails when the client is in bed is a form of restraint and increases the risk for falls and injury. Apply one soft wrist restraint. Applying one soft wrist restraint is a physical restraint requiring a prescription. Other forms of distraction or intervention to maintain client safety should be attempted for clients who have dementia. Dim the lights in the client's room. Dimming the lights in the room for a client who has dementia can reduce visibility and increase the risk for injury.
A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? Combine client care tasks when caring for multiple clients. Wait until the end of the shift to document client care. Use the planning step of the nursing process to prioritize client care delivery. Allow for interruptions in tasks to discuss client care issues with colleagues.
Correct Answer: Use the planning step of the nursing process to prioritize client care delivery. Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management. Incorrect Answer: Combine client care tasks when caring for multiple clients. The nurse should complete the tasks for one client before beginning the tasks for another client to reduce fragmentation of care and avoid potential errors. Wait until the end of the shift to document client care. Documentation should be completed in a timely manner after care is performed to reduce errors and unsafe client care. Performing documentation at the end of the shift is not effective time management. Allow for interruptions in tasks to discuss client care issues with colleagues. An important principle of time management is controlling interruptions to reduce errors and loss of care delivery time.
A nurse is teaching a client and their family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? Remove the outer cannula cautiously for routine cleaning. Use tracheostomy covers when outdoors. Use sterile technique when performing tracheostomy care at home. Cleanse irritated skin with full-strength hydrogen peroxide.
Correct Answer: Use tracheostomy covers when outdoors. Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles. Incorrect Answer: Remove the outer cannula cautiously for routine cleaning. The outer cannula stabilizes the airway; therefore, the client should never remove it for cleaning. Use sterile technique when performing tracheostomy care at home. In the home environment, medical asepsis with clean technique is appropriate. Cleanse irritated skin with full-strength hydrogen peroxide. Hydrogen peroxide can irritate the skin; therefore, the nurse should instruct the client and family to use 0.9% sodium chloride irrigation to cleanse the site and prevent further irritation.
A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? Walking briskly Riding a bicycle Performing isometric exercises Engaging in high-impact aerobics
Correct Answer: Walking briskly Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy. Incorrect Answer: Riding a bicycle Cycling has no weight-bearing advantages; therefore, it does not help prevent osteoporosis. Performing isometric exercises Isometric exercises have no weight-bearing advantages; therefore, they do not help prevent osteoporosis. Engaging in high-impact aerobics High-impact aerobics can injure bones that have lost density; therefore, the nurse should not recommend these exercises for a client who is at risk for developing osteoporosis.
A nurse is admitting a client to a health care facility. The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply. Wear an N95 mask when caring for the client. Place a container for soiled linens inside the client's room. Place the client in a negative airflow room. Remove mask after exiting the client's room. Wear a sterile, water-resistant gown if within 3 feet of the client.
Correct Answer: Wear an N95 mask when caring for the client. The nurse should identify the client has tuberculosis, which requires airborne isolation. Therefore, the nurse should wear an N95 mask when caring for the client. Place a container for soiled linens inside the client's room. The nurse should identify the client has tuberculosis, which requires airborne isolation. Therefore, the nurse should place a container for soiled linens inside the client's room to prevent transmission of the infection. Place the client in a negative airflow room. The nurse should identify the client who has tuberculosis should be placed in a negative airflow pressure room that provides at least 6 to 12 air exchanges per hour through a HEPA filtration system. Remove mask after exiting the client's room. The nurse should remove their mask after leaving the room of a client who is in airborne precautions for tuberculosis to prevent exposure to the infection. Incorrect Answer: Wear a sterile, water-resistant gown if within 3 feet of the client. The nurse should identify that the client has tuberculosis, which requires airborne precautions. Sterile gowns are not indicated when caring for a client who is in airborne precautions. Water-resistant gowns are only indicated if there is a likelihood of contact with the client's body fluids.
