ATI TEST B FUNDAMENTALS

A nurse is preparing to transfer a client who can bear weight in one leg from the bed to the chair. After securing a safe environment, which of the following actions should the nurse take next?

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.

A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about this incident?

"Client found lying on floor." 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.

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 she understands the use of this assistive device?

"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.

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

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.

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 what?

"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.

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following finding should the nurse identify as an indication of fluid volume excess?

Distended neck veins 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 is assessing an adult who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene?

Erythema on pressure points Erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from breakdown.

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? Activate the emergency fire alarm. Extinguish the fire. Evacuate the client. Confine the fire.

Evacuate the client. According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area. R - rescue the clients. A - activate the alarm. C - contain the fire by closing all the doors and windows in the area. E - extinguish the fire.

A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify with the provider?

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.

A nurse is preforming a peripheral vascular assessment for a client, when placing the bell of the stethoscope on the clients neck, the nurse hears the following sound. This sound indicates which of the following? (Click on the audio button to listen to the clip.)

Narrowed arterial lumen Blowing sounds resulting from blood flowing through occluded or narrowed arteries are known as a bruit.

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. What action 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.

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.

A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as an indication of infiltration?

Skin blanching Skin blanching, edema, and coolness at the IV site indicate infiltration.

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 inch) 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.

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.

A nurse is discussing the use of herbal supplements for health promotion to a client. Which of the following client statements indicates an understanding of herbal supplement use? I can take echinacea to improve my immune system." "I can take feverfew to reduce my level of anxiety." "I can take ginger to improve my memory." "I can take ginkgo biloba to relieve nausea."

"I can take echinacea to improve my immune system." Echinacea is taken to promote immunity and reduce the risk of infection.

A nurse is planning teaching to 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 the learning? Role play Group discussions Question-answer meetings Practice sessions

Practice sessions Practice sessions require psychomotor skills when learning.

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?

A client who has asthma Some essential oils can cause bronchospasm; therefore, the nurse should consult the client's provider before using this therapy for a client who has asthma.

A nurse has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm the correct tube placement?

An x-ray shows the end of the tube above the pylorus. An abdominal x-ray showing the end of the tube above the pylorus indicates gastric placement.

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include? "You should have an eye examination every 2 years." "You should receive a tetanus booster every 5 years." "You should receive a shingles vaccine when you are 70 years old." "You should receive a pneumococcal vaccine when you are 65

"You should receive a pneumococcal vaccine when you are 65 years old." 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 community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension? client who is 52 years old A client who smokes one pack of cigarettes each day A client who walks for 30 min every day A client who drinks one glass of wine three times per week

A client who smokes one pack of cigarettes each day A client who smokes one pack of cigarettes each day is at an increased risk for hypertension.

A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?

Ambulating a client who is postoperative 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.

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? Drink a cup of hot cocoa before bedtime." "Maintain a consistent time to wake up each day." "Exercise 1 hour before going to bed." "Watch a television program in bed before going to sleep."

"Maintain a consistent time to wake up each day." 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.

A nurse has accepted a verbal prescription for "three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

0.3 mg The use and placement of a decimal point can potentially cause a medication error if documented incorrectly. A zero should precede a decimal point, as in 0.3 mg, but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg.

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? Most people are happy when their children grow up and leave home." "You should be proud that your children are becoming independent." "Maybe you should consider why you are feeling useless." "People in middle adulthood often find satisfaction in nurturing and guiding young people."

"People in middle adulthood often find satisfaction in nurturing and guiding young people." 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 is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make? "We can talk about advance directives, and I can also give you some brochures about them." "You should set up a time to talk with your provider about that." "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better." "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." With this statement, the nurse offers to provide the information the client needs in a direct and simple way.

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?"

"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.

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." To descend stairs, the client should first shift his body weight to his right, unaffected leg.

A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpated the popliteal pulse after 92 mm Hg. Which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure?

120 mm Hg To obtain an accurate blood pressure measurement, the nurse should inflate the cuff 30 mm Hg beyond the point at which the nurse was last able to palpate the pulse. If the nurse last palpated the pulse at 92 mm Hg, then this would be the correct pressure to which the nurse should inflate the cuff.

A nurse is preparing a heparin infusion for a client who was hospitalized with DVT. The order reads 25,000 unit of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round to nearest whole number)

8 mL/hr Follow these steps for the Dimensional Analysis method of calculation: Step 1: What is the unit of measurement the nurse should calculate? (Place the unit of measure being calculated on the left side of the equation.) X mL/hr = Step 2: Determine the ratio that contains the same unit as the unit being calculated. (Place the ratio on the right side of the equation, ensuring that the unit in the numerator matches the unit being calculated.) 250 mLX mL/hr = 1 hr Step 3: Place any remaining ratios that are relevant to the item on the right side of the equation, along with any needed conversion factors, to cancel out unwanted units of measurement. 250 mL1 hr800 unitsX mL/hr = × × 1 hr25,000 units1 hr Step 4: Solve for X. X mL/hr = 8 mL/hr Step 5: Round if necessary. Step 6: Determine whether the amount to administer makes sense. If there are 25,000 units/250 mL and the prescription reads 800 units/hr, it makes sense to administer 8 mL/hr. The nurse should set the infusion pump to administer 8 mL/hr.

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

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.

A nurse is caring for a group of clients on a medical surgical unit. Which of the following situations does the nurse demonstrate the ethical principle of veracity? A client who is unaware of her recent cancer diagnosis asks the nurse if she has 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.

A client who is unaware of her recent cancer diagnosis asks the nurse if she has 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.

A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines?

A nurse asks a nurse from another unit to assist with documentation for a client. Only health care professionals directly caring for a client should have access to the client's medical information; therefore, this is a violation of HIPAA guidelines.

A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the clients 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.

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.

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? Assign a staff member to feed the client. Provide small-handled utensils for the client. Thicken liquids on the client's tray. Arrange food in a consistent pattern on the client's plate.

Arrange food in a consistent pattern on the client's plate. 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 who reports abdominal pain. Exhibit 1 Nurses' Notes 1200: Client arrives to ED and reports abdominal pain and no bowel movement for the past 7 days. Client is undergoing chemotherapy for pancreatic cancer and has been taking 40 mg oxycodone extended-release tablets daily for the past 3 months. Client states they have attempted to relieve constipation for the last 7 days with bisacodyl suppositories and magnesium citrate oral suspension. Client reports that neither therapy initiated defecation. 1230: Client transported for abdominal x-ray. 1245: Client returned from x-ray. Provider prescribes a hypertonic cleansing enema. 1300: Procedure explained to client who verbalized understanding. Diagnostic Results 1245: Abdominal x-ray indicates a large amount of fecal material throughout the colon. No evidence of gastrointestinal obstruction observed. 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.

Assist the client to a left side-lying position with the right knee flexed is correct. 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. 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. Administer a cleansing enema is correct. 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 is correct. 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 is correct. 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. Administer oxycodone extended-release tablets is incorrect. Although the client has a prescription for oxycodone to treat pain related to pancreatic cancer, opioid medications can cause the adverse effect of constipation. Because the client reports not having experienced a bowel movement for an extended period of time, the nurse should withhold further opioids until the cause of the client's constipation is determined. 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.

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.

A nurse in the emergency department (ED) is caring for a client who reports abdominal pain. Exhibit 1 Nurses' Notes 1200: Client arrives to ED and reports abdominal pain and no bowel movement for the past 7 days. Client is undergoing chemotherapy for pancreatic cancer and has been taking 40 mg oxycodone extended-release tablets daily for the past 3 months. Client states they have attempted to relieve constipation for the last 7 days with bisacodyl suppositories and magnesium citrate oral suspension. Client reports that neither therapy initiated defecation.1230: Client transported for abdominal x-ray.1245: Client returned from x-ray. Provider prescribes a hypertonic cleansing enema. 1300: Procedure explained to client who verbalized understanding. Diagnostic Results 1245: Abdominal x-ray indicates a large amount of fecal material throughout the colon. No evidence of gastrointestinal obstruction observed.

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.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation?

Bladder scan shows 525 mL of urine. 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.

A nurse is giving 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

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.

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 give to the client and his family? (Select all that apply.) Check the cord routinely for frays or tearing. Keep the unit at least 1.2 m (4 feet) away from a gas stove. Consider purchasing a generator for power backup. Observe for signs of hypoxia. Select synthetic clothing and bedding.

Check the cord routinely for frays or tearing is correct. 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 is correct. 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 is correct. 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.

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? Seal unused medications from the facility in a plastic bag. Evaluate the client's ability to self-administer medications. Report an identified discrepancy to The Joint Commission. Compare prescriptions with medications the client received while at the facility.

Compare prescriptions with medications the client received while at the facility. When performing medication reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with those the provider has prescribed for the client to take after discharge.

A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long term care facility. Which of the following documentation should the nurse include? Client flow sheet Acuity ratings Current medications Incident reports

Current medications The nurse should include the client's medications in the discharge summary to ensure client safety and continuity of care.

A nurse in a medical-surgical unit is caring for six clients. Exhibit 1 Nurses' Notes​ 0800: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 .Diagnostic Results​ 0900:Client 1: C-reactive protein 3.2 mg/dL (less than 1.0 mg/dL)Client 2: Cholesterol 250 mg/dL (less than 200 mg/dL)Client 3: Oxygen saturation 88% (95% to 100%)Client 4: Potassium 3.2 mEq/L (3.5 to 5.0 mEq/L) Client 5: Prealbumin 14 mg/dL (15 to 36 mg/dL) Client 6: Glycosylated hemoglobin 8% (less than 7%) which clients first

Drop Down 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. Client 3 is correct. 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. Drop Down 2: Client 4 is correct. 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. 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 who has a newly placed ileostomy. Exhibit 1 Nurses' Notes 0800: Client is 2 days postoperative following an ileostomy. Pouch is one-fourth full of stool. Stoma is red. Abdomen is soft and nontender. Bowel sounds present in all quadrants. 1200: Stoma site appears dark purple with blistering on the skin around the stoma. Pouch is slightly leaking and is three-fourths full of brown, liquid stool. Diagnostic Results 1200: Hgb 19 g/dL (12 to 16 g/dL)Hct 46% (37% to 47%)

Dropdown 1: Stoma color is correct. The greatest risk to the client is the necrosis of the bowel. The nurse should identify that the color of the stoma indicates the client is at greatest risk for necrosis of the bowel; therefore, the nurse should notify the provider immediately about the color of the client's stoma. Hemoglobin level is incorrect. The nurse should report the client's hemoglobin level because it is greater than the expected reference range. However, there is another finding that is a greater risk to the client and that the nurse should address first. Ostomy leakage is incorrect. The nurse should address the leakage around the client's stoma because it can cause irritation to the skin surrounding the stoma. However, there is another finding that is a greater risk to the client and that the nurse should address first. Dropdown 2: Ostomy pouch seal is incorrect. The nurse should address the ostomy pouch seal because it can cause irritation to the skin surrounding the stoma. However, there is another finding that is a greater risk to the client and that the nurse should address next. Skin around the stoma is correct. The nurse should identify that the skin condition around the stoma is the next priority finding to address because it places the client at risk for infection. Amount of stool in the pouch is incorrect. The nurse should address the amount of stool in the client's pouch to avoid further leakage, which can cause irritation. However, there is another finding that is a greater risk to the client and that the nurse should address next.

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?

Droplet 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.

A nurse is caring for a client. Exhibit 1 Medical History Client is receiving chemotherapy for treatment of breast cancer. Diagnostic Results Week 1:Hct 42% (37% to 47%)Hgb 15 g/dL (12 g/dL to 16 g/dL)WBC count 8,000/mm3 (5,000 to 10,000/mm3)Platelet count 350,000/mm3 (150,000 to 400,000/mm3)Potassium 3.7 mEq/L (3.5 to 5 mEq/L) Week 2:Hct 37% (37% to 47%)Hgb 12 g/dL (12 g/dL to 16 g/dL)WBC count 6,000/mm3 (5,000 to 10,000/mm3)Platelet count 100,000/mm3 (150,000 to 400,000/mm3)Potassium 3.6 mEq/L (3.5 to 5 mEq/L) client at risk for by evidence by

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. Bleeding is correct. The client's platelet count is less than the expected reference range. Therefore, the client is at risk for bleeding. 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. Drop Down 2: Platelet count is correct. The client's platelet count is less than the expected reference range. Therefore, the client is at risk for bleeding. 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 is planning to administer multiple medications to a client who has an enteral tube feeding. Which of the following actions should the nurse plan to take? Dissolve each medication in 5 mL of sterile water. Draw up medications together in the syringe. Push the syringe plunger gently when feeling resistance. Flush the tube with 15 mL of sterile water.

Flush the tube with 15 mL of sterile water. The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication.

A nurse is preparing to administer 0.5 mL of oral single dose liquid medication to a client. Which of the following actions should the nurse take? Gently shake the container of medication prior to administration. Transfer the medication to a medicine cup. Place the client in a semi-Fowler's position prior to medication administration. Verify the dosage by measuring the liquid before administering it.

Gently shake the container of medication prior to administration. The nurse should gently shake the liquid medication to ensure that the medication is mixed.

A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching? Assign the client to a room with a negative airflow system. Use alcohol-based hand sanitizer when leaving the client's room. Clean contaminated surfaces in the client's room with a phenol solution. Have family members wear a gown and gloves when visiting.

Have family members wear a gown and gloves when visiting. 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 preforming a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use?

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.

A nurse is caring for a client who had limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

Have the client use a trapeze bar when changing position. 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.

A nurse is caring for a client who is receiving 24 hour urine collection. Which of the following statements by the client indicates an understanding of the teaching? "I had a bowel movement, but I was able to save the urine." "I have a specimen in the bathroom from about 30 minutes ago." "I flushed what I urinated at 7:00 a.m. and have saved all urine since." "I drink a lot, so I will fill up the bottle and complete the test quickly."

I flushed what I urinated at 7:00 a.m. and have saved all urine since." For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings.

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the scope of RN practice? Insert an implanted port. Close a laceration with sutures. Place an endotracheal tube. Initiate an enteral feeding through a gastrostomy tube.

Initiate an enteral feeding through a gastrostomy tube. It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes.

A nurse is caring for a client who is receiving pain medication through a PCA pump. Which of the following actions should the nurse take? Instruct the family to refrain from pushing the button for the client while she is asleep. Inform the client that because she is on PCA, vital signs will be taken every 8 hr. Teach the client to avoid pushing the button until pain is above a 7 on a scale of 0 to 10. 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 she is asleep. 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.

A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client? Gown N95 respirator Shoe covers Surgical cap

N95 respirator The nurse should wear an N95 respirator when providing care for a client who requires droplet precautions as a result of tuberculosis to prevent the transmission of bacteria.

A nurse is caring for a client who had a spinal cord injury and has paraplegia. Exhibit 1 Nurses' Notes Day 1:Client is alert and oriented.Client is repositioned every 2 hr.Passive range-of-motion exercises to lower extremities performed once each day.Day 5:Client is alert and oriented.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. 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.

Passive range-of-motion exercises to lower extremities performed once each day is correct. Plantar flexion contractures noted bilaterally is correct. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact is correct.

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.) Place the client in a room with negative-pressure airflow. Wear gloves when assisting the client with oral care. Limit each visitor to 2-hr increments. Wear a surgical mask when providing client care. 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. 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 admitting a client. Exhibit 1 Nurses' Notes 0930:Client reports a sore throat, productive cough, shortness of breath, and fever for the past 4 days. 1030:Client has swollen lymph nodes of the neck upon palpation. Client reports chills and coughs up yellow-colored mucus. Client's face is flushed and diaphoretic. States lack of appetite. Chest x-ray obtained and positive for pneumonia. Vital Signs 1030:Blood pressure 110/68 mm Hg Heart rate 110/minRespiratory rate 24/minTemperature 38.6° C (101.5° F)Oxygen saturation 91% on room air The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply. Place the client on droplet isolation precautions. Apply oxygen at 2 L/min via nasal cannula. Request a prescription for an antipyretic medication. Wear an N-95 mask when providing care to the client. Request a prescription for an antihypertensive medication. 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 36.6° C (101.5° F), indicating a fever. Therefore, the nurse should request an antipyretic medication to treat the client's fever. 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 completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. What assessment finding should the nurse expect? Neck vein distention Urine specific gravity 1.010 Rapid heart rate Blood pressure 144/82 mm Hg

Rapid heart rate Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.

A nurse is admitting a client who reports experiencing a sore throat, productive cough, and fever for the past 3 days. Exhibit 1 Nurses' Notes 1000:Client reports sore throat, productive cough with yellow-colored mucus, and fever for the past 3 days. Client has swollen lymph nodes. Client also reports headache that, "won't go away." Client's face is flushed and diaphoretic. Throat culture and blood work obtained as prescribed. Vital Signs 1000:Blood pressure 132/68 mm Hg Heart rate 99/minRespiratory rate 20/minTemperature 38.3° C (101° F)Oxygen saturation 96% on room air Diagnostic Results 1100:Positive throat culture for streptococci bacteria. The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply. Request a prescription for an antibiotic medication. Apply oxygen at 2 L/min via nasal cannula. Initiate droplet precautions. Wear a mask within 1 m (3 feet) of the client. Place the client in a negative airflow room. Apply a mask on the client when they leave their room

Request a prescription for an antibiotic medication is correct. The nurse should identify that the client has streptococcal pharyngitis due to the client's manifestations and a positive throat culture. Therefore, the nurse should request an antibiotic medication, such as penicillin, to treat the client's infection. Apply oxygen at 2 L/min via nasal cannula is incorrect. The client's oxygen saturation is greater than 95% on room air. Therefore, no further action is required by the nurse. Initiate droplet precautions is correct. The nurse should identify that the client has streptococcal pharyngitis, which is transmitted through droplets greater than 5 microns in the air. Therefore, the nurse should initiate droplet precautions for the client. Wear a mask within 1 m (3 feet) of the client is correct. The nurse should identify that the client has streptococcal pharyngitis. Therefore, the nurse should wear a mask when within 1 m (3 feet) of the client to prevent the spread of the infection. Place the client in a negative airflow room is incorrect. The nurse should initiate droplet precautions, which do not require a negative airflow room. A negative airflow room is indicated for clients who require airborne precautions. Apply a mask on the client when they leave their room is correct. The nurse should identify that the client has streptococcal pharyngitis. Therefore, the nurse should apply a mask on the client when they leave their room to prevent transmission of the infection.

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? Rinse the feeding bag with water between feedings. Tell the client to keep the head of the bed elevated at least 30°. Make sure the enteral formula is at room temperature. Wipe the top of the formula can with alcohol.

Tell the client to keep the head of the bed elevated at least 30°. 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.

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 a potential indication of elder abuse?

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.

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.

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 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

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.

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?

Withhold the blood transfusion. The principle of autonomy ensures that a client who is competent has the right to refuse treatment.

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility?

Witness the client's signature on the consent form. The nurse is responsible for witnessing the client sign the consent form. The nurse should confirm that the client appears competent to give consent and that the client understands the procedure.

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?

Wrap blankets around all four sides of the bed. 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.

A nurse in a surgical suite notes documentation on a client's medical record he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? Ensure sterilization of nondisposable items with ethylene oxide. Wrap monitoring cords with stockinette and tape them in place. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication. Wear hypoallergenic latex gloves that contain powder.

Wrap monitoring cords with stockinette and tape them in place. 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.

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?

You should have a fecal occult blood test every year." Colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a fecal occult blood test annually.