B202 ATI questions Final Exam

A nurse is teaching assistive personnel (AP) about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching? a. "Skin changes cause the synthesis of vitamin B to decrease with age." b. "The layers of the skin become detached with age." c. "Older adult clients have more moisture in the skin, placing them at risk for maceration." d. "The skin of older adults is thinner and has less subcutaneous padding over bony prominences."

**d. "The skin of older adults is thinner and has less subcutaneous padding over bony prominences."

1. A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? A. Give the client thin liquids. B. Instruct the client to tuck their chin when swallowing. C. Have the client use a straw. D. Encourage the client to lie down and rest after meals.

B. Instruct the client to tuck their chin when swallowing.

A nurse is providing discharge teaching to the caregiver for a client who has a stage 1 pressure injury to the sacrum. Which of the following instructions should be included to the caregiver to prevent further skin breakdown? a. Be sure to keep the skin moist. b. Do not use pillows to support extremities. c. Flex the client's knees while in bed. d. Provide a firm mattress for the client.

**c. Flex the client's knees while in bed.

A nurse is caring for a client who had an amphetamine toxicity and has sensory overload. Which of the following interventions should the nurse implement? a. Immediately complete a thorough assessment B. encourage visitors to distract the client c. provide a private room, limit stimulation d. speak at a higher volume to the client

**c. provide a private room, limit stimulation

4. A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. Which of the following are manifestations of a systemic infection? (Select all that apply.) A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate

B. Malaise E. Increase in pulse and respiratory rate

a nurse is caring for a client who is at risk for developing a pressure injury. which of the following interventions should the nurse use to help maintain the integrity of the clients skin? (select all that apply) A. keep the head of the bed elevated 30 degrees B. massage the clients bony prominences frequently C. apply cornstarch liberally to the skin after bathing D. have the client sit on a gel cushion when in a chair E. reposition the client at least every 3 hr while in bed

**A. keep the head of the bed elevated 30 degrees **D. have the client sit on a gel cushion when in a chair

A nurse is performing an admission skin assessment on a client and notes that the client has a stage 3 pressure injury to the coccyx. How should the nurse document the appearance of this pressure injury? a. "Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue." b. "Stage 3 pressure injury to the coccyx observed with a non-blanchable area of erythema." c. "Stage 3 pressure injury to the coccyx observed with partial-thickness skin loss, wound bed pink and moist." d. "Stage 3 pressure injury to the coccyx observed with full-thickness skin loss, muscle and bones visible."

**a. "Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue."

A nurse is providing teaching to a client who is in a wheelchair about measures to avoid skin breakdown. Which of the following instructions by the nurse is related to preventing skin breakdown? a. "You should shift your weight off your buttocks at intervals throughout the day." b. "You should be sure your legs are placed on the floor prior to transferring." c. "Position yourself in the back of the wheelchair after transferring." d. "Lock your brakes when you are sitting in the wheelchair."

**a. "You should shift your weight off your buttocks at intervals throughout the day."

A nurse has completed the Braden scale on four clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity? a. A client who has a Braden Scale score of 9 b. A client who has a Braden Scale score of 23 c. A client who has a Braden Scale score of 12 d. A client who has a Braden Scale score of 15

**a. A client who has a Braden Scale score of 9

A nurse is observing an assistive personnel (AP) care for a client. Which of the following actions by the AP places the client at risk for alterations in skin integrity? a. The AP places the client in high-Fowler's position. b. The AP places pillows under the client's lower extremities. c. The AP feeds the client 80% of each meal. d. The AP cleans and dries the client's perineum after each episode of incontinence.

**a. The AP places the client in high-Fowler's position.

A nurse is planning care for an older adult clients who is bedridden. Which of the following actions should the nurse include in the plan to prevent skin breakdown? a. Firmly massage lotion into the client's skin. b. Tilt the client on their side at 30°. c. Slide the client to the edge of the bed to transfer. d. Keep the head of the bed at 45° when in the supine position.

**b. Tilt the client on their side at 30°.

A nurse in a dermatology clinic is developing a skin anatomy poster to display for clients. Which of the following information should the nurse plan to include on the poster? a. The epidermis contains cells that assist in systemic immune responses. b. Collagen and elastin fibers increase with age. c. The skin consists of four distinct layers. d. The dermis contains blood vessels that help nourish the epidermis.

**d. The dermis contains blood vessels that help nourish the epidermis.

a nurse is assessing a client who has had diarrhea for 4 days. which of the following findings should the nurse expect? (Select all that apply) A. Bradycardia B. Hypotension C. Elevated temperature D. Poor skin turgor E. peripheral edema

*B. Hypotension *C. Elevated temperature *D. Poor skin turgor

A nurse is providing dietary teaching for a client who reports constipation. which of the following foods should the nurse recommend? A. macaroni and cheese B. one medium apple with skin C. one cup of plain yogurt D. roast chicken and white rice

*B. one medium apple with skin

a nurse is planning care for a client who reports blood in their stool. which of the following tests should the nurse anticipate the provider ordering? a. Fecal occult blood test b. Stool culture c. Flexible sigmoidoscopy d. Endoscopic retrograde cholangiopancreatography (ERCP)

*a. Fecal occult blood test

A nurse is caring for client who reports having daily constipation. Which of the following information should the nurse provide to the client regarding fiber intake? (Select all that apply.) a. Increasing daily fiber intake can help alleviate the issue of constipation. b. Eating more whole grains can promote regular bowel movements. c. Consume 10 g of fiber per day. d. Foods such as white rice increase fiber intake. e. Decreasing daily fiber intake can help alleviate digestive discomfort.

*a. Increasing daily fiber intake can help alleviate the issue of constipation. *b. Eating more whole grains can promote regular bowel movements.

A nurse is reviewing a client's medical record and notes that their BMI is 25.5. How should the nurse interpret this finding? a. The client is overweight. b. The client is underweight. c. The client's BMI is within normal range. d. The client is obese.

*a. The client is overweight.

A nurse is caring for a group of clients who are at risk for an alteration in urinary elimination of the following groups should the nurse identify as being at an increased risk? (Select all that apply.) a. Uncircumcised infants b. School-age children c. Middle adults d. Older adultse. Young adults

*a. Uncircumcised infants *b. School-age children *d. Older adultse. Young adults

a nurse is caring for a client who has a colostomy and does not wear a colostomy pouch. which of the following actions should the nurse anticipate performing on this client to maintain expected bowel function? a. Administer an enema. b. Administer a laxative. c. Perform colostomy irrigation. d. Insert a rectal tube.

*c. Perform colostomy irrigation.

A nurse is caring for a client who has a history of irritable bowel syndrome and reports that their last bowel movement was 5 days ago. The nurse should identify this as which of the following types of altered elimination pattern? a. Encopresis b. Diarrhea c. Fecal incontinence d. Constipation

*d. Constipation

a nurse is educating a client who has paraplegia about urinary catheter use. which of the following catheter types should the nurse include in the teaching to help facilitate urinary elimination for this client? a. Suprapubic catheter b. Indwelling catheter c. Condom catheter d. Intermittent catheter

*d. Intermittent catheter

1. A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." The nurse tells the client,"I will call the surgeon and ask for a change in diet." The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? A. Basic B. Commitment C. Complex D. Integrity

A. Basic

2. A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? A. Check to see whether the catheter is patent. B. Reassure the client that it is not possible for them to urinate. C. Recatheterize the bladder with a larger-gauge catheter. D. Collect a urine specimen for analysis.

A. Check to see whether the catheter is patent.

A nurse is caring for a client who weighs 80kg (176lb) and 1.6m (5ft 3in) tall. Calculate the BMI and determine whether this client's BMI indicates that she is of a healthy weight, overweight, or obese.

31.25, obese because it is over 30

4. A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? A. Complete a fall-risk assessment. B. Educate the client and family about fall risks. C. Eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in their possession.

A. Complete a fall-risk assessment.

3. A nurse is caring for a client who has a prescription for a 24-hr urine collection. Which of the following actions should the nurse take? A. Discard the first voiding. B. Keep the urine in a single container at room temperature. C. Dispose of the last voiding. D. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container.

A. Discard the first voiding.

3. A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A. Encourage the client to perform antiembolic exercises every 2 hr. B. Instruct the client to cough and deep breathe every 4 hr. C. Restrict the client's fluid intake. D. Reposition the client every 4 hr.

A. Encourage the client to perform antiembolic exercises every 2 hr.

4. A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over the body, which of the following areas should the nurse wash first? A. Face B. Feet C. Chest D. Arms

A. Face

1.A nurse in a providers office is caring for a client Who states that, for the past week, "I have felt tired during the day and cannot sleep at night" Which of the following responses should the nurse ask when collecting data about the client's difficulty sleeping? (Select all that apply) A. "Have your working hours changed recently,. B. "Do you feel confused in the late afternoon. C."Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day." D. Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?" E. "Tell me about any personal stress you are experiencing.'

A. "Have your working hours changed recently,. C."Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day." D. Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?" E. "Tell me about any personal stress you are experiencing.'

3. A nurse is consoling the partner of a client who just died after a long battle with liver cancer. The grieving partner states, "I hate them for leaving me." Which of the following statements should the nurse make to facilitate mourning for the partner? (Select all that apply.) A. "Would you like me to contact the chaplain to come and speak with you?" B. "You will feel better soon. You have been expecting this for a while now" C. "Let's talk about your children and how they are going to react." D. "You know, it is quite normal to feel anger toward your loved one at this time.' E. "Tell me more about how you are feeling."

A. "Would you like me to contact the chaplain to come and speak with you?"

2. A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation

A. Assessment

3. A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? (Select all that apply.) A. Find a mentor. B. Use a journal to write about the outcomes of clinical judgments. C. Review articles about evidence-based practice. D. Limit consultations with other professionals involved in a client's care. E. Make quick decisions when unsure about a client's needs.

A. Find a mentor. B. Use a journal to write about the outcomes of clinical judgments. C. Review articles about evidence-based practice.

4. A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a client who has recurrent UTIs. Which of the following factors should the nurse include? (Select all that apply) A. Frequent sexual intercourse B. Lowering of testosterone levels C. Wiping from front to back to clean the perineum D. Location of the urethra closer to the anus E. Frequent catheterization

A. Frequent sexual intercourse D. Location of the urethra closer to the anus E. Frequent catheterization

5. A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply.) A. Hold the cane on the right side. B. Keep two points of support on the floor. C. Place the cane 38 cm (15 in) in front of the feet before advancing. D. After advancing the cane, move the weaker leg forward. E. Advance the stronger leg so that it aligns evenly with the cane.

A. Hold the cane on the right side. B. Keep two points of support on the floor. D. After advancing the cane, move the weaker leg forward.

2.A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (Select all that apply.) A. Inspect the feet daily. B. Use moisturizing lotion on the feet. C. Wash the feet with warm water and let them air dry. D. Use over-the-counter products to treat abrasions E.Wear cotton socks

A. Inspect the feet daily. B. Use moisturizing lotion on the feet. E.Wear cotton socks

4• A nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? A. Knowledge B. Experience C. Intuition D. Competence

A. Knowledge

4. A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in the teaching? (Select all that apply). A. Medication error B. Needle sticks C. Conflict with provider and nursing staff D. Omission of prescription E. Missed specimen collection of a prescribed laboratory test

A. Medication error B. Needle sticks D. Omission of prescription

5. A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply.) A. Older adults are more prone to dehydration than younger adults are. B. Older adults need the same amount of most vitamins and minerals as younger adults do. C. Many older men and women need calcium supplementation. D. Older adults need more calories than they did when they were younger. E. Older adults should consume a diet low in carbohydrates.

A. Older adults are more prone to dehydration than younger adults are. B. Older adults need the same amount of most vitamins and minerals as younger adults do. C. Many older men and women need calcium supplementation.

2. A nurse is talking with a client about ways to help sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? (Select all that apply,) A. Practice muscle relaxation techniques. B. Exercise each morning. C. Take an afternoon nap. D. Alter the sleep environment for comfort. E. Limit fluid intake at least 2 hr before bedtime.

A. Practice muscle relaxation techniques. B. Exercise each morning. D. Alter the sleep environment for comfort. E. Limit fluid intake at least 2 hr before bedtime.

4. A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining rapid eye movement (REM) sleep, which of the following characteristics should the nurse include? (Select all that apply.) A. REM sleep provides cognitive restoration. B. REM sleep lasts about 90 min. C. It is difficult to awaken a person in REM sleep. D. Sleepwalking occurs during REM sleep. E. Vivid dreams are common during REM sleep.

A. REM sleep provides cognitive restoration. C. It is difficult to awaken a person in REM sleep. E. Vivid dreams are common during REM sleep.

1. By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reasons for inadequate pain relief. B. Wait to see whether the pain lessens during the next 24 hr. C. Change the plan of care to provide different pain relief interventions. D. Teach the client about the plan of care for managing the pain.

A. Reassess the client to determine the reasons for inadequate pain relief.

5. A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply.) A. Repeat the details of the prescription back to the provider. B. Have another nurse listen to the telephone prescription. C. Obtain the provider's signature on the prescription within 24 hr. D. Decline the verbal prescription because it is not an emergency situation. E. Tell the charge nurse that the provider has prescribed morphine by telephone.

A. Repeat the details of the prescription back to the provider. B. Have another nurse listen to the telephone prescription. C. Obtain the provider's signature on the prescription within 24 hr.

3. A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply.) A. Respiratory rate is 22/min with even, unlabored respirations. B. The client's partner states, "They said they hurt after walking about 10 minutes." C. The client's pain rating is 3 on a scale of O to 10. D. The client's skin is pink, warm, and dry. E. The assistive personnel reports that the client walked with a limp.

A. Respiratory rate is 22/min with even, unlabored respirations. D. The client's skin is pink, warm, and dry. E. The assistive personnel reports that the client walked with a limp.

3. A nurse is caring for a client who has left-sided hemiplegia resulting from a cerebrovascular accident The client works as a carpenter and is now experiencing a situational role change based on physical limitations. The client is the primary wage earner in the family. Which of the following describes the client's role problem? A. Role conflict B. Role overload C. Role ambiguity D. Role strain

A. Role conflict

3. A nurse is planning care for a client who develops dyspnea and feels tired after completing morning care. Which of the following actions should the nurse include in the client's plan of care? A. Schedule rest periods during morning care. B. Discontinue morning care for 2 days. C. Perform all care as quickly as possible. D. Ask a family member to come in to bathe the client.

A. Schedule rest periods during morning care.

1. A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the client's head to the side. B. Place two fingers in the client's mouth to open it. C. Brush the client's teeth once per day. D. Inject a mouth rinse into the center of the client's mouth.

A. Turn the client's head to the side.

2. Which of the following actions should the nurse take when demonstrating an empathic presence to a client? (Select all that apply) A. Use an open posture. B. Write down what the client says to avoid forgetting details. C. Establish and maintain eye contact. D. Nod in agreement with the client throughout the conversation. E. Sit facing the client.

A. Use an open posture. C. Establish and maintain eye contact. E. Sit facing the client.

5. A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? (Select all that apply.) A. Warm the enema solution prior to instillation. B. Position the client on the left side with the right leg flexed forward. C. Lubricate the rectal tube or nozzle. D. Slowly insert the rectal tube about 5 cm (2 in). E. Hang the enema container 61 cm (24 in) above the client's anus.

A. Warm the enema solution prior to instillation. B. Position the client on the left side with the right leg flexed forward. C. Lubricate the rectal tube or nozzle.

5. A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process? A."I will determine the most important client problems that we should address. B. "I will review the past medical history on the client's record to get more information." C. "I will carry out the new prescriptions from the provider." D. "I will ask the client if their nausea has resolved."

A."I will determine the most important client problems that we should address.

2. A nurse is providing dietary teaching for a client who reports constipation. Which of the following foods should the nurse recommend? A. Macaroni and cheese B. One medium apple with skin C. One cup of plain yogurt D. Roast chicken and white rice

B. One medium apple with skin

4. A charge nurse is assigning client care for four clients. Which of the following tasks should the nurse assign to a PN? A. Creating a plan of care for a client whois recovering following a stroke B. Assessing a pressure injury on a client who is on bed rest C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Teaching a client who has asthma to use a metered-dose inhaler

C. Providing nasopharyngeal suctioning for a client who has pneumonia

4. A nurse is evaluating a client's understanding of the use of a sequential compression device. Which of the following client statements indicates client understanding? A. "This device will keep me from getting sores on my skin." B. "This device will keep the blood pumping through my leg." C. "With this device on, my leg muscles won't get weak." D. "This device is going to keep my joints in good shape."

B. "This device will keep the blood pumping through my leg."

5. A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (Select all that apply.) A. Restrict the client's intake of fluids during the daytime. B. Have the client record urination times. C. Gradually increase the urination intervals. D. Remind the client to hold urine until the next scheduled urination time. E. Provide a sterile container for urine.

B. Have the client record urination times. C. Gradually increase the urination intervals. D. Remind the client to hold urine until the next scheduled urination time.

1. Anurse is caring for a client whose partner passed any months ago. The client has a recent diagnosis of diabetes mellitus. The client is tearful and states, "How could you possibly understand what I am going through?" Which of the following responses should the nurse make? A. "It takes time to get over the loss of a loved one" B. "You are right. I cannot really understand Perhaps you'd like to tell me more about what you're feeling." C. "Why don't you try something to take your mind off your troubles, like watching a funny movie." D. "I might not share your exact situation, but I do know what people go through when they deal with a loss."

B. "You are right. I cannot really understand Perhaps you'd like to tell me more about what you're feeling."

2. A nurse manager is reviewing with nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on their side." B. "I will go to the nurses' station for assistance." C."I will note the time that the seizure begins." D. "I will prepare to insert an airway."

B. "I will go to the nurses' station for assistance."

5. A nurse is instructing a client who has narcolepsy about measures that might help with self-management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "Ill add plenty of carbohydrates to my meals." B. "Ill take a short nap whenever l fella litle sleepy? C. "'Il make sure I stay warm when 1am at my desk at work." D. "It's okay to drink alcohol as long as I limit it to one drink per day."

B. "Ill take a short nap whenever l fella litle sleepy?

4. A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions for stress, coping, and adherence to the treatment plan should the nurse initiate at this time? (Select all that apply.) A. Suggest coping skills for the client to use in this situation. B. Allow the client to provide input in the treatment plan. C. Assist the client with time management, and address the client's priorities. D. Provide extensive instructions on the client's treatment regimen. E. Encourage the client in the expression of feelings and concerns.

B. Allow the client to provide input in the treatment plan. C. Assist the client with time management, and address the client's priorities. E. Encourage the client in the expression of feelings and concerns.

2. A nurse is caring for a client who is postoperative Which of the following interventions should the nurse take to reduce the risk of thrombus development? (Select all that apply.) A. Instruct the client not to perform the Valsalva maneuver. B. Apply elastic stockings. C. Review laboratory values for total protein level. D. Place pillows under the client's knees and lower extremities. E.assist the client to change positions often

B. Apply elastic stockings. E.assist the client to change positions often

1. A nurse is caring for a client who decides not to have surgery despite significant blockages of the coronary arteries. The nurse understands that this client's choice is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Non-maleficence

B. Autonomy

5. A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A. Pull down and out at the back of the upper denture to remove. B. Brush the dentures with a toothbrush and denture cleaner. C. Rinse the dentures with hot water after cleaning them. D. Place the dentures in a clean, dry storage container after cleaning them.

B. Brush the dentures with a toothbrush and denture cleaner.

4. While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? A. Have the client hold their breath briefly and bear down. B. Clamp the enema tubing. C. Remind the client that cramping is common at this time. D. Raise the level of the enema fluid container.

B. Clamp the enema tubing.

A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? (Select all that apply.) A. Limit total daily fluid intake. B. Decrease or avoid caffeine. C. Take calcium supplements. D. Avoid drinking alcohol. E. Use the Credé maneuver.

B. Decrease or avoid caffeine. D. Avoid drinking alcohol.

1. A nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows that health care professionals are required to report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.) A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks

B. Determining public health priorities C. Ensuring proper medical treatment E. Monitoring for common-source outbreaks

4. Which of the following strategies should a nurse use to establish a helping relationship with a client? A. Make sure the communication is equally distributed between the nurse's and client's desires. B. Encourage the client to communicate their thoughts and feelings. C. Give the nurse-client communication no time lints D. Allow communication to occur spontaneousy throughout the nurse-client relationship.

B. Encourage the client to communicate their thoughts and feelings.

2. A nurse manager is discussing the HIPAA PrivacyRule with a group of newly hired nurses during orientation. Which of the following information should the nurse manager include? (Select all that apply.) A. A single electronic records password is provided for nurses on the same unit. B. Family members should provide a code prior to receiving client health information. C. Communication of client information can occur at the nurses' station. D. A client can request a copy of their medical record. E. A nurse can photocopy a client's medical record for transfer to another facility.

B. Family members should provide a code prior to receiving client health information. C. Communication of client information can occur at the nurses' station. D. A client can request a copy of their medical record. E. A nurse can photocopy a client's medical record for transfer to another facility.

3. A nurse is assessing a client who has had diarrhea for 4 days. Which of the following findings should E. Hang the enema container 61 em (24 in) above the client's anus. the nurse expect? (Select all that apply.) A. Bradycardia B. Hypotension C. Elevated temperature D. Poor skin turgor E. Peripheral edema

B. Hypotension C. Elevated temperature D. Poor skin turgor

3. A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (Select all that apply.) A. Cover errors with correction fluid, and write in the correct information. B. Put the date and time on all entries. C. Document objective data, leaving out opinions. D. Use as many abbreviations as possible. E. Wait until the end of the shift to document.

B. Put the date and time on all entries. C. Document objective data, leaving out opinions.

1. A nurse is caring for a client who states, "I have to check with my partner and see if they think | am readytogo The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client? A. Pacing B. Reflecting C. Paraphrasing D. Restating

B. Reflecting

2. A nurse manager is assigning care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members? A. Charge nurse B. Registered nurse (RN). C. Practical nurse (PN) D. Assistive personnel (AP)

B. Registered nurse (RN).

2. A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client's medical record, discovers that the client is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? A. Fairness B. Responsibility C. Risk-taking D. Creativity

B. Responsibility

5. A nurse is preparing an in-service program about delegation. Which of the following are components of the five rights of delegation? (Select all that apply.) A. Right place B. Right supervision and evaluation C. Right direction and communication D. Right documentation E. Right circumstances

B. Right supervision and evaluation C. Right direction and communication E. Right circumstances

5. A nurse is caring for a school-age child who is sling in a chair. To facilitate effective communication, whit of the following actions should the nurse take? A. Touch the child's arm. B. Sit at eye level with the child. C. Stand facing the child. D. Stand with a relaxed posture.

B. Sit at eye level with the child.

3. A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP.Which of the following information should the nurse share with the AP? (Select all that apply.) A. The roommate ambulates independently. B. The client ambulates wearing slippers over anti embolic stockings. C. The client uses a front-wheeled walker when ambulating. D. The client had pain medication 30 min ago. E. The client is allergic to codeine. F. The client ate 50% of breakfast this morning.

B. The client ambulates wearing slippers over anti embolic stockings. C. The client uses a front-wheeled walker when ambulating. D. The client had pain medication 30 min ago.

5. A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include? (Select all that apply.) A. Place the client in a room that has negative air pressure of at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. D. Use sterile gloves when handling soiled linens. E. Wear a gown when performing care that might result in contamination from secretions.

B. Wear a mask when providing care within 3 ft of the client. C. Place a surgical mask on the client if transportation to another department is unavoidable. E. Wear a gown when performing care that might result in contamination from secretions.

4. A nurse is caring for a client who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate the body mass index (BMI) and determine whether this client's BMI indicates a healthy weight, underweight, overweight, or obese.

BMI= weight (kg) ÷ height (mz). Step 1: Client's weight (kg) and height (m) = 80 kg and 1.6 m Step 2: 1.6 x 1.6 = 2.56 m Step 3: 80 ÷ 2.56 = 31.25 A BMI greater than 30 identifies obesity.

1. A nurse is caring for a client who will perform- Fecal occult blood testing at home. Which Application Exercises the following information should be included. When explaining the procedure to the client 'A. Eating more protein is optimal prior to testing. B. One stool specimen is sufficient for testing. C. A red color change indicates a positive test. D. The specimen cannot be contaminated with urine.

D. The specimen cannot be contaminated with urine.

3. A nurse is caring for a client who is concerned about being discharged to home with a new colostomy because of being an avid swimmer. Which of the following statements should the nurse make? (Select all that apply.) A. "You will do great! You just have to get used it* B. "Why are you worried about going home?" C. "Your daily routines will be different when you get home." D. "Tell me about the support system you'll have after you leave the hospital." E. "It sounds like you are not sure how having a colostomy will affect swimming."

C. "Your daily routines will be different when you get home." D. "Tell me about the support system you'll have after you leave the hospital." E. "It sounds like you are not sure how having a colostomy will affect swimming."

5. A nurse is instructing a group of newly licensed nurses about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the newly licensed nurses identify as an ethical dilemma? A. A nurse on a medical-surgical unit demonstrates signs of chemical impairment. B. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints. C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill. D. A client who is terminally ill hesitates to name their partner on their durable power of attorney form.

C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill.

2. A nurse is caring for a client awaiting transport the Argical suite for a coronary nt el so pass graft. Julia, she transport team arrives, the nurse takes the cient; Uhtal signs and notes an elevation in blood pressure an Wear rate. The nurse should recognize this response)? Which part of the general adaptation syndrome (GAS) A. Exhaustion stage B. Resistance stage C. Alarm stage D. Recovery stage

C. Alarm stage

3. A nurse is caring for a client who has been following the facility's routine and bathing in the morning. However, at home, the client always takes a warm bath just before bedtime. Now the client is having difficulty sleeping at night. Which of the following actions should the nurse take first? A. Rub the client's back for 15 min before bedtime. B. Offer the client warm milk and crackers at 2100. C. Allow the client to take a bath in the evening. D. Ask the provider for a sleeping medication.

C. Allow the client to take a bath in the evening.

5. A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? (Select all that apply.) A. Remove the dentures from the body. B. Make sure the body is lying completely flat. C. Apply fresh linens and place a clean gown on the body. D. Remove all equipment from the bedside- E. Dim the lights in the room.

C. Apply fresh linens and place a clean gown on the body. D. Remove all equipment from the bedside- E. Dim the lights in the room.

2. A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states, "I told myself that i would go through with the surgery and quit smoking, if I could just live long enough to attend my child's wedding." Based on the Kübler-Ross model, which stage of grief is the client experiencing? A. Anger B. Denial C. Bargaining D. Acceptance

C. Bargaining

1. A nurse is preparing information for a change-of-shift report. Which of the following information should the nurse include in the report? A. Input and output for the shift B. Blood pressure from the previous day C. Bone scan scheduled for today D. Medication routine from the medication administration record

C. Bone scan scheduled for today

3. A nurse is instructing a group of newly licensed nurses about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the newly licensed nurses should understand that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Non-maleficence

C. Justice

1. A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) A. Place a belt restraint on the client when they are sitting on the bedside commode. B. Keep the bed in its lowest position with all side rails up. C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment.

C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear. E. Complete a fall-risk assessment.

3. A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire. B. Activate the fire alarm. C. Move clients who are nearby. D. Close all open doors on the unit.

C. Move clients who are nearby.

1. A nurse is caring for a client who has been sting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure injury D. Fecal impaction

C. Pressure injury

1. A nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? A. Updating the plan of care for a client who is postoperative B. Reinforcing teaching with a client who is learning to walk using a quad cane C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile dressing to a pressure injury

C. Reapplying a condom catheter for a client who has urinary incontinence

4. A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription.Which of the following interventions should the charge nurse include? (Select all that apply.) A. Writing a prescription for morphine sulfate as needed for pain B. Inserting a nasogastric (NG) tube to relieve gastric distention C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning a client every 2 hr to reduce pressure injury risk

C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning a client every 2 hr to reduce pressure injury risk

1. A nurse is caring for a client who has terminal lung dancer. The nurse observes the client's family assisting with all ADs. Which of the following rationales for self care should the nurse communicate to the family? A. Allowing the client to function independently will strengthen muscles and promote healing. B. The client needs privacy at times for self-reflecting and organizing life. C. The client's sense of loss can be lessened through retaining control of some areas of life. D. Performing ADs is a requirement prior to discharge from an acute care facility

C. The client's sense of loss can be lessened through retaining control of some areas of life.

3. A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A. Cooked barley B. Pureed broccoli C. Vanilla custard D. Lentil soup

C. Vanilla custard

2. A nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions? A. Allergic reaction B. Ringworm C.Systemic lupus erythematosus D. Tuberculosis

D. Tuberculosis

2. A nurse offers pain medication to a client whois postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Beneficence

D. Beneficence

2. A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy? A. Fat B. Protein C. Glycogen D. Carbohydrates

D. Carbohydrates

5. A nurse is caring for a family who is experiencing a crisis. Which of the following approaches should the nurse use when working with a family using an open structure for coping with crisis? A. Prescribing tasks unilaterally B. Delegating care to one member C. Speaking to the primary client privately D. Convening a family meeting

D. Convening a family meeting

4. A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client's family is at the bedside and asks the nurse what to expect at this time. Which of the following findings should the nurse include? A. Regular breathing patterns B. Warm extremities C. Increased urine output D. Decreased muscle tone

D. Decreased muscle tone

5. A nurse uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? A. Confidence B. Perseverance C. Integrity D. Discipline

D. Discipline

3. A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness

D. Illness

4. A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles? A. Fidelity B. Autonomy C. Justice D. Non-maleficence

D. Non-maleficence

5. A nurse discovers a small paper fire in a trash can in a client's bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take? A. Open the windows in the client's room to allow smoke to escape. B. Obtain a class C fire extinguisher to extinguish the fire. C. Remove all electrical equipment from the client's room. D. Place wet towels along the base of the door to the client's room.

D. Place wet towels along the base of the door to the client's room.