Dynamic Quizes

A nurse is caring for a middle-aged adult client. The nurse should identify which of the following statements as an indication that the client has completed Erikson's developmental task for her age group?

"I think I have done a good job with my children since they are all independent now"

A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching?

"I will put a night-light in the hallway"

A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure?

"Raise your index finger if you need to pause during the insertion."

A Nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?

Impaired peristalsis of the intestines

A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in which of the following position for evaluation?

Sitting

A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for a client?

Soak the inner cannula of the tracheostomy tube in normal saline

A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight?

Weigh the client on arising

A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include?

When lifting an object, spread your feet apart to provide a wide base of support

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration?

Edema at the infusion site

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of primary prevention?

Educating clients about the recommended immunization schedule for adults

A nurse is caring for a client who has protein malnutrition. Which of the following foods should the nurse identify as a source of complete protein?

Eggs

A nurse is preparing to administer a feeding via a gastrostomy tube to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding?

Elevate the head to the client's bed

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take?

Encourage the client to express thoughts about death and dying

A nurse is working with the facility's language interpreter to explain a wound-care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when describing the procedure to the client?

Ensure the interpreter and the client speak the same dialect

A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take?

Establish client outcomes

A nurse is discussing fire safety with newly hired nurses. Which of the following actions is the priority if a fire occurs in the health care facility>?

Evacuate clients from the unit

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in teaching?

Granulation tissue fills the wound during healing

A nurse is assessing a client who is postoperative. Which of the following findings should the nurse identify as an indication that the client is experiencing pain?

Grimacing

A nurse is changing the dressing for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider?

Halo of erythema on the surrounding skin

A nurse is caring for a client who starts to experience a seizure while sitting in a chair. Which of the following actions should the nurse take?

Lower the client to the floor and place a pad under the clients head

A nurse is admitting a client who has a hearing aid. Which of the following actions should the nurse take before beginning the interview process?

Make sure the device is functioning

A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, paCO2 40, and HCO3-18. Which of the following acid-base imbalances should the nurse identify and report to the provider?

Metabolic acidosis

A nurse is assessing the heart sounds of a client who has developed chest pain to worsen with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?

Pericardial friction rub

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take?

Place the client in a lateral position with the head turned to the side before beginning the procedure

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take

Place the client in the Trendelenburg position

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care?

Renew the prescription for the use of restraints within 24 hr

A nurse is planning to perform passive range-of-motion exercises for a client. which of the following actions should the nurse take?

Repeat each joint motion 5 times during each session

A nurse is preparing to administer a bolus feeding to a client through an NG tube and observes that the exit mark on the tube has moved since the last feeding. Which of the following actions should the nurse plan to take?

Request an X-ray of the client's abdomen

A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?

The signature on the preoperative consent form is the client's

A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings?

Turn the stocking inside out up to the heel before applying

A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication of an infection?

WBC 15,000 mm^3

A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) items should the nurse don prior to providing client care? (Select all that apply)

-Gown -Gloves

A nurse is caring for a client who has a dysrhythmia. Which of the following techniques should the nurse to use to assess for a pulse deficit?

Obtain the apical and radial rates simultaneously

A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of this equipment?

The client has slightly flexed elbows when ambulating with the crutches

A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors increases the client's risk of developing complicated grief?

The death was sudden

A nurse is developing a plan of care for a client. Which of the following pieces of information should the nurse consider when planning care that is culturally congruent?

The meaning of disease can vary widely across cultures

During a client care staff meeting, a nurse manager discusses potential problems with data security that affect confidential client information. Which of the following environments should the nurse manager identify as an acceptable place for discussing client's information?

Areas with no public access

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understands medical asepsis?

"I'll wash my hands before I remove the old dressing and again before putting on the new one"

A nurse is teaching a client who is postoperative about the importance of turning, coughing, and breathing deeply. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"If I do this often, I wont get pneumonia"

A nurse is supervising a newly licensed nurse who is administering a controlled substance. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Asking another nurse to observe the disposal of an unused portion of the medication

A nurse discovers that a client received the wrong medication. Which of the following actions should the nurse take first?

Assess the client

A nurse in a provider's clinic is taking a client's age, height, weight, and vital signs. The nurse should identify this action as art of which of the following components of the nursing process?

Assessment

A nurse is a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make?

"It must be difficult to care for someone who is confined to bed"

A nurse is performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying?

"It sounds like your pain is intermittent"

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

"Sit on the toilet 30 min after eating a meal."

An adolescent client in an outpatient mental health facility tells the nurse that he struggles to follow his treatment plans because his friends discourage him. which of the following statements should the nurse make?

"Tell me more about how your friends discourage you"

A nurse is assessing a client's thyroid gland. which of the following instruction should the nurse give the client before inspecting and palpating this gland?

"Tilt your head back and swallow"

A nurse is teaching a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching?

"i'll wear non sterile gloves"

A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview?

Client's level of comfort and ability to participate in the interview

A nurse is teaching a newly licensed nurse about pain management in clients age 65 and older. Which of the following pieces of information should the nurse include in the teaching?

Clients who are age 65 or older are reluctant to report pain

A nurse is caring for a client who had a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of this device?

Collapse the device to remove air after emptying

A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning

Have the client demonstrates the procedure

A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for this client?

Hct 55%

A nurse in a same-day procedure unit is caring for several client who are undergoing different types of procedures. The nurse should anticipate that the client who has which of the following deceives can safely undergo magnetic resonance imaging (MRI).

Hearing aids

A nurse is teaching a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make commitment to these lifestyle changes?

Help the client identify ways that these changes will result in positive personal outcomes

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?

Hemolytic

A nurse is changing the bed linens for a client who is on bedrest. Which of the following actions should the nurse perform?

Hold the linens away from the body and clothing

As a nurse is preparing to administer liquid medication from a bottle to a client. Which of the following actions should the nurse take?

Hold the medication bottle with the label against the palm of the hand when pouring

A nurse is preparing a sterile field for a procedure that provider will perform at the client's bedside. Which of the following actions should the nurse take?

Hold the sterile drape above the waist and away from the body

A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take?

Hyperoxygenate the client before suctioning

A nurse is caring for a client who requires a chest X-ray. Prior to client being transported for the procedure, which of the following actions should the nurse take first?

Identify the client using 2 identifiers

A home health nurse enters a client's home and finds a used insulin syringe without a cap on the table. Which of the following actions should the nurse take?

Place the syringe in a puncture-proof disposal container.

A nurse on a rehabilitation unit preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?

Place the wheelchair at a 45-degree angle to the bed

A nurse is planning an in-service training session about nutrition. Which of the following pieces of information should the nurse include?

Protein serves as an energy source when other sources are inadequate

A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use?

Vastus lateralis

A nurse is caring for a client who reports using several herbal medicines. Which of the following actions should the nurse take?

Verify the herbal supplements do not interact with medications the provider has prescribed

A nurse is assessing a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields?

Vesicular

A nurse is planning an in-service training session about nutrition. Which of the following statements should the nurse include in the teaching?

"Fats provide energy"

A nurse is caring for an adult client who communicates an unmet spiritual need. Which of the following client statements should indicate to the nurse that the client is experiencing spiritual distress?

"God is punishing me for something."

A client is being discharged home with oxygen therapy delivered through a nasal cannula. Which of the following instructions should the nurse provide to the client and family members?

Wear cotton clothing to avoid static electricity

A nurse is caring for a client who has a Clostridium difficile infection and is in contact isolation. Which of the following actions should the nurse take?

Wear gloves when changing the client's gown

A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take?

Warm the irrigation solution to 37 degrees Celsius (98.6 degrees Fahrenheit)

A nurse is caring for a client who has a deficiency of vitamin D. Which of the following foods should the nurse recommend the client include in his diet?

Whole milk

A nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student should the nurse identify as a potential problem with achieving Erikson's developmental task for this age group?

"I go home on the weekends to be with my family because I do not have any good friends here on campus"

A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make?

"I can see that this is upsetting you."

A nurse is provider's office is talking with an older adult client who reports having trouble sleeping. Which of the following statements should the nurse identify as a possible cause of the client's sleep difficulties?

"I often have a cup of coffee with my dessert before going to bed"

A charge nurse is providing teaching to a newly licensed nurse about removing sutures from a client's laceration. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I will clip each suture close to the skin and pull it through from the other side"

A nurse is teaching a client who has asthma about the proper use of an albuterol inhaler. Which of the following client statements indicates an understanding of the teaching?

"I will shake the inhaler well right before I use it"

A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make?

"Keep a diary of the foods your child eats each day"

A nurse is providing teaching about crutches to a client who has a fracture of the right foot. Which of the following instruction should the nurse include?

"Keep the rubber crutch tips securely in place."

A nurse is performing a spiritual assessment of a client. Which of the following questions should the nurse ask?

"What is your source of strength and hope?"

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse provide?

"What worries you about being without your teeth?"

A nurse is teaching a client how to perform range-of-motion exercises of the wrist. To perform adduction, which of the following instructions should the nurse include?

"With your palms facing down, move your wrist sideways toward your thumb"

A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make?

"Would you like to talk about how you feel?"

A nurse is assessing a client. Which of the following findings should the nurse identify as an indication of protein-calorie malnourishment? (Select all that apply)

-Dru, brittle hair -Edema -Poor wound healing

A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients?

A client who has a prescription for a transfusion of packed red blood cells

A nurse is beginning a therapeutic relationship with a client. Which of the following actions should the nurse take to convey empathy when using the therapeutic communication technique of active listening?

Assume an open position

A nurse is planning weight-loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss?

Attempt to increase the client's self-motivation

A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse use next when assessing the client's abdomen?

Auscultation

A nurse is preparing to administer a tuberculin skin test to a client. After performing hand hygiene, which of the following actions should the nurse take?

Circle the injection area with a pen

A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take?

Count the apical pulse rate for 1 full min and describe the rhythm in the chart

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?

Fidelity

A nurse is caring for a client who has the head of his bed elevated to a 45 degree angle with his knee slightly flexed. Which of the

Fowler's

A nurse is caring for a client who is having difficulty breathing. The nurse should assist the client into which of the following positions?

Fowler's

A nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to assess which of the following?

Gait

A nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse include?

Limit drinking liquids with food

A nurse is providing teaching to a client about a surgical procedure that she is scheduled for alter in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take?

Stop the teaching and check with the surgeon about informed consent

A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client?

Test for the presence of the client's gag reflex

An assistive personnel (AP) is helping a nurse care for a female client who has a indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?

The AP hangs the collection bag at the level of the bladder

A nurse is providing nutritional teaching to a group of clients. Which of the following definitions for the recommended dietary allowance (RDA) should the nurse include in the teaching?

The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups

A nurse is teaching a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching?

The client holds the cane on the unaffected side

A nurse is providing teaching to a client with heart failure about reducing his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?

The involvement of the client in planning the change

A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand washing technique?

The nurse holds her hands higher than her elbows while washing

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

Tie the restraint with a quick-release knot

A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse perform?

Cleanse the wound with 0.9% sodium chloride irrigation

A nurse is caring for a client who has cancer and is experiencing pain. The nurse should implement which of the following interventions to assist the client with pain relief?

Encourage the client to listen to soft music

A nurse is communicating with a group of clients about what to expect during the postoperative phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as an evaluation of effective communication?

Feedback is provided

A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein?

Lentils

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?

Obtaining cotton balls for tracheostomy care

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take?

Position that client on his left side

A nurse is monitoring a client's laboratory results. Which of the following results should the nurse report to the provider?

Potassium 3.0 mEq/L

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of car to promote wound healing?

Provide a protein intake of 1.5 g/kg of body weight per day

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus?

"Bear down"

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month and may require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse share with the client?

"Donate autologous blood before the surgery"

A nurse is teaching client who has low back pain about heat therapy. Which of the following statements by the client indicates an understanding of the teaching?

"I need to place a towel between the heating pad and my skin"

A nurse is providing discharge teaching to a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching?

"A nurse will show me how to care for my wound"

A nurse is performing a mental-status examination on a client who has manifestations of dementia. Which of the following directions should the nurse give the client when evaluating the client's ability to think abstractly?

Discuss the meaning of a common proverb

A nurse is taking a client's vital signs. Which of the following findings should the nurse identify as outside the expected reference range?

BP 145/90 mmHg

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse have the client perform just before inserting the catheter?

Bear down gently

A nurse is assessing a client's pulses of the lower extremities. The nurse should identify which of the following as the location of the most distal pulse?

Dorsalis pedis

A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

Carefully remove the gloves and proceed with hand hygiene

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take?

Clamp the tubing below the collection port

A nurse is caring for a client who requires a dressing change. Which of the following action should the nurse take?

Clean the drain site from the center outward

A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent?

Cold extremities

A nurse is assessing a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect?

Depressed deep-tendon reflexes

A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger-stick blood sample. Which of the following actions by the AP requires the nurse to intervene?

Elevating the finger about heart level

A nurse is auscultating a client's lungs and identifies rhonchi over the trachea and bronchi. Which of the following actions should the nurse take?

Encourage the client to cough

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take?

Exert pressure on the bony prominences when holding the eyelids open

A nurse is caring for a client who is postoperative following vascular surgery on the left femoral artery. The nurse should identify that the surgical wound should be cleansed in which of the following directions?

From the wound toward the surrounding skin

A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching?

Gelatin

A nurse is an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?

Grasp a skin fold on the chest under the clavicle, release it, and note weather it springs back

A nurse is caring for a client who has a stage II pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer?

Hydrocolloid

A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur

Hyperglycemia

A nurse is caring for a toddler at a well-child visit when the mother calls, "Help! My baby is choking on his food." Which of the following findings indicates the toddler has an airway obstruction?

Inability to cry or speak

A nurse is providing teaching about nutritious diets to a group of adult women. which of the following statements should the nurse include?

Include 2.5 cups of vegetables in your daily diet

A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take?

Provide more water with feedings

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take?

Pull the NG tube back slightly

A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?

Raise the level of the bed

A nurse is caring for a client in a long-term care facility. Which of the following findings should alert the nurse to the possibility that the client has developed delirium

Reduced level of consciousness

A nurse is caring for a client who has chronic kidney disease. The kidneys regulate body fluids as well as assisting with which of the following functions?

Regulation of acid-base balance

A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?

Remove the safety pin from the extinguisher

A nurse is caring for a client who has a fecal impaction. Before the digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces?

Oil retention

A nurse is instructing a client about collecting a 24-hr urine specimen for creatinine clearance. Which of the following statements should the nurse identify as an indication that the client understands the procedure?

"i'll make sure to keep the collection bottle in the container of ice they gave me"

A nurse on a medical unit is caring for a client who has difficulty sleeping. Which of the following actions should the nurse take to promote the client's ability to fall asleep?

Allow the client to maintain the same bedtime routine as at home

A nurse is preparing to administer an otic antibiotic to an adult client who has Otitis media. Which of the following actions should the nurse plan to take?

Hold the dropper 1 cm (0.5 in) above the ear canal during administration

A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect?

Increased blood pressure

A nurse is obtaining a capillary blood sample to determine a client's blood glucose level. the nurse prepares and punctures the clients finger for the procedure but does not obtain an adequate amount of blood. Which of the following actions should the nurse take next?

Wrap the clients finger in a warm washcloth

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices that machine begins to measure the blood pressure at varied intervals, and the readings are inconsistent. Which of the following actions should the nurse take?

disconnect the machine and measure the blood pressure manually every 15 min.

A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client?

"What do you think caused the onset of your pain?"

A nurse on a mental health urit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship?

Loss

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a form of secondary prevention?

Screening groups of older adults in nursing care facilities for early influenza manifestations

A nurse is performing an abdominal assessment of a client. Which of the following positions should the nurse tell the client to assume for this examination

Supine

A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?

Tachycardia

A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first?

Ask the client to identify the specific food allergies

A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?

Increased heart rate

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take?

Insert the tip of the rubing 8 cm (3.1 in)

After assessing a client, the nurse documents "1+ pedal edema bilaterally." This indicates that the nurse observed an indentation of which of the following depths after applying pressure?

2 mm

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states, "All this equipment is making me nervous." Which of the following responses should the nurse offer?

"All of this equipment can be frightening"

A nurse is teaching a client with lower extremity weakness how to use a 4-point crutch gait. Which of the following instructions should the nurse include in the teaching?

"Bear weight on both of your legs."

A nurse is administering medication to a client who asks the nurse to leave the medication at the bedside to be taken at a later time. Which of the following responses should the nurse make?

"Call me when you are ready, and I will return with the medication."

A nurse is caring for a client who just received a diagnosis of cancer. The client states, "I just don't know what i'm going to do now." Which of the following responses should the nurse make?

"Can you explain the concerns you're having right now?"

During the completion of a health history with a nurse, a client reports intermittent chest pain for the past week. Which of the following questions is the nurse's priority?

"Can you tell me what the pain felt like and show me exactly where it was?"

A nurse is teaching a client how to use an albuterol metered-dose inhaler. After removing the cap from the inhaler and shaking the canister, what sequence of introductions should the nurse give the client? (Move the steps into the box on the right, placing them in the order of performance. use all the steps.)

-"Hold the mouthpiece 1 to 2 inches in front of your mouth." -"Tilt your head back slightly and open your mouth wide." -"Depress the canister while taking a slow, deep breath." -"Hold your breath for 10 seconds."

A community health nurse is conducting a class about body mechanics for county office workers. Which of the following instructions should the nurse include? (Select all that apply)

-"Sit with your back supported" -"Keep your knees at hip level" -"Use an ergonomically designed computer keyboard"

A nurse in a provider's office is teaching a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching? (select all that apply)

-Black beans -Whole-grain bread

A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? (Select all that apply)

-Coat the tip of the tube with a water-soluble lubricant -Ask the client to swallow water while the tube enters her throat -Tell the client to tilt her head backward as insertion begins

A nurse is preparing to administer 700 mL of 0.9% sodium chloride IV to a child to infuse over 24 hr. the drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero)

29

A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessment should the nurse expect?

Absent bowel sounds with distention

A nurse asks a client to explain to statement, "A bird in the hand is worth two in the bush." Through this question, the nurse is evaluating the client's ability in which of the following intellectual functions?

Abstract reasoning

A nurse is caring for a group of clients in a long-term care facility. One of the clients is walking along the hallway and bumping into walls and does not respond to his name. Which of the following actions should the nurse take first?

Accompany the client back to his room

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

Administer analgesics to the child on a routine schedule throughout the day and night

A nurse is supervising a newly licensed nurse who is suctioning a client's tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?

Administering high-flow oxygen prior to the procedure

A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. Which of the following actions should the nurse take?

Advice the client to perform range-of-motion exercises while in bed

A nurse is performing a focused assessment of a client's peripheral vascular system. In which of the following locations should the nurse palpate the posterior tibial pulse?

Below the medial malleolus

A nurse is caring for a client who requires ventilatory assistance with breathing following a motor vehicle crash. The nurse should suspect an injury to which of the following parts of the brain?

Brainstem

A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing?

Cranial nerve XII

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status?

Daily weight

A nurse is planning care for a young adult client who has a terminal illness. Which of the following concepts of death should the nurse consider for this client?

Death is viewed as an interruption of what might have been

A nurse is reviewing the laboratory values of a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect?

Decreased calcium

A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations?

Decreased cardiac output

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give to the dietary assistant?

Don gloves when entering the room and use hand sanitizer when exiting

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?

Drop the eye medication into the lower conjunctival sac

While admitting a client to the medical unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make healthcare decisions for me if I am not able." The nurse should identify that the client is referring to which of the following documents?

Durable power of attorney document

A nurse is admitting a client who is experiencing an exacerbation of heart failure. At which of the following times should the nurse initiate discharge planning?

During the admission process

A new resident provider asks the charge nurse for an access code to review clients' online records. The resident is not scheduled to attend the facility's orientation computer class until next week. Which of the following actions should the nurse take?

Explain that it is against policy to share access codes and refer the resident to his supervisor

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?

Explain the procedure to the client

A nurse is teaching a middle-aged female client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of this client's routine health screening?

Eye examination every 2 years

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?

Face the client when speaking

A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of impaired skin integrity?

Faint pedal pulses

A client who has glaucoma of the right eye self-administers timolol eye drops looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and apply gentle pressure to the lower lip with a facial tissue. After observing this process, which of the following actions should the nurse take?

Instruct the client to apply pressure to the inside corner of the eye after instillation

A nurse is an acute care facility is planning care for a client who is alert but temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse plan to take to prevent a complication of immobility?

Instruct the client to perform foot and leg exercises every 1-2 hr while awake to help prevent thrombophlebitis

A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client's HIV infection status. Which of the following actions should the nurse take?

Instruct the guard to ask the inmate

A nurse is teaching a group of unit nurses about the experiences of clients who are having surgery. In which phase of care is the client transferred to the surgical suite table before being transferred to the PACU?

Intraoperative

A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique?

Keep microorganisms from entering the wound

A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the client's body?

Lungs

A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift in which the client received atenolol instead of allopurinol. Which of the following interventions is the nurse's priority?

Measure the client's apical pulse

A nurse is measuring a client's vital signs. The client's resting radial pulse rate is 55/min. Which of the following actions should the nurse take next?

Measure the client's apical pulse rate

A nurse is caring for a client who had a stroke and is at risk for of fallings. Which of the following actions should the nurse take?

Monitor the client at least once every hour

A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take?

Monitor the client at least once every hour

A nurse is changing the dressings for a client who has 2 penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?

Montgomery straps

A nurse is preparing a client who is scheduled for a hysterotomy for transport to the operating room. The client states she no longer wants to have the surgery. Which of the following actions should the nurse take?

Notify the provider of the client's decision

A nurse is using the braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate?

Nutrition

A nurse in a long-term care facility is in the dining room while residents are eating lunch. One resident begins to choke and is coughing strongly. Which of the following actions should the nurse take?

Observe the client closely

A client who reports shortness of breath requests the nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next?

Observe the rate, depth, and character of the client's respirations

During the insertion of a urinary catheter for a client, the tip of the catheter brushes against the nurse's arm. Which of the following actions should the nurse take?

Obtain a new catheter and reattemp insertion

A nurse on medical-surgical unit is caring for a client. Which of the following actions should the nurse prioritize when using the nursing process?

Obtain client information

A nurse is provider's office is measuring a client and notes a loss in height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system

Osteoporosis

A nurse is initiating seizure precautions for a client who has a seizure disorder. Which of the following pieces of equipment should the nurse have readily available at the client's bedside?

Oxygen equipment

A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use?

PC for after meals

A nurse is collecting health history data from a client who is deaf and uses American Sign Language (ASL) to communicate. The nurse will be working with an ASl interpreter. Which of the following action should the nurse take when working with the interpreter?

Pace speech to allow time for the interpreter to convey the words

A nurse is performing a physical examination for a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques?

Palpation

A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

People who practice Judaism stay with the body of the deceased until burial

A nurse is performing a physical assessment of a client. Which of the following actions should the nurse take to assess the client's tissue perfusion?

Perform a clanch test

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse perform first?

Perform hand hygine

A nurse is assessing a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings?

Peripheral pulses bilaterally symmetric, equal, and strong in all 4 extremities

A nurse is caring for a group of clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Provide oral care to a client who cannot take oral fluids

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take?

Pull suction catheter back 1 cm (0.5 in) if the client starts coughing

A nurse is changing the dressings for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage?

Purulent exudate

A nurse is preparing to administer a partial dose of a prefilled opioid analgesic parenterally to a client. Which of the following actions should the nurse plan to take?

Record the amount of medication wasted on the controlled substance inventory record

A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. The nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. Which of the following actions should the nurse take?

Remove IV catheter

A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take?

Remove the restraints at least every 2 hr

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?

Remove the restraints one at a time

A nurse is helping a client change his hospital gown. The client has an IV infusion via an infusion pump. Which of the following actions should the nurse take first?

Remove the sleeve of the gown from the arm without the IV line

A nurse is assessing a client's incision and observes the drainage to be blood-tinged. Which of the following terms should the nurse use to document this finding?

Sanguineous

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

Second intercostal space to the right of the sternum

A nurse is assessing a client who is unconscious. Family members are present and answer the nurse's questions about the client's medical history. The nurse should document this information as which of the following types of data?

Secondary-source data

A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection?

Side hip between the iliac crest and anterior iliac spine

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?

Sit and hold the client's hand

A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an assistive personnel (AP). The nurse later observes the AP emptying the bag without wearing gloves. Which of the following actions should the nurse take?

Talk with the AP about the technique used

A nurse is caring for a client who is receiving IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site?

Taut skin around the IV catheter site that is cool to the touch

A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 degrees Celsius (102.6 degrees fahrenheit), a heart rate of 105 min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority?

Temperature

A nurse is planning to obtain the vital signs of a 2-year-old child who is expecting diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the child's temperature

Temporal

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of information should the nurse include in the teaching?

hold the breath for 5 sec after goal volume is rached

A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following? (Select all that apply)

-Stabilizing the position of the tube -Preventing aspiration of secretions -Preventing air leaks

A nurse is preparing to administer a unit of packed RBCs to a client . Which of the following pieces of information must the nurse? (Selection all that apply)

-The client's ID number -The client's name -ABO compatibility -Rh compatibility

A nurse is assessing a client's notional status. The nurse determines the client is consuming 500 calories more per day than his energy level requires. If his dietary habits do not change, how long will it take the client to gain 4.5 kg (10 lb)?

10 weeks

A nurse is measuring the blood pressure of several clients. Which of the following results is within the expected reference range for blood pressure?

116/70 mmHg

A nurse is calculating the protein needs of a young adult client who weighs 132 lb. The RDA for protein for an adult who has no medical conditions is 0.8 g/kg. How many grams of protein per day should the nurse recommend for this client?

132/2.2=60 kg 60kg X 0.8g= 48g

A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative. Which of the following clients should the nurse see first?A

A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy ball full of bright red, bloody drainage

A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions?

Assigning another client with the same infection to share the room with the client

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

Airborne

A nurse is admitting a client who has tuberculosis. In addition to standard precautions, which of the following transmission-based precautions should the nurse add to the client's plan of care?

Airborne

A nurse on a surgical unit is receiving a client who had abdominal surgery form the postanesthetic care unit. Which of the following assessment should the nurse make fist?

Airway

A nurse is caring for a client who is well-hydrated and has no visible evidence of nutritional deficiencies. A laboratory result within the expected reference range for which of the following substances indicates adequate protein uptake and synthesis?

Albumin

A nurse is teaching a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups is responsible for movement at the knee joint?

Antagonistic

A nurse is using a portable ultrasound bladder scanner to measure a client's post-void residual volume. Which of the following actions should the nurse take?

Apply light pressure to the scanner head once it is in position

A nurse is an urgent-care center is caring for a 15-year-old client whose symptoms suggest a sexually transmitted infection (STI). The client's parent is unavailable, but the client's grandmother accompanied the client to the clinic. Which of the following actions should the nurse take?

Ask the adolescent to sign the consent form

A nurse is preparing to administer oral phenytoin to a client who has a seizure disorder. Before administering the medication, which of the following actions should the nurse take?

Check the medication dose and the client's identification

A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following sites should the nurse select?

Choose a vein that is soft on palpation

A nurse is beginning her shift and reviewing the medication administration records (MARs) for her clients. She notes a dosage of a medication above the safe range and sees that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take?

Call the provider to clarify the dosage

A nurse is caring for a middle-aged adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks?

Ceasing to compare personal identity with others

A nurse is caring for a client who is having difficulty with muscle coordination following a head injury. the nurse should suspect injury to which of the following areas of the brain?

Cerebellum

A nurse is implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take?

Check capillary refill before applying an ice pack to the affected area

A nurse enters a client's room and finds the client sitting on the floor and learning against the side of the bed. The client states she slipped while getting out of bed. Which of the following actions should the nurse take fist?

Check the client for injuries

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?

Check the client's capillary blood glucose level every 4 hr

A nurse is caring for a client who has a stage III pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first?

Check the client's pain level

A nurse is teaching a middle-aged adult client about health promotion and disease prevention. The nurse should inform the client that which of the following changes could occur?

Decreased estrogen and testosterone production

A nurse is caring for a client who has terminal cancer. The client is proceeding with plans to build a new home. The nurse should identify that this behavior typically indicates which of the following stages of grief?

Denial

A nurse is caring for client who has terminal pancreatic cancer. When the client state, "it's devastating that I will not be here to see my child graduate, "the nurse should identify that the client is in which of the following stages of grief as defined by kubler-ross?

Depression

A nurse is caring for a client who has a BMI of 29 and expresses a desire to lose weight. Which of the following actions should the nurse take first?

Determine the client's intention to change current eating habits

A nurse is assisting a client who is eating at mealtime. suddenly, the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first?

Determine whether the client is able to breathe

A nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following?

Diuresis

A nurse is replacing the surgical dressing on a client who had abdominal surgery. Which of the following actions should the nurse take?

Don clean gloves and to remove the old dressing

A nurse is receiving a client from the PACU who is postoperative following actions should the nurse perform to transfer the client from the stretcher to the bed?

Lock the wheels on the bed and stretcher

A nurse in rehabilitation facility is observing an assistive personnel (AP) help a client transfer from a bed to a wheelchair. Which of the following action indicated to the nurse that the AP understands how to perform this task?

Locking the brakes on the bed and the wheelchair before moving the client

A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing?

Lower abdomen

A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first?

Lower the client to the floor

A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks both the client's native language and the nurse's, arrives to drive the client home. Which of the following actions should the nurse take?

Obtain the services of an interpreter

A nurse is employing a thorough, systematic method while obtaining objective data about a client. Through which of the following methods should the nurse collect this information?

Physical examination

A nurse preparing to remove an NG tube for a client who has a partial colectomy. Which of the following actions should the nurse take?

Pinch the NG tube while removing the rube

A nurse is leading an education session about disposing of biohazardous materials. Which of the following instructions should the nurse include in teaching?

Place soiled linen in a single linen bag

A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take?

Place the client in a left Sims' position

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen?

Plan the stool specimen collection container in a biohazard bag

A nurse has received a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the following functional classifications?

Plasma volume expanders

A nurse is caring for a client who is receiving continuous enteral feedings through a NG tube and develops diarrhea. Which of the following actions should the nurse take?

Request a prescription for an isotonic enteral nutrition formula

A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3-24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances?

Respiratory alkalosis

A home health nurse is visiting an older adult client with severe dementia. The client's son, who serves as her primary caregiver, reports being "exhausted" from working part-time and caring for his mother at home. Which of the following options should the nurse suggest to the caregiver?

Respite care

A nurse is preparing to administer a unit of packed RBCs to a client when she discovers that the IV line is no longer patent. The IV team informs her that someone can come to initiate a new line in 30 min. Which of the following actions should the nurse take?

Return the blood to the laboratory

A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin discharge planning?

Upon the client's admission to the care facility

A nurse is preparing to assist an older adult client with ambulation following bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall?

Use a gait belt during ambulation

A nurse is preparing to instill a vaginal medication in suppository form to a client. Which of the following actions should the nurse take during this procedure?

Use the index finger to insert the suppository

A nurse is planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first?

Use the pain scale to determine the client's pain level

A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client?

Washing dishes

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse in maintaining sterile technique?

Wiping the labia minora in an anteroposterior direction

A nurse is evaluation the development of a group of clients. According to Erikson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development?

Young adulthood

A charge nurse is reviewing routes of medication administration with a newly licensed nurse when providing care to a client. Which of the following routes of administration should the charge nurse include as having the slowest onset action?

oral

A nurse is caring for a group of clients in long-term care facility. The nurse should understand that which of the following clients is eligible for hospice services at this time?

A client who has end-stage cirrhosis

A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first?

A client who has heart failure and is receiving 100% oxygen via partial rebreather mask

A nurse is an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first?

Ask the client about first aid performed at the scene

A nurse is caring for a client who is terminal illness. The client is restless and reports severe pain but refuses the prescribed opioid pain medication. Which of the following actions should the nurse take first?

Ask why the client is refusing the pain medication

A nurse is using the I-Sbar communication tool to give a client's provider information about the client. The nurse should convey this client's pain status in which portion of the report?

Assessment

A nurse documents the presence of clubbing the fingernails for a client who has emphysema. Which of the following is the underlying cause of this finding?

Chronic hypoxemia

A nurse is providing teaching about proper care to a client who has a new colostomy. Which of the following pieces of information should the nurse include in the teaching?

Cleanse the skin around the stoma with warm water

A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance?

Romberg test

A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding?

Sit at the bedside while feeding the client

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription states "clear liquids; advance diet as tolerated." Which of the following responses should the nurse make?

"I a going to listen to your abdomen."

A nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instruction?

"I can still use my transcutaneous electrical nerve stimulation unit while im pushing the PCA button?

A nurse is caring for a client who has injuries resulting from a motor vehicle crash. Which of the following clients statements should the nurse address first?

"I can't sleep well because whenever I move in my sleep, the pain wakes me up"

A nurse is an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?

"I keep having nightmares about my upcoming surgery"

A nurse is teaching a group of older adults about expected age-related changes. Which of the following statements by a group member indicates that teaching has been effective?

"I should expect my heart rate to take longer to return to normal after exercise as I get older."

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning how to self-inject insulin. Which of the following statements should the nurse make?

"Tell me what I can do to help you overcome your fear of giving yourself injections."

A nurse is providing discharge teaching for a client who has type 2 diabetes mellitus and will be caring for herself at home. The client expresses concerns about preparing an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse offer?

"The dietitian will help you choose foods you are used to that also meet your health needs."

A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?

"There are times I should use soap and water rather than an alcohol-based rub to clean my hands"

A nurse is teaching a client who has urinary incontinence about bladder retraining. Which of the following instructions should the nurse include?

"Try to block the urge to urinate until the next scheduled time"

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular-sized cuff for a client who is obese. Which of the following explanations should the nurse give the AP?

"Using a cuff that is too small will result in an inaccurately high reading"

A middle-aged adult client is discussing future plans with a nurse. Which of the following statements should the nurse identify as an indication that the client is having difficulty achieving Erikson's developmental task for this age group?

"We miss our daughter so much that we are going to move closer to her"

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply)

-Provide oral hygiene frequently -Measure the amount of drainage from the NG tube every shift -Secure the NG tube to the client's gown

A nurse is assessing the pH of a client's gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect?

2

A nurse is preparing to administer sotalol to a client with a prescription for 320 mg/day divided equally every 12 hr. The medication is available in 80 mg tables. How many tablets should the nurse administer per dose?

2

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. which of the following pieces of information should the nurse include?

A 10-month-old infant can pull up to a standing position

After assessing a client's radial pulses, the nurse documents "radial pulses 4+ bilaterally." The nurse should document this finding when a client's pulses have with of the following qualities?

Bounding

A nurse is a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings is another clinical manifestation of fluid volume excess?

Bounding pulse

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following cations should the nurse take first?

Check the client's perineum

A nurse is caring for a client who was transferred to the surgical unit by stretcher form the PACU. Which of the following actions should the nurse perform immediately following the transfer?

Check the client's vital signs

A nurse is caring for a postoperative client who has an indwelling urinary catheter for gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first?

Check the determine if the catheter tubing is kinked

A nurse is explaining Piaget's theory of cognitive development to a group of daycare providers for employees' children at an acute care facility. Which of the following activities should the nurse include as an example of concrete operational thinking?

Collecting and trading game cards

A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client's bedside and perform which of the following verification procedures?

Compare the medical record number and name on the MAR with the client's identification band

A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?

Confirm unresponsiveness

A newly licenced nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to him. Which of the following actions should the nurse take?

Consult the medication reference book available on the unit

A nurse is preparing to assess the function of the client's trigeminal nerve ( cranial nerve V ). Which of the following items should the nurse gather for the test?

Cotton wisps

A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include?

Cough deeply after each use

A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire healthcare-associated infections (HAIs). Which of the following routes of infection should the manager identify as an iatrogenic HAI?

Infection acquired from a diagnostic procedure

A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first?

Inspect both breasts simultaneously

A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first?

Inspection

A nurse is caring for a client who has a temperature of 38.7 Celsius (101.7 degrees fahrenheit). Which of the following actions should the nurse take?

Keep the client's bed linens dry

A nurse is planning an in-service training session about various dietary practices. Which of the following pieces of information should the nurse include in the teaching?

Kosher diet have restrictions regarding how the food must be prepared

A nurse is presenting an in-service training session about nutrition. Which of the following simple sugars should the nurse identify as the carbohydrate found in milk?

Lactose

A nurse is reviewing a client's laboratory results and notes a WBC count of 3,600mm^3. The nurse should identify this result as which of the following conditions?

Leukopenia

A nurse is provider's office is collecting information from an older adult client who reports taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects?

Liver damage

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

Place the bladder of the cuff over the posterior aspect of the thigh

A nurse is preparing to perform postural drainage for a client. Which of the following actions should the nurse take?

Position the client for drainage of secretions by gravity

A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring?

Right communication

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following action should the nurse take first?

Start chest compressions

A nurse is preparing to administer a medication to a client. Which of the following administration schedules should the nurse identify as a prescription to administer the medication once and as soon as possible?

Stat prescription

A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following entries should the nurse enter into the client's medical record?

The client threw the medication on the floor

A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client's insomnia?

The client watches television in her bed during the day

A nurse is providing nutrition counseling to a middle-aged adult client who has a sedentary job. Which of the following factors should the nurse consider?

The client's basal metabolic rate could decrease

A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?

Ventrogluteal

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet?

Vitamin C and zinc

A nurse is caring for a toddler at a well-child visit when the mother calls, "Help! My baby is choking on his food." Which of the following finding indicates the toddler has an airway obstruction

Inability to cry or speak

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps to relieve pain. Which of the following responses should the nurse make?

"It modulates the transmission of the pain impulse"

a nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) of pain management. The client asks the nurse how a TENS unit helps relieve pain. Which of the following responses should the nurse make?

"It modulates the transmission of the pain impulse"

A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care?

"Let's set up a meeting time with the doctor to discuss your options for home care"

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastrostomy tube for enteral feedings. Which pieces of information are critical to communicate to the next nurse who will be caring for this client? (Select all the apply)

-New prescriptions -Arterial blood gas results -Tracheal secretion characteristics

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurse take? (Select all the apply)

-Place the client in a supine position with the hips and knees flexed - Cover the wound and intestine with a sterile, moistened dressing -Monitor the client for manifestations of shock

A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states, "it's too late for me to quit." Which of the following actions should the nurse take?

Assist the client in finding local smoking-cessation assistance programs

A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the clients risk of aspiration?

Elevate the head of the bed to 30 degrees or 45 degrees

A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion?

Sodium 123 mEq/L

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen?

Collection the specimen when the client rises in the morning

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse perform first after discovering that the client's wound has eviscerated?

Cover the incision with a moist sterile dressing

A nurse on a medical-surgical unit observes smoke billowing from a client's room. Which of the following actions should the nurse take fist?

Evacuate the client from the room

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?

Evaluate pedal pulses

A nurse is caring for an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source for this sound?

Excessive wax in the ear canal

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take?

Fill the bag 2/3 full with ice

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. This manifestation is consistent with which of the following eye disorder?

Glaucoma

A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first?

Gloves

A nurse is reviewing a client's 24 hr dietary recall. The client reports eating a slice of toasted white bread with butter, a butter, a banana, a glass of milk, and a cup of coffee for breakfast; grilled chicken, a baked potato, and a glass of milk for lunch; an apple and cheddar cheese for a snack; and 2 servings of chicken, 2 cups of steamed broccoli, and a glass of milk for dinner. This client's diet is deficient in which of the following food groups?

Grains

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching?

Granulation tissue fills the wound during healing

A nurse is assessing a client who is experiencing stress following a near fall out of bed. Which of the following physiological responses should the nurse expect due to the fight-or-flight response?

Increased blood pressure

A nurse is teaching a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group?

Independent moral development

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime?

Offer the client tart or sour foods first

A nurse is caring for a client who is dehydrated. The nurse should expect that insensible fluid loss of approximately 500 to 600 mL occurs each day through which of the following organs?

Skin

A nurse is caring for a client who has xerostomia with a lack of saliva. Which of the following nutrients will be affected by the lack of salivary amylase?

Starch

As part of a neurological examination, a nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique?

Stereognosis

A nurse on a medical-surgical unit is caring for a client who is at risk of experiencing seizures. Which of the following pieces of equipment must be available at the client's bedside at all times?

Suction equipment

A nurse is caring for a client who has breast cancer. The client has been receiving radiation therapy for several months and now refuses to undergo further treatment. Which of the following actions should the nurse take?

Support the client's decision

A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes?

Supports self-determination

A nurse is teaching range-of-motion exercises to a client who has osteoarthritis. Which of the following client positions demonstrates an understanding of supination of the hand?

The client holds the hand with the palm up

A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP indicates that further teaching is required?

"If the client seems confused, I'll raise all 4 sides rails so that he doesn't hurt himself."

A nurse is caring for a client who has an NG tube intermittent enteral feedings. Which of the following actions should the nurse take?

Elevate the head of the client's bed to 45 degrees before the feeding

A nurse is caring for a semiconscious client who had a small-bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement? (Select all that apply)

- Verify the initial X-ray examination -Measure the length of the exposed tube -Determine the PH of aspirated fluid

A nurse on medical-surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client's record first?

Assessment

A nurse is assessing a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries?

Auscultation of the arteries for bruits with the bell of the stethoscope

A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider?

Sodium 150 mEq/L

A nurse rates a client's biceps reflex as 2+. Which of the following characteristics should the nurse document about the client's reflexes?

Average

A nurse is caring for a client who reports not sleeping at night, which interferes with her ability to function during the day. Which of the following interventions should the nurse suggest to this client?

Avoid beverages that contain caffeine

A nurse is performing an otoscopic examination of a client's right eat. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding?

Document this as an expected finding

While in the hospital, a client who has a terminal illness tells the nurse, "I cant believe im dying. A lot of bad people in the world are healthy, and here I am dying!" Which of the following responses should the nurse provide?

"Tell me more about how you feel about dying"

A nurse is assisting a client who has dysphagia at mealtimes. Which of the following actions should the nurse take?

Advise the client to tuck his chin downward

A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear?

Air conduction is less than bone conduction in the left ear

A nurse is preparing to administer eye drops for a client who has glaucoma. When instilling the medication, which of the following action should the nurse take.

Apply pressure to the puncta after instilling the medication

During a physical examination of a client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect additional data?

Corneal Light Reflex

A nurse is assessing a client who has fluid-volume excess. which of the following findings should the nurse expect?

Crackles in the lung fields

A nurse is caring for a client who has a temperature of 38.7 degrees C (101.7 degrees Fahrenheit) Which of the following actions should the nurse take?

Keep the client's bed linens dry

A nurse is performing a neurological assessment of a client. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests?

Romberg

A nurse is screening a client who has an S-shaped spinal column with unequal shoulder heights. The nurse should identify these findings as manifestations of which of the following abnormalities

Scoliosis

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume?

Sodium

A nurse on a medical unit is caring for a client who has been coughing intermittently during meals, attempting to clear her throat repeatedly, and eating only a small portion of each meal. The nurse should recommend a referral to which of the following members of the interprofessional team to evaluate the client for dysphagia?

Speech-language pathologist

A nurse is measuring a client's vital signs. The client's heart rate is 105/min. The nurse should document this finding as which of the following alteration?

Tachycardia

A nurse is assisting a client who has right-sided weakness while ambulating using a cane. Which of the following client actions should indicate to the nurse that the client understands the procedure of cane walking?

The client keeps 2 points of support on the ground

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who is scheduled for emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?

The client reports severe pain