FOUNDATIONS ATI
A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as risk factors for the development of this electrolyte imbalance? A. Crohn's disease B. Postoperative following appendectomy C. History of bone cancer D. Hyperthyroidism
A
A nurse observes an assistive personnel (AP) reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing? A. Assault B. Battery C. False imprisonment D. Invasion of privacy
A
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 (this gives all members input and an opportunity to express their feelings)
A nurse prepares an injection of morphine to administer to a client who reports pain. Prior to administering the medication, the nurse assists another client onto a bedpan. She asks a second nurse to give the injections. Which of the following actions should the second nurse take? A. offer to assist the client who needs the bedpan B. Administer the injection the other nurse prepared C. Prepare another syringe and administer the injection D. Tell the client who needs the bedpan she will have to wait for her nurse
A
A nurse in a providers office is preparing to auscultate and percuss a client's abdomen as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A. Tympani B. High pitched clicks C. Borborygmi D. Friction rubs E. Bruits
A B
A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications, that the client currently takes, should alert the nurse to a further risk for ototoxicity? (select all that apply) A. furosemide B. ibuprofen C. cimetidine D. simvastatin E. amiodarone
A B
A nurse is caring for a client who is about to undergo an elective surgical procedure. The nurse should take which of the following actions regarding informed consent? (Select all that apply) A. Make sure the surgeon obtained the client's consent B. Witness the client's signature on the consent form. C. Explain the risks and benefits of the procedure D. Describe the consequences of not having the surgery E. Tell the client about alternatives to having the surgery
A B
A nurse is performing a neurosensory examination for a client. Which of the following assessments should the nurse perform to test the client's balance? (Select all that apply) A. Romberg test B. Heel-to-toe walk C. Snellen test D. Spinal accessory function E. Rosenbaum test
A B
A nurse in a provider's office is documenting his findings following an examination he performed for a client new to the practice. Which of the following parameters should he include as part of the general survey? (Select all that apply.) A. posture B. skin lesions C. speech D. allergies E. immunization status
A B C
A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting would and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (Select all that apply) A. Increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst
A B C
A nurse is performing dietary needs assessments for a group of clients. A blenderized liquid diet is appropriate for which of the following clients? (Select all that apply) A. A client who has a wired jaw due to a motor vehicle crash B. A client who is 24 hr postoperative following temporomandibular joint repair C. A client who has difficulty chewing due to oral surgery D. A client who has hypercholesterolemia due to coronary artery disease E. A client who is scheduled for a morning colonoscopy the next morning
A B C
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 clients anus.
A B C
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 conversation C. Obtain the provider's signature on the prescription within 24 hours 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 B C
A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (Select all that apply) A. Intensive care unit B. Oncology treatment center C. Burn center D. Cardiac rehabilitation E. Home health care
A B C (Tertiary health care involves the provision of specialized and highly technical care)
A nurse is instructing a group of nursing students in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (select all that apply) A. place the client in semi-Fowler's B. have the client rest an arm across the abdomen C. observe one full respiratory cycle before counting the rate D. count the rate for 30 sec if it is irregular E. count and report any sighs the client demonstrates
A B C (note that a sigh is an expected finding in adults and can assist to expand airways)
A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated with aging? (Select all that apply) A. Slower light touch sensation B. Some vision and hearing decline C. Slower fine finger movement D. Some short-term memory decline E. Decreased risk of depression
A B C D
A nurse is acquainting a group of newly licensed nurses with the roles of the various members of the health care team they will encounter on a med-surg unit. When she gives examples of the types of tasks CNAs may perform, which of the following client activities should she include? (Select all that apply) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs
A B C E
A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SARS). The nurse is aware 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
A B C E
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 the 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
A B C E
A nurse in a senior center is counseling a group of older adults about their nutritional needs & considerations. Which of the following info 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 & minerals as younger adults do C. Many older men & 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 carbs
A B C (osteoporosis)
A charge nurse is conducting a nutritional class for a group of newly licensed nurses regarding basal metabolic rate (BMR). The charge nurse should inform the class that which of the following factors increases BMR? (Select all that apply) A. Lactation B. Prolonged stress C. Malnutrition D. Puberty E. Age older than 60 years old
A B D
A nurse is caring for a group of clients on a med-surg unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (select all that apply) A. A client who has terminal cancer requests hospice care in her home B. A client asks about community resources available for older adults C. A client states she wants her child baptized before surgery D. A client requests an electric wheelchair for use after discharge E. A client states that she does not know how to use a nebulizer
A B D
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 B D
A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (Select all that apply) A. Request assistance when repositioning a client B. Avoid twisting your spine or bending at your waist C. Keep your knees slightly lower than your hips when sitting for long periods of time D. Use smooth movements when lifting and moving clients E. Take a break from repetitive movements every 2 to 3 hours to flex and stretch your joints and muscles
A B D
A school nurse is teaching a high school health class about the possible causes of a negative nitrogen balance. Which of the following causes should the nurse include in the teaching? (Select all that apply) A. Illness B. Malnutrition C. Adolescence D. Trauma E. Pregnancy
A B D
A nurse is discussing restorative health care with a newly licensed nurse. Which of the following examples should the nurse include in the teaching? (Select all that apply) A. Home health care B. Rehabilitation facilities C. Diagnostic centers D. Skilled nursing facilities E. Oncology centers
A B D (Restorative health care involves intermediate follow-up care for restoring health and promoting self-care)
A nurse is administering bolus enteral feedings to a client who has malnutrition. Which of the following are appropriate nursing interventions? (Select all that apply) A. Verify the presence of bowel sounds B. Flush the feeding tube with warm water C. Elevate the head of bed to 20 degrees D. Administer the feeding at room temperature E. Inspect the tube insertion site
A B D E
A nurse is admitting a client who has acute cholecystitis to a medical-surgical unit. which of the following actions are essential steps of the admission procedure? (Select all that apply) A. Explain the roles of other care delivery staff B. Begin discharge planning C. Inform the client that advance directives are required for hospital admission D. Document the client's wishes about organ donation E. Introduce the client to his roommate
A B D E
A nurse is caring for a client who had a stroke and is scheduled for transfer to a rehabilitation center. Which of the following tasks are the responsibility of the nurse at the transferring facility? (Select all that apply) A. Ensure that the client has possession of his valuables B. Confirm that the rehab center has a room available at the time of transfer C. Assess how the client tolerates the transfer D. Give a verbal transfer report via telephone E. Complete a transfer form for the receiving facility
A B D E
A nurse is planning care for a client who has a new prescription for peripheral parenteral nutrition (PPN). Which of the following actions should the nurse include in the plan of care? (Select all that apply) A. Examine trends in weight loss B. Review prealbumin finding C. Administer an IV solution of 20% dextrose D. Add a micron filter to IV tubing E. Use and IV infusion pump
A B D E
A nurse is talking with a client about ways to help him 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 hours before bedtime
A B D E
A nurse educator is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. The nurse indicates understanding when she states that 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
A B E
A nurse educator is teaching a module about safe medication administration to newly licensed nurses. Which of the following statements should the nurse identify as an indication that one of the group understands how to implement medication therapy? (select all that apply) A. I will observe for side effects B. I will monitor for therapeutic effects C. I will prescribe the appropriate dose D. I will change the dose if adverse effects occur E. I will refuse to give a medication if I believe it is unsafe
A B E
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 dry D. Use OTC products to treat abrasions E. Wear cotton socks
A B E
A nurse is teaching a client who has a new prescription for oxybutynin about managing the medication's anticholinergic effects. Which of the following instructions should the nurse include? (select all that apply) A. Take sips of water frequently B. Wear sunglasses when outdoors in sunlight C. Use a soft toothbrush when brushing teeth D. Take the medication with an antacid E. Urinate prior to taking the medication
A B E
A client who is postoperative following a knee arthoplasty is concerned about the adverse effects of the medication he is taking for pain management. Which of the following members of the interprofessional care team can help the client understand the medication's effects? (Select all that apply) A. Provider B. Certified nursing assistant C. Pharmacist D. Registered nurse E. Respiratory therapist
A C D
A nurse is teaching a group of nursing students on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage the students to use? (select all that apply) A. guided imagery B. massage therapy C. meditation D. music therapy E. therapeutic touch
A C D
A nurse is planning care for a client who is receiving enteral nutrition through continuous infusion. Which of the following interventions should be included in the plan of care? (Select all that apply) A. Administer with an infusion pump B. Measure residual every 8 hr. C. Flush the feeding tube every 4 hr. D. Reinstill the residual feeding into the stomach E. Reassess tolerance if the residual volume is greater than the prescribed amount
A C D E
A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? A. Obtain a walker for the client to use to transfer back to bed. B. Call for additional staff to assist with the transfer C. Use a transfer belt and assist the client back into bed D. Determine the client's ability to help with the transfer
D
A nurse in a provider's office is caring for a client who states that, for the past week, she has 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. Does your lack of sleep interfere with your ability to function during the day? 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 C D (periods of apnea warrant a prompt referral for diagnostic sleep studies) E (Note that a week of sleeping trouble should not result in confusion)
A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crustings. The nurse should identify the client has manifestations of which of the following conditions? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster
D
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
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 minutes 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 C E
A nurse is reviewing complementary and alternative therapies with a group of nursing students. The nurse should classify which of the following interventions as a mind-body therapy? (select all that apply) A. art therapy B. acupressure C. yoga D. therapeutic touch E. biofeedback
A C E (note that therapeutic touch is considered energy therapy)
A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering the medication, which of the following actions is the nurse's priority? A. Teaching the client about the purpose of the medication B. Giving the medication at the administration time the provider prescribed C. Identify the client's medication allergies D. Documenting the client's anxiety level
C
A nurse is caring for an 82-year-old client in the emergency department who has an oral body temperature of 38.3 C (101 F), pulse rate 114/min, and respiratory rate 22/min. He is restless and his skin is warm. Which of the following interventions should the nurse take? (select all that apply) A. obtain culture specimens before initiating antimicrobials B. restrict the client's oral fluid intake C. encourage the client to rest and limit activity D. allow the client to shiver to dispel excess heat E. assist the client with oral hygiene frequently
A C E (this helps prevent cracking of dry mucous membranes of the mouth and lips)
A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse check the surgical would and finds it separated with viscera protruding. Which of the following actions should the nurse take? (Select all that apply) A. Cover the area with saline-soaked sterile dressings. B. Apply an abdominal binder snugly around the abdomen C. Use sterile gauze to apply gentle pressure to the exposed tissues D. Position the client supine with his hips and knees bent E. Offer the client a warm beverage, such as herbal tea
A D
A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement? A. immediately complete a thorough assessment B. put the client in a room with a client who has a hearing loss C. provide a private room, and limit stimulation D. speak at a higher volume to the client, and encourage ambulation
C
A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (select all that apply) A. Weber test showing lateralization to the right ear B. light reflex at 10 o'clock in the left ear C. indications of obstruction in the left ear canal D. Rinne test showing less time for air and bone conduction E. Rinne test showing air conduction less than bone conduction in the left ear
A D
A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply) A. Keep the end of the bed elevated 30 degrees B. Massage the client's 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 hours while in bed
A D
A nurse is preparing to administer a 0900 medication to a client. Which of the following are acceptable administration times for this medication? (select all that apply) A. 0905 B. 0825 C. 1000 D. 0840 E. 0935
A D
A nurse is caring for a client who has been sitting 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 ulcer D. Fecal impaction
C
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, unlabeled respirations B. The client's partner states, "He said he hurts after walking about 10 minutes C. Pain rating is 3 on a scale of 0 to 10 D. Skin is pink, warm, and dry E. The assistive personnel reports the client walked with a limp
A D E
A nurse in a provider's office is preparing to perform a crease examination for an older adult client who is postmenopausal. Which of the following findings should the nurse expect? (Select all that apply) A. Smaller nipples B. Less adipose tissue C. Nipple discharge D. More pendulous E. Nipple inversion
A D E
A nurse in a providers office is preparing to assess a client's skin as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A. Capillary refill less than 3 seconds B. 1+ pitting edema in both feet C. Pale nail beds in both hands D. Thick skin on the soles of the feet E. Numerous light brown macules on the face
A D E
A nurse is assessing a client's thyroid gland as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A. Palpating the thyroid in the lower half of the neck B. Visualizing the thyroid on inspection of the neck C. Hearing a bruit when auscultations the thyroid D. Feeling the thyroid ascend as the client swallows E. Finding symmetric extension off the trachea on both sides of the midline
A D E
A nurse is consoling the partner of a client who just expired after a long battle with liver cancer. The partner is displaying grief and states, "I hate him for leaving me." Which of the following statements by the nurse successfully facilitate mourning for the grieving partner? (Select all that apply.) A. "Would you like me to contact the chaplain to come 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 husband at this time." E. "Tell me more about how you are feeling."
A D E
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 D. Location fo the urethra in relation to the anus E. Frequent catheterization
A D E
A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (select all that apply) A. The temperature around the IV site is cooler B. The rate of infusion increases C. The skin at the IV site is red D. The IV dressing is damp E. The tissue around the venipuncture site is swollen
A D E
A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply) A. Stage III pressure ulcer B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area
A E
A nurse is caring for a client who has stage IV lung cancer and is 3 days postop 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 daughter's wedding." Based on Kubler-Ross' model, which stage of grief is the client experiencing? A. Anger B. Denial C. Bargaining D. Acceptance
C
A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit?
**apical - radial = deficit** 84-68 = 16/min
A nurse is collecting data from a client who is receiving IV therapy and reports pain in his arm, chills, and "not feeling well." The nurse notes warmth, edema, induration, and red streaking on the client's arm close to the IV insertion site. Which of the following actions should the nurse take first? A. Obtain a specimen for culture B. Apply a warm compress C. Administer analgesics D. Discontinue the infusion
D
A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She states, "The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hours ago. The prescription reads every 4 hours PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 minutes later, and he said his pain is going away." The charge nurse should inform the newly licensed nurse that she left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation
A ( should have used this step by asking the client to rate pain on scale, also should have asked about the characteristics of the pain and assessed for changes that could have resulted in worsening of pain)
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 her to urinate C. Recatheterize the bladder with a larger-gauge catheter D. Collect a urine specimen for analysis
A (a clogged or kinked catheter promotes bladder filling, which induces the "need" to urinate)
A nurse is instructing an assistive personnel (AP) about caring for a client who has a low platelet count as a result of chemotherapy. Which of the following instructions is the priority for measuring vital signs for this client? A. "do not measure the client's temperature rectally" B. "count the client's radial pulse for 30 seconds and multiply it by 2" C. "do not let the client know you are counting her respirations" D. "let the client rest for 5 minutes before you measure her BP"
A (at risk of bleeding)
A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients are at risk for hypovolemia? A. A client who has nasogastric suctioning B. A client who has chronic constipation C. A client who has syndrome of inappropriate antidiuretic hormone D. A client who took an overdose of sodium bicarbonate antacids
A (due to excessive gastrointestinal losses) **note that antidiuretic stops patient from peeing
A nurse is preparing to administer digoxin to a client who states, "I don't want to take that medication. I do not want one more pill." Which of the following responses should the nurse make? A. Your physician prescribed it for you, so you should really take it B. Well, let's just get it over quickly then C. Okay, I'll just give you your other medications D. Tell me your concerns about taking this medication
D
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 clients environment D. Make sure the client uses assistive airs in his possession
A (first action the nurse should take using the nursing process is to assess or collect data from the client. So the priority action is to determine the client's fall risk. This will guide the nurse in implementing appropriate safety measures.)
A nurse is performing an admission assessment for an older adult client. After gathering the assessment data and performing the review of systems, which of the following actions is a priority for the nurse? A. Orient the client to his room B. Conduct a client care conference C. Review medical prescriptions D. Develop a plan of care
A (greatest risk for the client at the moment is injury from unfamiliar surroundings — older adult client!)
A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should recognize which of the following findings is a manifestation of dehydration? (Select al that apply) A. Hct 55% B. Serum osmolarity 260 mOsm/kg C. Serum sodium 150 mEq/L D. Urine specific gravity 1.035 E. Serum creatinine 0.6 mg/dL
A (hct is greater than the range and is an indication of dehydration due to hemoconcentration) C D
A charge nurse is providing information about fat emulsion added to total parenteral nutrition (TPN) to a group of nurses. Which of the following statements by the charge nurse are appropriate? (Select all that apply) A. Concentration of lipid emulsion can be up to 30% B. Adding lipid emulsion gives the solution a milky appearance C. Check for allergies to soybean oil D. Lipid emulsion prevents essential fatty acid deficiency E. Lipids provide calories by increasing the osmolality of the PN solution
A (lipid emulsion is available in 10, 20, and 30 % concentrations) B (lipid emulsion is formulated from safflower and/or soybean oils and egg phospholipid, making the solution appear milky) C D (lipid emulsion is used for additional calories as concentrated energy and to prevent essential fatty acid deficiency)
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 his pain.
A (nurse should collect further data on client to determine why he has not achieved satisfactory pain relief, various factors could be interfering with his comfort)
A nurse is contributing to the plan of care for a client who is being admitted to the facility w/a suspected diagnosis of pertussis. Which of the following should the nurse include in the plan of care? Select all. A. Place the client in a room that has negative air pressure of at least 6 exchanges/hr 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 dept is unavoidable D. Use sterile gloves when handling soiled linens E. Wear a gown when preforming care that may result in contamination from secretions
B C E
A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? A. Collaborating with providers to perform obesity screenings during routine office visits B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity C. Providing specialized intraoperative training regarding surgical treatments for obesity D. Educating acute care nurses on postoperative complications related to obesity
A (primary health care emphasizes health promotion and disease control, is often delivered during office visits, and includes screenings —> SCREENING = PRIMARY)
A nurse is caring for a client who has a prescription for a 24-hour 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. Ask the client to urinate and pour the urine into a specimen container D. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container
A (should discard first void and note the time)
A nurse is introducing herself to a client as the first step of a comprehensive physical examination. Which of the following strategies should the nurse use with this client? (Select all that apply) A. Address the client with the appropriate title and her last name. B. use a mix of open- and closed-ended questions C. reduce environmental noise D. have the client complete a printed history form E. perform the general survey before the examination
B C E
A nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired 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 go carry out the new prescriptions from the provider D. I will ask the client if his nausea has resolved
A (should prioritize client problems during the planning stage)
A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include? A. Flush the tube before and after each medication B. Mix your medications with your enteral feeding C. Push tablets through the tube slowly D. Mix all the crushed medications prior to dissolving them in water
A (this is to prevent clogging of the tube) (note that the client should self-administer one medication at a time and should not administer tablets through a JG tube)
A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse anticipate including in the plan of care? A. Infuse hypotonic IV fluids B. Implement a fluid restriction C. Increase sodium intake D. Administer sodium polystyrene sulfonate
A (this will expand the ECF volume and rehydrate the cells)
A nurse is caring for a client who is receiving TPN through a central line, but the next bag of solution is not available for administration at this time. Which of the following is an appropriate action by the nurse? A. Administer 20% dextrose in water IV until the next bag is available B. Slow the infusion rate of the current bag until the solution is available C. Monitor for hyperglycemia D. Monitor for hyperosmolar diuresis
A (this will prevent hypoglycemia)
A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge report? (Select all that apply) A. Advance directives status B. Follow-up care C. Instructions for diet and medications D. Most recent vital sign data E. Contact information for the home health care agency
B C E
A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the clients head to the side B. Place two fingers in the client's mouth to open C. Brush the client's teeth once per day D. Inject a mouth rinse into the center of the client's mouth
A
A nurse is planning care for a client who develops dyspnea and feels tired after completing her morning care. Which of the following action 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
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
A nurse is caring for a client who weights 80 kg (176 lbs) and is 1.6 m (5'3') tall. Calculate her BMI and determine whether this client's BMI indicates that she is of a healthy weight, overweight, or obese.
80kg/(1.6)^2m = 31.25 —> client is obese
A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. Which of the following pain characteristics is the nurse attempting to determine? A. presence of associated manifestations B. location of the pain C. pain quality D. aggravating and relieving factors
A
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? A. Hypotension B. Bradycardia C. Clammy skin D. Bradypnea
A
A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client? A. Get up and change positions slowly B. Avoid eating aged cheese and smoked meat C. Report any unusual bruising or bleeding to the doctor immediately D. Eat the same amount of foods that contain vitamin K every day
A
A nurse is assessing a client as part of an admission history. The client reports drinking an herbal tea every afternoon at work to relieve stress. The nurse should suspect which of the following ingredients? A. chamomile B. ginseng C. ginger D. echinacea
A
A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over him, which of the following areas should the nurse wash first? A. Face B. Feet C. Chest D. Arms
A
A nurse is caring for a client scheduled for abdominal surgery. The client reports being worried. Which of the following actions should the nurse take? A. offer information on a relaxation technique and ask the client if he is interested in trying it B. request a social worker see the client to discuss meditation C. attempt to use biofeedback techniques with the client D. tell the client many people feel the same way before surgery and to think of something else
A
A nurse is caring for a client who asks what her Snellen eye test results mean. The client's visual acuity is 20/30. Which of the following responses should the nurse make? A. Your eyes see at 20 feet what visually unimpaired eyes see at 30 feet B. Your right eye can see the chart clearly at 20 feet, and your left eye can see the chart clearly at 30 feet C. Your eyes see at 30 feet what visually unimpaired eyes see at 20 feet D. Your left eye can see the chart clearly at 20 ft and your right eye can see the chart clearly at 30 ft
A
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
A nurse is caring for a client who has hypothyroidism. Which of the following is associated with the disorder? A. Decreased metabolic demand B. Weight loss C. Increased heart rate D. Diarrhea
A
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
A nurse is caring for a client who is 24 hr postoperative following and 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 that she will call the surgeon and ask. 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
A nurse in an ambulatory care clinic is caring for a client who had a mastectomy 6 months ago. The client tells the nurse that she has not had much desire for sexual relations since her surgery, stating, "My body is so different now." Which of the following responses should the nurse make? A. "Really, you look just fine to me. There's no need to feel undesirable." B. "I'm interested in finding out more about how your body feels to you." C. "Consider an afternoon at a spa. A facial will make you feel more attractive." D. "It's still too soon to expect to feel normal. Give it a little more time."
B
A nurse is caring for a client who decides not to have surgery despite significant blockages in his 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. Nonmaleficence
B
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 her chin when swallowing C. Have the client use a straw D. Encourage the client to lie down and rest after meals
B
A nurse is caring for a client who is recovering from a myocardial infarction and a cardiac catheterization. The client states "I am concerned that things might be a little, ya know, different with my wife when i get home." Which of the following statements should the nurse make? A. Sounds like something you should discuss with her when you get home B. It sounds like you are concerned about sexual functioning. Let's discuss your concerns. C. Oh, i wouldn't be too concerned. Things will be fine as soon as we get you home. D. Just make sure you take your medication as directed and you should be fine.
B
A nurse is caring for a client whose partner passed away 4 months ago and who has been recently diagnosed with diabetes mellitus. He 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 dont 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
A nurse is caring for a competent adult client who tells the nurse that he is thinking about leaving the hospital against medical advice. The nurse believes that this is not the client's best interest, so she prepares to administer a PRN sedative medication the client has not requested along with his usual medication. Which of the following types of tort is the nurse about to commit? A. Assault B. False imprisonment C. Negligence D. Breach of confidentiality
B
A nurse is collecting data for a client's comprehensive physical examination. After the nurse inspects the client's abdomen, which of the following skills of the physical examination process should she perform next? A. olfaction B. auscultation C. palpation D. percussion
B
A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure? A. I will thread the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood B. I will insert the needle into the client's skin at an angle of 10 to 30 degrees with the bevel up C. I will apply pressure approximately 1.2 inches below the insertion site prior to removing the needle D. I will choose a vein in the antecubital fossa for IV insertion due to its size and easily accessible location
B
A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? A. Monitoring evidence-based practice for clients who have a specific diagnosis B. Ensuring that health care providers comply with regulations C. Setting quality standards for accreditation of health care facilities D. Determining if medications are safe for administration to clients
B
A nurse is evaluating client teaching on a client who has a new prescription for a sequential compression device. Which of the following client statements should indicate to the nurse the client understands the teaching? A. This device will keep me from getting sores on my skin B. This thing will keep the blood pumping through my leg C. With this thing on, my leg muscles won't get weak D. This device is going to keep my joints in good shape
B
A nurse is performing an integumentary assessment for a group of clients. Which of the following findings should the nurse recognize as requiring immediate intervention? A. Pallor B. Cyanosis C. Jaundice D. Erythema
B
A nurse is planning care for a client who is a devout Muslim and is 3 days postop following a hip arthroplasty. The client is scheduled for two physical therapy sessions today. Which of the following statements by the nurse indicates culturally appropriate care to the client? A. I will make sure the menu includes kosher options B. I will discuss the daily schedule with the client to make sure the client will have time for prayer C. I will make sure to use direct eye contact when speaking with this client D. I will make sure daily communion is available for this client
B
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
A nurse is reviewing a client's medications. They include cimetidine and imipramine. Knowing that cimetidine decreases the metabolism of imipramine, the nurse should identify that this combination is likely to result in which of the following effects? A. Decreased therapeutic effects of cimetidine B. Increased risk of imipramine toxicity C. Decreased risk of adverse effects of cimetidine D. Increased therapeutic effects of imipramine
B
A nurse is teaching a group of clients how to care for their colostomies. Which of the following statements should alert the nurse that one of the clients is having an issue with self-concept? A. I was having difficulty with attaching the appliance at first, but my wife was able to help. B. I'll never be able to care for this at home. Could you just send a nurse to the house? C. I met a neighbor who also has a colostomy, and he taught me a few things D. It may take me a while to get the hang of this. I have to admit, i am pretty nervous.
B
A nurse is teaching an adult client how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands the proper technique? A. I will straighten my ear canal by pulling my ear down and back. B. I will gently apply pressure with my finger to the front part of my ear after putting in the drops C. I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in D. After the drops are in, I will place a cotton ball all the way into my ear canal
B
A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client's medical record, discovers that she 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
A nurse is preparing to inject heparin subcutaneously for a client who is postop. Which of the following actions should the nurse take? A. Use a 22-gague needle B. Select a site on the client's abdomen C. Spread the skin with the thumb and index finger D. Observe bleb formation to confirm proper placement
B (note subq injections should use 25 to 27-gague needle)
A nurse is caring for an adolescent client who is 2 days postoperative following an appendectomy and has type 1 diabetes mellitus. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain medication every 6-8 hours while reporting pain at a 2 on a scale of 0-10 after receiving the medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (Select all that apply) A. Extremes in age B. Impaired circulation C. Impaired/suppressed immune system D. Malnutrition E. Poor wound care
B C
A 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 C
A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (Select all that apply) A. My line of gravity should fall outside my base of support B. The lower my center of gravity, the more stability I have C. To broaden my base of support, I should spread my feet apart D. When I lift an object, I should hold it as close to my body as possible E. When pulling an object, I should move my front food forward
B C D
A nurse is assessing an older adult client who has significant tenting of the skin over his forearm. Which of the following factors should the nurse consider as a cause for this finding? (Select all that apply) A. Thin, parchment-like skin B. Loss of adipose tissue C. Dehydration D. Diminished skin elasticity E. Excessive wrinkling
B C D
A nurse is caring for a client receiving dextrose 5% in 0.9% sodium chloride IV at 120 mL/hr. Which of the following statements by the client should alert the nurse to suspect fluid overload? (select all that apply) A. I feel lightheaded B. I feel as though my heart is racing C. I feel a little short of breath D. The nurse technician told me that my blood pressure was 150 over 90 E. I think my ankles are less swollen
B C D
To promote adherence with medication self‑administration, a nurse is making recommendations for an older adult client. Which of the following instructions should the nurse include? (Select all that apply.) A. Adjust dosages according to daily weight. B. Place pills in daily pill holders. C. Ask for liquid forms if the client has difficulty swallowing pills. D. Ask a relative to assist periodically. E. Request child‑resistant caps on medication containers.
B C D
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. Establish a schedule of urinating prior to meal times 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 C D (Bladder training should involve intervals around every 4 hours, which does not correlate to meal times; also bladder retraining does not require or involve collecting sterile urine specimens)
A nurse is delegating the ambulatory 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 ambulated independently B. The client ambulates with his slippers on over his antiembolic stockings C. The client uses a front-wheeled walker when ambulating D. The client had pain medication 30 minutes ago E. The client is allergic to codeine F. The client ate 50% of his breakfast this morning
B C D (These are all needed to complete the assignment safely, all others are not necessary)
A nurse is discussing the HIPAA Privacy Rule with nurses during new employee orientation. Which of the following information should the nurse 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 her medical record E. A nurse may photocopy a clients medical record for transfer to another facility
B C D E
A nurse is performing a comprehensive physical examination of an older adult client. Which of the following interventions should the nurse use in consideration of the client's age? (select all that apply) A. collect the data in one continuous session B. plan to allow plenty of time for position changes C. Make sure the client has any essential sensory aids in place D. tell the client to take her time answering questions E. invite the client to use the bathroom before beginning the examination
B C D E
A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse including in her counseling? (Select all that apply) A. Most food poisoning is a virus B. Immunocompromised individuals are at risk for complications from food poisoning C. Clients who are at high risk should eat or drink only pasteurized dairy products D. Healthy individuals usually recover from the illness in a few weeks E. Handling raw and fresh food separately can prevent food poisoning
B C E
A nurse is assessing postoperative circulation of the lower extremities for a client who had knee surgery. The nurse should include which of the following? (Select all that apply) A. Range of motion B. Skin color C. Edema D. Skin lesions E. Skin temperature
B C E
A nurse is caring for a group of clients on a med surg unit. Which of the following clients are at risk for body image disturbances? (Select all that apply) A. 30 year old male client following laparoscopic appendectomy B. 45 year old female client following mastectomy C. 20 year old female client following left above the knee amputation D. 65 year old male client following cardiac catheterization E. 55 year old male client following stroke with right-sided hemiplegia
B C E
A nurse is collecting data from a client who takes haloperidol to treat schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms (ESP)? (select all that apply) A. Orthostatic hypotension B. tremors C. acute dystonia D. decreased level of conciousness E. restlessness
B C E
A nurse is providing discharge instruction to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? (Select all that apply) A. Family members who smoke must be at least 10 ft from the client when oxygen is in use B. Nail polish should not be used near a client who is receiving oxygen C. A "no smoking" sign should be placed on the front door D. Cotton bedding and clothing should be replaced with items mad from wool E. A fire extinguisher should be readily available in the home
B C E
A nurse is assisting a client who has a prescription for a mechanical soft diet with the food selections. Which of the following are appropriate selections by the client? (Select all that apply) A. Dried prunes B. Ground turkey C. Mashed carrots D. Fresh strawberries E. Cottage cheese
B C E (Require minimal chewing before swallowing)
A nurse is caring for a client who is 24 hr postoperative following abdominal surgery. The nurse suspects the client's acute pain management is inadequate. Which of the following data reinforce this suspicion? (Select all that apply) A. The client seems easily agitated B. The client is nonadherent with coughing, deep breathing, and dangling C. The client may have pain medication every 4-6 hours but accepts it every 6-7 hours D. The client reports tenderness in his right lower leg E. The client's vital signs are HR 124, temp 37C, and blood pressure 156/80 mmHg
B C (acceptance of pain medication only at or beyond the maximum interval suggests that the client has pain between the time the effects of the previous dose subside and the new does takes effect) E
A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing hand washing? (Select all that apply) A. Apply 3-5mL of liquid soap to dry hands B. Wash the hands with soap and water for at least 15 seconds C. Rinse the hands with hot water D. Use a clean paper towel to turn off the faucet E. Allow the hands to air dry after washing
B D
A nurse is preparing to administer intermittent enteral feeding to a client who has neuromuscular disorder. Which of the following are appropriate nursing interventions? (Select all that apply) A. Fill the feeding bag with 24 hr worth of formula B. Discard feeding equipment after 24 hr C. Leave unused portions of formula at the bedside D. Label the unused portion of the formula E. Elevate the head of bed for 15 minutes after administration
B D (*note that bag should only be filled with 4 hours of feeding to prevent contamination)
A nurse in a provider's office is evaluating a client who reports losing control of urine whenever she coughs, laughs, or sneezes. The client relates a history of three vaginal births, but no serious accidents or illnesses. Which of the following interventions should the nurse suggest for helping to control or eliminate the client's incontinence? (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 Crede maneuver
B D (Limiting fluids would not be the solution since stress incontinence comes from weak muscles, calcium has no effect on stress incontinence, Crede maneuver helps with reflex incontinence, not stress incontinence)
A nurse is assessing an adult client's internal ear canals with an otoscope as part of a head and neck examination. Which of the following actions should the nurse take? (Select all that apply) A. Pull the auricle down and back B. Insert the speculum slightly down and forward C. Insert the speculum 2-2.5 cm (0.8-1 in) D. Make sure the speculum does not touch the ear canal E. Use the light to visualize the tympanic membrane in a cone shape
B D E
A nurse is caring for a client who recently had a cerebrovascular accident and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? (select all that apply) A. increase the volume of your voice B. make sure only one person speaks at a time C. avoid discouraging the client by saying that you do not understand him D. allow plenty of time for the client to respond E. use brief sentences with simple words
B D E
A nurse is using an interpreter to communicate with a client. Which of the following actions should the nurse use when communicating with a client and his family? (Select all that apply) A. Talk to the interpreter about the family while the family is in the room B. Ask the family one question at a time C. Look at the interpreter when asking the family questions D. Use lay terms if possible E. Do not interrupt the interpreter and the family as they talk
B D E
A nurse is collecting data from a client who has hypercalcemia as a result of long-term use of glucocorticoids. Which of the following findings should the nurse expect? (Select all that apply) A. Hyperreflexia B. Confusion C. Positive Chvostek's sign D. Bone pain E. Nausea and vomiting
B D E (along with anorexia)
A nurse is caring for a client who is postop. 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 position often
B E
A nurse is explaining the various types of health care coverage clients might have to a group of nursing students. Which of the following heath care financing mechanisms are federally funded? (Select all that apply) A. Preferred provider organization B. Medicare C. Long-term insurance D. Exclusive provider organization E. Medicaid
B E
A nurse is caring for a client following an appendectomy. The nurse verifies the postoperative prescription, which reads "discontinue NPO status; advance diet as tolerated." Which of the following are appropriate for the nurse to offer the client? (Select all that apply) A. Applesauce B. Chicken broth C. Sherbet D. Wheat toast E. Cranberry juice
B E (Clear liquids right after NPO)
A nurse is caring for a client who has multiple sclerosis and requires liquids with honey-like thickness. Which of the following foods can the client consume without adding a thickening agent? A. Ice cream B. Yogurt C. Buttermilk D. Cream of chicken soup
B (can be eaten with a spoon but not sipped with a straw)
A nurse is instructing a client who has a new diagnosis of 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. I'll add plenty of carbohydrates to my meals B. I'll take a short nap whenever I feel a little sleepy C. I'll make sure I stay warm when I am at my desk at work D. "It's okay to drink alcohol as long as I limit it to one drink per day
B (clients who have narcolepsy should take short naps to reduce feelings of drowsiness)
A nurse is caring for a client who has had diarrhea for 4 days. When assessing the client, the nurse should expect which of the following findings? (Select all that apply.) A. Bradycardia B. Hypotension C. Elevated temp D. Poor skin turgor E. Peripheral edema
B (dehydration leads to decrease in blood pressure) C D (Note that dehydration and diarrhea patients should have tachycardia, not bradycardia)
A nurse manager is reviewing with nurses on the unit 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 his side B. I will go the the nurses station for assistance C. I will administer his medications D. I will prepare to insert an airway
B (during a seizure, the nurse should stay with the client and use the call light for assistance)
A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply) A. The provider drops a sterile instrument onto the near side of the sterile field B. The nurse moistens a cotton ball with sterile normal saline and places it onto the sterile field C. The procedure is delayed 1 hour because the provider receives an emergency call D. The nurse turns to speak to someone who enters through the door behind the nurse E. The client's hand pushes against the outer edge of the sterile field
B (fluid permeation of the sterile drape or barrier contaminates the field) C D
A nurse is planning to use healing intention with a client who is recovering from a lengthy illness. Which of the following is the priority action the nurse should take before attempting this particular mind-body intervention? A. tell the client the goal of the therapy is to promote healing B. ask whether the client is comfortable with using prayer C. encourage the client participate actively for best results D. instruct the client to relax during therapy
B (healing intention uses caring, compassion, and empathy in the context of prayer to facilitate healing)
A nurse is caring for a client who is receiving enteral tube feedings due to dysphasia. Which of the following bed positions should th nurse use for safe care of this client? A. Supine B. Semi-Fowler's C. Semi-prone D. Trendelenburg
B (helps prevent regurgitation and aspiration by clients who have difficulty swallowing)
A nurse is talking to a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? A. Macaroni and cheese B. Fresh fruit and whole wheat toast C. Bread pudding and yogurt D. Roast chicken and white rice
B (high fiber diet promotes normal bowel elimination. The nurse should recommend fresh fruits/veggies with whole-grain carbohydrates)
A nurse is caring for a client who is to receive a Level 2 dysphagia diet due to a recent stroke. Which of the following dietary selections is most appropriate? A. Turkey sandwich B. Poached eggs C. Peanut butter crackers D. Granola
B (moist and semi-solids in level 2, all the other answers were level 3)
A nurse who is admitting a client who has a fractured femur obtains a BP reading of 140/94 mmHg. The client denies any history of HTN. Which of the following actions should the nurse take next? A. Request a prescription for an antihypertensive med B. Ask the client if she is having pain C. Request a prescription for an anti-anxiety med D. Return in 30min to recheck the client's BP
B (priority is a pain assessment)
A nurse is teaching a client who is starting continuous feedings about the various types of enteral nutrition (EN) formulas. Which of the following should the nurse include in the teaching? A. Formula rich in fiber is recommended when starting EN B. Standard formula contains whole protein C. Hydrolyzed formula is recommended for a full-functioning GI tract D. The high-calorie formula has increased water content
B (requires full functioning GI tract)
A nurse on a med-surg unit is caring for a group of clients. For which of the following clients should the nurse anticipate a prescription for fluid restriction? A. A client who has a new diagnosis of adrenal insufficiency B. A client who has heart failure C. A client who is receiving treatment for diabetic ketoacidosis D. A client who has abdominal ascites
B (should expect this because it will reduce the workload on the heart)
A nurse manager of a medical-surgical unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which of the following staff members should the nurse assign this client? A. Charge nurse B. RN C. Practical nurse (PN) D. Assistive personnel (AP)
B (this client needs an RN's assessment and establishment of a plan of care, especially if the client is potentially unstable)
A young adult client in a provider's office tells the nurse that she uses fasting for several days each week to help control her weight. The client takes several medications for various chronic conditions. The nurse should explain to the client that which of the following mechanisms that results from fasting puts her at risk for medication toxicity? A. Increasing the metabolism of the medications over time B. Increasing protein-binding response C. Increasing medications' transit time through the intestines D. Decreasing the excretion of medications
B (this increases the medications response and thus increases the risk for medication toxicity)
A charge nurse is teaching a group of nurses about medication compatibility with TPN. Which of the following statements should the charge nurse make? A. Use the Y-port on the TPN IV tubing to administer antibiotics B. Regular insulin may be added to the TPN solution C. Administer heparin through a port on the TPN tubing D. Administer vitamin K IV bolus through a Y-port on the TPN tubing
B (this is done to decrease hyperglycemia)
A nurse is working with a newly licensed nurse who is administering medications to clients. Which of the following actions should the nurse identify as an indication that the newly hired nurse understands medication error prevention? A. Taking all medications out of the unit-dose wrappers before entering the client's room B. Checking with the provider when a single dose requires administration of multiple tablets C. Administering a medication, then looking up the usual dosage range D. Relying on another nurse to clarify a medication prescription
B (this might indicate a prescription error so it is better to check)
A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? A. Administer antihypertensive on schedule B. Check the client's weight each morning C. Notify the provider of a urine output greater than 30 mL/hr D. Encourage independent ambulation four times a day
B (this will evaluate if the patient is responding well to treatment)
A nurse in a family practice clinic is performing a physical examination of an adult client. Which part of her hands should she use during palpation for optimal assessment of skin temperature? A. palmar surface B. fingertips C. dorsal surface D. base of the fingers
C
A nurse in a surgeon's office is providing preoperative teaching for a client who is scheduled for surgery the following week. The client tells the nurse that he will prepare his advance directives before he goes to the hospital. Which of the following statements made by the client should indicate to the nurse an understanding of advance directives? A. I'd rather have my brother make decisions for me, but i know it has to be my wife B. I know they won't go ahead with the surgery unless i prepare these forms C. I plan to write that i don't want them to keep me on a breathing machine D. I will get my regular doctor to approve my plan before I hand it in at the hospital
C
A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family? A. Allowing the client to function independently will strengthen her muscles and promote healing. B. The client needs to be given privacy at times for self-reflecting and organizing her life C. The client's sense of loss can be lessened through retaining control of certain areas of her life D. Performing ADLs is required prior to discharge from an acute care facility
C
A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicated that the client knows how to use the device? A. I'll wait to use the device until it's absolutely necessary B. I'll be careful about pushing the button too much so I don't get an overdose C. I should tell the nurse if the pain doesn't stop while I am using the device D. I will ask my adult child to push the dose button when I am sleeping
C
A nurse is caring for a client who reports pain with internal rotation of her right shoulder. This discomfort can affect the client's ability to perform which of the following activities? A. Mopping her floors B. Brushing the back of her hair C. Fastening her bra behind her back D. Reaching into a cabinet above her sink
C
A nurse is caring for a client who shares the nurse's religious background. Which of the following information should the nurse anticipate? A. Members of the same religion share similar feelings about their religion B. A shared religious background generates mutual regard for one another C. The same religious beliefs can influence individuals differently D. The nurse and client should discuss the differences and commonalities in their beliefs.
C
A nurse is caring for an older adult client who has been following the facility's routine and bathing in the morning. However, at home, she always takes a warm bath just before bedtime. Now she is having difficulty sleeping at night. Which of the following actions should the nurse take first? A. Rub the client's back for 15 minutes 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
A nurse is completing discharge instructions for a client who has COPD. The nurse should identify that the client understands the orthopedic position when she states that she will do which of the following when she has difficulty breathing at night? A. Lie on her back with her head and shoulders on a pillow B. Lie flat on her stomach with her heat to one side C. Sit on the side of her bed and rest her arms over pillows on top of her bedside table D. Lie on her side with her weight on her hip and shoulder with her arm flexed in front of her
C
A nurse is instructing a group of nursing students 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 students 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. Nonmaleficence
C
A nurse is teaching a client who is lactating about taking medications. Which of the following actions should the nurse recommend to minimize in the entry of medication into breast milk? A. Drink 8 oz milk with each dose of medication B. Use medications that have extended half-life C. Take each dose right after breastfeeding D. Pump breast milk and freeze it prior to feeding to the newborn
C
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 all clients who are nearby D. Close all open doors on the unit
C
A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/L. When notifying the provider, the nurse should anticipate which of the following actions? A. Starting an IV infusion of 0.9% sodium chloride B. Consulting with dietitian to increase intake of potassium C. Initiating continuous cardiac monitoring D. Preparing the client for gastric lavage
C
When entering a client's room to change a surgical dressing, A nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? A. Keep the sterile field at least 6ft away from the client's bedside B. Instruct the client to refrain from coughing and sneezing during the dressing change C. Place a mask on the client to limit the spread of micro-organisms into the surgical wound D. Keep a box of facial tissues nearby for the client to use during the dressing change
C
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 hours to reduce pressure ulcer risk
C D E
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 he is 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 D E
A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? (select all that apply) A. urinary incontinence B. diarrhea C. bradypnea D. orthostatic hypotension E. nausea
C D E
A nurse is performing a head and neck examination for an older adult client. Which of the following age-related findings should the nurse expect? (Select all that apply) A. Reddened gums B. Lowered vocal pitch C. Tooth loss D. Glare intolerance E. Thickened eardrums
C D E
A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (Select all that apply) A. Distended neck veins B. Hyperthermia C. Tachycardia D. Syncope E. Decreased skin turgor
C D E
A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply) A. A bottle containing sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand
C D E
A nurse is assisting a newly licensed nurse with postmortem care of a client. The family wishes to view the body. Which of the following statements by the newly licensed nurse indicate an understanding of the procedure? (Select all that apply) A. I will remove the dentures from the body B. I will make sure the body is lying completely flat C. I will apply fresh linens and place a clean gown on the body D. I will remove all equipment from the bedside E. I will dim the lights in the room
C D E (Note that body shouldn't be completely flat, ATI says there should be a pillow under the client's head
A nurse in a provider's office is preparing to test a client's cranial nerve function. Which of the following directions should she include when testing cranial nerve V? (Select all that apply) A. Close your eyes B. Tell me what you can taste C. Clench your teeth D. Raise your eyebrows E. Tell me when you feel a touch
C E
A nurse in a providers office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A. Concave thoracic spine posteriorly B. Exaggerated lumbar curvature C. Concave lumbar spine posteriorly D. Exaggerated thoracic curvature E. Muscles slightly larger on his dominant side
C E
A nurse in a providers office is preparing to auscultate and percuss a client's thorax as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply) A. Rhonci B. Crackles C. Resonance D. Tactile fremitus E. Bronchovesicular sounds
C E
A nurse is caring for a client who is 1 day postop following a total knee arthroplasty. The client states his pain level is 10 on a scale of 0 to 10. After reviewing the client's medication administration record, which of the following medications should the nurse administer? A. meperidine 75 mg IM B. Fentanyl 50 mcg/hr transdermal patch C. Morphine 2 mg IV D. Oxycodone 10 mg PO
C (IV is rapid onset)
A nurse is reviewing prescribed medications for a newly admitted client. Which of the following medications decreases the body's rate of metabolism? A. Prednisone B. Levothyroxine C. Amitriptyline D. Epinephrine
C (antidepressant that decreases body's metabolic rate)
A nurse is caring for a client awaiting transport to the surgical suite for a coronary artery bypass graft. Just as the transport team arrives, the nurse takes the client's vital signs and notes an elevation in blood pressure and heart rate. The nurse should recognize this response as which part of the general adaptation syndrome (GAS)? A. Exhaustion stage B. Resistance stage C. Alarm reaction D. Recovery reaction
C (body functions are heightened in order to respond to the stressor during this stage)
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. Puréed broccoli C. Vanilla custard D. Lentil soup
C (foods low in fiber and easy to digest = dairy products and eggs)
A nurse is discussing the use of a low-profile gastrostomy device with the parent of a child who is receiving an enteral feeding. Which of the following is an appropriate statement by the nurse? A. "The device can be uncomfortable for children." B. "Checking residual is much easier with this device" C. "Tub baths are allowed with this device" D. "Mobility of the child is limited with this device"
C (low-profile gastrostomy device is fully immersible in water)
A nurse is instructing a group of nursing students about how to know and what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma? A. A nurse on a med surg 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 her spouse on her durable power of attorney form
C (making the decision about initiating enteral feedings is an example of ethical dilemma - a recites of scientific data cannot resolve the issue, and it is not easy to resolve. The decision will have a profound effect on the situation and the client)
A nurse is preparing information for a change-of-shift report. Which of the following information should the nurse include in the report? A. Intake 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 (new nurse might have to modify patients care in order to prepare for leaving the unit)
A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain? A. ask the client what precipitates the pain B. question the client about the location of the pain C. offer the client a pain scale to measure his pain D. use open-ended questions to identify the client's pain sensations
C (scale determines INTENSITY, open-ended questions will help determine the quality of the pain)
A nurse is preparing to administer lipid emulsion and notes a layer of fat floating in the IV solution bag. Which of the following actions should the nurse take? A. Shake the bag to mix the fat B. Turn the bag upside down one time C. Return the bag to the pharmacy D. Administer the bag of solution
C (this indicates that "cracking" of the solution has occurred, and therefore should not be administered)
A nurse on a medical-surgical unit has received change-of-shift report and will care for four patients. Which of the following client's needs 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 ulcer
C (this is a noninvasive routine procedure that the nurse may delegate to the AP)
A nurse is caring for a client who is crying while reading from his devotional book. Which of the following interventions should the nurse take? A. Contact the hospital's spiritual services. B. Ask him what is making him cry C. Provide quiet times for these moments D. Turn on the television for a distraction
C (this will support the client's spiritual health)
During an abdominal examination, a nurse in a providers office determines that a client has abdominal distinction. The protrusion is at midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distinction should the nurse suspect? A. Fat B. Fluid C. Flatus D. Hernias
C (with flatus, the protrusion is mainly midline, and there is no change in the flanks)
A nurse is providing education for a client who has severe hypomagnesemia due to alcohol use disorder. The client is to receive magnesium sulfate. Which of the following information should the nurse include in the teaching? A. "You will receive magnesium in a series of IM injections B. You should receive a prescription for a thiazides diuretic to take with the magnesium C. You should eliminate who grains from you diet until you Mg level increases D. You will have your deep-tendon reflexes monitored while you are receiving Mg
D
A client who has had a cerebrovascular accident has persistent problems with dysphasia (difficulty swallowing). The nurse caring for the client should initiate a referral with which member of the interprofessional care team? A. Social worker B. certified nursing assistant C. Occupational therapist D. Speech-language pathologist
D
A goal for a client who has difficulty with self-feeding due to RA is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the interprofessional team? A. Social worker B. Certified nursing assistant C. Registered dietician D. Occupational therapist
D
A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on a break. Which of the following actions should the nurse take? A. Alert the ANA B. Fill out an incident report C. Report the observations to the nurse manager on the unit D. Leave the nurse alone to sleep
D
A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flab farthest from the body
D
A nurse is assessing a client's neurosensory system. To evaluate stereognosis, the nurse should ask the client to close his eyes and identify which of the following items? A. A word she whispers 30 cm from his ear B. A number she traces on the palm of his hand C. The vibration of a tuning fork she places on his foot D. A familiar object she places in his hand
D
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 about anticipated findings at this time. Which of the following findings should the nurse include in the discussion? A. Regular breathing patterns B. Warm extremities C. Increased urine output D. Decreased muscle tone
D
A nurse is caring for a client who is 3 days postop following a below-the-knee amputation as a result of a motor vehicle crash. Which of the following client statements indicates to the nurse that the client has a distorted body image? A. Ill be able to function exactly as i did before the incident B. I just can't stop crying C. I am so mad at that guy who hit us. I wish he lost his leg D. I don't even want to look at my leg. You can change the dressing
D
A nurse is caring for a client who is a Jehovah's Witness and is scheduled for surgery as a result of a motor vehicle crash. The surgeon tells the client that a blood transfusion is essential. The client tells the nurse that based on his religious values and mandates, he cannot receive a blood transfusion. Which of the following responses should the nurse make? A. I believe in this case you should really make an exception and accept the blood transfusion B. I know your family would approve of your decision to have a blood transfusion C. Why does your religion mandate that you cannot receive any blood transfusions? D. Let's discuss the necessity for a blood transfusion with your religious and spiritual leaders and come to a reasonable solution
D
A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. I use a damp cloth to clean the outside part of my hearing aids B. I clean the ear molds of my hearing aids with rubbing alcohol C. I keep the volume of my hearing aids turned up so I can hear better D. I take the batteries out of my hearing aids when I take them out at night
D
A nurse offers pain medication to a client who is 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
A nurse uses a heat-to-toe assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes does the nurse demonstrate? A. Confidence B. Perseverance C. Integrity D. Discipline
D
As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client who has dementia. Which of the following components of the nutrition evaluation is the priority for the nurse to determine from the client's family? A. BMI B. Usual times for meals and snacks C. Favorite foods D. Any difficulty swallowing
D
During new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of the preventive strategies? A. "I will leave the IV catheter in place after the client completes the course of IV antibiotics." B. "As long as I am working with the same client, I can use the same IV catheter for my second insertion attempt." C. "If my client needs to use the rest room, it would be safer to disconnect his IV infusion as long as I clean the injection port thoroughly with an antiseptic swab." D. "I will replace any IV catheter when I suspect contamination during insertion."
D
A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the patient? 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 (Blue color = positive result for blood. Proteins can alter the test results. Patient should obtain three different specimens from three different bowel movements)
A nurse is teaching a client about taking multiple oral medications at home to include time-release capsules, liquid medications, enteric-coated pills, and opioids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. I can open the capsule with the beads in it and sprinkle them on my oatmeal B. If I am having difficulty swallowing, I will add the liquid medication to a batch of pudding C. I can crush the pills with the coating on them D. I will eat two crackers with the pain pills
D (note that liquid medications should not be added to large quantities of food in case the client cannot finish the entire serving -- "batch")
A nurse is performing skin assessments on a group of clients. Which of the following lesions should the nurse identify as vesicles? (Select all that apply) A. Acne B. Warts C. Psoriasis D. Herpes simplex E. Varicella
D E
A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients should the nurse assign to the room closest to the nurses station? A. A middle adult who is post op following a laparoscopic cholecystectomy B. A middle adult who requires telemetry for a possible myocardial infarction C. A young adult who is post op following an open reduction internal fixation of the ankle D. An older adult who is post op following a below-the-knee amputation
D (age+immobility+balance+analgesics)
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 (carbs are the body's greatest energy source; providing energy for the cells is their primary function, they are also a ready source of energy and they spare proteins from depletion) (Note that although the body gets over half of its energy from fat, it is an inefficient means of obtaining energy since it requires energy from a different source to burn the fat)
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 his breath briefly and bear down B. Discontinue the fluid instillation C. Remind the client that cramping is common at this time D. Lower the enema fluid container
D (slows the rate of instillation)
A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by a participant indicates understanding of the instructions? A. I will set my water heater at 130 F B. Once my baby can sit up, he should be safe in the bathtub C. I will place my baby on his stomach to sleep D. Once my infant starts to push up, I will remove the mobile from over the crib
D (so that the infant wont touch them)
An RN is making assignments for a practical nurse (PN) at the beginning of the shift. Which of the following assignments should the PN question? A. Assisting a client who is 24‑hr postoperative to use an incentive spirometer B. Collecting a clean‑catch urine specimen from a client who has a wound infection C. Providing nasopharyngeal suctioning for a client who has pneumonia D. Teaching a client who has asthma to use a metered‑dose inhaler
D (the RN is responsible for primary teaching, PNs may only reinforce teaching)
A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? A. a client who has a broken femur and reports hip pain B. A client who has incisional pain 72 hr following pacemaker insertion C. a client who has food poisoning and reports abdominal cramping D. a client who has episodic back pain following a fall 2 years ago
D (this pain lasts more than 6 months, continues beyond the time of tissue healing)
A home health nurse is discussing the dangers of carbon monoxide poisoning with a client. Which of the following information should the nurse include in her counseling? A. Carbon monoxide has a distinct odor B. Water heaters should be inspected every 5 years C. The lungs are damaged from carbon monoxide inhalation D. Carbon monoxide binds with hemoglobin in the body
D (ultimately reduces the oxygen supplied to the tissues in the body)
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. Nonmaleficence
D`
