Foundations Final Study Guide

6. A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. Room 208 is a private, negative-pressure airflow room; room 212 is a semi-private, positive-pressure airflow room; 214 is a negative-pressure, semi-private room; and room 216 is a private, positive-pressure airflow room. To which of the following rooms should the nurse assign the client? 208 212 214 216

208

A nurse is preparing to instill 840 mL of enteral nutrition via a client's gastrostomy tube over 24 hr using an infusion pump. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

35mL/hr

A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect? 6.0 4.0 7.0 8.0

4.0

A nurse is preparing to administer total parental nutrition (TPN) 1800 mL to infuse over 24 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

75mL/hr

A charge nurse is providing an in-service to a group of staff nurses about unexpected events. Which of the following should the nurse include in the teaching as an example of a sentinel event? A client had bowel surgery and died from sepsis. A client was almost given another client's medication. A client fell out of bed and fractured their hip. A client was prescribed a medication they were allergic to, but the prescription was canceled before the medication was given.

A client had bowel surgery and died from sepsis.

A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions? Top of Form A client who has scabies A client who has pertussis A client who has streptococcal pharyngitis A client who has measles

A client who has measles

A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at highest risk for developing a pressure injury? A client who is unresponsive to verbal commands and changes position occasionally. A client who alert and responsive and eats 25% of each meal. A client who makes frequent slight changes in position and walks occasionally. A client who is receiving enteral feeding and can change position independently.

A client who is unresponsive to verbal commands and changes position occasionally.

A nurse is prioritizing client care after receiving change-of-shift report. Which of the following clients should the nurse plan to see first? A client who is scheduled for an abdominal x-ray and is awaiting transport A client who has a prescription for discharge A client who received oral pain medication 30 min ago A client who told an assistive personnel he is short of breath

A client who told an assistive personnel he is short of breath

A nurse is performing an integumentary assessment for a client. Which of the following findings should the nurse identify as possible squamous cell carcinoma? Top of Form Painless, raised purple nodules on the hard palate A firm nodule with a hard crust A small macule with a yellow-brown scale Yellow-white patches of growth on the tongue

A firm nodule with a hard crust

A nurse is developing a care plan based on the data collected from the patient and the patient's medical record. Which definition of a goal indicates that the nurse has a good understanding of its purpouse? A goal is a broad statement that describes a desire change in a patient's behavior. A goal is a statement that describes the patient's accomplishment without a time restriction. A goal is measurable change in a patient's physical state. A goal is a realistic statement that predicts any negative response to treatments

A goal is a broad statement that describes a desire change in a patient's behavior

A nurse is teaching a newly licensed nurse about a nonrebreather oxygen mask. Which of the following instructions should the nurse include? The reservoir bag on a nonrebreather mask should collapse with exhalation. Use a nonrebreather mask to deliver low-flow oxygen. A nonrebreather mask dries a client's mucous membranes. A nonrebreather mask should fit snugly over a client's face.

A nonrebreather mask should fit snugly over a client's face.

A nurse is teaching about intentional torts with a group of newly licensed nurses. The nurse should include which of the following examples? A nurse witnessed the consent for surgery for a client who received the procedure on the wrong location. A nurse informs their sibling who works on another unit that the nurse's client has HIV. A nurse forgets to lock the wheels on a client's bed and the client falls. A nurse administers a client's scheduled antibiotic 2 hours late because of an oversight.

A nurse informs their sibling who works on another unit that the nurse's client has HIV.

A nurse is providing care to a client that has been having pain without a clear etiology. Which nursing diagnose should the nurse write as most appropriate for this client? Acute pain related to psychosomatic condition. Acute pain related to unknown etiology. Acute pain related to unknown factors. Acute pain manifested by client's repor

Acute pain related to unknown etiology.

The nurse is caring for a dying patient. Which intervention is NOT considered futile? Planning for surgery for a small cyst on the scapular area Administer Oxygen to a client with shortness of breath Administering the influenza vaccine Administering a chemotherapy pill to a client with metastatic liver cancer

Administer Oxygen to a client with shortness of breath

A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention? Prepare for mechanical ventilation. Administer oxygen via face mask. Prepare to administer a sedative. Assess for indications of pulmonary embolism.

Administer oxygen via face mask.

A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take? Raise the foot of the bed to a 90° angle. Remove the dressing to inspect the wound. Prepare to insert a central line. Administer oxygen via nasal cannula.

Administer oxygen via nasal cannula.

A provider prescribes a sublingual medication for a client who has an NG tube in place. Which of the following actions should the nurse take? Request a prescription for an oral formulation of the medication. Administer the crushed medication through the NG tube. Dissolve the medication in water and give it through the NG tube. Administer the medication under the client's tongue.

Administer the medication under the client's tongue.

A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client? Top of Form Contact Droplet Protective Airborne

Airborne

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? Creatine kinase Troponin Total bilirubin Albumin

Albumin

A nurse is caring for a client who has cancer and is receiving total parenteral nutrition (TPN). Which of the following lab values indicates the treatment is effective? Hct 43% WBC 8,000/uL Albumin 4.2 g/dL Calcium 9.4 mg/dL

Albumin 4.2 g/dL

A nurse is preparing to obtain an electronic blood pressure measurement on a client. Which of the following actions should the nurse plan to take? Place the blood pressure cuff 5 cm (2 in) above the client's antecubital space. Select a cuff that covers 50% of the client's upper arm. Elevate the client's arm above the level of the heart. Align the artery indicator on the blood pressure cuff with the client's brachial artery.

Align the artery indicator on the blood pressure cuff with the client's brachial artery.

A nurse is teaching a newly licensed nurse about incident reports. The nurse should include that which of the following events requires an incident report? A client vomits their morning medications. A lipid-lowering medication is administered to a client 1 hr after the scheduled time. A client has an allergic reaction to an antibiotic. An IV medication is administered via an oral route.

An IV medication is administered via an oral route.

A nurse on the medical-surgical unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall? Top of Form An older adult client who is confused and has urinary frequency A client with diabetes mellitus who has a leg ulcer A client who is 1 day postoperative and has a nursing assistant helping him out of bed An adolescent client who has a leg fracture and has been using crutches for the past 2 days

An older adult client who is confused and has urinary frequency

A nurse is teaching a class about the steps of critical thinking. The nurse should include that interpreting data is included in which of the following steps? Analysis Creativity Questioning Intuition

Analysis

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take? Adjust the water temperature to feel hot. Apply 4 to 5 mL of liquid soap to the hands. Hold the hands higher than the elbows. Rub hands and arms to dry.

Apply 4 to 5 mL of liquid soap to the hands.

A nurse is caring for a client who is receiving a continuous IV through a peripheral intravenous device. The nurse notes the catheter site is warm and painful to touch. Which of the following actions should the nurse take? Place a pressure dressing over the IV site. Slow the IV infusion Place the affected extremity below the level of the client's heart. Apply a warm compress to the IV site.

Apply a warm compress to the IV site.

A nurse in an emergency department is caring for a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following interventions should the nurse perform first? Apply a tourniquet just above the wound. Apply pressure directly to the wound. Start two large-bore IV catheters. Place the client in a modified Trendelenburg position.

Apply pressure directly to the wound.

1. A nurse is preparing to administer an ophthalmic medication to a client. Which of the following actions should the nurse plan take? Apply pressure to the client's nasolacrimal duct after instillation. Clean the client's eye from the outer canthus to the inner canthus before instillation. Ask the client to tightly squeeze their eyes shut after the instillation. Instill the ophthalmic medication directly on the client's cornea.

Apply pressure to the client's nasolacrimal duct after instillation.

A nurse is designing a poster presentation for staff nurses about therapeutic communication. Which of the following techniques should the nurse include? Offering approval or disapproval Offering sympathy Asking open-ended questions Asking for explanations

Asking open-ended questions

A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective? Top of Form Inspecting the site for reduced swelling Monitoring the client's pulse rate Asking the client to rate the pain Having the client perform range-of-motion of the affected arm

Asking the client to rate the pain

A nurse is planning care for a client who is receiving enteral feedings through an NG tube. Which of the following actions should the nurse plan to take first? Aspirate the client's stomach contents. Hang the feeding bag 30 cm (12 in) above the client. Label the feeding bag with the date and time of the start of the feeding. Warm the feeding to room temperature.

Aspirate the client's stomach contents.

The nurse is assessing a postsurgical patient who is in acute pain. The patient is not willing to change position for x-rays. The nurse tells the patient that a sedative injection will be administered if the patient does not cooperate for the procedure. Which tort is indicated? Battery Assault False Imprisonment Invasion of Privacy

Assault

A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first? Top of Form Call the client's provider. Assess the client. Notify the nurse manager. Complete an incident report.

Assess the client.

1A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process? Top of Form Planning Evaluation Assessment Implementation

Assessment

A nurse is caring for a client who has an irregular heart rate. Which of the following actions should the nurse take? Auscultate the client's apical pulse. Ask the client to perform the Valsalva maneuver. Palpate the client's pulse at the third intercostal space. Check the clients heart rate for 30 sec.

Auscultate the client's apical pulse.

A nurse is caring for a client who is requesting not to be mechanically ventilated. The nurse notifies the client's provider about the client's concerns and respects the client's request. Which of the following professional values is the nurse utilizing? Social justice Integrity Autonomy Altruism

Autonomy

A nurse is caring for a client who is scheduled for an elective surgery. The client informs the nurse that they no longer wish to proceed with surgery. Which of the following ethical principles should the nurse uphold for the client? Justice Fidelity Veracity Autonomy

Autonomy

A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect? Peripheral edema Spoon nails Barrel chest Pleural friction rub

Barrel chest

A clinical nurse educator is preparing an educational program about transmission of methicillin-resistant Staphylococcus aureus (MRSA) in hospitalized clients. Which of the following information should the nurse include in the program? Place clients who have MRSA on airborne precautions. MRSA can be effectively treated with an antiviral medication. MRSA can live on the hands for 1 hr. Bathe clients with water and chlorhexidine gluconate.

Bathe clients with water and chlorhexidine gluconate.

A nurse is assessing a client who has arteriosclerosis and increased peripheral vascular resistance. Which of the following findings should the nurse expect? Blood pressure 160/88 mm Hg Reduced cardiac output Respiratory rate 10/min Pulse deficit of 14/min

Blood pressure 160/88 mm Hg

A nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. Which of the following actions should the nurse take? Obtain the client's blood glucose every 12 hr. Change the IV tubing every 24 hr. Change the IV site dressing every 4 days. Weigh the client every other day.

Change the IV tubing every 24 hr.

A nurse is assessing a client for orthostatic hypotension. Which of the following actions should the nurse take first? Determine the client's blood pressure 1 min after each position change. Place the client in a sitting position Assist the client into a standing position. Check the blood pressure with the client in a supine position.

Check the blood pressure with the client in a supine position.

A nurse is administering a powdered medication to a client. Which of the following actions should the nurse take first? Mix the medication at the client's bedside. Document that the medication was administered. Determine the client's response to the medication. Check the client for allergies.

Check the client for allergies.

A nurse administers the wrong medication to a client. Which of the following actions should the nurse take first? Fill out an incident report. Notify the provider. Check the client's vital signs. Document the client's condition in the electronic medical record.

Check the client's vital signs.

A nurse is caring for a client who came to the emergency department with abdominal distention and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority? Request a prescription for a medication to ease the client's anxiety. Irrigate the NG tube with 100 mL of sterile water. Check to see if the suction equipment is working. Remove and reinsert the NG tube.

Check to see if the suction equipment is working.

A patient who had abdominal surgery yesterday is receiving morphine through patient-controlled analgesia (PCA). What action by the nurse is a priority?

Checking the respiratory rate

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations? Kussmaul respirations Apneustic respirations Cheyne-Stokes respirations Stridor

Cheyne-Stokes respirations

A nurse is obtaining an oxygen saturation on a client. Which of the following actions should the nurse take? Relocate the sensor every 8 hrs. Wait 10 sec after placing the probe before obtaining the oxygen saturation reading. Place the sensor probe on the same extremity as an electronic blood pressure cuff. Choose a finger with a capillary refill less than 2 sec.

Choose a finger with a capillary refill less than 2 sec.

A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take? Top of Form Keep the formula cold until instillation. Withhold the feeding if the residual volume is 150 mL. Cleanse the top of the can of formula with an alcohol wipe. Flush the tube with 30 mL of sterile water before the feeding

Cleanse the top of the can of formula with an alcohol wipe.

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture? Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. Irrigate the wound with an antiseptic prior to obtaining the specimen. Include intact skin at the wound edges in the culture. Swab an area of skin away from the wound to identify the usual flora.

Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.

A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective? Increased respiratory rate Stable oxygen saturation Clear breath sounds Brisk capillary refill

Clear breath sounds

A nurse is providing a handoff report using the introduction, situation, background, assessment, recommendation, and readback (I-SBSR-R) for a client postoperative a total hip placement. Which of the following information should be included in the background component? Client requests a change in prescribed diet Client reports pain a 6 on 0 to 10 pain scale Request prescription for oxygen administration Client broke hip 24 hr ago due to fall

Client broke hip 24 hr ago due to fall

A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse rely on for accurate information about the client and be considered as a primary source? Top of Form Client concerns Family information Medical history Progress note

Client concerns

A nurse is caring for a client. Medication Administration Record Budesonide 6 mg PO daily Laboratory Results Hct 47% (37% to 52%) Hgb 16 g/dL (12 to 18 g/dL) Potassium 3.6 mEq/L (3.5 to 5.0 mEq/L) History and Physical Client has a BMI of 16 History of type 2 diabetes mellitus Client is a nonsmoker Admitted with new diagnosis of Crohn's disease Click to highlight the findings that increase the client's susceptibility to infection. To deselect a finding, click on the finding again. Client has a BMI of 16 History of type 2 diabetes mellitus Client is a nonsmoker Hct 47% (37% to 52%) Budesonide 6 mg PO qd

Client has a BMI of 16 History of type 2 diabetes mellitus

The nurse writes an expected outcome statement in measurable terms. An example is: Client will have less pain by discharge date Client will be pain free Client will report pain acuity less than 4 on a scale of 0-10 by 6/20/2023 Client will take pain medication every 4 hours around the clock

Client will report pain acuity less than 4 on a scale of 0-10 by 6/20/2023

A nursing is preparing to give a handoff report to the oncoming nurse. In which of the following areas should the nurse provide report to the oncoming nurse? Client's bedside Nurse's lounge Outside client's room Conference area

Client's bedside

A nurse in the emergency department (ED)[MH1] [TB2] is preparing to teach a newly licensed nurse about the Emergency Medical Treatment and Labor Act (EMTALA). Which of the following information should the nurse include? If client is uninsured the ED can decline to render services The ED has the right to refuse to provide client services. The ED can transfer medically unstable clients to other facilities. Clients must receive a medical screening evaluation (MSE).

Clients must receive a medical screening evaluation (MSE)

Which of the following is a component of clinical decision-making that the nurse should use to make an evidence-based decision? Clinical reasoning Concept mapping Critical thinking Clinical judgement

Clinical judgement

A nurse sees smoke coming from the central supply room. Which of the following actions should the nurse take first? Stay close to the ground. Wrap clients in blankets. Close all the doors. Walk to a safe area.

Close all the doors.

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as result of the long-term inadequate oxygenation? Restlessness Retractions Dependent edema Clubbing of the fingers

Clubbing of the fingers

A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process? Top of Form Critically analyze client data to determine priorities. Collect and organize client data. Set client-centered, measurable and realistic goals. Determine effectiveness of interventions.

Collect and organize client data.

A nurse is caring for a client. Nurses' Notes Client has an NG tube in the right nare, placed to intermittent low wall suction, draining moderate green-brown drainage. Vital Signs Day 1: Temperature 37.2° C (99° F) Blood pressure 104/56 mm Hg Heart rate 98/min Respiratory rate 20/min Oxygen saturation 96% on room air Day 2: Temperature 37.2° C (99° F) Blood pressure 108/66 mm Hg Heart rate 100/min Respiratory rate 14/min Oxygen saturation 95% on room air Diagnostic Results Day 1: ABGs pH 7.35 (7.35 to 7.45) PCO2 36 mm Hg (35 to 45 mm Hg) HCO3- 22 mEq/L (21 to 28 mEq/L) PO2 92 mm Hg (80 to 100 mm Hg) Casual glucose 120 mg/dL (less than 200 mg/dL) Total calcium 10.0 mg/dL (9.0 to 10.5 mg/dL) Potassium 3.6 mEq/L (3.5 to 5.0 mEq/L) Day 2: ABGs pH 7.50 (7.35 to 7.45) PCO2 42 mm Hg (35 to 45 mm Hg) HCO3- 30 mEq/L (21 to 28 mEq/L) PO2 88 mm Hg (80 to 100 mm Hg) Casual glucose 110 mg/dL (less than 200 mg/dL) Total calcium 9.3 mg/dL (9.0 to 10.5 mg/dL) Potassium 3.5 mEq/L (3.5 to 5.0 mEq/L) Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing:------ due to: --------- Condition respiratory acidosis hypoxia hyperkale

Condition: metabolic alkalosis Finding: nasogastric suctioning

A patient is receiving an opioid narcotic. What common side effect should the nurse be aware of when assessing this patient?

Constipation

A nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci (VRE). Which of the following types of precautions should the nurse plan to initiate? Droplet Contact Airborne Protective

Contact

A nurse is preparing to admit a client who has a new diagnosis of methicillin-resistant Staphylococcus aureus (MRSA). The nurse should plan to place the client in which of the following types of transmission-based precautions? Airborne Contact Droplet Protective

Contact

A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take? Check the tubing connections for leaks. Check the suction control outlet on the wall. Clamp the chest tube. Continue to monitor the client's respiratory status.

Continue to monitor the client's respiratory status

A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations? Constant bubbling in the suction-control chamber Continuous bubbling in the water-seal chamber Bloody drainage in the collection chamber Fluid-level fluctuations in the water-seal chamber

Continuous bubbling in the water-seal chamber

A nurse is caring for a client who is 2 days postoperative following abdominal surgery and observes that the client's wound has eviscerated. After calling for help, Which of the following actions should the nurse take first? Raise the head of the client's bed 15° to 20°. Place the client supine with knees bent. Assess the client for manifestations of shock. Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.

Cover the area with a sterile dressing, moistened with 0.9% sodium chloride irrigation.

A nurse is providing preoperative teaching for a client. Which of the following outcomes should the nurse include? Decrease in postoperative respiratory function Increase in anxiety Increase in length of stay in the health care facility Decrease in postoperative pain

Decrease in postoperative pain

A nurse is assessing a client who has impaired mobility. The nurse should monitor the client for a pressure injury due to which of the following factors? Increased muscle mass Decreased serum calcium Increased collagen Decreased circulation

Decreased circulation

A nurse is caring for a client who has constipation and is bearing down to have a bowel movement. The nurse should monitor the client for which of the following? Increased respirations Decreased exhaled carbon dioxide Increased temperature Decreased heart rate

Decreased heart rate

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The pharmacy is delayed in supplying the client's next container of TPN. Which of the following fluids should the nurse infuse until the next container arrives? Dextrose 5% in water 0.9% sodium chloride Dextrose 10% in water Lactated Ringer's solution

Dextrose 10% in water

A nurse prepares to replace the nearly empty container of total parenteral nutrition (TPN) for a client when she finds that there has been a delay in receiving the new container of solution from the pharmacy. Which of the following solutions should the nurse infuse until the next container of TPN solution becomes available? Lactated Ringer's 3% sodium chloride Dextrose 10% in water 0.9% sodium chloride

Dextrose 10% in water

A nurse is caring for a client who is receiving enteral tube feeding and has a new prescription to dilute the formula. The nurse recognizes this is being done to resolve which of the following conditions? Electrolyte imbalance Diarrhea Constipation Delayed gastric emptying

Diarrhea

A nurse is preparing to initiate a continuous enteral feeding through an open system to a client. Which of the following actions should the nurse take? Reconstitute the formula with tap water. Discard unused formula after 8 hr. Administer 200 mL of formula during the initial infusion. Give the initial feeding over 15 min.

Discard unused formula after 8 hr.

A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material? Discard the dressing in the bedside trash receptacle. Dispose of the dressing in a biohazardous waste container. Enclose the dressing in a single clear plastic bag and discard in the bedside trash receptacle. Double-bag the dressing in clear bags and label it "biohazard".

Dispose of the dressing in a biohazardous waste container.

A nurse is completing the initial admission assessment and history for a client. Which of the following is the priority action for the nurse to take? Top of Form Teach the client about his diagnosis. Provide a schedule of visiting hours to the client's family. Document the client's allergies in the electronic medical record. Develop a plan of care for the client.

Document the client's allergies in the electronic medical record.

A nurse is admitting a client who has pertussis. Which of the following types of transmission-based precautions should the nurse initiate? Airborne Contact Droplet Protective

Droplet

A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations? Top of Form Finger Earlobe Toe Skin fold

Earlobe

A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse? Top of Form Symmetrical convex sphere shape Concave umbilicus Bilateral bowel sounds in lower quadrants Ecchymosis

Ecchymosis

A nurse is preparing an in-service about communication for a group of staff nurses. Which of the following information should the nurse include when discussing the electronic mode of communication? Social media is not a form of electronic communication. Electronic communication does not have a risk of privacy violations. Providers can send prescriptions to a pharmacy on an unencrypted device. Electronic communication includes video conference calls with clients.

Electronic communication includes video conference calls with clients

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse? Observe client's respiratory status. Elevate the head of the client's bed 30° to 45°. Monitor intake and output every 8 hr. Check residual volume every 4 to 6 hr.

Elevate the head of the client's bed 30° to 45°.

A nurse is teaching a newly licensed nurse about assessing a client who received naloxone to treat opioid toxicity. The nurse should include that which of the following findings indicate the intervention is effective? Substernal retractions during respirations Kussmaul respirations Elevated respirations Cheyne-stokes respirations

Elevated respirations

A nurse is caring for a client who has an oxygen saturation of 88%. Which of the following actions should the nurse take? Decrease the head of the client's bed. Ask the client to cough every 4 hr. Encourage the client to take deep breaths. Request a prescription for an opioid analgesic.

Encourage the client to take deep breaths.

A nurse is caring for a client who reports chronic pain. Which of the following actions by the nurse uses holistic nursing? Obtain blood work from the client. Encourage the client to take slow, deep breaths. Check the client's oxygen saturation level. Request a prescription for an analgesic for the client.

Encourage the client to take slow, deep breaths.

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include? Encourage brief exercise before meals to promote appetite. Place food in the affected side of the mouth. Encourage the client to take small bites. Place the client with the head reclined back to facilitate swallowing.

Encourage the client to take small bites.

A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? Perform range-of-motion exercises Place suction equipment at the bedside Encourage the use of an incentive spirometer Administer an expectorant

Encourage the use of an incentive spirometer

A nurse is teaching a newly licensed nurse about reducing the risk of needlestick injuries. Which of the following instructions should the nurse include? Use sharps containers until they are completely full. Bend needles without safety devices before disposing of them. Dispose of large-bore needles into waterproof wastebaskets. Engage the safety device immediately after using a needle.

Engage the safety device immediately after using a needle.

A nurse is planning to administer a unit of PRBCs for a client. Which of the following actions should the nurse plan to take? Flush the transfusion tubing with 5% dextrose in water. Administer the blood transfusion over 1 hr. Ensure 2 nurses check the label on the unit of blood. Stay with the client for the first 10 min after starting the transfusion.

Ensure 2 nurses check the label on the unit of blood.

A nurse is teaching a newly licensed nurse about the loss of body heat. The nurse should include that heat loss that occurs when sweat dries on the skin is caused by which of the following mechanisms? Conduction Convection Radiation Evaporation

Evaporation

A patient has a new order to have an NG tube removed. The nurse should initially

Explain the process to the patient

A nurse is planning to provide discharge teaching for a client who has hearing loss. Which of the following actions should the nurse plan to take? Increase the rate of speech when talking with the client. Answer client's question using medical terminology. Face the client while talking. Dim the lights in the client's room.

Face the client while talking.

11. A nurse does not take a client's apical heart rate, but documents that it was taken in the client's electronic health record (EHR). Which of the following terms describes the nurse's actions? Battery Libel Slander Falsification

Falsification

A nurse assessing a client who has iron deficiency. Which of the following findings should the nurse expect? Fatigue Goiter Tooth decay Tetany

Fatigue

A nurse is caring for a client who is desiring their wound care to be provided at 1400. The nurse returns at 1400 to perform wound care for the client. Which of the following ethical principles is the nurse demonstrating? Autonomy Fidelity Justice Veracity

Fidelity

A nurse is planning care for a client who has a superficial wound with no exudate. The nurse should plan to use which of the following dressings to cover the wound? Hydrofiber dressing Alginate dressing Film dressing Foam dressing

Film dressing

The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly? Fluctuation of the fluid level within the water seal chamber Absence of fluid in the drainage tubing Continuous bubbling within the water seal chamber Equal amounts of fluid drainage in each collection chamber

Fluctuation of the fluid level within the water seal chamber

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take? Mix the three medications together prior to administering. Dilute each medication with 10 mL of tap water. Maintain the head of the bed in a flat position for 30 min following medication administration. Flush the NG feeding tube with 30 mL of water immediately following medication administration

Flush the NG feeding tube with 30 mL of water immediately following medication administration

The nurse is preparing to insert a nasogastric tube. To determine the length of the tube needed to be inserted, how should the nurse measure the tube?

From the tip of the nose to the earlobe to the xiphoid process

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect? Top of Form Frothy sputum Dependent edema Nocturnal polyuria Jugular distention

Frothy sputum

A nurse is teaching a class about herbal supplements that can decrease nausea. Which of the following supplements should the nurse include? Ginger Echinacea Garlic Cranberry

Ginger

A nurse is caring for a patient with chronic pain from arthritis. Which action is best for the nurse to take?

Give pain medication around the clock

A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove first? Top of Form Mask Gloves Gown Goggles

Gloves

A nurse is changing the bed linen for a client who is on contact precautions. Which of the following personal protective equipment should the nurse wear? Gloves Goggles N-95 respirator Face shield

Gloves

A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first? Top of Form Gloves Gown Face shield Mask

Gown

The nurse identified that the patient has pain of 7 on a scale of 1 to 10 and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. Which component is the S in a three-part nursing diagnostic statement using the PES format? Acute Pain Chronic Pain Related to incisional trauma Guarding and resisting movement

Guarding and resisting movement

A nurse on the day shift is preparing to change a client's total parenteral nutrition (TPN) solution, but the new TPN solution has not arrived from the pharmacy. The client receives additional IV fat emulsion during the night shift. Which of the following actions should the nurse take? Hang dextrose 10% in water (D10W) until the TPN solution is delivered. Saline lock the IV catheter after discontinuing the TPN solution. Hang the IV fat emulsion solution. Call the provider for new TPN orders.

Hang dextrose 10% in water (D10W) until the TPN solution is delivered.

A nurse is caring for a client who has respiratory alkalosis and is hyperventilating. Which of the following actions should the nurse take? Plan to administer sodium bicarbonate to the client. Have the client place their head between their knees. Have the client breath into a paper bag. Plan to administer insulin to the client.

Have the client breath into a paper bag.

A nurse is caring for a client who has active pulmonary tuberculosis (TB). The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray? Top of Form Ask the x-ray technician to come to the client's room to obtain a portable x-ray. Have the client wear a mask. Notify the x-ray department that the client requires airborne precautions. Wear a filtration mask and gloves during transport.

Have the client wear a mask.

The wound care nurse is monitoring a patient with a stage III pressure ulcer whose wound presents with healthy tissue. How should the nurse document this ulcer in the patient's medical record?

Healing stage III pressure ulcer

A nurse notes that a coworker left her computer open with her notes visible to everyone every time she go to lunch . The nurse talks with the nursing manager because this action is a violation of which act? Health Insurance Portability and Accountability Act (HIPAA) Patient Self-Determination Act (PSDA) Emergency Medical Treatment and Active Labor Act Mental Health Parity Act

Health Insurance Portability and Accountability Act (HIPAA)

6. A nurse in a provider's office is assessing a client who reports dyspnea and fatigue. Physical assessment reveals tachycardia and weak peripheral pulses. The nurse should recognize these findings as manifestations of which of the following conditions? Top of Form Asthma Aortic valve regurgitation Heart failure Aortic stenosis

Heart failure

A nurse is assessing a client who has an oral temperature of 39? C (102.2? F). Which of the following findings should the nurse expect? Dilated pupils Heart rate 108/min Decreased peripheral pulses Respiratory rate 10/min

Heart rate 108/min

A nurse is teaching a class about oxygen transport in the cardiopulmonary system. Which of the following transports oxygen in the blood? Neutrophils Platelets Lymphocytes Hemoglobin

Hemoglobin

A nurse is observing a newly licensed nurse prepare a sterile field. For which of the following actions should the nurse intervene? Positions the wrapped package on the bedside table so the outer flap is away from her. Holds a bottle of solution with the label away from the palm of the hand. Holds gauze packages 15 cm (6 in) above the sterile field. Wears sterile gloves when moving sterile items on the sterile field.

Holds a bottle of solution with the label away from the palm of the hand.

A nurse is observing a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? Turns off the faucet with their hands Uses hot water to wash their hands Holds their hands below the elbows while rinsing off soap Washes their hands for 10 seconds

Holds their hands below the elbows while rinsing off soap

Which medication should the nurse administer for a patient with cancer who describes the pain as "deep, aching and at a level 8 on a 0 to 10 scale"

Hydromorphone (Dilaudid) IV

A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse recognize as a complication of this therapy? Hyperglycemia Aspiration Diarrhea Stomatitis

Hyperglycemia

A nurse is assessing a client who is experiencing anxiety. Which of the following findings should the nurse expect? Drowsiness Hyperventilation Bradycardia Peripheral vasodilation

Hyperventilation

A nurse is caring for a client who requests nonpharmacological assistance with smoking cessation. Which of the following therapies should the nurse recommend? Massage therapy Chiropractic medicine Pilates Hypnotherapy

Hypnotherapy

Which of the following nursing diagnoses is stated correctly? Impaired Bed Mobility related to postcardiac catheterization Constipation related to hard stools Fluid Volume Excess related to edema on lower extremities Impaired Physical Mobility related to inability to turn and position in bed

Impaired Physical Mobility related to inability to turn and position in bed

A patient is admitted to the hospital with a pressure ulcer stage 2 that has a foul odor and purulent drainage. What is the most appropriate nursing diagnosis? Risk for Infection Chronic Pain Impaired Skin Integrity Impaired Peripheral Circulation

Impaired Skin Integrity

A nurse assessing a client who has vitamin A deficiency. Which of the following findings should the nurse expect? Bleeding gums Constipation Swollen tongue Impaired vision

Impaired vision

A nurse has completed the planning step of the nursing process for a client who has an acid-base imbalance. Which of the following steps should the nurse take next? Evaluation Analysis Implementation Assessment

Implementation

A nurse has completed the planning step of the nursing process for a client who has an acid-base imbalance. Which of the following steps should the nurse take next? Evaluation Implementation Analysis Assessment

Implementation

A nurse is planning care for a client who has dehydration and hypotension. Which of the following actions should the nurse plan to take? Elevate the head of the client's bed. Instruct the client to perform the Valsalva maneuver. Increase the client's fluid intake. Encourage the client to use guided imagery to relax.

Increase the client's fluid intake.

A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client? Top of Form Respiratory alkalosis Increased anteroposterior diameter of the chest Oxygen saturation level 96% Petechiae on chest

Increased anteroposterior diameter of the chest

A nurse is teaching a class about the stages of infection. The nurse should include that which of the following is the first stage of an infection? Incubation Acute illness Period of convalescence Prodromal

Incubation

A nurse is assessing a client who is receiving continuous IV therapy through a peripheral IV. The catheter site is cool and taut, and there is IV fluid leaking. The nurse should identify that the client has manifestations of which of the following complications? Circulatory overload Infection Phlebitis Infiltration

Infiltration

A nurse is observing a newly licensed nurse set up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? Opens the first flap of the sterile package towards the nurse's body. Inspects the sterile package for holes before opening Places the sterile field against a wall in the client's room Prepares the sterile field 2 hr before it is needed

Inspects the sterile package for holes before opening

A nurse is assessing a client who has a stage 1 pressure injury. Which of the following findings should the nurse expect? Intact skin with localized erythema Full thickness skin loss with visible adipose tissue. Partial-thickness skin loss with red tissue in wound bed Full thickness skin loss with visible bone

Intact skin with localized erythema

A nurse is teaching a class about routes of medication administration. The nurse should include that which of the following routes has the fastest rate of absorption? Intravenous Topical Intramuscular Enteral

Intravenous

A nurse is preparing to irrigate a wound for a client. Which of the following actions should the nurse plan to take? Irrigate the wound until the solution that is draining is clear. Flush the wound from the most contaminated area to the cleanest area. Chill the irrigant prior to the procedure. Hold the tip of the syringe at least 1.3 cm (0.5 in) above the wound while irr

Irrigate the wound until the solution that is draining is clear.

A nurse is caring for a client who has a newly inserted chest drainage system with a water seal. Which of the following actions should the nurse take? Clamp the tube when the client is ambulating. Keep the collection device below the level of the client's chest. Coil the tubes carefully to prevent kinking. Lay the client flat to avoid leaks in the tubing

Keep the collection device below the level of the client's chest.

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take? Clamp the chest tube prior to transferring the client to a wheelchair. Disconnect the chest tube from the drainage system during transport. Keep the drainage system below the level of the client's chest at all times. Empty the collection chamber prior to transport.

Keep the drainage system below the level of the client's chest at all times.

A nurse is reinforcing teaching with a newly licensed nurse about barriers with interprofessional collaboration among members of the health care team. Which of the following information should the nurse include? Trust in care provided among team members Resolved conflict among team members Lack of communication among team members Knowledgeable of scope among team members

Lack of communication among team members

A nurse is teaching a class about aromatherapy. The nurse should include that which of the following essential oils can promote sleep. Ginger Orange Lavender Peppermint

Lavender

A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect? Lethargy Numbness of fingers Abdominal pain Dry skin

Lethargy

A nurse is instructing a newly licensed nurse about the scope and standard of nursing practice. Which of the following describes standards of practice? Lists a set of skills that all nurses should be competent performing. Outlines responsibilities that every nurse is expected to provide regardless of their role. Provides competencies for the nurses to achieve before licensure. Establishes a protocol for care to provide for a specific health problem. Specifies the nurses provide care that reflects current practice competent level of behavior when providing client care.

Lists a set of skills that all nurses should be competent performing. Outlines responsibilities that every nurse is expected to provide regardless of their role.

A nurse is assessing a client who was brought to the emergency department with an ankle injury. Which of the following manifestations should the nurse identify as localized inflammation of the tissues? Full range of motion at the site of injury Sanguineous drainage at the site of injury 3+ palpable pedal pulses below the affected injury site Localized warmth at the site of injury

Localized warmth at the site of injury

A nurse is reviewing the documentation of a client's blood pressure by a newly licensed nurse. The documentation states, "Blood pressure 102/58 mm Hg, client sitting up in a chair." Which of the following information should the nurse clarify? Position of the client Location of blood pressure cuff Unit of measurement Systolic blood pressure

Location of blood pressure cuff

Which option is an example of a nurse managing indirect care activities? Making a consultation with a Social Worker Medication administration Patient education before discharge Performing CPR on a patient with a Code Blue

Making a consultation with a Social Worker

6. A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray? Top of Form Gloves Goggles Gown Mask

Mask

A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove last? Mask Gloves Gown Goggles

Mask

A nurse is admitting an older adult client who has a suspected cognitive disorder. Which of the following inventories should be included as part of the admission assessment? Top of Form Mental status examination (MSE) Brief Patient Health Questionnaire (Brief PHQ) Abnormal Involuntary Movements Scale (AIMS) Scale for Assessment of Negative Symptoms (SANS)

Mental status examination (MSE)

1. A nurse is caring for a client who has nausea and is vomiting. The nurse should identify the client is at risk for which of the following acid-base imbalances? Respiratory acidosis Respiratory alkalosis Metabolic alkalosis Metabolic Acidosis

Metabolic alkalosis

When caring for a patient receiving total parenteral nutrition, the nurse knows that it is essential to

Monitor for blood glucose

A nurse is reviewing a client's medical record. Which of the following findings should the nurse identify as a fall risk? Hyperlipidemia Inguinal hernia Multiple sclerosis Hyperthyroidism

Multiple sclerosis

A nurse is assessing a client who has diarrhea. Which of the following findings is a manifestation of hypokalemia? Cerebral edema Muscle weakness Hypertension Hyperactive bowel sounds

Muscle weakness

A nurse is teaching a class about massage therapy. The nurse should include that which of the following is a possible adverse effect of massage therapy. Headaches Nerve injury Depression Arthritis

Nerve injury

A nurse is caring for a client who has a Clostridium difficile infection. Which of the following cleansing agents should the nurse use for hand hygiene? Top of Form Chlorhexidine Povidone-iodine Nonantimicrobial soap Alcohol-based hand rub

Nonantimicrobial soap

The nurse decides not to administer the medication due to possible harmful effects for the client. The nurse is acting upon which ethical principle? Beneficence Autonomy Justice Nonmaleficence

Nonmaleficence

Your patient is about to undergo an orthopedic procedure. The procedure may cause periods of pain. Although nurses agree to do no harm, this procedure may be the patient's only treatment choice. This example describes the ethical principle of Fidelity Nonmaleficence Justice Autonomy

Nonmaleficence

A nurse enters a client's room and finds the client on the floor. After the nurse has ensured the client's safety, which of the following actions should the nurse take? Request another nurse to complete the occurrence report. Document the completion of an occurrence report in the client's medical record. Contact risk management about the occurrence. Notify the client's provider about the occurrence.

Notify the client's provider about the occurrence.

A nurse is discussing factors that influence communication with a group of newly licensed nurses. Which of the following information should the nurse include? Clients who have developmental deficits are less distracted by environmental noises than client who do not have these deficits. Nurses might focus on a client's physiological needs over psychosocial needs when communicating during care. Nurses caring for clients experiencing a highly emotional situation report that communication is rarely affected. Hearing loss is considered a development factor that has minimal effect on nurse-client communication.

Nurses might focus on a client's physiological needs over psychosocial needs when communicating during care.

A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? Irrigate and perform a dressing change for a client who has a pressure injury wound. Administer oral PRN pain medication to a client who has arthritis. Obtain a daily weight on a client who has heart failure. Teach the use of an incentive spirometer to a postoperative client.

Obtain a daily weight on a client who has heart failure.

A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parental nutrition administration and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first? Weigh the second client. Obtain vital signs for both clients. Administer pain medication to the first client. Change the dressings of both clients.

Obtain vital signs for both clients.

A nurse is caring for a client who reports frequent headaches. Which of the following statements by the nurse uses holistic nursing? "Do any medications relieve your headaches?" "We should check your blood pressure when you have a headache." "Do you feel nausea when you have your headaches?" "Are you feeling stressed before you have a headache?"

"Are you feeling stressed before you have a headache?"

A nurse is providing teaching to a group of assistive personnel (AP) about hand hygiene. Which of the following statements by one of the APs indicates a need for further teaching? "As long as I change gloves between clients, it is not necessary to wash my hands." "I should wash my hands before I provide client care." "I will not wear artificial nails when providing client care." "It is acceptable to use alcohol-based hand products after most client contact."

"As long as I change gloves between clients, it is not necessary to wash my hands." "I should wash my hands before I provide client care."

A nurse is providing teaching for a client who has a new prescription for an antibiotic. Which of the following statements should the nurse make? "Check with your provider before taking over-the-counter medications." "Bloody stools are expected while taking antibiotics." "Discontinue the medication when you feel better." "Antibiotics are administered to treat viral infections."

"Check with your provider before taking over-the-counter medications."

A nurse is teaching a newly licensed nurse about wearing medical masks. Which of the following statements should the nurse include? "Touch the front of your mask while wearing it." "Discard your mask after each use." "Remove your mask prior to removing your gloves." "Position the mask on your face with the flexible metal piece at the bottom

"Discard your mask after each use."

A nurse is preparing to witness informed consent for a client who is preoperative. The client asks the nurse, "Are there other options besides surgery?" Which of the following responses should the nurse make? "It is time to sign the consent so your treatment can begin." "I would not have this type of surgery if I were you." "Have you discussed other treatments with your provider?" "I can inform the surgeon you do not want the surgery."

"Have you discussed other treatments with your provider?"

A nurse is teaching a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client needs further instruction? "A high concentration of carbon monoxide can cause death." "I can detect the presence of carbon monoxide by a metallic odor." "I should purchase a carbon monoxide detector for my home." "Breathing in carbon monoxide can cause headaches and nausea."

"I can detect the presence of carbon monoxide by a metallic odor."

A nurse is teaching a client's adult son about how to position the client when administering enteral feedings at home. Which of the following statements by the son indicates an understanding of the teaching? "I will allow him to be in the position where he is most comfortable during the feeding." "I will elevate the head of the bed 10 degrees during the feeding." "I will turn him on his left side during the feeding." "I will have him sit in his chair during the feeding."

"I will have him sit in his chair during the feeding."

A nurse is teaching an assistive personnel (AP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions? Top of Form "I will wear gloves whenever I am in contact with clients." "I will wear gloves and a gown when bathing a client who has open skin lesions." "I will wear gloves to minimize the number of times I have to wash my hands." "I will wear gloves when measuring a client's blood pressure."

"I will wear gloves and a gown when bathing a client who has open skin lesions."

A nurse manager is reviewing the Good Samaritan laws with a group of newly licensed nurses. Which of the following statements by the nurse manager is appropriate? "Federal laws require a licensed nurse to render aid in an emergency." "A nurse who volunteers at a summer camp for children is covered by Good Samaritan laws." "If you render aid in an accident, do not leave the scene until another competent person can take over." "Good Samaritan laws prohibit the victim from filing a lawsuit against the nurse."

"If you render aid in an accident, do not leave the scene until another competent person can take over."

A nurse is teaching about values to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding? "Value clarification involves maintaining clinical competency." "It is important that the nurse is aware of the client's values." "A nurse's personal values should not influence ethical decisions." "A nurse behaviors and actions are called values."

"It is important that the nurse is aware of the client's values."

A nurse is caring for a client who is 9 days postoperative following a total laryngectomy. The nurse removes the client's NG tube and initiates oral feedings. Which of the following statements should the nurse make? "Tuck your chin when you swallow so you won't choke." "It is no longer possible for you to choke on or aspirate food." "You should have no trouble swallowing fluids." "I will add a thickener to your liquids to prevent aspiration."

"It is no longer possible for you to choke on or aspirate food."

A nurse is reviewing ethical principles with a nursing colleague. Which of the following statements by the nursing colleague indicates an understanding of ethical principles? "Beneficence is our duty to provide care to our clients that causes an intentional outcome." "1400 refers to our client's loyalty to their nurse." "Veracity is the ability of our clients to provide us with truthful information." "Nonmaleficence is our nursing obligation to do no harm to our clients."

"Nonmaleficence is our nursing obligation to do no harm to our clients."

A nurse is preparing an in-service to review the Code of Ethics (COE) with a group of nursing colleagues. Which of the following statements should the nurse make during the in-service about the COE? "Student nurses are not held accountable to COE." "Professional expectations are included in the COE." "The use of social media is not included in the COE." "Criteria for obtaining licensure is included in the COE."

"Professional expectations are included in the COE."

A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include? Top of Form "If you wear gloves, you do not have to wash your hands." "Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds." "Use an alcohol rub when your hands are visibly soiled." "If you don't have an infection, your hands won't infect others."

"Rub all surfaces of your hands with an alcohol rub for 20 to 30 seconds."

A nurse is caring for a client who is unconscious and has a living will. The client's family asks if they can make changes to lifesaving measures now that the client is unconscious. Which of the following statements should the nurse make? "The durable power of attorney for health care can cancel the client's living will." "The case manager can make changes to the client's living will." "The Patient Self-Determination Act (PSDA) will explain your rights to change lifesaving measures." "The living will states the client's wishes regarding lifesaving measures."

"The living will states the client's wishes regarding lifesaving measures."

A nurse is teaching about professional values with a newly licensed nurse. The newly licensed nurse requests that the nurse provide more information about social justice. Which of the following statements should the nurse make? "It is our duty to ensure that all clients are able to receive their medications." "You must report concerns that could potentially be harmful for the client." "You must allow all clients to make their own decisions about their health care." "You must treat all clients fair regardless of any personal bias."

"You must treat all clients fair regardless of any personal bias."

A nurse is teaching a client who has COPD about purse-lipped breathing. Which of the following statements should the nurse make? "You should cough forcefully during exhalation when you are purse-lipped breathing." "You should inhale through your nose and exhale through your mouth during purse-lipped breathing." "Your inspiration should be longer than expiration during purse-lipped breathing." "You should be flat on your back when you perform purse-lipped breathing."

"You should inhale through your nose and exhale through your mouth during purse-lipped breathing."

An older adult client is scheduled to have an elective surgical procedure and informs the nurse that she wants to be designated as a "do not resuscitate" (DNR) case. Which of the following responses should the nurse provide? "You need to let your provider know your wishes after the procedure." "This is a minor procedure; there is no need for this request." "You need to discuss your request with the hospital chaplain." "Your provider needs to talk with you concerning your request."

"Your provider needs to talk with you concerning your request."

The nurse review the plan of care for a client and notes the client's outcome: " Client will have a decrease in pain level (down to a 3) within 45 minutes of receiving oral analgesic". Which client's statement should the nurse use to evaluate this outcome? 'My pain is 4/10" "I still have pain" "I am feeling sleepy after the medications" "I had nausea after the medication was administered"

'My pain is 4/10"

A nurse is providing discharge teaching to a client who will be receiving total parenteral nutrition (TPN) at home. Which of the following instructions should the nurse include? (Select all that apply.) "Keep the TPN refrigerated when not in use." "Infuse 10 percent dextrose and water if the solution runs out." "Shake the TPN bag with fat emulsion if precipitate is present." "Stop using TPN once weight gain is achieved." "Maintain TPN infusion rate when behind schedule."

- "Keep the TPN refrigerated when not in use." - "Infuse 10 percent dextrose and water if the solution runs out." - "Maintain TPN infusion rate when behind schedule."

A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Which of the following precautions should the nurse include when creating a sign to post outside of the client's room? (Select all that apply.) A protective mask A closed door A gown A puncture-proof sharps container Hand hygiene

- A protective mask - A closed door - A puncture-proof sharps container - Hand hygiene

A nurse is administering several medications via a client's gastrostomy tube. At which of the following times should the nurse instill 15 to 30 mL of warm water? (Select all that apply.) After each medication Before aspirating gastric contents When the flow of the medication by gravity slows Prior to administering each medication After giving multiple medications

- After each medication - Prior to administering each medication - After giving multiple medications

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.) Bradycardia An increase in neutrophils An increase in RBCs An increase in platelets Localized edema

- An increase in neutrophils - Localized edema

A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

- Ask the client about having a history of abdominal pain. - Inspect the abdomen for skin integrity. - Auscultate the abdomen for bowel sounds. - Percuss the abdomen in each of the four quadrants. Palpate the abdomen lightly for tenderness

A nurse is preparing to teach a client about a new medication. Which of the following strategies should the nurse plan to use? (Select all that apply.) Ask the client open-ended questions during the session. Use active listening methods during the session. Provide educational material written at a 9th grade reading level. Begin the session with the least important information. Use the teach-back method d

- Ask the client open-ended questions during the session. - Use active listening methods during the session. - Use the teach-back method during the session

A nurse is caring for a client who has a history of angina. Nurses' Notes 1000: Client is awake, alert, and oriented to person, time, and place. Bilateral breath sounds clear and present throughout. Apical pulse regular. 1200: Client reports chest tightness radiating to jaw, not relieved with rest, and periods of nausea, dizziness, and palpitations. Client is diaphoretic and appears anxious. Bilateral breath sounds clear and present throughout. Apical pulse irregular and rapid. Vital Signs 1000: Temperature 37.5° C (99.5° F) BP 150/80 mm Hg Heart rate 90/min Respirations 20/min Pulse oximetry 97% on room air 1200: Temperature 37.5° C (99.5° F BP 180/86 mm Hg Heart rate 112/min Respirations 24/min Pulse oximetry 95% on room air Which of the following findings require follow-up by the nurse? Blood pressure Anxiety Oxygen saturation Breath sounds Breath sounds Irregular heart rate Chest tightness

- Blood pressure - Anxiety - Irregular heart rate - Chest tightness

A nurse is caring for a client who has a history of angina. Nurses' Notes Vital Signs Nurses' Notes 1000: Client is awake, alert, and oriented to person, time, and place. Bilateral breath sounds clear and present throughout. Apical pulse regular. 1200: Client reports chest tightness radiating to jaw, not relieved with rest, and periods of nausea, dizziness, and palpitations. Client is diaphoretic and appears anxious. Bilateral breath sounds clear and present throughout. Apical pulse irregular and rapid. Vital Signs 1000: Temperature 37.5° C (99.5° F) BP 150/80 mm Hg Heart rate 90/min Respirations 20/min Pulse oximetry 97% on room air 1200: Temperature 37.5° C (99.5° F BP 180/86 mm Hg Heart rate 112/min Respirations 24/min Pulse oximetry 95% on room air Which of the following findings require follow-up by the nurse? Select all that apply. Blood pressure Anxiety Oxygen saturation Breath sounds Breath sounds Irregular heart rate Chest tightness

- Blood pressure - Anxiety - Irregular heart rate - Chest tightness

6. A nurse is assisting with the care of a client. Admission Assessment Day 1: Client admitted with a history of dyspnea and inspiratory pain. Breath sounds decreased at right upper lobe. Vital Signs Day 1: Temperature 38.0° C (100.4° F) BP 114/56 mm Hg Heart rate 99/min Respiratory rate 32/min Pulse oximetry 85% on room air (95% to 100%) Laboratory Results Day 1: Chest x-ray shows soft tissue mass at right upper lobe Diagnostic results Day 3: Lung biopsy positive for lung cancer Nurses' Notes Day 3: Central venous access device (CVAD) inserted into right subclavian vein for chemotherapy. Gauze dressing applied over insertion site. The nurse is assisting with catheter care for the client to prevent a central line-associated bloodstream infection (CLABSI bundle). Which of the following actions should the nurse take? Select all that apply. Use clean technique when changing the catheter dressing. Change the catheter dressing every 2 days. Clean the access port on the CVAD line with povidone-iodine prior to use. Perform hand hygiene for 10 sec prior to changing the catheter dressing. Use friction when cleaning the access port.

- Change the catheter dressing every 2 days. - Clean the access port on the CVAD line with povidone-iodine prior to use. - Use friction when cleaning the access port.

A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via a nasal cannula. Which of the following should the nurse include in the teaching? (Select all that apply.) Verify the oxygen flow rate every other day. Check the cannula position on a regular basis. Check the tops of the ears for skin breakdown. Post "no smoking" signs in a prominent location in the home. Apply petroleum ointment to nares if they become dry and irritated.

- Check the cannula position on a regular basis. - Check the tops of the ears for skin breakdown. - Post "no smoking" signs in a prominent location in the home.

A nurse is documenting assessment findings on a client. Which of the following entries should the nurse identify as subjective data? Client reports dull, aching pain in lower right calf. Client's oral temperature is 38.4° C (101.2° F). Client has a vesicular rash on their upper back. Client reports nausea following administration of pain medication. Client reports the rash on their back is itchy.

- Client reports dull, aching pain in lower right calf. - Client reports nausea following administration of pain medication. - Client reports the rash on their back is itchy.

A nurse is documenting assessment findings on a client. Which of the following entries should the nurse identify as subjective data? (Select all that apply.) Client reports dull, aching pain in lower right calf. Client's oral temperature is 38.4° C (101.2° F). Client has a vesicular rash on their upper back. Client reports nausea following administration of pain medication. Client reports the rash on their back is itchy.

- Client reports dull, aching pain in lower right calf. - Client reports nausea following administration of pain medication. - Client reports the rash on their back is itchy.

A nurse is completing the assessment to a new admission. Which findings will the nurse report as objective data? (Select all that apply) (Select All that Apply.) Client's Blood pressure Client's statement of pain Client's surgical wound drainage amount and characteristics. Client's describing fear about surgical procedure. Client's temperature.

- Client's Blood pressure - Client's surgical wound drainage amount and characteristics - Client's temperature.

A nurse is caring for a client who is postoperative. Vital Signs 0800: BP 118/72 mm Hg Heart rate 82/min Respiratory rate 16/min Temperature 36.7° C (98° F) SaO2 98% on room air 1000: BP 128/82 mm Hg Heart rate 94/min Respiratory rate 18/min Temperature 36.7° C (98° F) SaO2 98% on room air Nurses' Notes 0745: Client awake and eating breakfast while watching the news on television. Client has hearing loss, does not wear hearing aid, and TV volume is loud. Rates pain as a 2 on a 0 to 10 pain scale. Incisional dressing dry and intact. 1000: Client ambulated in hallway with physical therapist. Client grimacing, appears upset, and is guarding incisional site. Reports pain a 5 on a 0 to 10 pain scale. Opioid analgesic administered. 1045: Client resting with eyes closed and listening to music with earphones. Reports feeling "very sleepy" after pain medication. Now rates pain as a 3 on a 0 to 10 pain scale. Which of the following factors could present a barrier to the nurse effectively communicating with the client? Select all that apply. Client's hearing deficit Volume of the client's television Numerous visitors in the client's room Increase in pain after ambulation Adverse effects

- Client's hearing deficit - Volume of the client's television - Numerous visitors in the client's room - Increase in pain after ambulation - Adverse effects of opioid analgesic - Using earphones while listening to music

A nurse is caring for a client who is scheduled for surgery. Laboratory Results 1000: Prealbumin level 13 mg/dL (15 to 36 mg/dL) Cholesterol 230 mg/dL (<200 mg/dL) Fasting glucose 110 mg/dL (70 to 110 mg/dL) History and Physical 0800: Client has a history of hyperlipidemia, rheumatoid arthritis, diabetes mellitus Has been taking prednisolone 20 mg/day for the past 2 years. The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply. Hyperlipidemia Diabetes mellitus Medication history Cholesterol level Prealbumin level

- Diabetes mellitus - Medication history - Prealbumin level

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following situations requires that the nurse wear gloves? (Select all that appy) Emptying urine from an indwelling urine collection bag Providing oral care Changing an ostomy pouch Delivering a food tray to a client who has AIDS Placing oral medication tablets into a client's hand

- Emptying urine from an indwelling urine collection bag - Providing oral care - Changing an ostomy pouch

A nurse is reviewing the laboratory results of a client who is postoperative. Which of the following laboratory findings should the nurse identify as an indication of postoperative infection? (Select all that apply.) Increased band neutrophils Elevated erythrocyte sedimentation rate Absence of ketones in urine Negative leukocyte esterase in urine Increased hemoglobin

- Increased band neutrophils - Elevated erythrocyte sedimentation rate

A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

- Inspection - Auscultation - Superficial palpation - Deep palpation

A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective eye equipment? (Select all that apply.) Top of Form Providing hygiene care to a client who is HIV-positive Emptying a urinary drainage bag for a client who has pneumonia Irrigating a client's abdominal wound Transporting a cerebrospinal fluid specimen to the laboratory Suctioning a client's new tracheostomy tube

- Irrigating a client's abdominal wound - Suctioning a client's new tracheostomy tube

A nurse is caring for a client who has heart failure Nurses' Notes Day 1: Bilateral breath sounds clear and present throughout.Weight 80 kg (176 lb)Urine output 480 mL/8 hr Day 4: Breath sounds scattered, crackles heard bilaterally.Apical heart rate rapid and irregular. Audible S3 gallop.Weight 82.1 kg (181 lb)Urine output 320 mL/8 hr Vital Signs Day 1: Temperature 37.6º C (99.7º F)Blood pressure 108/50 mm HgPulse 98/minRespiratory rate 20/minPulse oximetry 95% on room air Day 4: Temperature 36.8º C (98.2º F)Blood pressure 138/80 mm HgPulse 112/minRespiratory rate 28/minPulse oximetry 88% on room air A nurse is reviewing the assessment finding for the client on day 4. Which of the following findings requires further action? (Select all that apply.) Oxygen saturation Breath sounds Weight Urine output Temperature Blood pressure

- Oxygen saturation - Breath sounds - Weight - Blood pressure

The nurse is caring for a patient with a surgical incision that eviscerates. Which action will the nurse take? (Select all that apply)

- Place moist sterile gauze over the site - Contact the surgical team - Monitor for shock

A nurse is providing teaching for a client who has a prescription for home oxygen. Which of the following instructions should the nurse include? Post a "No Smoking" sign inside the home. Attach oxygen containers to a fixed object. Store spare oxygen containers in a closet. Notify the fire department that oxygen is used in the home. Ensure oxygen tubing is no longer than 60 feet in length.

- Post a "No Smoking" sign inside the home. - Attach oxygen containers to a fixed object. - Notify the fire department that oxygen is used in the home.

A nurse is preparing to insert an NG tube for a client who requires gastric suctioning. Place the following steps in the appropriate order. (Move the steps of NG tube placement into the box on the right, placing them in the selected order of performance. Use all the steps.) Prepare equipment at bedside Measure the NG tube Instruct the client to extend the neck backward Instruct the client to flex his head forward Obtain an x-ray Connect the tube to the suction device

- Prepare equipment at bedside - Measure the NG tube - Instruct the client to extend the neck backward - Instruct the client to flex his head forward - Obtain an x-ray - Connect the tube to the suction device

A charge nurse is teaching a newly licensed nurse about fall prevention strategies when caring for clients. Which of the following information should the nurse include in the teaching? Provide under-bed lighting at night. Lock the wheels on the bed. Keep the bed in the high position. Apply socks on clients when ambulating. Place breaks on the clients' wheelchairs.

- Provide under-bed lighting at night. - Lock the wheels on the bed. - Place breaks on the clients' wheelchairs.

A nurse is wearing personal protective equipment and is preparing to leave a client's room after providing care. Which of the following actions should the nurse take? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) Remove the gloves Remove the protective eyewear Remove the gown Remove the mask

- Remove the gloves - Remove the protective eyewear - Remove the gown - Remove the mask

Which action would the nurse take when a nursing goal is not met in the care of a patient? Select all that apply. (Select All that Apply.) Discontinue the care plan Revise the care plan Reassess the patient Notify the HCP immediately Repeat the entire nursing process

- Revise the care plan - Reassess the patient - Repeat the entire nursing process

A nurse is caring for a client. Vital Signs 1000: T 38.2° C (100.8°F), oral. BP 114/56 mm Hg, supine HR 99/min R 32/min Pulse oximetry 85% on room air (95% to 100%) 1100: T 38.6° C (101.5°F), oral. BP 112/54 mm Hg, supine Apical HR 108/min R 22/min Pulse oximetry 95% on 40% O2 via face mask Nurses' Notes 1000: Client is admitted with a productive cough for thick yellow sputum. Breath sounds with crackles heard in left upper lobe and decreased breath sounds at bases bilaterally. Mucous membranes pale. 1015: Head of bed elevated to 90° Client encouraged to cough and deep breath 40% face mask applied as prescribed 1100: Client has a productive cough for thick yellow sputum. Breath sounds with crackles heard in left upper lobe and decreased breath sounds at bases bilaterally. Mucous membranes pink. Click to highlight the findings at 1100, that require follow-up. To deselect a finding, click on the finding again. T 38.6° C (101.5°F), oral. BP 112/54 mm Hg, supine Apical HR 108/min R 22/min Pulse oximetry 90% on 40% O2 via face mask Mucous membranes pink.

- T 38.6° C (101.5°F), oral. - Apical HR 108/min

A nurse is caring for a client who has anemia. Laboratory Results 0900: Hct 26% (37% to 47%) Hgb 8 g/dL (12 to 16 g/dL) WBC count 7,500/mm3 (5,000 to 10,000/mm3) Potassium 4.2 mEq/L (3.5 to 5 mEq/L) Nurses' Notes 1000: One unit of packed RBCs started through an 18-gauge IV in the client's left hand. Unit of blood infusing well. IV site dry and intact, without redness or swelling. 1015: Client is flushed and reports new onset of flank back pain and chills. Client voided 250 mL of reddish-brown urine. Bilateral breath sounds clear and present throughout. IV site dry and intact, without redness or swelling. Vital Signs 1000: Temperature 36.8° C (98.2° F) Blood pressure 106/66 mm Hg Heart rate 108/min Respiratory rate 22/min Oxygen saturation 97% on room air 1015: Temperature 39.6° C (103.3° F) Blood pressure 78/50 mm Hg Heart rate 122/min Respiratory rate 28/min Oxygen saturation 95% on room air Select the 4 findings that require immediate follow-up. IV site Oxygen saturation Temperature Back pain Breath sounds Urine color Blood pressure

- Temperature - Back pain - Urine color - Blood pressure

1. A nurse is writing a teaching plan using the Specific, Measurable, Attainable, Relevant, and Timed outcome (SMART) goals for a client who is learning to walk with crutches. Client Education Client Education Day 1: The client will teach back information about safe crutch walking on day 1. The client will describe: The importance of not placing pressure on their axilla Why they should not use crutches that are not measured for them How to check crutch tips and replace them if they are worn That they should keep crutch tips dry and how to dry them if they become wet How to inspect crutches for damage, such as cracks or bends. The client will demonstrate safe crutch walking. The client will not lean on the crutches to support their body weight. The client will sit in a chair within 2 hrs. The client will stand up from a chair within 2 hrs. The client will ambulate 5 feet in one day. Day 2: The client will walk up 3 stairs by day 2. The client will walk down 3 stairs by day 2. The client will walk 10 feet by day 2. Day 3: The client will walk up 10 stairs by day 3. The client will walk down 10 stairs by day 3. The client will walk 20 feet by day 3. The client will explain 4 principle

- The client will teach back information about safe crutch walking on day 1. - The client will ambulate 5 feet in one day - The client will walk 10 feet by day 2. - The client will walk 20 feet by day 3.

A nurse is assessing a client who is postoperative.. Which of the following findings should the nurse identify as objective data? The client states they are experiencing "extreme pain". The client's current blood pressure is below their preoperative reading. The client's urine output has been 150 mL over the past 3 hr. The client is reporting nausea. The client's right calf is swollen and warm to the touch

- The client's current blood pressure is below their preoperative reading. - The client's urine output has been 150 mL over the past 3 hr. - The client's right calf is swollen and warm to the touch

A nurse is preparing to administer intravenous fluids via an infusion pump to a client. Which of the following actions should the nurse take to prevent an electrical hazard? Unplug the cord by grasping the plug. Ensure the plug has three prongs. Avoid rolling equipment over extension cords. Plug in the pump close to sink. Run additional cord under carpeting.

- Unplug the cord by grasping the plug. - Ensure the plug has three prongs. - Avoid rolling equipment over extension cords

A nurse is caring for a client who is scheduled for a procedure. Which of the following actions should the nurse take during the time-out? Use two acceptable client identifiers. Verify that the surgical site has been marked. Ask the client to state the surgery being performed. Ask the client to read their identification bracelet. Ask the client to point to the surgical site.

- Use two acceptable client identifiers. - Verify that the surgical site has been marked. - Ask the client to state the surgery being performed. - Ask the client to point to the surgical site

A nurse is assessing a client who has an infection. Which of the following findings is a manifestation of sepsis? Vomiting Hypoglycemia Hypertension Altered mental status Elevated WBC's count

- Vomiting - Altered mental status - Elevated WBC's count

6. A nurse is caring for a client. Nurses' Notes 0800: Client is admitted with a 3-day history of abdominal cramps and diarrhea. Client reports 4 to 5 liquid stools/day. Client was taking amoxicillin/clavulanate for a respiratory tract infection, 500 mg PO q 12 hr for 10 days. Antibiotics completed 7 days ago. Abdomen soft, nondistended with hyperactive bowel sounds audible in 4 quadrants. Stool contains mucous and is foul-smelling. Stool sent for culture Laboratory Results 1400: Stool culture positive for Clostridium difficile (negative) A nurse is caring for the client. Which of the following actions should the nurse take? Select all that apply. Wear a protective gown while caring for the client. Place the client in a private room. Wear an N-95 respirator while caring for the client. Place the client in a negative pressure room. Place a mask on the client when they leave their room.

- Wear a protective gown while caring for the client. - Place the client in a private room.

The nurse is admitting a new client to her unit. While completing the health history, what information should the nurse include when asking about the present illness? (Select all that apply) (Select All that Apply.) Where is location of the problem (ex: pain) Vaccination record Allergies What makes the problem worse. When the symptoms started.

- Where is location of the problem (ex: pain) - What makes the problem worse. - When the symptoms started.

A nurse is assisting a provider with a sterile procedure and prepares to pour solution onto a piece of sterile gauze. In what order should the nurse perform the following steps when pouring sterile solution? (Move the steps on the left into the box on the right, placing them in the selected order of performance. Use all the steps.) perform hand hygiene remove the bottle cap place the cap face-up on a clean surface pick up with the label against the palm of the hand pour 1 to 2 mL of solution into a receptacle pour the solution onto the sterile gauze

- perform hand hygiene remove the bottle cap - place the cap face-up on a clean surface - pick up with the label against the palm of the hand - pour 1 to 2 mL of solution into a receptacle - pour the solution onto the sterile gauze

A nurse is preparing to administer an enteral feeding via nasogastric tube. Identify the correct sequence the nurse should follow to initiate the feeding. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.)Bottom of Form - verify tube placement - check the residual feeding contents - administer the feeding - evaluate tolerance of feeding. Bottom of Form

- verify tube placement - check the residual feeding contents - administer the feeding - evaluate tolerance of feeding. Bottom of Form

6. A nurse is caring for a school-age child. Diagnosis: Bilateral pneumonia Past medical history: Cystic fibrosis Plan: Aggressive airway clearance therapy Intravenous antibiotic therapy Nurses' Notes Day 1: Caregiver reports child has had increased coughing, fatigue, and a poor appetite for the past several days. Wheezing and rhonchi auscultated bilaterally. Respirations labored with accessory muscle use. Frequent cough productive with thick, yellow blood-streaked sputum. Dyspnea noted with activity. Child reports "a bit of a stomachache" and rates the discomfort as 3 on a scale of 0 to 10. Abdomen soft and non-tender to palpation. Active bowel sounds auscultated. Day 3: Respirations rapid with accessory muscle use. Dyspnea noted while at rest. Frequent cough. Thick yellow sputum expectorated following airway clearance therapy. Child reports chest discomfort as 4 on a scale of 0 to 10. Child consumes approximately 50% of meals. Denies abdominal pain. Passed three large, frothy, foul-smelling stools. Vital Signs Day 1 (Hospital Admission): Oral temperature 39.1° C (102.4° F) Heart rate 116/min Respiratory rate 32/min Blood pressure 102/60 mm Hg Oxygen saturation 95% on room air Day 3: O

-Blood pressure -Respiratory effort -Oxygenation -Pain

A nurse is caring for a client. Laboratory Results Day 4: Hct 37% (37% to 47%) Hgb 13 g/dL (12 g/dL to 16 g/dL) WBC 13,500/mm3 (5000 to 10,000 mm3) Vital Signs Day 1: Temp 37.2° C (99° F) BP 122/58 mm Hg HR 78/min R 16/min Pulse oximetry 97% on room air (95% to 100%) Day 4: Temp 38.9° C (102° F) BP 108/56 mm Hg HR 106/min R 24/min Pulse oximetry 95% on room air (95% to 100%) Nurses' Notes Day 1: Client has a 2 cm (0.79 in) x 3 cm (1.2 in) stage 2 pressure injury on right heel. No drainage noted, wound bed is red. Hydrocolloid dressing applied over wound. Day 4: Hydrocolloid dressing removed. Client has a 2.5 cm (1 in) x 3 cm (1.2 in) stage 3 pressure injury on right heel. Redness noted at wound borders, skin surrounding wound is warm to touch, purulent drainage noted. Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again. Wound bed is red. Redness noted at wound borders, skin surrounding wound is warm to touch, purulent drainage noted Temp 38.9° C (102° F) Hct 37% (37% to 47%) WBC 13,500/mm3 (5000 to 10,000 mm3)

-Redness noted at wound borders -Skin surrounding wound is warm to touch -Purulent drainage noted - temp 38.9° C (102° F) -WBC 12,000/mm3 (5000 to 10,000 mm3)

The nurse is evaluating the need for the use of restraints when managing a patient with delirium. Which condition must be met before the nurse may use restraints? Select all that apply. (Select All that Apply.) The patient's behavior is improving There is a written Rx from a HCP The patient refused to undergo a necessary procedure The safety of the patient is at risk Less restrictive patient interventions have failed

-There is a written Rx from a HCP -The safety of the patient is at risk -Less restrictive patient interventions have failed

A nurse is preparing a sterile field prior to inserting a urinary catheter for a client. Identify the sequence of steps the nurse should plan to follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) -perform hand hygiene -Place package on work surface -Open outermost flap away from self -Open the side flap, pulling it to the side. -Open innermost flap toward self. -Use inner surface of package as a sterile field

-perform hand hygiene -Place package on work surface -Open outermost flap away from self -Open the side flap, pulling it to the side. -Open innermost flap toward self. -Use inner surface of package as a sterile field

A nurse is preparing to administer levothyroxine 50 mcg PO to a client. How many milligrams (mg) should the nurse plan to administer? 0.5 mg 50 mg 500 mg 0.05 mg

0.05 mg

A nurse is caring for a client who has a potassium deficiency. Which of the following foods should the nurse recommend as the best source of potassium? 1 banana 1 wedge of cantaloupe 1 slice of wheat bread 1 slice of cheddar cheese

1 banana

A nurse is preparing to administer cefotaxime 1,000 mg IM to a client. How many grams (g) should the nurse plan to administer? 0.1 g 1 g 100 g 10 g

1 g

A nurse is providing teaching to a client who has a prescription for amoxicillin 5 mL PO. How many teaspoons (tsp) should the nurse instruct the client to take? 5 tsp 0.5 tsp 1 tsp 2.5 tsp

1 tsp

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse notices that the solution bag is almost empty and there is not another bag of TPN to administer. Which of the following IV solutions should the nurse administer until the next bag of TPN solution is available? Top of Form 10% dextrose in water (D10W) 0.45% sodium chloride (0.45% NaCl) Lactated Ringer's solution 5% dextrose in lactated Ringer's solution (D5LR)

10% dextrose in water (D10W)

A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field? Top of Form Placing a sterile dressing 5 cm (2 in) from the border of the sterile field Holding a sterile item at just above waist level Opening a sterile package over the middle of the sterile field Opening the sterile tray by first unfolding the flap farthest from his body

Opening a sterile package over the middle of the sterile field

Nurses' Notes 1500:Adolescent's parents report the adolescent has been weak and short of breath, and has not eaten in the past 3 days. Dry cough with some wheezing noted in bilateral upper lobes. Dyspnea noted during assessment with adolescent sitting in upright position. Adolescent reports, "I breathe better sitting straight up." Provider notified. 1515:Respiratory therapist administered humidified oxygen via nasal cannula at 2 L/min 1930:Adolescent sitting upright. Reports dyspnea with activity. Maintaining oxygen at 2 L/min via nasal cannula. Ate a portion of their dinner tray. Mild wheezing noted in upper lung lobes. Voided 900 mL clear yellow urine. Vital Signs 1500:Blood pressure 143/92 mm HgApical pulse rate 110/minRespiratory rate 26/minTemperature 37.2º C (99º F)Oxygen saturation 94% on room airWeight 50 kg (110 lb) 1930:Blood pressure 129/72 mm HgApical pulse rate 92/minRespiratory rate 20/minTemperature 37.1º C (98.8º F)Oxygen saturation 97% on 2 L/min via nasal cannula Provider Prescriptions 1510:Humidified oxygen at 2 L/min via nasal cannula Furosemide IV 20 mg daily Digoxin 0.5 mg PO daily; hold if apical pulse is less than 70/min Enalopril 5 mg PO twice daily Regular diet

Oral intake(Improved) Dyspnea(No Change) Lung sounds(No Change) Heart rate(Improved) Respiratory rate(Improved) Blood pressure(Improved) Oxygen saturation(Improved)

A nurse is teaching a class about medication interactions. The nurse should include that iron preparations should be administered with which of the following? Milk Antacids containing magnesium Orange juice Cheese

Orange juice

A nurse is teaching a class about organ donation. Which of the following information should the nurse include? Each organ donation request should be reported to a facility's ethics committee. A nurse can initiate a request for tissue donation from a client. Tissue donation is involuntary. Organ donation can be authorized by an emancipated minor

Organ donation can be authorized by an emancipated minor

A patient reports to the nurse that he is experiencing a moderate amount of back pain rated 6 out of 10 on the pain scale. What should the nurse recognize about this assessment?

Pain is subjective for the patient

The nurse working in the ER is admitting a toddler to the orthopedic unit. The parents and grandparents are at bedside. What should the nurse use as the best source of data for this client? Admitting provider. Medical record. Parents. Grandparents.

Parents.

A nurse is assessing a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect? Intact skin with localized erythema. Full thickness skin loss with visible bone Partial-thickness skin loss with red tissue in wound bed. Full thickness skin loss with visible adipose tissue.

Partial-thickness skin loss with red tissue in wound bed.

Which patient care goal is a long-term goal for a newly diagnosed medically unstable patient with Diabetes? Patient will explain the importance of administering insulin Patient will achieve glucose control Patient will describe 3 actions to take for low blood sugar Patient will list the steps for preparing insulin in a syringe

Patient will achieve glucose control

A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs) and is partially immobilized because of a Stroke. The nurse turns the patient and finds that the skin over the sacrum is clean and intact. The patient has had fecal incontinence on and off for the last 3 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following is a GOAL appropriate for the patient? Patient's skin integrity will remain intact through discharge. Erythema of skin will be mild to none within 48 hours. Patient will be turned every 2 hours within 24 hours Patient will have normal bowel function within 72 hours

Patient's skin integrity will remain intact through discharge.

Which goal is appropriate for the patient who is at high risk of skin injuries? Patient will be turned every 2 hrs within 24 hrs Patient's skin condition will improve by discharge Patient will begin a weight-loss program Patient's skin will remain intact through discharge

Patient's skin will remain intact through discharge

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take? Obtain a cardiology consult. Suction the client less frequently. Administer an antidysrhythmic medication. Perform pre-oxygenation prior to suctioning.

Perform pre-oxygenation prior to suctioning.

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection? Top of Form Changing the client's bed linens each day Encouraging the client to consume a high-protein diet Performing hand hygiene before, during, and after direct contact with the client Placing the client in a room with positive-pressure airflow

Performing hand hygiene before, during, and after direct contact with the client

A nurse is teaching a newly hired group of assistive personnel (AP) about infection-control measures on the unit. It is crucial for the nurse to remind the APs that which of the following is the most effective way to prevent the spread of pathogens during client care? Top of Form Properly disposing of contaminated equipment Discarding used syringes in appropriate containers Changing soiled linens daily for clients who have draining wounds Performing hand hygiene frequently and consistently

Performing hand hygiene frequently and consistently

A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge? Attending a class given about tracheostomy care Verbalizing all steps in the procedure Performing the procedure independently Asking appropriate questions about suctioning

Performing the procedure independently

A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect? Heart murmur Crackles in lungs Chest pain Peripheral edema

Peripheral edema

A nurse is caring for a client who is placed on supplemental oxygen for hypoxia. The nurse should identify that which of the following findings indicate the intervention was effective? Heart rate 110/min Restlessness Respiratory rate 28/min Pink mucous membranes

Pink mucous membranes

A nurse is caring for a client who is placed on droplet precautions. Which of the following actions should the nurse take? Remove fresh flowers from the client's room. Place a surgical mask on the client when they leave their room. Wear a surgical mask when within 0.6 m (2 ft) of the client. Move the client to a positive airflow room.

Place a surgical mask on the client when they leave their room

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? Place a towel under the client's head. Leave the client to get help. Place the client in the prone position. Hold the client's arms and legs still.

Place a towel under the client's head.

A nurse is teaching a newly licensed nurse how to set up a sterile field. Which of the following instructions should the nurse include? Set the sterile field up below waist level. Open both side flaps of a sterile package at the same time. Place the sterile field 15.2 cm (6 in) from a wall. Place sterile items in the middle of the sterile field.

Place sterile items in the middle of the sterile field.

A nurse is admitting a new client. Which of the followings steps of the nursing process is the nurse performing when formulating goals for a positive outcome? Evaluation Planning Implementation Assessment

Planning

A nurse is working with a social worker and a physical therapist in preparing a discharge projection for a client who is postoperative. Which of the following steps of the nursing process is the nurse engaging in? Assessment Evaluation Planning Analysis

Planning

A nurse is caring for a client. Nurses' Notes Day 1: Client is admitted to a rehabilitation unit following a repair of a right hip fracture. Client has limited mobility and requires assistance to turn and transfer out of bed. Day 1: Client is alert and oriented to person, place, and time. Voided 350 mL of clear yellow urine into a bed pan. Right hip dressing is dry and intact. Abdomen soft, nondistended, bowel sounds hypoactive. Day 4: Client is oriented to person but disoriented to time and place. Client is incontinent of a moderate amount of Laboratory Results Day 1: Albumin level 3.6 g/dL (3.5 to 5 g/dL) Calcium level 10.7 mg/dL (9.0 to 10.5 mg/dL) Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at greatest risk for developing Select... Muscle loss Pressure injury Foot drop due to Select... Bowel sounds Urinary incontinence Calcium level

Pressure injury Urinary incontinence

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of heling will the nurse focus the care plan?

Primary intention

6. A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen? Top of Form After palpating the abdomen Prior to percussing the abdomen After assessing for kidney tenderness Prior to inspecting the abdomen

Prior to percussing the abdomen

The nurse checks a patient's intravenous (IV) line in his right arm and sees inflammation where the catheter enters the skin. The nurse uses a finger to apply light pressure just above the IV site. The patient tells the nurse the area is tender. The nurse checks to see if the IV line is running at the correct rate. This is an example of which type of assessment? Integumentary assessment Objective assessment Problem Focus assessment Head to toe assessment

Problem Focus assessment

The nursing diagnosis "Impaired Physical Mobility related to inability to turn and position in bed" is an example of a(n): Health Promotion Nursing Diagnosis Wellness Nursing Diagnosis Risk Nursing Diagnosis Problem-Focused Nursing Diagnosis

Problem-Focused Nursing Diagnosis

A nurse is caring for a client who has had an allogeneic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client? Airborne Protective Contact Droplet

Protective

A nurse is caring for a client who is immunocompromised following an allogenic hematopoietic stem cell transplant. The nurse should place the client on which of the following precautions? Contact Airborne Droplet Protective

Protective

A nurse is preparing to teach a client about a new medication. Which of the following actions should the nurse take? Use technical language in the educational session. Provide educational material written at a 6th grade reading level. Turn on the television in the client's room. Begin with the least important information.

Provide educational material written at a 6th grade reading level

A nurse sees an assistive personnel (AP) entering the room of a client who requires transmission-based precautions without using the appropriate personal protective equipment (PPE). Which of the following actions should the nurse take first? Provide the appropriate PPE to the AP. Notify the charge nurse about the AP's need for training. Volunteer to provide an inservice about infection control. Speak with the AP when he exits the room about the appropriate proto

Provide the appropriate PPE to the AP.

A nurse is providing a handoff report using the introduction, situation, background, assessment, recommendation, and readback (I-SBSR-R) on a client. Which of the following information should be included in the situation component? Client is grimacing due to pain Provider notified of client's back pain Client admitted with ruptured disc at L5 Request prescription for opioid medication for pain relief

Provider notified of client's back pain

A school nurse is performing a routine health assessment for a school-age child. Which of the following findings indicates the nurse should investigate further for pediculosis capitis? Top of Form Bald patches on the scalp Blisters on the scalp Pruritus of the scalp Dry patches on the scalp

Pruritus of the scalp

A nurse is caring for a client who experienced an infection at the insertion site of her intravenous catheter. Which of the following findings should the nurse expect? Top of Form The client reports numbness at the site. Purulent drainage is noted from the site. The vein appears cordlike. Skin over the site is sloughing.

Purulent drainage is noted from the site.

A nurse is teaching a newly licensed nurse about documenting vital signs. Which of the following documentations made by the newly licensed nurse indicates an understanding of the teaching? BP 148/72 mm Hg Temp 36° C (96.8° F) Radial pulse regular 68/min SpO2 95%

Radial pulse regular 68/min

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first? Administer oxygen at 2 L/min. Administer prescribed analgesic medication. Encourage coughing and deep breathing. Raise the head of the bed.

Raise the head of the bed.

A nurse is preparing a sterile field. Which of the following actions should the nurse perform when opening the sterile pack? Top of Form Place the pack on a sterile work surface. Reach around the pack and open the top flap away from the body. Open the right flap with the left hand. Move to the opposite side of the pack to open the fourth flap.

Reach around the pack and open the top flap away from the body.

A patient is working in the medical surgical unit and is assessing a client complaining of headache. The nurse administers Acetaminophen as ordered for pain and headache relief. Which nursing intervention is considered a priority for this patient? Review and make changes to the plan of care Eliminate headache from the patient's nursing care plan Direct the unlicensed assistive personnel (UAP) to ask to the patient if the headache is relieved Reassess the patient's level of pain in 30 minutes to evaluate effectiveness.

Reassess the patient's level of pain in 30 minutes to evaluate effectiveness.

A patient has a pain in the left arm secondary to coronary insufficiency. This is a example of what type of pain?

Referred pain

A nurse is caring for a client who has a radiation injury. Which of the following actions should the nurse take? Remove the client's clothing. Place the client in a semi-private room. Keep a distance of within 0.3 meters (1 foot) of the client. Have the client shower within 8 hr.

Remove the client's clothing

A nurse is caring for a client who has a new diagnosis of Clostridium difficile and is placed on contact precautions. Which of the following actions should the nurse take? Shake bed linens before placing them in a linen bag. Remove the protective gown before leaving the client's room. Use an electronic thermometer to take the client's temperature. Remove protective gown before removing gloves.

Remove the protective gown before leaving the client's room.

A nurse is teaching a newly licensed nurse about preventing puncture injuries. Which of the following instructions should the nurse include? Dispose of used razors in wastebaskets. Break needles on syringes before disposal. Replace sharps containers when they are full. Use two hands to recap a needle after administering a medication.

Replace sharps containers when they are full.

Which finding will alert the nurse to potential wound dehiscence?

Report by patient that soothing has given way

A nurse is assessing a client who has a heart rate of 56/min. Which of the following findings should the nurse expect? Report of dizziness Temperature of 39° C (102.2° F). History of cigarette smoking Hypoglycemia

Report of dizziness

A nurse opens a unit-dose of a prescribed medication prior to administering it to a client. The client refuses to take the medication. Which of the following actions should the nurse take? Fill out an incident report. Notify the facility's ethics committee. Return the opened medication to the medication cart. Report the incident to the provider.

Report the incident to the provider.

The nurse is reviewing interventions written for a client. Which of the following the nurse will consider as being independent? Reposition the client every 2 hours Starting IV antibiotics. Administer medication for high blood pressure Administering medication for pain

Reposition the client every 2 hours

A nurse is preparing to assess a client for a pulse deficit. Which of the following actions should the nurse plan to take first? Check the client's pulse rate for 1 min. Request assistance from a second nurse. Calculate the difference between the client's peripheral pulse and the client's apical pulse. Count the client's apical pulse.

Request assistance from a second nurse.

A nurse is caring for a client who is postoperative. Medication Administration Record Morphine 8 mg subcutaneous q 3 hr PRN pain Nurses' Notes 0800: Client is alert and oriented to person, place, and time. Reports incisional pain of 9 on a scale of 1 to 10. Morphine 8 mg, administered subcutaneous as prescribed. 0900: Client is sleeping and is difficult to arouse. Pupils are 3 mm, equal and reactive to light Vital Signs 0800: Temperature 37.6° C (99.7° F) BP 138/76 mm Hg Heart rate 98/min Respirations 22/min Pulse oximetry 96% on room air 0900: Temperature 37.5° C (99.5° F) BP 98/46 mm Hg Heart rate 58/min Respirations 10/min Pulse oximetry 87% on room air Click to highlight the documentation in the client's medical record that require further action by the nurse? To deselect a finding, click on the finding again. Temperature 37.5° C (99.5° F) Respirations 10/min Pulse oximetry 87% on room air Pupils are 3 mm, equal and reactive to light

Respirations 10/min Pulse oximetry 87% on room air

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L Respiratory acidosis Metabolic acidosis Metabolic alkalosis Respiratory alkalosis

Respiratory acidosis

A nurse is caring for a client who has COPD. The nurse should identify the client is at risk for which of the following acid-base imbalances? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic Acidosis

Respiratory acidosis

A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis

Respiratory acidosis

A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Respiratory acidosis

A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate of which of the following acid base balances? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis

Respiratory acidosis

A nurse is assessing a client who has opioid toxicity. Which of the following findings should the nurse expect? Temperature 38.2? C (100.8? F) Heart rate 112/min Blood pressure 168/90 mm Hg Respiratory rate 10/min

Respiratory rate 10/min

A nurse is teaching a client about how to administer a topical medication. After showing the client the procedure, the nurse asks the client to perform the skill. Which of the following types of teaching strategies is the nurse using? Return demonstration Role play Discussion Question and answer

Return demonstration

A nurse palpates a client's radial pulses bilaterally and notes the client's right radial pulse is bounding, and the client's left radial pulse is as expected. The client's heart rate is 80/min. Which of the following documentations should the nurse make? Right radial pulse 4+, 80/min, palpated Left radial pulse 4+, 80/min, palpated Right radial pulse 2+, 80/min, palpated Left radial pulse 1+, 80/min, palpated

Right radial pulse 4+, 80/min, palpated

A nurse is preparing to obtain a sputum specimen for a client. Which of the following actions should the nurse plan to take? Save the sputum specimen in a clean container. Obtain the specimen from the client in the evening. Rinse the client's mouth before collecting the specimen. Collect the sputum specimen after a meal.

Rinse the client's mouth before collecting the specimen.

Which nursing observations will indicate the patient's wound healed by the process of secondary intention? Minimal scar tissue Minimal loss of function Permanent dark redness at site Minimum scar tissue Scarring that may be severe

Scarring that may be severe

The nurse caring for a patient in the burn unit should expect what type of wound healing when planning care for this patient?

Secondary intention

A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain? Vital signs Self-report of pain Severity of the condition Nonverbal behavior

Self-report of pain

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? Top of Form Serous Purulent Sanguineous Serosanguineous

Serosanguineous

A nurse is preparing to administer a metered dose inhaler (MDI) medication to a client. Which of the following actions should the nurse take? Shake the MDI prior to administration. Ask the client to hold their breath for 2 seconds after inhalation. Wash the MDI canister in warm water after each use. Ask the client to inhale the medication quickly for 1 second.

Shake the MDI prior to administration.

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions? Excessive thirst and urination Shakiness and diaphoresis Fever and chills Hypertension and crackles

Shakiness and diaphoresis

A nurse is caring for a client who has been exposed to an unknown chemical. Which of the following actions should the nurse take? Place the client's clothing in a plastic bag. Remain at least 1.8 meters (6 feet) from the client Shower and scrub the client's skin. Instruct the client to remove their clothing.

Shower and scrub the client's skin.

A nurse is caring for a client who requires total parenteral nutrition (TPN). Which of the following actions should the nurse take when finding that the TPN solution is infusing too rapidly? Turn the client on his left side. Sit the client upright. Prepare to add insulin to the TPN infusion. Stop the TPN infusion.

Sit the client upright.

A nurse is assessing a client who has a wound that is healing by first intention. Which of the following findings should the nurse expect? Wound is contaminated at the time of injury. Healing of the wound is prolonged. Granulation tissue forming at the bottom of the wound bed. Skin edges of the wound are sutured closed.

Skin edges of the wound are sutured closed.

A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated? Low body temperature Jugular vein distention Skin tenting present Blood pressure 178/90 mm Hg

Skin tenting present

A nurse is teaching a class about manual therapies. The nurse should include that which of the following treatments is part of chiropractic medicine? Spinal manipulation Surgical procedures Prescription medications Acupuncture

Spinal manipulation

The nurse admitting an older patient notes a shallow open, reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?

Stage II

A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement? Top of Form Droplet Contact Airborne Standard

Standard

Which type of order describes a prewritten prescription in the Intensive Care Unit (ICU) that states in case of a headache, Acetaminophen is to be given to the patient? Intervention Protocol Standard Prescription Standing Order

Standing Order

A nurse is caring for a client who is receiving a unit of PRBCs. The nurse suspects the client is experiencing a transfusion reaction. Which of the following actions should the nurse take first? Infuse 0.9% sodium chloride. Stop the transfusion. Return the unit of blood to the blood bank. Obtain a blood sample from the client.

Stop the transfusion

A nurse is teaching a client who has a prescription for home oxygen therapy. Which of the following instructions should the nurse include? Keep oxygen tanks 4 feet away from an electric stove. Store oxygen tanks upright. Use petroleum-based ointments to moisturize lips. Choose a wool blanket when using oxygen.

Store oxygen tanks upright.

A nurse is receiving shift report about a group of assigned clients. Which of the following actions should the nurse plan to take first? Ask the provider about advancing a client's diet. Reinsert an intravenous catheter that was removed due to infiltration. Suction the tracheostomy of a client who has copious secretions. Check the laboratory findings of a preoperative client scheduled for surgery later in the shift.

Suction the tracheostomy of a client who has copious secretions.

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take? Suction two to three times with a 60-second pause between passes. Perform chest physiotherapy prior to suctioning. Lubricate the suction catheter tip with sterile saline. Hyperventilate the client on 100% oxygen prior to suctioning.

Suction two to three times with a 60-second pause between passes.

A nurse in an acute care mental health facility is admitting a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following is the nurse's assessment priority? Coping abilities Support systems Suicide risk Psychiatric history

Suicide risk

A nurse is caring for a client. Nurses' Notes 1000: Client reports diarrhea for 24 hrs and dizziness. Client is alert and oriented to person, place, and time. Skin warm and dry to touch, excess blankets removed. Bilateral breath sounds clear and present throughout. 1200: Client is alert and oriented to person, place, and time. Skin warm to touch. Bilateral breath sounds clear and present throughout. Apical pulse regular. Vital Signs 1000: T 38.9°C (102°F), oral BP 88/56 mm Hg, supine HR 112/min R 18/min Pulse oximetry 96% on room air 1200: T 38°C (100.4°F), oral. BP 106/60 mm Hg, supine HR 104/min R 20/min Pulse oximetry 95% on room air Provider Prescriptions 1000: Insert a peripheral IV catheter Administer 500 mL 0.9% sodium chloride IV bolus then infuse at 125 mL/hr Click to highlight the findings that indicate the interventions were effective. To deselect a finding, click on the finding again. T 38° C (100.4)°F, oral. BP 106/60 mm Hg, supine HR 99/min R 20/min Pulse oximetry 95% on room air

T 38° C (100.4)°F, oral. BP 106/60 mm Hg, supine HR 99/min

A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take? Tape the connections on the client's chest tube. Strip the client's chest tube every 2 hrs. Place the chest tube drainage system above the level of the client's heart. Loop the tubing of the chest tube on the client's bed.

Tape the connections on the client's chest tube.

A nurse is teaching a client about how to instill eye drops. The nurse asks the client to explain the procedure in their own words. Which of the following types of teaching methods is the nurse using? Lecture Question and answer Role play Teach-back

Teach-back

A nurse is preparing a client for a procedure. Which of the following is an acceptable identifier to use identify the client? Telephone number Home address Room number Medical condition

Telephone number

A nurse is admitting a client who speaks a different language than the nurse. Which of the following actions should the nurse take? Use an electronic translating service from the internet to interpret the information. Telephone the interpreter that is designated for the facility to interpret the information. Ask the client's partner to interpret the information. Call a nursing colleague who speaks the same language as the client to interpret the information.

Telephone the interpreter that is designated for the facility to interpret the information.

6. A nurse is caring for a client. Nurses' Notes 1000: Client is admitted with a productive cough for thick yellow sputum. Breath sounds with crackles heard in left upper lobe and decreased breath sounds at bases bilaterally. Mucous membranes pale. 1015: Head of bed elevated to 90° Client encouraged to cough and deep breath 40% face mask applied as prescribed 1100: Client has a productive cough for thick yellow sputum. Breath sounds with crackles heard in left upper lobe and decreased breath sounds at bases bilaterally. Mucous membranes pink. Vital Signs 1000: T 38.2° C (100.8°F), oral. BP 114/56 mm Hg, supine Apical HR 99/min R 32/min Pulse oximetry 85% on room air (95% to 100%) 1100: T 38.6°C (101.5°F), oral. BP 112/54 mm Hg, supine Apical HR 102/min R 22/min Pulse oximetry 95% on 40% O2 via face mask For each finding at 1100, click to specify if the finding indicates that the client's condition has improved, worsened, or is unchanged. Temperature Pulse oximetry Respiratory rate Blood pressure Mucous membrane color

Temperature(Worsened) Pulse oximetry(Improved) Respiratory rate(Improved) Blood pressure(Unchanged) Mucous membrane color(Improved)

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding? Warm the feeding solution to body temperature. Place the client in low Fowler's position. Discard any residual gastric contents. Test the pH of gastric aspirate.

Test the pH of gastric aspirate.

A nurse is reviewing the medical record for a client who has a health care-associated infection (HAI). The nurse should identify which of the following findings as a risk factor for acquiring an HAI? Top of Form The client had an appendectomy 6 months ago. The client has bipolar disorder. The client is a male. The client is 71 years old.

The client is 71 years old.

A nurse is preparing to administer a client's antihypertensive medication. When using clinical judgment, which of the following findings indicates the nurse should further assess the client before administering medication? The client reports dizziness when ambulating to the bathroom. The client reports having trouble sleeping the previous night. The client ate 60% of their breakfast. The client has a urine output of 400 mL for the past 8 hr.

The client reports dizziness when ambulating to the bathroom.

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia? The client who has a tracheostomy tube attached to humidified oxygen The client who has an indwelling urinary catheter to gravity drainage The client who has a chest tube to water seal The client who has a nasogastric (NG) tube to suction

The client who has a nasogastric (NG) tube to suction

A nurse is caring for a client who has postural hypotension. The nurse assists the client gradually from a lying down to standing position. The nurse should identify that which of the following findings indicates the intervention is effective? The client reports nausea. The client reports dizziness. The client's systolic blood pressure decreases from 110 mm Hg to 105 mm Hg. The client's heart increases from 100/min to 108/min.

The client's systolic blood pressure decreases from 110 mm Hg to 105 mm Hg.

A nurse is preparing to exit the room of a client who has methicillin-resistant Staphylococcus aureus (MRSA) in a draining wound. Identify the sequence the nurse should follow before leaving the client's room. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) The gloves the eyewear the gown the mask perform hand hygiene

The gloves the eyewear the gown the mask perform hand hygiene

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene? The nurse initiates the feeding after aspirating 50 mL of gastric residual. The nurse irrigates the NG tube with tap water after feeding. The nurse administers the feeding through a syringe barrel by gravity. The nurse allows the client to rest in a supine position during feeding.

The nurse allows the client to rest in a supine position during feeding.

Which factor is unique to malpractice when comparing negligence and malpractice? There is harm to the patient as a result of the care The action did not meet standards of care The nurse owes "duty" to client. There is a contractual relationship between the nurse and client The inappropriate care is an act of commission

The nurse owes "duty" to client. There is a contractual relationship between the nurse and client

A nurse is using critical thinking skills while conducting evaluation of a care plan. Which statement best describe the action take by the nurse? The nurse review the effectiveness of nursing interventions. Examine the meaning of the data. Search for links between the data and the nurse's assumptions. Support findings and conclusions.

The nurse review the effectiveness of nursing interventions.

37. A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

The nurse should auscultate the client's apical pulse over the apex of the heart, at the anatomical landmarks of the 5th intercostal space and below the left nipple line 7.6 cm (about 3 in) to the left of the sternum.

A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patient's behavior?

The patient's culture is possibly influencing the patient's experience of pain

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? To confirm the placement of the NG tube To remove gastric acid that might cause dyspepsia To determine the client's electrolyte balance To identify delayed gastric emptying

To identify delayed gastric emptying

Which of the following statements is true about informed consent? A consent is only valid for 1 days after that they must sign a new form A nurse or physician can give the client the necessary information to obtain informed consent for surgery Clients need to know about the procedure, they don't need to be frightened with information about potential risks To witness the consent, the nurse must be present to see the client sign the form. Client must be competent to sign the consent

To witness the consent, the nurse must be present to see the client sign the form. Client must be competent to sign the consent

A nurse is teaching a class about pharmacodynamics. The nurse should include that which of the following medication levels occurs when a medication is at the lowest serum concentration? Half-life Toxic Peak Trough

Trough

A nurse is planning care for a client who is to start receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include in the plan of care? Use a 1.2 micron filter when infusing TPN with fat emulsions added. Allow 18 hr for the lipids to infuse when not mixed with the TPN solution. Change the TPN solution after 36 hr. Change the TPN tubing every 48 hr.

Use a 1.2 micron filter when infusing TPN with fat emulsions added.

A nurse is planning care 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? Use a transfer device to lift the client up in bed. Apply cornstarch to keep sensitive skin areas dry. Massage the skin over the client's bony prominences. Elevate the head of the bed no more than 45°.

Use a transfer device to lift the client up in bed.

The nurse is caring for a 4-year-old child who is demonstrating signs of pain. Which technique will the nurse use to best assess pain in this child?

Use face scales

A nurse is preparing to complete an occurrence report for a client who fell at the facility. Which of the following actions should the nurse take? Use objective terminology when documenting Wait at least 12 hrs. to report the occurrence Omit the name of the individuals involved Document completion of the report in the client's medical record

Use objective terminology when documenting

A nurse is planning to perform a sterile dressing change for a client. Which of the following actions should the nurse plan to take? Top of Form Hold gauze packages 7.6 cm (3 in) above the sterile field. Place sterile supplies within the 2.54 cm (1 in) border of the sterile field. Use sterile forceps to move the sterile items on the sterile field. Position the wrapped package on the bedside table so the outer flap opens towards her.

Use sterile forceps to move the sterile items on the sterile field

A nurse is preparing an in-service about communication for a group of staff nurses. Which of the following techniques should the nurse include when discussing therapeutic communication? Offering personal opinions Offering sympathy Using silence Providing passive responses

Using silence

A nurse is preparing to remove an NG tube from a client. Which of the following actions should the nurse take first? Disconnect the tube from the wall suction. Perform hand hygiene. Provide mouth care to the client. Verify the provider's prescription to discontinue the tube.

Verify the provider's prescription to discontinue the tube.

A nurse is assessing a patient who began experiencing severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, "The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most." Which type of pain does the nurse document the patient is having at this time?

Visceral pain

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection? Top of Form BUN Potassium RBC count WBC count

WBC count

A nurse is reviewing laboratory values for a client. Which of the following findings indicates the presence of an infection? Platelet count 200,000/mm3 WBC count 22,000/mm3 Creatine kinase 75 units/L Hgb 15 g/dL

WBC count 22,000/mm3

A nurse is preparing to administer an otic medication to a client. Which of the following actions should the nurse take? Ask the client to remain in a side-lying position with the affected ear down for several minutes after instillation. Press a cotton ball into the client's ear canal after instillation. Warm the medication to room temperature before administration. Pull the client's pinna down and back prior to instillation.

Warm the medication to room temperature before administration.

A nurse is orienting a new assistive personnel (AP) to the unit. For which of the following actions should the nurse intervene? Top of Form Wears a gown when entering the room of a client who requires contact precautions Dons gloves to empty a urinary drainage device Washes and rinses her hands for 10 seconds Wears a respirator mask when entering the room of a client who requires airborne precautions

Washes and rinses her hands for 10 seconds

A nurse is admitting a client who requires droplet precautions due to influenza. Which of the following actions should the nurse take? Top of Form Place the client in a room with negative airflow. Wear a mask when providing care to the client. Ensure the client's room has HEPA filtration. Wear a gown when providing care to the client.

Wear a mask when providing care to the client.

A nurse is planning care for a client who requires airborne precautions. Which of the following actions should the nurse take? Top of Form Provide a positive-pressure airflow room. Wear an N95 respirator mask. Allow the client to ambulate in the hall. Stand 1.8 m (6 feet) away from the client.

Wear an N95 respirator mask.

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take? Wear an N95 respirator mask. Wear sterile gloves. Wear clean gloves. Wear protective eyewear.

Wear clean gloves.

A nurse reports to their manager that the ostomy nurse is improperly managing the ostomies on the unit. The nurse informs their manager that they are afraid that the ostomy nurse is going to be mad at them now. Which of the following legal principles should the nurse manager plan to discuss with the nurse? Whistleblowing Libel Defamation Good Samaritan Law

Whistleblowing

A small-bore feeding tube is placed. Which technique will the nurse use to best verify tube placement?

X-ray