Fundamental Dynamic Quizzes

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

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

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

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

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

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

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

"Include 2.5 cups of vegetables in your daily diet"

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

"It sounds like your pain is intermittent."

A nurse is providing teaching about benzodiazepines to a client who is discontinuing long-term alprazolam use. Which of the following pieces of information should the nurse include in the teaching?

"Plan to taper the dose slowly over several months."

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

"What is your source of strength and hope?"

A nurse is assessing a clients nutritional status. The nurse determines the client is consuming 500 cal more per day than his energy level requires. If his dietary habits do not change, how long will it take the client to gain 4.5 kg?

10 weeks

A nurse is caring for a client who has a prescription of acetaminophen 325 MG by mouth for an oral temperature above 38.4°. Above what Fahrenheit temperature should the nurse administer acetaminophen to the client?

101.1°F

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

116/70 mmHg

A nurse is assessing the pH of a clients gastric fluid to confirm the placement of the NG tube in the stomach. Which of the following pH value should the nurse expect?

2

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

2 mm

A nurse is preparing to administer 700 mL of 0.9% sodium chloride IV to a child to infuse over 24 hours. The drop factor of the manual IV tubing is 60 ggt/mL. The nurse should said the menu IV infusion to deliver how many ggt/mL per minute?

29

A nurse is responding to a Parents question about his infants expected physical development during the first year of life. Which of the following pieces of information should the nurse include?

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

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

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

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

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

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

A client who has end-stage cirrhosis

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

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

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

A client who is today's postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage

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

A client who is two days post operative following a colectomy due to colorectal cancer And has an ostomy bag full of bright red, bloody drainage

A nurse is preparing to change the bed linens of a client who has aids and is in continent of stool. Which of the following PPE items should the nurse don prior to providing client care?

A. Gotten B. Gloves

A nurse is teaching a client how to use an albuterol metered dose inhaler. After removing the cab from the inhaler and shaking the canister, what sequence of instructions should the nurse give the client?

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

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

A. Placed a client in a supine position with the hips and knees flexed B. Cover the wound and intestine was a sterile, moistened dressing C. Monitor the client for manifestations of shock

A community health nurse is conducting a class about body mechanics for county office workers. Which of the following instructions to the nurse include?

A. Sit with your back supported B. Keep your knees at hip level C. Use an ergonomically designed computer keyboard

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

Absent bowel sounds with distention

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

Accompany the client back to his room

A nurse is caring for a client who is in the emergency department after ingesting a bottle of acetaminophen. Which of the following medication should the nurse plan to administer?

Acetycystine

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

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

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

Administering high-flow oxygen prior to the procedure

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

Advise the client to perform range of motion exercises while in bed

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

Advise the client to tuck his chin down word

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

Air conduction is less than bone conduction in the left ear

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

Airborne

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

Airborne

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

Albumin

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

All of this equipment can be frightening

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

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

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

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

A nurse is preparing to administer eyedrops for a client who has glaucoma. When installing the medication, which of the following actions should the nurse take?

Apply pressure to the puncta after instilling the medication

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

Areas with no public access

A nurse in an urgent care center is caring for a 15 year old client who symptoms suggest a sexually transmitted infection. The clients parents are unavailable, but the clients grandmother accompanied the client to the clinic. Which of the following actions should the nurse take?

Ask the adolescent to sign the consent form

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

Ask the client about first aid performed at the scene.

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

Ask why the client is refusing the pain medication

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

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

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

Assess the client

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

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

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

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

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

Assist the client in finding local smoking cessation assistance programs

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

Assume an open position

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

Attempt to increase the client's self-motivation

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

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

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

Average

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

Avoid beverages that contain caffeine

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instruction should the nurse give the client to ease the passage of the catheter there was a urinary meatus?

Bear down

A nurse in a providers office is teaching a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching?

Black beans Whole-grain bread

A nurse is taking a clients vitals. Which of the following findings should the nurse identify as outside the expected reference range?

Blood pressure 145/90 mmHg

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

Bounding

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

Bounding pulse

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

Brainstem

A nurse is administrating medication to a client who asks the nurse to leave the medication at the bedside to be taking at a later time. Which of the following responses to the nurse made?

Call me when you're ready, and I will return with the medication

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

Call me when you're ready, and I will return with the medication

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

Call the provider and clarify the dosage

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

Can you explain the concerns you're having right now

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

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

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

Ceasing to compare personal identity with other

A nurse enters a clients room and find the client sitting on the floor and leaning against the side of the bed. The client states she slipped while getting out of bed. Which of the following actions should the nurse take first?

Check the client for injuries

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

Check the client's perineum

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

Check the client's vital signs.

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

Check the clients capillary blood glucose level every four hours

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

Check the clients pain levels

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

Check the medication dose and the client's identification

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

Check the medication dose and the clients identification

A nurse is caring for a postoperative client who has an indwelling urinary catheter for gravity drainage. The nurse notes know you're in output in the past two hours. Which of the following actions should the nurse take first?

Check to determine if the catheter tubing is kinked

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

Choose a vein that is soft on palpation

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

Chronic hypoxemia

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

Circle the injection area with a pen

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

Clean the drain site from the center outward

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

Cleanse the skin around the stoma with warm water

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

Cleanse the wound with 0.9% sodium chloride irrigation

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

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

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

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

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

Cold extremities

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

Collapse the device to remove air after emptying

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

Collect the specimen upon arising in the morning

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

Collecting and trading game cards

Charge Nurse is teaching adult cardio pulmonary resuscitation to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as a first response and CPR?

Confirm unresponsiveness

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

Consult the medication reference book available on the unit

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

Consult the medication reference book available on the unit

A nurse is preparing to assess the function of a clients trigeminal nerve. Which of the following items should the nurse gather for the test?

Cotton wisps

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

Cover the incision with a moist sterile dressing.

A nurse is assessing a client who has fluid volume excess. Which of the following findings should the nurse report?

Crackles in the lung fields

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

Cranial Nerve XII

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

Daily weight

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

Death is viewed as an interruption of what might have been

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

Decreased calcium

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

Decreased cardiac output

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

Decreased estrogen and testosterone production

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

Depressed deep tendon reflexes

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

Depression

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

Determine the client's intention to change current eating habits

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

Determine whether the client is able to breathe

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

Determines whether the client is able to breathe

A nurse is caring for a client who is receiving total parenteral nutrition therapy and has just returned to the room following physical therapy. The nurse knows that the infusion pump for the clients TPN is turned off. After we starting the infusion pump, the nurse should monitor the client for which of the following findings?

Diaphoresis

A nurse in a rehabilitation center is performing an assessment for a client who is recovering from the left hemisphere stroke, which of the following findings should the nurse expect

Difficulty with speech

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

Disconnect the machine and measure the blood pressure manually every 15 minutes

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

Discuss the meaning of a common proverb

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

Document this as an expected finding

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

Don clean gloves to remove the old dressing

The client hold the hand with the palm up A nurse is caring for a client who has MRSA. A dietary assistant asked the nurse what precautions are necessary for entering the clients room with the lunch tray. Which of the following instruction should the nurse give to the dietary assistant?

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

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

Donate autologous blood after the storm

A nurse is preparing to administer eyedrops to a client following surgery. Which of the following actions should the nurse take one instilling the eyedrops?

Drop the eye medication into the lower conjunctival sac

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

Durable power of attorney document

A nurse is assessing a client who had pericarditis. Which of the following manifestations should the nurse expect?

Dyspnea with hiccups

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

Edema at the infusion site

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

Educating clients about the recommended immunization schedule for adults

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

Elevate the head of the clients bed to 45° before the feeding

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

Elevated head of bed to 30° or 45°

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

Elevating the finger above heart level

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

Elevating the finger above the heart level

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

Encourage the client to cough

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

Encourage the client to express thoughts about death and dying

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

Encourage the client to express thoughts about death and dying

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

Ensure the interpreter and the client speak the same dialect

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

Establish client outcomes

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

Evacuate clients from the unit

A nurse on a medical surgical unit observed smoke billowing from a clients room. Which of the following actions should the nurse take first?

Evacuate the client from the room

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

Evaluate pedal pulses

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

Evaluate pedal pulses

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

Excessive wax in the ear canal

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

Exert pressure on the bony prominences when holding the eyelids open

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

Explain the procedure to the client

A new resident provider asked the Charge Nurse for an access code to review clients online records. The resident is not scheduled to attend the facilities orientation computer class until next week. Which of the following actions should the nurse take?

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

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

Face the client when speaking

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

Faint pedal pulses

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

Fats provide energy

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

Feedback is provided

A nurse is caring for a client who is in labor. Which of the following assessment findings should the nurse report to the provider?

Fetal heart rate baseline of 90 bpm

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

Fill the bag 2/3 full with ice

A nurse is caring for a client who has the head of his bed elevated to 45° with his knees slightly flexed. Which of the following positions should the nurse document for this client?

Fowlers

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

Fowlers

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

From the wound toward the surrounding skin

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

Gelatin

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

God is punishing me for something

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

Grains

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

Granulation tissue fills the wound during healing

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

Grasp a skin fold on the chest under the clavicle, release it, and know whether it springs back

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

Halo of erythema on the surrounding skin

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

Hct 55%

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

Hearing aids

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

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

A nurse is preparing to administer an otic anabiotic to an adult client who has otitis media. Which of the following action should the nurse plan to make?

Hold of the dropper 1 cm above the ear canal during administration

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

Hold the breath for 5 sec after goal volume is reached

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

Hold the linens away from the body and clothing

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

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

A nurse is caring for a client who has stage 2 pressure ulcer. Which of the following bone dressings should the nurse apply to the ulcer?

Hydrocolloid

A nurse is caring for a client who has stage to pressure ulcer. Which of the following one dresser to the nurse apply to the ulcer

Hydrocolloid

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

Hyperglycemia

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

I am going to listen to your abdomen

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

I can see that this is upsetting you

A nurse is teaching a client who is using a patient controlled analgasia pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

I can still use my transcutaneous electrical nerve stimulation while I am pushing the PCA button

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

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

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

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

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

I keep having nightmares about my upcoming surgery

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

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

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

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

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

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

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

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

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

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

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

I will put a night light in the hallway

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

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

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

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

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

I'll wear non-sterile gloves

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

Identify the client using two identifiers

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

If I do this often, I won't get pneumonia

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

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

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

If the client seems confused, I'll raise all for rails so that he doesn't hurt himself

A nurse is caring for a client who is 40 hours postoperative following a small bowel resection. The client reports gas pain in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?

Impaired peristalsis of the intestine

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

Impaired peristalsis of the intestines

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

Inability to cry or speak

A nurse is providing teaching about Nutritious diet's to a group of adult women. Which of the following statements should the nurse include?

Include 2.5 cups of vegetables in your daily diet

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

Increased blood pressure

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

Increased heart rate

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

Increased heart rate

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

Independent moral development

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

Infection acquired from a diagnostic procedure

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

Insert the tip of the tubing 8 cm

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

Inspect both breasts simultaneously

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

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

A nurse in an acute care facilities planning care for a client who is alert but temporary mobile due to a total hip arthroplasty. Which of the following intervention should the nurse plan to take to prevent a complication of immobility?

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

A nurse in an acute care facilities planning care for a client who is alerted by temporary immobile due to a total hip arthoplasty. Which of the following intervention should the nurse plan to take to prevent a complication of immobility?

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

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

Instruct the guard to ask the inmate

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

It modulates the transmission of the pain impulse

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

Keep a diary of the foods your child eats each day

A nurse is caring for a client who has a temperature of 101.7°F. Which of the following actions should the nurse take?

Keep the clients bed linens dry

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

Keeping the microorganisms from entering the wound

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

Kosher diets have restrictions regarding how the food must be prepared

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

Lentils

A nurse is reviewing a clients laboratory results and notes a white blood cell count of 3,600/mm^3. The nurse should identify this result as which of the following conditions?

Leukopenia

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

Limit drinking liquids with fluid

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

Liver damage

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

Lock the wheels of the bed and stretcher

A nurse and a rehabilitation facility is observing an AP help a client transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse that the AP understands how to perform this task?

Locks the brakes on the bed and the WC before moving the client.

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

Lower abdomen

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

Lower the client to the floor

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

Lower the client to the floor and place a pad under the client's head.

A nurse is performing a physical examination of a client. The nurse should use per cushion to evaluate which of the following parts of the clients body?

Lungs

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

Make sure the device is functioning

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

Measure the clients apical pulse rate

A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and hc03 - 18. Which of the following acid base imbalances should the nurse identify and report to the provider?

Metabolic acidosis

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

Milk

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

Monitor the client at least once every hour

A nurse is changing the dressing for a client who has 2 Penrose drain's near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?

Montgomery straps

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

Notify the provider of the client's decision

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

Nutrition

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

Observe the client closely

A client who reports SOB requests the nurses help and changing positions. After repositioning the client, which of the following actions should the nurse take next?

Observe the rate, depth, and character of the clients respirations

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

Obtain a new catheter and reattempt insertion

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

Obtain the optical and radial rates simultaneously

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

Obtain the services of an interpreter

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

Obtaining cotton balls for the tracheostomy care

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

Obtaining cotton balls for the tracheostomy care

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

Offer the client tart or sour foods first

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

Oil retention

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

Oxygen equipment

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

PC for after meals

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

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

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

Perform a blanch test

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

Perform hand hygiene

A nurse is assessing the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse auscultated a high-pitched Scratching sound during both systole and diastolic with the diaphragm of the stethoscope position at the left sternal border. Which of the following heart sounds shut the nurse document?

Pericardial friction rub

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

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

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

Pinch the NG tube while removing the tube

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

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

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

Place the client in Trendelenburg's position.

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

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

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

Place the client in a left Sims' position

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

Place the stool specimen collection container and a biohazard bag

A home health nurse enters a clients home and find a used insulin syringe without a cap on the table which of the following actions should the nurse take?

Place the syringe in a puncture proof disposal container

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

Place the wheelchair at a 45 degree angle to the bed

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

Position the client for drainage of secretions by gravity

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

Position the client on his left side.

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

Potassium 3.0 mEq/L

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

Protein serves as an energy source when other sources are inadequate

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

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

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

Provide oral care to a client who cannot take oral fluids

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

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

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

Pull the NG tube back slightly

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

Purulent exudate

A nurse is planning to perform mouse care for an unresponsive client. Which of the following action should the nurse plan to take?

Raise the level of the bed

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

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

A nurse is preparing to administer a partial dose of a pre-filled opioid analgesic parenterally to a client. Which of the following action should the nurse plan to make?

Record amount of medication wasted on the controlled substance inventory record

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

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

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

Reduced level of consciousness

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

Regulation of acid base balance

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

Remove the IV catheter

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

Remove the restraints at least every 2 hr

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

Remove the restraints one at a time

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

Remove the safety pin from the extinguisher

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

Renew the prescription for the use of restraints within 24 hours

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

Repeat is joint motion five times during each session

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

Request a prescription for an isotonic eternal nutrition formula

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

Request an x-ray of the clients abdomen

A nurse is reviewing a clients laboratory report. The clients ABG levels are pH 7.5, PC CO232MMHG & HC03-24 mEq/L. The nurse should determine that the client has which of the following acid base imbalances?

Respiratory alkalosis

And there's delegates the collection of a clients temperature to an AP. The nurse notes in the documentation that the AP obtained the clients auxiliary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented the situation from occurring?

Right communication

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

Romberg

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

Sanguineous

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

Scoliosis

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

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

A nurse at a screening clinic is assessing a client who reports a history of a Heart murmur related to aortic valve stenosis. Which of the following anatomical error should the nurse place the stethoscope to ask you to the aortic valve?

Second intercostal space to the right of the sternum

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

Second intercostal space to the right of the sternum

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

Side hip between the iliac crest and the interior iliac spine

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

Sit and hold the client's hand

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

Sit on the toilet 30 minutes after eating a meal

A community health nurse is conducting a class about body mechanics for county office workers. Which of the following instruction should the nurse include?

Sit with your back supported, use an ergonomically designed computer keyboard, keep your knees at hip level

A nurse is examining a client for signs of cost over Tebow angle tenderness. The nurse should place the client in which of the following positions for evaluation?

Sitting

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

Soak the inner cannula of the tracheostomy tube in normal saline

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

Sodium

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

Sodium 150 mEq/L

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

Starch

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

Start chest compressions

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

Stereognosis

A nurse is caring for an older adult who is on bedrest. Which of the following foods should the nurse plan to include in the clients breakfast tray to prevent constipation?

Stewed prunes

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

Suction equipment

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

Supports self-determination

While in the hospital, a client who has a terminal illness tells the nurse, "I can't believe I'm dying. A lot of bad people in the world are healthy, and here I am dying!" Which of the following responses should the nurse provide?

Tell me more about how you feel about dying

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

Tell me more about how your friends discourage you

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

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

A nurse is planning to obtain the vital signs of a two-year-old child who is experiencing diarrhea and may have a right ear infection. Which of the following roads should the nurse used to obtain the child's temperature?

Temporal

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

Test for the presence of the clients gag reflex

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

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

A nurse in a health clinic is providing teaching to a client about bench eating disorder. Which of the following client statements indicates an understanding of the teaching?

The abdominal pain I have often is due to the amount of food that I eat

A nurse is evaluating the injection site of a client who had a Mantoux skin test 48 hours ago. The nurse finds 10 MM of induration with slight redness. Which of the following conclusions should the nurse make?

The client had an exposure to tuberculosis

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

The client has slightly flexed elbows when ambulating with the crutches

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

The client hold the hand with the palm up

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

The client holds the cane on the unaffected side

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

The client keeps two points of support on the ground

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

The client keeps two points of support on the ground

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

The client through the medication on the floor

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

The client watches television in her bed during the day

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

The client's basal metabolic rate could decrease

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

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

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

The involvement of the client and planning the change

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

The nurse holds her hands higher than her elbows while washing

A nurse is witnessing a client sign and informed consent form to surgery. What is the nurse affirming by this action?

The signature on the preoperative consent form is the clients

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

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

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

Tilt your head back and swallow

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

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

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

Turn the stockings inside out up to the heel before applying

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

Upon the client's admission to the care facility

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

Use a gait belt during ambulation

A nurse is preparing to install a vaginal medication in suppository for them to a client. Which of the following action should the nurse take during this procedure

Use the index finger to insert the suppository

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

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

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

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

A nurse is administrating a IM injection to a five-year-old infant. Which of the following injection sites should the nurse use?

Vastus lateralis

A nurse is administrating and I am injection to a five month old infant. Which of the following injection sites should the nurse use?

Vastus lateralis

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

Ventrogluteal

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

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

A nurse is caring for a semi conscious client who had a small bore NG tube placed yesterday for the administration of internal feeding. Which of the following methods should the nurse use to verify correct tube placement?

Verify the initial x-ray examination Measure the length of the exposed a tube Determine the pH of aspirated fluid

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

Vesicular

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

Vitamin C and zinc

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

Warm the irrigating solution to 37C (98.6F)

A nurse is preparing to irrigate a clients wound. Which of the following action should the nurse take?

Warm the irrigation solution to 37°C or 98.6 Fahrenheit

A middle aged adult client is disgusting future plans with the nurse. Which of the following statements to the nurse identify as an indication that the client is having difficulty achieving Ericksons developmental task for this age group?

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

A nurse is caring for a client who has MRSA. Which of the following precautions should the nurse implement?

Wear a gown when in the client's room

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

Weigh the client on arising

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

What do you think caused the onset of your pain?

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

What worries you about being without your teeth?

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

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

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

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

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

Wiping the labia minora in an anteroposterior direction

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

Would you like to talk about how you feel?

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

Wrap the client's finger in a warm washcloth

A nurse is evaluating the development of a group of clients. According to Ericsson, the developmental task of intimacy versus isolation occurs during which of the following stages of development?

Young adulthood

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

a. New prescriptions b. Arterial blood gas results c. Tracheal secretion characteristics

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

a. Stabilizing the position of the tube b. Preventing aspiration of secretions c. Preventing air leaks

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

a. Verify the initial x-ray examination b. Measure the length of the exposed tube c. Determine the pH of aspirated fluid

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

a. provide oral hygiene frequently b. measure drainage from the NG tube every shift c. secure the NG tube to client's gown

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

abstract reasoning

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

antagonistic

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

antagonistic

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

assessment

A nurse on a medical surgical unit is admitting a client. Which of the following pieces of information should the nurse document and the clients record first?

assessment

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

auscultation

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

below medial malleolus

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

cerebellum

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

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

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

corneal light reflex

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

cough deeply after each use

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

depressed deep tendon reflexes

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

dorsalis pedis

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

elevate HOB

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

encourage the client to listen to soft music

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

eye examination every two years

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

fidelity

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

gait

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

glaucoma

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

gloves

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

hemolytic

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

inspection

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

intraoperative

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

lactose

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

loss

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

osteoporosis

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

physical examination

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

plasma volume expanders

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

secondary source of data

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

skin

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

speech language pathologist

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

stereognosis

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

supine

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

support clients decision

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

tachycardia

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

with your palm facing down, move your wrist sideways toward your thumb