Fundamental Questions (250 question practice)

A nurse is removing an isolation gown that has waist ties in the front after caring for a client who requires contact precautions. Which of the following steps should the nurse take?

Using the front waist ties, remove the gloves and untie the neck ties.

A nurse is collecting data about a clients cardiac functioning. The nurse auscultates an S3 sound. Which of the following causes should the nurse suspect?

Ventricular gallop An S3 sound represents a ventricular gallop. Possible causes are hypertension and heart failure

A nurse is preparing to count the controlled substances in the secure cabinet. Which of the following actions should the nurse take?

Verify that the amounts of each medication she counts match the amounts on the inventory record

A nurse is caring for a client who has a large surgical would healing by secondary intention. the nurse should recommend a diet high in protein and which of the following nutrients?

Vitamin C

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?

WBC count

A nurse has accidentally punctured his finger with a needle he used to give an IM injection. Which of the following actions should the nurse take?

Wash the puncture site with soap and water

A home health nurse is conducting a home safety rick appraisal for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply)

Water heater temperature is 54.4 C (130 F) Throw rugs

A nurse is assisting with developing the plan of care for a client who requires airborne precautions. Which of the following actions should the nurse suggest?

Wear an N95 respirator mask

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high pitched squeaking sounds. The nurse should document this as which of the following adventitious lung sounds?

Wheezes

A nurse is assisting with the implementation of a bowel training program for a client. for the program to be effective, the nurse should take the client to the bathroom at which of the following times?

When the client has the urge to defecate

A nurse is caring for a group of clients. For which of the following tasks should the nurse plan to wear protective eye equipment?

Withdrawing cord blood from a neonate Suctioning secretions from a Childs newly place tracheostomy tube

a nurse is planning care for a client who has anorexia and has manifestations of Malnutrition. When reviewing the clients laboratory values, which of the following test results should the nurse expect to be low?

albumin

A nurse is caring for four clients who have drainage tubes. The nurse should identify the client who has which of the following tubes as being at risk for hypokalemia?

an NG tube to suction

A nurse is caring for a client who has a prescription for a stool guaiac test. The client asks the nurse about the purpose of the test. The nurse should respond by stating that the stool guaiac is testing for which of the following findings in the clients feces?

blood a guaiac (fecal occult blood) test detects microscopic amounts of blood in the stool and is a screening tool for colorectal cancer

a nurse is observing an AP who is preparing to deliver a meal tray to client who practices orthodox Judaism. on the tray is a roast beef dinner with nonfat milk. which of the following actions should the nurse take?

call the dietary department and ask for a kosher meal tray

a nurse is caring for a client who is HIV positive and is 1 day postoperative following an appendectomy. which of the following actions requires the nurse to wear a gown as ppe?

changing a wound dressing

A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse use as a primary source of accurate data about the client?

client concerns

A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. When collecting data from the client, the nurse should identify which of the following findings as an indication of adverse effect of oxygen therapy?

cracks in oral mucous membranes

A nurse is observing the IV catheter insertion site of a client who is receiving continuous iv therapy. which of the following manifestations should the nurse identify as an indication that the client has developed phlebitis?

erythema

A nurse is collecting data from a client following surgery for a brain tumor near the hypothalamus. for which of the following findings should the nurse monitor the client because of the risks of surgery on this area of the brain?

inability to regulate body temperature

A nurse is reinforcing teaching with a client about relationship development. The nurse should explain that, according to Erikson, establishing relationships with commitment is a primary task of which of the following stages of psychosocial development.

intimacy versus isolation

a nurse is reinforcing discharge teaching for a client who requires home oxygen therapy. which of the following statements should the nurse identify as an indication that the client needs further teaching?

" I will wear synthetic clothing and woolen socks when using my oxygen"

A nurse is caring for a client who had severe traumatic brain injury 3 weeks ago, remain unconscious, and is unlikely to recover. While bathing the client, the AP talks to him about current events. The client's partner asks the nurse why the AP talks to the client. Which of the following responses should the nurse make?

"Although your partner is not responding to us, he might still be able to hear."

As a nurse prepares an older adult client for bed on the first night of her hospital stay, the client says "I am afraid that I may fall getting to the bathroom during the night. I tend to get a bit disorientated in new surroundings" which of the following actions should the nurse take?

keep a night light on in the clients room

a nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. which of the following actions should the nurse contribute to the plan? (select all that apply)

keep a night light on in the clients room and bathroom lock the wheels on beds and wheelchairs during transfers place the bedside table with the clients reach

A nurse is counting a clients apical pulse rate. Identify where the nurse should place the stethoscope to auscultate the apical pulse.

left mid clavicular line in 5th intercostal space

a client receiving a cleansing enema reports mild cramping. after a few minutes he asks the nurse to stop the enema and allow him to go to the bathroom. which of the following actions should the nurse take?

lower the height of the solution bag

a nurse is caring for a client when the safety on the bed plugs electrical outlet pops and begins to smoke. which of the following actions is the nurse priority?

move any clients

With whom should a nurse should share her password for access to the facility's computer system?

no one

A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field?

opening a sterile package directly over the middle of the sterile field

A nurse is checking a clients bowel sounds. At which of the following times should the nurse auscultate the clients abdomen?

prior to percussing the abdomen

A nurse observes an AP taking the call light away from a client and reprimanding him for using it frequently. Which of the following actions should the nurse take first?

reassure the client

When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. the nurse calls the provider but he is unavailable for several days. which of the following actions should the nurse take?

request to speak with the provider who is covering for the prescriber

A nurse is collecting data from a client who has a respiratory insufficiency. Which the following findings should the nurse identify as an early sign of inadequate oxygenation?

restlessness

A nurse identifies an extravasation of vesicant solution at a clients peripheral IV catheters insertion site. identify the sequence the nurse should perform the following action?

stop infusion disconnect the catheter from tubing attack a syringe aspirate remove iv catheter

a nurse is caring for an older adult client who has dementia and wanders at night. which of the following actions should the nurse take?

take the client to the bathroom on a regular schedule

A nurse is discussing respite care with the caregiver of an older adult client. When the caregiver asks about the purpose of respite care program, the nurse should reply that it provides which of the following services?

temporary care

a nurse is caring for an older adult who is alert and competent and comes to the facility with her adult son for elective cataract extraction. after the provider explains the procedure, who should the nurse have sign the consent form?

the client

A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine?

the clients current weight bearing status

a nurse on a medical unit is reinforcing teaching with a group of assistive personnel about handling clients bed lines safely. which of the following instructions should the nurse include?

tie linen bags securely at the top

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 identify delayed gastric emptying

a client is about to undergo an elective surgical procedure. which of the following is the role of the nurse providing preoperative care regarding informed consent?

witness the clients signature

A nurse is reinforcing teaching with a group of assistive personnel about hand hygiene. Which of the following statements by an AP should the nurse identify as an indication that the AP requires further teaching?

"As long as I change my gloves between clients, it is not necessary to wash my hands."

A nurse is caring for a client who received a sedative medication at bedtime and becomes confused during the night. The client falls while getting out of bed, sustaining a laceration to the head that requires suturing. which of the following notations should the nurse make when documenting in the clients medical record?

"Client found lying on the floor with a 3 cm laceration 1 cm above left eyebrow. client orientated to name only"

A nurse is preparing to document a clients information in the electronic medical record. Which of the following nursing statements identifies the purpose of documentation?

"Documentation provides a communication tool for the health care team."

A nurse is caring for a client who has an electrical burn. With the clients permission, the nurse is answering questions from the family about his status. which of the following responses should the nurse make?

"He has an electrical burn. He is stable, and we will update you with any changes."

A nurse is reinforcing teaching with a client who is obese and has obstructive sleep apnea about how to decrease the number of apneic episodes he has each night. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I am going to try to lose about 50 pounds"

A nurse is reinforcing teaching for a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

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

A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs further reinforcement of teaching?

"I have a set of my brother's crutches in my basement that I can also use."

A nurse is caring for a client who has a new diagnosis of chronic renal failure. The nurse should recognize which of the following client statements as an indication of anticipatory grief?

"I just can't believe that my whole like is going to be ruined by dialysis."

A nurse is reinforcing teaching for with a client about healthful sleep habit. Which of the following statements should the nurse identify as an indication that the client needs further instructions?

"I watch television until I fall asleep at night"

A nurse is assisting with discharge planning. Which of the following statements indicates that the nurse understands when to begin offering her input into the client's discharge plan?

"I will begin upon the clients admission to the facility."

A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. The client says, "Go away! no one can help me." Which of the following response should the nurse make?

"I will come back later and we can talk"

A nurse is reinforcing teaching about home safety for a client who has a history of falls. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I will place a bath seat in my shower to use when I bathe."

A nurse is reinforcing teaching with a family member about how to position a client when administering enteral feedings at home. Which of the following statements from the family member should the nurse identify as an indication that he understands the instructions?

"I will position the head of the bed 45 degrees during the feeding"

A nurse is reinforcing teaching with a group of AP about caring for clients who require restraints. Which of the following statements by one of the AP's should the nurse identify as indicating understanding of the teaching?

"I will tie the restraints to the moving part of the bed frame"

A nurse is reinforcing teaching with an AP about using ppe while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions?

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

A client receiving oxygen therapy via nasal cannula. When the client asks the nurse why he needs to have oxygen tubing in his nose, which of the following explanations about the cannula should the nurse give him?

"It delivers the low concentration of oxygen you need"

A nurse is reinforcing teaching with a new group of assistive personnel about the importance of hand hygiene. Which of the following statements should the nurse include?

"Make sure the clients wash their hands before they eat."

A nurse is reinforcing teaching with a client about crutch walking using the swing-through gait. Which of the following statements should the nurse include?

"Move both crutches forward, then lift and move your body past the crutches."

a new nurse is seeking advice from her preceptor on whether personal professional liability insurance should be purchased. which of the following statements by the preceptor is appropriate?

"Personal liability coverage is not mandatory, but you should consider purchasing your own coverage"

A nurse is reinforcing preoperative teaching with a client who will undergo abdominal surgery. The nurse explains that the client will wear anti embolism stockings after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

"They'll improve your circulation to keep blood from pooling in your legs."

An AP asks a nurse what precautions he should take when measuring the the vital signs of a client who has pneumonia. Which of the following responses should the nurse make?

"Wear a mask when entering the client's room"

A nurse at an extended care facility is instructing a class of AP about the use of assistive devices during ambulation. Which of the following instructions should the nurse include about assisting clients who use a cane?

"When the client moves, he should move the cane forward first."

A nurse is assisting with the readmission of a client to the medical unit after a transfer to the ICU following a suicide attempt using an overdose of medication. The client looks down at the floor and mumbles, " Hello." Which of the following responses should the nurse make?

"Would you like to talk about what happened"

A nurse on a medical-surgical unit is caring for a client who asks to review his medical record. Which of the following responses should the nurse make?

"You will have to sign a written request for access to your record."

A nurse is preparing a client for magnetic resonance imaging (MRI) which of the following statements should the nurse include when reinforcing teaching?

"You'll have to remove metal objects such as watches and Boyd jewelry"

A nurse is caring for a client who is receiving oxygen at 2 L/min via nasal cannula. From this information, the nurse should identify that the client is receiving which of the following oxygen concentrations?

28% a flow rate of 2 l/min delivers an oxygen concentration of about 28%

A nurse is collecting data from a client about pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following numbers should the nurse document to indicate the intensity of the clients edema?

3+

At 0330, a nurse is caring for a client who is postoperative. The clients IV fluids are infusing at 120ml/hr. how many ml of IV fluid should infuse by 0600?

300ml

A nurse is preparing to administer amoxicillin 320 mg po every 12 hr to an infant. The amount available is 400mg/5 ml. How many ml should the nurse administer per dose?

4 320 x 5 divided by 400=4

A nurse is caring for a client who requires an NG tube. After inserting the tube, the nurse tests the pH of the clients aspirate. Which of the following pH levels should the nurse identify as an indication of correct placement of the tube?

4.0 This is an acidic pH, which indicates gastric drainage. The tube is likely to be in the stomach.

A nurse is preparing to administer 400 ml 60 gtt/ml. how many gtt a min?

50

A nurse is calculating the fluid intake for an infant at the end of an 8hr shift. For oral intake, the infant had 10 ml of medication, 3 oz of formula, and 2 oz of juice. In addition, the infant had IV fluid infusing at 20mL/hr via an IV pump. The nurse should record how many mL of intake on the clients record?

60mL

A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection into the clients ventrogluteal muscle?

90 degrees, with this angle the nurse will deposit the medication deeply into the muscle to ensure rapid absorption the medication due to the vascularity of muscle tissue

A nurse is collecting data about the fluid status of four clients. which of the following clients should the nurse identify as being a risk for fluid volume deficit?

A client who has gastroenteritis and receiving oral fluids

An older adult client in a long-term care facility had a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility?

A reddens area over the sacrum

When auscultating a clients heart sounds, the nurse hears turbulence between S1 and S2. The nurse should document this finding as which of the following?

A systolic murmur

A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?

Add fluid and fiber to diet

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?

Administer the medication under the clients tongue

A nurse on a medical unit is coaching a group of nursing students about the variety of roles nurses assume while working with clients. The nurse should explain that which of the following roles focuses on protecting the client and supporting the clients decisions.

Advocate

A nurse is assisting with the admission of a client who has tuberculosis with a productive cough. Which type of isolation precautions should the nurse initiate for the client?

Airborne

An older adult client falls and fractures her hip while a nurse is assisting her to the bathroom. The client sues the nurse for negligence. the nurse should identify which of the following principles as the standard that will legally determine her liability for the clients injury?

Another staff nurse describes how a reasonably prudent nurse would have performed under the same circumstances

A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. while the client waits for the x-ray technician, which of the following actions should the nurse take? (Select all that apply)

Apply ice to the ankle Apply a compression bandage elevate the foot

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the clients strength?

Ask the client to push her legs and feet against the nurses palms

A nurse is caring for a client who is 1 day postoperative following gynecology surgery and reports incisional pain. Which of the following actions should the nurse take first?

Ask the client to rate her pain on a scale of 0-10

Before administering client medications, the nurse must identify the client. Which of the following methods of identification should the nurse use?

Ask the clients full name and date of birth

A nurse is caring for a client who has schizophrenia. The client asks the nurse about her prescribed medications and their effects. The nurse asks the client why she wants to this information. Which of the following non therapeutic communication techniques is the nurse using?

Asking for an explanation

A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take?

Assist the client to the left sims position This position makes it easier for the enema solution to flow by gravity into the sigmoid and rectum and promotes retention of the solution. The nurse should also have the client's right leg flexed to facilitate tube insertion.

A nurse is planning care for a group of clients. When planning the assignment for an assistive personnel, which of the following activities should the nurse consider unsafe for the AP to perform?

Assisting an older adult client to take acetaminophen the AP crushed in apple sauce

A nurse is collecting data from a client who is 2 days postoperative. The nurse auscultates bilateral breath sounds but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?

Atelectasis Atelectasis is incomplete alveolar expansion or collapse. Breath sounds are absent over areas of alveolar collapse.

A nurse is collecting data from a client who is receiving intermittent enteral feedings. which of the following laboratory values should the nurse identify as an indication that the client needs a change in the formula?

BUN 28mg/dl

A nurse is preparing to collect a specimen from a client for a guaiac test. The client asks what the test will detect in his stool. Which of the following responses should the nurse make?

Blood

A nurse is evaluating an older adult client who is receiving end of life care and has cheyne stokes respirations. Which of the following observation should the nurse identify as confirmation of this respiratory pattern.

Breathing ranging from very deep to very shallow with periods of apnea.

A client tells the nurse that he suspects that he grinds his teeth at night. Along with giving the client a dental referral, the nurse should explain that the client should see a dentist for this problem, which she should document as which of the following disorders?

Bruxism

A nurse is reinforcing teaching to a newly licensed nurse about caring for a client who is a member of the seventh day adventist church. The nurse should include in the teaching that which of the following foods are restricted with this religion?

Caffeinated coffee

A nurse enters a client's room and finds the client pulseless. The nurse knows the client's family has requested do-not-resuscitate (DNR) status from the provider, but the provider has not written the prescription yet. Which of the following actions should the nurse take?

Call the emergency response team Unless the provider writes a DNR prescription, the nurse must make every effort to resuscitate the client. The nurse should follow the facilities protocol for initiating the emergency response procedure.

A nurse is assisting with the care of a client who has developed cariogenic shock. When evaluating circulation to the client's brain, which of the following pulse sites should the nurse use?

Carotid

A nurse is collecting data about a clients circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?

Carotid

A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought a standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take?

Check that the client lifts the walker and then places it down in front of her.

A nurse is providing hygiene care for a client who is immobilized. Which of the following actions should the nurse take? (Select all that apply)

Check the bed linens when removing them for personal items Keep the bath waters temperature between 43.3 (110) and 46.1 (115) Shave the clients hair in the direction of the hair growth

A nurse in a long term care facility finds and older adult client lying on the floor next to the bed. Which of the following actions should the nurse take?

Check the client for injuries

A nurse is preparing to administer an enema when the client states, "My doctor didn't tell me I was suppose to receive an enema." which of the following actions should the nurse take?

Check the clients medical record for the providers prescription

During a change-of shirt report, a nurse sees that a clients IV bag of 0.9% sodium chloride has 900ml fluid left in it. The nurse makes rounds 30 min later and notes that the IV bag is empty. Which of the following actions should the nurse take?

Check the clients respiratory rate and lung sounds

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 reports anxiety, discomfort, and feeling of bloating. Which of the following actions is the nurses priority?

Check to see if the suction equipment is working

A nurse notes that a clients iv tubing has disconnected from the IV catheter, resulting in the clients blood spilling onto the sides of the bed and floor. Which of the following solutions should the nurse use to disinfect the spill?

Chlorine bleach solution

While collecting data from an older adult client, the nurse learns that the client has had difficulty sleeping at night for several months. When evaluating the clients sleep disturbances, the nurse should factor in which of the following principles that can affect older adults and sleep?

Chronic pain and illness interfere with the sleep patterns of older adults

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

Clean under the nail with an orange stick

A nurse is caring for a client who is postoperative. The nurse should recognize that which of the following methods is the most reliable source when determining the intensity of the clients pain?

Client self report of pain The nurse should attempt to obtain a self-report of the clients pain as this is the most reliable method of determining the intensity of a clients pain.

A nurse is caring for a client who reports constipation. The provider has prescribed an enema. Identify the sequence of steps the nurse should take to administer the enema.

Confirm the clients identity by checking her wristband provide for the clients privacy by closing the curtains assist the client into sims position insert the tip of enema tubing in clients rectum

A nurse is caring for a client who is postoperative. When helping to manage the clients pain, which of the following principles should the nurse apply? (select all that apply)

Consider the clients individual expression of pain use scale 0-10 to monitor severity of the clients pain Expect the client to express his pain both verbally and nonverbally

A nurse is assisting with the admission of a toddler who has respiratory syncytial virus. Which of the following types of transmission-based precautions should the nurse initiate?

Contact precautions

A nurse is monitoring a client for complications of immobility. Which of the following findings should the nurse expect? (Select all that apply)

Contractors of extremities Crackles in the lungs Pressure ulcers

A nurse is caring for a client whose hysterectomy wound has eviscerated. Which of the following actions should the nurse take?

Cover the wound with a moist sterile dressing

A nurse is caring for a client who is 2 days postoperative following a right hemicolectomy. When the nurse enters the clients room, he states that, following a bout of coughing, "something popped in my belly." The nurse lifts the sheets and sees that the clients gown is bloody. After sending a coworker to get the charge nurse and call the surgeon, which of the following actions should the nurse take next?

Cover the wound with moist sterile gauze

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the clients lunch tray?

Cranberry juice

a nurse is caring for a client who requires contact precaution. which of the following actions should the nurse take?

Dedicate equipment and supplies for use with the client

A nurse in a dialysis center is caring for a client who has a new diagnosis of end stage renal disease. At the first dialysis treatment, the client tells the nurse, "I decided to come today , but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." The nurse should recognize the client is demonstrating which stage of kubler ross stages of grieving?

Denial

A nurse on a medical-surgical unit is assisting with the admission of a client who has vision loss. Which of the following actions is the nurse's priority?

Describe the environment to the client.

A nurse is caring for an older adult client in a long-term care facility. Which of the following measures should the nurse take first when assisting with planing the clients care?

Determine the clients mobility

A nurse is caring for a client who is receiving enteral tube feedings of a dilute formula. Which of the following complications of enteral tube feeding should the nurse identify as a reason to administer dilute feedings to clients?

Diarrhea

A nurse is caring for a client receiving IV therapy in the left forearm and notices that the site is red, swollen, and warm. Which of the following actions should the nurse perform first?

Discontinue the existing IV infusion

A nurse is contributing to the plan of care for a client who is a seventh day adventist. to provide spiritually and culturally sensitive care, which of the following interventions should the nurse suggest for this client?

Do not schedule diagnostic test on saturdays

A nurse is planning care for a client who is immobile and requires continuous mitten restraints. Which of the following interventions should the nurse contribute to clients care plan? (Select all that apply)

Document restraint checks ever 2 hrs educate the clients family about the restraint use implement passive range of motion excercises

A nurse is preparing to insert an indwelling urinary catheter for a female client. After opening the catheter kit and preparing the supplies, which of the following steps should the nurse perform next?

Don sterile gloves

A nurse is caring for an older adult client who reports occasional constipation. The nurse should inform the client that straining while defecating can cause which of the following?

Dysrhythmias

A nurse is preparing to measure a clients oxygen saturation and notes edema of the clients hands and thickens toenails. The nurse should apply the pulse oximeter probe to which go the following locations?

Earlobe

A nurse is caring for an older adult client who reports constipation. Which of the following recommendations should the nurse make?

Eat raw vegetables

A nurse is collecting data about an IV infusion site on an infant's left hand. Which of the following findings should the nurse identify as indication of an infiltration?

Edema in the palm of the hand

A nurse is having difficulty caring for a client due to interpersonal variables affecting the communication process. Which of the following is an interpersonal variable? (select all that apply)

Education Gender Perception Time

A nurse is caring for a client is establishing a nurse client helping relationship. Which of the following communication techniques should the nurse use during the orientation phase?

Elicit information from the client

A nurse is caring for a group of clients. For which of the following tasks should the nurse wear gloves? (Select all that apply)

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

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to thin the clients respiratory secretions?

Encourage the client to drink more fluids.

A nurse is reinforcing teaching with a client has reports constipation. Which of the following should the nurse discuss as causes of the constipation?

Excessive laxative use Ignoring the urge to defecate inadequate fluid intake

A nurse is caring for a client who is competent, refuses further treatment, and ask to sign out of the hospital against medical advice. The nurse notifies the charge nurse, who tells the nurse that the provider has recommended restraining the client, if necessary to keep her from leaving the hospital. The nurse refuses to implement the action based on the knowledge that restraining the client would be committing which of the following torts?

False imprisonment

A nurse is reinforcing teaching with a client who has fibrocystic breast changes about dietary changes that can help minimize symptoms. Which of the following dietary elements should the nurse instruct the client to limit?

Fat

A nurse is caring for a client who requires a clear liquid diet. Which of the following foods should the nurse allow the client to have?

Grape juice

A nurse is caring for a client who is in the early stages of hypoxia and is receiving oxygen therapy. When collecting data from the client the nurse should expect to find which of the following early indications of hypoxia?

Hypertension

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via an infusion pump. When collecting data about the client receiving this therapy, which of the following factors should the nurse monitor?

IV insertion site

A charge nurse in a long term care facility will be implementing a new protocol to meet the joint commissions national safety goal of preventing health care associated pressure ulcers. when informing the staff nurse about the new standard, the nurse should emphasize that which of the following actions is the priority?

Identify the clients at greatest risk for development of pressure ulcers.

A home health nurse is caring for a client who has emphysema and has difficulty with mobility. The client spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect?

Increase calcium excretion Prolonged immobility leads to the breakdown of bone tissue. This results in increased calcium excretion.

A nurse is collecting data from 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)

Increase in neutrophils Localized edema

A nurse is planning home care for a school age child who is awaiting discharge to home following an acute asthma attack. Which of the following growth and development stages according to Erikson should the nurse consider in the planning?

Industry vs inferiority School age children, according to Erikson's developmental stages of industry vs. inferiority, engage in tasks and activities that help them develop competence and perseverance.

A nurse is measuring an adult clients tympanic temperature. Which of the following actions should the nurse take?

Insert the probe with a circular motion

A nurse is planning to collect data about the abdomen of a client who reports "stomach pain". Which of the following actions should the nurse take first?

Inspect

A nurse notes that the left eyelid of a client who is unconscious remains partially open. To protect the eye, which of the following actions should the nurse take?

Instill ophthalmic ointment into the lower lid

A nurse is developing a therapeutic relationship with a client. The nurse should perform which of the following actions during the working phase of a therapeutic relationship?

Instruct the client about methods to achieve goals

A nurse is collecting data as part of a neurological examination of a client who is receiving treatment for head trauma. Which of the following observations will give the nurse information about the function of the third cranial nerve?

Instruct the client to look up and down without moving his head. The nurse should observe the clients extra ocular eye movements as part of an evaluation of the function of the third cranial nerve.

A nurse is working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take? Select all that apply)

Instruct the clients to use the call light Place a fall risk wristband on each of the clients

A nurse is caring for several clients at various developmental stages. The nurse understands that according to Erikson, acceptance of death occurs at which of the following stages of psychosocial development?

Integrity vs. Despair

A nurses sibling had a diagnostic test at the nurse facility. The sibling ask the nurse to look up the result in the computer. The nurse should identify which of the following reason for her decision about her siblings request?

It is not permissible because there is no nurse-client relationship between the sibling and the nurse

A nurse on a medical unit is caring for a client who requires seizure precautions. Which of the following interventions should the nurse contribute to the clients plan of care?

Keep the clients bed in the lowest position.

A nurse is caring for a client who practice Orthodox Judaism. The nurse should identify that which of the following foods together on the same dinner tray violates the clients religious practices?

Kosher roast beef and ice cream prohibit mixing meat and milk products

A nurse is assisting with the care of a client who arrives at the emergency department after an industrial explosion. the nurse inspects the wound on the clients leg has and finds torn skin tissue underneath. the nurse should report this as which of the following types of wounds?

Laceration

A nurse is preparing medication for a client when another client has an emergency. Which of the following actions should the nurse take?

Lock the medication in a room and finish preparing it after returning from the emergency

A nurse is assisting a client who has generalized weakness out of bed to a wheelchair. Which of the following actions should the nurse take?

Lock the wheels of the bed and the wheelchair

A nurse is preparing to help with transferring a client who can partially assist to a gurney. Which of the following actions should the nurse take?

Lower the head of the bed

A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?

Lower the height of the solution container.

A nurse is caring for a client who ingested a poison and is now having seizures. Which of the following is the priority action the nurse should take?

Maintain the latency of the clients airway.

A nurse is caring for a client on a medical-surgical unit who is attempting to leave the facility. Which of the following actions should the nurse take?

Make sure the client understands the he is leaving against medical advice.

A nurse is administering an IM injection using a passive needle safety device. After injection, which of the following actions should the nurse take?

Make sure the needle retracts into the barrel of the syringe

A provider is discharging a client with a prescription for home oxygen therapy. The nurse should reinforce with of the following instructions with the client and his family? (Select all that apply)

Make sure the straps on the mask are secure but not too tight Check the tops of his eats regularly for skin breakdown Post "no smoking" warning signs at home in a prominent location

A nurses inadvertent medication error results in a severe allergic reaction and prolongs the clients hospitalization. the client could rightfully sue the nurse for which of the following?

Malpractice

A nurse is caring for a client who requires droplet precautions. Which of the following ppe is should the nurse wear when setting up the clients meal tray?

Mask

A nurse is caring for a client who requires isolation has just finished a care procedure. Which of the following pieces of ppe should the nurse remove last?

Mask

An older adult client who lives alone tells the nurse at the clinic that he is unable to drive himself to the store and is afraid to cook on the stove. The nurse should recommend which of the following community resources for this client?

Meals on wheels

A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?

Measure from the clients heel to the popliteal space

A nurse is caring for a client whose arterial blood gases include a pH of 7.30 and HCO3- of 18 meq/L and a paCO2 of 28 mm Hg. The nurse should suspect that the client has developed which of the following acid-base imbalance?

Metabolic acidosis

A nurse is collecting data from a client who reports persistent vomiting, dizziness, palpitations, and numbness and tingling in his fingers and toes and around his mouth. The nurse notes the clients respirations are slow and shallow. The nurse should suspect that the client has developed which of the following acid-base imbalances?

Metabolic alkalosis

A nurse is caring for an older adult client who has confusion and weakness. The client has a HCT of 53%, a BUN of 25 mg/dl and a urine specific gravity of 1.232. Which of the following actions should the nurse contribute to the clients plan of care? (select all that apply)

Monitor the clients intake and output Weigh the client daily Instruct the client to sit on the side of the bed for a few minutes before standing Check the clients orientation to person, place, and time regularly

A nurse in an extended-care facility is reinforcing teaching for with a group of newly licensed nurses about the expected physiologic changes of aging. Which of the following information should the nurse include? (Select all that apply)

More difficulty seeing due to a greater sensitivity to glare decreased cough reflex decreased bladder capacity Dehydration of intervertebral discs

A nurse is collecting data from a client who has Bell's palsy. which of the following findings should the nurse expect? (Select all that apply)

Muscle distortion Pain behind ear Impaired taste

After signing an informed consent form, a client tells the nurse, "I have changed my mind and do not want to have the procedure." Which of the following actions should the nurse take?

Notify the surgeon that the client wishes to withdraw informed consent for the procedure

A client receives the wrong medication in error. The nurse who made the medication error should do which of the following first?

Observe the client

A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. which of the following actions should the nurse take?(select all that apply)

Offer the client a back rub remind the client to use incisional splinting identify the clients pain level change the clients position

A nurse is caring for a client who states, " I have got to get out of this hospital! They have found my address and are coming for my family!" The nurse responds, "Don't worry, no one will harm your family" What type of non therapeutic communication technique does this response represent?

Offering false reassurance

A nurse is reinforcing teaching with a client who is to collect stool at home for a fecal occult blood test. Which of the following should the nurse instruct the client to avoid 3 days before the test?

Orange juice

A nurse plans to reinforce discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Pain

A nurse is collecting data from a client who has ataxia. Which of the following is appropriate to evaluate the clients ability to safely ambulate?

Perform a Romberg test

A nurse is caring for a client who is postoperative. Which of the following actions should the nurse take to help prevent an incisional infection?

Perform hand hygiene prior to dressing changes

A nurse is attending a social gathering when another guest suddenly coughs weakly once, grasps her throat with her hands and cannot talk. Which of the following actions should the nurse take?

Perform the Heimlich maneuver on the guest.

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to interrupt the transmission of the clients infection?

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

A nurse is reinforcing teaching with a group of assistive personnel about infection control measures on the unit. The nurse should remind the AP's that which of the following is the most effective way to prevent the spread of pathogens during client care?

Performing hand hygiene frequently and consistently

A nurse is collecting data from an older adult client who comes to the clinic with dry, flaky skin on her upper back. Which of the following actions should the nurse take?

Pinch up a fold of skin to check for turgor

A nurse is preparing to transfer a client from a bed to a chair. Which of the following actions should the nurse take?

Place a transfer belt on the client A transfer or gait belt helps stabilize the client during the transfer and helps keep him from falling.

A nurse is preparing to administer the hepatitis B vaccine to a client. Which of the following techniques should the nurse use to locate the deltoid muscle?

Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm.

A nurse is reinforcing teaching with group of newly licensed nurses about preventing needle stick injuries. Which of the following actions should the nurse recommend?

Place uncapped needles in a puncture proof container after use

A nurse in a long-term care facility is observing an assistant personnel changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control?

Places clean linen that touched the floor in the soiled linen bag.

A nurse is preparing to remove a clients urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?

Position the client supine

A nurse is caring for a client whose hand movement is limited. Which of the following actions should the nurse take to assist the client with feeding?

Provide an adaptive feeding device for the client.

A nurse is caring for an older adult client who is at risk for skin breakdown. which of the following interventions should the nurse use to help maintain the client's skin integrity?

Provide the client with a diet high in protein. Inadequate protein, iron, vitamins, and calories increase the risk for skin breakdown.

A nurse whose left hand is dominant is preparing to perform a straight catheterization for a client who is paraplegic. Which of the following actions should the nurse take?

Raise the bed to a comfortable working height

A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?

Raise the head of the bed

A nurse is reinforcing teaching with a newly licensed nurse about zones of personal space. Which of the following examples should the nurse include as representing the personal zone?

Reinforcing teaching with a client

A nurse is discussing indications or urinary catheterization with a newly licensed nurse. which of the following indications should the nurse include? (select all that apply)

Relief of urinary retention Measurement of residua urine after urination presence of an open perineal wound

A nurse is preparing to exit the room of a client who has a draining wound that contains methicillin-resistant Staphlcoccus areus (MRSA) and requires contact precautions. Identify the sequence the nurse should follow to remove PPE after caring for this client.

Remove gloves, eyewear, gown and then mask

A nurse in a long-term care facility enters the day room and finds the window curtains on fire. Clients are panicking and the room is filling with smoke. Indicate the emergency actions the nurse must take.

Remove the clients from the room Activate the fire alarm Close the door Extinguish the fire

When auscultating a clients lungs, the nurse identifies crackles in the left posterior base. Which of the following actions should the nurse take?

Repeat the auscultation after asking the client to breathe deeply and cough

A nurse finds an open vial of morphine lying on top of the cabinet in a clients room. Which of the following actions should the nurse take?

Report the discrepancy immediately

A nurse contributing to the plan of care for a client who practices the muslim faith, which of the following actions should the nurse include in the plan?

Request a meal tray without pork

A nurse delegates the application of wrist restraints for a client who is confused to an AP. The AP padded the wrist restraints and secured the straps to the bed frame with a double knot. Which of the following actions should the nurse take?

Retie the restraint straps with a slipknot

A nurse is collecting data about a client's pulmonary system. While auscultating the clients lungs, the nurse hears continuous gurgling, low pitched sounds over the trachea and bronchi. Which of the following terms should the nurse use to document this finding?

Rhonchi Harsh sounds similar to snoring or moaning. Air passing through swelling or obstructions causes these adventitious breath sounds.

A nurse is documenting information in a clients electronic medical record. which of the following actions should the nurse identify as jeopardizing the confidentiality of the clients data?

Sharing passwords for computer access with colleagues

A nurse is caring for a client who is about to undergo exploratory surgery to remove a malignant tumor and to determine the extent of any metastasis. The client tells the nurse that she is not hopeful that she will recover and begins to cry. Which of the following response should the nurse make?

Sit quietly with the client and follow her cues. This demonstrates using silence and active listening, therapeutic techniques that offer support and acceptance and encourage further communication.

A nurse is collecting data from a client. Which of the following findings should the nurse report to the charge nurse as an indicator of dehydration?

Skin tenting

A nurse is caring for a client who is Hindu and adheres strictly to the traditional dietary laws of this religion. The client has no other dietary restrictions. Which of the following foods should the nurse select as a component of the clients meals?

Steamed vegetables

During an admission interview, a client tells the nurse that he takes echinacea, but does not remember why his provider recommended it for him. The nurse should remind the client that this herbal supplement has which of the following actions?

Stimulates the immune system

A nurse is collecting data from a client who has narcolepsy. Which of the following manifestations should the nurse expect? (Select all that apply)

Sudden attacks of sleep sleep wake cycle hallucinations

A client comes to the clinic reporting chronic low back pain. He asks the nurse to recommend specific exercises for him. Which of the following activities should the nurse suggest?

Swimming

A nurse is assisting with the admission of a client who is about to have elective surgery. the client tells the nurse she feels anxious. which of the following responses should the nurse make?

Tell me more about your concerns

A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. the nurse should monitor the client for which of the following expected outcomes after catheter removal?

Temporary urinary retention

A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?

Test the pH of gastric aspirate

A nurse is reviewing the goals of a nurse-client therapeutic relationship with a newly licensed nurse. Which of the following information should the nurse include in the teaching?

The client achieves optimal personal growth

A nurse in a long-term care facility sees a client who is choking. Which of the following data should the nurse identify the abdominal thrust?

The client cannot speak

A nurse is completing an incident report after finding a client lying on the floor. Which following information is appropriate for the nurse to include?

The client was lying on the floor next to his bed

A nurse is observing a clients nonverbal behavior. When evaluating this behavior, the nurse should factor in which of the following principles that influence nonverbal communication?

The clients sociocultural background influence nonverbal communication. Sociocultural backgrounders has a major influence on what a clients nonverbal behavior means.

A nurse is caring for a client who has impaired renal function. The nurse should notify the provider if clients hourly urine output falls below what amount?

The nurse should report a urinary output that is less than 30 mL/hr to the provider. This indicates a fluid imbalance, a decreased circulating, fluid volume, and possible inadequate renal perfusion.

A charge nurse is observing a staff nurse caring for a client who has multiple skin lesions from a varicella zoster infection. Which of the following actions should the charge nurse identify as an indication that the nurse understands the precautions to take when caring for a client who has this infection?

The nurse wears a high-efficiency particulate air (HEPA) filter mask.

A nurse is collecting data from a client who sustained blood loss. Which of the following findings should the nurse identify as a manifestation of hypovolemia?

Thready pulse

A nurse is caring for a client who has a chest tube to water seal drainage plans to straighten the clients bed linens, rub her back, and assist her to reposition in bed. For which of the following purposes should the nurse perform these actions for these clients?

To modify the clients perception of pain

A nurse is caring for an older adult client who is Chinese and is recovering from bowel obstruction. The client is prescribed a clear-liquid diet and asks the nurse for a cup of hot ginger tea. The nurse should identify that this request is for which of the following purposes?

To promote digestion

A nurse in a long-term care facility is caring for a client who is unresponsive. when performing oral hygiene for the client, which of the following actions should the nurse take?

Turn the client on his side before starting oral care.

A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use?

Two nurses using friction-reducing device.

A nurse is preparing an in-service presentation about preventing health care associated infections. The nurse should include which of the following as a common cause of these infections?

Urinary catheterization

A nurse is emptying a clients urinal when she notices the urine is dark amber, cloudy and has an unpleasant odor. The nurse should identify that these findings are likely to be the result of which of the following?

Urinary tract infection

A nurse is planning to monitor a client for dehydration following several episodes of vomitting and increase in the clients temperature. Which of the following findings should the nurse identify as an indication that the client is dehydrated?

Urine specific gravity of 1.,034