Fundamentals ATI Practice B - rationales

A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? round to the nearest whole number

8 mL/hr

A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use? a. touch the face with a cotton ball b. apply vibrating tuning fork to the client's forehead c. have the client stand with their arms at their sides and their feet together d. perform direct percussion over the area of the kidneys

c. have the client stand with their arms at their sides and their feet together Rationale: A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance.

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess? a. hypotension b. weak, thready pulse c. slow capillary refill d. distended neck veins

d. distended neck veins Rationale: Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? a. "when descending the stairs, I will first shift my weight to my right leg" b. "I should place my crutches 12 inches in front and to the side of each foot" c. "As I sit down, I will hold one crutch in each hand" d. "I will make sure the shoulder rests are snug against my armpits"

a. "when descending the stairs, I will first shift my weight to my right leg" Rationale: to descned stairs, the client should first shift his body weight to his right, unaffected leg

A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client? a. gown b. N95 respirator c. shoe covers d. surgical cap

b. N95 respirator Rationale: The nurse should wear an N95 respirator when providing care for a client who requires droplet precautions as a result of tuberculosis to prevent the transmission of bacteria.

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? a. ask the client to consider a direct donation b. withhold the blood transfusion c. request a consultation with the ethics committee d. ask the client's family to intervene

b. withhold the blood transfusion Rationale: The principle of autonomy ensures that a client who is competent has the right to refuse treatment.

A nurse is caring for a client who requires 24 hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? a. "I had a bowel movement, but I was able to save the urine" b. "I have a specimen in the bathroom from about 30 minutes ago" c. "I flushed what I urinated at 7 am and have saved all urine since" d. "I drink a lot, so I will fill up the bottle and complete the test quickly"

c. "I flushed what I urinated at 7 am and have saved all urine since" Rationale: for a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a. wear sterile gloves when removing the old dressing b. warm the irrigation solution to 40.5(105 degrees farenheit) c. cleanse the wound from the center outward d. use a 20 mL syringe to irrigate the wound.

c. cleanse the wound from the center outward

A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify with the provider? a. medication name b. route of administration c. medication dose d. frequency of administration

c. medication dose Rationale: In the prescription, the medication dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer.

A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? a. place a pillow under the client's knees b. position a trochanter toll under each of the client's hips c. advise the client to wear rubber-soled slippers d. apply an ankle-foot orthotic device to the client's feet

d. apply an ankle-foot orthotic device to the client's feet Rationale: The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress.

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding? a. assign a staff member to feed the client b. provide small handled utensils for the client c. thicken liquids on the client's tray d. arrange food in a consistent pattern on the client's plate

d. arrange food in a consistent pattern on the client's plate Rationale: consistency in preparing the client's plate helps to facilitate self-feeding for clients who have vision loss. Staff can describe the location of food on the plate by using a clock pattern, allowing the client to have greater independence during meals

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following action should the nurse plan to take? a. dissolve each medication in 5 mL of sterile water b. draw up medications together in the syringe c. push the syringe plunger gently when feeling resistance d. flush the tube with 15 mL of sterile water

d. flush the tube with 15 mL of sterile water Rationale: The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication.

A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident? a. "incident report completed" b. "client climbed over the side rails" c. "client found lying on the floor" d. "client was trying to get out of bed"

c. "client found lying on the floor"

A nurse in the emergency department (ED) is caring for a client. Nurses' Notes 1100: Client arrives to ED and reports nausea, vomiting, and diarrhea for 3 days. Client is febrile.1110:Provider at bedside; prescriptions received.1115:IV initiated to right arm with 20-gauge catheter. Acetaminophen and metoclopramide administered. 1200: Client appears fatigued, with no energy. Hair is thin and sparse. Cachectic, with flaccid muscle tone. Oriented x 3, able to move all extremities. Tachycardia, edema to lower extremities. Respirations unlabored, chest clear. Bowel sounds x 4 hyperactive, abdomen distended. Reports no difficulty with urination. Skin dry and scaly with bruises on extremities. Exhibit 2 Medication Administration Record 1115: Acetaminophen 650 mg rectal every 6 hr PRN temperature greater than 38.3° C (101° F)Metoclopramide 10 mg IV every 6 hr PRN nausea/vomiting Exhibit 3 Vital Signs 1100: Temperature 39.2° C (102.6° F) Pulse rate 118/min Respiratory rate 18/min Blood pressure 92/68 mm Hg Oxygen saturation 95%Weight 44.9 kg (99 lb) BMI 17 Click to highlight the findings that indicate the client is malnourished.

-Cachectic, with flaccid muscle tone is correct. The client's lack of energy, flaccid muscle tone, and wasting appearance can be an indication of malnutrition. -Skin dry and scaly with bruises on extremities is correct. The client's dry, scaly, and bruised skin can be an indication of malnutrition. -Pulse rate 118/min is correct. The client's tachycardia can be an indication of malnutrition. -Abdomen distended is correct. The client's abdominal distention can be an indication of malnutrition. -BMI 17 is correct. A BMI of 17 is considered underweight and can be an indication of malnutrition.

A nurse is caring for a client who had a spinal cord injury and has paraplegia. Nurses' Notes Day 1: Client is alert and oriented. Client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities performed once each day. Day 5: Client is alert and oriented. Client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities performed once each day. Feet warm. Pedal pulses 2+ bilaterally.Plantar flexion contractures noted bilaterally. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact. The nurse is reviewing the client's medical record. Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding again.

-Passive range-of-motion exercises to lower extremities performed once each day is correct. The nurse should perform passive range-of-motion exercises to the client's lower extremities two to three times each day to reduce the risk for contractures. -Plantar flexion contractures noted bilaterally is correct. The nurse should place a footboard at the end of the client's bed or apply foot boots to the client's feet to protect the client's heels and decrease the contractures. -Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact is correct. The client has a stage 1 pressure injury on the heel. The nurse should apply foot boots to the client's feet to protect the client's heels and promote healing.

A nurse in the emergency department (ED) is caring for a client who reports abdominal pain. Exhibit 1: Nurses' Notes 1200:Client arrives to ED and reports abdominal pain and no bowel movement for the past 7 days. Client is undergoing chemotherapy for pancreatic cancer and has been taking 40 mg oxycodone extended-release tablets daily for the past 3 months. Client states they have attempted to relieve constipation for the last 7 days with bisacodyl suppositories and magnesium citrate oral suspension. Client reports that neither therapy initiated defecation. 1230:Client transported for abdominal x-ray. 1245:Client returned from x-ray. Provider prescribes a hypertonic cleansing enema. 1300:Procedure explained to client who verbalized understanding. Exhibit 2:Diagnostic Results: 1245: Abdominal x-ray indicates a large amount of fecal material throughout the colon. No evidence of gastrointestinal obstruction observed.Based on the client's clinical findings, which of the following actions should the nurse take?Select all that apply.

Assist the client to a left side-lying position with the right knee flexed is correct. The nurse should place the client in a left side-lying position with the right knee flexed prior to administering an enema. Because the provider prescribed a cleansing enema for the client, the nurse should prepare the client for the procedure. Administer a cleansing enema is correct. The nurse should administer a cleansing enema for the client as a result of the provider's prescription. A cleansing enema is intended to assist with bowel elimination and remove any impacted fecal matter indicated by the abdominal x-ray. Auscultate the client's bowel sounds is correct. The nurse should auscultate the client's bowel sounds to determine the status of the client's peristalsis. This is a necessary part of determining the presence of bowel sounds, which are an indication of the status of the client's gastrointestinal tract. Perform a manual digital examination of the client's rectum is correct. The nurse should perform a manual digital examination of the client's rectum to determine if impacted stool is present. This is a part of the necessary evaluation of the status of the client's gastrointestinal tract.

A nurse is providing discharge instructions to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? Select all that apply

Check the cord routinely for frays or tearing is correct. Oxygen concentrators require electrical power. Safe use of this delivery system includes assessing the electrical function of the device; therefore, the nurse should instruct the client to routinely check the condition of the cord. Consider purchasing a generator for power backup is correct. Loss of electricity prevents the oxygen concentrator from functioning and could deprive the client of necessary oxygen. The nurse should also instruct the family to have the client placed on their municipality's priority list for restoring power after an outage occurs. Observe for signs of hypoxia is correct. The nurse should instruct the family to observe for and report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and respirations, pallor, and cyanosis. Even with supplemental oxygen, the client's status can worsen, resulting in the development of hypoxia.

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (select all that apply) a. place the client in a room with negative airflow pressure b. wear gloves when assisting the client with oral care c. limit each visitor to 2 hr increments d. wear a surgical mask when providing client care e. use antimicrobial sanitizer for hand hygiene

Place the client in a room with negative-pressure airflow is correct. The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions. Wear gloves when assisting the client with oral care is correct. The nurse should wear gloves when assisting the client with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever their hands might come in contact with a client's bodily fluids, such as saliva, and the mucous membranes in the mouth. Use antimicrobial sanitizer for hand hygiene is correct. The nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. Nurses should also wash their hands with soap and water when their hands are visibly soiled.

A nurse is admitting a client. Nurses' Notes 0930: Client reports a sore throat, productive cough, shortness of breath, and fever for the past 4 days. 1030: Client has swollen lymph nodes of the neck upon palpation. Client reports chills and coughs up yellow-colored mucus. Client's face is flushed and diaphoretic. States lack of appetite. Chest x-ray obtained and positive for pneumonia. Vital Signs 1030: Blood pressure 110/68 mm Hg Heart rate 110/min Respiratory rate 24/min Temperature 38.6° C (101.5° F) Oxygen saturation 91% on room air The nurse is reviewing the client's medical record. Which of the following actions should the nurse take?

Place the client on droplet isolation precautions is correct. The nurse should identify that the client has pneumonia, which is transmitted through droplets greater than 5 microns in the air. Therefore, the nurse should place the client on droplet isolation precautions. Apply oxygen at 2 L/min via nasal cannula is correct. The nurse should identify that the client's oxygen saturation is less than 95% on room air, indicating a decrease in oxygen in the client's blood, which can lead to hypoxia. Therefore, the nurse should apply oxygen at 2 L/min via nasal cannula to the client. Request a prescription for an antipyretic medication is correct. The nurse should identify that the client has a temperature of 36.6° C (101.5° F), indicating a fever. Therefore, the nurse should request an antipyretic medication to treat the client's fever. Remain 1 m (3 feet) from the client is correct. The nurse should identify that the client has pneumonia. Therefore, the nurse should wear a sterile mask and remain within 1 m (3 feet) from the client.

A nurse is admitting a client who reports experiencing a sore throat, productive cough, and fever for the past 3 days. Nurses' Notes 1000: Client reports sore throat, productive cough with yellow-colored mucus, and fever for the past 3 days. Client has swollen lymph nodes. Client also reports headache that, "won't go away." Client's face is flushed and diaphoretic. Throat culture and blood work obtained as prescribed. The nurse is reviewing the client's medical record. Which of the following actions should the nurse take?

Request a prescription for an antibiotic medication is correct. The nurse should identify that the client has streptococcal pharyngitis due to the client's manifestations and a positive throat culture. Therefore, the nurse should request an antibiotic medication, such as penicillin, to treat the client's infection. Initiate droplet precautions is correct. The nurse should identify that the client has streptococcal pharyngitis, which is transmitted through droplets greater than 5 microns in the air. Therefore, the nurse should initiate droplet precautions for the client. Wear a mask within 1 m (3 feet) of the client is correct. The nurse should identify that the client has streptococcal pharyngitis. Therefore, the nurse should wear a mask when within 1 m (3 feet) of the client to prevent the spread of the infection. Apply a mask on the client when they leave their room is correct. The nurse should identify that the client has streptococcal pharyngitis. Therefore, the nurse should apply a mask on the client when they leave their room to prevent transmission of the infection.

A nurse in a medical-surgical unit is caring for six clients. Nurses' Notes​ 0800: Client 1: Client is admitted with a new diagnosis of rheumatoid arthritis. Client 2: Client has a history of hyperlipidemia. Atorvastatin 20 mg PO administered as prescribed. Client 3: Client is 1 day postoperative. Reports pain as 8 on a scale of 0 to 10. Morphine 5 mg subcutaneous administered as prescribed. Client 4: Client is admitted with a new diagnosis of heart failure. Client 5: Client has a stage 2 pressure injury on the left heel. Client 6: Client is admitted with a new diagnosis of diabetes mellitus. Complete the following sentence by using the lists of options.

The first client the nurse should asses is CLIENT 3 followed by CLIENT 4 Rationale: Client 3 is correct. When using the airway, breathing, circulation approach to client care, the nurse should determine that this client is the priority client to assess. The client has an oxygen saturation that is less than the expected reference range, which is an indication of hypoxia. Client 4 is correct. When using the airway, breathing, circulation approach to client care, the nurse should determine that this client is the next priority client to assess. The client has a potassium level that is less than the expected reference range, which places the client at risk for dysrhythmias.

A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity? a. a client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. b. a client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes c. a client who has a DNR order has a cardiac arrest, and the nurse does not perfrom CPR despite requests from the client's family d. a client who is about to undergo a painful procedure receives pain medication 30 minutes before the procedure that the nurse previously promised to administer

a. a client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. Rationale: Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others.

A nurse is preparing to delegate client care tasks to an assistive personnel(AP). Which of the following tasks should the nurse delegate? a. ambulating a client who is postop b. inserting an indwelling urinary catheter for a client c. demonstrating the use of an incentive spirometer to a client d. confirming that a client's pain has decreased after receiving an analgesic

a. ambulating a client who is postop Rationale: Ambulating a client is within the range of function of an AP. The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching.

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as priority? a. auscultate lung sounds b. measure urine output c. monitor blood pressure readings d. monitor electrolyte levels

a. auscultate lung sounds Rationale: The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and shortness of breath.

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care? a. wrap blankets around all 4 sides of the bed b. apply restraints during seizure activity c. place the client in a supine position during seizure activity d. have a tongue depressor at the client's bedside

a. wrap blankets around all 4 sides of the bed

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? a. "I'm having mild pain" b. "the pain is like a dull ache in my stomach" c. "I notice that the pain gets worse after I eat" d. "the pain makes me feel nauseous"

b. "the pain is like a dull ache in my stomach" Rationale: The client is describing the quality of the pain, which is how the pain feels in the client's own words

A nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? a. .3 mg b. 0.3 mg c. 0.30 mg d. 3/10 mg

b. 0.3 mg Rationale: The use and placement of a decimal point can potentially cause a medication error if documented incorrectly. A zero should precede a decimal point, as in 0.3 mg, but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg.

A community health nurse is checking blood pressure for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension? a. a client who is 52 years old b. a client who smokes one pack of cigarettes each day c. a client who walks for 30 minutes every day d. a client who drinks one glass of wine 3 times per week

b. a client who smokes one pack of cigarettes each day Rationale: A client who smokes one pack of cigarettes each day is at an increased risk for hypertension.

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? a. describe the procedure to the client b. witness the client's signature on the consent form c. inform the client of alternatives to the procedure d. tell the client which team members will assist with the procedure

b. witness the client's signature on the consent form Rationale: The nurse is responsible for witnessing the client sign the consent form. The nurse should confirm that the client appears competent to give consent and that the client understands the procedure.

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have routine screening. What does that involve?" Which of the following responses should the nurse make? a. "I'll get a blood sample from you and send it for a screening test." b. "beginning at age 60, you should have a colonoscopy" c. " you should have a fecal occult blood test every year" d. "the recommendation is to have a sigmoidoscopy every 10 years'

c. " you should have a fecal occult blood test every year" Rationale: Colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a fecal occult blood test annually.

A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include? a. client flow sheet b. acuity ranges c. current medications d. incident reports

c. current medications Rationale: the nurse should include the client's medications in the discharge summary to ensure client safety and continuity of care

A client who is non ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next? a. activate the emergency fire alarm b. extinguish the fire c. evacuate the client d. confine the fore

c. evacuate the client Rationale: According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area.

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make? a. "most people are happy when their children grow up and leave home" b. "you should be proud that your children are becoming independent" c. "maybe you should consider why you are feeling useless" d. "people in middle adulthood often find satisfaction in nurturing and guiding young people"

d. "people in middle adulthood often find satisfaction in nurturing and guiding young people"

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? a. a client who has a history of physical abuse b. a client who has a permanent pacemaker c. a client who has ulcerative colitis d. a client who has asthma

d. a client who has asthma Rationale: Some essential oils can cause bronchospasm; therefore, the nurse should consult the client's provider before using this therapy for a client who has asthma.

A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile infection. Which of the following information should the nurse include in the teaching? a. assign the client to a room with a negative airflow system b. use alcohol-based hand sanitizer when leaving the client's room c. clean contaminated surfaces in the client's room with a phenol solution d. have family members wear a gown and gloves when visiting

d. have family members wear a gown and gloves when visiting Rationale: Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Staff must also wear gowns and gloves.

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? a. place the client in high-Fowler's position. b. increase the client's intake of carbohydrates c. massage reddened areas with unscented lotion d. have the client use a trapeze bar when changing position

d. have the client use a trapeze bar when changing position

A nurse is caring for a client who has a pressure injury. Nurses' Notes Day 1: Client is alert and oriented to person, place, and time. Client has stage 2 pressure injury on coccyx. Wound tissue is pink with no drainage. Lungs clear on auscultation. Heart sounds are regular. +2 peripheral pulses and no presence of edema in lower extremities. Bowel sounds active x 4 quadrants. Client ate 50% of breakfast. Client reports pain to pressure injury as 2 on a scale of 0 to 10. Client repositioned every 2 hr while in bed. Day 4: Client has stage 2 pressure injury on coccyx. Wound tissue is yellow with purulent drainage. Wound has foul odor. Client ate 75% of breakfast. Client reports pain to pressure injury as 6 on a scale of 0 to 10. Client repositioned every 2 hr while in bed. Vital Signs Day 4: Temperature 38.3° C (101° F) Pulse rate 80/min Respiratory rate 20/min Blood pressure 128/64 mmHg Oxygen saturation 93% on room air Diagnostic Results Day 4: Potassium 4.2 mEq/L (3.5 to 5 mEq/L)Hgb 13 g/dL (12 to 16 g/dL) Hct 38% (37% to 47%) WBC count 12,000/mm3 (5,000 to 10,000/mm3) Prealbumin12 mg/dL (15 to 36 mg/dL) Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again.

-Temperature is correct. The nurse should identify that the client has a fever, which is a manifestation of an infection. Therefore, the nurse should report this finding to the provider. -WBC count is correct. The nurse should identify that the client has a WBC count that is greater than the expected reference range, which is a manifestation of an infection. Therefore, the nurse should report this finding to the provider. -Prealbumin level is correct. The nurse should identify that the client has a prealbumin level that is lower than the expected reference range. This is a manifestation of malnutrition, which contributes to delayed wound healing. Therefore, the nurse should report this finding to the provider. -Pain level is correct. The nurse should identify that the client's pain level has increased over 3 days and is an indication of complications associated with wound healing. Therefore, the nurse should report this finding to the provider. -Odor of wound is correct. The nurse should identify that a foul odor of a wound is a manifestation of an infection. Therefore, the nurse should report this finding to the provider.

A nurse is caring for a client. Medical History Client is receiving chemotherapy for treatment of breast cancer. Diagnostic Results Week 1: Hct 42% (37% to 47%) Hgb 15 g/dL (12 g/dL to 16 g/dL) WBC count 8,000/mm3 (5,000 to 10,000/mm3) Platelet count 350,000/mm3 (150,000 to 400,000/mm3) Potassium 3.7 mEq/L (3.5 to 5 mEq/L) Week 2: Hct 37% (37% to 47%) Hgb 12 g/dL (12 g/dL to 16 g/dL) WBC count 6,000/mm3 (5,000 to 10,000/mm3) Platelet count 100,000/mm3 (150,000 to 400,000/mm3) Potassium 3.6 mEq/L (3.5 to 5 mEq/L) Complete the following sentence by using the lists of options.

The client is at risk for BLEEDING as evidenced by the client's PLATELET COUNT. Bleeding is correct. The client's platelet count is less than the expected reference range. Therefore, the client is at risk for bleeding. Platelet count is correct. The client's platelet count is less than the expected reference range. Therefore, the client is at risk for bleeding.

A nurse is caring for a client who has a newly placed ileostomy. Exhibit 1 Nurses' Notes 0800: Client is 2 days postoperative following an ileostomy. Pouch is one-fourth full of stool. Stoma is red. Abdomen is soft and nontender. Bowel sounds present in all quadrants. 1200:Stoma site appears dark purple with blistering on the skin around the stoma. Pouch is slightly leaking and is three-fourths full of brown, liquid stool. Exhibit 2 Diagnostic Results 1200: Hgb 19 g/dL (12 to 16 g/dL)Hct 46% (37% to 47%)The nurse should first address the (pick one)-stoma color-hemoglobin level-ostomy leakagefollowed by the(pick one)-ostomy pouch seal-skin around the stoma-amount of stool in the pouch

The nurse should first address the ____________ followed by the ________. Rationale: Stoma color is correct. The greatest risk to the client is the necrosis of the bowel. The nurse should identify that the color of the stoma indicates the client is at greatest risk for necrosis of the bowel; therefore, the nurse should notify the provider immediately about the color of the client's stoma. Skin around the stoma is correct. The nurse should identify that the skin condition around the stoma is the next priority finding to address because it places the client at risk for infection.

The nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? select all that apply. a. check the cord routinely for frays and tearing b. keep the unit at least 1.2 m (4 feet) away from a gas stove c. consider purchasing a generator for power backup d. observe for signs of hypoxia d. select synthetic clothing and bedding

a,c,d

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make? a. "we can talk about advance directives, and I can also give you some brochures about them" b. "you should set up a time to talk with your provider about that" c. "let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better" d. "why do you want to discuss this without your partner here to plan this with you?"

a. "we can talk about advance directives, and I can also give you some brochures about them" Rationale: With this statement, the nurse offers to provide the information the client needs in a direct and simple way.

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? a. "what could i have done to deserve this illness?" b. "I blame medical science for not curing me" c. "where is my daughter at a time like this? d. "will i ever begin to feel in charge of my life again?"

a. "what could i have done to deserve this illness?" Rationale: The client's terminal illness might prompt the client to review their life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to them.

A nurse is admitting a client who has rubella. Which of the following types of transmission based precautions should the nurse initiate? a. droplet b. airborne c. contact d. protective environment

a. droplet

A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene? a. erythema on pressure points b. lower-extremity pulse strength of 2+ c. fluid intake of 3,000 mL per day d. one bowel movement every other day

a. erythema on pressure points

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? a. gently shake the container of medication prior to administration b. transfer the medication to a medicine cup c. place the client in the semi-Fowler's position prior to medication administration d. verify the dosage by measuring the liquid before administering it

a. gently shake the container of medication prior to administration Rationale: The nurse should gently shake the liquid medication to ensure that the medication is mixed.

A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia(PCA) pump. Which of the following actions should the nurse take? a. instruct the family to refrain from pushing the button for the client while she is asleep b. inform the client that because she is on PCA, vital signs will be taken every 8 hours c. teach the client to avoid pushing the button until pain is above a 7 on a scale of 0-10 d. increase the basal rate and shorten the lock-out interval time if the client's pain level is too high

a. instruct the family to refrain from pushing the button for the client while she is asleep Rationale: The nurse should instruct family members not to activate the button for the client while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain.

A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse? a. the newly licensed nurse places the cap of a bottle of sterile solution on the sterile field b. the newly licensed nurse places sterile objects 2.5 cm (1 in) within the border of the field c. the newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring d. the sterile field is positioned at the level of the newly licensed nurse's waist

a. the newly licensed nurse places the cap of a bottle of sterile solution on the sterile field Rationale: The newly licensed nurse should place the cap with the sterile side up on a clean surface because the outer edges are unsterile and will contaminate the sterile field.

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? a. walking briskly b. riding a bicycle c. performing isometric exercise d. engaging in high-impact aerobics

a. walking briskly Rationale: weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use? a."I can take echinacea to improve my immune system" b. "I can take feverfew to reduce my level of anxiety" c. "I can take ginger to improve my memory" d. "I can take ginkgo biloba to relieve nausea"

a."I can take echinacea to improve my immune system" Rationale: Echinacea is taken to promote immunity and reduce the risk of infection.

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? a. "drink a cup of hot cocoa before bedtime" b. "maintain a consistent time to wake up each day" c. "exercise 1 hour before going to bed" d. "watch a television program in bed before going to sleep"

b. "maintain a consistent time to wake up each day" Rationale: The client should maintain a consistent time for waking up and going to sleep. This helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client.

A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines? a. a nurse who is caring for a client reviews the client's medical chart with a nursing student who is working with the nurse. b. a nurse asks a nurse from another unit to assist with documentation for a client c. a nurse who is caring for a client returns a call to a person appointed in the health care proxy to discuss the client's care d. a nurse discussed a client's status with the physical therapist who is caring for the client.

b. a nurse asks a nurse from another unit to assist with documentation for a client Rationale: Only health care professionals directly caring for a client should have access to the client's medical information; therefore, this is a violation of HIPAA guidelines.

A nurse has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement? a. the tube aspirate has a pH of 7 b. an x-ray shows the end of the tube above the pylorus c. bowel sounds are present on auscultation d. the client reports relief of nausea

b. an x-ray shows the end of the tube above the pylorus

A nurse is giving change of shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of info is the priority for the nurse to provide? a. admitting diagnosis b. breath sounds c. body temperature d. diagnostic test results

b. breath sounds Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds.

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? a. use resuscitation bag with 80% oxygen prior to the procedure b. select a suction catheter that is half the size of the lumen c. place the end of the suction catheter in water soluble lubricant d. adjust the wall suction apparatus to pressure of 170 mmHg

b. select a suction catheter that is half the size of the lumen Rationale: The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? a. rinse the feeding bag with water between feedings b. tell the client to keep the head of the bed elevated at least 30 degrees c. make sure the enteral formula is at room temperature d. wipe the top of the formula can with alcohol

b. tell the client to keep the head of the bed elevated at least 30 degrees Rationale: The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula into the esophagus.

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? a. ensure sterilization of non-disposable items with ethylene oxide b. wrap monitoring cords with stockinette and tape them in place c. cleanse latex ports on IV tubing with chlorhexidine before injecting medication d. wear hypoallergenic latex gloves that contain powder.

b. wrap monitoring cords with stockinette and tape them in place Rationale: Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them.

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of the steps for this procedure. a. inject 5 units of air into the bottle of regular insulin b. withdraw the correct dose of NPH insulin from the bottle c. inject 10 units of air into the bottle of NPH insulin d. withdraw the correct dose of regular insulin from the bottle

c,a,d,b Rationale: The nurse should first inject air into the vial of NPH insulin without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? a. 2 cups of soup b. 1 quart of water c. 8 oz of ice chips d. 6 oz of tea

c. 8 oz of ice chips Rationale: The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid.

A nurse is caring for a client who has recently started using a behind the ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device? a. "this type of hearing aid does not allow for fine tuning of volume" b. "I shouldn't have trouble keeping the hearing aid in place during exercise c. "I expect to hear a whistling sound when I first insert the hearing aid" d. "I will be sure to remove my hearing aid before taking a shower"

d. "I will be sure to remove my hearing aid before taking a shower"

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next? a. rock the client up to a standing position b. pivot on the foot that is the farthest from the chair c. assess the client for orthostatic hypotension d. apply gait belt to the client

c. assess the client for orthostatic hypotension Rationale: The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation? a. urine has an unusual odor b. urine specific gravity is 1.035 c. bladder scan shows 525 mL of urine d. urine is positive for ketones

c. bladder scan shows 525 mL of urine

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? a. neck vein distention b. urine specific gravity 1.010 c. rapid heart rate d. blood pressure 144/82 mmHg

c. rapid heart rate Rationale: tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration? a. purulent exudate b. warmth c. skin blanching d. bleeding

c. skin blanching Rationale: Skin blanching, edema, and coolness at the IV site indicate infiltration.

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include? a. "You should have an eye exam every 2 years" b. "You should receive a tetanus booster every 5 years" c. "You should have a fecal occult blood test every 2 years" d. "You should receive a pneumococcal immunization every 10 years"

d. "You should receive a pneumococcal immunization every 10 years" Rationale: The nurse should instruct older adult clients to receive one of the two pneumococcal vaccines when they are 65 years old. The vaccines can be given to clients who are 19 years of age and older and have certain conditions, such as chronic heart, lung, or liver disease, diabetes mellitus, and alcohol disease, or to those who smoke cigarettes.

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? a. seal unused medications from the facility in a plastic bag b. evaluate the client's ability to self-administer medications c. report an identified discrepancy to The Joint Commission. d. compare prescriptions with medications the client received while at the facility

d. compare prescriptions with medications the client received while at the facility Rationale: When performing medication reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with those the provider has prescribed for the client to take after discharge.

A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following should the nurse identify as a potential indication of elder abuse? a. the caregiver is the client's financial power of attorney b. the client is in a wheelchair with the wheels locked c. the client reports receiving a full bath twice each week d. the caregiver insists on remaining in the room

d. the caregiver insists on remaining in the room

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? a. insert an implanted port b. close a laceration with sutures c. place an endotracheal tube d. initiate an enteral feeding through a gastrostomy tube

d. initiate an enteral feeding through a gastrostomy tube Rationale: It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as psychomotor approach to learning? a. role play b. group discussions c. question-answer meetings d. practice sessions

d. practice sessions Rationale: Practice sessions require psychomotor skills when learning.