General Concepts

When changing the dressing on a pressure ulcer, a nurse notes necrotic tissue on the edges of the wound. Which action should the nurse anticipate that the physician will order? incision and drainage irrigation culture debridement

debridement

The nurse is teaching an older adult how to prevent falls. The nurse should tell the client to: encourage the client to not use assistive devices because they reduce independence. instruct the client not to exercise painful joints. turn on bright lights in the room so the client can see items in the room. instruct the client to rise slowly from a supine position.

instruct the client to rise slowly from a supine position.

Which client is at increased risk for developing a wound infection? a client that does not ambulate on first post-op day a client with a hemoglobin of 11.4 a client with a body mass index (BMI) of 27 A client with an albumin level of 2.4 g/dl

A client with an albumin level of 2.4 g/dl

Indicate on the illustration the area that correctly identifies the position of the distal tip of a central line that is inserted into the subclavian vessel.

above the heart in the superior vena cava

The nurse is taking care of a client with neutropenia. Which nursing action is most important in preventing cross-contamination? wearing protective coverings standing 2 feet (61 cm) from the client speaking minimally when in the room changing gloves immediately after use

changing gloves immediately after use

Which nursing intervention is most important in preventing postoperative complications? progressive diet planning early ambulation pain management bowel and elimination monitoring

early ambulation

A nurse is performing a sterile dressing change. Which action contaminates the sterile field? holding sterile objects above the waist leaving a 1″ (2.5-cm) edge around the sterile field pouring solution onto a sterile field cloth opening the outermost flap of a sterile package away from the body

pouring solution onto a sterile field cloth

The nurse gives a client an oral narcotic analgesic medication to treat postoperative pain. Which follow-up assessment most clearly indicates that the treatment was effective? Within 10 minutes the client is moving down the hall. Within 30 minutes the client says that the pain is reduced. Within 40 minutes the client breathes slowly with eyes closed. Within 20 minutes the client is reading with a relaxed posture.

Within 30 minutes the client says that the pain is reduced.

A client's blood test results are: white blood cell (WBC) count is 1,000/μl; hemoglobin (Hb) level, 14 g/dl; hematocrit (HCT), 42%. Which goal is most important for this client? promote rest promote fluid balance prevent injury prevent infection

prevent infection

A client informs the nurse that the venipuncture site "hurts." The nurse should assess the site for which findings? Select all that apply.

redness pain coolness blanching firmness edema

The nurse recognizes that the goals established for a client's discharge are more likely to be accomplished when

the client assists in developing the goals.

The expected outcome of withholding food and fluids from a client who will receive general anesthesia is to help prevent: pressure on the diaphragm with poor lung expansion during surgery. vomiting and possible aspiration of vomitus during surgery. gas pains and distention during the immediate postoperative period. constipation during the immediate postoperative period.

vomiting and possible aspiration of vomitus during surgery.

Which nursing intervention should the nurse perform for a client receiving enteral feedings through a gastrostomy tube? Check the gastrostomy tube for position every 2 days. Maintain the head of the bed at a 15-degree elevation continuously. Maintain the client on bed rest during the feedings. Change the tube feeding administration set at least every 24 hours.

Change the tube feeding administration set at least every 24 hours.

Which nursing assessment is recommended to confirm placement of the nasogastric (NG) tube into the stomach of a client? Obtain a chest X-ray and measure the pH of stomach contents. Measure NG tube length to confirm it is equal to the distance from the client's ear lobe to the nose plus the distance from the nose to the tip of the xiphoid process. Apply the stethoscope to the xiphoid process and instill 50 mL of air into the tube and listen for a gurgling or popping sound. Measure to the second or third black marking on the NG tube.

Obtain a chest X-ray and measure the pH of stomach contents.

The nurse is caring for a client with a nasogastric tube who is receiving intermittent tube feedings by gravity every 4 hours. The nurse aspirates 75 mL of residual prior to the next feeding. What action should the nurse take next? Return the residual and begin the feeding. Discard the residual and subtract the residual amount from the feeding. Hold the feeding and recheck the residual in 4 hours. Administer an amount of water equivalent to the feeding.

Return the residual and begin the feeding.

During assessment, a nurse measures a client's respiratory rate at 32 breaths/minute with a regular rhythm. When documenting this pattern, the nurse should use which term? Eupnea Bradypnea Apnea Tachypnea

Tachypnea

A clinical educator is discussing nasogastric (NG) tube insertion with a new graduate nurse. What information demonstrates understanding by the graduate nurse to stop, if the client is experiencing difficulty during the procedure? The client's face becomes flushed during the procedure. Initial choking when the tube is placed in the client's nare is normal. The client gags after insertion of the NG tube. The client becomes cyanotic as the NG tube is inserted.

The client becomes cyanotic as the NG tube is inserted.

When performing external chest compressions on an adult during cardiopulmonary resuscitation, how deep should the rescuer depress the sternum? 0.5 in (1 cm) 1 in (2.5 cm) 1.5 in (4 cm) 2 in (5 cm)

2 in (5 cm)

What does the Code of Ethics for Registered Nurses include? Tips for correctly performing a procedure in the hospital environment. Regulations stating criteria for nursing licensure. Bylaws that state clients' rights. A code of ethics that states the nurse's obligation and responsibility to the client.

A code of ethics that states the nurse's obligation and responsibility to the client.

A physician orders morphine for a client who complains of postoperative abdominal pain. For maximum pain relief, when should the nurse anticipate administering morphine? Before the pain becomes severe When the pain becomes severe As seldom as possible to avoid morphine dependency Every 3 hours, whether or not the client has pain

Before the pain becomes severe

Which action must a nurse perform when cleaning the area around a Jackson-Pratt wound drain? Clean briskly around the site with alcohol. Wear sterile gloves and a mask. Remove the drain before cleaning the skin. Clean from the center outward in a circular motion.

Clean from the center outward in a circular motion.

A physician orders hourly urine output measurement for a postoperative client with an indwelling catheter. The nurse records these amounts of output for 2 consecutive hours: 8 a.m. (0800): 50 ml; 9 a.m. (0900): 60 ml. Based on these amounts, which action should the nurse take? Irrigate the indwelling urinary catheter. Increase the I.V. fluid infusion rate. Notify the physician. Continue to monitor and record hourly urine output.

Continue to monitor and record hourly urine output.

Which nursing action is essential when providing continuous enteral feeding? Positioning the client on his left side Elevating the head of the bed Warming the formula before administering it Adding methylene blue to the enteral feeding to detect aspiration

Elevating the head of the bed

A nurse is transferring a client from the bed to a chair. Which action should the nurse take during this client transfer? Position the head of the bed flat. Stand behind the client. Help the client dangle his legs. Place the chair facing away from the bed.

Help the client dangle his legs.

A client has a reddened area over a bony prominence. The nurse finds an unlicensed nursing personnel (UAP) massaging this area. What should the nurse do? Instruct the UAP that massage is contraindicated because it decreases blood flow to the area. Explain to the UAP that massage is effective because it improves blood flow to the area. Reinforce the UAP's use of this intervention over the bony prominence. Inform the UAP that massage is even more effective when combined with the use of lotion.

Instruct the UAP that massage is contraindicated because it decreases blood flow to the area.

A client who is on nothing-by-mouth status is constantly asking for a drink. Which nursing intervention is the most appropriate? Offer ice chips every hour to decrease thirst. Divert the client's attention by turning on the television. Offer the client frequent oral hygiene care. Reexplain to the client why she cannot drink.

Offer the client frequent oral hygiene care.

Which statement is a guideline to help nurses protect themselves from liability? Obtain malpractice insurance. Practice within the scope of the nursing standards of practice.. Follow all physician's orders. Do what the client desires even though the nurse may disagree.

Practice within the scope of the nursing standards of practice..

The nurse is taking care of a client who has an infusion pump. The pump alarm rings. What should the nurse do in order from first to last? All options must be used.

Silence the pump alarm. Assess the client's access site for infiltration or inflammation. Assess the tubing for hindrances to flow of solution. Determine if the infusion pump is plugged into an electrical outlet.

A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, what should the nurse do? Massage the abdomen once a shift. Institute range-of-motion (ROM) exercise every 4 hours. Elevate the lower extremities. Use an alternating air pressure mattress.

Use an alternating air pressure mattress.

A nurse is changing a dressing and providing wound care. Place the following activities in the correct order. All options must be used.

Wash hands thoroughly. Put on latex gloves. Slowly remove the soiled dressing. Assess the drainage in the dressing

A client has an order for a clear liquid diet. The nurse is assisting the client to complete a menu. Which item would be appropriate for the client to order? Select all that apply. apple juice broth cream soup tea pudding

apple juice broth tea

A nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein? chicken cutlet, spinach, and soda spaghetti with cream sauce, broccoli, and tea baked beans, hamburger, and milk bouillon, spinach, and soda

baked beans, hamburger, and milk

A nurse monitors a client receiving enoxaparin 30 mg subcutaneously BID after hip replacement surgery. Which adverse reaction is the client most likely to experience? anaphylactic shock hypersensitivity bronchospasm bleeding

bleeding

A client is recovering from an infected abdominal wound. Which foods should the nurse encourage the client to eat to support wound healing and recovery from the infection? cheese omelet and bacon chicken and orange slices gelatin salad and tea cheeseburger and french fries

chicken and orange slices

Which nursing intervention for catheter care should have the highest priority? cleaning the area around the urethral meatus clamping the catheter periodically to maintain muscle tone changing the location where the catheter is taped to the client's leg irrigating the catheter with several milliliters of normal saline solution

cleaning the area around the urethral meatus

Which clinical signs would indicate to a nurse caring for a terminally ill client that death may be imminent? Narrow pulse pressure and a body temperature of 98.6°F (37°C) respirations regular at 18 breaths/min and weak pedal pulses swallowing reflex and bowel sounds present diminished urine output and Cheyne-Stokes respirations

diminished urine output and Cheyne-Stokes respirations

A nurse is assessing a client for the risk of falls. The nurse should obtain the family's psychosocial history. gait and balance information. the facility's restraint policy. the client's level of activity at home.

gait and balance information.

A nurse is caring for a client with diarrhea caused by Clostridium difficile. Which personal protective equipment should the nurse use? Select all that apply. gloves mask gown shoe covers eye protection

gloves gown

A staff nurse on the oncology unit must teach the new unit assistant about infection-control practices. The nurse should explain that which measure is most important for preventing the spread of infection? using sick time when not feeling well performing proper hand hygiene restricting fresh fruit and flowers from the client's room double-bagging contaminated body fluids

performing proper hand hygiene

The nurse should plan to use an abduction pillow (or splint) after a total hip replacement to: prevent hip flexion. increase peripheral circulation. prevent dislocation of the prosthesis. decrease formation of sacral pressure ulcers.

prevent dislocation of the prosthesis.

When changing a sterile surgical dressing, a nurse first must remove the old dressing while wearing clean gloves. open sterile packages and moisten the dressings with sterile saline solution. wash her hands. put on sterile gloves.

wash her hands.

A nurse has been asked to obtain a client's signature on an operative consent form. When the nurse approaches the client, who is scheduled for a cholecystectomy later in the day, the client asks the nurse why the procedure is needed. Which response by the nurse is appropriate? "You have stones in your gallbladder and the treatment is to remove the gallbladder." "I will ask the surgeon to come speak to you about the procedure." "The surgeon feels this is the best option for you at this time based on your symptoms." "This is a common procedure performed using a scope and will relieve your symptoms."

"I will ask the surgeon to come speak to you about the procedure."

A nurse has completed discharge teaching for a client, which involves instructions for changing a leg dressing. Which statement would indicate that the teaching has been effective? "The dressing should be changed next time I have an appointment with my healthcare provider." "I will report any signs of redness or drainage when I change the dressing." "I should change this dressing once a week when it starts to hurt." "I don't need to worry about this dressing because the home health nurse will change it."

"I will report any signs of redness or drainage when I change the dressing."

The nurse is to administer insulin to a client with diabetes mellitus. Which illustration indicates the appropriate syringe to use?

the normal insulin needle

A nurse is teaching a group of nursing assistants about infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is: administering antibiotics. assigning clients to private rooms. washing hands. wearing gloves.

washing hands.

A nurse having difficulty setting up humidified oxygen at 40% per Venturi mask doesn't know how many liters of flow should be used. Which intervention should the nurse perform to ensure that the oxygen is properly administered? Read the package directions. Use a conventional oxygen mask. Ask a nursing assistant what to do. Consult with a respiratory therapist.

Consult with a respiratory therapist.

The laboratory notifies the nurse that a client who had a total knee replacement 3 days ago and is receiving heparin has an activated partial thromboplastin time (aPTT) of 95 seconds. After verifying the values, the nurse calls the health care provider (HCP). What prescription for the client should the nurse recommend the HCP consider?

protamine sulfate

The nurse is caring for a client on a ventilator in the intensive care unit (ICU). A person who identifies as a neighbor approaches the nurse and asks how many days will the client remain in the ICU. What is the best response by the nurse? " I encourage you to speak with the healthcare provider about the plan of care." " I am unable to share medical information without authorization by the client." "In my experience, clients such as this spend about 2 weeks in the ICU." "It is very hard to predict how long a client will remain in the ICU."

" I am unable to share medical information without authorization by the client."

Two days following abdominal surgery, a client is refusing to take a narcotic pain medication, even though the pain rating is an 8 on a 0 to 10 scale. The client tells the nurse, "I don't want to get dependent on that stuff." Which response from the nurse is the most appropriate? "You don't need to worry about becoming addicted so soon." "Newer pain medications don't cause dependence or addiction." "You will recover more quickly and more effectively if you take pain medication now." "It's your right to not take pain medication."

"You will recover more quickly and more effectively if you take pain medication now."

A physician orders a soap suds enema, 500 ml. What does this amount equal in liters?

0.5 L

The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. When coaching the client about the diet, what should the nurse do first? Determine the client's knowledge level about cholesterol. Ask the client to name foods that are high in fat, cholesterol, and salt. Explain the importance of complying with the diet. Assess the client's and family's typical food preferences.

Assess the client's and family's typical food preferences.

The nurse is making rounds and observes the client receiving oxygen (see figure). What should the nurse do next? Position the mask lower on the client's nose. Loosen the elastic band on the client's face. Verify that the reservoir bag remains deflated. Confirm that the flow rate is set to deliver oxygen at 6 to 10 L/min.

Confirm that the flow rate is set to deliver oxygen at 6 to 10 L/min.

While assessing the incision of a client who had surgery 2 weeks ago, a nurse observes that the suture line has a shiny, light pink appearance. Which step should the nurse take next? Continue to monitor the suture line, and document findings. Prepare the client for debridement of the suture line. Apply normal saline solution to keep the wound moist. Notify the physician that the wound may be infected.

Continue to monitor the suture line, and document findings.

As the nurse assists the postoperative client out of bed, the client reports having gas pains in the abdomen. To reduce this discomfort, what should the nurse do? Encourage the client to drink carbonated liquids. Encourage the client to ambulate. Insert a nasogastric (NG) tube. Insert a rectal tube.

Encourage the client to ambulate.

Which is the correct technique when the nurse is applying an elastic bandage to a leg? Secure the bandage with clips over the area of the inner thigh. Start at the distal end of the extremity and move toward the trunk. Overlap each layer twice when wrapping. Increase tension with each successive turn of the bandage.

Start at the distal end of the extremity and move toward the trunk.

A nurse gives a client the wrong medication. After assessing the client, the nurse completes an incident report. Which statement describes what will happen next? The incident report will provide a basis for promoting quality care and risk management. The facility will report the incident to the state board of nursing for disciplinary action. The nurse will be suspended and, possibly, terminated from employment at the facility. The incident will be documented in the nurse's personnel file.

The incident report will provide a basis for promoting quality care and risk management.

When giving a client a tube feeding, what should the nurse do first? Verify position of the tube before beginning feeding. Place the client in a left side-lying position. Aspirate residual gastric contents before the feeding and discard. Warm the feeding solution before administration.

Verify position of the tube before beginning feeding.

Which statement demonstrates a safe practice for taking telephone orders from a healthcare provider? Telephone orders should be avoided therefore, no orders should be taken over the phone. Verify the order by reading it back to the physician. The order must be authenticated by the ordering physician within 72 hours. Inform the physician that he can text the order.

Verify the order by reading it back to the physician.

When administering blood, the nurse must check the name on the label of the blood with the name on the client's: Wristband with a family member present. Medical chart with the unit clerk. Medication administration record with the pharmacist. Wristband in the presence of another nurse.

Wristband in the presence of another nurse.

A nurse is obtaining a sterile urine specimen from a client's indwelling urinary catheter. During the procedure, the nurse should disconnect the catheter from the tubing and collect urine. open the drainage bag and pour out some urine. aspirate urine from the tubing port, using a sterile syringe and needle. wear sterile gloves when collecting urine.

aspirate urine from the tubing port, using a sterile syringe and needle.

A client who requested a do-not-resuscitate (DNR) order upon admission to the hospital now states a desire for the medical team to do everything possible to help the client get better. The client is concerned about the DNR order. Which response by the nurse is best? "Do you want to rescind the DNR, or just change it?" "Have you talked this over with your family?" "It isn't a problem to rescind your DNR order; I'll let your physician know your wishes right away." "You know that we will do everything needed to keep you comfortable even though you have the DNR in place."

"It isn't a problem to rescind your DNR order; I'll let your physician know your wishes right away."

The nurse manager of a surgical unit observes a nurse providing colostomy care to a client without using any personal protective equipment (PPE). What is the most appropriate response by the nurse manager in relation to PPE use? "You should be aware that PPE is used when caring for any client in the hospital." "PPE should be used when you risk exposure to blood or bodily fluids." "In the future, have the physician write an order for PPE for clients with colostomies." "If you're not using PPE, you need to be careful not to touch any of the drainage."

"PPE should be used when you risk exposure to blood or bodily fluids."

A physician orders a bland, full-liquid diet for a client. Which response, if made by the client, would indicate to the nurse that the client has understood the nurse's dietary teaching? "Today I can have apple juice, chicken broth, and vanilla ice cream." "For breakfast I will choose pineapple juice, a bran muffin, and milk." "I will have orange juice, farina, and coffee." "I can have oatmeal, custard, and tea."

"Today I can have apple juice, chicken broth, and vanilla ice cream."

The nurse is observing a spouse administer eye drops, as shown in the figure. What should the nurse instruct the spouse to do? Administer the drops in the center of the lower lid. Move the dropper to the inner canthus. Have the client raise the eyebrows. Have the client squeeze both eyes after administering the drops.

Administer the drops in the center of the lower lid.

The nurse is collaborating with the physician to develop a care plan to help control chronic pain in a client with cancer who is receiving hospice home care. Which of the following plans would be most appropriate for managing the client's pain? Keeping the client sedated with tranquilizers to prevent awareness of pain sensations. Administering analgesics on a regular basis, with administration of additional analgesics for break-through pain. Encouraging the client to avoid intravenous pain medication until the client's condition has reached the terminal stage. Administering analgesics when the client's vital signs indicate that the severity of the pain is increasing.

Administering analgesics on a regular basis, with administration of additional analgesics for break-through pain.

A client requests a narcotic analgesic shortly after the oncoming nurse receives change-of-shift report. The nurse who is leaving reported that the client had received morphine 10 mg (IM) within the past hour. In what order from first to last should the oncoming registered nurse (RN) perform the actions? All options must be used.

Assess the client for manifestations of pain. Check the medication documentation as to when morphine 10 mg (IM) was dispensed and to whom. Validate with the outgoing RN that morphine 10 mg (IM) had been administered. Check to ascertain if any discrepancy had been documented with accompanying reasons.

The nurse is performing a surgical dressing change and drops a sterile gauze on the bedside table outside of the sterile dressing tray's field. What would be the appropriate action of the nurse? Use sterile gloves to put the gauze back in the dressing tray. Discard the gauze and use another sterile piece. Use the gauze anyway because the bedside table was clean. Turn the gauze inside out so that the contaminated part is not next to the wound.

Discard the gauze and use another sterile piece.

A client with cancer-related pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia? Document the client's choice and re-assess pain in 1 hour. Emphasize the rationale for taking the medication now as ordered. Ask the client's spouse to hold the client's hands while the nurse puts the pill under the tongue. Try to persuade the client to take the medication as ordered by the doctor.

Document the client's choice and re-assess pain in 1 hour.

A drug must enter the bloodstream before it can act within the body. Which parenteral administration route places a drug directly into the circulation, requiring no absorption? I.M. Subcutaneous (subQ) I.V. Intradermal

I.V.

A nursing instructor is instructing a group of new nursing students. The instructor reviews that surgical asepsis will be used for which procedure? colostomy irrigation instilling eye drops nasogastric tube irrigation IV catheter insertion

IV catheter insertion

A client on prolonged bed rest has developed a pressure ulcer. The wound shows no signs of healing even though the client has received skin care and has been turned every 2 hours. Which factor is most likely responsible for the failure to heal?

Inadequate protein intake

When the nurse performs oral hygiene for an unconscious client, which nursing intervention is the priority? Place the client in a prone position. Use gauze wrapped around the fingers to clean the client's gums. Keep a suction machine available. Wear sterile gloves while brushing the client's teeth.

Keep a suction machine available.

The nurse is caring for a client with a nasogastric tube who is due for an enteral feeding. Which of the following assessments by the nurse would indicate the need to withhold at this time? Select all that apply. Watery contents upon aspiration with a pH of 5 Material like coffee grounds noted in the nasogastric tube Distention of the upper abdomen with vomiting Aspiration of milky contents and reports of nausea Auscultation of air in the epigastric area when checking placement

Material like coffee grounds noted in the nasogastric tube Distention of the upper abdomen with vomiting Aspiration of milky contents and reports of nausea

A healthcare provider obtains informed consent for a surgical procedure after the adult client had received sedation. Which is the nurse's best action? Notify the healthcare provider that the consent is not valid. Request that the client sign a waiver so the surgery can proceed. Call the client's next of kin to sign the surgical permit. Reschedule the procedure for the next day.

Notify the healthcare provider that the consent is not valid.

A client returned from surgery 8 hours ago and has not voided. Which action should the nurse take first? Palpate over the symphysis pubis for fullness. Tell the client to bear down and try to void. Call the health care provider to report the client's condition. Catheterize the client with a straight catheter.

Palpate over the symphysis pubis for fullness.

A hospitalized client is receiving pain medication. The nurse is providing instruction to the unlicensed assistive personnel (UAP) about the care of this client. Which task would be appropriate to delegate to the UAP? Reposition the client for comfort. Ask client about pain level. Collaborate with the RN about what decreases the client's pain. Encourage client to increase fiber in the diet.

Reposition the client for comfort.

The nurse walks into the room of a client who has a "do not resuscitate" prescription and finds the client without a pulse, respirations, or blood pressure. What should the nurse do first? Page the client's health care provider (HCP). Push the emergency alarm to call a code. Stay in the room, and call the nursing team for assistance. Pull the curtain, and leave the room.

Stay in the room, and call the nursing team for assistance.

During a teaching session, a nurse demonstrates to a client how to change a tracheostomy dressing. Then the nurse watches as the client returns the demonstration. Which client action indicates an accurate understanding of the procedure? The client rinses around the clean incision site, using gauze squares moistened with tap water. The client cleans around the incision site, using gauze squares and full-strength hydrogen peroxide. After cleaning around the incision site, the client applies cotton-filled gauze squares as the sterile dressing. The client rinses around the clean incision site, using gauze squares moistened with normal saline.

The client rinses around the clean incision site, using gauze squares moistened with normal saline.

Which example may illustrate a breach of confidentiality and security of client information? The nurse provides information to a professional caregiver involved in the care of the client. The nurse provides information over the phone to the client's family member who lives in a neighboring state. The nurse accesses client information on the computer at the nurse's station then logs off before answering a client's call bell. The nurse informs a colleague that the colleague should not be discussing client information in the hospital cafeteria.

The nurse provides information over the phone to the client's family member who lives in a neighboring state.

The nurse has just received change-of-shift report for four clients. Based on this report, the nurse should assess which client first? an 84-year-old with resolving left-sided weakness who is slightly confused and has been awake most of the night a 52-year-old with pneumonia and chronic back pain who is requesting pain medication a 38-year-old who is 2 days postmastectomy due to breast cancer, having difficulty coping with the diagnosis a 35-year-old admitted after motor vehicle accident whose urine output has totaled 30 mL over the last 2 hours

a 35-year-old admitted after motor vehicle accident whose urine output has totaled 30 mL over the last 2 hours

A client who's a member of Jehovah's Witnesses refuses a blood transfusion based on religious beliefs and practices. The client's decision must be followed based on which ethical principle? autonomy of the client substituted judgment the right to die advance directive

autonomy of the client

When planning pain control for a client with terminal gastric cancer, a nurse should consider that clients with terminal cancer may develop tolerance to opioids. pain medication should be given only when a client requests it. a client who can fall asleep isn't in pain. only low doses of opioids are safe; higher doses may cause respiratory depression.

clients with terminal cancer may develop tolerance to opioids.

While hospitalized, a child develops a Clostridium difficile infection. The nurse can anticipate adding which type of precautions for this client? standard precautions airborne precautions droplet precautions contact precautions

contact precautions

A client has a soft wrist-safety device. Which assessment finding should the nurse investigate further? a palpable ulnar pulse pink nail beds cool, pale fingers a palpable radial pulse

cool, pale fingers

The nurse is developing a primary disease prevention program for older adults. Which topic is the most appropriate? immunizations for influenza diet and exercise for people with heart disease range of motion exercises blood glucose screening for diabetes

immunizations for influenza

The nurse is evaluating a client who is using a flow incentive spirometer (see figure) following abdominal surgery 1 day ago. The client is performing the procedure correctly when the client does what? Select all that apply. inhales before using the spirometer coughs after using the spirometer uses the spirometer once every 8 hours sits upright inhales for 3 seconds following fully expanding the lungs exhales passively before using the spirometer again

inhales for 3 seconds following fully expanding the lungs coughs after using the spirometer exhales passively before using the spirometer again sits upright

The nurse is making rounds and observes a client who is unconscious (see figure). The unlicensed assistive personnel (UAP) has just turned the client from lying on her back and raised the side rail next to the bedside stand. Before raising the side rail on the opposite side, the nurse should: assist the UAP in moving the client closer to the head of the bed. ask the UAP to add a pillow under the right arm. elevate the head of the bed to 30 degrees. inspect the skin at pressure points from the back-lying position.

inspect the skin at pressure points from the back-lying position.

Before inserting a nasogastric (NG) tube in an adult client, the nurse estimates the length of tubing to insert. Identify the point on the illustration where the nurse would end the measurement.

left and below the nipple

The nurse is planning care for a client on complete bed rest. To prevent venous thrombosis, what should the nurse include in the plan of care? Select all that apply. maintaining the client in the supine position passive and active range-of-motion exercises increasing fluid intake to 3,500 mL per day use of thromboembolic disease support (TED) hose turning every 2 hours

maintaining the client in the supine position

A nurse presents a client with the informed consent form for an abdominal paracentesis. The client asks the nurse what the procedure involves. The nurse should explain the procedure and the benefits and risks associated with it, then have the client sign the form. notify the physician that the client doesn't understand the procedure. explain the form and have the client's healthcare power of attorney sign it. have the client sign the form and ask the physician explain the procedure again.

notify the physician that the client doesn't understand the procedure.

Which guidelines define and regulate what the nurse may and may not do as a professional? nurse practice act standards of care state legislature facility policies and procedures

nurse practice act

A client hasn't voided since before surgery, which took place 8 hours ago. When assessing the client, a nurse will palpate the bladder at the umbilicus. palpate the bladder above the symphysis pubis. feel that the bladder is smooth. be unable to palpate the bladder.

palpate the bladder above the symphysis pubis.

Over the past few weeks, a client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure does not comply with a least restraint policy? raising all side rails while the client is in bed placing the client in a bed with a bed alarm raising one bed rail to offer stabilization when standing providing a bed that is low to the floor

raising all side rails while the client is in bed

A nurse is assigned to a client with a cardiac disorder. The nurse should question an order to monitor the client's body temperature by which route? axillary tympanic rectal oral

rectal

Immediately following endoscopy of the upper gastrointestinal tract, it is most important for the nurse to assess for: bowel sounds. intake and output. return of the gag reflex. peripheral pulses.

return of the gag reflex.

Professional regulations and laws that govern nursing practice are in place for which reason? to protect the safety of the public to ensure that enough new nurses are always available to ensure that practicing nurses are of good moral standing to limit the number of nurses in practice

to protect the safety of the public

A client with chronic cancer pain has been receiving opiates for 4 months. She rated the pain as an 8 on a 10-point scale before starting the opioid medication. Following a thorough examination, there is no new evidence of increased disease, yet the pain is close to 8 again. What is the most likely explanation for the increasing pain? tolerance to the opioid withdrawal from the opioid placebo effect has decreased development of an addiction to the opioids

tolerance to the opioid

A nurse is supervising a new nurse who is preparing to perform wound care for a client whose abdominal wound is infected with vancomycin-resistant enterococci. The supervising nurse should make sure that the new nurse wears a gown when entering the client's room. removes the gown first, then the mask, eyewear, and gloves when leaving the client's room. wears a gown, gloves, a mask, and eye protection when entering the client's room. assembles all wound care supplies before entering the client's room.

wears a gown, gloves, a mask, and eye protection when entering the client's room.

A healthcare provider gives the nurse an order over the telephone. Which action is the appropriate nursing action? Verify the order by repeating it back to the healthcare provider. Explain that the healthcare provider must sign the order within 1 hour. No action is needed at this time. Request that a second healthcare provider repeat the order to the nurse over the telephone.

Verify the order by repeating it back to the healthcare provider.

What finding indicates that performing passive range-of-motion (ROM) exercises on an unconscious client has been successful? increase in muscle tone preservation of muscle mass prevention of bone demineralization maintenance of joint mobility

maintenance of joint mobility

A client with fever and urinary urgency must provide a urine specimen for culture and sensitivity. The nurse should instruct the client to collect the specimen from the first stream of urine from the bladder. full volume of urine from the bladder. middle stream of urine from the bladder. final stream of urine from the bladder.

middle stream of urine from the bladder.

A physician orders supplemental oxygen for a client with a respiratory problem. Which oxygen delivery device should the nurse use to provide the highest possible oxygen concentration? nasal cannula nonrebreather mask simple mask venturi mask

nonrebreather mask

Which is appropriate for the nurse to include in a plan for the prevention of pressure ulcers? daily skin cleaning with soap and hot water gentle massage of bony prominences every shift systematic skin assessment at least once per shift encouraging the client to sit up as much as possible

systematic skin assessment at least once per shift

A nurse completes preoperative teaching for a client scheduled for a cholecystectomy. The client states, "If I lie still and avoid turning, I will avoid pain. Do you think this is a good idea?" What is the nurse's best response? "Why don't you decide about activity after you return from recovery?" "It is always a good idea to rest quietly after surgery, which will help minimize further pain." "The physician will probably order you to lie flat for 24 hours." "Turn from side to side every 2 hours, and the nurse will administer pain medication to assist in movement."

"Turn from side to side every 2 hours, and the nurse will administer pain medication to assist in movement."

The client has sore nares while a nasogastric (NG) tube is in place. Which nursing measure would be most appropriate to help alleviate the client's discomfort? Apply a water-soluble lubricant to the nares. Reposition the tube in the nares. Irrigate the tube with a cool solution. Have the client change position more frequently.

Apply a water-soluble lubricant to the nares.

A client in the emergency department reported vomiting and diarrhea for the previous 24 hours. The client's blood pressure is 90/60 mm Hg, respiration is 20 breaths per minute, heart rate is 92 beats per minute, and temperature is 37.5° C (99.5° F). Which intervention will the nurse perform first? Increase fluids. Assess for dehydration. Raise the head of bed. Administer acetaminophen.

Assess for dehydration.

While making rounds, the nurse enters a client's room and finds the client on the floor between the bed and the bathroom. In which order of priority from first to last should the nurse take the following actions? All options must be used.

Assess the client's current condition and vital signs. If no acute injury, get help, and carefully assist the client back to bed. Notify the client's health care provider (HCP) and family. Document as required by the facility

Which intervention should a nurse use when administering oxygen by face mask to a client? Assist the client to the semi-Fowler's position if possible. Secure the elastic band tightly around the client's head. Apply the face mask from the client's chin up over the nose. Loosen the connectors between the oxygen equipment and humidifier.

Assist the client to the semi-Fowler's position if possible.

In which way does a nurse play a key role in error prevention? Identifying incorrect dosages or potential interactions of ordered medications Never questioning a physician's order because the physician is ultimately responsible for the client outcome Informing the client of the Patient's Bill of Rights Notifying the Occupational Safety and Health Administration (OSHA) of workplace violations

Identifying incorrect dosages or potential interactions of ordered medications

To reduce the possibility of catheter-related urinary tract infections (CAUTIs), the nurse should take which precaution? Use sterile technique when providing catheter care. Minimize urinary catheter use and duration of use in all clients. Ensure that clients who are incontinent have indwelling urinary catheters. Clean the periurethral area with antiseptics.

Minimize urinary catheter use and duration of use in all clients.

What should the nurse do to prevent pressure ulcers in an older adult? Massage bony prominences gently every shift. Clean the skin daily using mild soap and hot water. Perform a systematic skin assessment at least once a day. Encourage the client to sit in a chair as much as possible.

Perform a systematic skin assessment at least once a day.

A nurse is caring for an elderly client who is being discharged to a skilled nursing facility. What should the nurse consider as a priority intervention in developing the discharge plan for this client? Instruct the client's family to go to the facility during mealtime. Provide instructions that ensure continuity of care. Give the facility the client's therapy schedule. Send all of the client's belongings to the skilled nursing facility.

Provide instructions that ensure continuity of care.

An adult client who is alert and oriented requires surgery. The client cannot read. Which nursing interventions is the best? Read the consent form to the client and have the client verbalize understanding. Have a family member that can read sign the consent form. Tell the client in the nurse's own words what the surgical procedure involves. Ensure that the healthcare provider signs the consent form for the client.

Read the consent form to the client and have the client verbalize understanding.

A non-English-speaking client with chest pain has been admitted to the healthcare facility. Because the assigned nurse does not know the client's language, what would be the most appropriate action in this case? Communicate with the client nonverbally. Obtain a language dictionary and translate. Request the help of a professional interpreter. Ask the supervisor to assign some other client.

Request the help of a professional interpreter.

Which concept refers to a professional nurse's role in client advocacy? The nurse promotes and protects the client's interests and rights. The nurse follows the basic standards of care and hospital policies and procedures for providing client care. The nurse adopts a paternalistic approach to client care. The nurse makes decisions for clients who can't make decisions for themselves.

The nurse promotes and protects the client's interests and rights.

When assessing a client's pain, which is the most reliable indicator of the existence and intensity of acute pain? the severity of the condition causing the pain the client's self-report the client's vital signs the nurse's assessment

the client's self-report

The adult daughters of an older adult client inform the nurse that they fully expect their father to be combative after surgery. Preoperatively, they request that the nurse put all four side rails up and use restraints to keep him safe. What should the nurse tell the daughters? "We will first try to keep him safe without restraint." "Certainly; we will want to be sure to keep your father safe, too." "We will call the health care provider to get a prescription right away." "Restraint use is prohibited at our hospital at all times."

"We will first try to keep him safe without restraint."

Which actions by the nurse will most likely ensure that the correct client receives a medication? Select all that apply. Have the client state his or her name. Learn to recognize the client. Compare the date of birth on the client's medical record to the date of birth on the client's armband. Check the client's room number. Check the name on the armband with the name on the medication.

Check the name on the armband with the name on the medication. Compare the date of birth on the client's medical record to the date of birth on the client's armband.

A client with a nasogastric (NG) tube who is 2 days postoperative bowel resection is reporting increased abdominal pain and nausea. Which action by the nurse would be most appropriate? A client with a nasogastric (NG) tube who is 2 days postoperative bowel resection is reporting increased abdominal pain and nausea. Which action by the nurse would be most appropriate?

Check the patency and amount of drainage from the NG tube.

A client is scheduled for an appendectomy. What is the nurse's highest priority when planning preoperative teaching for this client? The client's skin should be assessed hourly. Surgical wound infection is most likely to occur during the first postoperative day. The client should be encouraged to take food and fluids to prevent dehydration and malnutrition. The client should begin coughing and deep-breathing exercises as soon as the client is able to follow instructions.

The client should begin coughing and deep-breathing exercises as soon as the client is able to follow instructions.

A nurse has been teaching a client how to use an incentive spirometer that he must use at home for several days after discharge. Which client action indicates an accurate understanding of the technique? The client uses the device while lying supine. The client takes slow, deep breaths to elevate the spirometer ball. The client tilts the spirometer down when using it. The client takes rapid, shallow breaths to elevate the ball.

The client takes slow, deep breaths to elevate the spirometer ball.