Midpoint practice

A nurse is reviewing the medical records for a client who has a pressure ulcer. Which of the following is an expected finding? A.Serum albumin level of 3 g/dL B. HDL level of 90 mg/dL C. Norton scale score of 18 D. Braden scale score of 20

A

A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedematous 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

A nurse is planning care for a client who has dysphagia following a stroke. The nurse should initiate a referral for which of the following therapies? A. Physical therapy B. Speech therapy C. Occupational therapy D .Respiratory therapy

B

A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to take the client's vital signs every 15 min and call him back in 1 hr. From a legal perspective, which of the following actions should the nurse take next? A. Document the provider's statement in the medical record. B. Complete an incident report. C. Consult the facility's risk manager. D. Notify the nursing manager.

D

A nurse is giving an end-of-shift report about a client admitted earlier that day with pneumonia. Which of the following pieces of information is most essential to provide? A. Admitting diagnosis B. Diagnostic test results C. Body temperature D. Breath sounds

D

To prevent foot drop in a client who has decreased mobility, the nurse should A. place a pillow under the client's knees. B. position a trochanter roll under the client's feet. C. advise the client to wear rubber-soled slippers. D. place the client's feet against a foot board perpendicular to the mattress.

D

A nurse is caring for a client and performing blood glucose monitoring. Which of the following is an appropriate nursing intervention? A. Wipe away the first drop of blood from the client's finger. B. Gently massage the client's finger in a distal to proximal direction. C. Puncture the tip of the client's finger. D. Hold the client's finger in an elevated position prior to testing.

A

A nurse is preparing to care for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in the lungs. In addition to a gown and gloves, the nurse will need which of the following equipment in order to provide care? A. Face shield B. High-filtration mask C. Shoe covers D. Surgical cap

A

A nurse is monitoring an older adult client who is receiving IV fluid therapy. Which of the following assessment findings should the nurse recognize as an adverse effect of excess fluid therapy? (Select all that apply.) A. Edema B. Crackles in lungs C. Oliguria D. Elevated blood pressure E. Jugular venous distention

A, B, D, E

A nurse is checking blood pressures at a community health screening. Which of the following clients is at high risk for primary hypertension? A. A client who is pregnant B. A client who has an elevated LDL C. A client who takes oral contraceptives D.A client who has kidney disease

B

A nurse is planning to insert a peripheral IV catheter in an older adult client. Which of the following actions should the nurse plan to take? A. Insert the catheter at a 45° angle B. Position the client's arm in the dependent position C. Shave excess hair from the insertion site D. Initiate IV therapy in the veins of the hand

B

A nurse is preparing a change-of-shift report. Which of the following is an appropriate method to communicate continuity of care? A. Critical pathway B. Transfer document C. Situation, Background, Assessment, and Recommendation (SBAR) D.Medication Administration Record (MAR)

C

A nurse is preparing to administer morphine 4 mg IV bolus to a client. Available is morphine 5mg/mL. Which of the following is an appropriate nursing intervention? a. Return the unused medication to the automatic dispensing system. b. Keep the remaining medication at the client's bedside for later use. c. Have a second nurse witness the disposal of remaining medication. d. Lock remaining medication in secure cabinet.

C

3. Which indicator suggests to the nurse that hypoxemia is occurring? a. Decrease PaO2 b. Decreased HCO3 c. Decreased pH d. Decreased paCO2

a

9. A 14- year old boy describes dysfunctional home life to the nurse. He states that he is running 10 miles or more a day to keep his mind off of his home. The nurse identifies this as which type of coping a. Beneficial - not this because its horrible for your joints b. Maladaptive c. Generational d. Cultural

b

A nurse is preparing to transfer a client from the bed to the stretcher using a slide board. Which of the following actions should the nurse take? A. Lower the head of the bed. B. Instruct the client to place both arms down by his sides. C. Position the bed slightly lower than the stretcher. D. Remind the client to extend his neck during transfer.

A

A nurse is caring for a client who has HIV. Which of the following infection control precautions should the nurse use while caring for this client? A. Airborne B. Standard C. Contact D. Droplet

B

A nurse is caring for a client in the immediate postoperative period. The nurse should recognize that which of the following positions maximizes the effectiveness of incentive spirometry? A. Side-lying B. Supine C. Semi-Fowler's D. Trendelenburg

C

A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse recognize as infiltration? A. Purulent exudate B. Warmth C. Skin blanching D. Bleeding

C

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following is an appropriate response by the nurse? A. "It allows the court to overrule an adult client's refusal of medical treatment." B. "It permits a client to withhold medical information from health care personnel." C. "It indicates the form of treatment a client is willing to accept in the event of a serious illness." D. "It allows health care personnel in the emergency department to stabilize a client's condition."

C

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° C (105° F). C. Cleanse the wound from the center outwards. D. Use a 20 mL syringe to irrigate the wound.

C

A nurse is caring for a client who has an NG tube that is irrigated every 8 hr. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance? A. Tap water B. Sterile water C. 0.9% sodium chloride D. 0.45% sodium chloride

C

A nurse assessing a client who is 2 days postoperative auscultates bilateral breath sounds but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications? A Atelectasis B Rales C Rhonchi D Pneumothorax

A

A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next? A. Clean sutures along with the incision site. B. Grasp the sutures at the knot with a pair of forceps. C. Cut the sutures close to the skin on one side. D. Pull out the sutures with forceps in one piece.

A

A nurse is providing teaching to a client who is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching? A. "I will disinfect my toothbrush weekly." B. "I will eat fresh fruit for breakfast." C. "I can take a plane to visit my grandson." D ."I can shower up to three times a week."

A

A nurse is teaching a client about self-administering NPH insulin. Which of the following actions by the client indicates a need for further teaching? A. The client inserts the needle at a 30°-angle. B. The client rolls the vial between both hands. C. The client holds the syringe in place for 5 seconds following injection. D. The client uses her anterior thigh as the injection site.

A

The nurse is observing a newly licensed nurse who is preparing a sterile field for a dressing change. Which of the following actions by the newly licensed nurse should cause the nurse to intervene? A. The newly licensed nurse places the cap of the sterile saline bottle on the sterile field. B. The newly licensed nurse places sterile objects 1 inch from 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 table is positioned at the level of the newly licensed nurse's waist.

A

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an AP? (Select all that apply.) A. Assist the client with a partial bed bath. B. Measure the client's BP after the nurse administers an antihypertensive medication. C. Test the client's swallowing ability by providing thickened liquids. D. Use a communication board to ask what the client wants for lunch. E. Irrigate the client's indwelling urinary catheter.

A, B, C

A 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 give to the client and his family? A. Check the cord routinely for frays or tearing. B. Keep the unit at least 4 feet away from a heat source. C. Consider purchasing a generator for power backup. D .Monitor for signs of hypoxia. Select clothing and bedding made of synthetic materials.

A,C,D

A nurse contacts the facility's interpreter to explain a therapeutic procedure for a client who does not speak English. Which of the following guidelines should the nurse follow when working with the interpreter? A. Speak slowly to allow the interpreter to interpret each word. B. Explain the purpose of the communication to the interpreter. C. Address the interpreter when explaining the procedure information. D. Supplement words with gestures and nonverbal reinforcement.

B

A nurse has just inserted an NG tube for a client. Which of the following assessment findings indicates that the tube is properly positioned? 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

A nurse in a community health clinic is caring for a client who has warts on his hands, the nurse should include which of the following in the teaching plan for this client? A. An antibiotic will be prescribed to treat the warts. B. Warts on the hands are usually not painful. C. Warts are most common in older adults. D. A biopsy will be prescribed on all warts rule out malignancy.

B

A nurse is caring for a client who had a fasting blood sugar drawn at 0600. The client tells the nurse, "All I have had since midnight is water and some juice." Which of the following nursing actions is appropriate? A. Document the caloric intake. B. Reschedule this lab test for the next morning. C. Notify the lab to obtain another specimen. D. Obtain a prescription for a glucose tolerance test.

B

A nurse is reviewing a protocol in preparation for suctioning a client who has a new tracheostomy. Which of the following is an appropriate action for the nurse to take? A. Use a 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 a pressure of 170 mm Hg.

B

A nurse is reviewing laboratory data for a client who has contusions to the chest wall following a motor vehicle crash. Which of the following values should the nurse report? A. Hct 40% B. SaO2 86% C. WBC 9,000 mm3 D. Serum potassium 4.1 mEq/L

B

A client demonstrates anger when the nurse does not respond within 5 min of ringing for the nurse. Which of the following is an appropriate response by the nurse? A. "I'm sorry, but another client needed my attention." B. "I arrived as soon as I could. What can I do for you?" C. "It must be frustrating. I have a few minutes now." D. "We had an emergency on the unit, but now I'm here."

C

A client is receiving continuous tube feeding via NG tube. The client has 3 episodes of vomiting in 12 hr. Which of the following actions should the nurse take? A.Flush the tubing with 100 mL of water. B.Dilute the formula with sterile water. C. Aspirate for residual. D.Place the client in a supine position.

C

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? A. Verify the client's name on his identification bracelet with the MAR. B. Call the pharmacy to determine if the client's medications are available. C. Compare the client's home medications with the provider's prescriptions. D. Place the client's home medication bottles in a secure location.

C

A charge nurse is observing a newly hired nurse prepare a sterile field. Which of the following indicates to the charge nurse that the sterile field is contaminated? A. Outer edge of the sterile field is touching a bottle. B. First fold is opened away from the body. C. Sterile objects are held above the waist. D. Sterile field is opened on a wet surface.

D

A client is scheduled for surgery. The intraoperative nurse finds a necklace on the client after anesthesia has been administered. Which of the following interventions should be initiated? A. Leave the necklace on the client. B. Give the necklace to a family member. C. Place the necklace in the client's chart. D. Notify security for placement of the necklace.

D

A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following should the nurse suggest to promote neck rotation? A. Move her head backward B. Touch her chin to her chest C. Touch her ear to her shoulder D. Move her head from side to side

D

A nurse is caring for a client who is having difficulty voiding following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take? A. Assess for bladder distention after 6 hr. B. Encourage the client to use the bed pan in the supine position. C. Restrict the client's intake of oral fluids. D. Pour warm water over the client's perineum

D

A nurse is planning to teach a preschool child how to properly use a metered dose inhaler. Which of the following methods is appropriate for this child? A. Hold the child in the lap while giving explanations. B. Help the child identify her feelings about using an inhaler. C. Encourage independent learning. D. Use role play and imitation when explaining.

D

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? A. BUN 15 mg/dL B. Creatinine 0.8 mg/dL C. Sodium 143 mEq/L D.Potassium 5.4 mEq/L

D

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions falls 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 PEG tube.

D

4. A nurse is discussing indications for the use of urinary catheterization with a newly licensed nurse. Which of the following should the nurse identify as an appropriate indication? Select all that apply a. Relief of urinary retention b. Convenience for the nursing staff or clients family c. Measurement of residual urine after urination d. Routine acquisition of a urine specimen e. Presence of an open perineal wound

a, c and e

2. A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving O2 therapy via NC. Which of the following interventions is the nurse's priority a. Increase O2 flow b. Assist the client to fowlers position c. Promote removal of pulmonary secretions d. Obtain a specimen for ABG

b

7. The nurse is planning care for a client who has been identified as at risk for falling. Which nursing intervention is most likely to prevent injury if the client falls? (NOTE; PREVENT INJURY IF YOU FALL) a. Obtain a bedside commode b. Place the bed in the lowest position c. Have a sitter stay with the client d. Move the chair to the window

b

8. A nurse is caring for a client who has angina pectoris and is prescribed propranolol hydrochloride (Inderal) 40mg bid. While reviewing the patient history, which of the following findings would cause the nurse to question the prescription? a. Hypothyroidism b. Bronchial asthma c. HTN d. Migraine headaches

b

A nurse is caring for a client who is combative in the emergency department. The provider orders wrist restraints after the client attempts to assault the admitting nurse. Which of the following actions is appropriate for the nurse to take? A. Tie restraints to the lower edge of the side rail. B. Remove each restraint one at a time every 2 hr. C. Ensure 3 finger-widths of space between the restraint and the client's wrist. D. Use a square knot to securely tie the restraints to the bed.

b

A nurse is obtaining a health history from a client who has hearing loss. Which of the following actions by the nurse is appropriate? A. Speak loudly with the mouth close to the client's ear. B. Rephrase rather than repeat misunderstood information. C. Ask a family member about the client's health history. D. Use a high tone of voice instead of a low tone of voice.

b

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions is appropriate for the client and family? a. Remove the outer cannula cautiously for routine cleaning. b. Use tracheostomy covers when outdoors. c. Use sterile technique when performing tracheostomy care at home. d. Cleanse irritated skin with full-strength hydrogen peroxide.

b

5. The nurse gave a client twice as much narcotic pain med as was prescribed. The client stopped breathing and was resuscitated, but died. What type of error is this classified as? a. Adverse event (NOTE: adverse effects for our purpose DON'T INVOLVE DEATH, ONLY INJURIES) b. Near miss c. Sentinel event d. System error

c

A nurse is orienting a new assistive personnel (AP) to the unit. Which of the following actions by an AP necessitates intervention by the nurse? A. Places soiled towels in laundry bag. B. Dons gloves to empty urinary drainage device. C. Washes and rinses hands for 10 seconds. D. Wears respirator mask when entering room designated as airborne precaution.

c

A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile. Which of the following information should the nurse include in the teaching? A. Assign the client to a room with a negative air-flow 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

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

C

A nurse is performing a Romberg's 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 a vibrating tuning fork to the client's forehead. C. Have the client stand with arms at side and feet together. D. Perform direct percussion over the area of the kidneys

C

A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care? A. Limit the adolescent's visitors. B.Select the adolescent's food choices. C. Allow the adolescent to make decisions regarding his daily routine. D.Encourage the adolescent's parent to assist with personal hygiene.

C

A nurse is preparing to administer oral medications to a client who has dysphagia. Which of the following is an appropriate action by the nurse? A. Have the client drink water from a straw after taking the medication. B. Instruct the client to lift his chin upward when swallowing medications. C. Offer each medication one at a time. D. Place the medication in the client's mouth.

C

A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid? A. Lemon-lime sports drinks B. Ginger ale C. Black coffee D. Orange sherbet

D

A nurse is speaking with the parent of an infant who has a cardiac defect. After the parent expresses concern, which of the following is an appropriate response? A. "Do any of your other children have congenital defects?" B. "Is anything concerning you that I can explain?" C. "She is going to grow up to be a healthy child." D. "Tell me a about your baby while I bathe her."

D

A nurse in a long-term care facility notes that a client coughs frequently during meals and suspects dysphagia. The nurse should assess the client for which of the following behavioral signs of dysphagia? A. Storing food in the mouth B. Sipping warm liquids C. Chewing excessively D. Refusing soft foods

A

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to this client? A. Use a bed exit alarm system B. Raise 4 side rails while client is in bed C. Apply one soft wrist restraint D. Dim the lights in the client's room

A

A nurse is checking for cyanosis on an adult client whose skin is a dark color. Which of the following sites should the nurse check to assess for cyanosis in this client? A. Circumoral area B. Sclera C. Conjunctiva D. Dorsal surface of the foot

A

A nurse is transcribing new orders for insulin based on a client's blood glucose readings. The nurse notes that the provider did not write the frequency for checking blood glucose levels on the order sheet. Which of the following is the appropriate action by the nurse? A. Follow the agency policy for routine blood glucose checks. B. Call the health care provider to determine the frequency of blood glucose checks. C. Place a note in the client's chart for the provider to review the order the next day. D. Contact the pharmacist to determine the frequency of blood glucose checks.

B

A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence? A. Request an occupational therapy consult to determine the need for assistive devices. B. Assign assistive personnel to perform self-care tasks for the client. C. Instruct the client to focus on gradually resuming self-care tasks. D. Ask the client if a family member is available to assist him with his care.

C

A nurse is caring for a client who has taken in 2,600 mL of fluids in 24 hr. Which of the following is an expected output for the client? A. 1,800 mL B. 2,100 mL C. 2,500 mL D. 3,200 mL

C

A nurse is caring for an older adult client who reports constipation. Which of the following is an appropriate nursing recommendation? A. Bear down hard when defecating. B. Drink 600 mL of water daily. C. Eat raw vegetables. D. Limit activity.

C

6. A nurse is caring for a client who has pneumonia. The clients O2 sat is 85%. Which of the following should the nurse do first? a. Administer O2 at 2L/min b. Notify the provider c. Encourage coughing and deep breathing d. Raise the head of the bed.

d

A nurse in a clinic is providing teaching to an older adult client about nutritional considerations associated with aging. Which of the following should the nurse include in the teaching? A. Protein intake is often inadequate in older adults B. Vitamin and mineral requirements decline in older adults C. Thirst sensation increases in older adults D. Lack of adequate fat in the diet is often seen in older adults

A

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? A. During the admission process B. As soon as the client's condition is stable C. During the initial team conference D. After consulting with the client's family

A

A nurse is providing teaching to a client about techniques to promote sleep. Which of the following instructions should the nurse include in the teaching? A. Consume a light snack of carbohydrates at bedtime. B. Drink warm tea at bedtime. C. Watch TV in bed until drowsy. D. Exercise 1 hr before bedtime.

A

A nurse is caring for a client who has left-sided paralysis after a cerebrovascular accident. The client is unable to bear his own weight. Which of the following actions is an appropriate method to move the client from his bed to his wheelchair? A. Use a draw sheet and have two assistive personnel (AP) help move the client. B. Use a hydraulic lift and have an AP help move the client. C. Obtain a transfer belt and have two AP help move the client. D. Help the client stand and then pivot to the wheelchair with assistance from an AP.

B

dyspnea is caused by what

hypoxemia

A client who is non-ambulatory notifies the nurse to tell her that his trash can is on fire. After confirming the fire, which of the following actions should the nurse take next? A. Call emergency fire code. B. Extinguish the fire. C. Confine the fire. D. Evacuate the client.

D

A nurse is preparing to assist a client who can partially bear weight and is cooperative from the bed to a chair. Which of the following actions by the nurse will be most safe for the client and the nurse? A. Enlist help of another staff member. B. Adjust bed to appropriate height. C. Use a powered standing-assist lift. D. Avoid movements that twist the spine.

c

A nurse is caring for a young child who is prescribed a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take? A. Examine personal values about the issue. B. Tell the parents that this is a necessary procedure. C. Inform the parents that their consent is not required. D. Contact the chaplain to explain the importance of the procedure.

A

A nurse is evaluating a client who has right leg weakness and is learning to use a rubber-tipped standard walker. Which of the following actions by the client indicates proper use of the walker? A. Uses a lifting motion to move the walker B. Uses the walker to pull himself up to stand C. Takes a step while moving the walker forward D. Locks elbows when stepping forward

A

A nurse is implementing a plan of care for an older adult client who is at risk for falls. Which of the following is an appropriate nursing action? A. Implement a regular toileting schedule. B. Encourage the client to wear athletic socks when ambulating. C. Place all 4 bed rails in the upright position. D.Require a family member to remain at the bedside.

A

A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection? A. Thread the IV catheter so that the hub rests at the insertion site. B. Shave excess hair from around the insertion site. C. Cleanse the site with hydrogen peroxide before IV catheter insertion. D. Palpate the site carefully just before inserting the IV catheter.

A

A nurse is caring for four clients. Which of the following actions should the nurse take to prevent the spread of infection? A. Carry a client's soiled linens out of the room in a mesh linen bag. B. Place a client who has tuberculosis in a room with negative-pressure airflow. C. Provide disposable plates and utensils to a client who has HIV. D. Dispose of a client's blood-saturated dressing in a garbage bag placed inside a second garbage bag.

B

A nurse notices an assistive personnel (AP) preparing to deliver a food tray to a client who is Orthodox Jewish. On the tray is a roast beef dinner with nonfat milk. Which of the following is an appropriate nursing action? A. Allow the AP to deliver the food tray to the client. B. Call the dietary department and ask for a kosher tray. C. Replace the nonfat milk with apple juice. D. Explain to the client that he needs the protein in the milk and the beef.

B

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. The nurse understands that the preoperative teaching regarding pain control has been effective when the client states which of the following? A. "I think I should take my pain medication more often, since it is not controlling my pain." B. "Breathing faster will help me keep my mind off of the pain." C."It may help me to listen to music while I'm lying in bed." D. "I don't want to walk today, because I'm experiencing some pain."

C

A hospice nurse is providing end-of-life care to a client who has terminal lung cancer. The client states, "I am so tired and afraid of not being able to catch my breath." Which of the following is an appropriate response by the nurse? A. "We should restrict your visitors so that you can get more rest." B. "Shortness of breath is temporary and should subside." C. "I will be able to give you a medication to help your breathing." D. "Fatigue is a common experience among hospice clients."

C

A nurse is caring for a client who is at risk for hypokalemia. Which of the following foods should be included in the client's diet? A.Avocados B. Corn C. Asparagus D. Cucumbers

A

A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure? A. "When do you usually bathe, in the morning or in the evening?" B. "Do you prefer a bath or a shower?" C. "At what temperature do you prefer your bath water?" D ."Are you able to help with your hygiene care?"

D

A nurse is caring for several clients at various developmental stages. The nurse understands that according to Erikson, acceptance of death occurs at which of the following stages of psychosocial development? A. Autonomy versus Shame and Doubt B. Generativity versus Stagnation C. Identity versus Role Diffusion D. Integrity versus Despair

D

A nurse is providing instructions for an older adult client who has a prescription for an electric heating pad to his lumbosacral area. Which of the following client statements indicates a correct understanding of the teaching? A. "I will remove the heating pad in 30 minutes." B. "I will need to turn up the heating pad after it has been in place for 10 minutes." C. "I'll sleep on top of the pad to get better heat penetration." D. "I can pin the heating pad to my gown to keep it in place."

A

A nurse is working with an Orthodox Jewish client who has just given birth to a stillborn infant. Which of the following interventions is appropriate? A. Ask the family if there are any special rituals that they would like to follow at this time. B. Inform the parents of the importance of conforming to hospital policy regarding the death of a fetus. C. Remain in the room, giving the parents the opportunity to initiate a discussion about cultural rituals. D. Take the fetus out of the room, and allow the parents time to grieve together.

A

A nurse is caring for an older adult client who has left-sided weakness. Which of the following information regarding the use of a cane is appropriate? A. Hold the cane with the left hand. B. Place cane on right side, and advance left foot forward. C. Advance the cane forward 30 to 45 cm (12 to18 in) with each step. D. Move the right leg forward first when using the cane.

B

A nurse is performing assessments on clients of various ages. Which of the following is an appropriate physical assessment technique? A.Use of a standardized numeric pain rating scale for assessment of a 4 year old's postoperative pain B. Measurement of an adult's blood pressure with a cuff whose bladder surrounds 80% of the client's arm circumference C. Placement of a stethoscope at the second intercostal space left of the sternum in order to count an infant's apical heart rate D. Palpating an older adult client's abdomen before auscultating bowel sounds

B

A nurse finds a client on the floor upon entering the client's room. The roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following is correct documentation of this incident? A. Incident report completed. B. Client climbed over the bedrails. C. Client found lying on floor. D. Client was trying to get out of bed.

C

A nurse manager is preparing to report disciplinary action of a staff nurse for substance abuse. Which of the following has the authority to revoke a professional nurse's license? A. Civil judicial process B. Chief nursing officer of a hospital C. State board of nursing D. American Nurses Association

C

A nurse on an oncology unit is caring for a client who has tears in his eyes and states, "The doctor just told me that I don't have long to live." Which of the following is an appropriate response by the nurse? A. "I'm sure that you will feel better soon." B. "Chemotherapy is almost always effective." C. "Tell me more about how you're feeling." D. "We will do our best to keep you as comfortable as possible."

C

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? A. "Is your pain constant or intermittent?" B. "What would you rate your pain on a scale of 0 to 10?" C."Does the pain radiate?" D. "Is your pain sharp or dull?"

D

A nurse is caring for a client for whom a nasogastric tube is ordered for stomach decompression. Which of the following actions is appropriate when inserting the NG tube? A. Position the client with the head of the bed elevated to 30° prior to insertion of the NG tube. B. Remove the NG tube if the client begins to gag or choke. C. Apply suction to the NG tube prior to insertion. D. Have the client take sips of water to promote insertion of the NG tube into the esophagus.

D

A nurse is caring for a client who has recently started using a hearing aid worn behind the ear. Which of the following client statements indicates to the nurse that he 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

A nurse is caring for a client who is refusing a scheduled 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. Ask the client's family to intervene. C. Request a consultation with the ethics committee. D. Withhold the scheduled blood transfusion.

D

A nurse is caring for a client who is receiving medication intramuscularly. The nurse should recognize that this route A. increases infection rates. B. is the safest option. C. has the slowest absorption rate. D. decreases the client's risk for reactions.

A

A nurse is caring for a client who is postoperative following a cholecystectomy and is reporting pain. Which of the following actions should the nurse take? (Select all that apply.) A. Offer the client a back rub. B. Look for nonverbal pain indicators. C. Identify the client's pain level. D. Assist the client to ambulate. E. Change the client's position.

A, C, E

A nurse is instructing a client newly diagnosed with Raynaud's disease about the prevention of the onset of symptoms. Which of the following client statements should indicate to the nurse the need for additional teaching? A. "I will wear gloves when removing food from the freezer." B. "I will try to anticipate and avoid stressful situations when possible." C. "I will complete the smoking cessation program I started." D. "I will take my medications at the first sign of an attack."

D

A nurse is performing a spiritual assessment on a client newly admitted to the unit. The nurse recognizes that the purpose of performing a spiritual assessment is to A. identify the client's religious and spiritual beliefs, affiliations, and practices. B. apply commonly accepted concepts of spirituality to the nurse's interactions with the client. C. allow the nurse to make educated assumptions about the client's spiritual needs related to health care. D. encourage the client to focus on beliefs that are consistent with health care interventions.

A

A prescription for morphine sulfate IV bolus has been ordered for a child who is in pain. The nurse preparing to administer the medication realizes that the client appears small for her age. Which of the following actions should the nurse take? A. Weigh the child and calculate the dosage range. B. Give the child one-half the ordered dose. C. Give the dose as prescribed by the provider. D. Call the provider to ask to change the route to oral.

A

An assistive personnel (AP) is obtaining a client's oral temperature. The client informs the AP that he has just had some ice chips. Which of the following is an appropriate action by the AP? A. Wait 15 min and return to take the oral temperature B. Provide a sip of warm water, wait 5 min, and take the temperature. C. Document that a temperature was unable to be obtained. D. Proceed to take the oral temperature.

A

Which of the following is the responsibility of a nurse who is caring for a client receiving PCA? 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 hr. C. Teach the client to avoid pushing the button unless pain is above a 7 on a scale of 0 to 10. D. Increase the basal rate and shorten the lock-out interval time if the client's pain level is too high.

A

A nurse is planning teaching for a client who has a new diagnosis of type 1 diabetes mellitus about insulin self-administration. Which of the following actions should the nurse take first? A. Encourage the client to include a family member in the teaching. B. Determine the client's learning style. C. Provide written directions for the client to use. D. Schedule a series of teaching sessions.

B

Following administration of levothyroxine 125 mcg at 0800, the nurse discovers the medication was given to a client for whom it was not prescribed. Which of the following is the correct way to document this error in the medical record of the client who received the medication? A. Levothyroxine 125 mcg given at 0800 in error. Client is in no distress. B. Levothyroxine 125 mcg given at 0800. Provider notified. C. Levothyroxine 125 mcg given at 0800. Incident report filed. D. Levothyroxine 125 mcg given at 0800 in error. Client informed of error.

B

Which of the following precautions is important to take when a nurse is caring for a client who has diarrhea due to Shigella? A. Have the client wear a mask when receiving visitors. B. Wash hands before and after client contact. C. Assign the client to a room with negative pressure airflow exchange. D. Instruct all visitors to limit time with the client.

B

A client is reporting pain at the insertion site of his IV catheter. The nurse observes a red line extending outward from the insertion site. Which of the following actions should the nurse take first? A. Place a warm compress over the site. B. Restart the IV line at a different site. C. Discontinue the infusion. D. Document the findings.

C

A nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg weakness. Which of the following should the nurse include in the teaching? A. Use the cane on the weak side of the body. B. Advance the cane and the strong leg simultaneously. C. Maintain two points of support on the floor. D. Advance the cane 30 to 45 cm (12 to 18 in) with each step.

C

A nurse is conducting a respiratory assessment for four clients. Which of the following should the nurse recognize as an abnormal respiratory assessment finding? A. A male client who has diaphragmatic breathing. B. A female client who has thoracic muscle movement when breathing. C. An infant who has an irregular breathing pattern. D. An adolescent who has visible accessory muscle movement when breathing.

D

1. The following statements are true about the incentive spirometer EXCEPT which one? a. It has a mouth piece, a goal piston, and a main piston b. The incentive spirometer is frequently used with postop clients c. Taking slow inspiration is better than breathing a big volume d. It helps clients learn how to cough

d

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 negative pressure room. 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.

A, B, E

A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate? A. "The transfer of your family member is being done because it's in his best interest." B. "Have a seat and let me tell you what has happened." C. "Why are you so concerned about this transfer?" D. "I know how you feel. My father had to be sent to a long-term care facility."

B

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 makes me feel nauseous." C. "I notice that the pain gets worse after I eat." D. "The pain is like a dull ache in my stomach."

D

A nurse is caring for a client with a diagnosis of terminal cancer. The nurse understands that the client is ready to hear information regarding palliative care when the client states which of the following? A. "I am ready to learn about chemotherapy to help cure my cancer." B. "I just want you to give me something to get this over with soon." C. "I know that many people have recovered fully from cancer, and so will I." D. "I want you to tell me about measures available to keep me comfortable."

D

A nurse is caring for a client with cancer who lives at home with her spouse. The spouse tells the nurse that the client is in pain "all of the time." Which of the following actions is most important for the nurse to take? A. Assess the client's vital signs. B. Assess the spouse's understanding of the client's pain. C. Ask the spouse how he has been managing the client's pain. D.Ask the client to rate her pain.

D

A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next? A. Place a warm compress over the IV site. B. Record the findings in the client's chart. C. Notify the client's primary care provider. D. Prepare to insert a new IV catheter.

A

A nurse is caring for a client who cannot bear weight on his fractured ankle. Which of the following client statements indicates a need for further teaching regarding three-point gait crutch walking? A. "When I get out of a chair, I'll hold both crutches on the side next to my weak leg." B. "When I sit down, I'll transfer my weight to my crutches and my strong leg." C. "When I go up stairs, I'll alternate putting weight on my crutches and my strong leg." D. "When I go down stairs, I'll start by moving both my crutches to the step below."

A

A nurse is caring for a client who has had a triple lumen catheter inserted into the left subclavian vein of a client who is septic. The nurse obtains vital signs and records T 101°F, BP 88/48, P 118 bpm, R 36 bpm and O2 Sat 88%. An order is written to begin IV fluids and initiate antibiotic therapy. Which of the following should the nurse do immediately? A. Initiate the IV therapy and begin the antibiotics. B. Notify the provider of the vital signs. C. Order a stat chest X-ray. D. Page respiratory stat.

A

A nurse is caring for a client who is postoperative following colostomy placement. Which of the following findings should the nurse report to the provider? A. Stoma appears purple in color B. Protrusion of stoma from the abdomen C. Mucosa of the stoma bleeds slightly when touched D. Red peristomal skin under the adhesive

A

A nurse is leading the team of nurse managers and is planning to make a major announcement. The nurse would use which of the following nonverbal communication techniques to enhance the importance of the announcement? A. Sit in front of the group for the meeting and then stand for the announcement. B. Cross arms over the chest when beginning the announcement. C. Stare at the persons who will be most affected while making the announcement. D. Lean gently over the back of a chair sitting to one side of the room when making the announcement.

A

Which of the following should indicate to a nurse the need to suction a client's tracheostomy? A. Irritability B. Hypotension C. Flushing D .Bradycardia

A

A nurse is caring for a preschooler who has heart disease. The provider prescribes digoxin at the maximum adult dose. Which of the following actions should the nurse take? A. Give the medication as prescribed using the Six Rights of Medication Administration. B. Call the provider to discuss concerns regarding the dosage for the child. C.Assess the client's heart rate and rhythm before deciding whether or not to give the medication. D. Administer the pediatric dose recommended in a medication-reference book.

B

A nurse is preparing to administer meperidine 80 mg IM from a 100 mg prefilled syringe. After the injection, which of the following is an appropriate action by the nurse? A. Return the unused portion to the pharmacy. B. Have another nurse witness the disposal of the excess medication. C. Place the syringe with the unused portion in a locked medication drawer. D. Discard the unused medication in the sharps container.

B

Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client? A. Insert the suction catheter while the client is swallowing. B. Apply intermittent suction when withdrawing the catheter. C. Place the catheter in a location that is clean and dry for later use. D. Hold the suction catheter with the clean, nondominant hand.

B

A nurse is working a night shift and caring for several clients at risk for falls. Which of the following actions should the nurse take? (Select all that apply.) A. Keep the clients' room dark. B. Teach the clients to use the call light. C. Move the clients' away from the nurses' station. D. Place a fall risk sign above the clients' beds. E. Perform client checks every 4 hr.

B, D

A nurse is admitting a client for a scheduled surgery. The client is anxious. Which of the following responses by the nurse is appropriate? A "You have nothing to worry about." B. "Other's who have had this procedure have had great results." C. "Tell me more about your concerns." D. "Why are you feeling so anxious?"

C

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter should be irrigated? A. Urine has an unusual odor. B. Urine specific gravity is 1.035. C. Bladder scan reveals 525 mL of urine. D. Urine is positive for ketones.

C

A nurse is caring for a client who has been on strict bed rest for 1 week. Which of the following findings indicates client readiness to ambulate? A. Requires assistance raising legs to put on socks B. Demonstrates mild dyspnea when eating breakfast C. Performs active range of motion exercise to all extremities D. Becomes fatigued when assisting with morning hygiene care

C

A nurse is developing a plan of care for an African-American child who is preschool-age and experiencing pain. Which of the following is the best way for the nurse to assess the child's pain? A. Ask the parents of the child to describe the pain. B. Measure the child's vital signs. C. Show the child the Oucher Pain Scale D. Observe the child's facial expressions.

C

A nurse is caring for a postoperative adult client who refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action? A. Request that a respiratory therapist discuss the technique for incentive spirometry. B. Administer a pain medication to the client. C. Chart the client's refusal to participate in health restorative activities. D. Determine the reasons why the client is refusing to use the incentive spirometer.

D

A nurse is checking a client's blood pressure to assess for orthostatic hypotension. Which of the following actions should the nurse take? A. Obtain blood pressure 30 min after each meal. B. Obtain blood pressure immediately after the client ambulates. C. Obtain blood pressure in each arm and leg. D.Obtain blood pressure 2 min after assisting the client to a sitting position.

D

A nurse is completing an admission assessment of an older adult client. Which of the following findings is a potential indication of abuse? A. Loss of skin turgor on the back of the hands B. Varicosities on lower extremities C. Thickened discolored nails with ridges D. Presence of bruises on the arms in various stages of healing

D

A nurse is educating a family member of a client who is immobile about how to prevent back injury associated with moving the client up in bed. Which of the following statements by the family member should indicate to the nurse that he understands the teaching? A. "I will relax my abdominal muscles when preparing to move her." B. "I will keep my knees straight and my feet together." C. "I will move back from the bed and bend at the waist." D. "I will leverage my weight against my wife and shift it as I move her."

D

A nurse is planning care to promote improved self-feeding for a client who has a visual impairment. Which of the following interventions should the nurse include in the plan of care? A.Direct the client in what order to consume the food. B. Provide small-handled utensils for the client. C. Thicken liquids on the client's tray. D. Use a clock pattern to describe food on the plate to the client.

D

A nurse is planning to delegate client care to an assistive personnel (AP). Which of the following factors is most important for the nurse to consider before delegating care? A. The AP's previous training B. Other tasks assigned to the AP C. The amount of supervision the AP requires D. The facility's job description for the AP

D

A nurse is preparing to perform nasopharyngeal suctioning for a client who is unable to cough up excessive secretions. Which of the following actions is appropriate? A. Use the clean technique throughout the procedure. B. Insert the catheter as the client exhales. C. Apply suction for up to 20 seconds. D. Perform suctioning while removing the catheter.

D

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following statements by the client indicates a need for further instruction by the nurse? A. "I will tape electrical cords to the baseboards in each room." B. "I will hire someone to trim the tree that overhangs the front porch stairs." C. "I will remove the table from the hall." D. "I will replace the old throw rug in the kitchen with a new one."

D

A nurse is transcribing new prescriptions for a client. Which of the following prescriptions is accurately transcribed by the nurse? A. Digoxin 0.25 mg PO q.d. B. NPH insulin 3 units sub q daily before breakfast C. Zolpidem 5 mg PO qhs for sleep D. Morphine 4 mg IV bolus every 2 hr PRN for incisional pain

D

A nurse manager is overseeing the care of a unit. Which of the following should the nurse manager identify as a violation of HIPAA guidelines? A. The assigned nurse reviews the medical chart with a nursing student. B. A nursing student discusses a client's status with the assigned nurse at the bedside. C. The assigned nurse returns a call to a client's Power of Attorney to discuss the client's care. D. A nursing student consults a former classmate to assist with her documentation.

D

A nurse receives report on a client who is receiving 0.9% sodium chloride at 125 mL/hr. When the nurse performs the initial assessment she notes that the client has received 80 mL for the last 2 hr. Which of the following actions should the nurse take first? A. Reposition the client. B. Document the client's IV intake in the medical record. C. Request a new IV fluid prescription. D. Check the IV tubing for obstruction.

D

10. Acutely ill client with COPD. Which method of O2 will you give in an ACUTE case? (need to give just as much O2 that he can tolerate) a. A NC b. An oropharyngeal catheter c. A non-rebreathing mask d. A venturi mask

d