NURS 209 Midterm/Final

Select all the apply- which of the following food choices are appropriate for a client who is prescribed a full liquid diet A. Plain yogurt B. Custard C. Ice cream D. Mashed potatoes E. Pureed meat F. Gelatin

A, B, C, F

A nurse is preparing to measure a client's vital signs. The nurse should identify that which of the following factors will affect the methods that are used? (select all that apply) A. BMI of 35 B. Nausea for 2 days C. Reporting "stuffy nose" D. Fasting for blood tests E. Taking digoxin for irregular heart rate F. Mastectomy 2 years ago

A, C, E, F

A nurse is instructing an assistive personnel (AP) about caring for a client who has low platelet count. Which of the following instructions is the priority for measuring vital signs for this client? A. "Do not measure the client's temperature rectally." B. " Count the client's radial pulse for 30 seconds multiply it by 2 if it is irregular" C. Do not let the client know you are counting their respirations." D. Let the client rest for 5 minutes before you measure their blood pressure."

A. "Do not measure the client's temperature rectally."

A nurse is consoling the partner of a client who just died after a long battle with liver cancer. The grieving partner states, "I hate them for leaving me." Which of the following statements should the nurse make to facilitate mourning for the partner? (Select all that apply.) A. "Would you like me to contact the chaplain to come and speak with you?" B. "You will feel better soon. You have been expecting this for a while now." C. "Let's talk about your children and how they are going to react." D. "You know, it is quite normal to feel anger toward your loved one at this time. E. "Tell me more about how you are feeling."

A. "Would you like me to contact the chaplain to come and speak with you?" D. "You know, it is quite normal to feel anger toward your loved one at this time. E. "Tell me more about how you are feeling."

A nurse is reviewing a client's lab values. Which of the following info is correct regarding albumin levels and nutritional status A. Albumin level is a poor short-term indicator of protein status B. Hydration status doe not affect a client's albumin level C. An albumin level of 3.2 g/dL is within expected reference range D. Albumin level is calculated keeping a 24-hr record of protein intake

A. Albumin level is a poor short-term indicator of protein status

A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? (Select all that apply) A. Apply suction while withdrawing the catheter B. Perform suctioning on a routine basis every 2 to 3 hr C. Maintain medical asepsis during suctioning D. Use new catheter for each suctioning attempt E. Apply suction for 10 to 15 seconds

A. Apply suction while withdrawing the catheter D. Use a new catheter for each suctioning attempt E. Apply suction for 10 to 15 seconds

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (Select all that apply) A. Apply the oxygen source loosely if the SpO2 decreases during the procedure B. Use surgical asepsis to remove and clean inner cannula C. Clean the outer cannula surfaces in a circular motion from the stoma site outward D. Replace the tracheostomy ties with new ties E. Cut a slit in the gauze squares to place beneath the tube holder.

A. Apply the oxygen source loosely if the SpO2 decreases during the procedure B. Use surgical asepsis to remove and clean inner cannula C. Clean the outer cannula surfaces in a circular motion from the stoma site outward

Which of the following actions should a nurse take to assess a client who had a stroke for complications secondary to inadequate swallowing? A. Auscultate the client's lungs B. Place the tip of a tongue depressor on the client's posterior tongue C. Inspect the client's uvula and soft palate with a penlight D. Place fingers on client's throat at the level of the larynx and ask client to swallow

A. Auscultate the client's lungs

A nurse is caring for a client who has developed a stage 1 pressure injury in the area of the right ischial tuberosity. Which of the following should the nurse plan to apply to the client's pressure injury? A. Barrier creams B. Anti-fungal ointment C. Chemical debridement agent D. Antibiotic agent

A. Barrier creams

A nurse is obtaining a health history from a client who has a colostomy. The client reports frequent episodes of loose stools over the last month but has no signs of infection or bowel obstruction. The client tells the nurse that they have to avoid participation in social activities because they are concerned about leakage. Which of the following should the nurse recommend? A. Consume foods that are low in fiber content. B. Take an ounce of mineral oil twice a day C.Add buttermilk and cranberry juice to the diet D. Increase water intake to 3 to 3.5 L per day.

A. Consume foods that are low in fiber content

A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (Select all that apply.) A. Cover the area with saline-soaked sterile dressings. B. Apply an abdominal binder snugly around the abdomen. C. Use sterile gauze to apply gentle pressure to the exposed tissues. D. Position the client supine with the hips and knees bent. E. Offer the client a warm beverage (herbal tea).

A. Cover the area with saline-soaked sterile dressings. D. Position the client supine with the hips and knees bent.

A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (Select all that apply) A. Cover the area with saline-soaked sterile dressings. B.Apply an abdominal binder snugly around the abdomen. C.Use sterile gauze to apply gentle pressure to the exposed tissues. D.Position the client supine with the hips and knees bent. E.Offer the client a warm beverage (herbal tea).

A. Cover the area with saline-soaked sterile dressings. D.Position the client supine with the hips and knees bent.

A nurse is reviewing the medical record of a client who has a blood glucose 260 mg/dL and no documented history of diabetes mellitus. Which of the following types of medications can cause hyperglycemia an adverse effect? (Select all that apply) A. Diuretics B. Corticosteroids c. Oral anticoagulants D. Opioid analgesics E. Antipsychotics

A. Diuretics B. Corticosteroids E. Antipsychotics

Oxygen therapy is prescribed for a client who is brought to an emergency department in the early stages of hypoxia. When assessing this client, a nurse should expect which of the following findings? A. Elevated blood pressure B. Decreased RR C. Cyanosis D. Peripheral edema

A. Elevated blood pressure

A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? A. Encourage the client to perform antiembolic exercises every 2 hrs. B. Instruct the client to cough and deep breathe every 4 hr. C. Restrict the client's fluid intake D. Reposition the client every 4 hr

A. Encourage the client to perform antiembolic exercises every 2 hrs.

A nurse is beginning to complete bed bath for a client. After removing the client's gown and placing a bath blanket over the body, which of the following areas should the nurse wash first? A. Face B. Feet C. Chest D. Arms

A. Face

A charge nurse is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. Which of the following are manifestations of a systemic infection? (Select all that apply.) A. Fever B. Malaise C. Edema D. Pain or tenderness E. Increase in pulse and respiratory rate

A. Fever B. Malaise E. Increase in pulse and respiration rate

A nurse is instructing a client who has an injury to the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (Select all that apply) A. Hold the can on the right side B. Keep two points of support on the floor C. Place the can 38 cm (15 in) in front of the feet before advancing D. After advancing the cane, move the weaker leg forward E. Advance the stronger leg so that it aligns evenly with the cane

A. Hold the can on the right side B. Keep two points of support on the floor D. After advancing the cane, move the weaker leg forward

Which of the following interventions should a nurse use at mealtimes for client who has visual impairment? A. Identify the food locations as though the plate were a clock B. Direct the order in which food items are consumed C. Have the client tilt their head forward while eating D. Avoid talking to the client during mealtime

A. Identify the food locations as though the plate were a clock

A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (Select all that apply. A. Increase in incisional pain B. Fever and chills C. Reddened wound edges D. Increase in serosanguineous drainage E. Decrease in thirst

A. Increase in incisional pain B. Fever and chills C. Reddened wound edges

A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (Select all that apply) A. Inspect the feet daily B. Use moisturizing lotion on the feet C. Wash the feet with warm water and let them air dry D. Use over-the-counter products to treat abrasions E. Wear cotton socks

A. Inspect the feet daily B. Use moisturizing lotion on the feet E. Wear cotton socks

Which of the following is an advantage of using alcohol-based gel? A. It takes less time to use than washing with soap and water B. It removes gross contamination better than soap and water C. Its protective mature reduces the need for frequent hand washing D. It provides adequate before surgical applications

A. It takes less time to use than washing with soap and water

A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply.) A. Keep the head of the bed elevated 30°. B. Massage the client's bony prominences frequently. C. Apply cornstarch liberally to the skin after bathing. D. Have the client sit on a gel cushion when in a chair. E. Reposition the client at least every 3 hr while in bed.

A. Keep the head of the bed elevated 30°. D. Have the client sit on a gel cushion when in a chair.

A nurse is teaching a client who has bladder cancer about urinary diversion options. Then nurse should inform the client which of the following options will allow them to have some control over urinary diversion. A. Kock's pouch B. Ileal conduit C. Cutaneous ureterostomy D. Nephrostomy

A. Kock's pouch

A nurse is caring for a client who has a suspected UTI. Which of the following urinalysis results should the nurse identify as a manifestation of a UTI? A. Leukocyte esterase B. Trace amount of protein C. Specific gravity of 1.010 D. pH of 6..0

A. Leukocyte esterase

A nurse in a long-term care facility is caring for a client who is on bed rest and requires frequent linen changes. Which of the following should the nurse identify as the priority rationale for frequent linen changes? A. Moisture from excessive diaphoresis can cause skin breakdown B. Moisture on the sheets can cause discomfort C. Provides opportunity to frequently evaluate the skin on the client's backside D. Opportunity to turn client from side to side to facilitate clearing potential fluid from the lungs

A. Moisture from excessive diaphoresis can cause skin breakdown

A nurse stands facing a client to demonstrate active ROM exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip? A. Move the leg behind their body B. Move their leg forward and up C. Move their leg medially toward their other leg D. Turn their foot and leg away from their other leg

A. Move the leg behind their body

A nurse is collecting data about a client's respiratory condition. Which of the following actions should the nurse take to determine the depth of client's respiration? A. Observe the degree of chest-wall movement during inspiration and expiration B. Count how many breathing cycles are observed per minute C. Notice whether or not expiration takes longer than inspiration D. Measure the precise amount of air the client takes in and breathes out

A. Observe the degree of chest-wall movement during inspiration and expiration

A nurse is caring for a client in the emergency department who has an oral body temperature of 38.8 degrees Celcius, pulse rate of 114/min, and respiratory rate of 22/min. The client is restless with warm skin. Which of the following interventions should the nurse take? (Select all that apply) A. Obtain culture specimens before initiating antimicrobials B. Restrict the client's oral fluid intake C. Encourage the client to rest and limit activity D. Allow the client to shiver to dispel excess heat E. Assist the client with oral hygiene frequently

A. Obtain culture specimens before initiating antimicrobials. C. Encourage the client to rest and limit activity E. Assist the client with oral hygiene frequently

A nurse is teaching a client about the home collection of a stool specimen for fecal occult blood testing. Which of the following instructions should the nurse include? A. Obtain specimens from the three different stools B. Eat a diet low in fiber and residue C. Avoid foods that are high in fat D. Refrigerate the specimen card after obtaining

A. Obtain specimens from the three different stools

Administering oxygen therapy with a non-rebreather mask has which of the following advantages? A. Offers the highest oxygen concentration of the low-flow systems B. Provides oxygen concentration of 40 60% C. Incorporates a design that requires minimal monitoring of the client D. Is designed for safety once the mask's valves and flaps are sealed.

A. Offers the highest oxygen concentration of the low-flow systems

A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply) A. Older adults are more prone to dehydration than younger adults are B. Older adults need the same amount of most vitamins and minerals as younger adults do. C. Many older men and women need calcium supplementation D. Older adults need more calories than they did when they were younger E. Older adults should consume a diet low in carbohydrates

A. Older adults are more prone to dehydration than younger adults are B. Older adults need the same amount of most vitamins and minerals as younger adults do. C. Many older men and women need calcium supplementation

A nurse is preparing to administer a cleansing enema to a client who has poor sphincter control. Which of the following actions should the nurse take? A. Place the client in a dorsal recumbent position on a bedpan B. Administer the enema while the client sits on the toilet C. Administer an antidiarrheal medication 3 hr prior to the enema D. Instill 200 mL of fluid over an hour at 15-min intervals

A. Place the client in a dorsal recumbent position on a bedpan

A nurse is instructing a group of assistive personnel in measuring a client's respiratory rate. Which of the following guidelines should the nurse include? (Select all that apply) A. Place the client in semi-fowler's position B. Have the client rest an arm across the abdomen C. Observe one full respiratory cycle before counting the rate. D. Count the rate for 30 sec if it is regular E. Count and report any sighs the client demonstrates

A. Place the client in semi-fowler's position B. Have the client rest an arm across the abdomen C. Observe one full respiratory cycle before counting the rate.

A nurse is providing discharge teaching with a client who is going home on continuous liquid oxygen therapy. Which of the following instructions should the nurse include? A. Place the oxygen tank in a clutter-free environment B. Keep the oxygen tank at least 6 feet away from a heat source C. Ensure you are close to electricity to use your oxygen tank D. Turn the valve until an alarm sounds

A. Place the oxygen tank in a clutter-free environment

A nurse is measuring a client's temp orally. Which of the following actions should the nurse take? A. Place the probe in the posterior lingual pocket lateral to the midline B. Rest the probe on the lower lingual frenulum C. Place the probe centrally on top of the tongue D. Rest probe under tongue just beyond teeth

A. Place the probe in the posterior lingual pocket lateral to the midline

A nurse is caring for a client who has severe acute respiratory syndrome (SARS). The nurse knows that healthcare professionals are required to report communicable diseases. Which of the following illustrates the rationale for reporting? (Select all that apply.) A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common-source outbreaks

A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment E. Monitoring for common-source outbreaks

A nurse is teaching a client about stool collection for fecal occult blood testing. Which of the following should the nurse instruct the client to avoid before and during the testing period A. Poultry B. Vitamin E supplements C. Calcium supplements D. Yogurt

A. Poultry

A nurse at a clinic is collecting data about pain from of a client who reports severe abdominal pain. The nurse asks the client if there has been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine? A. Presence of associated manifestations B. Location of the pain C. Pain quality D. Aggravating and relieving factors

A. Presence of associated manifestations

To decontaminate their hands with an alcohol-based gel, the nurse should rub their hands together until all of the gel is evaporated from and their hands are dry. Which of the following is the correct rationale for why hands should be rubbed together until dry? A. Provides full antiseptic effect B. Residual alcohol can easily stain clothing C. Excess gel could transfer to patient D. Slippery gel can make the nurse drop supplies

A. Provides full antiseptic effect

A nurse is caring for a client who has been receiving oxygen via nasal cannula for 4 hours. Which of the following assessment findings helps indicate oxygen therapy has been effective? A. RR 14/min B. SaO2 90% C. Cardiac output 5.6 L/min D. PaCO2 68 mmHg

A. RR 14/min

A nurse is performing a complete bed bath for a client. Which of the following actions should the nurse take? A. Raise the room temp B. Completely remove the linens C. Add soap to the water in the basin before beginning the bath D. Bathe one side of client at a time

A. Raise the room temp

A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (Select all that apply.) A. Request assistance when repositioning a client. B. Avoid twisting your spine or bending at the waist. C. Keep your knees slightly lower than your hips when sitting for long periods of time. D. Use smooth movements when lifting and moving clients E. Take a break from the repetitive movements every 2 to 3 hours to flex and stretch your joints and muscles.

A. Request assistance when repositioning a client. B. Avoid twisting your spine or bending at the waist. D. Use smooth movements when lifting and moving clients

A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (select all that apply) A. Restlessness B. Tachypnea C. Bradycardia D. Confusion E. Hypertension

A. Restlessness B. Tachypnea D. Confusion E. Hypertension

A nurse is planning care for a client who develops dyspnea and feels tired after completing morning care. Which of the following actions should the nurse include in the client's plan of care? A. Schedule rest periods during morning care B. Discontinue morning care for 2 days. C. Perform all care as quickly as possible D. Ask a family member to come in to bathe the client

A. Schedule rest periods during morning care

A nurse is documenting data about a healing wound on a client's lower leg. The predominant exudate in the wound is watery in consistency and light red in color. The nurse should document which of the following types of wound drainage? A. Serosanguineous B. Sanguineous C. Serous D. Purulent

A. Serosanguineous

A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply.) A. Stage 3 pressure injury B. Sutured surgical incision C. Casted bone fracture D. Laceration sealed with adhesive E. Open burn area

A. Stage 3 pressure injury E. Open burn area

A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the client's head to the side B. Place two fingers in the client's mouth to open it C. Brush the client's teeth once per day D. Inject a mouth rinse into the center of the client's mouth

A. Turn the client's head to the side

A nurse is preparing to administer the first large-volume, cleansing enemas prescribed for a client in preparation for a diagnostic procedure. Which of the following actions should the nurse take? A. Warm the enema solution prior to installation B. Prepare 1,500 mL of enema C. Use tap water as the enema fluid D. Hang the enema container 24 inches above the anus

A. Warm the enema solution prior to installation

A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? (Select all that apply.) A. Warm the enema solution prior to instillation. B. Position the client on the left side with the right leg flexed forward. C. Lubricate the rectal tube or nozzle. D. Slowly insert the rectal tube about 5 cm (2 in). E. Hang the enema container 61 cm (24 in) above the client's anus.

A. Warm the enema solution prior to instillation. B. Position the client on the left side with the right leg flexed forward. C. Lubricate the rectal tube or nozzle.

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurses' priority? A. Complete a fall-risk assessment B. Educate the client and family about the fall risk C. Eliminate safety hazards from the client's environment D. Make sure the client uses assistive aids in their possession

A.Complete a fall-risk assessment

A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (Select all that apply.) A.Increase in incisional pain B.Fever and chills C.Reddened wound edges D.Increase in serosanguineous drainage E.Decrease in thirst

A.Increase in incisional pain B.Fever and chills C.Reddened wound edges

A nurse is caring for a client who is at risk for developing a pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply.) A.Keep the head of the bed elevated 30°. B.Massage the client's bony prominences frequently. C.Apply cornstarch liberally to the skin after bathing. D.Have the client sit on a gel cushion when in a chair. E.Reposition the client at least every 3 hr while in bed.

A.Keep the head of the bed elevated 30°. D.Have the client sit on a gel cushion when in a chair.

A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply.) A.Stage 3 pressure injury B.Sutured surgical incision C.Casted bone fracture D.Laceration sealed with adhesive E.Open burn area

A.Stage 3 pressure injury E.Open burn area

A nurse is evaluation a client's understanding of the use of a sequential compression device. Which if the following client statements indicates client understanding? A. "This device will keep me form getting sores on my skin" B. " This device will keep the blood pumping through my legs." C. "With this device on, my leg muscles wont get weak." D. "This device is going to keep my joints in good shape."

B. " This device will keep the blood pumping through my legs."

A nurse manager is reviewing with the nurses on the unit in the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on their side." B. "I will go to the nurse's station for assistance." C. "I will note the time that the seizure began." D. "I will prepare to insert an airway."

B. "I will go to the nurses station for assistance"

A nurse educator is reviewing proper body mechanics during employee orientation. Which of following statements should the nurse identify as an indication that an attendee understands the teaching? (Select all that apply.) A. "My line of gravity should fall outside my base of support." B. "The lower my center of gravity the more stability I have." C. "To broaden my base of support, I should spread my feet apart." D. "When I lift an object, I should hold it as close to my body as possible." E. "When pulling an object, I should move my front foot forward."

B. "The lower my center of gravity the more stability I have." C. "To broaden my base of support, I should spread my feet apart." D. "When I lift an object, I should hold it as close to my body as possible."

A nurse is caring for a client who has a HAI. Which of the following describes an exogenous HAI? A. An infection that occurs during a therapeutic procedure B. A Salmonella infection that occurs after eating contaminated food from the cafeteria C. A yeast infection that occurs while receiving broad spectrum antibiotics D. A UTI that occurs after a sterile catheter insertion

B. A Salmonella infection that occurs after eating contaminated food from the cafeteria

A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (select all that apply) A. Instruct the client not to perform the Valsalva maneuver B. Apply elastic stockings C. Review laboratory values for total protein level D. Place pillows under the client's knees and lower extremities E. Assist the client to change positions often

B. Apply elastic stockings E. Assist the client to change positions often

A nurse is measuring the blood pressure of a client who has a fractured femur. The blood pressure reading is 140/94 mmHg, and the client denies any history of hypertension. Which of the following actions should the nurse take first? A. Request a prescription for an antihypertensive medication B. Ask the client if they are having pain C. Request a prescription for an anti-anxiety medication. D. Return in 30 min to recheck the client's blood pressure

B. Ask the client if they are having pain

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula . Which of the following interventions is the nurse's priority? A. Increase oxygen flow B. Assist the client to Fowler's position C. Promote removal of pulmonary secretions D. Obtain a specimen for arterial blood gases

B. Assist the client to Fowler's position

A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A. Pull down and out at the back of the upper denture to remove B. Brush the dentures with a toothbrush and denture cleaner C. Rinse the dentures with hot water after cleaning them D. Place the dentures in a clean, dry storage container after cleaning them.

B. Brush the dentures with a toothbrush and denture cleaner

A nurse is caring for a client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. Their Hgb is 12g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? select all that apply A. Extremes in age B. Chronic Illness C. Low hemoglobin D. Malnutrition E. Poor wound care

B. Chronic Illness C. Low hemoglobin D. Malnutrition

A nurse is caring for a client who is 2 days has type I diabetes mellitus. Their Hgb is 12 g/aL Astoporative follower tus. Their Hob 05 y2 nd and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the thent has which of the following risk factors for impaired wound healing? (Select all that apply.) A. Extremes in age B. Chronic illness C. Low hemoglobin D. Malnutrition E. Poor wound care

B. Chronic illness C. Low hemoglobin D. Malnutrition

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? A. Have the client hold their breath briefly and bear down B. Clamp the enema tubing. C. Remind the client that cramping is common at this time. D. Raise the level of the enema fluid container.

B. Clamp the enema tubing.

A nurse is caring for a client who has multiple sclerosis and a chronic non-healing wound. The nurse should recognize which of the following types of medication is known to delay wound healing. A. Tricyclic antidepressants B. Corticosteroids C. Beta-blockers D. Anticholinergics

B. Corticosteroids

A nurse is caring for a client who has dyspnea, slight cyanosis, and a RR of 28/min. During which of the following phases of the nursing process will the nurse determine that the client has impaired gas exchange. A. Assessment B. Diagnosis C. Planning D. Evaluation

B. Diagnosis

Which of the following dietary modifications should adolescent who participates in sports implement A. Increase fats 30-40% of kilocalories B. Drink water before and after sports activities C. Keep protein intake at the same level D. Decrease carbs to 30-40% of daily kilocalories

B. Drink water before and after sports activities

A nurse is assessing respirations. Which of the following actions should the nurse take? A. Have the client lie flat with their head on the pillow B. Elevate the head of the bed to 45-60 degrees C. Encourage slow breathing D. Ask the client to take several deep bretahs prior to assessment

B. Elevate the head of the bed to 45-60 degrees

A nurse is teaching a client who has a new ileostomy about preventing the excoriation and breakdown of the peristomal skin after they have returned home. Which of the following instructions should the nurse include? A. Apply hydrocortisone cream to the skin when changing the appliance B. Empty the pouch when it is less than half full C. Wash the peristomal skin frequently with deodorizing D. Choose a time shortly after a meal for replacing

B. Empty the pouch when it is less than half full

A nurse is about to irrigate a client's open wound. Besides gloves, which of the following PPE should the nurse wear? A. Sterile gown B. Face Shield C. Goggles D. N95 respirator

B. Face shield

A nurse is caring for a client who has been hospitalized and is performing active ROM exercises. Which of the following body movements should indicate to the nurse that the client has full ROM of the shoulder? A. Adducting the arm so that it lies next to the client's side B. Flexing the shoulder by raising the arm from a side to a 180 degree angle C. Abducting the arm to a 90 degree angle from the side of the body D. Circumducting the shoulder in a 180 half circle

B. Flexing the shoulder by raising the arm from a side to a 180 degree angle

After completing a procedure that required donning PPE consisting of a gown, n95 respirator, face shield, and gloves, which of the following should the nurse remove first? A. Gown B. Gloves C. Face shield D. N95 respirator

B. Gloves

A nurse is assessing a client who has had diarrhea for 4 days. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Hypotension C. Elevated temperature D. Poor skin turgor E. Peripheral edema

B. Hypotension C. Elevated temperature D. Poor skin turgor

A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? A. Give the client thin liquids B. Instruct the client to tuck their chin when swallowing C. Have the client use a straw. D. Encourage the client to lie down and rest after meals.

B. Instruct the client to tuck their chin when swallowing

A nurse is observing an AP who is using a mechanical lift with a hammock sling to transfer a client from the bed to a chair. For which of the following actions by the AP should the nurse intervene. A. Places removable cover over the sling B. Leaves the bed in the lowest position throughout the sling to the lift C. Locks the hydraulic valve before attaching the sling to the lift D. Raises the head of the bed to a sitting position just before a transfer

B. Leaves the bed in the lowest position throughout the sling to the lift

A nurse is administering a return-flow enema to a client. After instilling 100 mL of enema fluid, which of the following actions should the nurse take? A. Instruct the client to retain the fluid B. Lower the container to allow the solution to flow back out C. Help the client to the toilet or bedside commode D. Wait 5 min and instill another 100 mL of fluid

B. Lower the container to allow the solution to flow back out

A nurse is providing dietary teaching for a client who reports constipation. Which of the following foods should the nurse recommend? A. Macaroni and cheese B. One medium apple with skin C. One cup of plain yogurt D. Roast chicken and white rice

B. One medium apple with skin

A nurse is caring for a client who has Mycoplasma pneumoniae. The client has been placed on droplet precautions. Which of the following actions should the nurse take when caring for the client? A. Wear a respirator B. Protect the eyes C. Put on clean gloves D. Wear should covers

B. Protect the eyes

A nurse is caring for a client who has Mycoplasma pneumoniae. The client has been placed on droplet precautions. Which of the following actions should the nurse take when caring for the client? A. Wear a respirator B. Protect their eyes C. Put on clean gloves D. Wear shoe covers

B. Protect their eyes

A nurse is preparing to record the difference between a client's systolic and diastolic blood pressure. Which of the following terms defines this information when documenting? A. Auscultatory gap B. Pulse pressure C. Orthostatic hypotension D. Pulse deficit

B. Pulse pressure

A nurse is obtaining vital signs from a client. Which of the following findings is the priority for the nurse to report to the provider? A. Oral temp 37.8 C (100.0 F) B. RR 30/min C. BP 148/88 mmHg D. Radial pulse rate 45 beats/30 seconds

B. RR 30/min

A home health nurse is teaching a client who has just started receiving oxygen therapy via mask. The nurse should emphasize that the client must A. Clean the mask with soapy water once every other day B. Reposition the elastic band frequently C. Apply petroleum jelly around and inside the nares D. Make sure there is adequate condensation in the tubing

B. Reposition the elastic band frequently

A client who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should expect the provider to prescribe which of the following types of enemas. A. Cleansing B. Return-flow C. Medicated D. Oil-retention

B. Return-flow

A nurse caring for a group of clients in an ambulatory care clinic is collecting urine for several prescribed diagnostic tests. For which of the following tests is a random sample voided into a clean cup appropriate? A. Urine culture and sensitivity B. Routine analysis C. Urine creatinine clearance D. Urine pregnancy testing

B. Routine analysis

A nurse is collecting a blood specimen for culture from a client. Which of the following actions should the nurse take? A. Keep the tourniquet in place from the selection of the vein to the completion of the collection B. Rub the client's arm at the selected site prior to venipuncture C. Elevate the client's arm above heart level for the venipuncture D. Puncture the selected vein while the antiseptic solution is still visible on the skin

B. Rub the client's arm at the selected site prior to venipuncture

A nurse is caring for a client who is receiving enteral tube feedings due to dysphasia. Which of the following bed positions should the nurse use for the safe care of this client? A. Supine B. Semi-Fowler's C. Semi-prone D. Trednelenberg

B. Semi-Fowler's

A nurse is documenting data about a deep necrotic wound on a client's left buttock. Which of the following assessment findings should the nurse document? A. Keloid B. Slough C. Granulation D. Eschar

B. Slough

A nurse is caring for a client who has sustained a head injury and whose level of consciousness fluctuates. The provider prescribes a full thin liquid diet progressing to a pureed as tolerated. Before initiating feedings, it is essential that this client undergo which of the following? A. Chest x-ray B. Swallowing examination C. Nasogastric tube insertion D. Olfactory nerve evaluation

B. Swallowing examination

A nurse is caring for a client who has a tracheostomy. Which of the following pieces of equipment should the nurse use when administering oxygen to this client? A. Distilled water for humidification B. Tracheostomy collar C. Nasal cannula D. Aerosal mask

B. Tracheostomy collar

A nurse is providing preoperative teaching for a client who is scheduled for creation of a sigmoid colostomy. Which of the following information should the nurse include in the teaching? A. Expect the effluent from the sigmoid colostomy to be loose and continuous B. Use irrigation to help establish a regular bowel pattern. C. Change the stoma's appliance every other day D. Expect effluent from the newly created stoma within 24 hours after surgery.

B. Use irrigation to help establish a regular bowel pattern.

A nurse is reviewing hand hygiene techniques with a group of assistive personnel (AP). Which of the following instructions should the nurse include when discussing handwashing? (select all that apply) A. apply 3 to 5 mL of liquid soap to dry hands. B. Wash the hands with soap and water for at least 15 seconds. C. Rinse the hands with hot water D. Use a clean paper towel to turn off hand faucets. E. Allow the hands to air dry after washing

B. Wash the hands with soap and water for at least 15 seconds. D. Use a clean paper towel to turn off hand faucets.

After assisting a newly admitted client with removing their shoes and outerwear, the nurse notices what appears to be soil or grime on their hands. Which of the following actions should the nurse take? A. Cleanse their hands with an alcohol-based gel B. Wash their hands with soap and water C.Brush off the soil against a cloth surface D. Use a wet paper towel to remove the soil

B. Wash their hands with soap and water

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include? (Select all that apply.) A. Place the client in a room that has a negative air pressure of at least six exchanges per hour B. Wear a mask when providing care within 3 ft of the client C. Place a surgical mask on the client if transportation to another department is unavoidable D. Use sterile gloves when handling soiled linens E. Wear a gown when performing scare that might result in contamination from secretions

B. Wear a mask when providing care within 3 ft of the client C. Place a surgical mask on the client if transportation to another department is unavoidable E. Wear a gown when performing scare that might result in contamination from secretions

A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the field (Select all that apply) A. provider drops a sterile instrument onto the near side of the sterile field B. nurse moistens a cotton ball with sterile normal saline and places it on a sterile field C. procedure is delayed 1hr because the provider receives an emergency call D. nurse turns to speak to someone who enters through the door behind the nurse E. client's hand brushes against the outer edge of the sterile field

B. nurse moistens a cotton ball with sterile normal saline and places it on sterile field C. procedure is delayed 1hr because the provider receives an emergency call D. nurse turns to speak to someone who enters through the door behind the nurse

A nurse is caring who weighs 80 kg (176 lb) and is 1.6 m (5 ft 3 in) tall. Calculate the body mass index (BMI) and determine whether this client's BMI indicated a health weight, underweight, or obese.

BMI = weight (kg) / height (m^2) = 31.25

A nurse is caring for client who is receiving morphine via a patient controlled analgesia PCA infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? A. "I'll wait to use the device until absolutely necessary" B. " I'll be careful about pushing the button too much so I don't get an overdose." C. " I should tell the nurse if the pain doesn't stop while I am using this device" D. " I will ask my adult child to push the dose button when I am sleeping."

C. " I should tell the nurse if the pain doesn't stop while I am using this device"

A charge nurse is reviewing anthropometric values with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "Isolated measurements of height and weight are greater significance than changes over time" B. "A weight increase of 4 pounds in a client who has renal failure indicates retention of 1,000 mL of fluid" C. "Client should be weighed on the same scale at the same time of day" D. "The ratio of height-to-wrist circumference is the most accurate way to identify obesity"

C. "Client should be weighed on the same scale at the same time of day"

A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make? A. "Lie on your back with your head and shoulders supported by a pillow." B. "Have your head turned to the side while you lie on your stomach." C. "Have the table beside your bed so you can sit on the bedside and rest your arms on the table." D. "Lie on your side with your top arm resting on the bed and your weight on your hip."

C. "Have the table beside your bed so you can sit on the bedside and rest your arms on the table."

A nurse is in an ED is providing discharge teaching to a client who has a knee injury and will be using a pair of axillary crutches for the first time. Which of the following instructions should the nurse include. A. "Lean on the crutches to support to support your body weight when standing" B. "Fully extend your arms when holding onto the hand grips" C. "Hold the crutches on your unaffected side when preparing to sit in a chair" D. "Hold the crutches 9 inches in front of and to the side of each foot"

C. "Hold the crutches on your unaffected side when preparing to sit in a chair"

A nurse is administering an enema medicated with sodium polystyrene to an adult client who has hyperkalemia. To which of the following lengths should the nurse insert the rectal tube A. 2.5-3.75 cm (1-1.5 inches) B. 5-7 cm (2-3 in) C. 7.5-10 cm (3-4 in) D. 10-12.5 cm (4-5 in)

C. 7.5-10 cm (3-4 in)

A nurse is caring for a client who has heavy drainage from a moist red wound that is bleeding. Which of the following types of dressings should the nurse select to help promote hemostasis A. Transparent B. Hydrogel C. Alginate D. Dry gauze

C. Alginate

A nurse is preparing to transfer a client who has left-sides weakness from the bed to the chair. Which of the actions by the nurse demonstrates correct transfer technique A. Positioning the chair slightly behind the nurse so that the seat faces the client's bed B. Placing the client's left leg in from of the right leg prior to the transfer C. Aligning the nurse's knee with the client's knee just before the transfer D. Grasping the client under the axillae to assist them to their feet

C. Aligning the nurse's knee with the client's knee just before the transfer

A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? (Select all that apply.) A. Remove the dentures from the body. B. Make sure the body is lying completely flat. C. Apply fresh linens and place a clean gown on the body. D. Remove all equipment from the bedside. E. Dim the lights in the room.

C. Apply fresh linens and place a clean gown on the body. D. Remove all equipment from the bedside. E. Dim the lights in the room.

A nurse is planning morning hygiene care for a postoperative client. Which of the following actions should the nurse take? A. Inform the client when morning hygiene care is provided at the hospital B. Schedule the morning hygiene at the same time as the roommate C. Ask the client what order they typically perform their morning care D. Plan to provide care before the next scheduled dose of pain meds

C. Ask the client what order they typically perform their morning care

A nurse is caring for a client who has stage IV lung cancer and is 3 days postoperative following a wedge resection. The client states, "| told myself that I would go through with the surgery and quit smoking, if I could just live long enough to attend my child's wedding." Based on the Kübler-Ross model, which stage of grief is the client experiencing? A. Anger B. Denial C. Bargaining D. Acceptance

C. Bargaining

A nurse is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the nurse identify as an adverse effect of opioids? (Select all that apply) A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea

C. Bradypnea D. Orthostatic hypotension E. Nausea

A provider is discharging a client with a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following? (Select all that apply) A. Apply petroleum jelly around the inside of the nares B. Remove the nasal cannula during mealtimes C. Check the position of the cannula often D. Report any nasal stuffiness, nausea, or fatigue E. Post "no smoking" signs in a prominent location

C. Check the position of the cannula often D. Report any nasal stuffiness, nausea, or fatigue E. Post "no smoking" signs in a prominent location

A nurse is caring for a client who was admitted with community-acquired pneumonia and has been receiving oxygen therapy for several days. Which of the following findings indicates an adverse effect of oxygen therapy? A. Poor skin turgor B. Copious respiratory secretions C. Cracks in the oral mucosa D. Elevated heart rate

C. Cracks in the oral mucosa

What should a nurse do to maintain standards precautions? A. Rinse gloves that become visibly soiled during use B. Use antimicrobial soap for routine hand washing C. Disinfect hands immediately after removing gloves D. Keep gloves on when touching environmental surfaces

C. Disinfect hands immediately after removing gloves

A nurse is caring for a client who has impaired swallowing due to cerebrovascular accident. Which of the following interventions should the nurse use to assist the client with feeding? A. Provide the client with a straw B. Offer the client thin fluids C. Elevate the head of the bed 45-90 degrees D. Place food in the weaker side of the mouth"

C. Elevate the head of the bed 45-90 degrees

A nurse is caring for a client who needs to collect a midstream urine specimen. Which of the following actions should the nurse take? A. Give the client a clean urine cup from the laboratory B. Instruct the client to cleanse the perineal area from back to front C. Have the client urinate a small amount of urine before starting the collection D. Tell the client to collect about 10 mL of urine

C. Have the client urinate a small amount of urine before starting the collection

A nurse is teaching self-monitoring of blood glucose (SMBG) to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply.) A. Perform SMBG once daily at bedtime. B. Wipe the hand with an alcohol swab. C. Hold the hand in a dependent position prior to the puncture. D. Place the puncturing device perpendicular to the site. E. Prick the outer edge of the fingertip for the blood sample.

C. Hold the hand in a dependent position prior to the puncture. D. Place the puncturing device perpendicular to the site. E. Prick the outer edge of the fingertip for the blood sample.

A nurse is teaching a newly licensed nurse about providing oral hygiene for clients who are unconscious. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. I'll swab the client's mouth with lemon-glycerin swabs B. I'll swab the client's mouth with mouthwash C. I'll swab the client's mouth with chlorhexidine D. I'll swab the client's lips with a very small amount of mineral oil

C. I'll swab the client's mouth with chlorhexidine

A nurse is reinforcing teaching with a client who has colon cancer and is scheduled for a procedure to remove their entire large intestine and rectum. The nurse should reinforce to the client that they are scheduled for which of the following types of ostomy procedure? A. Cecostomy B. Loop colostomy C. Ileostomy D. Descending colostomy

C. Ileostomy

Contact precautions should be implemented for an adult who has been hospitalized and has which of the following? A. Hepatits B B. Measles C. Infectious diarrhea D. Meningitis

C. Infectious diarrhea

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? A. Measure the client's vitals B. Notify the primary care provider C. Lower the enema fluid container D. Stop the enema instillation

C. Lower the enema fluid container

A nurse is caring for a client who fell at a nursing home. The client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply) A. Place a belt restraint on the client when they are sitting on the bedside commode B. Keep the bed in the lowest position with all the side rails up C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear E. Complete a fall-risk assessment

C. Make sure that the client's call light is within reach. D. Provide the client with nonskid footwear E. Complete a fall-risk assessment

Which of the following strategies for enhancing the intake of healthy foods of healthy foods is appropriate for an adolescent? A. Encouraging the adolescent to consume snack foods from the grains group family B. Permitting the adolescent to skip breakfast to enhance appetite at later meals C. Making healthful food choices more convenient and available for adolescent D. Allowing the adolescent to complete autonomy in making food choices

C. Making healthful food choices more convenient and available for adolescent

A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which if the following actions should the nurse take to determine the intensity of the clients pain? A. Ask the client what precipitates the pain B. Question the client about the location of the pain C. Offer the client a pain scale to measure their pain D. Use open ended questions to identify the clients pain sensations

C. Offer the client a pain scale to measure their pain

A nurse is preparing to auscultate a client's apical pulse at the point of maximal impulse (PMI). In which of the following locations should the nurse position the stethoscope? A. Over right mid-clavicular line B. Over the angle of Louis C. Over the fifth intercostal space at the left mid-clavicular line D. Over the supra-sternal notch

C. Over the fifth intercostal space at the left mid-clavicular line

Which of following products can affect the permeability latex gloves? A. Antimicrobial soap and water B. Alcohol-based antiseptic gel C. Petroleum-based hand lotion D. Water-based hand lotion

C. Petroleum-based hand lotion

When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? A. Keep the sterile field at least 6 ft away from the client's bedside B. Instruct the client to refrain from coughing and sneezing during the dressing change C.Place mask on the client to limit the spread of microorganisms into the surgical wound. D. Keep a box of facial tissues near by for the client to use during the dressing change

C. Place mask on the client to limit the spread of microorganisms into the surgical wound.

A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? A. Decreased subcutaneous fat B. Muscle atrophy C. Pressure injury D. Fecal impaction

C. Pressure injury

A nurse is preparing to use a tympanic thermometer to acquire a client's temp. Which of the following actions should the nurse take to ensure an accurate reading? A. Attach the disposable probe cover B. Assess the external ear for redness C. Pull the pinna back and upward D. Replace the thermometer in its charger

C. Pull the pinna back and upward

A nurse is caring for a client who has a stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement. Which of the following is a form of mechanical debridement that the nurses should expect the client to receive? A. Placing a transparent dressing over the pressure injury B. Applying hydrocolloids C. Pulsating lavage D. Using a topical enzyme solution in the wound bed

C. Pulsating lavage

A nurse is reinforcing teaching with a client about replacing an ostomy pouching system. The client reports that they occasionally experience pain when removing the skin barrier. Which of the following techniques should the nurse suggest? A. Lift up on both sides of the skin barrier simultaneously B. Release one corner of the barrier and pull it quickly over the stoma C. Push the skin away from the barrier while removing it D. Gently roll the barrier end-over-end across the stoma

C. Push the skin away from the barrier while removing it

A nurse is caring for a client who has a stage III pressure injury in the sacral area. Which of the following actions should the nurse take when obtaining a wound culture specimen from the pressure injury? A. Irrigate the wound with an antiseptic solution before collecting the specimen B. Wipe the crusty area from the outside of the wound with a sterile swab C. Rotate a sterile swab in the area of drainage D. Collect drainage from the wound dressing

C. Rotate a sterile swab in the area of drainage

A nurse is caring for a client who has terminal lung cancer. The nurse observes the clients family assisting with all ADL's. Which of the following rationales for self care should the nurse communicate to the family? A. Allowing the client to function independently will strengthen muscles & promote healing B. The client needs privacy at times for Self-reflecting and organizing life. C. The client's sense of loss can be lessened through retaining control of some areas of life D. Performing ADL's is a requirement prior to discharge from an acute care facility

C. The client's sense of loss can be lessened through retaining control of some areas of life

A nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching the sterile technique? (Select all that apply.) A. A bottle containing a sterile solution B. The edge of the sterile drape at the base of the field C. The inner wrapping of an item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

C. The inner wrapping of an the item on the sterile field D. An irrigation syringe on the sterile field E. One gloved hand with the other gloved hand

A nurse is caring for a client who requires a low residue diet. The nurse should expect to see which of the following foods on the client's meal tray? A. Cooked barley B. Pureed broccoli C. Vanilla custard D. Lentil soup

C. Vanilla custard

A nurse is caring for a critically ill client who has COPD and requires delivery of precise oxygen. Which of the following types of oxygen therapy devices is indicated for this client? A. Simple face mask B. Nasal cannula C. Venturi mask D. Face tent

C. Venturi mask

A nurse is auscultating a client's apical pulse to the S1 and S2 heart sounds. The S2 heart sounds are heard when which of the following occurs? A. When the atria contracts vigorously B. As the ventricular walls contract C. When semilulnar valves close D. As mitral valve snaps open

C. When semilulnar valves close

A nurse caring for a client who has diabetes mellitus is having difficulty obtaining a capillary finger stick blood sample for point-of-care blood glucose testing. Which of the following actions should the nurse take to help increase blood flow to the client's finger? A. Elevate the hand on a pillow B. Pierce the skin in the middle of the finger pad C. Wrap the finger in a warm cloth D. Firmly milk the puncture site

C. Wrap the finger in a warm cloth

A nurse attempting to collect a capillary blood specimen via finger stick for blood glucose monitoring is unable to obtain an adequate drop of blood for the reagent strip. Which of the following actions should the nurse take first? A. Puncture another finger to obtain a capillary specimen. B. Test the urine with a urine reagent strip. C. Wrap the hand in a warm, moist cloth. D. Perform a venipuncture to obtain a venous sample.

C. Wrap the hand in a warm, moist cloth.

A nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? A. Extinguish the fire B. Activate the fire alarm C. Move clients who are nearby D. Close all open doors on the unit

C.Move clients who are nearby

An AP is collecting urine specimens from a client. Which of the following statements by the Ap indicates that specimen collection will have to be restarted? A. "I used a container from the lab that has a preservative in it" B. "The client just voided into the toilet, so the next void can be collected" C. "I have the container in a plastic bucket filled with ice" D. "The client just told me they forget to put the urine in the container"

D. "The client just told me they forget to put the urine in the container"

A nurse us discussing the care of a group of clients with a newly licensed nurse. Which of the following client should the newly licensed nurse identify as experiencing chronic pain? A. A client who has a broken femur and reports hip pain B. A client who has incisional pain 72 hrs following pacemaker insertion C. A client who has food poisoning and reports abdominal cramping D. A client who has episodic back pain following a fall 2 years ago

D. A client who has episodic back pain following a fall 2 years ago

A nurse is observing an AP make a client's bed while the nurse is out of the room. Which of the following acts by the AP indicates an understanding of the procedure? A. AP records the task when it is completed B. AP wears sterile gloves while making the bed C. AP changes the client's pillowcase D. AP reuses the client's clean blanket and spread.

D. AP reuses the client's clean blanket and spread.

A nurse obtains a capillary blood glucose result of 180 mg/dL from a client who has diabetes mellitus. Which of the following actions should the nurse take? A. Encourage the client to get up and exercise B. Repeat the test using a different glucometer C. Give the client a glass of orange juice. D. Administer insulin according to the patient's sliding scale orders

D. Administer insulin according to the patient's sliding scale orders

A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing which of the following should the nurse include in the plan of care? A. Leave non-bleeding wounds open to air B. Administer a corticosteroid medication C. Initiate mechanical debridement D. Apply oxygen at 2L/min via nasal cannula

D. Apply oxygen at 2L/min via nasal cannula

A nurse is preparing to administer an oil retention enema to a client who has constipation. The nurse should instruct the client to retain the solution for which of the following durations? A. The duration of the procedure B. 10-15 mins C. Until the client feels the urge to defecate D. At least 30 min

D. At least 30 min

A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain which of the following nutrients provides the body with the most energy? A. Fat B. Protein C. Glycogen D. Carbohydrates

D. Carbohydrates

A nurse is assisting a client with personal hygiene care. Which of the following actions should the nurse take to reduce the risk of infection? A. Massage reddened areas of the client's skin B. Wash the eyes from the outer canthus to the inner canthus C. Wash the client from the down to the fingertips with smooth, short strokes D. Clean the least-soiled areas prior to cleaning the most-soiled areas

D. Clean the least-soiled areas prior to cleaning the most-soiled areas

A nurse is replacing the ostomy appliance for a client whose newly created colostomy is functioning. After removing the pouch, which of the following actions should the nurse take first? A. Measure the stoma B. Cover the stoma with gauze C. Remove the backing on the skin barrier D. Cleanse the soma and the peristomal skin

D. Cleanse the soma and the peristomal skin

A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client's family is at the bedside and asks the nurse what to expect at this time. Which of the following findings should the nurse include? A. Regular breathing patterns B. Warm extremities C. Increased urine output D. Decreased muscle tone

D. Decreased muscle tone

A nurse is caring for a client sitting in a chair and asks to return to bed. Which of the following actions is the nurse's priority at this time? A. Obtain a walker for the client to use to transfer back to bed. B. Call for additional staff to assist with the transfer C. Use the transfer belt to assist the client back into bed. D. Determine the client's ability to help with the transfer

D. Determine the client's ability to help with the transfer

When teaching the guardian of a toddler about feeding and eating, the nurse should include which of the following safety measures? A. Do not give the child peanut butter B. Have the child drink 28-32 oz of milk per day C. Give the child 8-12 oz of use daily D. Do not offer the child raw veggies

D. Do not offer the child raw veggies

A nurse is assisting with the ambulation of a client who becomes light-headed and begins to fall. Which of the following actions should the nurse take? A. Wrap both arms around the client's arms and shoulders B. Move both feet together when the client begins to fall C. Protect the client's extremities while lowering them to the floor D. Extend one leg and allow the client to slide down the leg to the floor

D. Extend one leg and allow the client to slide down the leg to the floor

2. A nurse teaching a client how to check blood glucose levels. The nurse should include which of the following instructions about transferring blood onto the reagent portion of the test strip? A. Smear the blood onto the strip. B. Squeeze the blood onto the strip. C. Touch the puncture to stimulate bleeding. D. Hold the test strip next to the blood on the fingertip

D. Hold the test strip next to the blood on the fingertip

A nurse is selecting dressings for a client who has a full-thickness pressure injury and is experiencing pain during dressing changes, despite the administration of the prescribed analgesic prior to wound care. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes? A. Wet-to-dry B. Abdominal pads (ABD) C. Dry gauze D. Hydrogel

D. Hydrogel

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection? A. Prodromal B. Incubation C. Convalescence D. Illness

D. Illness

A nurse is taking an adult client's temp rectally. Which of the following actions should the nurse take? A. Rotate the probe if any resistance is met as the thermometer is inserted B. Insert the probe to aim at the client's pelvic area C. Dip the probe about .58 (2 in) into a tube of lubricant D. Insert the probe about 2.5 cm (1 in) into the client's anus

D. Insert the probe about 2.5 cm (1 in) into the client's anus

A nurse is obtaining a BP and notices the pressure reading on the manometer when listening to the fourth Korotkoff sound. Which of the following factors does this pressure reading correlate to? A. Systolic bp B. Diastolic bp C. loudest Korotkoff sound D. It might not follow with a fifth Korotkoff sound

D. It might not follow with a fifth Korotkoff sound

A nurse is preparing an adult client for an enema. The nurse should assist the client in which of the following? A. Prone B. Dorsal recumbent C. Right lateral with both knees at chest D. Left lateral with the right leg flex

D. Left lateral with the right leg flex

A nurse is caring for a client who has a prescription for knee-length antiembolic stockings. Which of the following actions should the nurse take? A. Place the stockings on the client after the client ambulates to the restroom B. Ensure the client's ties are visible after placing the stockings on the client C. After applying the stockings, place two fingers between the client's legs and stocking to check the fit D. Measure the client's calf circumference and leg length from heel to knee

D. Measure the client's calf circumference and leg length from heel to knee

A nurse is establishing baseline for a client's respirations. Which of the following actions should the nurse take? A. Instruct the client to breathe in and exhale out as normal B. Count the respirations for 15 secs then multiply by 4 C. Determine if the client has a history of any chronic respiratory problems D. Observe the client's chest movements while appearing to assess their pulse

D. Observe the client's chest movements while appearing to assess their pulse

A nurse discovers a small paper fire in a trash can in the client's bathroom. The client has been taken to safety and the alarm has been activated. Which of the following actions should the nurse take? A.Open the windows in the client's room to allow smoke to escape B. Obtain a class C fire extinguisher to extinguish the fire C. Remove all electrical equipment from the client's room D.Place wet towels along the base of the door to the client's room

D. Place wet towels along the base of the door to client's room.

A nurse is teaching a client about extended-wear skin barriers. Which of the following strategies should the nurse instruct the client to use for maximal adherence? A. Use an oil-baed lotion on the periostomal area B. Apply the skin barrier while the skin is slightly moist C. Leave the residue from the previous appliance on the skin D. Press gently around the barrier for 30 seconds to 1 min

D. Press gently around the barrier for 30 seconds to 1 min

A nurse should recognize that which of the following findings is an indication for oxygen therapy? A. RR 32/min B. PaO2 90 mmHg C. Fraction of inspired air (FiO2) 65% for 4 days D. SaO2 90%

D. SaO2 90%

A nurse is staging a pressure injury over a client's heel area. The pressure injury has no eschar or slough and no exposed muscle or bone. The nurse should identify that this pressure injury is classified as which of the following? A. Unstageable B. A suspected deep tissue injury C. Stage 4 D. Stage 3

D. Stage 3

A nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? A. The flap closest to the body B. The right side flap C. The left side flap D. The flap farthest from the body

D. The flap farthest from the body.

A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should be included when explaining the procedure to the client? A. Eating more protein is optimal prior to testing. 3. One stool specimen is sufficient for testing. c. Ared color change indicates a positive test. D. The specimen cannot be contaminated with urine.

D. The specimen cannot be contaminated with urine.

Which of the following is the primary purpose for asking a client for asking a client to keep a 3-7 day food diary A. To allow the client to rely on health care professionals to identify problem areas B. To determine any changes in client's appetite C. To evaluate any significant changes in body weight D. To assess the pattern of intake and compare with daily reference

D. To assess the pattern of intake and compare with daily reference

A nurse is caring for a client who has had a cough for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions? A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Tuberculosis

D. Tuberculosis

A nurse is washing their hands within soap and water prior to repositioning a client in bed. During the hand washing procedure, it is important to take which of the following actions? A. Remove rings and watches first B. Use a liquid soap preparation C. Make sure the water is hot D. Wash for at least 20 seconds

D. Wash for at least 20 seconds

A nurse is providing discharge teaching to a client who will continue oxygen therapy at home. The nurse should instruct the client that turning the knob on the oxygen flow meter all the way to the right? A. starts the flow of oxygen B. provides the maximal oxygen flow C. provides a minimal oxygen flow D. stops the flow of oxygen

D. stops the flow of oxygen

Name 4 droplet diseases

Influenze Meningitis Streptococcal Pharyngitis

Name two airborne precautions

Measles Tuberculosis

A nurse is performing an admission assessment on a client. The nurse determines the client's radial pulse rate is 68/min and the simultaneous apical pulse rate is 84/min. What is the client's pulse deficit?

16/min. The pulse deficit is the difference between the apical and radial pulse rates. It reflects the number of ineffective or non perfusing heartbeats that do not transmit pulsation's to the peripheral pulse points. 84-68=16