Quiz 2 ATI
A nurse is wearing gloves while caring for a client. In which of the following situation should the nurse obtain a new pair of gloves? -After donning a gown and before collecting vital signs on the client. -After removing food items off the clients tray and before removing soiled linens from the clients bed. - After helping the client stand up and before helping them brush their teeth. -After changing the dressing on the client and before documenting findings on a computer
-After changing the dressing on the client and before documenting findings on a computer
A nurse is planning care for a client who is postoperative. Which of the following intervention should the nurse plan to include to promote emotional comfort for the client? -Encourage the client to verbalize their needs and concerns. -Limit time spent with client. -Ask the client to splint the incision when coughing. -Administer pain medication as prescribed
-Encourage the client to verbalize their needs and concerns.
A nurse is caring for a client who has kidney stones. Which of the following manifestations is an objective indicator of pain? -The client is diaphoretic -The client is experiencing stabbing pain -The client is nauseated -The client states feeling dizzy
-The client is diaphoretic
A nurse is assisting with teaching a newly licensed nurse about airborne infection isolation rooms (AIIR). Which of the following information should the nurse include.? -The door to the AIIR should remain closed. -Clients who are on contact precautions require AIIR. -An AIIR has at least 4 air exchanges each hr. -A mask is not needed for care for clients who are in an AIIR.
-The door to the AIIR should remain closed.
A nurse is caring for a client who has a health care-associated infection (HAI). Which of the following describes an exogenous HAI? -A Salmonella infection that occurs after eating contaminated foods from the cafeteria -An infection that occurs during a therapeutic procedure -A yeast infection that occurs while receiving broad spectrum antibiotics -A urinary tract infection that occurs after a sterile catheter insertion
A Salmonella infection that occurs after eating contaminated food from the cafeteria
A nurse is reviewing information for several clients on the unit. The nurse should recognize that which of the following clients is at greatest risk for depression? -A client who has chronic pain and recently started taking paroxetine -A client who has cancer and has taken oxycodone PRN for several months -A client who has been accidentally taking twice the amount of prednisone as prescribed -A client who had surgery 3 hr ago and is receiving IV Hydromorphone PRN
A client who had surgery 3 hr ago and is receiving IV Hydromorphone PRN
A nurse is evaluating a group of clients who are experiencing pain. Which of the following client should the nurse identify as experiencing neuropathic pain? A client who has osteoarthritis and reports difficulty ambulating for the past 6 months A client who had surgery to repair a fractured tibia and reports incisional pain A client who has diabetes mellitus and reports bilateral burning foot pain without signs of injury A hospice client who has prostate cancer and reports pelvic pain
A client who has diabetes mellitus and reports bilateral burning foot pain without signs of injury
A nurse is about to irrigate a client's open wound. Besides gloves, which of the following personal protective equipment should the nurse wear? -A sterile gown -Goggles -A face shield -An N95 respirator
A face shield
A nurse is discussing problem-oriented medical records with a group of newly licensed nurses. Which of the following information should the nurse include? -A problem-oriented medical record is created using the PIE model for documentation entries. -A problem-oriented medical record contains separate sections for laboratory and diagnostic information. -A problem-oriented medical record promotes information sharing among members of the interdisciplinary team." -A problem-oriented medical record is rarely used in acute care settings.
A problem-oriented medical record promotes information sharing among members of the interdisciplinary team.
A nurse is explaining the practice of Ayurveda to a newly licensed nurse. The nurse should indicate that Ayurveda is based on establishing a balance between the body, mind, and spirit with which of the following elements? (Select all that apply.) A. Earth B. Sky C. Darkness D. Light E. Water
A, B, E
A nurse is assisting with teaching a newly licensed nurse about hand hygiene for surgical asepsis. Which of the following instructions should the nurse include? -Use a brush to scrub the surface of the hands. -Rinse anti-septic solution from the hands before it dries. -Apply chlorhexidine and ethanol to the hands. -Leave jewelry on hands when cleansing them.
Apply chlorhexidine and ethanol to the hands.
A nurse is reviewing the concepts of central sleep apnea with a colleague. Which of the following statements by the colleague indicates an understanding of central sleep apnea? -Common causes of central sleep apnea are opioid overdose and congestive heart failure. -Central sleep apnea is caused by obesity and inactive tongue. -Central sleep apnea is easily diagnosed using polysomnography. -Central sleep apnea is related to the recurrent episodes of upper airway collapse and obstruction
Common causes of central sleep apnea are opioid overdose and congestive heart failure
A nurse is caring for a client who has narcolepsy NT1 with cataplexy. The nurse should identify that this condition is caused by lack of which of the following hormones? -Hypocretin -Melatonin. -Estrogen. -Insulin.
Hypocretin
A charge nurse is discussing health records with a newly licensed nurse. Which of the following information should the nurse identify as a component of a health record? -Immunization data -Record of client health care payments -Complete medical information for household members" -Facility policies
Immunization data
A nurse is assessing a client who reports difficulty staying awake during the day and experiencing involuntary episodes of lost muscle tone. The nurse should identify that these are manifestations of which of the following conditions? -Hypersomnia. -Narcolepsy. (NT2) -Narcolepsy (NT1) -Insomnia
Narcolepsy (NT1)
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? -Wear a respirator. -Protect their eyes. -Put on clean gloves. -Wear shoe covers.
Protect their eyes.
A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. Which of the following information should the nurse include as a benefit of electronic documentation? -The system alerts providers of possible actions that could cause client harm. -An electronic system prevents breaches of confidentiality of client data. -Providers can document client information in the electronic record during system downtime. -System encryption eliminates the need for security firewalls.
The system alerts providers of possible actions that could cause client harm.
A nurse is caring for a client who has severe pain and repeatedly asked for pain medication. The nurse was busy and forgets to assess the clients pain and administer prescribe pain medication. Which of the following can the nurse be charged with? -Malpractice -negligence -nonmaleficence -beneficence
negligence
A nurse is washing their hands with 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? -Make sure that the water is hot. -Wash for at least 20 seconds. -Use a liquid soap preparation. -Remove rings and watches first.
Wash hands for at least 20 seconds.
Contact precautions should be implemented for an adult client who has been hospitalized and has which of the following? -Hepatitis B -Measles -Meningitis -Infectious diarrhea
Infectious diarrhea
A nurse is discussing the FLACC scale with a newly licensed nurse. Which of the following categories should the nurse include? (Select all that apply.) A. Face B. Legs C. Alert D. Circulation E. Consolability
A,B,E
A nurse is reviewing the plan of care for several clients who are receiving treatment for pain. Which of the following actions should the nurse plan to take to evaluate the clients pain control? (Select all that apply.) A. Consider each clients cultural preferences B. Determine the effectiveness of nonpharmacological strategies C. Record the clients objective reports rather than the nurses objective observations D. Recognize that older adult clients over-report their pain level E. Use a pain scale specific to each client's cognitive abilities
A,B,E
And this is discussing to use a free therapy with the newly licensed nurse. The nurse should include that heat therapy is effective for which of the following conditions? (Select all that apply.) A. Muscular pain B. Active bleeding C. Backache D. Menstrual discomfort E. Swollen extremity
A,C,D
A nurse is caring for a client who has a history of migraines. The client tells the nurse, "I have not been sleeping well. My migraine headaches have returned after not having one for over a year." The nurse should identify that which of the following are potential contributing factors to the clients migraines? (Select all that apply.) A. Sleep-wake homeostasis. B. Sensory overload. C. Sleep deprivation. D. Increase melatonin. E. Decreased hypocretin levels
B, C
A nurse is caring for a client who has acquired an infection from a visitor. The client is an example of which of the following links in the chain of infection? -Reservoir. -Susceptible host. -Portal of entry. -Portal of exit
Susceptible host.
A nurse is discussing the status of the sleep cycle with a client. The nurse should include that the immune system is strengthened and tissues and bones are repaired during which of the following stages of the sleep cycle? Stage one. Stage two. Stage three. Stage four.
Stage three
A nurse is assisting with providing an in-service for staff members about complementary an integrative health. Which of the following statements by a staff member indicates an understanding of the teaching? A. "Scented oils my decrease discomfort" B. "natural substances do not have adverse effects" C. "acupressure an acupuncture are the same thing" D. "meditation involves the use of electronic device to regulate body function"
A. "Scented oils my decrease discomfort"
A nurse is caring for a client who is scheduled for an emergency appendectomy and reports increasing anxiety. Which of the following statements should the nurse make to implement a complementary health strategy? A. "Try to take slow, deep breaths in and out" B. "Would you like a prescription for anti-anxiety medication?" C. "Why are you feeling so anxious?" D. "You'll have that appendix out in no time, then you'll feel better."
A. "Try to take slow, deep breaths in and out"
A nurse is teaching a client about food choices that promote immunity and healing. Which of the following foods is the best source of vitamin C? A. 1 cup grapes B. 1 cup strawberries C. 1 cup sliced apple D. 1 small banana
B. 1 cup strawberries
A nurse is preparing to administer morphine 15 m PO every 4 hr PRN pain for a client who has a new prescription. By which of the following routes should the nurse plan to administer the medication? -By mouth -Intramuscularly -Per rectum -Intravenously
By mouth
A nurse Is monitoring a client who is 2 hr postoperative and is receiving morphine via PCA pump. Which of the following findings should the nurse plan a monitor to detect opioid-induced ventilatory impairment (OIVI)? (Select all that apply) A. bowel sounds B. deep tendon reflexes C. respiratory rate D. capnography E. oxygen saturation
C, D, E
A nurse is caring for a client who asks about using aromatherapy for nausea. Which of the following scents should the nurse recommend? (Select all that apply) A. Ginseng B. Evening primrose C. Peppermint D. Ginger E. Orange
C, D, E
A nurse is assisting with teaching a newly licensed nurse about laboratory tests that can indicate generalized inflammation. The nurse should include which of the following laboratory tests? -C-reactive proteins. -Troponins. -Creatine kinase. -Lactic acid.
C-reactive proteins
A nurse is reinforcing teaching about traditional Chinese medicine (TCM) to a client. Which of the following statements by the client demonstrates an understanding of the teaching? A. "I will take my blood pressure medication every morning." B. "I will have my heart rate checked once a month." C. "I will practice Tai Chi every day." D. "I will weigh myself weekly"
C. "I will practice Tai Chi every day."
A nurse is assisting with teaching a class about using holistic nursing interventions to care for clients. Which of the following information should the nurse include? A. Holistic nurses use herbal supplements because they do not cause adverse effects B. The goal of holistic nursing is to cure a clients illness C. Holistic nurses empower clients to actively participate in their own care D. A holistic nurse discourages the use of prescribed medication for clients
C. Holistic nurses empower clients to actively participate in their own care
A nurse is assisting with teaching a class about US food and drug administration (FDA) Regulation of nutritional supplements. Which of the following information should the nurse include in the teaching? A. A nutritional supplement can be applied topically B. If a nutritional supplement contains natural products, it is considered safe. C. The FDA approves nutritional supplements for safety before they are placed on the market D. A nutritional supplement contains at least one nutritional component
D. A nutritional supplement contains at least one nutritional component
A nurse is assisting with an in-service for staff members about culturally competent care. Which of the following information should the nurse include about traditional Native American beliefs? A. There should be a balance between yin and yang. B. Cupping is used to promote wellness. C. Use biofeedback to reduce stress. D. Music can produce healing energy.
D. Music can produce healing energy
A nurse is caring for a client reports that they use their smart phone at night while they are in bed. The nurse should identify that access a smart phone you can increase the clients risk for which of the following? -Depression. -Binge eating disorder. -Restless leg syndrome (RLS). -Diminished circadian rhythm
Depression
A nurse is caring for a client who works overnight shifts. The nurse should identify that individuals who perform shift work are at an increased risk for developing which of the following conditions? -Diabetes mellitus -Central sleep apnea -Hypersomnia -Restless leg syndrome (RLS)
Diabetes mellitus
What should the nurse do to maintain standard precautions? -Rinse gloves that become visibly soiled during use. -Use an antimicrobial soap for routine hand washing. -Disinfect hands immediately after removing gloves. -Keep gloves on when touching environmental surfaces.
Disinfect hands immediately after removing gloves.
A nurse is assisting with teaching a newly licensed nurse about infectious agents. The nurse should include in the teaching that pertussis is transmitted by which of the following modes of transmission? -Direct contact. -Droplet. -Airborne. -Indirect contact.
Droplet
A nurse is caring for an older adult client who has a cognitive impairment and his post operative. Which of the following actions should the nurse take? -Use the crying, requires action, increases vital signs, expression, sleeplessness (CRIES) pain scale -Reassure family members that adult clients have a decreased ability to sense pain -Evaluate the client for pain by observing their behavior -Assign a pain scale number based on the FACES pain scale
Evaluate the client for pain by observing their behavior
A nurse is discussing legal regulations regarding medical records with a newly hired assistive personnel (AP). Which of the following information should the nurse include? -American Nurse Association (ANA) standards prevent client records from being uses for legal proceedings. -HIPAA regulations vary from one state to another -Privacy regulations apply to electronic data transfer rather than verbal communication. -Facilities can establish their own rules for documentation methods.
Facilities can establish their own rules for documentation methods.
A nurse is reviewing discharge instructions for a client who has a prescription for morphine oral solution 10 to 20 mg every 4 hr PRN. Which of the following statements by the client indicates an understanding of the instructions? I can use the morphine as needed as long as I don't take it more than six times a day I will use household teaspoon to measure the correct amount of morphine I will monitor for high blood pressure while taking the morphine I will keep the morphine bottle in a locked cabinet in my kitchen
I will keep the morphine bottle in a locked cabinet in my kitchen
Which of the following is an advantage of alcohol-based gel? -It takes less time to use than washing with soap and water. -It removes gross contamination better than soap and water does. -Its protective nature reduces the need for frequent hand washing. -It provides adequate protection before surgical applications.
It takes less time to use than washing with soap and water.
A nurse is caring for a client who is postoperative following abdominal surgery and has a morphine PCA pump. Which of the following medication should the nurse and she is available in case the client develops respiratory depression? -Naloxone -Lidocaine -Prednisone -Amitriptyline
Naloxone
A nurse is caring for a client who is being evaluated for obstructive sleep apnea. Which of the following findings should the nurse identify as a risk factor for obstructive sleep apnea? -Hypersomnia. -Obesity. -Active glossal muscle. -History of tonsillectomy
Obesity
A nurse is caring for a client who has a prescription for oxycodone 5 to 10 mg PO every 4 to 6 hr as needed for pain rating 7 to 10 on a 0 to 10 scale. 15 minutes after receiving the dose, the client reports to the nurse their pain is still a seven and has not changed. Which of the following actions should the nurse take? -Administer another 5 mg dose of the oral opioid now -Administer 10 mg of oxycodone every 2 hr -Inform the providers of the clients pain medication is not effective -Offer to assist the client with nonpharmacological relief strategies
Offer to assist the client with nonpharmacological relief strategies
A nurse in a clinic is reviewing a client's prescription prior to discharge. The nurse should instruct the client that which of the following abbreviations indicates the medication can be taken as needed? -PRN -NPO -AC -Ad lib
PRN
Which of the following products can affect the permeability of latex gloves? -Antimicrobial soap and water -Alcohol-based antiseptic gel -Petroleum-based hand lotion -Water-based hand lotion
Petroleum-based hand lotion
A charge nurse is reviewing SOAP documentation with a group of newly licensed nurses. Which of the following chart entries should the nurse include as an example of objective data? -The client states, "I've had abdominal pain for the past 3 days. -The client reports consuming about 1,500 mL of water per day. -Rebound tenderness noted in RLQ of the abdomen. -Recommend client referral to a registered dietician.
Rebound tenderness noted in RLQ of the abdomen.
A nurse is assisting with teaching a newly licensed nurse about surgical asepsis. Which of the following statements of the nurse make? -You can wear artificial fingernails if they are kept short. - Leave rings on your fingers from performing surgical hand asepsis. -Keep your fingernails less than half an inch in length. -Remove nail polish on your fingernails if it is chipped.
Remove nail polish on your fingernails if it is chipped.
A nurse is caring for a client who acquired an infection after touching a passage that an infected person had touch. Which of the following links in the chain of infection does the faucet represent? -Reservoir. -Susceptible host. -Portal of entry. -Portalof exit.
Reservoir
A nurse is performing hand hygiene after caring for a client who has Clostridium difficile. Which of the following hand hygiene methods should the nurse use? -Alcohol-based sanitizer. -Soap and water. -Iodine solution. -Chlorhexidine solution
Soap and water
A nurse manager is conducting an in-service about physiological functions of sleep for a group of staff nurses. Which of the following statements by one of the nurses indicates an understanding of the teaching? -Sleep is a process that decreases the development of new neural pathways that assist with retention of knowledge and memorization. -The brain and neurons continue to communicate with each other during sleep to remove toxins that built up in the brain while awake. -The circadian rhythm is an external process that controls the sleep-wake cycle. -Clients experience the highest quality sleep when they complete three out of the four stages of sleep
The brain and neurons continue to communicate with each other during sleep to remove toxins that built up in the brain while awake.
After completing a procedure that required donning personal protective equipment (PPE) consisting of a gown, an N95 respirator, a face shield, and gloves, which of the following should the nurse remove first when removing PPE separately?
The gloves
A nurse is caring for a client who is receiving palliative care. Which of the following Non-pharmacological nursing intervention should the nurse provide the client? Acupuncture acupressure chiropractic therapy therapeutic touch
Therapeutic touch
A nurse is supervising a newly licensed nurse perform hand hygiene. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? -Washes their hands for 10 sec. -Turns out the faucet with a towel. -Uses hot water to wash their hands. -Hold their hands about their elbows while rinsing off the soap
Turns out the faucet with a towel.
A nurse is preparing an in-service about HIPAA. Which of the following information should the nurse plan to include? "Accessing the medical record of clients on units other than where you are assigned is allowed." "There are large financial penalties for charting vital signs you obtain for another nurses's client." "Personnel can be terminated for breaching a client's confidentiality." "Once you have cared for a client, it is acceptable to look at their medical record on subsequent health care visits."
"Personnel can be terminated for breathing a client's confidentiality."
A nurse is assisting with implementing an infection control bundle for clients at risk for catheter associated urinary tract infections (CAUTIs). Which of the following intervention should the nurse include in the bundle? -Try to use alternatives before inserting indwelling urinary catheter's. -Use clean technique for insertion of indwelling urinary catheter's. -Check clients every two days to evaluate the need for indwelling urinary catheter's. -Disconnect the system to obtain urine samples from indwelling urinary catheter's.
-Try to use alternatives before inserting indwelling urinary catheter's.
A nurse is providing end-of-life care for a client who is unresponsive a near death. The clients family asked the nurse about managing the clients pain. Which of the following statements to the nurse to make to the clients family? -Your family member will not require pain medication -Your family member can inform the provider about their decision for pain management -Your family member has the right to receive effective pain medication -Your family members will not be able to tolerate the effects of pain medication
-Your family member has the right to receive effective pain medication
A nurse is discussing transcutaneous electrical nerve stimulation (TENS) treatment with a client who has chronic lower back pain. Which of the following statements to the nurse include? (Select all that apply.) A. You can be taught how to use TENS therapy at home B. We will insert very small sterile needles into your skin to block your pain C. This therapy may result in you having some temporary bruising at the site of application D. The TENS therapy delivers low-voltage electrical impulses to the skin over the painful areas E. We will adjust the intensity, pulse rate, and duration of the electrical pulses during your therapy
A,D,E
A nurse is caring for a client who has a prescription for Hydromorphone 1 to 2 mg IM every 4 hr as needed for a pain rating of 4 to 6 on a 0 to 10 scale. The client has never taken Hydromorphone before. Which of the following actions should the nurse glad to take? Administer 1 mg IM Request a prescription to give the medication IV instead Request a prescription for a different medication. Administer 2 mg I am
Administer 1 mg IM
A nurse is caring for a client who has influenza. Client asked how they acquired the infectious agent. The nurse should inform the client that influenza is transmitted by which of the following modes? -Droplet. -Indirect contact. -Airborne. -Direct contact
Droplet
A nurse manager is reviewing the documentation of four newly licensed nurses. Which of the following medication entries should the nurse identity as being written correctly? -Synthroid 100 mg PO every morning ac -Enoxaparin 75 mg SQQ bid -Digoxin 0.25 mg PO and -Metformin 500.0 mg PO with evening meal
Synthroid 100 mg PO every morning ac
A nurse is caring for a client who takes an over-the-counter sleep aid medication every evening. Which of the following findings should the nurse identify as a potential adverse effects of OTC sleep aid medication? -Hyperactivity. -Diarrhea. -Excessive salivation. -Urinary retention
Urinary retention
A nurse is reviewing a new prescription with the client reports difficulty managing their chronic pain. Which of the following statements should the nurse include? -You should write down the pain intervention to use and your pain reading before and after -You should understand that it is impossible to fix everyone's pain -Your provider is best of determining whether your pain treatments are effective -Your care partner should manage your pain because you are unable
You should write down the pain intervention to use and your pain reading before and after
A nurse is talking with a client about their electronic health record (EHR) at the facility. Which of the following client statements indicates an understanding of EHRs? "I will be able to track my health information." "My personal information will be entered into a national database." "I will have one EHR that will encompass the health care I've received over my lifetime." "The goal of EHRs is to improve insurance coding."
"I will be able to track my health information."
A nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries should the nurse identify as meeting the American Nurses Association (ANA) standards for documentation? "The client is now asleep, and they ate most of their breakfast a few hours ago." "The client vomited 240 mL of clear emesis but denies pain or nausea." "The client reports not feeling good, but they look fine." "The client has 8 to 10 sores on their body."
"The client vomited 240 mL of clear emesis but denies pain or nausea."
A nurse is assisting with teaching about personal protective equipment with a newly licensed nurse. Which of the following instructions should the nurse include? -Gowns can be reused on the same client. -Masks should be removed after leaving a clients room. -Gloves should be removed from the inside out. -Eyeglasses can be used in place of goggles.
-Gloves should be removed from the inside out.
An employee health nurse is providing teaching about sleep promotion to a group of newly licensed nurses. Which of the following statements should the nurse include? -Taking a cool shower before bedtime bedtime can help with sleep -If you do not fall asleep within 20 minutes of lying down, go to another room and listen to soft music -To promote nighttime sleep, limit daytime naps to 1 hour -Exercising 1 hour before bedtime can help promote relaxation and sleep
-If you do not fall asleep within 20 minutes of lying down, go to another room and listen to soft music
A nurse is reviewing documentation guidelines with a newly licenses nurse. Which of the following abbreviations should the nurse note as being on The Joint Commission's Do Not Use List? -MSO4 -IU -PO -QRS -NKA
-MSO4 -IU -QRS
A nurse is evaluating a client after measures to promote comfort have been implemented. Which of the following statements by the client indicates that the client has been comforted? -I wish the staff would listen closer to my needs. -I am concerned about what is going to happen during my test tomorrow. -It seems to take the staff a while to answer the call light. -My healthcare team has helped me to feel safe during my stay
-My healthcare team has helped me to feel safe during my stay
A nurse is assisting with teaching a newly licensed nurse about holistic nursing. Which of the following information should the nurse include? (Select all that apply.) A. Use deep breathing to promote relaxation in clients B. Encourage clients to use guided imagery to decrease pain C. Apply essential oils to treat anxiety in clients D. Treat one medical issue for clients at a time E. Discourage family involvement in client care
A, B, C
A nurse is assisting with a staff in-service regarding pain control. Which of the following statements by staff member indicates an understanding of the information? (Select all that apply.) A. Clients religious beliefs might affect the way they respond to pain B. Herbal therapies are not permitted for a client receiving prescription pain medication C. The clients pass experiences are not related to the current pain and pain management D. If a client can write their pain using a numeric pain scale, there is no need to note nonverbal findings E. Pain control might be harder to achieve if the nurse and client speak different primary languages
A, C, E
A nurse is assessing a client who is nonverbal for the presence of pain. Which of the following findings indicate an increased level of discomfort? (Select all that apply) A. grimacing B. restlessness C. elevated temperature D. increased diaphoresis E. bradycardia
A,B,D
A nurse is caring for a client who asks about naturopathy. The nurse should include that which of the following is a component of naturopathy? (Select all that apply) A. Dietary Supplements B. Exercise C. Establishing harmony between fire, water, air, earth, and sky D. Traditional Chinese medicine E. Homeopathy
A,B,D,E
A nurse is assisting in recommending clients for chiropractic treatment. Which of the following clients to the nurse recommend? A. A client who has a sinus infection B. A client who has shoulder pain C. A client who has appendicitis D. A client who has heart failure
B. A client who has shoulder pain
A nurse is evaluating a clients pain level using the PQRST mnemonic. Which of the following question she's a nurse asked to evaluate the letter "R"? -Can you rate your pain on a scale of 1 to 10, with zero being no pain and 10 being the worst thing you can imagine? -Can you point to where you are having your pain? -What does your pain feel like? -What were you doing when your pain started?
Can you point to where you are having your pain?
A newly licensed nurse is orienting to a facility's documentation system. The facility requires staff to only document variations from an expected set of findings when performing a physical assessment. The nurse should identify this system as which of the following documentation methods? -Charting by exception -Subjective, objective, assessment, plan format -Problem, intervention, evaluation model -Data, action, response charting
Charting by exception
A nurse is admitting a client who has the vancomycin-resistant enterococcus (VRE) of the urine. The nurse should place the client on which of the following precautions? -Protective. -Contact. -Droplet. -Airborne.
Contact
A nurse is planning to admit a client who has respiratory syncytial virus (RSV). Which of the following transmission-based precautions should the nurse plan to implement? -Protective. -Contact. -Standard. -Airborne.
Contact
To decontaminate their hands with an alcohol-based gel, the nurse should rub their hands together until all of the gel has evaporated and their hands are dry. Which of the following is the correct rationale for why hands should be rubbed together until dry? -Drying provides the full antiseptic effect. -Residual alcohol can easily stain clothing. -Excess gel could transfer to the client. -Slippery gel can make the nurse drop supplies.
Drying provides the full antiseptic effect.
A nurse is assisting with teaching a newly licensed nurse about removing personal protective equipment (PPE). Which of the following items should the nurse instruct to remove first? -Mask. -Gloves. -Goggles. -Face shield.
Gloves
A nurse is caring for a client who has a new prescription for him non-benzodiazepine hypnotic promote sleep. For which of the following adverse effects should the nurse monitor the client? -Retrograde amnesia. -Urinary discomfort. -Dry mouth. -Hallucinations.
Hallucinations
A nurse is discussing computerized provider order entry (CPOE) systems with staff. Which of the following statements form a staff member indicates an understanding of a CPOE system? "CPOE systems are associated with a slightly higher error rate." "CPOE use does not include medication prescriptions." "CPOE systems can increase the speed of care delivery." "CPOE use is mandated by HIPPAA under the Privacy Rule."
"CPOE systems can increase the speed of care delivery."
A nurse is performing a throat culture on a client. Which of the following actions should the nurse take? -Swab the back of the clients pharyngeal wall. -Placed a swab in a clean container after obtaining the culture. -Insert the swab and the culture medium within one hour of obtaining the sample. -Don sterile gloves obtain the culture from the client.
-Swab the back of the clients pharyngeal wall.
A nurse is caring for client following a stroke. The nurse should recognize that which of the following individuals is allowed access to the client's medical record without obtaining special consent from the client first? -The admitting provider -The charge nurse on the unit -The client's sibling -The client -The client's spiritual advisor
-The admitting provider -The charge nurse on the unit -The client
A nurse is caring for a client who has a prescription for heat therapy for knee pain. The nurse should apply heat therapy to the clients knee for how long? 60 min 20 min 30 min 45 min
20 min
A nurse is caring for a client who is having difficulty falling asleep. Which of the following intervention should the nurse implement to promote sleep for the client? -Offer the client a caffeinated beverage three hours before their bedtime. -Turn on the clients television before they go to bed. -Warm the temperature of the clients room before they go to bed. -Dim the lights in the classroom at bedtime.
-Dim the lights in the classroom at bedtime.
A nurse is assisting with teaching a group of nurses on processes that can trigger an inflammatory response in the body. The nurse should include that which of the following is an infectious trigger? -Burn. -Frostbite. -Bacteria. -Radiation.
Bacteria
A nurse is caring for a client who reports muscle pain to the lower back that has persisted for over a year after a motor vehicle crash. In which way should the nurse categorize this clients pain? -Cancer pain -Acute pain -Chronic pain -Neuropathic pain
Chronic Pain
A nurse is teaching a newly licensed nurse about the development of dreams. The nurse should include that which of the following areas of the brain transmits the sensory data that is used to develop dreams? -Hypothalamus. -Thalamus. -Cerebral cortex. -Pineal gland
Thalamus
After assisting a newly admitted client with removing their shoes and outerwear, the nurse notices what appears to be soil or grim on their hands. Which of the following actions should the nurse take? -Cleanse their hands with an alcohol-based gel. -Wash their hands with soap and water. -Brush off the soil against a cloth surface. -Use a wet paper towel to remove the soil.
Wash their hands with soap and water.
A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. Which of the following statements by the newly licensed nurse indicates an understating of the information? "I can take a telephone prescription if a provider is making routine rounds in another area of the facility." "I can take a telephone prescription if a provider is directing a code for an unresponsive client." "If a client requires an over-the-counter medication for relief of nausea, it is okay to accept a telephone prescription." "If a client requires pain control for a terminal condition, it is okay to accept a telephone prescription."
"I can take a telephone prescription if a provider is directing a code for an unresponsive client."
A nurse is discussing cutaneous stimulation with a client who has back pain. Which of the following methods should the nurse include? (Select all that apply.) A. Transcutaneous electronic stimulating unit (TENS unit) B. Distraction techniques C. Massage D. Acupuncture E. Cold therapy
A,B,D,E
A nurse is assisting in providing an in-service about infectious agents to a group of nurses. The nurse should include in the teaching that tuberculosis is transmitted by which of the following modes of transmission? -Airborne. -Droplet. -Direct contact. -Indirect contact
Airborne
A nurse is reviewing the concept of comfort with an assistive personnel (AP). Which of the following statements by the AP indicates an understanding of comfort? -Providing comfort for a client is achieved by the relief of physical pain through the administration of medication -Providing comfort to a client involves alleviating the client's physical, mental, and emotional distress using warmth and empathy -Providing comfort for a client is achieved by taking control of the client's care and creating routines for the client to become familiar with. -Providing comfort to a client requires staff members to smile and remain cheerful no matter the outcome the client is facing.
-Providing comfort to a client involves alleviating the client's physical, mental, and emotional distress using warmth and empathy
A charge nurse is reviewing characteristics of electronic documentation with staff at a provider's office. Which of the following characteristics should the charge nurse plan to include? -Reduces medical errors -Improves listening skills Amon interdisciplinary team members -Less convenient than paper-based charting -Makes client medical history more easily available -Increases accuracy of coding procedures
-Reduces medical errors -Makes client medical history more easily available -Increases accuracy of coding procedures
A nurse is contributing to a representation about non pharmacological interventions used to promote sleep. Which of the following information should the nurse recommend including in the presentation? -Nonpharmacological interventions should only be practiced in the client's home setting -Massage is a nonpharmacological intervention that should be used to promote sleep for clients who are taking anticoagulants -Nonpharmacological interventions used to help promote sleep include acupuncture and their other app -Before implementing Nonpharmacological interventions, clients should be evaluated by a sleep specialist for sleep apnea and chronic lung disease
-Nonpharmacological interventions used to help promote sleep include acupuncture and their other app
A nurse is caring for an older adult client reports that they wake up frequently during the night. The nurse should identify that which of the following is a characteristic of older adults sleep patterns that might explain the clients frequent awakenings? -Older adults tend to spend more time in stage for sleep. -Other adults tend to spend more time in stage three sleep. -Older adults tend to spend less time in stage one sleep. -Older adults tend to spend more time in stage two sleep.
-Older adults tend to spend more time in stage two sleep.
A nurse is setting up a sterile field to perform a dressing change on a client. Which of the following actions should the nurse take? -Open the first flap on the sterile package away from their body. -Place objects on the sterile field at least 1.3 cm (0.5 in) from the edge. -Unwrap both sides of the sterile package at the same time. -Set up the sterile field next to a wall in the clients room.
-Open the first flap on the sterile package away from their body.
A nurse is caring for a client who is on contact precautions. Which of the following actions should the nurse take? -Wear an N95 respirator when caring for the client. -Place the client in a private room. -Place a mask on the client when they leave their room. -Place the client in a negative airflow room.
-Place the client in a private room.
A nurse is reviewing documentation principles with a group of newly hired assistive personnel (AP). Which of the following information should the nurse include? -Providers designate to other staff which abbreviations cannot be used. -A nurse who delegates a task to an AP will review the charting for that task. -Providers read and co-sign nursing documentation for accuracy. -Licensed personnel should document out-of-range vital signs for AP.
A nurse who delegates a task to an AP will review the charting for that task.
A nurse is discussing end-of-life pain management with a group of coworkers. Which of the following to the nurse include as barriers to end-of-life pain management? (Select all that apply) A. fear of addiction B. belief that pain is an expected part of their illness C. inability to sleep D. lack of support E. inadequate pain assessment
A,B,E
A charge nurse is reviewing factors that can affect the clients perception of pain with a newly licensed nurse. Which of the following should the charge nurse include? (Select all that apply.) A. Stress B. Dietary practices C. Culture D. Social support. E. Disease severity
A,C,D,E
A nurse is completing a postoperative health history for a client who reports taking several herbal supplements. Which of the following herbal supplements is the priority for the nurse to report? A. Ginkgo Biloba B. Echinacea C. Valerian D. Aloe Vera
A. Ginkgo Biloba
A nurse is planning complementary therapy for a client who has breast cancer. Which of the following treatments is a complementary therapy that the nurse can implement? A. Massage therapy B. Chemotherapy C. Teletherapy D. Brachytherapy
A. Massage therapy
A nurse is assisting with teaching a newly licensed nurse about infection control. The nurse should include in the teaching that which of the following types of precautions requires the use of an N 95 mask? -Protective isolation. -Contact. -Droplet. -Airborne.
Airborne
A nurse is caring for a group of clients on the pediatric unit. For which of the following clients should the nurse use the FLACC Pain Scale to determine their pain level? (Select all that apply) A. A 12-year-old client who has an appendectomy B. A 3-year-old toddler who has a fractured femur C. A 6-day-old infant who had a surgical repair of a heart defect D. A 14-year-old client who has a severe cognitive and developmental delays E. A 5-year-old preschool or who is experiencing pain during a sickle cell crisis
B,D,E
A nurse is caring for a client who follows a vegan diet and reports lethargy. Which of the following interventions should the nurse implement? A. Offer a massage with lavender oil B. Request a prescription for vitamin B12 supplements C. Give the client a cup of chamomile tea D. Provide peppermint oil for the client to inhale
B. Request a prescription for vitamin B12 supplements.
A nurse is assisting with teaching a client, who has a history of alcohol use disorder and is to be discharged following cataract surgery, about non-pharmacological therapies. Which of the following client statements indicates an understanding of the teaching? A. "I will take kava to reduce my eye pain." B. "I will find a Rolfing Practitioner to help decrease my alcohol cravings." C. "I will practice mediating when I feel stressed." D. "I will take niacin to promote healing for my eyes."
C. "I will practice meditating when I feel stressed."
A nurse is assisting a massage therapist to identify the best client for massage therapy. Which of the following clients to the nurse recommend? A. A client who is receiving anticoagulants following a mitral valve replacement B. An older adult client who has osteoporosis C. A client who has postpartum depression B. A client who has a thrombophlebitis
C. A client who has postpartum depression
A nurse is caring for an older adult client who is having difficulty sleeping and has a new prescription for a medication to help them sleep which of the following medication should the nurse identify as a first line sleep aid for older adults? -Alprazolam. -Eszopiclone -Controlled release melatonin. -Diphenhydramine
Controlled release melatonin
The nurse is caring for a client who states "I am feeling so much better. My fever is gone, and I have a good appetite." The nurse should identify the client is likely in which of the following stages of infection? -Incubation -Convalescence. -Acute infection. -Prodromal.
Convalescence
A nurse is assisting with teaching a client about homeopathy. Which of the following client statements indicates an understanding of the teaching? A. "Homeopathy uses traditional Chinese medicine to treat diseases." B. "Homeopathy uses imagery to promote wellness." C. "Homeopathy uses incantations to treat diseases." D. "Homeopathy believes a substance that can cause a disease can also cure it."
D. "Homeopathy believes a substance that can cause a disease can also cure it."
A nurse in the clinic is caring for a client who reports generalized aches and fever for the past 12 hour. The nurse suspects the client has acquired an infection. Which of the following stages of infection is the client likely experiencing? -Incubation -Convalescence. -Acute illness. -Prodromal.
Prodromal
A nurse is planning to teach coworkers about the legal and ethical principles used with pain management. Which of the following examples to the nurse include as an example of autonomy? -A nurse allows a client to wait longer for their pain medication than other clients -A nurse does not properly clean a vial of pain medication prior to withdrawing medication from the bile, which results in the client contracting an infection -A nurse administers scheduled pain medication and provides therapeutic distraction techniques for a client in pain -A nurse provides a client with the opportunity to take an intramuscular injection or oral medication for pain relief
-A nurse provides a client with the opportunity to take an intramuscular injection or oral medication for pain relief
A nurse is contributing to a presentation about hypersomnia. Which of the following information should the nurse recommend including in the presentation? -Hypersomnia does not improve with increased sleep. -Hypersomnia is associated with a disturbed circadian rhythm. -Clients who experience hypersomnia have a longer attention span. -Clients who experience hypersomnia like the hormone hypocretin
-Hypersomnia does not improve with increased sleep.
A nurse is reviewing the plan of care for a client who was admitted with them Sonia and recent weight gain. Which of the following is a benefit of increased sleep that could help prevent further waking for the client? -Increased ghrelin production. -Increased leptin production. -Decreased hypocretin levels. -Decreased melatonin levels
-Increased leptin production.
A nurse is caring for a client who has a sunburn. The nurse should identify that which of the following herbal supplements is used to treat sunburns? A. Green tea B. aloe vera C. lavender D. milk thistle
B. aloe vera
A nurse is teaching staff about the ethical principle of justice and how it relates to pain management for clients. Which of the following statements should the nurse make? -Justice allows the client the freedom of choice -Justice allows the client the opportunity to be treated fairly -Justice is causing no harm to the client -Justice is doing good for the client
-Justice allows the client the opportunity to be treated fairly
A nurse is caring for a client who has admitted following a report of lumbar pain. In addition to administering pain medication, which of the following intervention should the nurse implement to promote comfort? -Present information honestly. -Have another nurse present difficult information. -Do not include the clients concerns in the plan of care if they interfere with treatment. -Perform cognitive behavioral therapy with the client
-Present information honestly.
A nurse is caring for a client who needs to be awakened for the administration of an oral medication. What does the following findings should indicate to the nurse that the client was in stage 3 of the sleep cycle wanna weekend? -The client was easily awakened. -The client states they were having a pleasant dream. -The client experiences mental cloudiness for 30 to 60 minutes. -Prior to being awakened, the clients breathing was a regular and the heart rate was elevated
-The client experiences mental cloudiness for 30 to 60 minutes.
A nurse is assisting with teaching a newly licensed nurse about needlestick injuries. Which of the following instructions should the nurse include? -Empty sharps container when they become full. -Report needle stick injuries to the nursing supervisor. -Engage the safety device on a needle after documenting the medication administration. -Recap needles after medication administration
-Report needle stick injuries to the nursing supervisor.
A nurse is discussing the history of electronic health records (EHRs) during a staff in-service. The nurse should identify that which of the following agencies advocated for the nationwide use of EHRs? -The Institute of Medicine -Department of Veteran Affairs -American Hospital Association -The Joint Commission
The Institute of Medicine
A nurse is documenting information in a client's chart and makes the entry "client reports abdominal pain on exertion." Which of the following documentation formats describes this entry? -The "i" in PIE -The "S" in SOAP -The "R" in DAR -The "E" in PIE
The "S" in SOAP