Quiz 2 Practice Questions
A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?
"Client found lying on floor."
A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?
"People in middle adulthood often find satisfaction in nurturing and guiding young people." According to Erickson, The task of middle adulthood is generativity vs. self absorbtion and stagnation. The focus of this task is on offering support and guidance to future generation.
A nurse is caring for a client who has terminal liver cancer. Which of the following should the nurse identify as an indication that the client is experiencing spiritual distress?
"What could I have done to deserve this illness?"
A nurse is planning an educational program for a group of older clients at a senior living center. Which of the following recommendations should the nurse include?
"You should receive a pneumoccocal immunization every 10 years."
Normal magnesium levels
1.3-2.1 mEq/L Magnesium Levels
The nurse should preoxygenate a tracheostomy patient at what percentage?
100% percent oxygen
Expected range for WBC count
5,000 to 10,000/mm3.... is the expected range for a WBC count
A nurse is calculating a client's fluid intake over the past 8 hours. Which of the following items should the nurse plan to document on the client's I&O record as 120 mL of fluid?
8oz of ice chips
A nurse is caring for a group of clients on a medical surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?
A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.
A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate?
Ambulating a client who is postoperative
What is a Normal BUN range
BUN= 10-20 mg/dL
A nurse is giving change of shift report about a client they admitted that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?
Breath Sounds
A nurse is caring for a client who has a magnesium level of 3.1 mEq/L. the nurse should expect to administer which of the following medications?
Calcium gluoconate **The nurse should expect to administer IV calcium gluconate to the client and prepare to provide ventilatory support. The client is at risk for respiratory depression and cardiac dysrhythmias because a magnesium level of 3.1 mEq/L is above the expected reference range of 1.3 to 2.1 mEq/L.
A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? Select all that apply
Check the cord routinely for frays or tearing Consider purchasing a generator for power backup Observe for signs of hypoxia
What is Cinacalet used to treat?
Cincalet is administered to treat hypercalcemia
A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?
Cleanse the wound from the center outward
A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?
Distended neck veins Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.
A nurse is admitting a client who has rubella. Which of the following types of transmission based precautions should the nurse initiate?
Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and strepttococcal pharyngitis
Older adults should have an eye exam how often?
Every Year for older adults
A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?
Flush the tube with 15 ml of sterile water The nurse should flush the feeding tube with 15 to 30 ml of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30-60 mL of sterile water following the administration of the last medication
A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?
Have the client use a trapeze bar when changing positions This methods decreases the amount of friction during re-positioning
A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendation should the nurse make?
Maintain a consistent time to wake up each day
The nurse is planning care for a client who has tuberculosis? The nurse should use which of the following pieces of personal equipment when providing care for the client?
N95 respirator
Older adults should have a fecal occult blood test every how many years.
Older adults should have a fecal occult blood test every year
Older adults should receive a tetanus booster every how many years?
Older adults should receive a tetanus booster every 10 years
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? Select all that apply
Place the client in a room with negative pressure airflow Wear gloves when assisting the client with oral care Use antimicrobial sanitizer for hand hygiene
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?
Rapid Heart Rate Tachycardia indicate FVD, which is an expected finding for a client who has vomiting and diarrhea for 3 days
Regular Insulin
Regular insulin may be used to treat hyperkalemia
A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?
Second intercostal space to the right of the sternum
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?
Select a suction catheter that is half the size of the lumen The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.
A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating filtration?
Skin Blanching Skin Blanching, edema, and coolness at the IV site indicate infiltration.
At what pressure should the nurse adjust the wall suction apparatus at prior to suctioning a tracheostomy?
The nurse should adjust the suction pressure to approximately 120mm Hg and no higher than 150 mm Hg to prevent hypoxemia and trauma to the mucosa.
What should the nurse use to lubricate the end of the tracheostomy suction catheter with?
The nurse should lubricate the end of the suction catheter with sterile water or 0.9% sodium chloride irrigation to decrease trauma to the mucosa.
A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?
When descending stairs, I will first shift my weight to my right leg
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?
Withhold the blood transfusion
A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?
You should have a fecal occult blood test every year Colorectal cancer screenings for clients who are at average risk begins at age 50. One option for screening is a fecal occult blood test annually.