RN Fundamentals content mastery practice test

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress? -role ambiguity -sick role -role overlord -role conflict

- role over Load (can't find time)

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid deficit. Which of the following changes should the nurse identify as a indication that the treatment was successful ? -increase in hematocrit -increase in respiratory rate -decrease in heart rate -decrease in capillary refill time.

-decrease in heart rate (fluid volume deficit causes tachycardia)

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate. -contact -droplet -airborne -protective

-droplet

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? - activate the emergency fire alarm. -extinguish fire - evacuate the client - confine the fire

-evacuate the client

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make? -"we can talk about advance directives, and I can also give you some brochures about them" -"you should set up a time to talk with your provider about that" - "let's discuss how you are feeling today, and we'll save that planning for when you are feeling a little better. " - " why do u want to discuss this without your partner here to plan this with you? "

"We can talk about advance directives, I can also give you some brochures about them."

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the clients neck, the nurse hears the following sound. This sound indicated which of the following? (Blowing sounds) -narrowed arterial lumen -distended jugular veins -impaired ventricular contraction -asynchronous closure of the aortic and pulmonic valves

- narrowed arterial lumen

A nurse is discussing the use of herbal supplements for the Heath promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use ? -" I can take echinacea to improve my immune system" -" I can take feverfew to reduce my level of anxiety" -" i can take ginger to improve my memory" -" I can take ginkgo biloba to relieve nausea"

-" I can take echinacea to improve my immune system"

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress.? -" what could I have done to deserve this illness" - " i blame medical science for not curing me" -" where is my daughter at a time like this" -" will I ever begin to feel in charge of my life again"

-"what could I have done to deserve this illness"

A nurse is repairing to apply a dressing for a client who has stage 2 pressure injury. Which of the following types of dressing should the nurse use? -Alginate -gauze -transparent -hydrocolloid

-hydrocolloid

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 infiltration?. -purulent exudate -warmth -skin blanching -bleeding

-skin blanching (sing of infiltration)

A nurse is planning strategies to manage time effectively for a client care. Which of the following strategies should the nurse implement. -combine client care task when caring for multiple clients -wait until the end of the shit to document count care -use the planning step of the nurse process to prioritize client care delivery -allow for interruptions in task to discuss client care issues with colleagues

-use planning step of the nursing process to prioritize client care delivery.

A nurse is preparing to administer 0.9% sodium chloride 750 ml IV to infuse over 7hr. The nurse should set the infusion pump to deliver how many ml/hr ? (Round to neared whole number)

107 (use IV formula for ml/hr)

A nurse is preparing a heparin infusion for a client who was admitted with deep vain thrombosis. The prescription reads 25,000 units of heparin in 0.9% sodium chloride 250mL to infuse at 800units/hr. At what rate should the nurse set the infusion pump? (math )

8ml (use Iv formulas = 800/1 : 8ml)

A nurse is planning care for a client who has vision loss. Which following interventions should the nurse include in the plan of care to assist the client with feeding ? - assign a staff member to feed the client - provide small-handled utensils for the client - thicken liquids on the clients tray - arrange food in consistent pattern on the clients plate.

—arrange food in consistent pattern on the clients plate.

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? -hypotension -weak,thready pulse -slow capillary refill -distended neck veins.

-distended neck veins

A nurse is preparing to administer multiple medications to a client who an enteral feedings tube. Which of the following actions should the nurse plan to take? -dissolve each medication in 5 ml of sterile water -draw up medications together in the syringe -push the syringe plunger gently when feeling resistance -flush the tube with 15ml of sterile water.

-flush the tube with 15ml of water.

A nurse is preparing to administer 0.5ml of oral single-dose liquid medication to a client. Which of the following actions should the nurse take ? -gently shake the container of medication prior to administration. -transfer the medication to a medicine cup. - place the client in a semi-Fowler's position prior to medication administration - verify the dosage by measuring the liquid before administering it.

-gently shake the container of medication prior to administration

A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use ? - touch the face with a cotton ball - apply a vibrating tuning fork to the clients forehead. - Have the client stand with their arms at their sides and their feet together - perform direct percussion over the area of the kidneys.

-have Client stand with their arms at their sides and their feet together

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? -place the client in high-Fowler's position -increase the clients intake of carbohydrates. -massage reddened areas with unscented lotion -have the client use a trapeze bar when changing position.

-have the client use a trapeze bar when changing position.

A nurse is reviewing a client medication prescription that reads, "digoxin 0.25 by mouth every day". Which of the following components of prescription should the nurse verify with the providers. -medication name -route of administration -medication dose -frequency of administration

-medication dose ( dose in order didn't say Mg)

A nurse is auscultating the anterior chest of a client who was newly admitted to a medical-surgical unit. Listen to the Audio clip of what the nurse auscultates through the stethoscope and Identify the types of breath sounds. (Normal breathing) -crackles -rhonchi -friction rub -normal breath sounds

-normal breathes sounds

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? -role play -group discussion -questions-answering meetings -practice sessions

-practice sessions

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches inner ear ? -press gently on the Tragus on the client's ear -pack a small piece of cotton deep into the clients ear canal - move the client's auricle down and back toward her head. -tilt the clients head backward for 5 min.

-press gently on the Tragus of the clients ear.

A client who is postoperative is verbalizing pain as a 2 on a pain scale 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? -"I think I should take my pain medication more often, since it is not controlling my pain" -"breathing faster will help me keep my mind of the pain" -" it might help me to listen to music while I'm lying in bed" -" I don't want to walk today because I have some back pain"

-" it might help me to listen to music while I'm lying in bed"

A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpated the popliteal pile after 92mm Hg. Which of the following images displays the measurement of MM Hg to which nurse should inflate the cuff when obtaining the blood pressure ? -images shows 92mm Hg -image shows. 102 mm Hg -image shows 112 mm Hg -image shows 122mm Hg

- Image shows 122mm Hg . (Add 30 to 92)

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? -insert an implanted port -close a laceration with sutures -place an endotracheal tube -initiate an enteral feeding through a gastrostomy tube

-initiate an enteral feeding through a gastronomy tube.

A nurse is taking care for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the clients risk of developing plantar flexion contractures. -place a pillow under the client's knees. -position a trochanter roll under each of the clients hips. -advise the client to wear a rubber-soled slippers. -apply an ankle-foot orthotic device to the client's feet

- apply an ankle-foot orthotic decide to the client's feet.

A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following task should the nurse delegate? -Ambulating a client who is postoperative -Inserting an indwelling urinary catheter for a client -Demonstrating the use of an incentive spirometer to a client -Confirming that a client's pain has decreased after receiving an analgesic.

-Ambulating a client who is postoperative.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation? -Urine has an unusual order. -Urine specific gravity is 1.035. -Bladder scan shows 525 ml of urine -Urine is positive for ketones.

-Bladder scan shows 525 ml of urine

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication for a skin malignancy ? -a lesion with uniform pigmentation -new appearances of Petechiae -a mole with an asymmetrical appearance -the presence of a papule

-a mole with an asymmetrical appearance

A nurse is caring for a client who has herpes zoster and ask the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that his condition is a contraindication for which of the following therapies. -biofeedback -aloe -feverfew -acupuncture

-acupuncture (contraindication for any skin disease )

A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing. She says, " Every time you change my bandage, it hurts so much". Which of the following interventions is the nurse's priority action? -encourage the client to relax and take deep breaths during the dressing change. -educate the client about the importance of the dressing change to prevent infection -assist the client to a comfortable position for the dressing change. -administer pain medication 45min before changing the clients dressing.

-administer pain medication 45min before changing the clients dressing

A nurse is evaluating a clients use of a cane. Which of the following actions should the nurse identify as an indication of correct use? -The top of the cane is parallel to the clients waist. -when walking, the Client moves the cane 46cm (18in) forward. -The client holds the cane on the stronger side of her body -the client moves her stronger limb forward with the cane.

-the client holds the cane on the stronger side of her body.

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client? -have the client wear a mask when receiving visitors -limit the client's time with visitors to no more than 30 min per day. -assign the client to a room with negative-pressure airflow exchange. -wear a gown when caring for the client

-wear a gown when caring for the client. ( shigella is contact precautions )

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this objects? -bend at the waist -keep his feet close together -use his back muscles for lifting -stand close to the cabinet when lifting it.

-stand close to the cabinet when lifting it.

A charge nurse is discussing the responsibility of nurses caring for clients who have a clostridium difficile infection. Which of the following information should the nurse include in the teaching? -assign the client to a room with a negative airflow system. -use alcohol-based hand sanitizer when leaving the client's room. -clean contaminated surfaces in the clients room with a phenol solution. -have family members wear a gown and gloves when visiting.

- Have family members wear a gown and gloves when visiting.

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statement indicates understanding of the teaching ? -"I can place an extension cord across my living room to plug in my television" -"I will hire someone to trim the tree that hangs low over the stairs on my front porch" -"I will place my alarm clock on my bedroom dresser across the room " -" I will replace my old throw rug in my kitchen with a new one"

-"I will hire someone to trim the tree that hangs low over the stairs on my front porch"

A nurse has just inserted an NG tube for a client. Which of the following finding should the nurse expect to confirm correct tube placement? -the tube aspirate has a ph of 7 -an X-ray shows the end of the tube above the pylorus -bowel sounds are presents on auscultation -the client reports relief of nausea

-an X-ray shows the end of the tube above the pylorus

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? -insert the suction catheter while the client is swallowing -apply intermittent suctioning when withdrawing the catheter -place the catheter in a location that is clean and dry for later use -hold the suction catheter with her clean , non dominant hand.

-apply intermittent suctioning when withdrawing the catheter

A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of diarrhea? -the client is receiving formula at room temperature -the feedings infuse at a slow, continuous drip over 8 hr each night. -the client's caregiver washed out the feeding bag with warm water once every 24hrs -the clients caregiver flushed the tube with water before and after administering medications

-the client's caregiver washes out the feeding bag with warm water every 24 hr. (Needs to be washed after each feeding)

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend -walking briskly -riding a bicycle -performing isometric exercise -engaging in high-impact aerobics.

-walking briskly

A nurse 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 -"I'll get a blood sample from you and send it for a screening test" -"beginning at age 60, you should have a colonoscopy " -" you should have a fecal occult blood test every year" -"the recommendation is to have a sigmoidoscopy every 10 years"

"You should have a fecal occult blood test every year"

A nurse is caring for a client who is receiving pain medication through a patient controlled analgesia (PCA) pump. Which of the following actions should the nurse take? -Instruct family to refrain from pushing the button for the client white she is asleep -inform the client that because she is on PCA, vital signs will be take every 8 he -Teach the client to avoid pushing the button until pain is above a 7 on scale of 0-10 -Increase the basal rate and shorten the lock-out interval time if the client's pain level is too high.

- Instruct the family to refrain from pushing the button for the client while she is asleep.

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following task the nurse assign to an assistive personnel (AP) (select all the apply) -assist the client with a partial bed bath -measure the clients BP after the nurse administers an antihypertensive medication -test the clients swallowing ability by providing thickened liquids -use a communication board to ask what the client wants for lunch -irrigate the clients indwelling catheter

-assist the client with a partial bed bath -measure the clients BP after the nurse administers an antihypertensive medication -use a communication board to ask what the client wants for lunch

A nurse is administering Iv fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority? -auscultate lung sounds -measure urine output -monitor blood pressure readings -monitor electrolyte levels

-auscultate king sounds

A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide ? -admitting diagnosis -breath sounds -body temperature -diagnostic test results

-breath sounds

A nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the clients medical record? - .3 mg - 0.3 mg - 0.30 mg - 3/10 mg

"0.3 mg"

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? - seal unused medication from the facility in a plastics bag - evaluate the clients ability to self-administer medications. - report the identified discrepancy to the joint commission. - compare prescriptions with medications the client received while at the facility.

- compare prescriptions with medications the client received while at the facility

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include? -"you should have an eye examination every 2 years" - "you should receive tetanus booster every 5 years" - "you should receive a shingles vaccine when you are 70 years old" - "you should receive a pneumococcal vaccine when you are 65 years old"

"You should receive a pneumococcal vaccine when you are 65 years old"

A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating correct technique for eliciting the clients patellar reflex?

(Pick image showing assessing patellar reflex. On the knee )

A middle adult client tells the nurse, "I feel so useless now that my children don't need me anymore". Which of the following responses should the nurse make? - "most people are happy when their children grow up and leave home" - " you should be proud that your children are becoming independent" - " maybe you should consider why you are feeling useless " - " people in middle adulthood often find satisfaction in nurturing and guiding young people"

-"people in middle adulthood often find satisfaction in nurturing and guiding young people"

A nurse is caring for a client who reports pain. When documenting the quality of the clients pain on an initial pain assessment, the nurse should record which of the following clients statement.? -"I'm having mild pain" -"the pain is like a dull ache in my stomach -" I notice the pain get worse after I eat." -" the pain makes me feel nauseous"

-"the pain is like a dull ache in my stomach"

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client. -use a bed exit alarm system -raise four side rails while the client is in bed. -apply one soft wrist restraint -dim the light in the clients room.

-use a bed exit alarm system

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which to the following clients? - a client who has a history of physical abuse - a client who has a permanent pace maker - a client who has ulcerative colitis - a client who has asthma

- a client who has asthma

A nurse manager is overseeing the care activities of a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPPA Guidelines - a nurse who is caring for a client reviews the clients medical chart with a nursing student who is working with the nurse - a nurse asks a nurse from another unit to assist with document for a client. - a nurse who is caring for a client returned a call to the person appointed in the health proxy to discuss the clients care. - a nurse discusses a clients status with physical therapist who is caring for the client

- a nurse asks a nurse from another unit to assist with documentation for a client

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next? -rock the client up to a standing position -pivot the foot that is the farthest from the chair -asses the client for orthostatic hypotension -apply a gait belt to the client.

- asses the client for orthostatic hypotension

A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at risk for hypertension? - a client who is 52 years old - a client who smoked one pack of cigarettes each day - a client who walks for 30 min everyday - a client who drinks one glass of wine three times per week.

- client who smoked one pack of cigarettes each day

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? -Rinse the feeding bad with water between feedings - tell the client to keep the head of the bed elevated at least 30* -make sure the enteral feeding formula is at room temperature - wipe the top of the formula with alcohol.

- tell the client to keep the head of the bed elevated at least 30*

A nurse is teaching a client and his family how to car for the clients tracheostomy at home. Which of the following instructions should the nurse include in the teaching? -remove the outer cannula cautiously for routine cleaning -use tracheostomy covers when outdoors -use sterile technique when performing tracheostomy care at home. -cleans irritated skin with full strength hydrogen peroxide.

- use tracheostomy covers when outdoors.

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurses responsibility? -describe the procedure to the client - witness the clients signature on the consent form - inform the client of alternatives to the procedure -tell the client which team members will assist with the procedure.

- witness the clients signature on the consent form

A nurse in a surgical suite notes documentation on a clients medical record that he has a latex allergy. In preparation for the clients procedure, which of the following precautions should the nurse take? -ensure the sterilization of non disposable items with ethylene oxide. -wrap monitoring cords with stockinette and tape them in place -cleanse latex ports on IV tubing with chlorhexidine before injecting medication - wear hypoallergenic latex gloves that contain powder

- wrap monitoring cords with stockinette and tape them in place.

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the clients room. When the nurse ask if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? -"I will return shortly after I document this in your record" -"most men live a long life with prostate cancer" -" I am available to talk if you should change your mind" -" I will make a referral to a cancer support group for you"

-" I am available to talk if you should change your mind"

A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the clients partner indicates effective coping? -" I am not worried because I still have hope that he will be okay" -" I am relying on support from our family during this time" -" we can plan our family reunion once he recovers and comes home" -" we don't see any reason to start discussing funeral arrangements right now"

-" I am relying on support from our family during this time"

A nurse is caring for a client who requires 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? -"I had a bowel movement, but I was able to save the urine" - " I have a specimen in the bathroom from about 30 minutes ago" - " I flushed what I urinated at 7:00 am and have saved all urine since" - " I drink a lot, so I will fill up the bottle and complete the test quickly"

-" I flushed what I urinated at 7:00 am and have saved all the urine since"

A nurse is caring for a client who has recently started using a behind-the-ear heading aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device? -"this type of hearing aid does not allow for fine tuning of volume" -"I shouldn't have trouble keeping the hearing aid in this pace during exercise" - " I expect to hear a whistling sound when I first insert the hearing aid" -" I will be sure to remove my hearing aid before taking a shower"

-" I will be sure to remove my hearing aid before taking a shower"

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "what would happen if I arrived at the emergency department and i had difficulty breathing?". Which of the following responses should the nurses make?. -"we would consult the person appointed by your health care proxy to make decisions" -"we would give you oxygen through a tube in your nose" -"you would be unable to change your precious wishes about your care" -"we would insert a breathing tube while we evaluate your condition"

-" we would give you oxygen through a tube in your nose". (This isn't considered a resuscitation measure)

A nurse enters a clients 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 ? -"incident report completed" -"client climbed over the side rails" -"client found lying on floor" -"client was trying to get out of bed"

-"Client found lying on floor"

A nurse is assessing the clients readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? -" I can concentrate best in the morning" -" it is difficult to read the instructions because my glasses are at home" -" I'm wondering why I need to learn this " -" you will have to walk to my wife about this "

-"i can concentrate best in the morning" (setting time to learn)

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

-"is your pain sharp or dull?"

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? -"drink a cup of hot cocoa before bed time" -" maintain a consistent time to wake up each day" -"exercise 1 hour before going to bed" -"watch a television program in bed before going to sleep"

-"maintain a consistent time to wake up each day"

A nurse is caring for a client who ask about the purpose of advanced directives. Which of the following statements should the nurse make? -"they allow the court to overrule an adult clients refusal of medical treatment" -"they indicate the form of treatment a client is willing to accept in the even of serious illness" -" they permit a client to withhold medical information from health care personnel" -" they allow health care personnel in the emergency department to stabilize a clients condition"

-"they indicate the form of treatment a client is willing to accept in the event of a serious illness "

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching ? -"use the complete name of the medication magnesium sulfate" -"Delete the space between the numerical dose and the unit of measure " -"write the letter U when noting the dosage of insulin " -" use the abbreviations SC when indicating an injection"

-"use the complete name of the medication magnesium sulfate" (always write full name )

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." -"I should place my crutches 12 inches in-front and to the side of each food" -"as I sit down, I will hold one crutch in each hand." -"I will make sure the shoulder rest are snug against my armpits."

-"when descending stairs, I will first shift my weight to my right leg"

A nurse is calculating a client's fluid intake over the past 8hr. Which of the following items should the nurse plan to document on the clients intake and output record as 120-ml of fluid? -2 cups of soup -1 quart of water -8 oz of ice chips -6 oz of tea

-8 oz of ice chips

A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? -bladder distention -decreased blood pressure -calf swelling -diminished bowel sounds

-Calf swelling

A nurse is receives a report about a client who has 0.9% sodium chloride infusing IV at 125ml/hr. When the nurse performs the initial assessment, he notes that the client has received only 80ml over the last 2hr. Which of the following actions should the nurse take first? -reposition the client -document the clients IV intake in the medical record -request new iv fluid prescription -check the iv tubing for obstruction.

-Check The Iv tubing for obstruction.

A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following finding should the nurse intervene? - Erythema on pressure points - lower extremity pulse strength 2+ - fluid intake of 3000 ml per day. - one bowel movement ever other days

-Erythema on pressure points

A nurse is caring for a client who requires NG tube for decompression. Which of the following actions should the nurse take when inserting he NG tube. -position the client with the head of the bed elevated 30* prior to insertion of the NG tube -remove the NG tube if the client begins to gag or choke. -apply suction to the NG tube prior to insertion -have the client take sips of water to promote the insertion of an NG tube into the esophagus

-Have the client take sips of water to promote insertion of an NG tube into the esophagus.

A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client. - gown -n95 respirator -shoe covers - surgical cap

-N95 respirator

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 ask the nurse is she has cancer and the nurse responds affirmatively - a client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client wishes - a client who has a DNR order had a cardiac arrest, the nurse does not perform cpr despite requests from family. - a client is about to undergo a painful procedure receives pain medications 30 min before the procedure that the nurse previously promised to administer.

-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 caring for a client who has a sodium level of 125meq/L . Which of the following findings should the nurse expect? -numbness of the extremities -bradycardia -positive Chvostek's sign -abdominal cramping

-abdominal cramping (sodium levels are low, this a symptom of low sodium

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? -insert the needle at a 15* angle -aspirate for blood return prior to administration -administer the medication into the abdomen -massage the site following the injection.

-administer the medication into the abdomen (heparin is a subq injection )

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? -administer the medication with the needle at 45* angle. -administer the medication into the clients nondominant arm -pull the client's skin laterally or downward prior to administration. -massage the injection site after administration.

-administer the medication with a needle at 45* angle

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? -advocacy ensures client's safety, health and rights -advocacy ensure that nurses are able to explain their own actions -advocacy ensures that nurses follow through in their promises to client -advocacy ensures fairness in client care delivery and use of resources

-advocacy ensures the clients safety , Heath and right. ( fight for patient )

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1ml of the medication from a 2ml vial. Which of the following actions should the nurse take? -ask another nurse to observe the medication wastage -notify the pharmacy when wasting the medication -lock the remaining medication in the controlled substances cabinet -dispose of the coal with the remaining medication in a sharps container.

-ask another nurse to observe the medication wastage. (Second nurse much watch disposal of a controlled substance )

A nurse is responding to a call light and finds a client lying on the bathroom. Which of the following actions should the nurse take first? -check the client for injuries -move hazardous object away from the client -notify the provider -ask the client to describe how she felt prior to the fall.

-check client for injuries (save them first lol)

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 -keep the unit at least 1.2m (4 feet) away from a gas stove. -consider purchasing a generator for a power backup. -observe for signs of hypoxia -select synthetic clothing and bedding.

-check cord routinely for frays or tearing. -consider purchasing a generator for power backup -observe for signs of hypoxia

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take ? -wear sterile gloves when removing the old dressing. -warm the irrigation solution to 40.5* C (105* F) -cleanse the wound from the center outward. -use a 20-ml syringe to irrigate the wound.

-cleanse the wound from the center outward.

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation ? -verify the client's name on their identification bracelet with the medication administration record. -call the pharmacy to determine wether the client's medication are available. -compare the client's home medications with the provider's prescription. -place the client's home medication bottles in a secure location.

-compare the client's medication with the provider's prescriptions (should always compare with new client)

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? -protective environment -airborne is precautions -droplet precautions -contact precautions

-contact precautions (for any major wounds)

A nurse in an Acute care facility is preparing a discharge Summary for a client who is transferring to a long term care facility. Which of the following documentation should the nurse include? -client flow sheet -acuity ratings -current medications -incident reports

-current medications

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following a major abdominal surgery. Which of the following actions is the nurse's priority? -request that a respiratory therapist discuss the technique for incentive spirometry with the client. -determine the reasons why the clients is refusing to use the incentive spirometer -document the clients refusal to participate in health restorative activities -administer a pain medication to the client.

-determine the reasons why the clients is refusing to use the incentive spirometer

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate? -droplet -airborne -contact -protective environment

-droplet

A nurse is admitting a client who is having an exacerbation of heart failure. I'm planning this client's care, when should the nurse initiate discharge planning? -during the admission process -as soon as the clients condition is stable -during the initial team conference -after consulting with the client's family.

-during the admission process

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use ? -use the face, legs, activity, cry and consolability (flacc) pain rating scale for a client who is experiencing pain. -ensure the bladder of the blood pressure cuff surrounds 80% of the clients arm. -obtain an apical heart rate by auscultating at the third intercostal space left of the sternum -palpate the clients abdomen before auscultating bowel sounds

-ensure the bladder of the blood pressure cuff surrounds 80% of the clients arm.

A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take? -examine personal values about the issue. -tell the parents that this is a necessary procedure -inform the parents that the staff does not require their consent. -contact a spiritual support person to explain the importance of the procedure.

-examine personal values about the issue.

A nurse is talking with an older adult client who is contemplating retirement. The client states, "i keep thinking about how much I enjoy my job. I'm not sure I want to retire". Which of the following responses should the nurse make? -"you would have so much more time to spend with your family" -"you should consider getting a part-time job or doing volunteer work" -"lets talk about how the change in your job status will affect you" -"why wouldn't you want to retire and relax"

-let's talk about how the change in your job status will affect you"

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? -make sure the clients room has at least six air exchanges per hour. -make sure she client wears a mask when outside her room if there is construction in the area. -place the client in a private room with negative pressure airflow. -wear a N95 respirator when giving the client direct care.

-make sure the clients wears a mask when outside her room if there is construction in the area.

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take? -assist the client into a prone position -place a sleeve over the top of each leg with the opening at the knee. -make sure two fingers lift under the sleeves -set the ankle pressure at 65 mm Hg.

-make sure two fingers fit under the sleeves

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and report back in 1 hr. Which of the following actions should the nurse take next? -document the provider's statement in the medical record. -complete an incident report -consult the facility risk manager -notify the nursing manager

-notify the nursing manager ( need to activate chain of command)

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? -pad the clients wrist before applying the restraints -evaluate the clients circulation every 8hr after application -remove the restraints every 4 hrs to evaluate clients status -secure the restraint ties to the bed's side rails.

-pad the clients wrist before applying the restraints

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? -carry a clients soiled linens out of the room in a mesh linen bag -place a client who has tuberculosis in a room with negative-pressure airflow -provide disposable plates and utensils for a client who is HIV-positive -dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag.

-place a client who has tuberculosis in a room with negative-pressure air flow (this reduces the risk of infection transmission for someone who requires airborne precautions)

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take ? -insert the catheter at 45* angle. -place the clients arm in dependent position -shave the excess hair from the insertion site. -initiate IV therapy in the veins of the hand.

-place clients arm in dependent position ( place in position because the veins will dilate due to gravity)

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 room with a negative-pressure airflow -wear gloves when assisting a client with oral care. -limit each visitor to 2-hr increments. -wear a surgical mask when providing client care. -use antimicrobial sanitizer for hand hygiene

-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 reviewing a clients fluid and electrolyte status. Which of the following findings should the nurse report to the provider? -Bun 15 mg/dl -creatine 0.8 mg/dl -sodium 143 meq/dl -potassium 5.4 meq/L

-potassium 5.4 meq/L

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the clients safety needs? (select all that apply) -lacrimal apparatus -pupil clarity -appearance of bulbar conjuncativae -visual fields -visual acuity.

-pupil clarity -visual fields -visual acuity

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? -Neck vein distention -Urine specific gravity 1.010 -Rapid heart rate -Blood pressure 144/82 mm Hg

-rapid heart rate

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? -discuss Rick factors of colon cancer -focus teaching on what the client will need to do in the future to manage his illness -provide written information about the phases of loss and grief -reassure the client that this is an expected response to grief.

-reassure the client that this is an expected response to grief

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include ? -regulate the flow rate by aligning the rate with top of the ball inside the flow meter -regulate oxygen via nasal cannula at a flow rate of no more than 6L/min -make sure the reservoir bag of a partial rebreathing mask remains deflated. -use petroleum jelly to lubricants the clients nares, face, and lips.

-regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min

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? -use a resuscitation bad with 80% oxygen prior to the procedure - select suction Catheter that is half the size of the lumen - place the end of the suction catheter in water-soluble lubricant -adjust the wall suction apparatus to a pressure of 170mm Hg

-select suction catheter that is half the size of the lumen

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? -critical pathway -situation, background, assessment, and recommendation (SBAR) -transfer report -medication administration record (MAR)

-situation, background, assessment , and recommendation (sbar) = used to communicate reports between nurses shift.

A nurse is using an open irrigation technique to irrigate a clients indwelling urinary catheter. Which of the following actions should the nurse take? -place the client in side-Lying position -instill 15ml of irrigation fluid into the Cather with each flush. -subtract the amount of irrigant used from the clients urine output -perform the irrigation using a 20ml syringe

-subtract the amount of irrigant used from the clients urine output.

A charge nurse is observing a Newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse? - the newly licensed nurse placed the cap of a bottle of sterile saline solution on the sterile field. - the Newly licensed nurse places sterile objects 2.5cm (1 inch) within the border of the field. -the Newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring. -The sterile field is positioned at the level of the Newly licensed nurses waist.

-the Newly licensed nurse placed the cap of the bottle of sterile saline solution on the sterile field.

A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following finding should the nurse identify as a potential indication of elder abuse? -the caregiver is the clients financial power of attorney - the client is in a wheelchair with the wheels locked -the client reports receiving a full bath twice each week. -the caregiver insists on remaining in the room.

-the caregiver insists on remaining in the room

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? -the client uses a wool blanket on their bed. -the client uses nonacetone nail polish remover -the client stores an extra tank on its side under their bed. -the client has a weekly inspection checklist for oxygen equipment

-the client uses nonacetone nail polish remover. (Non flammable material)

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respiration's from secretions in their airway. Which of the following actions should the nurse take. ? -turn the client ever 2 hrs -administer an antiemetic every 6 hrs -hold oral care -increase the room's temperature

-turn the client ever 2hrs (to break up secretions in lungs)

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? -ask the client to consider a direct donation -withhold the blood transfusion -request a consultation with the ethics committee -ask the clients family to intervene

-withhold the blood transfusion

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the clients plan of care ? - wrap blankets around all four sides of the bed - apply restraints during seizure activity - place the client in spine position during seizures activity. - have tongue depressor at the client bedside.

-wrap blankets around all four sides of the bed.

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. -obtain the pronouncement of death from the provider -ask the clients family members if they would like to view the body. -remove tubes and indwelling lines. -place a name tag on the body. -wash the clients body.

1) obtain the pronouncement of death from the provider 2) remove tubes and indwelling lines 3) wash the clients body 4) ask the family members if they would like to view body. 5) place a name tag on the body.

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPh insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. -inject five units of air into the bottle of regular insulin. -withdraw the correct dose of NPH insulin from the bottle. -inject 10 units of aid into the bottle of NPH insulin -withdraw the correct dose of regular insulin from the bottle

1)inject 10 units of air into the bottle of insulin. 2)inject 5 units of air into bottle of regular insulin 3) withdraw the correct dose of regular insulin from bottle 4) withdraw correct dose of NPH insulin from the bottle