T1-4 Comprehensive Exam - Practice H - VN05

A nurse is assisting with providing teaching to a client who has a new prescription for an antibiotic. Which of the following statements should the nurse make? "Antibiotics are administered to treat viral infections." "Bloody stools are expected while taking antibiotics." "Check with your provider before taking over-the-counter medications." "Discontinue the medication when you feel better."

"Check with your provider before taking over-the-counter medications." The nurse should instruct the client to check with their provider before taking over-the-counter medications and herbal supplements, because these might interact with certain antibiotics.

A nurse is reinforcing teaching with a client who has kidney stones. Which of the following instructions should the nurse include? "Drink 1 liter of fluid each day." "Limit your calcium intake." "Filter your urine each day." "Choose sugar-sweetened beverages."

"Filter your urine each day." The client should filter their urine each day to identify the type of kidney stone.

A nurse is assisting with teaching a client who has constipation. Which of the following statements should the nurse include? "Reduce your daily activity." "Try to defecate at different times of the day." "Increase your daily fluid intake." "Consume a low-fiber diet."

"Increase your daily fluid intake." The client should drink about 1,900 mL (64 oz) of fluid each day to soften stool and promote peristalsis.

A nurse is using the NURSE mnemonic when speaking with a client who is experiencing grief. The client reports that they are feeling overwhelmed. Which of the following responses by the nurse demonstrates the "R" in the NURSE mnemonic? "It is impressive how you have managed to deal with this situation." "You have so much to deal with. How can I be of help to you?" "Tell me more about how you are feeling." "It sounds like you are exhausted."

"It is impressive how you have managed to deal with this situation." This statement demonstrates the concept of respect in the NURSE mnemonic. The nurse is showing respect and support to the client.

A nurse is using the NURSE mnemonic when speaking with a client who is experiencing grief. The client reports that they are feeling overwhelmed. Which of the following responses by the nurse demonstrates the "E" in the NURSE mnemonic? "Tell me more about how you are feeling." "It is impressive how you have managed to deal with this situation." "You have so much to deal with. How can I be of help to you?" "It sounds like you are exhausted."

"Tell me more about how you are feeling." This statement demonstrates the concept of exploring in the NURSE mnemonic. The nurse asks an open-ended question, providing an opportunity for the client to express their feelings in more detail.

A nurse is caring for a client who is at the end of life. The client's partner is concerned about using opioid narcotics to manage the client's pain. Which of the following statements should the nurse make? "The use of opioid narcotics is restricted to when death is imminent." "Using opioid narcotics will limit options available for future management of pain." "The dosage of the opioid narcotic is unlimited." "Opioid narcotics are restricted for the client because of the risk for addiction."

"The dosage of the opioid narcotic is unlimited." The dosage of the opioid narcotic can be increased as needed.

A nurse is assisting with teaching a class about converting household measurements into metric measurements. Which of the following information should the nurse include? 1 cup is equal to 240 mL 2 Tbsp is equal to 15 mL 1 pint is equal to 960 mL 1 tsp is equal to 10 mL

1 cup is equal to 240 mL When converting household measurements to metric measurements, the nurse should include that 1 cup is equal to 240 mL.

A nurse is preparing to administer cefotaxime 1,000 mg IM to a client. How many grams (g) should the nurse plan to administer? 1 g 100 g 10 g 0.1 g

1 g When converting mg to g, the nurse should move the decimal point three places to the left. Therefore, 1,000 mg is equal to 1 g.

A nurse is reinforcing teaching with a client who has a prescription for amoxicillin 5 mL PO. How many teaspoons (tsp) should the nurse instruct the client to take? 5 tsp 1 tsp 0.5 tsp 2.5 tsp

1 tsp When converting metric measurements to household measurements, the nurse should instruct the client that 5 mL is equal to 1 tsp.

A nurse is assisting with teaching a newly licensed nurse about an ileal conduit. The nurse should include which of the following information? An ileal conduit is a tube that directly connects a client's kidney to an external pouch. A client's ureters are attached to a section of the client's small intestine to form an ileal conduit. A client has control of elimination through an ileal conduit. Stool is passed through an ileal conduit located on a client's abdomen.

A client's ureters are attached to a section of the client's small intestine to form an ileal conduit. An ileal conduit is an incontinent urinary diversion in which a client's ureters are attached to a section of the client's small intestine. A segment of the small intestine is removed, and the ends of the intestine are reattached. The other end of the removed segment of the small intestine forms a stoma that is attached to the client's abdominal wall. Urine is passed through the stoma into a pouch.

A nurse is assisting with teaching a class about the stages of general adaptive syndrome (GAS). The nurse should include that which of the following is the first physiological response that occurs during GAS? The body remains alert, while blood pressure and heart rate return to prestress levels. A perceived stressor stimulates the central nervous system. Prolonged exposure to stress can result in illness. An increase in hormones cause an increase in blood pressure and heart rate.

A perceived stressor stimulates the central nervous system. According to evidence-based practice a perceived stressor that stimulates the central nervous system is the first physiological response that occurs during GAS. During the alarm phase, a perceived stressor stimulates the central nervous system causing release of hormones.

A nurse is caring for a client who has a terminal diagnosis and states, "I am ready to update my will." The nurse should identify that the client is experiencing which of the following Kubler-Ross stages of grief? Anger Acceptance Denial Bargaining

Acceptance A client who is experiencing the Kubler-Ross stage of acceptance acknowledges the situation and might plan for the inevitable, such as updating a will or adjusting their living arrangements.

A nurse is caring for a client whose partner has recently died. The client states, "I am learning how to pay my own bills." The nurse should identify that the client is experiencing which of the following tasks in Worden's Four Tasks of Grieving? Finding an enduring connection while embarking on a new life Accepting the reality of the loss Experiencing the pain of grief Adjusting to an environment without the deceased

Adjusting to an environment without the deceased A client who is experiencing Worden's third task of grieving is adjusting to living without the deceased.

A nurse is caring for a client who is at the end of life and is experiencing dyspnea. Which of the following actions should the nurse take? Place the head of the client's bed flat. Increase the heat in the client's room. Administer an opioid narcotic to the client. Perform nasotracheal suctioning for the client.

Administer an opioid narcotic to the client. The nurse should administer an opioid narcotic as prescribed to promote vasodilation, relieve anxiety, and improve breathing.

A nurse is preparing to obtain an electronic blood pressure measurement on a client. Which of the following actions should the nurse plan to take? Select a cuff that covers 50% of the client's upper arm. Elevate the client's arm above the level of the heart. Align the artery indicator on the blood pressure cuff with the client's brachial artery. Place the blood pressure cuff 5 cm (2 in) above the client's antecubital space.

Align the artery indicator on the blood pressure cuff with the client's brachial artery. The nurse should align the artery indicator on the blood pressure cuff with the client's brachial artery to obtain an accurate measurement.

A nurse is assisting with teaching an older adult client about a new medication. Which of the following actions should the nurse take? Present the information in lengthy segments. Provide reading material using small-sized font. Use a high tone of voice when speaking. Allow extra time for instruction.

Allow extra time for instruction. The nurse should allow extra time for instruction because the older adult client might require extra time to process new information.

A nurse is assisting with teaching a newly licensed nurse about incident reports. The nurse should include that which of the following events requires an incident report? A client vomits their morning medications. A client has an allergic reaction to an antibiotic. A lipid-lowering medication is administered to a client 1 hr after the scheduled time. An IV medication is administered via an oral route.

An IV medication is administered via an oral route. The nurse should check the client's vital signs and report the event to the provider. The client is at risk for an adverse reaction due to the medication error. Once the client is stable, the nurse should fill out an incident report. An incident report is used to tract unusual events and implement measures to reduce the reoccurrence of the events.

A nurse is preparing to administer an ophthalmic medication to a client. Which of the following actions should the nurse plan take? Instill the ophthalmic medication directly on the client's cornea. Clean the client's eye from the outer canthus to the inner canthus before instillation. Ask the client to tightly squeeze their eyes shut after the instillation. Apply pressure to the client's nasolacrimal duct after instillation.

Ask the client to tightly squeeze their eyes shut after the instillation. The client should gently close their eyes shut after the instillation to allow for absorption of the medication. Tightly squeezing the eyes shut can cause the medication to drain out of the eyes.

A nurse is caring for a client who has an irregular heart rate. Which of the following actions should the nurse take? Ask the client to perform the Valsalva maneuver. Check the clients heart rate for 30 sec. Auscultate the client's apical pulse. Palpate the client's pulse at the third intercostal space.

Auscultate the client's apical pulse. The nurse should auscultate the client's apical pulse for 1 min to obtain an accurate heart rate.

A nurse is caring for a client who has a terminal diagnosis and states, "If I get better, I promise to go to church every day." The nurse should identify that the client is experiencing which of the following Kubler-Ross stages of grief? Denial Depression Bargaining Anger

Bargaining A client who is experiencing the Kubler-Ross stage of bargaining might make a promise in exchange for a better outcome.

A nurse is assisting with teaching a class about stress. The nurse should include that which of the following is an example of acute stress? Being part of a dysfunctional family Being a victim of a crime Experiencing racism Experiencing poverty

Being a victim of a crime Being a victim of a crime is an example of acute stress that can lead to gastrointestinal disturbances and headaches.

A nurse is assisting with teaching a class about sources of stress. The nurse should include that which of the following is an example of a physiological stressor? Academic pressure Burn injury Change in marital status Financial difficulties

Burn injury Burn injury, trauma, illness, and pain are examples of physiological stressors.

A nurse is reinforcing teaching with a client about foods and beverages that can cause diarrhea. Which of the following should the nurse include in the teaching? Ripe bananas Low-fiber cereal Caffeinated beverages White rice

Caffeinated beverages Caffeine can stimulate gastric motility and cause diarrhea.

A nurse is collecting data on a client to check for orthostatic hypotension. Which of the following actions should the nurse take first? Place the client in a sitting position. Determine the client's blood pressure 1 min after each position change. Check the blood pressure with the client in a supine position. Assist the client into a standing position.

Check the blood pressure with the client in a supine position. According to evidence-based practice the first action the nurse should take when measuring a client for orthostatic hypotension, is to check the blood pressure with the client in a supine position. The supine position provides a baseline reading for the nurse to compare the client's blood pressure. A decrease of at least 20 mm Hg in the systolic pressure with a position change indicates orthostatic hypotension.

A nurse is administering a powdered medication to a client. Which of the following actions should the nurse take first? Check the client for allergies. Determine the client's response to the medication. Mix the medication at the client's bedside. Document that the medication was administered.

Check the client for allergies. The greatest risk to this client is injury from an allergic reaction. Therefore, the first action the nurse should take is to check the client for allergies.

A nurse administers the wrong medication to a client. Which of the following actions should the nurse take first? Document the client's condition in the electronic medical record. Notify the charge nurse. Check the client's vital signs. Fill out an incident report.

Check the client's vital signs. The first action the nurse should take when using the nursing process is to check the client's vital signs. The client is at risk for an adverse reaction due to the medication error. The nurse should collect data from, the client to monitor for any changes in the client's condition.

A nurse is collecting data on a preschooler whose parent has recently died. Which of the following findings should the nurse expect? Depends on their friends for emotional support Clings to their caregiver Displays high-risk behavior Reports tightness in their chest

Clings to their caregiver A preschooler might cling to their caregiver, become irritable, or have difficulty sleeping, in response to grief.

A hospice nurse tells another nurse that they are feeling overwhelmed after caring for multiple clients who are dying and reports having difficulty feeling sympathy for their clients. The nurse has manifestations of which of the following conditions? Compassion fatigue Adventitious stress Prolonged grief disorder Post-traumatic stress disorder (PTSD)

Compassion fatigue Compassion fatigue is cumulative stress from repeatedly caring for clients who are suffering and can result in difficulty feeling sympathy and connecting to clients.

A nurse is caring for a client who is at the end of life and is unresponsive. Which of the following actions should the nurse take? Whisper when talking in the client's room. Avoid touching the client. Continue to talk to the client as if they are awake. Limit the client's visitors to one at a time.

Continue to talk to the client as if they are awake. The nurse should continue to talk to the client as if they are awake to provide comfort and reassurance, because the client might be able to hear, even if they are unresponsive.

A nurse is preparing to administer cefadroxil oral suspension 15 mg/kg PO to a client who weighs 98 lb. Available is cefadroxil 250 mg/5 mL. Which of the following actions should the nurse take first? Convert the client's weight to kilograms. Calculate the dosage in milligrams. Round the amount to be administered to the nearest whole number. Calculate the dosage in milliliters.

Convert the client's weight to kilograms. According to evidence-based practice, the first action the nurse should take when calculating a dosage by weight is to convert pounds to kilograms. To convert pounds to kilograms, the nurse should divide the weight in pounds by 2.2.

A nurse is collecting data on a toddler whose parent has recently died. Which of the following findings should the nurse expect? Depends on their friends for emotional support Reports tightness in their chest Displays aggressive behavior Cries frequently

Cries frequently A toddler might cry frequently, cling to their caregiver, become irritable, or have difficulty sleeping in response to grief.

A nurse is collecting data on a client who has dehydration. Which of the following findings should the nurse expect? Cloudy urine Urine osmolality of 200 mOsm/kg Dark-colored urine Urine specific gravity of 1.015

Dark-colored urine Dark-colored urine indicates concentrated urine and is a manifestation of dehydration.

A nurse is caring for a client who has hypoglycemia. The nurse should monitor the client for which of the following adverse effects of hypoglycemia? Fever Increased urination Metabolic acidosis Decreased blood pressure

Decreased blood pressure A client who has hypoglycemia is at risk for hypotension. The nurse should monitor the client for hypotension.

A nurse is collecting data on a client who has had diarrhea for several days. Which of the following findings should the nurse expect?

Dehydration A client who has diarrhea is at risk for dehydration due to fluid loss.

A nurse is caring for a client who has a terminal diagnosis and a 3-month life expectancy. The client appears cheerful and states they are looking forward to a vacation next year. The nurse should identify that the client is experiencing which of the following Kubler-Ross stages of grief? Bargaining Depression Anger Denial

Denial A client who is experiencing the Kubler-Ross stage of denial might exhibit cheerfulness because they are not ready to accept the reality of the situation.

A nurse is collecting data on an adolescent client whose parent has recently died. Which of the following findings should the nurse expect? Reports tightness in their chest Clings to their caregiver Exhibits toileting problems Depends on their friends for emotional support

Depends on their friends for emotional support An adolescent client might depend on their friends for emotional support in response to grief.

A nurse is caring for a client who is a member of a marginalized sexual group . The nurse should recognize the client is at risk for which of the following conditions? Fractures Infectious diseases Rhinitis Depression

Depression A client who is a member of a marginalized sexual group is vulnerable to prejudice, social stigma, and discrimination. These clients are at risk for depression, post-traumatic stress disorder, unemployment, poor relationships, and chronic health problems.

A nurse is assisting with teaching a class about the general adaptive syndrome. The nurse should include that which of the following manifestations occur during the exhaustion stage? Depression Blood glucose levels return to the expected reference range. Blood pressure increases. Dilation of pupils

Depression Depression can occur during the exhaustion stage of the general adaptive syndrome in response to continuous, prolonged stress.

A nurse is assisting with teaching a class about physical manifestations associated with the fight-or-flight response to stress. Which of the following manifestations should the nurse include? Bronchial airway constriction Decreased blood pressure Hypoglycemia Dilated pupils

Dilated pupils Dilated pupils are associated with the fight-or-flight response to stress to increase the visual field.

A nurse is caring for a client whose partner has died. The client states, "One moment I am feeling sad about the loss of my partner, and the next moment I am making plans for my future." The nurse should identify that the client is experiencing which of the following responses to grief? Yearning and searching Dual Process Model Recollect and re-experience Disorganization and despair

Dual Process Model A client who is experiencing the Dual Process Model of Grief will shift back and forth between loss-oriented responses, such as feeling sad, and restoration-oriented responses, such as making plans for the future.

A nurse is assisting with teaching a newly licensed nurse about collecting data on a client who received naloxone to treat opioid toxicity. The nurse should include that which of the following findings indicate the intervention is effective? Elevated respirations Kussmaul respirations Substernal retractions during respirations Cheyne-stokes respirations

Elevated respirations Opioid toxicity causes respiratory depression. An increased respiratory rate and increased oxygen saturation indicate the intervention was effective

A nurse is planning to use the nursing process to care for a client who is experiencing grief. Which of the following actions should the nurse take first? Develop client-specific goals and outcomes. Establish whether the client's grieving is healthy or complicated. Determine whether coping strategies were successful. Incorporate the treatment into the client's care.

Establish whether the client's grieving is healthy or complicated. When using the nursing process, the first action the nurse should take is to establish whether the client's grieving is healthy or complicated. The nurse should check the client for manifestations of grieving, determine what phase of grieving the client is experiencing, and establish whether the client's grieving is healthy or complicated.

A nurse is caring for a client whose partner has died. The client states, "Even though I am in a new relationship, I treasure the memories of my former partner." The nurse should identify that the client is experiencing which of the following tasks in Worden's Four Tasks of Grieving? Accepting the reality of the loss Adjusting to an environment without the deceased Experiencing the pain of grief Finding an enduring connection while embarking on a new life

Finding an enduring connection while embarking on a new life A client who is experiencing Worden's fourth task of grieving finds a connection to memories of the deceased, while moving forward in life.

A nurse is assisting with teaching a newly licensed nurse about hospice care. Which of the following information should the nurse include? Hospice care cannot be discontinued once it is initiated. Hospice care is limited to clients who are in a health care facility. The goal of hospice care is to prolong life. Hospice care is restricted to clients who are terminally ill.

Hospice care is restricted to clients who are terminally ill. Hospice care is restricted to clients who are terminally ill, such as those who have a life expectancy of less than 6 months.

A nurse is collecting data on a client who reports acute pain at a level of 7 on a scale of 0 to 10. Which of the following findings should the nurse expect? Hypoglycemia Decreased respiratory rate Bradycardia Hypertension

Hypoglycemia Physiologic response to pain can result in hyperglycemia.

A nurse is assisting with teaching a newly licensed nurse about incident reports. Which of the following information should the nurse include? Include a note in the medical record that an incident report was completed. Identify the person responsible for the error in the incident report. Include personal opinions regarding an event in an incident report. Identify other people involved with the event in the incident report.

Identify other people involved with the event in the incident report. The nurse should include the facts about what happened, who was involved, and what actions were taken in an incident report to ensure accuracy.

A nurse is assisting with teaching a class about stress. The nurse should include that which of the following is a manifestation of prolonged stress? Impaired immune function Anemia Decreased blood pressure Hypoglycemia

Impaired immune function Impaired immune function can occur in response to prolonged stress, which places the client at risk for infection.

A nurse is assisting in the plan of care for a client who has dehydration and hypotension. Which of the following actions should the nurse plan to take? Increase the client's fluid intake. Instruct the client to perform the Valsalva maneuver. Elevate the head of the client's bed. Encourage the client to use guided imagery to relax.

Increase the client's fluid intake. The nurse should increase the client's fluid intake to increase circulatory blood volume and blood pressure.

A nurse is assisting with teaching a class about physical manifestations that occur during the fight-or-flight response to stress. Which of the following manifestations should the nurse include? Increased blood glucose level Constricted pupils Bronchial airway constriction Decreased blood pressure

Increased blood glucose level Blood glucose level increases during the fight-or-flight response to stress to increase energy.

A nurse is collecting data from a client who is receiving continuous IV therapy through a peripheral IV. The catheter site is cool and taut, and there is IV fluid leaking. The nurse should identify that the client has manifestations of which of the following complications? Circulatory overload Phlebitis Infiltration Infection

Infiltration Pain, swelling, cool temperature, taut skin, and leaking of IV fluid are manifestations of IV infiltration. The nurse should stop the IV infusion, elevate the affected extremity, and report the incident to the provider.

A nurse is assisting with teaching a class about the physical manifestations of grief. Which of the following manifestations should the nurse include? Blurred vision Bradycardia Insomnia Increased ability to concentrat

Insomnia Sleep disturbances, such as insomnia, are a manifestation of grief.

A nurse is performing cultural data collection on a client using the sunrise enabler tool. The nurse should identify that which of the following information is included in the technological factors element? Religious beliefs Family medical history Internet availability Marital status

Internet availability Internet availability is included in the technological factors element of the sunrise enabler cultural data collection tool. This information assists the nurse in planning client care related to communication and education.

A nurse is assisting with teaching a class about routes of medication administration. The nurse should include that which of the following routes has the fastest rate of absorption? Enteral Topical Intramuscular Intravenous

Intravenous Evidence-based practice indicates that medications administered via the intravenous route have the fastest rate of absorption because these medications are injected directly into the circulatory system.

A nurse is collecting data from a client who is at the end of life. Which of the following findings should the nurse expect? Moist mucous membranes Hypertension Tachycardia Irregular respirations

Irregular respirations A client who is at the end of life experiences irregular breathing with periods of apnea, called Cheyne-Stoke respirations.

A nurse is assisting with teaching a newly licensed nurse about the function of the large intestine. Which of the following information should the nurse include? It secretes enzymes to digest food. It prevents the reflux of food into the esophagus. It absorbs liquid to form stool. It produces vitamin D.

It absorbs liquid to form stool. The large intestine absorbs water and electrolytes to form stool.

A nurse is assisting with teaching a class about stress. The nurse should include that which of the following is an example of chronic stress? Loss of a loved one Living in poverty Motor vehicle accident Being a victim of a crime

Living in poverty Living in poverty, racism, and living in a dysfunctional family are examples of chronic stress that can lead to anxiety, depression, and suicide.

A nurse is reviewing the documentation of a client's blood pressure by a newly licensed nurse. The documentation states, "Blood pressure 102/58 mm Hg, client sitting up in a chair." Which of the following information should the nurse clarify?

Location of blood pressure cuff The location of the blood pressure cuff requires clarification to ensure accurate documentation.

nurse is documenting postmortem care for a client. Which of the following information should the nurse include? Name of the client's mortician Location of the client's belongings Whether an autopsy will be performed on the client Length of time the family stayed with the client's body

Location of the client's belongings The nurse should document the description and the location of the client's belongings

A nurse is assisting with teaching a class about spiritual influences on grief. Which of the following information should the nurse include? Members of the Jewish faith often request the body of the deceased face south after death. Members of the Christian faith often request the body of the deceased is bathed by a family member. Members of the Christian faith often hold a wake for the deceased. Members of the Jewish faith often request the sacrament of the sick performed before death.

Members of the Christian faith often hold a wake for the deceased. Members of the Christian faith often hold a wake for the deceased in which their friends and family members share memories and comfort each other.

A nurse is assisting with teaching a class about organ donation. Which of the following information should the nurse include? A nurse can initiate a request for tissue donation from a client. Tissue donation is involuntary. Organ donation can be authorized by a client's surrogate. Each organ donation request should be reported to a facility's ethics committee.

Organ donation can be authorized by a client's surrogate. The client or the client's surrogate, if the client is unable, can request organ or tissue donation.

A nurse is assisting with teaching a newly licensed nurse about palliative care. Which of the following information should the nurse include? Palliative care is not restricted to clients who are terminally ill. Palliative care is limited to clients who are in a health care facility. Palliative care should be avoided for a client who is receiving a curative treatment. The goal of palliative care is to prolong the life of a client.

Palliative care is not restricted to clients who are terminally ill. Palliative care can be provided for clients who have a life-limiting condition, regardless of their life expectancy. Hospice care is restricted to clients who are terminally ill, with a life expectancy of less than 6 month

A nurse is assisting with teaching a class for hospice nurses about interventions to reduce the risk for compassion fatigue. Which of the following interventions should the nurse include? Volunteer at a health clinic on days off work. Work through lunch breaks. Request to work additional shifts. Perform daily exercise.

Perform daily exercise. Compassion fatigue is cumulative stress from repeatedly caring for clients who are suffering and can result in difficulty feeling sympathy toward clients. Interventions that can reduce the risk for compassion fatigue include meditation, reading, spending time with friends, and exercising.

A nurse is planning care for a client who has diverticulitis. The nurse should plan to monitor the client for which of the following complications of diverticulitis? Ulcerative colitis Dysphagia Peritonitis Crohn's disease

Peritonitis Clients who have diverticulitis are at risk for a perforation of the colon, which can cause peritonitis. The nurse should monitor the client for manifestations of peritonitis, such as fever and a rigid abdomen.

A nurse is caring for a client who has a rectal temperature of 35° C (95° F). Which of the following actions should the nurse take? Request a prescription for an antipyretic medication. Decrease the temperature in the client's room. Place a warming blanket over the client. Place a cooling fan near the client.

Place a warming blanket over the client. The nurse should place a warming blanket on a client who has hypothermia to increase the client's temperature.

A nurse is assisting with teaching a client about a new medication. Which of the following actions should the nurse take? Begin with the least important information. Turn on the television in the client's room. Provide educational material written at a 6th grade reading level. Use technical language in the educational session.

Provide educational material written at a 6th grade reading level. The nurse should provide educational material written at a 5th- to 6th-grade reading level to promote learning.

A nurse is assisting with teaching a class about reducing the risk for medication errors. Which of the following information should the nurse include? Wait to document medications given to clients until the end of a shift. Provide the nurse administering medications with an identifying vest. Prepare medications for multiple clients at the same time. Remove medications from automatic dispensing systems before they are reviewed by pharmacists.

Provide the nurse administering medications with an identifying vest. CORRECT The nurse should provide the nurse administering medications with a vest to indicate they should not be interrupted. Interruptions while dispensing medications can result in medication administration errors.

A nurse is reinforcing teaching with a newly licensed nurse about documenting vital signs. Which of the following documentation made by the newly licensed nurse indicates an understanding of the teaching? SpO2 95% BP 148/72 mm Hg Temp 36° C (96.8° F) Radial pulse regular 68/min

Radial pulse regular 68/min TThe nurse should document the location where the pulse was taken and whether the pulse is regular or irregular.

A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should identify that the client is experiencing which of the following types of urinary incontinence? Overflow incontinence Urge incontinence Reflex incontinence Stress incontinence

Reflex incontinence Reflex incontinence is involuntary leakage of urine due to nerve damage in which the client is unaware of the need to void. Nerve damage can occur due to a spinal cord injury.

A nurse is caring for a client who has an oral temperature of 39.5° C (103.1° F). Which of the following actions should the nurse take? Place a warming blanket over the client. Increase the temperature in the client's room. Restrict the client's fluid intake. Remove excess clothing from the client.

Remove excess clothing from the client. The nurse should remove blankets and excess clothing to decrease the client's temperature without causing shivering.

A nurse is assisting with teaching a newly licensed nurse about preventing puncture injuries. Which of the following instructions should the nurse include? Use two hands to recap a needle after administering a medication. Dispose of used razors in wastebaskets. Break needles on syringes before disposal. Replace sharps containers when they are full.

Replace sharps containers when they are full. The nurse should replace sharps containers when they are full to reduce the risk of a puncture injury.

A nurse opens a unit-dose of a prescribed medication prior to administering it to a client. The client refuses to take the medication. Which of the following actions should the nurse take? Fill out an incident report. Return the opened medication to the medication cart. Report the incident to the provider. Notify the facility's ethics committee.

Report the incident to the provider. The client has the right to refuse a medication. The nurse should investigate the reason for the refusal, educate the client about the potential adverse effects of the refusal, and notify the provider.

A nurse is preparing to collect data on a client to check for a pulse deficit. Which of the following actions should the nurse plan to take first? Request assistance from a second nurse. Calculate the difference between the client's peripheral pulse and the client's apical pulse. Check the client's pulse rate for 1 min. Count the client's apical pulse.

Request assistance from a second nurse. According to evidence-based practice, the nurse should first request assistance from a second nurse. The two nurses should count the client's apical pulse and the client's peripheral pulse at the same time.

A nurse is reinforcing teaching with a newly licensed nurse about documenting vital signs. Which of the following documentation made by the newly licensed nurse indicates an understanding of the teaching? Temperature 36.9° C (98.4° F) Blood pressure 108/68 mm Hg Respirations auscultated, even at 22/min, client supine Pulse 82/min, client sitting in a chair

Respirations auscultated, even at 22/min, client supine The nurse should include the rate, character, method, and client position when documenting respirations.

A nurse is assisting with teaching a newly licensed nurse about end-of- life care. The nurse should include that which of the following services provides support for a client's caregiver? Restorative care Home care Postmortem care Respite care

Respite care Respite care provides short-term support for caregivers. This can include running errands, childcare, transportation, and visitation.

A nurse palpates a client's radial pulses bilaterally and notes the client's right radial pulse is bounding, and the client's left radial pulse is as expected. The client's heart rate is 80/min. Which of the following documentations should the nurse make? Right radial pulse 4+, 80/min, palpated Left radial pulse 4+, 80/min, palpated Right radial pulse 2+, 80/min, palpated Left radial pulse 1+, 80/min, palpated

Right radial pulse 4+, 80/min, palpated The nurse should document the strength of a pulse that is bounding as 4+.

A nurse is caring for a client who is at the end of life. Which of the following interventions is most effective in reducing the client's social isolation? Instruct the client to join an online support group. Ask the client's friends to text the client. Encourage family members to call the client. Schedule home visits with the client.

Schedule home visits with the client. According to evidence-based practice, in-person, face-to-face contact with the client is the most effective intervention for reducing the client's social isolation.

A nurse is assisting with teaching a class about the effects of spirituality for clients who are near the end of life. Which of the following information should the nurse include? Spirituality can increase the quality of life. Spirituality can increase depression. Spirituality can increase the desire to hasten death. Spirituality can increase feelings of hopelessness.

Spirituality can increase the quality of life. Spirituality can increase a client's quality of life by providing the client with hope and peace.

A nurse is assisting with teaching a client a client about how to instill eye drops. The nurse asks the client to explain the procedure in their own words. Which of the following types of teaching methods is the nurse using? Question and answer Role play Lecture Teach-back

Teach-back Teach-back is an active teaching method in which the client repeats the information in their own words. During teach-back, the nurse can evaluate the client's understanding of the education and determine whether further instruction is indicated.

A nurse is assisting with teaching a class about pharmacodynamics. The nurse should include that which of the following medication levels occurs when a medication is at the lowest serum concentration? Toxic Peak Half-life Trough

Trough Trough blood level is the lowest concentration of a medication in the circulatory system. It is measured before administering the next scheduled dose of a medication.

A nurse is preparing to administer an otic medication to a client. Which of the following actions should the nurse take? Warm the medication to room temperature before administration. Ask the client to remain in a side-lying position with the affected ear down for several minutes after instillation. Press a cotton ball into the client's ear canal after instillation. Pull the client's pinna down and back prior to instillation.

Warm the medication to room temperature before administration. The nurse should roll the medication between their hands to warm it to room temperature before administration to promote comfort.