304 exam 1 practice questions

Which action will the nurse anticipate needing to take when a client develops hypotension immediately after receiving spinal anesthesia? a. Increase intravenous flow rate. b. Reschedule the surgical procedure. c. Have the client move the extremities. d. Infuse medication to increase heart rate.

a

35. Which statement made by the client indicates the nurse's discharge teaching is effective for the client diagnosed with COPD? 1. "I need to get an influenza vaccine each year, even when there is a shortage." 2. "I need to get a vaccine for pneumonia each year with my influenza shot." 3. "If I reduce my cigarettes to six a day, I won't have difficulty breathing." 4. "I need to restrict my drinking liquids to keep from having so much phlegm."

1

The client diagnosed with COPD is admitted to the medical unit. The client has thin extremities, truncal obesity, and multiple ecchymotic areas on the arms. Based on the assessment data, which question should the nurse ask the client? 1. "Do you take prednisone?" 2. "Can you tell me who hurts you?" 3. "May I check your coccyx for pressure areas?" 4. "Do you sleep with the head of the bed elevated?"

1

The nurse is applying oxygen via nasal cannula to a client diagnosed with COPD. The client reports extreme shortness of breath. At which rate should the nurse set the flowmeter? 1. 2 LPM. 2. 4 LPM. 3. 6 LPM. 4. 10 LPM.

1

Which intervention should the nurse implement for a male client with a left-sided chest tube in place for 6 hours refusing to take deep breaths because of pain? 1. Medicate the client and have the client take deep breaths. 2. Encourage the client to take shallow breaths to help with the pain. 3. Explain that deep breaths do not have to be taken at this time. 4. Tell the client if he doesn't take deep breaths, he could die.

1

Which client problems are appropriate for the nurse to include in the plan of care for the client diagnosed with COPD? Select all that apply. 1. Impaired gas exchange. 2. Inability to tolerate temperature extremes. 3. Activity intolerance. 4. Inability to cope with changes in roles. 5. Alteration in nutrition.

1 2 3 4 5

The nurse is assessing a 79-year-old client diagnosed with pneumonia. Which clinical manifestations should the nurse expect to assess in the client? Select all that apply. 1. Confusion and lethargy. 2. High fever and chills. 3. Frothy sputum and edema. 4. Bradypnea and jugular vein distention. 5. Low body temperature and cough.

1 2 5

The nurse is caring for the client diagnosed with pneumonia. Which information should the nurse include in the teaching plan? Select all that apply. 1. Place the client on oxygen delivered by nasal cannula. 2. Plan for periods of rest during activities of daily living. 3. Place the client on a fluid restriction of 1,000 mL/day. 4. Restrict the client's smoking to two to three cigarettes per day. 5. Monitor the client's pulse oximetry readings every 4 hours.

1 2 5

Which action would the nurse plan to take to prevent respiratory complications after abdominal surgery? a. Assist client to use the incentive spirometer. b. Administer prescribed intravenous antibiotic. c. Take client vital signs every 4 hours. d. Auscultate breath sounds every 4 hours.

a

The UAP assists the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the RN? 1. The UAP keeps the chest tube below the chest level. 2. The UAP has the chest tube attached to suction. 3. The UAP allowed the client out of bed. 4. The UAP uses a bedside commode for the client.

2

The charge nurse receives morning laboratory and respiratory data on the clients. Which data requires immediate intervention? 1. ABG results of pH 7.35, Pco 2 56, Hco 3 29, Po 2 78 for a client diagnosed with COPD. 2. Pulse oximetry reading of 89% on a 2-day postsurgical total knee replacement client. 3. Hgb of 9 g/dL and Hct of 28% on a client receiving the second unit of blood. 4. B-type natriuretic peptide (BNP) of 100 on a client diagnosed with stage 4 congestive heart failure.

2

The client is admitted to the emergency department with chest trauma. Which clinical manifestations indicate to the nurse the diagnosis of a pneumothorax? 1. Bronchovesicular lung sounds and bradypnea. 2. Unequal lung expansion and dyspnea. 3. Frothy, bloody sputum, and consolidation. 4. Barrel chest and polycythemia.

2

The nurse is assessing the client diagnosed with COPD. Which data require immediate intervention by the nurse? 1. Large amounts of thick white sputum. 2. Oxygen flowmeter set on 8 liters. 3. Use of accessory muscles during inspiration. 4. Presence of a barrel chest and dyspnea.

2

The nurse is caring for a client diagnosed with a pneumothorax and chest tubes inserted 4 hours ago. There is no fluctuating (tidaling) in the water-seal compartment of the closed chest drainage system. Which action should the nurse implement first? 1. Milk the chest tube. 2. Check the tubing for kinks. 3. Instruct the client to cough. 4. Assess the insertion site.

2

The nurse is preparing to administer influenza vaccines to a group of clients in a longterm care facility. Which client should the nurse question receiving the vaccine? 1. The client diagnosed with congestive heart failure. 2. The client diagnosed with a documented allergy to eggs. 3. The client previously diagnosed with an anaphylactic reaction to penicillin. 4. The client with elevated blood pressure and pulse.

2

The nurse observes the UAP removing the nasal cannula from the client diagnosed with COPD while ambulating the client to the bathroom. Which action should the RN implement? 1. Praise the UAP because this prevents the client from tripping on the oxygen tubing. 2. Place the oxygen back on the client while sitting in the bathroom and say nothing. 3. Explain to the UAP in front of the client oxygen must be left in place at all times. 4. Discuss the UAP's action with the charge nurse so appropriate action can be taken.

2

Which assessment data indicate to the nurse the chest tubes inserted 3 days ago have been effective in treating the client diagnosed with a hemothorax? 1. Gentle bubbling in the suction compartment. 2. No fluctuation (tidaling) in the water-seal compartment. 3. The drainage compartment has 250 mL of blood. 4. The client is able to deep breathe without any pain.

2

Which statement indicates the client with a total laryngectomy requires more teaching concerning the care of the tracheostomy? 1. "I must avoid hair spray and powders." 2. "I should take a shower instead of a tub bath." 3. "I will need to cleanse around the stoma daily." 4. "I can use an electric larynx to speak."

2

The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? Select all that apply. 1. Place the client in the low Fowler's position. 2. Assess the chest tube drainage system frequently. 3. Maintain strict bedrest for the client. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema.

2 4 5

The client diagnosed with community-acquired pneumonia is admitted to the medical unit. Which HCP order should the nurse implement first? 1. Start IV with 1,000 mL 0.9% saline. 2. Ceftriaxone 1 gm IVPB every 12 hours. 3. Obtain sputum and blood cultures. 4. CBC and basic metabolic panel.

3

The day shift charge nurse on a medical unit is making rounds after the report. Which client should be seen first? 1. The 65-year-old client diagnosed with tuberculosis has a sputum specimen to be sent to the laboratory. 2. The 76-year-old client diagnosed with aspiration pneumonia has a clogged feeding tube. 3. The 45-year-old client diagnosed with pneumonia has a pulse oximetry reading of 92%. 4. The 39-year-old client diagnosed with bronchitis has an arterial oxygenation level of 89%.

3

Which action should the nurse implement for the client diagnosed with a hemothorax complicated by a right-sided chest tube with excessive bubbling in the water-seal compartment? 1. Check the amount of wall suction being applied. 2. Assess the tubing for any blood clots. 3. Milk the tubing proximal to distal. 4. Encourage the client to cough forcefully.

3

The nurse utilizing evidence-based practice (EBP) considers which factors when planning care? (Select all that apply.) a. Cost-saving measures b. Nurse's expertise c. Client preferences d. Research findings e. Values of the client f. Plan-do-study-act model

b c d e

Which clinical manifestations should the nurse expect to assess in the client recently diagnosed with COPD? Select all that apply. 1. Clubbing of the client's fingers. 2. Infrequent respiratory infections. 3. Chronic sputum production. 4. Nonproductive hacking cough. 5. Shortness of breath.

3 5

A client is admitted to the emergency department with dyspnea, a productive cough, and fever. The health care provider suspects pneumonia and writes prescriptions. In which order would the nursing actions be performed? 1. Administer the prescribed intravenous piggyback antibiotic. 2. Encourage cough and deep-breathing exercises on an ongoing basis 3. Elevate the head of the bed. 4. Review the results of the sensitivity test. 5. Obtain a sputum culture.

3 5 1 4 2

The charge nurse is making client assignments on a medical floor. Which client should the RN charge nurse assign to the LPN? 1. The client diagnosed with pneumonia, pulse oximeter reading of 91%. 2. The client diagnosed with a hemothorax, Hb of 9 g/dL, and Hct of 20%. 3. The client with chest tubes, jugular vein distention, and BP of 96/60. 4. The client 2 hours postbronchoscopy procedure.

4

The nurse is assessing the client diagnosed with COPD. Which health-promotion information is most important for the nurse to obtain? 1. The number of years the client has smoked. 2. Risk factors for complications. 3. Ability to administer inhaled medication. 4. Willingness to modify lifestyle.

4

The nurse is planning the care of a client diagnosed with pneumonia and writes a problem of "impaired gas exchange." Which is an expected outcome for this problem? 1. Performs chest physiotherapy three times a day. 2. Able to complete activities of daily living. 3. Ambulates in the hall several times during each shift. 4. Alert and oriented to person, place, time, and events.

4

Which diagnostic test should the nurse anticipate the HCP ordering to rule out the diagnosis of asthma in clients diagnosed with COPD? 1. A bronchoscopy. 2. An immunoglobulin E. 3. An arterial blood gas. 4. A bronchodilator reversibility test.

4

Which statement indicates to the nurse the client diagnosed with sleep apnea needs further teaching? 1. "If I lose weight I may not need treatment for sleep apnea." 2. "The CPAP machine holds my airway open with pressure." 3. "The CPAP will help me stay awake during the day while I am at work." 4. "It is all right to have a couple of beers because I have this CPAP machine."

4

Which statement made by the client diagnosed with chronic bronchitis indicates to the nurse more teaching is required? 1. "I should contact my health-care provider if my sputum changes color or amount." 2. "I will take my bronchodilator regularly to prevent having bronchospasms." 3. "This metered-dose inhaler gives a precise amount of medication with each dose." 4. "I need to return to the HCP to have my blood drawn with my annual physical."

4

Which of the nurse's assigned clients may have atelectasis? Client A: Decreased chest wall movement, Hyper-resonant percussion, Wheezes Client B: Increased vibrations over chest wall above effusion, Dull percussion, Diminished or absent over effusion Client C: Decreased fremitus, Dull percussion over affected area, Crackles Client D: Increased fremitus over affected area, Dull percussion over affected area, Bronchial sounds

Client C

Which action would the nurse take first for a client on intravenous medication who experiences an anaphylactic reaction? a. Stop the intravenous medication. b. Administer epinephrine (adrenaline). c. Start a normal saline infusion immediately. d. Report to the primary health care provider immediately.

a

A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Midsternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave

a

A nurse auscultates a harsh hollow sound over a client's trachea and larynx. What action would the nurse take first? a. Document the findings. b. Administer oxygen therapy. c. Position the client in high-Fowler position. d. Administer prescribed albuterol

a

2. A nurse is orienting a new client and family to the medical-surgical unit. What information does the nurse provide to best help the client promote his or her own safety? a. Encourage the client and family to be active partners. b. Have the client monitor hand hygiene in caregivers. c. Offer the family the opportunity to stay with the client. d. Tell the client to always wear his or her armband.

a

3. A nurse is caring for a postoperative client on the surgical unit. The client's blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action would the nurse take first? a. Call the Rapid Response Team. b. Document and continue to monitor. c. Notify the primary health care provider. d. Repeat the blood pressure in 15 minutes.

a

A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse would monitor which laboratory results? a. Sodium and chloride levels b. Bicarbonate and sulfate levels c. Magnesium and protein levels d. Calcium and phosphate levels

a

A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors? a. Bring a list of all medications and what they are for. b. Keep the provider's phone number by the telephone. c. Make sure that all providers wash hands before entering the room. d. Write down the name of each caregiver who comes in the room

a

A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril and warfarin. The client reports new-onset cough. What action by the nurse is most appropriate? a. Assess the client's lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of lisinopril

a

A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best? a. Assess the client for anxiety. b. Break the information into smaller bits. c. Give the client written information. d. Review the information again

a

A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention will the nurse suggest to the management team to make the biggest impact on decreasing complications? a. Initiate a dedicated team to insert access devices. b. Require additional education for all nurses. c. Limit the use of peripheral venous access devices. d. Perform quality control testing on skin preparation products

a

A new nurse is caring for a client receiving drug therapy via a smart pump. What statement by the new nurse demonstrates the need for more instruction on this technology? a. "I don't need to manually calculate IV infusion rates with smart pumps." b. "Responding to IV pump alarms is a high priority for client safety." c. "The hospital can preprogram the pumps for high-alert drug limits." d. "These pumps have a system to prevent fluids from free-flowing into the client."

a

A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best? a. Consult the primary health care provider about a dietitian referral. b. Document the findings thoroughly in the client's chart. c. Encourage the client to eat more after recovering from surgery. d. Refer the client to Meals on Wheels after discharge

a

A nurse assesses a client who had a myocardial infarction and has a blood pressure of 88/58 mm Hg. Which additional assessment finding would the nurse expect? a. Heart rate of 120 beats/min b. Cool, clammy skin c. Oxygen saturation of 90% d. Respiratory rate of 8 breaths/min

a

A nurse assesses a client who has aortic regurgitation. In which location in the illustration shown below would the nurse auscultate to best hear a cardiac murmur related to aortic regurgitation? a. Location A b. Location B c. Location C d. Location D

a

A nurse assesses a client who is recovering from a myocardial infarction. The client's blood pressure is 140/88 mm Hg. What action would the nurse take first? a. Compare the results with previous blood pressure readings. b. Increase the intravenous fluid rate because these readings are low. c. Immediately notify the primary health care provider of the elevated blood pressure. d. Document the finding in the client's chart as the only action

a

A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first? a. Assess the client's respiratory rate, rhythm, and depth. b. Measure the client's pulse and blood pressure. c. Document findings and monitor the client. d. Call the health care primary health care provider.

a

A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia? a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions. b. A 50 year old with an infection who is prescribed a sulfonamide antibiotic. c. A 67 year old who is experiencing pain and is prescribed ibuprofen. d. A 73 year old with tachycardia who is receiving digoxin

a

A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L (2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first? a. Depth of respirations b. Bowel sounds c. Grip strength d. Electrocardiography

a

A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience would the nurse provide this service? a. African-American churches b. Asian-American groceries c. High school sports camps d. Women's health clinics

a

A nurse is teaching a female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best? a. "No, women should only have one beer a day as a general rule." b. "No, you should not drink any alcohol with hypertension." c. "Yes, since you are larger, you can have more alcohol." d. "Yes, two beers per day is an acceptable amount of alcohol."

a

A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention would the nurse include in this client's plan of care? a. Assistance with activities of daily living b. Physical therapy activities every day c. Oxygen therapy at 2 L per nasal cannula d. Complete bedrest with frequent repositioning

a

A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement will the nurse include in this client's teaching? a. "Avoid carrying your grandchild with the arm that has the central catheter." b. "Be sure to place the arm with the central catheter in a sling during the day." c. "Flush the peripherally inserted central catheter line with normal saline daily." d. "You can use the arm with the central catheter for most activities of daily living."

a

A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best demonstrates this concept? a. Assesses for cultural influences affecting health care. b. Ensures that all the client's basic needs are met. c. Tells the client and family about all upcoming tests. d. Thoroughly orients the client and family to the room.

a

A postoperative client has just been admitted to the postanesthesia care unit (PACU). What assessment by the PACU nurse takes priority? a. Airway b. Bleeding c. Breathing d. Cardiac rhythm

a

An emergency department nurse obtains the health history of a client. Which statement by the client would alert the nurse to the occurrence of heart failure? a. "I get short of breath when I climb stairs." b. "I see halos floating around my head." c. "I have trouble remembering things." d. "I have lost weight over the past month.

a

An older client with shortness of breath is admitted to the hospital. The medical history reveals and a diagnosis of pneumonia 3 days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention? a. Oxygen saturation: 89% b. Body temperature: 101°F c. Blood pressure: 130/80 mm Hg d. Respiratory rate: 26 beats/minute

a

The nurse is caring for a client who experienced a crushing chest injury. A chest tube is inserted. Which observation indicates a desired response to this treatment? a. Increased breath sounds b. Increased respiratory rate c. Crepitus detected on palpation of the chest d. Constant bubbling in the drainage collection chamber

a

The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best? a. Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met. b. Encourage staff on both units to provide peer pressure to adhere to hand hygiene policy. c. Hold educational meetings with the nursing and surgical staff on infection prevention. d. Monitor staff on both units for consistent adherence to established hand hygiene practices

a

The postanesthesia care unit (PACU) nurse is caring for an older client following a lengthy surgery. The client's pulse is 48 beats/min which is 20 beats/min lower than the preoperative baseline. What assessment does the nurse make next? a. Temperature b. Level of consciousness c. Blood pressure d. Rate of IV infusion

a

When a client with newly diagnosed chronic bronchitis tells the home health nurse about continuing to smoke 1 or 2 cigarettes a day and not doing the prescribed pulmonary physiotherapy exercises, which response by the nurse is best? a. "Tell me about your typical day before you were diagnosed with chronic lung disease! b. "Smoking and not doing the exercises will make your lung disease continue to get worse c. "I can't make you stop doing what you are doing, and it's your choice to be sick or well." d. "Your shortness of breath is probably because of your smoking and not doing the exercises

a

When the nurse is assessing a client after tracheostomy placement, which finding requires immediate action by the nurse? a. Crackling of the skin on palpation b. Small amount of blood at the surgical site c. Client reports the area around incision is tender d. The client is unable to speak with a cuffed tube

a

Which action by the nurse working with a client best demonstrates respect for autonomy? a. Asks if the client has questions before signing a consent. b. Gives the client accurate information when questioned. c. Keeps the promises made to the client and family. d. Treats the client fairly compared to other clients.

a

Which action would the nurse take first when a client who is receiving a potassium infusion via a peripheral intravenous (IV) site reports a burning sensation above the IV site? a. Check the IV access for a blood return. b. Apply warm compresses to the affected extremity. c. Slow the IV infusion until the burning sensation is gone. d. Request an oral supplement from the primary health care provider.

a

Which action would the nurse take first when a client with acute bronchitis and emphysema reports feeling anxious and short of breath? a. Obtain the oxygen saturation. b. Provide oxygen at 2 L per minute. c. Offer the prescribed rescue inhaler. d. Suggest use of pursed-lip breathing.

a

Which action would the nurse take when a client reports pain and burning at a peripheral intravenous (IV) site after the nurse has flushed the saline lock with normal saline? a. Remove the IV catheter and restart the saline lock in another site. b. Document the findings per protocol and reassess the site in 8 hours. c. Flush the IV catheter and saline lock again vigorously with normal saline. d. Change the dressing and apply a new clean dressing per IV care protocol.

a

Which clinical manifestation would the nurse associate with successful fluid replacement therapy? a. A trended urinary output of at least 30 mL/h b. Central venous pressure reading of 1.5 mm Hg c. Baseline pulse rate of 120 beats per minute decreasing to 110 beats per minute within a 15- minute period d. Baseline blood pressure of 50/30 mm Hg increasing to 70/40 mm Hg within a 30-minute period

a

Which collaborative action would be best to rehydrate an alert client seen in the urgent care center with dehydration, a heart rate of 100 beats/minute, and blood pressure of 104/62 mm Hg? a. Offer frequent oral fluids for several hours. b. Administer 1 liter of normal saline over 2 hours. c. Give fluid and electrolytes per nasogastric tube. d. Infuse 500 mL of lactated Ringer's solution over 30 minutes.

a

Which finding by the nurse when assessing a client who is receiving intravenous (IV) fluids indicates need for a change in the fluid infusion rate? a. Crackles in lungs b. Supple skin turgor c. Urine output of 480 mL over 8 hours d. Heart rate decrease from 126 beats/minute to 96 beats/minute

a

Which prescribed action would the nurse question when caring for a client who has heart failure, with blood pressure 102/70 mm Hg, pulse 106 beats/minute, and bilateral lung crackles? a. Infuse normal saline at 100 mL/h. b. Give furosemide 40 mg intravenous now. c. Administer potassium chloride 10 mEg orally now. d. Titrate oxygen by mask to keep oxygen saturation 93% or higher.

a

While assessing a client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 1.5 inch (4-cm) venous cord. How will the nurse document this finding? a. "Grade 3 phlebitis at IV site" b. "Infection at IV site" c. "Thrombosed area at IV site" d. "Infiltration at IV site"

a

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization. What actions would the nurse take prior to the catheterization? (Select all that apply.) a. Assess for allergies to iodine. b. Administer intravenous fluids. c. Assess blood urea nitrogen (BUN) and creatinine results. d. Insert a Foley catheter. e. Administer a prophylactic antibiotic. f. Insert a central venous catheter.

a b c

Which information would the nurse educator include in a presentation on how to care for clients with a chest tube drainage system? Select all that apply. One, some, or all responses may be correct. a. Ensure the chest tube dressing is tight and intact. b. Palpate the skin to detect subcutaneous emphysema. c. Place the chest tube drainage system below the chest. d. Quickly attempt to reinsert the chest tube if it falls out. e. Strip the chest tube with long strokes to promote drainage.

a b c

Which pathophysiological changes in the lungs occur with emphysema? Select all that apply. One, some, or all responses may be correct. a. Collapse of alveolar walls b. Trapping of air in distal lung structures c. Increases in pulmonary artery pressures d. Increase in surface area for gas exchange e. Movement of fluid from capillaries into alveoli

a b c

A nurse is assessing a client's history of particular matter exposure. What questions are consistent with the I PREPARE tool? (Select all that apply.) a. Investigate all history of known exposures. b. Determine if breathing problems are worse at work. c. Ask the client what type of heating is in the home. d. Gather details about the geographic location of the client's home. e. Have client list all previous jobs and work experiences. f. Assess what hobbies the client and family enjoy.

a b c d e f

A nurse is interested in making interprofessional work a high priority. Which actions by the nurse best demonstrate this skill? (Select all that apply.) a. Consults with other disciplines on client care. b. Coordinates discharge planning for home safety. c. Participates in comprehensive client rounding. d. Routinely asks other disciplines about client progress. e. Shows the nursing care plans to other disciplines. f. Delegate tasks to unlicensed personnel appropriately.

a b c d f

A nurse learns older adults are at higher risk for complications after surgery. What reasons for this does the nurse understand? (Select all that apply.) a. Decreased cardiac output b. Decreased oxygenation c. Frequent nocturia d. Mobility alterations e. Inability to adapt to changes f. Slower reaction times

a b c d f

A nurse manager wants to improve hand-off communication among the staff. What actions by the manager would best help achieve this goal? (Select all that apply.) a. Attend hand-off rounds to coach and mentor. b. Create a template of suggested topics to include in report. c. Encourage staff to ask questions during hand-off. d. Give raises based on compliance with reporting. e. Provide education on the SBAR method of communication

a b c e

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) a. Hypokalemia—muscle weakness with respiratory depression b. Hypermagnesemia—bradycardia and hypotension c. Hyponatremia—decreased level of consciousness d. Hypercalcemia—positive Trousseau and Chvostek signs e. Hypomagnesemia—hyperactive deep tendon reflexes f. Hypernatremia—weak peripheral pulses

a b c e f

A nurse assists with the insertion of a central vascular access device. Which actions will the nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that apply.) a. Include a review for the need of the device each day in the client's plan of care. b. Remind the primary health care provider to perform hand hygiene prior to insertion if he or she forgets. c. Cleanse the preferred site with alcohol and let it dry completely before insertion. d. Ask everyone in the room to wear a surgical mask during the procedure. e. Plan to complete a sterile dressing change on the device every day. f. Minimal client draping and barrier precautions as blood loss are minimal.

a b d

A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) universal bar-coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.) a. Unique facility identifier b. Lot number related to the donor c. Name of the client receiving blood d. ABO group and Rh type of the donor e. Blood type of the client receiving blood f. Signature line for 2-person verification

a b d

Which observation by the nurse indicates a client with pneumonia is able to use an incentive spirometer correctly? Select all that apply. One, some, or all responses may be correct. a. Records the volume of the air inspired b. Performs 10 breaths per session every hour c. Inhales air fully before inserting the mouthpiece d. Takes a long, slow, deep breath keeping the mouthpiece in place e. Exhales deep breaths with the mouthpiece in their mouth

a b d

A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of competency. Which areas would the manager assess to determine if the nursing staff demonstrate competency according to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality? (Select all that apply.) a. Collaborating with an interprofessional team b. Implementing evidence-based care c. Providing family-focused care d. Routinely using informatics in practice e. Using quality improvement in client care f. Formalizing systems thinking when implementing care

a b d e

While obtaining a client's health history, the client states, "I am allergic to avocados, molds, and grass." Which responses by the nurse are best? (Select all that apply.) a. "What happens when you are exposed to those things? b. "How do you treat these allergies?" c. "When was the last time you ate foods containing avocados?" d. "I will document this in your record so all so everyone knows." e. "Have you ever been in the hospital after an allergic response?" f. "How do manage to avoid grass and mold?"

a b d e

A nurse prepares to insert a short peripheral venous catheter. What actions will the nurse take to use best practices? (Select all that apply.) a. Choose a distal site on the client's nondominant arm. b. Verify that the prescription is appropriate for peripheral infusion. c. Place the venous catheter near an area of joint flexion. d. Wear a surgical mask during the catheter insertion procedure. e. Perform hand hygiene before inserting the catheter. f. Limit unsuccessful attempts by up to three clinicians to one attempt each.

a b e

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? (Select all that apply.) a. Increased pulse rate b. Distended neck veins c. Decreased blood pressure d. Warm and pink skin e. Skeletal muscle weakness f. Visual disturbances

a b e f

A registered nurse (RN) occasionally delegates client care to licensed practical nurses (LPNs) or technicians. What information does the RN consider when delegating components of IV therapy? (Select all that apply.) a. Each state's Nurse Practice Act will regulate who can perform care related to IVs. b. The nurse would check the facility's Policies and Procedures manual. c. The LPN's level of experience primarily guides the decision. d. Technicians cannot participate in any part of caring for IV infusions. e. The RN remains accountable for all aspects of IV care and delegated actions. f. The Infusion Nurses Society has guidelines and standards of IV therapy competency

a b e f

A nurse assesses a client who has a peripherally inserted central catheter (PICC). For which common complications will the nurse assess? (Select all that apply.) a. Phlebitis b. Pneumothorax c. Thrombophlebitis d. Excessive bleeding e. Extravasation f. Pneumothorax g. Infiltration

a c

Which action would help prevent venous thrombosis in a client during the perioperative period? Select all that apply. One, some, or all responses may be correct. a. Administer subcutaneous heparin injections. b. Give intravenous thrombolytic medications. c. Assist the client to don antiembolism stockings. d. Apply pneumatic compression devices to the legs. e. Remind the client about the importance of bed rest.

a c d

Which action would the nurse take to prevent venous thrombus formation in a postoperative client? Select all that apply. One, some, or all responses may be correct. a. Encourage an increase in oral fluid intake. b. Massage the client's extremities with lotion. c. Instruct the client to avoid crossing the legs. d. Remind the client to dorsiflex the feet frequently. e. Help the client use prescribed pneumatic sequential stockings. f. Plan discharge teaching about the need to avoid taking aspirin.

a c d e

A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan? (Select all that apply.) a. Calculate pulse pressure with each blood pressure reading. b. Assess skin turgor using the back of the client's hand. c. Assess for pitting edema in dependent body areas. d. Monitor trends in the client's daily weights. e. Assist the client to change positions frequently. f. Teach client and family how to read food labels for sodium.

a c d e f

A nurse is caring for several clients in the morning prior to surgery. Which medications taken by the clients require the nurse to consult with the primary health care provider about their administration? (Select all that apply.) a. Insulin b. Omega-3 fatty acids c. Phenytoin d. Metoprolol e. Warfarin f. Prednisone

a c d e f

A nurse cares for a client who is recovering from a right-sided heart catheterization. For which complications of this procedure would the nurse assess? (Select all that apply.) a. Thrombophlebitis b. Stroke c. Pulmonary embolism d. Myocardial infarction e. Cardiac tamponade f. Dysrhythmias

a c e

A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations would the nurse assess? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output f. Increase in urine output

a c e

A nurse reviews a client's laboratory results. Which findings would alert the nurse to the possibility of atherosclerosis? (Select all that apply.) a. Total cholesterol: 280 mg/dL (7.3 mmol/L) b. High-density lipoprotein cholesterol: 50 mg/dL (1.3 mmol/L) c. Triglycerides: 200 mg/dL (2.3 mmol/L) d. Serum albumin: 4 g/dL (5.8 mcmol/L) e. Low-density lipoprotein cholesterol: 160 mg/dL (4.1 mmol/L)

a c e

A nurse assesses a client who is prescribed varenicline for smoking cessation. Which signs or symptoms would the nurse identify as adverse effects of this medication? (Select all that apply.) a. Visual hallucinations b. Tachycardia c. Decreased cravings d. Manic behavior e. Increased thirst f. Orangish urine

a d

Laboratory results for a client with small cell lung cancer reflect urine with a high specific gravity and a serum sodium level of 127 mEg/L. The client has gained 7 pounds in 3 days, has decreased urine output, and no edema is noted. Which nursing interventions are appropriate for this client? Select all that apply. One, some, or all responses may be correct. a. Initiate furosemide (Lasix). b. Introduce a potassium-restricted diet. c. Start an IV of hypertonic saline solution. d. Institute a fluid restriction of 800 to 1000 mL/day. e. Set a goal of increasing sodium by 15 to 20 mEg/L in the next 24 hours.

a d

A client has received several doses of midazolam. The nurse assesses the client to be difficult to arouse with respirations of 6 breaths/min. What actions by the nurse are most important? (Select all that apply.) a. Administer oxygen per protocol. b. Obtain one dose of flumazenil. c. Obtain naloxone, 0.04 mg for IV push. d. Ensure suction is working e. Transfer the client to intensive care. f. Monitor client every 10 to 15 minutes for the next 2 hours

a d e

A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements would the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.) a. "I held the client's morning bronchodilator medication." b. "The client is ready to go down to radiology for this examination." c. "Physical therapy states the client can run on a treadmill." d. "I advised the client not to smoke for 6 hours prior to the test." e. "The client is alert and can follow your commands."

a d e

A nurse teaches a client who is interested in smoking cessation. Which statements would the nurse include in this client's teaching? (Select all that apply.) a. "Find an activity that you enjoy and will keep your hands busy." b. "Keep snacks like potato chips on hand to nibble on." c. "Identify a consequence for yourself in case you backslide." d. "Drink at least eight glasses of water each day." e. "Make a list of reasons you want to stop smoking." f. "Set a quit date and stick to it."

a d e f

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance does the nurse assess? (Select all that apply.) a. Reports of palpitations b. Slow, shallow respirations c. Orthostatic hypotension d. Paralytic ileus e. Skeletal muscle weakness f. Tall, peaked T waves on ECG

a e f

7. A nurse asks a more seasoned colleague to explain best practices when communicating with a person from the lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) community. What answer by the faculty is most accurate? a. Avoid embarrassing the client by asking questions. b. Don't make assumptions about his or her health needs. c. Most LGBTQ people do not want to share information. d. No differences exist in communicating with this population.

b

8. A nurse is calling the on-call health care provider about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed opioid pain medication. Which statement comprises the background portion of the SBAR format for communication? a. "I would like you to order a different pain medication." b. "This client has allergies to morphine and codeine." c. "Dr. Smith doesn't like nonsteroidal anti-inflammatory meds." d. "This client had a vaginal hysterectomy 2 days ago."

b

A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best? a. Call the primary health care provider to request more analgesia. b. Demonstrate how to splint the incision. c. Have the client take shallower breaths. d. Tell the client that a little pain is expected

b

A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? a. "Do you have trouble affording your medications?" b. "Most people with hypertension do not have symptoms." c. "You are lucky; most people get severe morning headaches." d. "You need to take your medicine or you will get kidney failure."

b

A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a. Assess the client's support system. b. Assist in finding one change the client can control. c. Determine what stressors the client faces in daily life. d. Inquire about delegating some of the client's obligations.

b

A client is hospitalized for an exacerbation of emphysema. The client is experiencing a fever, chills, and difficulty breathing on exertion. Which is an important nursing action? a. Checking for capillary refill b. Encouraging increased fluid intake c. Suctioning secretions from the airway d. Administering a high concentration of oxygen

b

A client is scheduled for gastrointestinal surgery. Which is the most important nursing action that would be implemented the evening before surgery? a. Reviewing the client's pain history b. Ensuring the client's bowel preparation is initiated c. Discussing the importance of postoperative activity restrictions d. Reviewing postoperative comfort measure strategies

b

A client with chronic obstructive pulmonary disease is admitted to the hospital with a tentative diagnosis of pleuritis. It is important for the nurse to perform which intervention? a. Administer opioids frequently. b. Assess for signs of pneumonia. c. Give medication to suppress coughing. d. Limit fluid intake to prevent pulmonary edema.

b

A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the client's chart prior to administering the medication and notes it to have been inserted 4 months ago. The site has no redness, warmth, or swelling and flushes easily. What action does the nurse take? a. Notify the primary health care provider. b. Administer the prescribed medication. c. Discontinue the PICC. d. Switch the medication to the oral route

b

A new nurse is working with a preceptor on a medical-surgical unit. The preceptor advises the new nurse that which is the priority when working as a professional nurse? a. Attending to holistic client needs b. Ensuring client safety c. Not making medication errors d. Providing client-focused care

b

A newly graduated nurse in the hospital states that because of being so new, participation in quality improvement (QI) projects is not wise. What response by the precepting nurse is best? a. "All staff nurses are required to participate in quality improvement here." b. "Even being new, you can implement activities designed to improve care." c. "It's easy to identify what indicators would be used to measure quality." d. "You should ask to be assigned to the research and quality committee."

b

A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification would the nurse suggest to avoid further slowing of the heart rate? a. "Make certain that your bath water is warm." b. "Avoid straining while having a bowel movement." c. "Limit your intake of caffeinated drinks to one a day." d. "Avoid strenuous exercise such as running."

b

A nurse cares for a client who has an 80% blockage of the right coronary artery (RCA) and is scheduled for bypass surgery. Which intervention would the nurse be prepared to implement while this client waits for surgery? a. Administration of IV furosemide b. Initiation of an external pacemaker c. Assistance with endotracheal intubation d. Placement of central venous access

b

A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The client's health history includes a previous myocardial infarction and pacemaker implantation. What action would the nurse take? a. Schedule an electrocardiogram just before the MRI. b. Notify the primary health care provider before scheduling the MRI. c. Request lab for cardiac enzymes from the primary health care provider. d. Instruct the client to increase fluid intake the day before the MRI.

b

A nurse is assessing a client who is recovering from a lung biopsy. The client's breath sounds are absent. While another nurse calls the Rapid Response Team, what action by the nurse takes is most important? a. Take a full set of vital signs. b. Obtain pulse oximetry reading. c. Ask the patient about hemoptysis. d. Inspect the biopsy site

b

A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss? a. Client taking furosemide. b. Anxious client who has tachypnea. c. Client who is on fluid restrictions. d. Client who is constipated with abdominal pain

b

A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which primary health care provider order does the nurse implement first? a. Encourage oral fluid intake. b. Connect the client to a cardiac monitor. c. Assess urinary output. d. Administer oral calcitonin

b

A nurse is caring for a client who has just had a central venous access line inserted. What action will the nurse take next? a. Begin the prescribed infusion via the new access. b. Ensure that an x-ray is completed to confirm placement. c. Check medication calculations with a second RN. d. Make sure that the solution is appropriate for a central line.

b

A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse? a. Redness at the catheter insertion site b. Report of headache and stiff neck c. Temperature of 100.1° F (37.8° C) d. Pain rating of 8 on a scale of 0-10

b

A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. What action would the nurse take next? a. Administer an albuterol treatment. b. Notify the Rapid Response Team. c. Assess the client's peripheral pulses. d. Obtain blood and sputum cultures

b

A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, what action will the nurse take to relieve pain? a. Administer topical lidocaine to the site. b. Place warm compresses on the site. c. Administer prescribed oral pain medication. d. Massage the site with scented oils.

b

A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best? a. Measure intake and output every 4 hours. b. Assess client further for fall risk. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowler position.

b

A nurse is giving a client instructions for showering the night before surgery. What instruction is most appropriate? a. "After you wash the surgical site, shave that area with your own razor." b. "Use the prescribed solution and wash the area where you will have surgery very thoroughly." c. "Use a washcloth to wash the surgical site; do not take a full shower or bath." d. "Use warm water and scrub the surgical area vigorously.

b

A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question would the nurse ask the client in response to this finding? a. "Are you taking any medications or herbal supplements?" b. "Do you have any chronic breathing problems?" c. "How often do you perform aerobic exercise?" d. "What is your occupation and what are your hobbies?"

b

A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client would alert the nurse to the presence of edema? a. "I wake up to go to the bathroom at night." b. "My shoes fit tighter by the end of the day." c. "I seem to be feeling more anxious lately." d. "I drink at least eight glasses of water a day."

b

A nurse on the postsurgical inpatient unit is observing a client perform leg exercises. What action by the client indicates a need for further instruction? a. Client states "This will help prevent blood clots in my legs." b. Bends both knees, pushes against the bed until calf and thigh muscles contract. c. Dorsiflexes and plantar flexes each foot several times an hour. d. Makes several clockwise then counterclockwise ankle circles with each foot

b

A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition would the nurse include in this client's teaching? a. "The best way to lose weight is a high-protein, low-carbohydrate diet." b. "You should balance weight loss with consuming necessary nutrients." c. "A nutritionist will provide you with information about your new diet." d. "If you exercise more frequently, you won't need to change your diet."

b

A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met? a. Drainage from the surgical site is 30 mL less than yesterday. b. There is no redness, warmth, or drainage at the insertion site. c. The client reports adequate pain control with medications. d. Urine is clear yellow and urine output is greater than 40 mL/hr

b

A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important? a. Allow the client to rest. b. Auscultate lung sounds. c. Document the episode. d. Encourage the client to eat dry toast

b

After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood the teaching? a. "I must drink a quart (liter) of water or other liquid each day." b. "I will weigh myself each morning before I eat or drink." c. "I will use a salt substitute when making and eating my meals." d. "I will not drink liquids after 6 p.m. so I won't have to get up at night."

b

After thoracic surgery, a client has a chest tube connected to a water-seal drainage system that is attached to suction. When excessive bubbling is observed in the water-seal chamber, which action would the nurse take? a. Strip the chest tube catheter. b. Check the system for air leaks. c. Decrease the amount of suction pressure. d. Recognize that the system is functioning correctly.

b

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best? a. Answer the questions and document that teaching was done. b. Do not have the client sign the consent and call the primary health care provider. c. Have the client sign the consent, and then call the primary health care provider. d. Remind the client of what teaching the primary health care provider has done

b

The nurse is caring for a client who has fluid overload. What action by the nurse takes priority? a. Administer high-ceiling (loop) diuretics. b. Assess the client's lung sounds every 2 hours. c. Place a pressure-relieving overlay on the mattress. d. Weigh the client daily at the same time on the same scale.

b

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates that the client is managing this condition well with diet? a. A 4-ounce steak, French fries, iceberg lettuce b. Baked chicken breast, broccoli, tomatoes c. Fried catfish, cornbread, peas d. Spaghetti with meat sauce, garlic bread

b

When a client who has a chest tube after thoracotomy reports sharp chest pain at the chest tube and refuses to take deep breaths, which action by the nurse is best? a. Assist the client to sit up in a chair. b. Administer prescribed pain medications. c. Educate about the reason for deep breathing. d. Explain that some pain is normal with a chest tube.

b

When caring for a client with emphysema who becomes more restless, which action would the nurse take first? a. Auscultate lung sounds. b. Check oxygen saturation. c. Observe for increased respiratory effort. d. Ask about any increased shortness of breath.

b

Which element would the nurse conclude is likely to have contributed to the development of hyponatremia in an older client found unconscious at home and admitted to the hospital with a fractured hip, renal failure, and dehydration who received 3 L of intravenous fluid in the 24 hours since admission? a. Reduced dietary salt intake b. Intravenous fluid infusion c. Potassium reabsorption rate d. Increased glomerular filtration

b

Which intervention is most likely to decrease mortality in the septic client? a. Oxygen b. Antibiotics c. Vasopressors d. Intravenous fluids

b

Which clinical manifestation would the nurse expect to find in a client with hypokalemia? Select all that apply. One, some, or all responses may be correct. a. Thirst b. Anorexia c. Leg cramps d. Rapid, thready pulse e. Dry mucous membranes

b c

Which signs of hypokalemia would the nurse monitor in the postoperative surgical client with a nasogastric tube attached to continuous low suction? Select all that apply. a. Irritability b. Dysrhythmias c. Muscle weakness d. Abdominal cramps e. Acidosis

b c

A nurse is learning about different surgical procedures and their classifications. Which examples below does this include? (Select all that apply.) a. Rhinoplasty: curative b. Liver biopsy: diagnostic c. Arthroscopy: preventative. Ileostomy: palliative. Total shoulder replacement: reconstructive d. Body contouring: cosmetic

b c d

A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.) a. Blood glucose: 120 mg/dL (6.7 mmol/L) b. Hemoglobin: 7.8 mg/dL (78 mmol/L) c. pH: 7.68 d. Potassium: 2.9 mEq/L (2.9 mmol/L) e. Sodium: 142 mEq/L (142 mmol/L)

b c d

A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered to be at high risk? (Select all that apply.) a. Client with a humerus fracture b. Morbidly obese client c. Client who smokes d. Client with severe heart failure e. Wheelchair-bound client f. 50 years of age or older

b c d e

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? (Select all that apply.) a. Hypomagnesemia—kidney failure b. Hyperkalemia—salt substitutes c. Hyponatremia—heart failure d. Hypernatremia—hyperaldosteronism e. Hypocalcemia—diarrhea f. Hypokalemia—loop diuretics

b c d e f

A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.) a. Allow small sips of plain water. b. Check that consent is on the chart. c. Ensure that the client has an armband on. d. Have the client help mark the surgical site. e. Allow the client to use the toilet before giving sedation. f. Assess the client for fall risks.

b c d e f

A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are paired with the correct potential imbalance? (Select all that apply.) a. Sodium: 160 mEq/L (mmol/L): Overhydration b. Potassium: 5.4 mEq/L (mmol/L): Dehydration c. Osmolarity: 250 mOsm/L: Overhydration d. Hematocrit: 68%: Dehydration e. BUN: 39 mg/dL: Overhydration f. Magnesium: 0.8 mg/dL: Dehydration

b c d f

A nurse prepares a client who is scheduled for a bronchoscopy with transbronchial biopsy procedure at 9:00 AM (0900). What actions would the nurse take? (Select all that apply.) a. Provide a clear liquid breakfast. b. Verify that the informed consent was obtained. c. Document the client's allergies. d. Review laboratory results. e. Hold the client's bronchodilator. f. Monitor the client for at least 24 hours afterwards.

b c d f

An emergency department nurse assesses a female client. Which assessment findings would alert the nurse to request a prescription for an electrocardiogram? (Select all that apply.) a. Hypertension b. Fatigue despite adequate rest c. Indigestion d. Abdominal pain e. Shortness of breath

b c e

A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.) a. All phases require the client to be in the hospital. b. Phase I care may last for several days in some clients. c. Phase I requires intensive care unit monitoring. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III. f. Some clients may be discharged directly after phase I.

b c e f

A nurse assesses a client who is recovering after a coronary catheterization. Which assessment findings in the first few hours after the procedure require immediate action by the nurse? (Select all that apply.) a. Blood pressure of 140/88 mm Hg b. Serum potassium of 2.9 mEq/L (2.9 mmol/L) c. Warmth and redness at the site d. Expanding groin hematoma e. Rhythm changes on the cardiac monitor f. Oxygen saturation 93% on room air

b d e

A nurse assesses a client who is recovering from a thoracentesis. Which assessment findings would alert the nurse to a potential pneumothorax? (Select all that apply.) a. Bradycardia b. New-onset cough c. Purulent sputum d. Tachypnea e. Pain with respirations f. Rapid, shallow respirations

b d e

A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.) a. Administering antibiotics for 72 hours b. Disposing of dressings properly c. Leaving draining wounds open to air d. Performing proper hand hygiene e. Removing and replacing wet dressings

b d e

A nurse prepares a client for a pharmacologic stress echocardiogram. What actions would the nurse take when preparing this client for the procedure? (Select all that apply.) a. Assist the primary health care provider to place a central venous access device. b. Prepare for continuous blood pressure and pulse monitoring. c. Administer the client's prescribed beta blocker. d. Give the client nothing by mouth 3 to 6 hours before the procedure. e. Explain to the client that dobutamine will simulate exercise for this examination.

b d e

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications will the nurse assess? (Select all that apply.) a. Urine output of 25 mL/hr b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L) c. Urine specific gravity of 1.02 g/mL d. Serum sodium level of 128 mEq/L (128 mmol/L) e. Blood osmolality of 250 mOsm/kg (250 mmol/kg)

b e

A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on? (Select all that apply.) a. Hemorrhage prevention b. Infection prevention c. Malignant hyperthermia testing d. Stroke recognition e. Thromboembolism prevention f. Correct hair removal

b e f

Which actions will the nurse include in the plan of care for a client with a left pneumothorax who has a chest tube in place? Select all that apply. One, some, or all responses may be correct. a. Immobilize the left arm in a sling. b. Check the water-seal chamber for air bubbling. c. Avoid use of nonsteroidal anti-inflammatory drugs. d. Keep the client on bed rest in semi-Fowler position. e. Observe frequently for drainage in the collection chamber. f. Assist the client to cough and deep breathe every hour while awake.

b f

A client with an acute emphysema episode is dyspneic and anxious. To decrease the dyspnea, which action would the nurse take? a. Increase the client's oxygen intake. b. Have the client breathe into a paper bag. c. Teach the client to do pursed-lip breathing. d. Check the client's vital signs.

c

A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching? a. "Have you spouse watch you for irritability and anxiety." b. "Notify the clinic if you notice muscle twitching." c. "Call your primary health care provider for diarrhea." d. "Bake or grill your meat rather than frying it."

c

A client asks what "essential hypertension" is. What response by the registered nurse is best? a. "It means it is caused by another disease." b. "It means it is 'essential' that it be treated." c. "It is hypertension with no specific cause." d. "It refers to severe and life-threatening hypertension."

c

A client had a surgical procedure with spinal anesthesia. The client's blood pressure was 122/78 mm Hg 30 minutes ago and is now 138/60 and the client reports nausea. What action by the nurse is best? a. Call the Rapid Response Team. b. Increase the IV fluid rate. c. Notify the primary health care provider. d. Nothing; this is expected

c

A client with a chest tube is to be transported via a stretcher. When transporting the client, what would the nurse do? a. Keep collection device attached to mechanical suction b. Keep chest tube clamped distal to the water-seal chamber c. Keep collection device below the level of the client's chest d. Keep chest tube end covered with sterile gauze pads taped to the client

c

A client with chronic obstructive pulmonary disease (COPD) is breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. Which action would the nurse take? a. Encourage the client to take slow, deep breaths and administer 5 L/min oxygen per nasal cannula. b. Place the client in a side-lying position and perform chest physiotherapy using clapping and vibration c. Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula. d. Assist the client in assuming a position of comfort and perform postural drainage.

c

A client with emphysema reports increased shortness of breath and becoming increasingly anxious. The health care provider prescribes oxygen at 1 L/min via nasal cannula. The nurse recognizes that this prescription is appropriate for which reason? a. The client does not need any more than 1 L/min. b. High concentrations of oxygen cause alveoli to rupture. c. High concentrations of oxygen eliminate the respiratory drive in some patients. d. The oxygen at 1 L/min should be enough to diminish the anxiety.

c

A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure? a. Notifies the pharmacy of the IV potassium order. b. Assesses the client's IV site every hour during infusion. c. Sets the IV pump to deliver 30 mEq of potassium an hour. d. Double-checks the IV bag against the order with the precepting nurse.

c

A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. What action would the nurse take next? a. Elevate the leg and apply a sandbag to the entrance site. b. Increase the flow rate of intravenous fluids. c. Assess the color and temperature of the left leg. d. Document the finding as "left pedal pulse of +1/4."

c

A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? a. Client reports being dizzy—nurse calls the Rapid Response Team. b. Client's heart rate is 55 beats/min—nurse withholds pain medication. c. Client has reduced breath sounds—nurse calls primary health care provider immediately. d. Client's respiratory rate is 18 breaths/min—nurse decreases oxygen flow rate

c

A nurse assesses a client who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. Urinary output less than intake b. Bruising at the insertion site c. Slurred speech and confusion d. Discomfort in the left leg

c

A nurse assesses an older adult client who has multiple chronic diseases. The client's heart rate is 48 beats/min. What action would the nurse take first? a. Document the finding in the chart. b. Initiate external pacing. c. Assess the client's medications. d. Administer 1 mg of atropine.

c

A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration? a. A 36 year old who is prescribed long-term steroid therapy. b. A 55 year old who recently received intravenous fluids. c. A 76 year old who is cognitively impaired. d. An 83 year old with congestive heart failure

c

A nurse assesses clients on a medical-surgical unit. Which client would the nurse identify as having the greatest risk for cardiovascular disease? a. An 86-year-old man with a history of asthma. b. A 32-year-old man with colorectal cancer. c. A 65-year-old woman with diabetes mellitus. d. A 53-year-old postmenopausal woman who takes bisphosphonates

c

A nurse assesses female client who is experiencing a myocardial infarction. Which clinical manifestation would the nurse expect? a. Excruciating pain on inspiration b. Left lateral chest wall pain c. Fatigue and shortness of breath d. Numbness and tingling of the arm

c

A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. What action would the nurse take next? a. Call the primary health care provider and request food and water for the client. b. Provide the client with ice chips instead of a drink of water. c. Assess the client's gag reflex before giving any food or water. d. Let the client have a small sip to see whether he or she can swallow

c

A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is exhibiting cardiovascular changes. Which intervention will the nurse implement first? a. Prepare to administer patiromer by mouth. b. Provide a heart-healthy, low-potassium diet. c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. d. Prepare the client for hemodialysis treatment

c

A nurse cares for a client who is recovering from a myocardial infarction. The client states, "I will need to stop eating so much chili to keep that indigestion pain from returning." What is the nurse's best response? a. "Chili is high in fat and calories; it would be a good idea to stop eating it." b. "The primary health care provider has prescribed an antacid every morning." c. "What do you understand about what happened to you?" d. "When did you start experiencing this indigestion?"

c

A nurse is talking with a co-worker who is moving to a new state and needs to find new employment there. What advice by the nurse is best? a. Ask the hospitals there about standard nurse-client ratios. b. Choose the hospital that has the newest technology. c. Find a hospital that has achieved Magnet status. d. Work in a facility affiliated with a medical or nursing school.

c

A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60-pack-year smoking history. Which action is most important for the nurse to take when interviewing this client? a. Tell the client that he or she needs to quit smoking to stop further cancer development. b. Encourage the client to be completely honest about both tobacco and marijuana use. c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. d. Avoid giving the client false hope regarding cancer treatment and prognosis.

c

A nurse prepares a client for cardiac catheterization. The client states, "I am afraid I might die." What is the nurse's best response? a. "This is a routine test and the risk of death is very low." b. "Would you like to speak with a chaplain prior to test?" c. "Tell me more about your concerns about the test." d. "What support systems do you have to assist you?"

c

A nurse teaches a client who is prescribed a central vascular access device and is transferring to a skilled facility for long-term treatment. Which statement will the nurse include in this client's teaching? a. "You will need to wear a sling on your arm while the device is in place." b. "There is no risk of infection because sterile technique will be used during insertion." c. "Ask all providers to vigorously clean the connections prior to accessing the device." d. "You will not be able to take a bath with this vascular access device."

c

A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement would the nurse include in this client's teaching? a. "Make a list of reasons why smoking is a bad habit." b. "Rise slowly when getting out of bed in the morning." c. "Smoking while taking this medication will increase your risk of a stroke." d. "Stopping this medication suddenly increases your risk for a heart attack."

c

A nurse working on a cardiac unit delegated taking vital signs to an experienced assistive personnel (AP). Four hours later, the nurse notes that the client's blood pressure taken by the AP was much higher than previous readings, and the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome? a. Determining if the AP knew how to take blood pressure b. Double-checking the AP by taking another blood pressure c. Providing more appropriate supervision of the AP d. Taking the blood pressure instead of delegating the task

c

A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for postdischarge care? a. Married young adult who is the primary caregiver for children. b. Middle-age client who is post-knee replacement, and needs physical therapy. c. Older adult who lives alone at home despite some memory loss. d. Young client who lives alone, and has family and friends nearby

c

A postoperative client has respiratory depression after receiving morphine for pain. Which medication and dose does the nurse prepare to administer? a. Flumazenil 0.2 to 1 mg b. Flumazenil 2 to 10 mg c. Naloxone 0.4 to 2 mg d. Naloxone 4 to 20 mg

c

A postoperative nurse is caring for a client who received a neuromuscular blocking agent during surgery. On assessment the nurse notes the client has weak hand grasps. What assessment does the nurse conduct next? a. Ability to raise head off the bed b. Blood pressure and pulse c. Signs of oxygenation d. Level of orientation

c

A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team? a. Creatinine: 1.2 mg/dL (106.1 umol/L) b. Hemoglobin: 14.8 mg/dL (148 mmol/L) c. Potassium: 2.9 mEq/L (2.9 mmol/L) d. Sodium: 134 mEq/L (134 mmol/L)

c

A registered nurse (RN) is watching a new nurse change a dressing and perform care around a Penrose drain. What action by the new nurse warrants intervention? a. Cleaning around the drain per agency protocol b. Placing a new sterile gauze under the drain c. Securing the drain's safety pin to the sheets d. Using sterile technique to empty the drain

c

A telemetry nurse assesses a client who has a heart rate of 35 beats/min on the cardiac monitor. Which assessment would the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability

c

How would the nurse plan to position a client with a diagnosis of emphysema who is experiencing dyspnea? a. Supine b. Contour c. Orthopneic d. Semi-Fowler

c

The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client would the nurse assess first? a. Client with a blood pressure of 100/50 mm Hg b. Client with a pulse of 118 beats/min c. Client with a respiratory rate of 6 breaths/min d. Client with a temperature of 96° F (35.6° C)

c

When a client with emphysema who smokes 2 packs of cigarettes per day is attempting to quit smoking, which action would the nurse take first? a. Suggest that the client cut back to 1 pack per day. b. Refer the client to a tobacco-cessation program. c. Ask the client about previous attempts at tobacco cessation. d. Suggest that the client use medication to assist with quitting.

c

Which action would the nurse take to prevent aspiration recurrence in a client with aspiration pneumonia who is PO status with a nasogastric tube and a prescription for antibiotics? a. Obtaining vital signs after feedings b. Administering intravenous antibiotics c. Elevating the head of the bed to 30 degrees d. Determining residual every 4 hours

c

Which finding in a client who has just returned to the nursing unit after having right upper lobectomy requires rapid action by the nurse? a. 100 mL of blood in the chest tube drainage chamber b. Complaint of 9/10 (0 to 10 scale) right side chest pain c. Deviation of the client's trachea to the left side d. Decreased breath sounds on the client's right side

c

Which intervention is most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? a. Pouring warm water over the perineum b. Ensuring the patency of the catheter c. Removing the catheter within 24 hours d. Cleaning the catheter insertion site

c

Which laboratory result is important to communicate quickly to the health care provider? a. Blood glucose 98 mg/dL (5.44 mmol/L) b. Hemoglobin 14.1 g/dL (141 mmol/L) c. Potassium 3.0 mEg/L (3.0 mmol/L) d. White blood cell 9200/mm 3 (9.2 × 10 9/L)

c

Which statement would the nurse use to respond to an older adult client who states, walk 2 miles [3.2 km] a day for exercise, but now that the weather is hot, I am worried about becoming dehydrated"? a. "Drink fruit juices if you start to feel dehydrated." b. "Thirst is a good guide to use to determine fluid intake." c. "Fluids should be increased if the urine becomes darker" d. "Water should be consumed when the skin becomes dry."

c

After administering potassium chloride, a nurse evaluates the client's response. Which signs and symptoms indicate that treatment is improving the client's hypokalemia? (Select all that apply.) a. Respiratory rate of 8 breaths/min b. Absent deep tendon reflexes c. Strong productive cough d. Active bowel sounds e. U waves present on the electrocardiogram (ECG

c d

A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would the nurse complete prior to the procedure? a. Measure oxygen saturation before and after a 12-minute walk. b. Verify that the client understands all possible complications. c. Explain the procedure in detail to the client and the family. d. Validate that informed consent has been given by the client

d

A client admitted with a history of emphysema and a diagnosis of acute respiratory failure with respiratory acidosis has oxygen at 3 L/min nasal cannula. Four hours after admission, the client exhibits increased restlessness and confusion followed by a decreased respiratory rate and lethargy. Which intervention would the nurse implement at this time? a. Question the client about the confusion. b. Change the method of oxygen delivery. c. Percuss and vibrate the client's chest wall. d. Discontinue or decrease the oxygen flow rate.

d

A client has arrived in the inpatient postoperative unit. What action by the inpatient nurse takes priority? a. Assessing fluid and blood output b. Checking the surgical dressings c. Ensuring the client is warm d. Participating in hand-off report

d

A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" Which information would the nurse provide about the purpose of the chest tube? a. It checks for bleeding in the lung. b. It monitors the function of the lung. c. It drains fluid from the pleural space. d. It removes air from the pleural space.

d

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action? a. The client rates pain as a 5/10 at the site of the procedure. b. A small amount of drainage from the site is noted. c. Pulse oximetry is 93% on 2 L of oxygen. d. The trachea is shifted toward the opposite side of the neck

d

A nurse assesses a client after administering a prescribed beta blocker. Which assessment would the nurse expect to find? a. Blood pressure increased from 98/42 to 132/60 mm Hg. b. Respiratory rate decreased from 25 to 14 breaths/min. c. Oxygen saturation increased from 88% to 96%. d. Pulse decreased from 100 to 80 beats/min

d

A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern? a. The catheter has been in place for 20 hours. b. The client has poor vascular access in the upper extremities. c. The catheter is placed in the proximal tibia. d. The client's left lower extremity is cool to the touch.

d

A nurse assesses a client who has a radial artery catheter. Which assessment will the nurse complete first? a. Amount of pressure in fluid container b. Date of catheter tubing change c. Type of dressing over the site d. Skin color and capillary refill

d

A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment would the nurse complete as the priority prior to this procedure? a. Client's level of anxiety b. Ability to turn self in bed c. Cardiac rhythm and heart rate d. Allergies to iodine-based agents

d

A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and "feeling warm." For which complication of this therapy will the nurse assess the client? a. Allergic reaction b. Bowel obstruction c. Catheter lumen occlusion d. Infection

d

A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. What action will the nurse take next? a. Apply cold compresses to the IV site. b. Elevate the extremity on a pillow. c. Flush the catheter with normal saline. d. Stop the infusion of intravenous fluids

d

A nurse assesses a client's respiratory status. Which information is most important for the nurse to obtain? a. Average daily fluid intake. b. Neck circumference. c. Height and weight. d. Occupation and hobbies

d

A nurse cares for a client who has advanced cardiac disease and states, "I am having trouble breathing while I'm sleeping at night." What is the nurse's best response? a. "I will consult your primary health care provider to prescribe a sleep study." b. "You become hypoxic while sleeping; oxygen therapy via nasal cannula will help." c. "A continuous positive airway pressure, or CPAP, breathing mask will help you breathe at night." d. "Use pillows to elevate your head and chest while you are sleeping."

d

A nurse delegates care to an assistive personnel (AP). Which statement will the nurse include when delegating hygiene for a client who has a vascular access device? a. "Provide a bed bath instead of letting the client take a shower." b. "Use sterile technique when changing the dressing." c. "Disconnect the intravenous fluid tubing prior to the client's bath." d. "Use a plastic bag to cover the extremity with the device."

d

A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention? a. The initial site dressing is 3 days old. b. The PICC was inserted 4 weeks ago. c. A securement device is absent. d. Upper extremity swelling is noted.

d

A nurse is assessing the peripheral vascular system of an older adult. What action by the nurse would cause the supervising nurse to intervene? a. Assessing blood pressure in both upper extremities b. Auscultating the carotid arteries for any bruits c. Classifying capillary filling of 4 seconds as normal d. Palpating both carotid arteries at the same time

d

A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition? a. Assesses the client's Chvostek and Trousseau sign. b. Keeps the client's room quiet and dimly lit. c. Moves the client carefully to avoid fracturing bones. d. Administers bisphosphonates as prescribed.

d

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital? a. Ask family members to speak quietly to keep the client calm. b. Assess urine color, amount, and specific gravity each day. c. Encourage the client to drink at least 1 L of fluids each shift. d. Dangle the client on the bedside before ambulating

d

A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan? a. Increased respiratory rate from 12 to 22 breaths/min b. Decreased skin turgor on the client's posterior hand and forehead c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic changes when standing

d

A nurse prepares to insert a peripheral venous catheter in an older adult. What action will the nurse take to protect the client's skin during this procedure? a. Lower the extremity below the level of the heart. b. Apply warm compresses to the extremity. c. Tap the skin lightly and avoid slapping. d. Place a washcloth between the skin and tourniquet

d

A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team? a. Allergy to bee and wasp stings b. History of lactose intolerance c. No previous experience with surgery d. Use of multiple herbs and supplements

d

After signing a legal consent for hip replacement surgery and within hours before the surgery, the client states, "I decided not to go through with the surgery." Which response would the nurse use initially? a. "Then you shouldn't have signed the consent." b. "I can understand why you changed your mind." c. "Tell me why you decided to refuse the operation. d. "Let's talk about your concerns regarding the procedure.

d

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates that the client correctly understood the teaching? a. Slices of smoked ham with potato salad b. Bowl of tomato soup with a grilled cheese sandwich c. Salami and cheese on whole-wheat crackers d. Grilled chicken breast with glazed carrots

d

An emergency department nurse triages clients who present with chest discomfort. Which client would the nurse plan to assess first? a. Client who describes pain as a dull ache. b. Client who reports moderate pain that is worse on inspiration. c. Client who reports cramping substernal pain. d. Client who describes intense squeezing pressure across the chest.

d

Nursing actions after a client has had general anesthesia are directed at preventing which postoperative respiratory complication? a. Pleural effusion b. Empyema c. Pneumothorax d. Atelectasis

d

The postoperative nurse is caring for a client who reports feeling "something popped" after vomiting. What action by the nurse is best? a. Administer an antiemetic medication. b. Call the primary health care provider. c. Instruct client to avoid coughing. d. Gather sterile nonadherent dressings

d

Which assessment finding would be important for the nurse to report to the health care provider when caring for a client who is in the postanesthesia care unit after receiving general anesthesia? a. Attempting to push the airway out b. Unresponsive to verbal stimulation c. Respirations at 16 breaths/minute and unlabored d. Systolic blood pressure decrease from 130 mm Hg to 90 mm Hg

d

Which client is at an increased risk for hospital-acquired pneumonia? a. Client who was admitted yesterday with hypoxia and fever b. Client who has been on mechanical ventilation for 5 days c. Client who reports being on an airplane with other sick individuals d. Client who was admitted to the hospital 5 days ago for abdominal pain

d

Which finding in a client who has home oxygen therapy with a tracheostomy collar requires immediate action by the home health nurse? a. Condensation in the tubing b. Oxygen flow rate 9 L/min c. Low fluid level in the humidifier d. Scented candle burning in the room

d

Which intervention would the nurse implement when a client's intravenous cannula insertion site has become red, swollen, and warm to the touch with purulent drainage also noted? a. Temporarily slow the infusion rate to a "keep vein open" rate. b. Elevate the extremity slightly above the level of the client's heart. c. Frequently apply cold and warm compresses to the site. d. Clean the site with alcohol, remove the cannula, and save for culture.

d

Which prescription would the nurse question when a client's serum sodium is 123 mEg/L (123 mmol/L)? a. Add table salt to each meal. b. Fluid restriction of 1000 mL per day. c. Assess neurological status every 2 hours. d. Provide 0.45% sodium chloride (NaCL) intravenously at 125 mL/h

d

While walking in a hallway, a client with a chest tube becomes confused and pulls the chest tube out. Which action would the nurse take? a. Place the client in the supine position. b. Spread a clamp in the insertion site to hold the site open. c. Obtain a sterile Vaseline gauze to cover the opening. d. Cover the opening with the cleanest material available.

d