ATI CMS Fundamentals Practice
A nurse is performing a peripheral vascular assessment of a client. When placing the bell of the stethoscope on the clinet's neck, the nurse hears the following sound. This sound indicates which of the following? (click on the audio) rncms_2019_opfb_f un_4C-39.mp3 a) Narrowed arterial lumen b) Distended jugular veins c) Impaired ventricular contraction d) Asynchronous closure of the aortic and pulmonic valves
A.- Blowing sounds resulting from blood flowing through occluded or narrowed arteries are known as a bruit. Blood flowing through distended jugular veins does not produce a sound. Impaired ventricular function produces extra heart sounds, either S3 or S4. These sounds are best heard over the aortic area of the heart. Asynchronous closure of the aortic and pulmonic valves is known as "splitting" of S2, so the nurse should hear two "dub" sounds during auscultation. This sound is best heard over the aortic area of the heart
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? a) Insert an implanted port. b) Close a laceration with sutures. c) Place an endotracheal tube. d) Initiate an enteral feeding through a gastrostomy tube.
Correct answer: D. - It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes.
A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following action should the nurse plan to take? a) Dissolve each medication in 5 mL of sterile water. b) Draw up medications together in the syringe. c) Push the syringe plunger gently when feeling resistance. d) Flush the tube with 15 mL of sterile water.
Correct answer: The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication. When encountering resistance during administration of a medication, the nurse should stop and contact the provider. The nurse should draw up medications separately and not mix them together. The nurse should dissolve each medication in at least 30 mL of warm, sterile water.
A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? round to the nearest whole number
Correct answer: 250ml*800units/hr / 25000 units = 8ml/h
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? a) Place the client in a room with negative-pressure airflow b) Wear gloves when assisting the client with oral care. c) Limit each visitor to 2-hr increments. d) Wear a surgical mask when providing client care. e) Use antimicrobial sanitizer for hand hygiene
Correct answer: A, B, E. - Place the client in a room with negative-pressure airflow is correct. The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions. Wear gloves when assisting the client with oral care is correct. The nurse should wear gloves when assisting the client with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever their hands might come in contact with a client's bodily fluids, such as saliva, and the mucous membranes in the mouth. Limit each visitor to 2-hr increments is incorrect. The nurse does not need to limit the client's visitors. However, the nurse should limit the client's presence outside the room and the client should wear a surgical mask when outside of the room. Wear a surgical mask when providing client care is incorrect. The nurse should wear an N95 respirator during client care to meet the requirements of airborne precautions. Use antimicrobial sanitizer for hand hygiene is correct. The nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. Nurses should also wash their hands with soap and water when their hands are visibly soiled.
The nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? select all that apply. a) Check the cord routinely for frays or tearing. b) Keep the unit at least 1.2 m (4 feet) away from a gas stove. c) Consider purchasing a generator for power backup. d) Observe for signs of hypoxia. e) Select synthetic clothing and bedding.
Correct answer: A, C, D.- Check the cord routinely for frays or tearing is correct. Oxygen concentrators require electrical power. Safe use of this delivery system includes assessing the electrical function of the device; therefore, the nurse should instruct the client to routinely check the condition of the cord. Keep the unit at least 1.2 m (4 feet) away from a gas stove is incorrect. Safe use of home oxygen equipment includes keeping the unit at least 3.05 m (10 feet) away from open flames, such as from a fireplace or a gas stove, and at least 2.4 m (8 feet) away from other heat sources. Consider purchasing a generator for power backup is correct. Loss of electricity prevents the oxygen concentrator from functioning and could deprive the client of necessary oxygen. The nurse should also instruct the family to have the client placed on their municipality's priority list for restoring power after an outage occurs. Observe for signs of hypoxia is correct. The nurse should instruct the family to observe for and report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and respirations, pallor, and cyanosis. Even with supplemental oxygen, the client's status can worsen, resulting in the development of hypoxia. Select synthetic clothing and bedding is incorrect. Safe use of oxygen therapy includes choosing clothing and bedding made from material that does not generate static electricity; therefore, the nurse should instruct the client to select materials made from cotton.
A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. a) Inject 10 units of air into the bottle of NPH insulin. b) Withdraw the correct dose of regular insulin from the bottle c) Withdraw the correct dose of NPH insulin from the bottle. d) Inject 5 units of air into the bottle of regular insulin.
Correct answer: A, D, B, C.- The nurse should first inject air into the vial of NPH insulin without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin
A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as priority? a) Auscultate lung sounds. b) Measure urine output. c) Monitor blood pressure readings. d) Monitor electrolyte levels.
Correct answer: A- The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and shortness of breath.
A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate? a) Ambulating a client who is postoperative b) Inserting an indwelling urinary catheter for a client c) Demonstrating the use of an incentive spirometer to a client d) Confirming that a client's pain has decreased after receiving an analgesic
Correct answer: A.- Ambulating a client is within the range of function of an AP. The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching
A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate? a) Droplet b) Airborne c) Contact d) Protective environment
Correct answer: A.- Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis. Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles. Contact precautions are a requirement for clients who have infections that spread via direct contact with another person or contact with the environment, including vancomycin-resistant enterococci, methicillin-resistant Staphylococcus aureus, and scabies. Clients who have a compromised immune system, such as those who have had an allogeneic hematopoietic stem cell transplant, require a protective environment
A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use? a) "I can take echinacea to improve my immune system." b) "I can take feverfew to reduce my level of anxiety." c) "I can take ginger to improve my memory." d) "I can take ginkgo biloba to relieve nausea."
Correct answer: A.- Echinacea is taken to promote immunity and reduce the risk of infection. Feverfew is taken to promote wound healing and decrease inflammation associated with arthritis. Valerian and chamomile can be taken to reduce anxiety. Ginger is taken to relieve nausea and vomiting and aid in digestion. Ginkgo biloba can be taken to improve memory and reduce stress. Ginkgo biloba is taken to improve memory and reduce stress. Ginger can be taken to relieve nausea and vomiting and aid in digestion.
A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene? a) Erythema on pressure points b) Lower-extremity pulse strength of 2+ c) Fluid intake of 3,000 mL per day d) One bowel movement every other day
Correct answer: A.- Erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from breakdown. A lower-extremity pulse strength of 2+ is an expected finding. Clients should receive 2,000 to 3,000 mL of fluid per day. Bowel movements less frequent than three times per week can indicate constipation and the need for intervention. However, a bowel movement every other day does not require intervention
A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity? a) A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. b) A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes. c) A client who has a do-not-resuscitate (DNR) order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family. d) A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse previously promised to administer.
Correct answer: A.- Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others
A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? a) "What could I have done to deserve this illness?" b) "I blame medical science for not curing me." c) "Where is my daughter at a time like this?" d) "Will I ever begin to feel in charge of my life again?"
Correct answer: A.- The client's terminal illness might prompt the client to review their life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to them
A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse? a) The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field. b) The newly licensed nurse places sterile objects 2.5 cm (1 inch) within the border of the field. c) The newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring. d) The sterile field is positioned at the level of the newly licensed nurse's waist.
Correct answer: A.- The newly licensed nurse should place the cap with the sterile side up on a clean surface because the outer edges are unsterile and will contaminate the sterile field
A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care? a) Wrap blankets around all four sides of the bed. b) Apply restraints during seizure activity. c) Place the client in a supine position during seizure activity. d) Have a tongue depressor at the client's bedside.
Correct answer: A.- The nurse should affix linens or blankets around the head, foot, and side rails of the bed to pad them and prevent injury for a client who has been having frequent tonic-clonic seizures. The nurse should turn the client to the side so that the tongue does not occlude the airway and so that secretions can flow out of the side of the client's mouth
A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? a) Gently shake the container of medication prior to administration. b) Transfer the medication to a medicine cup. c) Place the client in a semi-Fowler's position prior to medication administration. d) Verify the dosage by measuring the liquid before administering it
Correct answer: A.- The nurse should gently shake the liquid medication to ensure that the medication is mixed.
A nurse if caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take? a) Instruct the family to refrain from pushing the button for the client while she is asleep. b) Inform the client that because she is on PCA, vital signs will be taken every 8 hr. c) Teach the client to avoid pushing the button until pain is above a 7 on a scale of 0 to 10. d) Increase the basal rate and shorten the lock-out interval time if the client's pain level is too high.
Correct answer: A.- The nurse should instruct family members not to activate the button for the client while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain
A nurse is caring for a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? a) "When descending stairs, I will first shift my weight to my right leg." b) "I should place my crutches 12 inches in front and to the side of each foot." c) "As I sit down, I will hold one crutch in each hand." d) "I will make sure the shoulder rests are snug against my armpits."
Correct answer: A.- To descend stairs, the client should first shift his body weight to his right, unaffected leg. The client should place his crutches 15 cm (6 in) in front and to the side of each foot. Just before sitting down, the client should hold both crutches by their hand bars in one hand. To avoid injury to the underlying nerves, the shoulder rests should be at least 2.5 to 5 cm (1 to 2 in) below the axillae
A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? a) Walking briskly b) Riding a bicycle c) Performing isometric exercises d) Engaging in high-impact aerobics
Correct answer: A.- Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy
A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make? a) "We can talk about advance directives, and I can also give you some brochures about them." b) "You should set up a time to talk with your provider about that." c) "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better." d) "Why do you want to discuss this without your partner here to plan this with you?"
Correct answer: A.- With this statement, the nurse offers to provide the information the client needs in a direct and simple way
The nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nuse transcribe the dosage of this medication in the medical record? a) .3 mg b) 0.3 mg c) 0.30 mg d) 3/10 mg
Correct answer: B - The use and placement of a decimal point can potentially cause a medication error if documented incorrectly. A zero should precede a decimal point, as in 0.3 mg, but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg
A nurse is giving chance-of shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide? a) Admitting diagnosis. b) Breath sounds. c) Body temperature. d) Diagnostic results.
Correct answer: B. Breath sounds - When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds.
A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? a) Rinse the feeding bag with water between feedings. b) Tell the client to keep the head of the bed elevated at least 30°. c) Make sure the enteral formula is at room temperature. d) Wipe the top of the formula can with alcohol.
Correct answer: B. - The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula into the esophagus
A community health nurse is checking blood pressure for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension? a) A client who is 52 years old b) A client who smokes one pack of cigarettes each day c) A client who walks for 30 min every day d) A client who drinks one glass of wine three times per week
Correct answer: B.- A client who smokes one pack of cigarettes each day is at an increased risk for hypertension
A nurse has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement? a) The tube aspirate has a pH of 7. b) An x-ray shows the end of the tube above the pylorus. c) Bowel sounds are present on auscultation. d) The client reports relief of nausea.
Correct answer: B.- An abdominal x-ray showing the end of the tube above the pylorus indicates gastric placement
A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? a) Ensure sterilization of nondisposable items with ethylene oxide. b) Wrap monitoring cords with stockinette and tape them in place. c) Cleanse latex ports on IV tubing with chlorhexidine before injecting medication. d) Wear hypoallergenic latex gloves that contain powder.
Correct answer: B.- Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them
A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to HIPAA guidelines? a) A nurse who is caring for a client reviews the client's medical chart with a nursing student who is working with the nurse. b) A nurse asks a nurse from another unit to assist with documentation for a client. c) A nurse who is caring for a client returns a call to the person appointed in the health care proxy to discuss the client's care. d) A nurse discusses a client's status with the physical therapist who is caring for the client.
Correct answer: B.- Only health care professionals directly caring for a client should have access to the client's medical information; therefore, this is a violation of HIPAA guidelines
A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? a) "I'm having mild pain." b) "The pain is like a dull ache in my stomach." c) "I notice that the pain gets worse after I eat." d) "The pain makes me feel nauseous."
Correct answer: B.- The client is describing the quality of the pain, which is how the pain feels in the client's own words
A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? a) "Drink a cup of hot cocoa before bedtime." b) "Maintain a consistent time to wake up each day." c) "Exercise 1 hour before going to bed." d) "Watch a television program in bed before going to sleep."
Correct answer: B.- The client should maintain a consistent time for waking up and going to sleep. This helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client
A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? a) Describe the procedure to the client. b) Witness the client's signature on the consent form. c) Inform the client of alternatives to the procedure. d) Tell the client which team members will assist with the procedure.
Correct answer: B.- The nurse is responsible for witnessing the client sign the consent form. The nurse should confirm that the client appears competent to give consent and that the client understands the procedure
A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plant to take? a) Use a resuscitation bag with 80% oxygen prior to the procedure. b) Select a suction catheter that is half the size of the lumen. c) Place the end of the suction catheter in water-soluble lubricant. d) Adjust the wall suction apparatus to a pressure of 170 mm Hg.
Correct answer: B.- The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa
A nurse is planning care for a client who has tuberculosis. The nurse should use which o the following pieces of personal protective equipment when providing care for the client? a) Gown b) N95 respirator c) Shoe covers d) Surgical cap
Correct answer: B.- The nurse should wear an N95 respirator when providing care for a client who requires droplet precautions as a result of tuberculosis to prevent the transmission of bacteria
A nurse is performing a Romberg test during a physical assessment of a client. Which of the following techniques should the nurse use? a) Touch the face with a cotton ball. b) Apply a vibrating tuning fork to the client's forehead. c) Have the client stand with their arms at their sides and their feet together. d) Perform direct percussion over the area of the kidneys.
Correct answer: C - A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance.
A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include? a) Client flow sheet b) Acuity ratings c) Current medications d) Incident reports
Correct answer: C. The nurse should include the client's medications in the discharge summary to ensure client safety and continuity of care.
41. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation? a) Urine has an unusual odor. b) Urine specific gravity is 1.035. c) Bladder scan shows 525 mL of urine. d) Urine is positive for ketones.
Correct answer: C.- A client who has an indwelling urinary catheter should have a continuous urine flow without an accumulation of urine in the bladder; therefore, the nurse should irrigate the catheter to resolve any existing blockage
A client who is non ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next? a) Activate the emergency fire alarm. b) Extinguish the fire. c) Evacuate the client. d) Confine the fire.
Correct answer: C.- According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area.
A nurse in a clinic is caring for a middle adult client who states, "the doctor says that, since I am an average risk for colon cancer, I should have a routine screening/ what does that involve?" Which of the following responses should the nurse make? a) "I'll get a blood sample from you and send it for a screening test." b) "Beginning at age 60, you should have a colonoscopy." c) "You should have a fecal occult blood test every year." d) "The recommendation is to have a sigmoidoscopy every 10 years."
Correct answer: C.- Colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a fecal occult blood test annually
A nurse is caring for a client who requires 24 hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? a) "I had a bowel movement, but I was able to save the urine." b) "I have a specimen in the bathroom from about 30 minutes ago." c) "I flushed what I urinated at 7:00 a.m. and have saved all urine since." d) "I drink a lot, so I will fill up the bottle and complete the test quickly."
Correct answer: C.- For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings
A nurse is reviewing client's medication prescription that reads, "digoxin 0.25 by mouth every day". Which of the following components of the prescription should the nurse verify with the provider? a) Medication name b) Route of administration c) Medication dose d) Frequency of administration
Correct answer: C.- In the prescription, the medication dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? a) Neck vein distention b) Urine specific gravity 1.010 c) Rapid heart rate d) Blood pressure 144/82 mm Hg
Correct answer: C.- Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days. Typically, a client's urine specific gravity is greater than 1.030 in the presence of fluid volume deficit. The expected reference range for urine specific gravity is 1.005 to 1.030. Hypotension is an expected finding for a client who has fluid volume deficit
A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next? a) Rock the client up to a standing position. b) Pivot on the foot that is the farthest from the chair. c) Assess the client for orthostatic hypotension. d) Apply a gait belt to the client.
Correct answer: C.- The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair
A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a) Wear sterile gloves when removing the old dressing. b) Warm the irrigation solution to 40.5° C (105° F). c) Cleanse the wound from the center outward. d) Use a 20-mL syringe to irrigate the wound.
Correct answer: C.- The nurse should clean the wound from the center outward to prevent introduction of micro- organisms from the outer skin surface
A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? a) 2 cups of soup b) 1 quart of water c) 8 oz of ice chips d) 6 oz of tea
Correct answer: C.- The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid.
A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident? a) "Incident report completed." b) "Client climbed over the side rails." c) "Client found lying on floor." d) "Client was trying to get out of bed."
Correct answer: C.- The nurse should include documentation of information that is descriptive and objective concerning what the nurse actually observed, without including any opinions or judgments about motives or cause
A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feedings? a) Assign a staff member to feed the client. b) Provide small-handled utensils for the client. c) Thicken liquids on the client's tray. d) Arrange food in a consistent pattern on the client's plate.
Correct answer: D. - Consistency in preparing the client's plate helps to facilitate self-feeding for clients who have vision loss. Staff can describe the location of the food on the plate by using a clock pattern, allowing the client to have greater independence during meals
A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following should the nurse identify as a potential indication of elder abuse? a) The caregiver is the client's financial power of attorney. b) The client is in a wheelchair with the wheels locked. c) The client reports receiving a full bath twice each week. d) The caregiver insists on remaining in the room.
Correct answer: D.- A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment.
A middle adult client tells the nurse, "I feel useless now that my children do not need me anymore." Which of the following responses should the nurse make? a) "Most people are happy when their children grow up and leave home." b) "You should be proud that your children are becoming independent." c) "Maybe you should consider why you are feeling useless." d) "People in middle adulthood often find satisfaction in nurturing and guiding young people."
Correct answer: D.- According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore opportunities for mastering the developmental tasks of this stage with the client, such as volunteering and mentoring young people
A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? a) Place the client in high-Fowler's position. b) Increase the client's intake of carbohydrates. c) Massage reddened areas with unscented lotion. d) Have the client use a trapeze bar when changing position.
Correct answer: D.- By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-injury development.
A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device? a) "This type of hearing aid does not allow for fine tuning of volume." b) "I shouldn't have trouble keeping the hearing aid in place during exercise." c) "I expect to hear a whistling sound when I first insert the hearing aid." d) "I will be sure to remove my hearing aid before taking a shower."
Correct answer: D.- Clients should remove any hearing devices before showering because exposure to water can damage them.
A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication if fluid volume excess? a) Hypotension b) Weak, thready pulse c) Slow capillary refill d) Distended neck veins
Correct answer: D.- Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure. A decrease in capillary refill time is an indication of fluid volume deficit. Other indications of fluid volume deficit, or dehydration, include output of less than 30 mL/hr and dark yellow urine. A weak, thready pulse is an indication of fluid volume deficit. Other indications of fluid volume deficit, or dehydration, include an increased hematocrit and urine specific gravity. Hypotension is an indication of fluid volume deficit. Other indications of fluid volume deficit, or dehydration, are dry mucous membranes and sunken eyeballs.
A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile infection. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative airflow system. b) Use alcohol-based hand sanitizer when leaving the client's room. c) Clean contaminated surfaces in the client's room with a phenol solution. d) Have family members wear a gown and gloves when visiting.
Correct answer: D.- Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Staff must also wear gowns and gloves. The nurse should use soap and water for hand hygiene because alcohol-based hand sanitizer does not kill Clostridium difficile spores. A client who has a Clostridium difficile infection requires a private room, but a negative airflow system is not necessary
A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? a) Role play b) Group discussions c) Question-answer meetings d) Practice sessions
Correct answer: D.- Practice sessions require psychomotor skills when learning. Question-answer meetings promote cognitive learning. Group discussions assist adolescents with cognitive and affective learning. Role play is a technique that promotes cognitive and affective learning
A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include? a) "You should have an eye examination every 2 years." b) "You should receive a tetanus booster every 5 years." c) "You should receive a shingles vaccine when you are 70 years old." d) "You should receive a pneumococcal vaccine when you are 65 years old."
Correct answer: D.- The nurse should instruct older adult clients to receive one of the two pneumococcal vaccines when they are 65 years old. The vaccines can be given to clients who are 19 years of age and older and have certain conditions, such as chronic heart, lung, or liver disease, diabetes mellitus, and alcohol disease, or to those who smoke cigarettes. The nurse should instruct older adult clients to receive a shingles vaccine when they are 60 years old. Older adults should receive a tetanus booster every 10 years. Older adults should have an eye examination every year.
A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take t decrease the client's risk of developing plantar flexion contractures? a) Place a pillow under the client's knees. b) Position a trochanter roll under each of the client's hips. c) Advise the client to wear rubber-soled slippers. d) Apply an ankle-foot orthotic device to the client's feet.
Correct answer: D.- The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress.
A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? a) Seal unused medications from the facility in a plastic bag. b) Evaluate the client's ability to self-administer medications. c) Report an identified discrepancy to The Joint Commission. d) Compare prescriptions with medications the client received while at the facility.
Correct answer: D.- When performing medication reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with those the provider has prescribed for the client to take after discharge.
A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration? a) Purulent exudate b) Warmth c) Skin blanching d) Bleeding
Correct answer: Skin blanching, edema, and coolness at the IV site indicate infiltration. Warmth indicates phlebitis, not infiltration. Exudate indicates infection, not infiltration. Bleeding can have a mechanical cause or can occur as the result of anticoagulation. It is not a sign of infiltration.
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? a) Ask the client to consider a direct donation. b) Withhold the blood transfusion. c) Request a consultation with the ethics committee. d) Ask the client's family to intervene.
Correct answer: The principle of autonomy ensures that a client who is competent has the right to refuse treatment
To obtain an accurate blood pressure measurement,
the nurse should inflate the cuff 30 mm Hg beyond the point at which the nurse was last able to palpate the pulse. If the nurse last palpated the pulse at 92 mm Hg, then this would be the correct pressure to which the nurse should inflate the cuff.
