ATI Comprehensive

A client with a cystocele is encouraged to exercise to strengthen pelvic floor muscles and prevent pelvic organ prolapse. What exercise will the client need to perform? Select One: A. Isometric exercises B. Uterine extension exercises C. Circumduction exercises D. Kegel exercises

D. Kegel exercises

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? A. Open all sterile supplies and solutions B. Stabilize the tracheostomy tube C. Don sterile gloves D. Perform hand hygiene

D. Perform hand hygiene

A client is prescribed antibiotic "A" 50 mg IV. The mixed IV solution contains 100 mL. The nurse is to administer the medication over ½ hour. The drip factor of the available IV tubing is 15gtt/mL. What is the drip rate in drops per minute? (Round to nearest whole number and enter only the number in the answer box).

50 gtt/min

A nurse on a medical surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first? A. Assessment B. Plan of care C. nursing interventions performed D. evaluation of progress

A. Assessment

A nurse is caring for a client who is postoperative and who has an indwelling urinary catheter to gravity drainage. The nurse notes no urine output in the past 2 hr. which of the following actions should the nurse take first? A. Check to determine if the catheter tubing is kinked B. palpate the bladder C. obtain a prescription to irrigate the catheter with 0.9% sodium chloride D. encourage the client to drink more fluids

A. Check to determine if the catheter tubing is kinked

A nurse is admitting a client who has decreased circulation to his left leg. Which of the following actions should the nurse take first? A. Evaluate pedal pulses B. Obtain a medical history C. Measure vital signs D. Assess for leg pain

A. Evaluate pedal pulses

A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicated that the teaching has been effective? A. I should expect my heart rate to take longer to return to normal after exercise as I get older B. Urinary incontinence is something I will have to live with as I get older C. I can expect to have less earwax as I get older D. my stomach will empty more quickly after meals as I get older

A. I should expect my heart rate to take longer to return to normal after exercise as I get older

A menopausal client is having difficulty getting to sleep and asks what actions she should incorporate in her daily routine to promote sleep. The nurse would encourage, which of the below measures to promote sleep? Select One: A. Limit alcohol and nicotine prior to bedtime. B. Consume a warm drink at bedtime. C. Take an afternoon nap. D. Take an evening walk before bedtime.

A. Limit alcohol and nicotine prior to bedtime.

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from the stretcher to the bed? A. Lock the wheels on the bed and stretcher B. Instruct the client to raise his arm above his head C. Elevate the stretcher 2.5 cm (1in) above the height of the bed D. Log Roll the client

A. Lock the wheels on the bed and stretcher

A nurse is caring for a client who has been prescribed furosemide. Which of the following foods should the nurse encourage this to include in his diet? Select One: A. Oranges B. White wine C. Egg yolks D. Table salt

A. Oranges

A nurse is caring for a client with heart failure who has evidence of dyspnea, bibasilar crackles and frothy sputum. What dietary recommendations should be provided to this client in management of their heart failure? Select One: A. Reduce sodium intake B. Decrease protein intake. C. Increase fluid intake. D. Decrease calcium intake.

A. Reduce sodium intake

A nurse manager is providing staff education on the correct use of restraints. Which of the following should be included in this education? Select all that apply. Choices: A. Restraints should never be used because of short staffing. B. Assess neurovascular and neurosensory status every 2 hours. C. It is not necessary to document the behaviors making restraint necessary. D. Restraints should never interfere with treatment. E. Staff must document type and location of the restraint and time applied.

A. Restraints should never be used because of short staffing. B. Assess neurovascular and neurosensory status every 2 hours. D. Restraints should never interfere with treatment. E. Staff must document type and location of the restraint and time applied.

A nurse is providing dietary education to a client with cholecystitis who has been prescribed a low-fat diet. Which of the following meal selections by the client indicates understanding of education? Select One: A. Roast turkey, rice pilaf, green beans B. Creamed chicken on a roll with peas C. Macaroni and cheese, salad, pudding D. Roast beef with gravy, mashed potatoes, ice cream

A. Roast turkey, rice pilaf, green beans

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers that the client is unresponsive to verbal or painful stimuli, has no respiration, and is pulseless. Which of the following actions should the nurse take first? A. Start chest compressions B. provide breaths with a manual resuscitation bag C. Administer oxygen D. Establish an airway

A. Start chest compressions

A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make? A. Tell me what I can do to help you overcome your fear of giving injections B. I am sure your provider will not be pleased that you refuse to give yourself insulin injections C. its ok I'm sure your partner will learn how to give you the insulin injections D. you won't be able to go home unless you learn to give yourself insulin injections

A. Tell me what I can do to help you overcome your fear of giving injections

A nurse is preparing to administer total parenteral nutrition (TPN) to a client. Which of the following findings indicates a need to obtain a new bag of TPN before administering? Select One: A. The TPN solution has an oily appearance and a layer of fat on top of the solution. B. The bag of TPN is labeled with the client's name, medical record number and prescription. C. The bag of TPN was prepared by the pharmacy 12 hours prior. D. The TPN solution contains added electrolytes, vitamins and trace elements.

A. The TPN solution has an oily appearance and a layer of fat on top of the solution.

A nurse is teaching an assistive personnel about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? A. There are times I should use soap and water rather than an alcohol based hand rub to clean my hands B. I will use cold water when I wash my hands to protect my skin from becoming too dry C. I will apply friction for at least 10 seconds when washing my hands D. After washing my hands I will dry them from the elbow down.

A. There are times I should use soap and water rather than an alcohol based hand rub to clean my hands

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? A. Vitamin C and Zinc B. Vitamin D C. Vitamin K and iron D. Calcium

A. Vitamin C and Zinc

A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? A. attempt to increase the client's self-motivation B. keep detailed records of each client's progress C. test client learning after each teaching session D. avoid discussing areas that might cause client anxiety

A. attempt to increase the client's self-motivation

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen? A. collect the specimen upon arising in the morning B. force fluids during the day and collect the specimen in the evening C. collect the specimen after antibiotics is started D. collect 2 mL of sputum before sending the specimen to the laboratory.

A. collect the specimen upon arising in the morning

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops? A. drop the eye medication in the outer third of the lower conjunctival sac B. apply gentle pressure in the outer opening of the eye for 2 min C. hold the eyedropper 0.5 cm (0.2 in) from the cornea D. instruct the client to close the eyes tightly after administration

A. drop the eye medication in the outer third of the lower conjunctival sac

A nurse is helping a client change his hospital gown. The client has an IV infusion on an infusion pump. Which of the following actions should the nurse take first? A. remove the sleeve of the gown from the arm without the IV line B. slow the infusion using the roller clamp C. Disconnect the IV line from the pump D. Bring the IV solution and tubing from the outside to the end side of the sleeve of the gown.

A. remove the sleeve of the gown from the arm without the IV line

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? A. renew the prescription for the use of restraints within 24 hours B. secure the restraint with the buckle side next to the client's skin C. ensure 4 fingers can be inserted under the secured restraint D. remove the restraint every 3 hours

A. renew the prescription for the use of restraints within 24 hours

A nurse is providing teaching to a client who has heart failure about how to decrease his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? A. the involvement of the client in planning the change B. the emphasis the provider places on the dietary changes C. the learning theory the nurse used to teach the dietary changes D. the extent of the dietary changes planned for the client

A. the involvement of the client in planning the change

A nurse is planning to administer pain medication to a client who has pain following abdominal surgery. Which of the following actions should the nurse take first? A. use the pain scale to determine the client's pain level B. discus the adverse effects of pain medication with the client C. obtain the clients vital signs D. check the client's allergies

A. use the pain scale to determine the client's pain level

A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client's risk for falls? Select one: A.Hourly rounding by the nurse B.Use of a night-light. C.Place bedside table in close proximity. D.Demonstrate how to use the call light.

A.Hourly rounding by the nurse

A nurse is caring for a client with a closed head injury. When pressure is applied to the client's nail beds, the client's eyes open and adduction of the arms with flexion of the elbows and wrists is noted. The client also moans with stimulation. What is this client's Glasgow Coma Score? Select One: A. 9 B. 7 C. 4 D. 10

B. 7

A nurse is caring for several clients prescribed heat/cold therapies. Which of the following clients are at risk of injury from these therapies? Select all that apply. Choices A. A middle age adult client prescribed cold therapy for muscle spasms. B. A client with diabetes prescribed cold therapy for a fractured toe. C. A cognitively impaired older adult prescribed alternating heat and cold therapy. D. An older adult client prescribed heat therapy for hip pain E. A fair-skinned, school age client prescribed heat therapy after a soccer injury.

B. A client with diabetes prescribed cold therapy for a fractured toe. C. A cognitively impaired older adult prescribed alternating heat and cold therapy. D. An older adult client prescribed heat therapy for hip pain. E. A fair-skinned, school age client prescribed heat therapy after a soccer injury.

A nurse is caring for a client who is postoperative and has a paralytic ileus. Which of the following abdominal assessments should the nurse expect? A. Frequent bowel sounds with flatus B. Absent bowel sounds with distention C. Hyperactive bowel sounds with diarrhea D. Normal bowel sounds with increased peristalsis

B. Absent bowel sounds with distention

A nurse is caring for a client who is admitted for observation and has full range of motion. Which is the best manner to encourage the client to void? Select One: A. Bedpan B. Client Bathroom C. Bedside Commode D. Urinal

B. Client Bathroom

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? A. change the topic because the client is trying to divert attention from the illness to the nurse B. Encourage the client to express his thoughts about death and dying C. Tell the clients that religious reliefs are a personal matter D. Offer to contact the client's minister or facilities chaplain

B. Encourage the client to express his thoughts about death and dying

A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for four days. Which of the following actions should the nurse take to assess the client's skin turgor? A. push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink B. Grasp as kin fold on the chest under the clavicle, release it and note whether it springs back C. Press the skin in above the ankle for 5 seconds, release it and note the depth of the impression D. measure the skinfold thickness at the upper arm using a pair of calibrated skinfold calipers

B. Grasp as kin fold on the chest under the clavicle, release it and note whether it springs back

A nurse is caring for a client receiving radiation treatments for cancer. The client states he is experiencing dryness, redness and scaling at the treatment area. Which of the following should the nurse instruct the client to do? Choices: A. Apply moist heat to the area twice daily. B. Liberally apply prescribed lotion to the area. C. Wash the affected area daily with antimicrobial soap. D. Sit in the sun for 15 minutes per day.

B. Liberally apply prescribed lotion to the area.

A nurse is preparing to anchor with tape the catheter tube for a male client who has a newly inserted indwelling urinary catheter. At which of the following locations should the nurse tape the catheter? A. Lateral thigh B. Lower Abdomen C. Mid Abdominal region D. medial thigh

B. Lower Abdomen

A nurse is changing the dressing for a client who has two Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation? A. Abdominal binder B. Montgomery straps C. Hypoallergenic tape D. Plastic tape

B. Montgomery straps

A nurse on a medical surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process? A. Identify goals for client care B. Obtain client information C. Document nursing care needs D. Evaluate the effectiveness of care

B. Obtain client information

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? A. Obtaining hydrogen peroxide for the tracheostomy care B. Obtaining cotton balls for the tracheostomy care C. obtaining sterile gloves for the tracheostomy care D. Obtaining a sterile brush for the tracheostomy care

B. Obtaining cotton balls for the tracheostomy care

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention? A. holding a community clinic to administer influenza vaccinations B. Screening groups of older adults in nursing care facilities for early influenza manifestations C. Educating parents of young children about dangers of influenza D. Finding rehabilitation programs for older adults who have complications from influenza

B. Screening groups of older adults in nursing care facilities for early influenza manifestations

A nurse is assisting a client with his meal that is at risk for aspiration due to a stroke. What interventions should the nurse take to prevent aspiration? Select all that apply. Choices A. Provide oral hygiene before meals. B. Support client's upper back, neck and head during feeding. C. Position the client in Fowler's position. D. Instruct the client to tuck his chin when swallowing. E. Keep the client in semi-Fowler's position for at least 1 hour after the meal.

B. Support client's upper back, neck and head during feeding. C. Position the client in Fowler's position. D. Instruct the client to tuck his chin when swallowing. E. Keep the client in semi-Fowler's position for at least 1 hour after the meal.

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? A. The client asks the nurse to repeat the instructions before attempting the exercises B. The client reports severe pain C. The client asks the nurse how often deep breathing should be done after surgery D. The client tells the nurse that this exercise will probably be painful after surgery

B. The client reports severe pain

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse plan to take? A. Place the soiled linens on the chair while making the bed B. hold the linens away from the body and clothing C. place the linens on the floor until able to place it in a linen bag D. Shake the clean linens to unfold

B. hold the linens away from the body and clothing

A nurse is caring for a toddler at a well-child visit when the mother calls to the nurse, "hey my baby is choking on his food". Which of the following findings indicates that the toddler has an airway obstruction? A. Flushing of the skin B. inability of the toddler to cry or speak C. presence of nausea and mild emesis D. capillary refill time 1.5 sec

B. inability of the toddler to cry or speak

A nurse is caring for an older adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? A. encourage the client to drink fluids before swallowing the food B. offer the client tart or sour foods first C. tilt the clients head backward when swallowing D. turn on the television

B. offer the client tart or sour foods first

A nurse is preparing to administer an Intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? A. the lower medial quadrant of the buttock near the coccyx B. the side hip between the iliac crest and the anterior iliac spine C. the tissue of the posterior upper arm D. the lower inner thighs 4 finger widths above the patella

B. the side hip between the iliac crest and the anterior iliac spine

A nurse is completing a nutritional assessment on a client and measures body mass index (BMI). Which of the following readings correlates with a BMI of an overweight client? Select One: A. 24.9 B. 32 C. 25 D. 18.5

C. 25

A nurse is caring for a client with encephalopathy secondary to liver failure. The client has been prescribed a high calorie, low protein diet. Which of the following meal selections is appropriate for this client? Select one: A. Grilled cheese sandwich, potato chips, chocolate pudding. B. Steak, french fries, corn. C. Chicken breast, mashed potatoes, spinach. D. Scrambled eggs, bacon and pancakes.

C. Chicken breast, mashed potatoes, spinach.

A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should a charge nurse teach ad the first response in CPR? A. Call for assistance B. Begin chest compressions C. Confirm unresponsiveness D. Give rescue breaths

C. Confirm unresponsiveness

A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? A. Measure the pulse using a Doppler ultrasound stethoscope B. check the clients pedal pulses C. Count the apical pulse rate for one full minute, and describe the rhythm in the chart D. Take the pulse at each peripheral site and count the rate for 30 seconds

C. Count the apical pulse rate for one full minute, and describe the rhythm in the chart

A nurse is preparing to insert and NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? A. Provide the client with a glass of water B. Assist the client to a sitting position C. Explain the procedure to the client D. Measure the length of tubing to be inserted

C. Explain the procedure to the client

A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? A. My parents are retired and they have to come help out with our children B. I am going to ask my husband to go to counseling with me C. I keep having nightmares about my upcoming surgery D. My girlfriends bought me a nice wig

C. I keep having nightmares about my upcoming surgery

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads: clear liquids; advance diet as tolerated. Which of the following responses should the nurse make? A. Lunch trays should be here within the hour B. I am going to listen to your abdomen C. I'll get you some water to drink D. I would wait a bit or you could feel sick

C. I'll get you some water to drink

What is the name of a legal document that instructs health care providers and family members about what, if any, life-sustaining treatment an individual wants if at some time the individual is unable to make decisions? Select one: A. Informed consent B. Durable power of attorney for health care C. Living will D. Do Not Resuscitate

C. Living Will

A nurse is caring for a client receiving opiates for pain management. Initially after the pain management plan was started, the client was sedated and sleeping most of the time. After three days on the plan the client is no longer sedated and sleeping regularly. What action should the nurse take? Select One: A. Notify the provider that a dosage adjustment is needed. B. Initiate additional non-pharmacological pain management techniques. C. No action is needed at this time. D. Contact the provider to request an alternate method of pain management.

C. No action is needed at this time.

A nurse is preparing to remove a NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? A. Maintain suction while removing the NG tube B. Instill 100 ML of air into the tube before removal C. Pinch the NG tube while removing the tube D. instruct the client to breath in and out during the removal of the NG tube

C. Pinch the NG tube while removing the tube

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? A. tie the restraints to the side rails B. perform range of motion exercises to the wrists every 3 hours C. Remove the restraints one at a time D. Obtain a PRN prescription for the restraints

C. Remove the restraints one at a time

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? A. Contact the family and ask them to stay with the client B. Offer to call the client's minister C. Sit and hold the clients hand D. Leave the room and allow the client to cry privately

C. Sit and hold the clients hand

A nurse on a medical surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical handwashing technique? A. The nurse washes each parts of her hands with 5 strokes B. the nurse washes from the elbow down to the hands C. The nurse washes with her hands held higher than her elbows D. the nurse uses minimal friction when washing her hands

C. The nurse washes with her hands held higher than her elbows

A client with hearing loss has been fitted for a hearing aid. Which of the following teaching points are important for the nurse to discuss with the client? Select One: A. Use the highest setting to promote full auditory comprehension. B. Immerse the hearing aid in saline solution to keep it hygienic. C. Use mild soap and water to clean the ear mold. D. Turn the hearing aid off to conserve battery life during hours of sleep only.

C. Use mild soap and water to clean the ear mold.

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? A. Encourage the child to cough frequently to clear congestion from anesthesia B. place a heating pad at the clients neck for comfort C. administer analgesics to the child on a routine schedule throughout the day and night D. provide the child with ice-cream when oral intake is initiated

C. administer analgesics to the child on a routine schedule throughout the day and night

A nurse is inserting an IV catheter for a client that results in blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? A. wash the gloved hands then throw the gloves away B. prepare an incident report to document the event C. carefully remove the glove and follow with hand hygiene D. ask the provider to order a blood culture to determine the risk of infection

C. carefully remove the glove and follow with hand hygiene

A nurse is assessing a client who is eating at mealtime. The client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? A. Place an oxygen mask on the client B. Check the client's pulse C. determine whether the client is able to breathe D. wrap arms around the client from behind

C. determine whether the client is able to breathe

A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take? A. Auscultate for bowel sounds after each feeding B. ensure the formula is cold before administering C. elevate the clients head of the bed 45 degrees before the feeding D. Flush the tubing with 15 ml of water after the enteral feeding

C. elevate the clients head of the bed 45 degrees before the feeding

A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? A. hold the irrigator 1.25 cm (0.5 in) above the eye B. direct the irrigation solution upward toward the upper eyelid C. exert pressure on the bony prominences when holding the eyelids open D. Direct the irrigation form the outer cantus to the inner cantus of the eye.

C. exert pressure on the bony prominences when holding the eyelids open

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? A. stand towards the client's stronger side B. instruct the client to lean backwards from the hips C. place the wheelchair at a 45 degrees angle the bed D. Assume a narrow stance with feet 15 cm (6in) apart

C. place the wheelchair at a 45 degrees angle the bed

A nurse is preparing to perform mouth care for an unresponsive patient. Which of the following actions should the nurse plan to take? A. Place the client supine B. Keep both side rails up C. raise the level of the bed D. Inspect the client's mouth using a finger sweep

C. raise the level of the bed

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? A. drink a minimum of 1000 of milliliters of fluids daily B. increase your intake of refined fiber foods C. sit on the toilet 30 minutes after eating a meal. D. Take a laxative every day to maintain regularity

C. sit on the toilet 30 minutes after eating a meal.

A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 deg C (102.6 deg. F), heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority? A. heart rate 105/min B. soft nontender abdomen C. temperature D. overdue menses

C. temperature

A nurse is assessing a client who has an onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? A. Does the medication you're taking relieve the pain? B. can you point to where the pain is the worst? C. what do you think caused the onset of your pain? D. changing positions makes your pain worst right?

C. what do you think caused the onset of your pain?

Match the following isolation precautions to the correct disease process. Contact precautions: - A private room or a room with other clients with the same infection. -Gloves and gowns worn by the caregivers and visitors. Airborne precautions: - A private room. - Masks or respiratory protection devices for caregivers and visitors. - An N95 or high-efficiency particulate air (HEPA) respirator is used if the client is known or suspected to have tuberculosis. - Negative pressure airflow exchange in the room of at least six exchanges per hour. Droplet precautions: - A private room or a room with other clients with the same infectious disease. - Masks for providers and visitors Choices Measles Pertussis Vancomycin Resistant Enteroccus (VRE)

Contact precautions: Vancomycin Resistant Enteroccus (VRE) - A private room or a room with other clients with the same infection. -Gloves and gowns worn by the caregivers and visitors. Airborne precautions: Measles - A private room. - Masks or respiratory protection devices for caregivers and visitors. - An N95 or high-efficiency particulate air (HEPA) respirator is used if the client is known or suspected to have tuberculosis. - Negative pressure airflow exchange in the room of at least six exchanges per hour. Droplet precautions: Pertussis - A private room or a room with other clients with the same infectious disease. - Masks for providers and visitors

A nurse is providing postoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client? A. Ask the provider to provide epoetin before the surgery B. you should ask your provider about taking iron supplements prior to the surgery C. Request a family member to donate blood for you D. Donate autologous blood before the surgery

D. Donate autologous blood before the surgery

A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure which of the following actions should the nurse take first? A. Explain the X-ray procedure to the client B. Help the client into a wheelchair before the transporter arrives C. Ask if the client has any questions D. Identify the client using two identifiers

D. Identify the client using two identifiers

Which of the following can cause a low pulse oximetry reading? Select One: A. Hyperthermia B. Low altitudes C. Increased hemoglobin level D. Inadequate peripheral circulation

D. Inadequate peripheral circulation

A nurse is verifying nasogastric tube placement by the pH of aspirated gastric fluid. Which of the following pH values provides a good indication of correct tube placement? Select one: A. 5 B. 7 C. 9 D. 2

D. 2

A nurse is caring for a client receiving chemotherapy that is experiencing neutropenia. Which of the following should the nurse include in this client's education? Select One: A. Eat plenty of fresh fruits and vegetables. B. Gardening is a good form of mild exercise. C. Take temperature weekly. D. Avoid crowded events.

D. Avoid crowded events.

A nurse is caring for a client who is unstable and have vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? A. turn on the machine every 15 minutes to measure the clients blood pressure B. record only blood pressures needed for the 15 minute interval C. Obtain manual and automatic readings and compare them D. Disconnect the machine and measure the blood pressure manually every 15 minutes.

D. Disconnect the machine and measure the blood pressure manually every 15 minutes.

A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document. A. Audible Click B. Murmur C. Third heart sound D. Pericardial friction rub

D. Pericardial friction rub

A nurse at a screening clinic is assessing a client who reports a history of heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? A. Fifth intercostal space just medial to the midclavicular line B. Second intercostal space to the left of the sternum C. Fifth intercostal space to the left of the sternum D. Second intercostal space to the right of the sternum

D. Second intercostal space to the right of the sternum

A nurse is planning to obtain the vital signs of a 2-year old child who is experiencing diarrhea and who might have right ear infection. Which of the following routes should then nurse use to obtain the temperature? A. Rectal B. Tympanic C. Oral D. Temporal

D. Temporal

A nurse is caring for a client with celiac disease. Which food should be removed from the meal tray? Select One: A. Corn bread B. Lentils C. Mashed potato D. Tortillas

D. Tortillas

A nurse observes an assistive personnel preparing to obtain blood pressure with a regular sized cuff for a client who is obese. Which of the following explanations should the nurse give the assistive personnel? A. The reading will be inaudible is the cuff is too small for the client B. The width of the cuff bladder should be 75% of the circumference of the client's arm C. As long as the cuff will circle the arm the reading will be accurate D. Using a cuff that is too small will result in an inaccurately high reading

D. Using a cuff that is too small will result in an inaccurately high reading

A nurse is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? A. tenderness when touched B. pink shiny tissue with a granular appearance C. serosanguinous drainage D. a halo of erythema on the surrounding skin

D. a halo of erythema on the surrounding skin

A nurse is caring for a client who has a major fecal incontinence and reports irritation to the perineal area. Which of the following actions should the nurse take first? A. apply a fecal collection system B. apply a barrier cream C. cleanse and dry the area D. check the client's perineum

D. check the client's perineum

A nurse is collecting a urine specimen for culture and sensitivity for a client who has a urinary tract infection. The client has an indwelling urinary catheter in place. Which of the following actions should the nurse take? A. withdraw the specimen from the drainage bag B. cleanse the collection port with soap and water C. place the specimen in a clean specimen cup D. clamp the tubing below the collection port

D. clamp the tubing below the collection port

A nurse is caring for a client who has a mastectomy and has a self-suction drainage evacuator in place. Which of the following actions should the nurse take to ensure proper operation of the device? A. irrigate the tubing with sterile normal water once each shift B. cleanse the opening with soap and water after emptying C. maintain the tubing above the level of the surgical incision D. collapse the device of air after emptying

D. collapse the device of air after emptying

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client? A. speak directly into the client's impaired ear B. exaggerate lip movements C. speak loudly D. face the client when speaking

D. face the client when speaking

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following information should the nurse include in the teaching? A. the wound edges are well approximated B. the wound is closed at a later date C. A skin graft is placed over the wound bed D. granulation tissue fills the wound during healing

D. granulation tissue fills the wound during healing

A nurse is preparing a client who is schedules for a hysterectomy for transport to the operating room when the client states she no longer wants to have the surgery. Which of the following actions should the nurse take? A. tell the client it is too late for her to change her mind because the surgery is already scheduled. B. telephone the operating room and cancel the surgery C. inform the clients family about the situation D. notify the provider about the clients decision

D. notify the provider about the clients decision

The nurse is obtaining a blood pressure in a client's lower extremity. Which of the following actions should the nurse take? A. Auscultate for the blood pressure at the dorsalis pedis artery B. Measure the blood pressure with the client sitting on the side of the bed C. place the cuff 7.6 cm (3in) above the popliteal artery D. place the bladder of the cuff over the posterior aspect of the thigh

D. place the bladder of the cuff over the posterior aspect of the thigh

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? A. instruct the client to defecate in the toilet bowel B. transfer the specimen to a sterile container C. refrigerate the collected specimen D. place the stool specimen collection container in a biohazard bag

D. place the stool specimen collection container in a biohazard bag

A nurse is changing the dressing for a client who is 3 days postoperative following a cholecystectomy. The nurse observes yellow, thick drainage on the dressing. The nurse should document this finding as which of the following types of drainage? A. Sanguineous exudate B. Serous exudate C. serosanguineous drainage D. purulent exudate

D. purulent exudate

A nurse is witnessing a client sign an informed consent for surgery. Which of the following describes what the nurse is affirming by this action? A. The client fully understands the provider's explanation of the procedure B. the client has been informed about the risks and benefits of the procedure C. the nurse witnessed the provider's explanation of the procedure D. the signature on the preoperative consent form is the client's

D. the signature on the preoperative consent form is the client's

A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings? A. roll the stocking partially down if too long B. remove the stockings once per day C. bunch and pull the stockings halfway up the calf D. turn the stockings inside out up to the heel before applying

D. turn the stockings inside out up to the heel before applying

A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make? A. it's for your safety. Dentures can slip and block your airway during surgery B. you wouldn't want your teeth to be lost or broken in surgery would you? C. the anesthesiologist requires everyone to remove their dentures D. what worries you about being without your teeth?

D. what worries you about being without your teeth?

A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment. Choices: Inspection Palpation Percussion Auscultation

Inspect, Auscultate, percussion, palpation

Match the description to the correct stage of pressure ulcer. Intact skin with an area of persistent, nonblanchable redness, typically over a bony prominence, that may feel warmer or cooler than the adjacent tissue. The tissue is swollen and has congestion, with possible discomfort at the site. With darker skin tones, the ulcer may appear blue or purple. Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common. Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage. Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material). Choices: Stage 1 Stage 2 Stage 3 Stage 4

Intact skin with an area of persistent, nonblanchable redness, typically over a bony prominence, that may feel warmer or cooler than the adjacent tissue. The tissue is swollen and has congestion, with possible discomfort at the site. With darker skin tones, the ulcer may appear blue or purple. - STAGE 1 Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common. -STAGE 3 Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage. - STAGE 2 Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material). - STAGE 4

Match the development tasks with the correct age group. Personalize values and beliefs and base reasoning on ethical fairness principles. Establish close relationships. Have influences that help with formation of healthy self-concept, such family and friends. Take on new experiences and when unable to accomplish task may feel guilty or misbehave. Generally do not exhibit stranger anxiety. Understand behavior in terms of what is socially acceptable. Develop sense of personal identity that family expectations influence. Peer relationships develop as support system. Concerned with body images that media portray. Develop sense of industry through advances in learning. Strive to develop healthy self- respect by finding out in what areas they excel. Peer groups play important role in social development. Choices preschoolers 3-6 years School-age children 6-12 years Adolescents 12-20 years young adults 20-35 years

Personalize values and beliefs and base reasoning on ethical fairness principles. Establish close relationships. Have influences that help with formation of healthy self-concept, such family and friends. - young adults 20-35 years Take on new experiences and when unable to accomplish task may feel guilty or misbehave. Generally do not exhibit stranger anxiety. Understand behavior in terms of what is socially acceptable. - Preschoolers 3-6 years Develop sense of personal identity that family expectations influence. Peer relationships develop as support system. Concerned with body images that media portray. - Adolescents 12-20 years Develop sense of industry through advances in learning. Strive to develop healthy self- respect by finding out in what areas they excel. Peer groups play important role in social development.- School-age children 6-12 years

A client with COPD is using accessory muscles to breath and has a productive cough. To promote energy, the nurse should encourage high-calorie foods. Select One: True False

True

A client with Parkinson's Disease has muscle rigidity. The nurse should encourage the client to stop occasionally when walking to slow down speed and reduce risk of injury. Select One: True False

True

A nurse is providing education to a client with a fractured femur who will need to use crutches for the next 6 weeks. Identify if the following directions provided by the nurse for walking upstairs using crutches are true or false. A. Hold to rail with one hand and crutches with the other hand. B. Push down on the stair rail and the crutches and step up with the 'unaffected' leg. C. If not allowed to place weight on the 'affected' leg, hop up with the 'unaffected' leg. D. Bring the 'affected' leg and the crutches up beside the 'unaffected' leg. E. Remember, the 'unaffected' leg goes up first and the crutches move with the 'affected' leg.

True

Dehydration in clients leads to increased registered levels of glucose, electrolytes and hematocrit. Select One: True False

True