ATI final
A nurse is calculating the intake and output for a client over the last 8 hr. The client is receiving a continuous IV infusion at 150 mL/hr and had 4 oz of juice and 0.5 L of water. How many ml of fluid should the nurse document as the client's intake for the last 8 hr?
1,820
A nurse is preparing to administer a medication to a preschooler and must convert the child's weight from pounds to kilograms. The child weighs 30 lb. How many kilograms does the child weigh?
13.6
A nurse is administering an intramuscular (IM) injection to an adult client. Which of the following actions should the nurse take? A. Identify the landmarks for the ventrogluteal site before cleaning the skin. B. Insert the medication after obtaining blood return in the syringe. C. Massage the site after injecting the medication. D. Administer the medication quickly into the injection site.
A
A nurse is assisting with the plan of care for a client who has a bacterial infection and a persistent oral temperature of 38.9° C (102° F). Which of the following interventions should the nurse include in the plan of care to treat the fever? A. Administer acetaminophen. B. Apply ice packs to the client's axillae. C. Maintain the room temperature at 18.3° C (64.9° F). D. Assist the client to ambulate four times a day.
A
A nurse is caring for a client who has dyspnea caused by a respiratory infection. The nurse should assist the client into which of the following positions? A. Orthopneic B. Dorsal recumbent C. Sims' D. Prone
A
A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching? A. "I know that I can change my advance directives if I need to in the future." B. "My health care proxy will make my health care decisions as soon as I have signed the power of attorney." C. "My family can overrule the decisions made by my health care proxy." D. "Advance directives from one state are valid in any other state."
A
A nurse is providing oral hygiene for a client who is unconscious. Identify the sequence of the steps the nurse should take. A. Assess the client's gag reflex. B. Place a towel under the client's head with an emesis basin under his chin. C. Position the client on his side with his head turned to the side. D. Separate the client's upper and lower teeth with an oral airway device. E. Cleanse the client's mouth using a toothbrush.
A, C, B, D, E
A nurse is contributing to the plan of care for a client who is dying. Which of the following interventions should the nurse recommend to include the client's family in the plan of care? (Select all that apply.) A. Keep the family updated about the client's status. B. Suggest that family members return home at night to allow the client to rest. C. Encourage the family to comb the client's hair. D. Tell the client's family what to expect as the client's death nears. E. Ask the family to encourage the client to eat.
A, C, D
A nurse is caring for a client who is disoriented and at risk for falls. Which of the following actions should the nurse plan to take? (Select all that apply.) A. Ensure that the client is wearing nonskid slippers. B. Move the bedside table away from the bedside. C. Place the client in a room near the nurses' station. D. Keep the bed's full side rails in the up position. E. Reinforce teaching about how to use the call bell.
A, C, E
A charge nurse is reinforcing teaching with a newly licensed nurse who is setting up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching? A. Opening the first flap of a sterile package toward herself B. Dropping sterile gauze onto the field from a height of 7.5 cm (3 in) C. Removing and inverting a lid before placing it onto a nonsterile surface D. Maintaining the sterile field below waist level
C
A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching? A. Select an alternate site to place the oximetry probe if the capillary refill is less than 2 seconds. B. Use an adhesive oximetry probe for a client who has a latex allergy. C. Remove polish from the client's fingernail before applying the oximetry probe. D. Lubricate the tip of the oximetry probe.
C
A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops. Which of the following instructions should the nurse include? A. "You will need to look to the side when you put the drops in your eye." B. "You should put the drops directly in the center of your eyeball." C. "You should cleanse your eye from the inner to the outer edge prior to putting in the drops." D. "You should avoid pressing on your tear duct after putting the drops in your eye."
C
A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take? A. Close the fire doors on the unit. B. Use a fire extinguisher to put out the fire. C. Evacuate clients from the area. D. Pull the lever on the fire alarm box.
C, D, A, B
A client who is scheduled to undergo surgery tells the nurse that she does not understand the procedure and is reconsidering her decision to have it. Which of the following actions should the nurse take? A. Offer information about alternative therapies to the procedure. B. Contact a family member to convince the client to change her mind. C. Tell the client the benefits of the surgery. D. Notify the charge nurse of the client's concerns.
D
A nurse has delegated various client care tasks to the assistive personnel (AP) on the care team. Which of the following actions by the AP should the nurse identify as correct? A. Using hand sanitizer to cleanse her hands of spilled food from a client's meal tray B. Setting aside her gown for future use in the room of a client who has a wound infection C. Removing her gloves after exiting a client's room D. Donning a mask to measure the vital signs of a client who has pertussis
D
A nurse in a long-term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take? A. Sit beside the client. B. Speak slowly and loudly to the client. C. Dim the lights in the client's room. D. Choose a private room for the interview.
D
A nurse is caring for a client who is postoperative following a mastectomy. The client states, "I can barely look at myself in the mirror." The nurse should identify that the client is experiencing which of the following? A. Complicated grief B. Maturational loss C. Disenfranchised grief D. Actual loss
D
A nurse is caring for a client who has an NG tube and is receiving a continuous enteral feeding. Which of the following actions should the nurse take? A. Hold the feeding for two consecutive gastric residuals greater than 250 mL. B. Change the bag and tubing every 12 hr. C. Flush the tube with 0.9% sodium chloride irrigant every 8 hr. D. Heat the formula to body temperature before administering.
A
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? A. Clean the perineal area at least once a day. B. Empty the drainage bag when it is three-fourths full. C. Flush the catheter with sterile water daily. D. Disconnect the drainage bag when emptying and measuring urine.
A
A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity? A. Use warm water when bathing the client. B. Place a donut-shaped cushion in the client's chair. C. Massage reddened areas over bony prominences. D. Maintain the client in high-Fowler's position.
A
A nurse is caring for a client who has metastatic cancer and practices Catholicism. The client asks the nurse to discuss the afterlife with her. Which of the following statements by the nurse assists in meeting the client's spiritual needs? A. "Tell me what the afterlife means to you." B. "You should discuss the afterlife with your priest." C. "Keep praying. A miracle could happen." D. "Maybe your condition will lead you closer to God."
A
A nurse is caring for a client who is receiving intermittent enteral feedings. Which of the following is the priority action for the nurse to take? A. Measure the client's gastric residual before each feeding. B. Change the bag and tubing every 24 hr. C. Monitor intake and output. D. Flush the tubing with 30 mL of water after each feeding.
A
A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make? A. "It must be difficult facing this type of surgery." B. "Other clients who have had this surgery have done just fine." C. "This facility is known for providing excellent care for people who need this type of surgery." D. "I can request a sleeping pill, if you think that will help."
A
A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take? A. Count the client's radial and apical pulses simultaneously with another nurse. B. Calculate the client's pulse for 30 seconds and multiply by 2. C. Assist the client to a side-lying position. D. Auscultate the area of the client's chest over the Erb's point.
A
A nurse is collecting data from a client who is 2 days postoperative following a colostomy. Which of the following findings should the nurse report to the provider? A. A purple-colored stoma B. Protrusion of the stoma C. A small amount of bleeding from the stoma D. Intestinal gas in the pouch
A
A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take? A. Administer an analgesic 30 min before starting the procedure. B. Hold the syringe 5 cm (2 in) above the upper end of the wound. C. Place the irrigation solution in a basin of cool water. D. Perform the wound irrigation with a 10-ml syringe with an angiocatheter.
A
A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make? A. "Stand with your feet together and your arms at your sides." B. "After I place the tuning fork, tell me when you no longer hear the sound." C. "I'm going to stroke the lateral side of the bottom of your foot." D. "Touch each fingertip as quickly as possible with your thumb."
A
A nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following methods should the nurse use to verify correct placement of the NG tube? A. Check the pH of the gastric aspirate. B. Observe the color of the gastric aspirate after adding blue dye to the formula. C. Auscultate over the epigastrium. D. Measure the length of the inserted NG tube.
A
A nurse is preparing to remove a client's peripheral IV catheter. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first? A. Clamp the infusion tubing. B. Remove the dressing. C. Withdraw the catheter from the vein. D. Ensure the catheter is intact.
A
A nurse is providing wound care for a group of clients. Which of the following wounds should the nurse identify as healing by secondary intention? A. A stage 3 pressure ulcer on the coccyx B. A contaminated wound that is closed after 72 hr C. A puncture wound that is sutured D. An abdominal surgical wound with intact staples
A
A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include? A. Young adults should receive a dental assessment every 6 months. B. Young adult males should have a testicular examination every 5 years. C. Young adult females should have a routine physical examination every 4 years. D. Young adults should receive a tuberculosis skin test every 3 years.
A
A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching? A. "I will be sure to keep the crutch tips dry." B. "I will hold a crutch in each hand when sitting down." C. "I will place my weight on my underarms." D. "I will lead with my right leg when going up stairs."
A
A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of health behavior change? A. Precontemplation B. Preparation C. Maintenance D. Action
A
A nurse is reinforcing teaching with a client who has a prescription for a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following information should the nurse include in the teaching? A. Place the electrodes near the pain site. B. The TENS unit has one constant frequency. C. The TENS creates a sharp burning sensation when turned on. D. The electrodes can be placed over hair.
A
A nurse is reinforcing teaching with a client who has insomnia. Which of the following statements by the client indicates an understanding of the teaching? A. "I should turn on the ceiling fan to block out unwanted noise." B. "I will limit my daily nap to 45 minutes." C. "I will drink a cup of green tea at bedtime to help me sleep." D. "I should get out of bed if I don't fall asleep within an hour of lying down."
A
A nurse is reinforcing teaching with a client who is receiving PCA. Which of the following statements by the client indicates an understanding of the teaching? A. "I will not allow anyone to press the PCA button for me." B. "I will overdose if I press the PCA button more than six times an hour." C. "I will wait to press the PCA button until my pain is intolerable." D. "I will inform my nurse of my pain level before I press the PCA button."
A
A nurse working in a community clinic is talking with an older adult client who states that his life has no purpose. The nurse should identify that the client is in which of the following stages of Erikson's Theory of Psychosocial Development? A. Ego integrity vs. despair B. Generativity vs. self-absorption C. Identity vs. role confusion D. Intimacy vs. isolation
A
A client who has advanced cancer tells the nurse that he has a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication? A. Keep the conversation moving by asking about his family. B. Let the client know that he is available and willing to listen. C. Ask if the client understands what to expect in the advanced stages of the illness. D. Ask the client's visitors to not say anything about the advanced disease.
B
A nurse in a long-term care facility is contributing to the plan of care for a client who is at risk for pressure ulcers. Which of the following recommendations should the nurse include in the plan? A. Complete a Braden scale at the first indication of pressure ulcer formation. B. Perform a thorough skin inspection each day. C. Gently massage skin over bony prominences. D. Place a dehumidifier in the client's room.
B
A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age-related changes? A. Body regulation of heat and cold increases with age. B. Circulation becomes less efficient with age. C. Increased metabolic rate occurs with age, increasing body temperature. D. Sweat gland activity is increased with age.
B
A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take? A. Restrict the client's visitors to the immediate family. B. Assign the client to a negative-pressure airflow room. C. Discard personal protective equipment outside the client's room. D. Have the client wear a HEPA mask during transportation throughout the facility.
B
A nurse is assisting with the care of a client who has a prescription for IV therapy. The client tells the nurse that he has numerous allergies. Which of following allergies should the nurse bring to the attention of the charge nurse prior to the initiation of the therapy? A. Eggs B. Latex C.Seafood D.Bee stings
B
A nurse is caring for a client who has a Clostridium difficile infection. Which of the following solutions should the nurse use to perform hand hygiene while caring for this client? A. Isopropyl alcohol B. Mild soap C. Chlorhexidine D. Triclosan
B
A nurse is caring for a client who has a prescription for a potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles? A. Autonomy B. Beneficence C. Justice D. Nonmaleficence
B
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infections? A. Empty the urine drainage bag every 12 hr. B. Drain urine from the tubing before ambulation. C. Use clean technique for urine specimen collection. D. Hang the urine drainage bag at the level of the bladder.
B
A nurse is caring for an older adult client who has advanced rheumatoid arthritis but seldom requests pain medication. Which of the following actions should the nurse take? A. Question the client using the FACES pain scale. B. Observe the client for nonverbal indications of pain. C. Wait for the client to report pain before offering medication. D. Take the client's vital signs to determine if he is experiencing pain.
B
A nurse is checking a client's muscle strength. Which of the following techniques should the nurse use? A. The nurse holds the sides of the client's head and attempts to turn it while the client resists. B. The client shrugs her shoulders while the nurse applies firm pressure over the midline of the shoulders. C. The nurse attempts to straighten the client's leg as the client offers resistance while in a seated position. D. The client holds her arms out and attempts to lower them while the nurse applies upward resistance.
B
A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan? A. Check that the restraint is tied to a fixed frame of the bed. B. Pad bony prominences on the wrist. C. Remove the restraint every 4 hr to allow movement. D. Tie the restraint with a knot that will tighten when pulled.
B
A nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care? A. Place the client in a room with another client who has pharyngitis. B. Ensure that the client wears a surgical mask during transportation throughout the facility. C. Limit the client's family member visitations to 30 min. D. Provide the client a room with negative-pressure airflow of six air exchanges per hr.
B
A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care? A. Check for capillary refill proximally to the elastic bandages every 12 hr. B. Compare the client's pedal pulses bilaterally every 4 hr. C. Place the client's legs in a dependent position for 30 min before applying the elastic bandages. D. Remove the elastic bandages every other day to inspect the skin.
B
A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following actions should the nurse recommend to include in the plan? A. Flex the client's feet using pillows. B. Support the client's feet with foot boots. C. Place a hand roll under the client's heels. D. Remove ankle-foot orthotic devices at bed time.
B
A nurse is contributing to the plan of care for four clients. For which of the following clients should the nurse initiate airborne precautions? A. A client who has pneumonia B. A client who has measles C. A client who has pertussis D. A client who has methicillin-resistant Staphylococcus aureus (MRSA)
B
A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off her right leg. Which of the following is the proper crutch gait for this client? A. Four-point B. Three-point C. Two-point D. Swing-through
B
A nurse is moving a client up in bed with the assistance of a second nurse. Which of the following actions should the nurse take? A. Stand facing the center of the bed at the client's side. B. Place feet apart with the foot nearest the head of the client's bed in front of the other foot. C. Keep knees and hips straight while bending at the waist towards the client. D. Encourage the client to keep his legs straight and remain still.
B
A nurse is palpating the pulse located on top of a client's foot. Which of the following pulses should the nurse document that she is palpating? A. Posterior tibial B. Dorsalis pedis C. Popliteal D. Femoral
B
A nurse is planning to administer medication to a client who has a Clostridium difficile infection. To prevent the transmission of this infection to others, which of the following actions should the nurse plan to take? A. Clean hands with an alcohol-based hand rub immediately after removing gloves. B. Remove the cover gown in the client's room after providing care. C. Place the client in a room with negative-pressure airflow. D. Wear a mask when administering oral medications to the client.
B
A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following client statements presents an ethical dilemma? A. "I might file a lawsuit because of how my surgery went." B. "Please don't tell my doctor, but I am taking my partner's oxycodone." C. "Please don't get me out of bed this morning. It hurts too much." D. "I don't want to take my medicine, It makes me sick to my stomach."
B
A nurse is reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of diabetes mellitus. Which of the following actions should the nurse take first? A. Use pictures of different food groups to help the client plan a daily menu. B. Ask the client what he already knows about meal planning. C. Give the client a brochure with sample menus for all meals. D. Involve the family in the discussion of the client's meal plan.
B
A nurse is reinforcing teaching with a client who has hearing loss about how to modify his home environment. Which of the following is a priority modification that the nurse should include? A. Alarm clock that shakes the bed B. Flashing smoke alarm C. Low-pitched buzzer doorbell D. Telephone with an amplified receiver
B
A nurse is reinforcing teaching with a client who is scheduled for a bladder scan. Which of the following instructions should the nurse include in the teaching? A. "You will need to sign a consent form before we begin the procedure." B. "I will place a gel pad directly above your pubic area before I place the probe." C. "You will need to hold your urine for 1 hour prior to the procedure." D. "You will receive a contrast dye through an IV catheter prior to the scan."
B
A nurse is reinforcing teaching with a group of clients about carbon monoxide poisoning. Which of the following information should the nurse include in the teaching? A. Carbon monoxide gas smells like rotten eggs. B. Headache is a manifestation of carbon monoxide poisoning. C. A pulse oximeter is used to diagnose carbon monoxide poisoning. D. Dusky mucous membranes are an early indication of carbon monoxide poisoning.
B
A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed? A. "Keep your feet close together." B. "Tighten your stomach muscles." C. "Straighten your knees." D."Bend at your waist."
B
A nurse is using Maslow's hierarchy of needs in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client? A. Volunteer at the local food pantry. B. Attend an exercise program. C. Find an enjoyable hobby. D. Support environmental conservation.
B
A nurse working in a hospital overhears the following conversation between two other nurses on the elevator. Which of the following actions should the nurse take? A. Inform the nurses that the neighbor's dog did not cause the wound. B. Tell the nurses that this conversation is not appropriate. C. Complete incident report upon returning to the unit. D. Report the nurses' conversation to the client's provider.
B
A nurse is caring for a group of clients in a long-term care facility. Which of the following actions should the nurse take to prevent health care- associated infections for these clients? (Select all that apply.) A. Place immunocompromised clients in the same room. B. Wash hands after removing gloves. C. Use antimicrobial hand gel after refilling the client's water pitcher. D. Clean the stethoscope with an antimicrobial wipe after obtaining vital signs. E. Administer a prophylactic dose of antibiotics prior to discharge.
B, C, D
A nurse is caring for a client who is postoperative and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit? (Select all that apply.) A. Full bounding pulse B. Decreased skin turgor Moist crackles in the lungs C. Orthostatic hypotension D. Flat neck veins
B, D, E
A client who had a recent below-the-knee amputation says, "I don't know how I can continue to live my life without my leg." Which of the following responses should the nurse make? A. "You can have a prosthesis after your recovery has progressed." B. "I am so sorry. I know I would hate to lose my leg." C. "Tell me what concerns you have about your future." D. "Your focus right now should be on recovering from the surgery."
C
A nurse in a provider's office is providing care for a middle adult client who has minimal exposure to sunlight. Which of the following interventions should the nurse recommend? A. Reduce intake of calcium-rich foods. B. Use sunscreen with skin protection factor (SPF) of 8. C. Take vitamin D supplements. D. Use a tanning bed 2 hr weekly.
C
A nurse in an acute care setting is documenting postmortem care for a client. Which of the following information should the nurse include in the documentation? A. Completion of an incident report B. Name of the nurse certifying the client's death C. Release of personal belongings form D. Listing of one identifier at the client's time of death
C
A nurse is assisting with the admission of a client who has brought her medications to the facility. Which of the following actions should the nurse take? A. Allow the client to continue taking the medications as she did at home. B. Take the medications from the client and discard them. C. Compare the medications the provider has prescribed with the client's medications from home. D. Place the medications in the medication cart and administer them as the client took them at home.
C
A nurse is assisting with the admission of an adult client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished? A. Heart rate 89/min B. Pink mucous membranes C. Pale, scaly skin D. Body mass index 23
C
A nurse is caring for a client who has been vomiting excessively and has diarrhea. Which of the following findings should the nurse identífy as an indication of fluid volume deficit? A. BUN 18 mg/dL B. A bounding pulse C. Urine specific gravity 1.045 D. Prominent neck veins
C
A nurse is caring for a client who has breast cancer and expresses fear about the future. Which of the following responses should the nurse make? A. "How long ago were you diagnosed with breast cancer?" B. "Don't be so frightened. Many people who have breast cancer survive." C. "You seem really afraid. Let's talk more about your feelings." D. "Have you talked to your family about your diagnosis? What do they think?"
C
A nurse is caring for a client who has chronic pain. The nurse recommends that the client concentrate on a memory of a pleasurable experience. Which of the following complementary therapies is the nurse suggesting? A. Art therapy B. Tai chi C. Guided imagery D. Biofeedback
C
A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse? A. "I don't understand why everyone is so worried about me." B. "I don't know if l'll ever find someone who wants to marry me." C. "When I look at myself in the mirror, I don't know if I can go on." D. "I feel like the doctor pressured me into having the mastectomy."
C
A nurse is caring for a client who is alert and in a long-term care facility. Which of the following actions should the nurse take to protect the client's privacy? A. Place laboratory results on the bedside table while ambulating the client. B. Give report about the client's status while standing in the hallway. C. Ask the client before discussing his condition when family is present. D. Place a message board in the client's room to post vital sign values.
C
A nurse is caring for a client who is receiving chemotherapy and has stomatitis. Which of the following actions should the nurse take to reduce the client's discomfort? A. Offer the client lemon-glycerin swabs. B. Encourage the client to drink hot tea. C. Use 0.9% sodium chloride solution to rinse the client's mouth. D. Provide a commercial mouthwash for the client's oral care.
C
A nurse is caring for a client who is receiving continuous NG tube feedings. The nurse listens to the client's bowel sounds. Which of the following actions should the nurse take? A. Replace the NG tube. B. Place the client in Sims' position. C. Decrease the rate of the feeding. D. Check the client's blood glucose.
C
A nurse is caring for a client who is refusing medical treatment. Which of the following actions should the nurse take? A. Explain the negative consequences of the refusal. B. Discuss with the client's partner why the treatment is necessary. C. Document the client's refusal of the treatment. D. Try to convince the client that the treatment is needed.
C
A nurse is caring for a female client who has urinary incontinence. Which of the following actions should the nurse take? A. Instruct the client to perform the Valsalva maneuver during urinary urges. B. Cleanse the client's labia minora before cleansing the labia majora. C. Apply a moisture skin barrier to the client's perineal area. D. Implement a toileting schedule for the client with 4 hr intervals.
C
A nurse is collecting data from a client who is menopausal. Which of the following statements indicates that the nurse should screen the client for depression? A. "Everything is fine. I started a glass blowing class this week." B. "I am really not old enough to be going through menopause." C. "My family doesn't need me anymore. I've failed them in so many ways." D. "I am only 50 and my children treat me like I am old."
C
A nurse is collecting data from a client who requires bed rest and reports abdominal discomfort. The nurse notes abdominal distention. Which of the following conditions should the nurse identify as an adverse effect of bed rest? A. Heartburn B. Anorexia C. Constipation D. Urinary urgency
C
A nurse is collecting data from an older adult client. Which of the following findings should the nurse report to the provider? A. The client has smooth, brown, irregular lesions on the back of each hand. B. The client has glossy, white circles around the periphery of the corneas. C. The client reports urinary incontinence. D. The client reports a decreased sense of taste.
C
A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify her religious preferences? A. "Do you receive Holy Communion?" B. "Do you follow a kosher diet?" C. "Do you consume pork products?" D. "Do you oppose receiving a blood transfusion if it is needed?"
C
A nurse is documenting client care in a client's electronic health record. Which of the following statements should the nurse include in the documentation? A. "The client complained about having to get out of bed." B. "The client was voiding well." C. "The client became short of breath when ambulating." D. "The client appears to be comfortable while in bed."
C
A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. Which of the following information should the nurse document? A. 1+ pitting edema B. 2+ pitting edema C. 3+ pitting edema D. 4+ pitting edema
C
A nurse is reinforcing teaching about hospice care measures with the family of a client who is dying. Which of the following statements by a member of the client's family indicates an understanding of the teaching? A. "We will make sure she eats three meals a day." B. "We will decrease her pain medication if she gets too drowsy." C. "We will keep her room cool to help her breathe better." D. "We will make sure to provide oral care twice a day."
C
A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure her blood pressure daily. Which of the following client statements indicates an understanding of the teaching? A. "I will wait 15 minutes after drinking coffee to measure my blood pressure." B. "I will measure my blood pressure while my arm is elevated above my heart." C. "I should remove constrictive clothing prior to measuring my blood pressure." D. "I should measure my blood pressure immediately after eating breakfast."
C
A nurse is reinforcing teaching with a new parent of an infant who is concerned about sudden infant death syndrome (SIDS). Which of the following statements by the client indicates an understanding of the teaching? A. "I will place my baby on her side to sleep." B. "I should avoid giving my baby a pacifier." C. "I will remove all stuffed animals from my baby's crib." D. "I will cover my baby with a light blanket when she is sleeping."
C
A nurse is reinforcing teaching with an older adult client who reports an inability to sleep. Which of the following information should the nurse include when teaching the client about aging and sleep? A. The need for sleep diminishes with age. B. Older adults have longer rapid eye movement (REM) periods. C. Sleep patterns change with age. D. Sleep apnea decreases with age.
C
A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the followìng responses should the nurse make? A. "Why are you angry about taking insulin?" B. "Don't worry. Diabetes runs in my family as well." C. "I see that you are angry. Let's sit down and talk." D. "You should take insulin, because it reduces the risk for complications."
C
A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. The nurse can disclose health information without the client's written permission to which of the following entities? A. An insurance agency offering a life insurance policy B. A family member who requests the client's diagnosis C. A physical therapist who is involved in the client's care D. An employer completing a pre-employment screening
C
A nurse writes client information on a piece of paper while receiving report, Which of the following actions should the nurse take to dispose of the paper? A. Give the paper to a member of the client's family. B. Place the paper in a receptacle at the nurse's station. C. Shred the paper in a secure container. D. Discard the paper at home.
C
A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that she is afraid to go to sleep, fearing she will not wake up. Which of the following is a therapeutic response the nurse should make? A. "I will have the nursing staff check on you frequently during the night." B. "You are right to be afraid. This is a new place for you." C. "I will give you your prescribed sleeping medication to help you fall asleep." D. "Describe your concerns about sleeping to me."
D
A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication? A. Provide an artificial voice box. B. Avoid using facial gestures. C. Speak to the client in a louder voice. D. Ask the client close-ended questions.
D
A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? A. Ensure a client can use crutches before discharge. B. Check a client's ability to swallow following a stroke. C. Obtain a client's pain rating prior to physical therapy. D. Assist a client to get out of bed after a breathing treatment.
D
A nurse is caring for a client who has a new diagnosis of cancer. Which of the following actions should the nurse take to maintain the client's confidentiality while providing care? A. Share the client's prognosis with a member of the client's family. B. Discuss the client's status with a member of pastoral care. C. Offer information to a friend of the client over the phone. D. Provide information to another nurse at change of shift.
D
A nurse is caring for a client who has a new prescription for oxygen at 7 L/min via simple face mask. Which of the following actions should the nurse take to ensure client safety? A. Keep the side holes of the mask closed. B. Ensure the reservoir bag is inflated on expiration. C. Apply petroleum jelly to the client's nostrils. D. Attach a humidifier to the base of the flow meter.
D
A nurse is caring for a client who has a prescription for a high-protein diet to promote wound healing following surgery. The client's religion prohibits eating meat on particular days. Which of the following actions should the nurse take? A. Encourage the client to eat meat during this time to promote healing. B. Advise the client to eat everything on the tray except the meat. C. Suggest the client receive high-protein enteral feedings. D. Ask the dietitian to recommend alternative food choices for the client.
D
A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority? A. Client reports voiding three times during the night. B. Client reports burning and discomfort with urination. C. The client's WBC count is 11,000/mm3. D. The client's output was 60 mL for the past 3 hr.
D
A nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the client? A. Offer the client a straw to drink liquids. B. Place food toward the back of the client's mouth. C. Encourage the client to lie down and rest for 30 min after meals. D. Instruct the client to tilt her head forward while eating.
D
A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? A. Arrange personal items on a table at the foot of the client's bed. B. Place the back of the bedside commode next to the client's bed. C. Raise four side rails on the client's bed during the night. D. Put the client's bed in the lowest position.
D
A nurse is caring for an older adult client and is concerned that the client may have a fecal impaction. Which of the following is the most important question for the nurse to ask? A. "What types of foods have you been eating?" B. "Are you using stool softeners or laxatives?" C. "Have you been passing gas?" D. "Have you had small liquid stools?"
D
A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic communication technique of silence? A. A client who plans to leave the facility against medical advice B. A client who informs the nurse that he has made his funeral arrangements C. A client who tells the nurse that the night shift nurse did not bring his medication D. A client who has just experienced the death of his child
D
A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicates hypomagnesemia? A. Bone pain B. Drowsiness C. Bowel hypomotility D. Positive Chvostek's sign
D
A nurse is collecting data from a client who is 1 day postoperative following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider? A. The client reports an incisional pain level of 7 on a scale of 0 to 10. B. The client reports increased nausea and chills. C. The client has an oral temperature of 39° C (102.2° F). D. The client has redness and warmth in his calf.
D
A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about a treatment is an example of which of the following ethical principles? A. Confidentiality B. Nonmaleficence C. Accountability D. Autonomy
D
A nurse is preparing to administer a topical medication to a client. Which of the following actions should the nurse take? A. Show the assistive personnel where to apply the medication. B. Ask the client when the previous nurse last applied the medication. C. Identify the client by comparing the medication administration record with the client's room number. D. Compare the label of the medication container with the medication administration record three times.
D
A nurse is preparing to admìnister oxygen to a client who has heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client? A. Nasal cannula B. Simple face mask C. Venturi mask D. Nonrebreather mask
D
A nurse is preparing to obtain a client's vital signs. When washing her hands, which of the following actions should the nurse take? A. Rinse her forearms with running water before applying soap. B. Hold her hands above elbow level while washing and rinsing. C. Generate a lather by rubbing the hands together vigorously for 5 seconds. D. Turn off the faucet with a clean paper towel after drying hands.
D
A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take? A. Lift the staple remover when squeezing the handle. B. Avoid completely closing the handle after squeezing. C. Expect the staples to bend at each outer side of the staple. D. Remove the staple from the skin after both sides are visible.
D
A nurse is reinforcing dietary teaching with a client who has chronic kidney disease and requires a low-potassium diet. Which of the following food choices by the client demonstrates an understanding of the teaching? A. 1 cup of cantaloupe B. 1 large baked potato C. 4 oz of banana chip D. 1 cup of applesauce
D
A nurse is reinforcing preoperative teaching with a client who does not speak the same language as the nurse. Which of the following actions should the nurse take? A. Ask a family member who speaks the client's primary language to interpret. B. Plan a long teaching session initially to introduce the necessary material. C. Provide the least important information first. D. Provide handouts written in the client's primary language.
D
A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of the following instructions should the nurse include? A. "Keep your knees in a locked position when standing for prolonged periods." B. "Bend at the waist when lifting a heavy object." C. "Keep your feet close together when lifting a heavy object." D. "When lifting a heavy object, keep it close to your body."
D
A nurse is reinforcing teaching with a client about using guided imagery. Which of the following actions should the nurse take? A. Instruct the client to alternately tighten and relax muscles. B. Evaluate the client's energy field. C. Attach electronic sensors to the client prior to beginning therapy. D. Direct the client to visualize tension leaving the body.
D
A nurse is reinforcing teaching with a client who has pneumonia and a productive cough. Which of the following instructions should the nurse include in the teaching? A."Your visitors should wear a protective gown." B. "You should receive a pneumonia vaccine every year." C. "You should stand 1 foot away from others when coughing." D. "You should cover your mouth with a tissue when you cough."
D
A nurse is reinforcing teaching with an older adult client about oral hygiene. Which of the following instructions should the nurse include in the teaching? A. Use a firm-bristled toothbrush. B. Use lemon-glycerin sponges between meals for dry mouth. C. Replace her toothbrush every 6 months. D. Replace her toothbrush following an illness.
D
A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of the following actions should the nurse take to prevent client musculoskeletal injury? A. Support the client's head with a pillow that maintains cervical flexion. B. Position the client's shoulders off the pillow for internal rotation. C. Place the client's arms at his sides to keep his elbows extended. D. Internally rotate the client's hips by using a trochanter roll.
D
A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following laboratory results as an indication that the client has fluid volume excess? A. Urine specific gravity 1.015 B. Hematocrit 42% C. Urine pH 6.5 D. BUN 8 mg/dL
D
A nurse is reviewing the vital signs of four clients. Which of the following findings requires further data collection by the nurse? A. A client who has a respiratory rate of 12/min B. A client who has a blood pressure of 110/74 mm Hg C. A client who has a temperature of 37.3° C (99.2° F) D. A client who has a pulse of 110/min
D