ATI fundamentals dynamic quizzes

A nurse is providing discharge teaching to an older adult client about personal safety. Which of the following statements by the client indicates an understanding of the teaching? A. "I will have the steps to my house painted a dark color" B. "I will put a night-light in the hallway." C. "I will put on socks when I get out of bed" D. "I will secure any wires in my home under rugs"

B. "I will put a night-light in the hallway."

A nurse is caring for a client who has a prescription for acetaminophen 325 mg PO for an oral temperature above 38.4 C. Above what F temper should the nurse administer acetaminophen to the client?

101.1 -F= (C x 9/5) + 32 -F= (38.4 x 9/5) + 32 -F= 101.12

A nurse is caring a client who is receiving dextrose 5% in water IV at 150 mL/hr. and has ingested 4oz of water and ½ pint of milk. What is the total 8-hr fluid intake in milliliters that the nurse should document for this client? (round the answer to the nearest whole number and fill in the blank with the numeric value only.)

1560 -1oz = 30 mL 4 oz x 30 mL= 120 mL -1 pint = 480 mL 1/2 pint = 240 mL -150 mL x 8 hr = 1200 mL + 120 mL + 240 mL = 1560

A nurse is preparing to administer sotalol to a client with a prescription for 320 mg/day divided equally every 12 hr. The medication is available in 80 mg tablets. How many tablets should the nurse administer per dose?

2 -X= 320 mg x 1 tablet/80 mg = 4 -4/2 = 2

A nurse is monitoring a client's fluid intake. For breakfast, the client consumed 8 oz of milk, 10 oz of water, 4 oz of flavored gelatin, 1 scrambled egg, 1 crisp piece of bacon, and 2 biscuits with jelly. The nurse should record the fluid intake as:

660 mL -8 oz+10 oz+4 oz= 22 oz 1 oz= 30mL 30mL x 22 oz= 660 mL

A nurse is caring for a client whose intake and output flow sheet for 0700 to 1500 indicates the following; voided x3: 350 mL, 200 mL, 150 mL; wound drainage 2 tsp; and emesis 2 oz. What total output in milliliters should the nurse document for this 8 hr period?

770 -2 tsp= 10 mL -2 oz= 60 mL -350 mL + 200 mL + 150 mL + 10 mL + 60 mL = 770

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 yourself injections." B) "Your provider will not be pleased that you refuse to give yourself insulin injections" C) "It's okay. I'm sure your partner will be able to 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 yourself injections."

A nurse on a medical-surgical unit is admitting a client. Which of the following pieces of 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 providing discharge teaching to a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching? A. "A nurse will show me how to care for my wound." B. "A nurse will stay with me at home during the day" C. "I will call the nurse to change my bed linens" D. "I will call the nurse to help me bathe in the morning"

A. "A nurse will show me how to care for my wound."

A nurse is caring for a client who has CKD. The kidneys regulate body fluids as well as assisting with with of the following functions? A. Regulation of acid-base balance B. Reabsorption of nutrients for cellular growth C. Regulation of body temp D. Secretion of hormones needed for growth

A. Regulation of acid-base balance

A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? A. Redness @ infusion site B. Edema @ infusion site C. Warmth @ the infusion site D. Oozing of blood @ infusion site

B. Edema @ infusion site

A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the client's body? A. Heart B. Lungs C. Thyroid gland D. Skin

B. Lungs

A nurse is teaching a client with lower extremity weakness how to use a 4-point crutch gait. Which of the following instructions should the nurse include in the teaching? A. "Support the majority of your weight on the axillae" B. "Keep your elbows extended" C. "Bear weight on both on both of your legs" D. "Move both crutches forward at the same time"

C. "Bear weight on both on both of your legs"

A nurse is assisting a client who has dysphagia at mealtimes. Which of the following actions should the nurse take? A. Assist the client into a semi-sitting position B. Have the client lean slightly backward C. Advise the client to tuck his chin downward D. Instruct the client to tilt his head slightly backward

C. Advise the client to tuck his chin downward

A nurse in a provider's clinic is taking a client's age, height, weight, and vital signs. The nurse should identify this action as part of which of the following components of the nursing process? A. Planning B. Evaluation C. Assessment D. Implementation

C. Assessment

A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test? A. Sugar B. Coffee C. Cotton Wisps. D. Snellen chart

C. Cotton Wisps.

A nurse is caring for a client who has xerostomia with a lack of saliva. Which of the following nutrients will be affected by the lack of salivary amylase? A. Fat B. Protein C. Starch D. Fiber

C. Starch

A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use? A. Deltoid B. Ventrogluteal C. Vastus lateralis D. Dorsogluteal

C. Vastus lateralis

A nurse is caring for a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect injury to which of the following areas of the brain? A) Hypothalamus B) Cerebral Cortex C) Pituitary D) Cerebellum

D) Cerebellum

A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take? A. Clean the incision from bottom to top B. Apply sterile gloves prior to opening dressing packages C. Remove the tape by pulling away from the wound D. Clean the drain site from the center outward

D. Clean the drain site from the center outward

A nurse is caring for a client who has terminal cancer. The client is proceeding with plans to build a new home. The nurse should identify this behavior typically indicates which of the following stages of grief? A. Acceptance B. Bargaining C. Anger D. Denial

D. Denial

A nurse is reviewing a client's laboratory results and notes a WBC count of 3,600/mm^3. The nurse should identify this result as which of the following conditions? A. Leukoplakia B. Leukemia C. Leukocytosis D. Leukopenia

D. Leukopenia

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 into the toilet bowl 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 home health nurse enters a client's home and finds a used insulin syringe without a cap on the table. Which of the following actions should the nurse take? A. Recap the needle on the syringe B. Schedule a nurse to administer future injections for this client C. Explain to the client that the syringe should be disposed of in the bathroom trash cans D. Place the syringe in a puncture-proof disposal container

D. Place the syringe in a puncture-proof disposal container

A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client? A. Vastus lateralis B. Dorsogluteal C. Deltoid D. Ventrogluteal

D. Ventrogluteal

A middle-aged client is discussing future plans with the nurse. Which of the following statements should the nurse identify as an indication that the client is having difficulty achieving Erikson's developmental task for this age group? A) "We miss out daughter so much that we are going to move closer to her" B) "I think this year I can plan on managing the funding at the church" C) "I really wish I could lose some of this weight" D) "I find I am spending more time at work now that my son is at college"

A) "We miss out daughter so much that we are going to move closer to her"

A nurse is caring for a client who has a dysrythmia. Which of the following techniques should the nurse use to assess for a pulse deficit? A) Obtain the apical and radial rates simultaneously B) Check the BP in the left and right arms C) Compare the pulse strength in the upper extremities D) Palpate the pulses in the lower extremities

A) Obtain the apical and radial rates simultaneously

A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take? A. Repeat each joint motion five times during each session B. Move the joint to the point of considerable resistance C. Sit approximately 2 feet from the side of the bed closest to the joint being exercised D. Exercise the smaller joints first.

A. Repeat each joint motion five times during each session

A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acid-base imbalances? A. Respiratory alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Metabolic alkalosis

A. Respiratory alkalosis

A nurse is assessing a client's incision and observes the drainage to be blood-tinged. Which of the following terms should the nurse use to document this finding? A. Sanguineous B. Purulent C. Serous D. Hyperemia

A. Sanguineous

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume? A. Sodium B. Calcium C. Potassium D. Magnesium

A. Sodium

A nurse is preparing to administer a medication to a client. Which of the following administration schedules should the nurse identify as a prescription to administer the medication once and as soon as possible? A. Stat Prescription. B. PRN prescription C. Standing prescription D. Single prescription

A. Stat Prescription.

A nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client? A. Test for the presence of client's gag reflex B. Place the client in the supine position C. Use a firm toothbrush for tooth and gum care D. Use 2 gauze-wrapped fingers to hold mouth open

A. Test for the presence of client's gag reflex

A nurse is providing teaching to a client with heart failure about reducing 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 change C. The learning theory the nurse uses 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 caring for a middle-aged adult client. The nurse should identify which of the following statements as an indication that the client has completed Erikson's developmental task for her age group? A) "I am comfortable with my decision to choose a lifelong partner" B) "I think I have done a good job with my children since they are all independent now." C) "As I look back over my life, I can see that I have achieved most of the goals I set for myself" D) "I love my work so much that it is difficult to think about retirement"

B) "I think I have done a good job with my children since they are all independent now."

A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse perform? A) Wear sterile gloves when collecting the specimen B) Cleanse the wound with 0.9% sodium chloride irrigation. C) Allow the collection swab to absorb old exudate D) Rotate the collection swab over the edges of the wound

B) Cleanse the wound with 0.9% sodium chloride irrigation.

A nurse is assessing a client who is experiencing an obstruction of the flow of the vitreous humor in the eye. This manifestation is consistent with which of the following eye disorders? A)Retinopathy B) Glaucoma C) Cataracts D) Macular degeneration Glaucoma

B) Glaucoma

A nurse is assessing a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries? A. Palpation of both carotid arteries simultaneously B. Auscultation of the arteries for bruits with the bell of the stethoscope C. Palpation of the arteries for bruits with the bell of the stethoscope D. Auscultation of the arteries for thrills with the diaphragm of the stethiscope

B. Auscultation of the arteries for bruits with the bell of the stethoscope

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. Lower medial quadrant of the buttock near the coccyx B. Side hip between the iliac crest and anterior iliac spine. C. Tissue of the posterior upper arm D. Lower inner thigh 4 finger-widths above the patella

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

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who is scheduled for 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 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 come to help 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 girlfriend bought me a nice wig"

C. "I keep having nightmares about my upcoming surgery."

A nurse is teaching a client who has asthma about the proper use of an albuterol inhaler. Which of the following client statements indicates an understanding of the teaching? A. "I should rinse my mouth out right before I use the inhaler" B. "After the first puff, I will wait 10 seconds before taking the second puff" C. "I will shake the inhaler well right before I use it." D. "I will tilt my head forward while inhaling the medication"

C. "I will shake the inhaler well right before I use it."

A nurse is caring for a client who has a terminal illness. The family wants to care for the client at home. Which of the following statements indicates that the nurse understands family-centered care? A. "Social services can contact various community resources that will be helpful" B. "I will review the care plan the make the necessary changes" C. "Lets set up a meeting time with the doctor to discuss your options for home care" D. "I will make a list of things we need to do before discharge"

C. "Lets set up a meeting time with the doctor to discuss your options for home care"

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 bowel sounds after each feeding B. Ensure the formula is cold before administering C. Elevate the client's head of bed 45 degrees before the feeding. D. Flush the tubing with 15 mL of water after the enteral feeding

C. Elevate the client's head of bed 45 degrees before the feeding.

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? A. Insert the rectal tube 15.2 cm (6in.) B. Wear sterile gloves to insert the tubing. C. Position the client on his left side. D. Hold the solution bag 91 cm (36 in) above the client's rectum.

C. Position the client on his left side.

A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take? A. Deliver the formula at a slower rate B. Request a lower-fat formula C. Provide more water with feedings. D. Instill a lactose-free formula

C. Provide more water with feedings.

A nurse is caring for a client who is receiving a fluid infusion through a peripheral IV catheter. The nurse notes that the area of the arm immediately surrounding the insertion site is red and feels warm. Which of the following actions should the nurse take? A. Change the infusion tubing B. Flush the IV catheter C. Remove the IV catheter D. Apply a cool compress

C. Remove the IV catheter

A nurse in the ER is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? A. Warm, dry skin B. Increased urinary output C. Tachycardia D. Bradypnea

C. Tachycardia

During the completion of a health history with a nurse, a client reports intermittent chest pain for the past week. Which of the following questions is the nurse's priority? A. "Did you report the chest pain episodes to your physician?" B. "Is there a history of heart disease in your family?" C. "Have you had this pain before?" D. "Can you tell me what the pain felt like and show me exactly where it was?"

D. "Can you tell me what the pain felt like and show me exactly where it was?"

a nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I'll limit pushing the button so I don't get an overdose" B. "If I push the button and still have pain after 2 minutes, I'll push it again" C. "I'll ask my niece to push the button when I am sleeping" D. "I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button"

D. "I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button"

A nurse is supervising a newly licensed nurse who is suctioning a client's tracheostomy. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A. Using clean technique to perform the procedure B. Apply suction while inserting the catheter C. Lubricating the suction catheter with an oil-based lubricating jelly D. Administering high-flow oxygen prior to the procedure

D. Administering high-flow oxygen prior to the procedure

A provider is planning an immunization clinic for older adults. At which of the following times should an older adult client receive the influenza vaccine? A. Once during the client's lifetime B. Every 10 years C. Every 5 years D. Annually in the fall

D. Annually in the fall

A nurse is assessing the heart sounds of a client who has developed chest pain that worsens 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 boarder. 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 is changing the dressings 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 exudate D. Purulent exudate

D. Purulent exudate

A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? A. Two-point discrimination test B. Glasgow coma scale C. Babinski reflex D. Romberg Test

D. Romberg Test

A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes? A. Allow minimal treatment B. Benefits the client's family C. Offers hope for a cure D. Supports self-determination

D. Supports self-determination

A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of the equipment? A. The client places a crutch on each side when assuming a sitting position B. The client moves the unaffected leg onto a step first when descending stairs C. The client places weight on the axillae when walking D. The client has slightly flexed elbows when ambulating with the crutches

D. The client has slightly flexed elbows when ambulating with the crutches

A nurse is assisting a client who has right-sided weakness while ambulating using a cane. Which of the following client actions should indicate to the nurse that the client understands the procedure of cane walking? A. The client holds the cane on the affected side B. The client advances the unaffected leg followed by the cane C. The client supports his weight on the unaffected leg when moving the cane forward D. The client keeps 2 points of support on the ground

D. The client keeps 2 points of support on the ground

A nurse in a same-day procedure unit is caring for several clients who are undergoing different types of procedures. the nurse should anticipate that the client who has which of the following devices can safely undergo magnetic resonance imaging (MRI)? a) coronary artery stents b) aneurysm clip c) hearing aids d) automated internal defibrillator

c) hearing aids

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 cotton balls for the tracheostomy care B) Obtaining hydrogen peroxide for the tracheostomy care C) Obtaining sterile gloves for the tracheostomy care D) Obtaining a sterile brush for the tracheostomy care

A) Obtaining cotton balls for the tracheostomy care

A nurse is administering medication to a client who asks the nurse to leave the medication at the bedside to be taken at a later time. Which of the following responses should the nurse make? A. "Call me when you are ready, and I will return with the medication." B. "Since you were taking this medication at home, I will leave it for you to take" C. "I will come back in 30 minutes to check that you took the medication so I can chart the time" D. "If you refuse to take the medication now, I can't give it again until your next scheduled time"

A. "Call me when you are ready, and I will return with the medication."

A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing? A. Cranial nerve XII B. Cranial nerve X C. Cranial nerve VIII D. Cranial nerve V

A. Cranial nerve XII

A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first? A. Inspect both breasts simultaneously B. Squeeze the nipples C. Palpate the breast and tail of Spence D. Palpate the axillary lymph nodes

A. Inspect both breasts simultaneously

A nurses planning to administer pain medication to a client 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. Discuss the adverse effects of pain medication with the client C. Obtain the client's vital signs D. Check the client's allergies

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

A nurse is assessing a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields? A. Vesicular B. Bronchial C. Rhonchi D. Bronchovesicular

A. Vesicular

A nurse is teaching a client who is recovering from gallbladder surgery how to use an incentive spirometer. Which of the following pieces of information should the nurse include in the teaching? A) Exhale slowly to reach the goal volume B) Hold the breath for 5 sec after goal volume is reached C) Continue to breathe deeply between each cycle D) Limit the repeat pattern of breathing to 5 breaths

B) Hold the breath for 5 sec after goal volume is reached

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse make? A. "You won't need the equipment very long." B. "All of this equipment can be frightening." C. "Why does the equipment bother you?" D. "Let me tell you about what each machine does."

B. "All of this equipment can be frightening."

A nurse is changing the bed linens for a client who is on bed rest. Which of the following actions should the nurse perform? 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 a linen bag is available D. Shake the clean linens to unfold

B. Hold the linens away from the body and clothing

A nurse is proving 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 1,000 mL of fluid daily" B. "Increase your intake of refined-fiber foods C. "Sit on the toilet 30 min after eating a meal" D. "Take a laxative every day to maintain regularity"

C. "Sit on the toilet 30 min after eating a meal"

A nurse is caring for a client who requires ventilatory assistance with breathing following a motor vehicle crash. The nurse should suspect an injury to which of the following parts of the brain? A. Hypothalamus B. Cerebral cortex C. Brainstem D. Cerebellum

C. Brainstem

An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates for further teaching? A. The AP uses soap and water to clean the perineal area. B. The AP tapes the catheter to the client's inner thigh. C. The AP hangs the collection bag at the level of the bladder. D. The AP ensures that there are no kinks in the drainage tubing.

C. The AP hangs the collection bag at the level of the bladder.

A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors increases the client's risk of developing complicated grief? A. The deceased was a close friend B. The client lived far from the deceased C. The death was sudden D. The client has not visited the deceased in a long time

C. The death was sudden

A nurse is taking a client's vital signs. Which of the following findings should the nurse identify as outside the expected reference range? A. Pulse rate 90/min B. Rectal temperature 38C (100.4F) C. Pulse oximetry 95% D. BP 145/90

D. BP 145/90

A nurse is evaluating the development of a group of clients. According to Erikson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development? A. Middle adulthood B. Adolescence C. Childhood D. Young adulthood.

D. Young adulthood.

A nurse is teaching a client how to perform range-of-motion exercises of the wrist. To perform adduction, which of the following instructions should the nurse include? A. "With your palm facing down, move your wrist sideways toward your thumb." B. "Move your palm toward the inner part of your forearm" C. With your palm facing down, move your wrist sideways toward your little finger" D. "Bring the back of your hand as far back toward the wrist as you can"

A. "With your palm facing down, move your wrist sideways toward your thumb."

After assessing a client, the nurse documents "1+ pedal edema bilaterally." This indicates that the nurse observed an indentation of which of the following depths after applying pressure? A. 2 mm. B. 4 mm C. 6 mm D. 8 mm

A. 2 mm.

A nurse is caring for a client who reports not sleeping at night, which interferes with her ability to function during the day. Which of the following interventions should the nurse suggest to this client? A. Avoid beverages that contain caffeine B. Take a sleep medication regularly at bedtime C. Watch television fro 30 min in bed to relax prior to falling asleep D. Advise the client to take several naps during the day

A. Avoid beverages that contain caffeine

After assessing the client's radial pulses, the nurse document "radial pulses 4+ bilaterally". The nurse should document this finding when a client's pulses have which of the following qualities? A. Bounding B. Full C. Variable D. Weak

A. Bounding

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? A. Daily weight B. Blood pressure C. Specific gravity D. Intake and output

A. Daily weight

A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? A. Place the client in a lateral position with the head turned to the side before beginning the procedure B. Use the thumb and index finger to keep the client's mouth open C. Rinse the client's mouth with an alcohol-based mouthwash following the procedure D. Cleanse the client's mucous membranes with lemon-glycerin sponges Place the client in a lateral position with the head turned to the side before beginning the procedure

A. Place the client in a lateral position with the head turned to the side before beginning the procedure

A nurse is caring for a group of clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? A. Provide oral care to a client who cannot take oral fluids B. Check a client's IV insertion site for manifestations of infiltration C. Assess a client's ability to ambulate D. Demonstrate the use of a glucometer to a client who has diabetes mellitus

A. Provide oral care to a client who cannot take oral fluids

A nurse in a provider's office is talking with an older adult client who reports having trouble sleeping. Which of the following statements should the nurse identify as a possible cause of the client's sleeping difficulties? A. "I take a warm shower when getting ready for bed" B. "I often have a cup of coffee with my dessert before going to bed" C. "I usually read a chapter in a book before I go to bed" D. "I make sure I do my exercises in the morning"

B. "I often have a cup of coffee with my dessert before going to bed"

A nurse is caring for a client who has a terminal illness. which of the following findings indicates that the client's death is imminent? A. Urinary retention B. Cold extremities C. Hypertension D. Tachycardia

B. Cold extremities

A nurse is caring for an older adult client who has dysphagia following a CVA. Which of the following actions should the nurse take when assisting the client at mealtime? A. Encourage the client to drink fluids before swallowing food B. Offer the client tart or sour foods first C. Tilt the client's head backward when swallowing D. Turn on the tv

B. Offer the client tart or sour foods first

A nurse is employing a thorough, systematic method while obtaining objective data about a client. Through which of the following methods should the nurse collect this information? A. Health history B. Physical Examination. C. Review of systems D. Interview

B. Physical Examination.

During a physical examination of a client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect additional data? A. Confrontation test B. Symmetry of palpebral fissures C. Corneal light reflex D. Accomodation test

C. Corneal light reflex

A nurse is measuring a client's vital signs 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 client's pedal pulse C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart D. Take the pulse at each peripheral site and count the rate for 30 sec

C. Count the apical pulse rate for 1 full min and describe the rhythm in the chart

A nurse is caring for a client who has terminal pancreatic cancer. When the client states, "It's devastating that I will not be here to see my child gradute," the nurse should identify that the client is in which of the following stages of grief as defined by Kubler-Ross? A. Anger B. Bargaining C. Depression D. Acceptance

C. Depression

A nurse is working with the facility's language interpreter to explain a wound-care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when describing the procedure? A. Make eye contact with the interpreter B. Break sentences into shorter segment to allow time for interpretation C. Ensure the interpreter and the client speak the same dialect D. Speak in a loud tone of voice Ensure the interpreter and the client speak the same dialect

C. Ensure the interpreter and the client speak the same dialect

A nurse is initiating seizure precautions for a client who has a seizure disorder. Which of the following pieces of equipment should the nurse have readily available at the client's bedside? A. Vest restraint B. Tongue blade C. Oxygen equipment D. Neck brace

C. Oxygen equipment

A nurse is assessing a client's peripheral pulses. Which of the following descriptions should the nurse use to document the findings? A. Peripheral pulses equal bilaterally at a rate of 60/min B. Radial, brachial, and pedal pulses bilaterally weak C. Peripheral pulses bilaterally symmetric, equal, and strong, in all 4 extremities D. Brachial, radial, popiteal, and dorsalis pedis pulses regular, 58, and bilaterally palpable

C. Peripheral pulses bilaterally symmetric, equal, and strong, in all 4 extremities

A home health nurse is visiting an older adult client with severe dementia. The client's son, who serves as her primary caregiver, reports being "exhausted" from working part-time and caring for his mother at home. Which of the following options should the nurse suggest to the caregiver? A. Rehabilitation B. Assisted living facility C. Respite care D. Adult daycare facility

C. Respite care

A nurse is caring for a client who is receiving an IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? A. Redness at the IV catheter entry site B. A palpable cord is felt along the vein used for the infusion C. Taut skin around the IV catheter site that is cool to the touch D. Bleeding at the IV insertion site

C. Taut skin around the IV catheter site that is cool to the touch

A nurse is caring for a client who states that she does not want to get out of bed due to pain from arthritis. Which of the following actions should the nurse take? A. Tell the client the provider does not want her to remain in bed B. Allow the client to remain in bed until her pain subsides C. Instruct the family to perform ADLs for the client D. Advise the client to perform range-of-motion exercises while in bed.

D. Advise the client to perform range-of-motion exercises while in bed.

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse have the client perform just before inserting the catheter? A. Swallow water B. Prepare for a painful sensation C. Hold her breath D. Bear down gently

D. Bear down gently

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 talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make? A. "During this phase, feed your child anything that she will eat." B. "Increase the amount of calories and water your child consumes." C. "Keep a diary of the foods your child eats each day." D. "Provide a large variety of fruit juices for your child to choose from."

C. "Keep a diary of the foods your child eats each day."

A nurse is planning care for a group of clients who are receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A. A client who has heart failure and is receiving 100% O2 via partial rebreather B. A client who has emphysema and is receiving at 3L/min via a transtracheal oxygen cannula C. A client with old tracheostomy, receiving 40% humidified oxygen via trach collar D. A client with COPD that is receiving oxygen at 2L/min via nasal cannula

A. A client who has heart failure and is receiving 100% O2 via partial rebreather

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

A nurse is beginning her shift and reviewing the medication administration records (MARs) for her clients. She notes a dosage of a medication above the safe range and sees that a nurse administered the dosage during the previous shift. Which of the following actions should the nurse take? A. Call the nurse to verify that the client received that dosage B. Give the medication in a safe dosage C. Give the dose the provider prescribed D. Call the provider to clarify the dosage

D. Call the provider to clarify the dosage

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

D. Perform hand hygiene

A nurse at a screening clinic is assessing a client who reports a history of a 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 providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? A. Sweeping the floor B. Shoveling snow C. Cleaning windows D. Washing dishes

D. Washing dishes

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. which of the following actions should the nurse take? A. Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube B. Position the client on the right side C. Insert the tip of the tubing 8 cm (3.1 in) D. Hold the enema container 61 cm (24 in) above the rectum

C. Insert the tip of the tubing 8 cm (3.1 in)

A nurse is instructing a client about collecting a 24-hr urine specimen for creatinine clearance. Which of the following statements should the nurse identify as an indication that the client understands the procedure? A. "The next time I urinate will be the first specimen of the collection" B. "I'll make sure to keep the collection bottle in the container of ice they gave me." C. "Once the container is half full, I no longer have to add any more urine" D. "It's okay if a piece of toilet paper gets in the bottle. The lab people will remove it when they do the test"

B. "I'll make sure to keep the collection bottle in the container of ice they gave me."

A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear? A. Air conduction is less than bone conduction in the left ear B. Air conduction is greater than bone conduction in the left ear C. Sound is lateralizing to the right ear D. Sound is lateralizing to the left ear

A. Air conduction is less than bone conduction in the left ear

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated? A. Cover the incision with a moist sterile dressing B. Have the client lie on his back with his knees flexed C. Call the client's surgeon D. Reassure the client

A. Cover the incision with a moist sterile dressing

A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? A. Decrease calcium B. Decreased potassium C. Increased potassium D. Increased calcium

A. Decrease calcium

A nurse is teaching a middle-aged adult client about health promotion and disease prevention. The nurse should inform the client that which of the following changes could occur? A. Decreased estrogen and testosterone production B. Increased tone of the large intestine C. Increased percentage of the body's muscle mass D. Decreased incidence of chronic ilnesses

A. Decreased estrogen and testosterone production

A nurse is presenting an in-service training session about nutrition. Which of the following simple sugars should the nurse identify as the carbohydrate found in milk? A. Lactose B. Sucrose C. Maltose D. Fructose

A. Lactose

A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks both the client's native language and the nurse's, arrives to drive the client home. Which of the following actions should the nurse take? A. Ask the client's neighbor to call a family member to interpret B. Ask the client's neighbor to translate the information C. Obtain the services of an interpreter D. Document the inability to provide discharge instructions

C. Obtain the services of an interpreter

A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? A. Aim the hose at the base of the fire B. Squeeze the handle of the extinguisher C. Remove the safety pin from the extinguisher D. Sweep the hose from side to side to dispense material

C. Remove the safety pin from the extinguisher

A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make? A. "I would try to get it over with because you won't get better without this tube." B. "You should talk to your provider about it." C. "Why don't you want the tube inserted?" D. "I can see that this is upsetting you."

D. "I can see that this is upsetting you."

While in the hospital, a client who has a terminal illness tells the nurse, "I can't believe I'm dying. A lot of bad people in the world are healthy, and here I am dying!" Which of the following responses should the nurse provide? A. "Everyone dies sometimes; some die sooner than others" B. "Who do you think deserves to die more than you?" C. "It does seem unfair, doesn't it?" D. "Tell me more about how you feel about dying."

D. "Tell me more about how you feel about dying."

During a client care staff meeting, a nurse manager discuss potential problems with data security that affect confidential client information. Which of the following environments should the nurse identify as an acceptable place for discussing client information? A. Areas with no public access B. Outside the door of a client's room C. In the cafeteria during break D. In the hallway near the nurses' station

A. Areas with no public access

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary bag. The nurse recognizes these manifestations as which of the following types of transfusion reaction? A. Hemolytic B. Febrile C. Circulatory overload D. Sepsis

A. Hemolytic

A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse that the AP understands how to perform this task? A. Locking the brakes on the bed and the wheelchair before moving the client B. Lowering the footplates of the wheelchair before the transfer C. Placing the wheelchair perpendicular to the bed D. Placing the wheelchair on the client's weaker side prior to the transfer

A. Locking the brakes on the bed and the wheelchair before moving the client

A nurse in a provider's office is measuring a client and notes a loss in height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders? A. Osteoporosis B. Scoliosis C. Kyphosis D. Lordosis

A. Osteoporosis

A nurse is performing a neurological assessment of a client. To promote safety during the examination, the nurse stands nearby as the client follows the instructions for which of the following tests? A. Romberg B. Kinesthetic Sensation C. 2 Point Discrimination D. Weber

A. Romberg

A nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student should the nurse identify as a potential problem with achieving Erikson's developmental task for this age group? A. "I am in no hurry to get married. I think ill enjoy being single for a while" B. "I go on the weekends to be with my family because I do not have any good friends here on campus" C. "I am interested in politics and may consider becoming an elected official" D. "I am looking forward to finishing school and going to work for my family's business" "I go on the weekends to be with my family because I do not have any good friends here on campus"

B. "I go on the weekends to be with my family because I do not have any good friends here on campus"

A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. The client states that she slipped while getting out of bed. Which of the following actions should the nurse take first? A. Complete an incident report B. Check the client for injuries C. Make sure the client has skid-free footwear D. Remind the client to ask for help when getting out of bed

B. Check the client for injuries

A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? A. Blow into the spirometer to elevate the balls in the device B. Cough deeply after each use C. Clean the mouth piece with an alcohol swab after each use D. Use the spirometer every 8 hr.

B. Cough deeply after each use

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention? A. Teaching clients to perform self-examinations of breasts and testicles. B. Educating clients about the recommended immunization schedule for adults. C. Teaching clients who have type 1 diabetes mellitus about care of the feet D. Recommending that clients over the age of 50 have a fecal occult blood test annually

B. Educating clients about the recommended immunization schedule for adults.

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

B. Inability to cry or speak

A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following should indicate to the nurse that the client is experiencing fluid volume deficit? A. Decreased urine specific gravity B. Increased heart rate C. Decreased hematocrit D. Increased skin turgor

B. Increased heart rate

A nurse is caring for a client who has a temperature of 38.7C (101.7F). Which of the following actions should the nurse take? A. Apply an alcohol-water solution to the client's skin B. Keep the client's bed linens dry C. Apply ice packs to the groin D. Limit the client's fluid intake to 1183 mL (40 oz) of fluid per day

B. Keep the client's bed linens dry

A nurse is changing the dressings for a client who has 2 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 is caring for a client who reports using several herbal medicines. Which of the following actions should the nurse take? A. Discourage the use of unregulated medications and supplements B. Verify the herbal supplements do not interact with medications the provider has prescribed C. Tell the client to limit the number of herbal supplements to no more than 2 D. Describe the dangers of taking plant-derived medications and supplements

B. Verify the herbal supplements do not interact with medications the provider has prescribed

A nurse is caring for a semiconscious client who has a small-bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement? (Select all that apply) A. Auscultate injected air B. Verify the initial X-ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid E. Check the aspirated fluid for glucose

B. Verify the initial X-ray examination C. Measure the length of the exposed tube D. Determine the pH of aspirated fluid

A nurse is providing discharge teaching for a client who has type 2 diabetes mellitus and will be caring for herself at home. The client expresses concerns about preparing an appropriate diet for her diabetes due to her cultural beliefs and preferences. Which of the following responses should the nurse offer? A. "The home health dietitian will visit and help you learn to cook all over again" B. "The dietitian will give you a list of foods and dietary choices to keep your diabetes under control" C. "The dietitian will help you choose foods you are used to that also meet your health needs." D. "It may be difficult, but I know you can change your eating and cooking habits with some help from the dietitian"

C. "The dietitian will help you choose foods you are used to that also meet your health needs."

A nurse is assessing a client who has a sudden onset of severe back pain on unknown origin. Which of the following questions should the nurse ask to encourage discussion w/ the pt? A. "Does the med you've been 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 worse, right?"

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

A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions? A. Shaking soiled linen before putting it in a hamper B. Removing a face mask when standing 0.5 m (1.6 ft) from the client C. Assigning another client with the same infection to share the room with the client D. Allowing the client to visit a family member in the lobby of the facility

C. Assigning another client with the same infection to share the room with the client

A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for this client? A. BUN 18 mg/dL B. Capillary refill 1.5 sec C. HCT 55% D. Urine specific gravity 1.001

C. HCT 55%

A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning? A. Ask the client if he want to self-administer his insulin. B. Have the client list the steps of the procedure. C. Have the client demonstrates the procedure. D. Ask the client if he understands the purpose of insulin.

C. Have the client demonstrates the procedure.

A nurse is assessing a client who is experiencing stress following a near fall out of bed. Which of the following physiological responses should the nurse expect due to the fight-or-flight response? A. Decreased respiratory rate B. Pinpoint pupils C. Increased blood pressure D. Bronchiolar construction

C. Increased blood pressure

A nurse is caring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? A.Carminative B. Hypertonic C. Oil retention D. Sodium polystyrene sulfate

C. Oil retention

A nurse in an urgent-care center is caring for a 15-year-old client whose symptoms suggest a sexually transmitted disease (STI). The client's parent is unavailable but the client's grandmother accompanied the client to the clinic. Which of the following actions should the nurse take? A. Explain that the treatment can wait until the parent is available B. Inform the grandmother that she may give consent for the treatment C. Invoke the principle of implied consent and prepare the client for treatment D. Ask the adolescent to sign the consent form

D. Ask the adolescent to sign the consent form

A nurse is assessing a client who is postoperative. Which of the following findings should the nurse identify as an indication that the client is experiencing pain? A. Diarrhea B. Pupillary constriction C. Flushing D. Grimacing

D. Grimacing

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room. 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 client's family about the situation D. Notify the provider of the client's decision

D. Notify the provider of the client's decision

A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include? A. Stand 3 feet from the client when assisting with lifting B. Lock your knees when standing for long periods C. Lift up to 22.6 kg (50lbs) without the use of assistive devices D. When lifting an object, spread your feet apart to provide a wide base of support

D. When lifting an object, spread your feet apart to provide a wide base of support

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 when the client rises in the morning B. Force fluids during the day and collect the specimen in the evening C. Collect the specimen after antibiotics have been started D. Collect 2 mL of sputum before sending the specimen to the laboratory

A. Collect the specimen when the client rises in the morning

A nurse is providing teaching about proper care to a client who has a new colostomy. Which of the following pieces of information should the nurse include in the teaching? A. Change the colostomy bag following breakfast B. Cleanse the skin around the stoma with warm water C. Change the pouch every day D. Place an aspirin in the ostomy pouch to decrease odor

B. Cleanse the skin around the stoma with warm water

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastrostomy tube for enteral feedings. Which pieces of information are critical to communicate to the next nurse who will be caring for this client? (Select all that apply) A. Room temperature B. New prescriptions C. Number of visitors D. Arterial blood gas results E. Tracheal secretion characteristics

B. New prescriptions D. Arterial blood gas results E. Tracheal secretion characteristics

A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse prioritize 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 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 immunizations B. Screening groups of older adults in nursing care facilities for early influenza manifestations C. Educating parents of young children about the dangers of influenza D. Finding rehabilitation programs for older adults who have complications related to influenza

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

A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider A. Calcium 9.5 mg/dL B. Sodium 150 mEq/L C. Potassium 4 mEq/L D. Magnesium 1.5 mEq/L

B. Sodium 150 mEq/L

A nurse is providing nutrition counseling to a middle-aged adult client who has a sedentary job. Which of the following factors should the nurse consider? A. The risk of eating disorders increases at this age B. The client's basal metabolic rate could decrease. C. Daily vitamins will become necessary to meet nutritional needs D. Limiting the intake of fish to once per week reduces cardiovascular risks

B. The client's basal metabolic rate could decrease.

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

C. Carefully remove the gloves and follow with hand hygiene

A nurse is assisting a client who is eating @ a mealtime. Suddenly, the client grabs her neck w/ both hands & appears frightened. Which of the following actions should the nurse take first? A. Place an O2 mask on the pt B. Check the pt's pulse C. Determine whether the pt is able to breathe D. Wrap arms around the Pt from behind

C. Determine whether the pt is able to breathe

A nurse in an emergency department is caring for a client who reports developing severe eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first? A. Instill proparacaine hydrochloride eye drops B. Perform ocular irrigation of the right eye C. Place the client in a supine position with the head turned toward the affected side D. Ask the client about first aid performed at the scene

D. Ask the client about first aid performed at the scene

A nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to assess which of the following? A. Liver size B. Pedal edema C. Skin texture D. Gait

D. Gait

A nurse is reviewing a client's 24 hr dietary recall. The client reports eating a slice of toasted white bread with butter, a banana, a glass of milk, and a cup of coffee for breakfast; grilled chicken, a baked potato, and a glass of milk for lunch; an apple and cheddar cheese for a snack; and 2 servings of chicken, 2 cups of steamed broccoli, and a glass of milk for dinner. This client's diet is deficient in which of the following food groups? A. Dairy B. Vegetables C. Fruits D. Grains

D. Grains

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of 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 in an acute care facility is planning care for a client who is alert but temporary immobile due to a total hip arthroplasty. Which of the following interventions should the nurse plan to take to prevent a complication of immobility? A. Move the client from supine to a low-Fowler's position every 2-3 hr to help prevent orthostatic hypotension B. Limit fluid intake to 1L (33.8 oz) in 24 hr to help prevent dependent edema C. Encourage the client to turn from side to side every 3-4 hr to help prevent respiratory complications D. Instruct the client to perform foot and leg exercises every 1-2 hours while awake to help prevent thrombophlebitis

D. Instruct the client to perform foot and leg exercises every 1-2 hours while awake to help prevent thrombophlebitis

A nurse is developing a plan of care for a client. Which of the following pieces of information should the nurse consider when planning care that is culturally congruent? A. Illness is not influenced by culture B. The meaning of disease can vary widely across cultures. C. Assigning clients to specific cultural categories facilitates communication D. Predetermined criteria should generate client care activities

B. The meaning of disease can vary widely across cultures.

A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first? A. Give the client a glass of water B. Assist the client into 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 is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching? A. Cream of rice B. Cottage cheese C. Gelatin D. Ice cream

C. Gelatin

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 into the lower conjunctival sac B. Apply gentle pressure to the outer opening of the eye for 2 min C. Hold the eyedropper 0.5 (0.2 in) from the cornea D. Instruct the client to close the eyes tightly after administration

A. Drop the eye medication into the lower conjunctival sac

A nurse is preparing to administer medication to a client who has gout. The nurse discovers that an error was made during the previous shift in which the client received atenolol instead of allopurinol. Which of the following interventions is the nurse's priority? A. Measure the client's apical pulse B. Administer the allopurinol to the client C. Inform the nurse manager D. Complete an incident report

A. Measure the client's apical pulse

A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first? A. Document the client's food allergies in the medical record B. Ask the client to identify the specific food allergies C. Monitor the client for indications of anaphylaxis D. Have epinephrine available for administration

B. Ask the client to identify the specific food allergies

A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure? A) "Inhale forcefully during insertion B) "Raise your index finger if you need to pause during the insertion" C) "Bear down during insertion" D) "Avoid making any swallowing motions during the insertion"

B) "Raise your index finger if you need to pause during the insertion"

As part of a neurological examination, a nurse instructs a client to keep his eyes closed, places an object in his hand, and asks him to identify the object. Which of the following abilities is the nurse evaluating with this technique? A) Gustation B) Stereognosis C) Proprioception D) Kinesthesia

B) Stereognosis

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurse take? (Select all that apply.) A. Carefully reinsert the intestine through the opening in the wound B. Place the client in a supine position with the hips and knees flexed C. Leave the room to call the surgeon D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

B. Place the client in a supine position with the hips and knees flexed D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

A nurse is assessing a client's thyroid gland. Which of the following instructions should the nurse give the client before inspecting and palpating this gland? A. "Tilt your head slightly forward" B. "Keep your head straight and look ahead of you" C. "Tilt your head back and swallow." D. "Turn your head to the side against my hand"

C. "Tilt your head back and swallow."

A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client's HIV infection status. Which of the following actions should the nurse take? A. Inform the guard that the warden must request this information B. Ask the guard to sign a release of information C. Instruct the guard to ask the inmate D. Complete an incident report

C. Instruct the guard to ask the inmate

A nurse is providing teaching to a client regarding protein intake. Which of the following foods should the nurse include as an example of an incomplete protein? A. Eggs B. Soybeans C. Lentils D. Yogurt

C. Lentils

A nurse is discussing fire safety with newly hired nurses. Which of the following actions is the priority if a fire occurs in the health care facility? A) Close the fire doors on the unit B) Use a fire extinguisher on the fire C) Pull the nearest fire alarm D) Evacuate clients from unit

D) Evacuate clients from unit

A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health-associated infections (HAIs). Which of the following should the nurse identify as an iatrogenic HAI? A. Infection acquired from improper hand hygiene B. Infection caused by drug resistance C. Infection acquired by inappropriate waste disposal D. Infection acquired from a diagnostic procedure

D. Infection acquired from a diagnostic procedure

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 stocking once per day C. Bunch and pull the stocking halfway up the calf D. Turn the stocking inside out up to the heel before applying.

D. Turn the stocking inside out up to the heel before applying.

A nurse is preparing to administer 700mL of 0.9% sodium chloride IV to a child to infuse over 24 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero, if applicable. Do not use a trailing zero.)

X= Quantity/1 mL x Conversion (hr)/Conversion (min) x Volume (mL)/ Time (hr) X gtt/min= 60 gtt/1mL x 1 hr/60min x 70mL/24 hr X= 29.1666 X= 29

A nurse is caring for a client who has clostridium difficile and is in contact isolation. Which of the following actions should the nurse take? A. Wear gloves when changing the client's gown B. Use alcohol-based sanitizer to cleanse the hands. C. Wear a mask when assisting the client with his meal tray. D. Place the client on complete bed rest.

A. Wear gloves when changing the client's gown

A nurse is supervising a newly licensed nurse who is administering a controlled substance. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A. Placing an unused portion of the medication in a sharps box B. Asking another nurse to observe the disposal of an unused portion of the medication. C. Counting the inventory of the available narcotic after administering the medication D. Ensuring that another nurse signs the control inventory form after disposal of an unused portion of medication

B. Asking another nurse to observe the disposal of an unused portion of the medication.

A nurse is caring for a client who was transferred to the surgical unit by stretcher from the PACU. Which of the following actions should the nurse perform immediately following the transfer? A. Administer pain medication B. Check the clients vital signs. C. Instruct the client to use the incentive spirometer every 1 hr D. Provide ice chips as per provider prescription

B. Check the clients vital signs.

A nurse is assessing a client. Which of the following finding should the nurse identify as an indication of protein-calorie malnourishment? (Select all that apply) A. Gingivitis B. Dry, brittle hair C. Edema D. Spoon-shaped nails E. Poor wound healing

B. Dry, brittle hair C. Edema E. Poor wound healing

A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing? A. Lateral thigh B. Lower abdomen C. Mid-abdominal region D. Medial thigh

B. Lower abdomen

A nurse is caring for a client who starts to experience a seizure while sitting in a chair. Which of the following actions should the nurse take? A. Place a padded tongue blade in the client's mouth B. Lower the client to the floor and place a pad under the client's head. C. Seek the help of a coworker and lift the client into bed D. Use an oropharyngeal airway to keep the upper airway passages open

B. Lower the client to the floor and place a pad under the client's head.

A nurse is caring for a client who has injuries resulting from a motor-vehicle crash. Which of the following client statements should the nurse address first? A.) "I'm afraid this injury will cause me to lose my job." B.) "I can't sleep well because whenever I move in my sleep, the pain wakes me up." C.) "Idk what I will do if my car isn't safe or even drivable after the crash." D.) "I wonder how I am going to be able to take care of my family"

B.) "I can't sleep well because whenever I move in my sleep, the pain wakes me up."

A nurse is caring for a client who requires a peripheral IV insertion. When choosing the site, which of the following sites should the nurse select? A) Select a vein in the client's dominant arm B) Choose the most proximal vein in the extremity C) Choose a vein that is soft on palpitation D) Select a site distal to previous venipuncture attempts

C) Choose a vein that is soft on palpitation

A nurse is caring for a client who has a BMI of 29 and expresses a desire to lose weight. Which of the following actions should the nurse take first? A) Refer the client to a nutritionist B) Discuss eating strategies with the client C) Determine the client's intention to change current eating habits. D) Instruct the client to perform 30 min of vigorous exercise daily

C) Determine the client's intention to change current eating habits.

A nurse is caring for a client who had a stroke and is at risk of falling. Which of the following actions should the nurse take? A) Assign the client to a private room B) Keep 4 side rails up while the client in in bed C) Monitor the client at least once every hour D) Request a PRN prescription for restraints

C) Monitor the client at least once every hour

A nurse is teaching a client about how to remove a soiled dressing. Which of the following statements by the client indicates an understanding of the teaching? a) "Ill wear nonsterile gloves" b) "Ill use adhesive remover each time" c) "Ill take my pain pill after I change the dressing" d) "Ill fold the dressing with the soiled surface facing outward"

a) "Ill wear nonsterile gloves"

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription states, "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. "Ill get you some water to drink" D. "Let's wait a bit so you don't feel sick"

B. "I am going to listen to your abdomen"

A nurse is witnessing a client sign an informed consent form 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 using the Braden scale to predict the pressure ulcer risk of a client in a long-term care facility. Using this scale, which of the following parameters should the nurse evaluate? A. Incontinence B. Mental state C. Nutrition D. General physical condition

C. Nutrition

A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in which of the following positions for evaluation? A. Sims' B. Supine C. Sitting D. Standing

C. Sitting

A nurse is using a portable ultrasound bladder scanner to measure a client's post-void residual volume. Which of the following actions should the nurse take? A. Have the client urinate 20 min before the scan B. Assist the client into a semi-Fowler's position C. Position the scanner head at the symphysis pubis D. Apply light pressure to the scanner head once it is in position

D. Apply light pressure to the scanner head once it is in position

A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit, and her ankles are edematous. Which of the following findings is another clinical manifestation of fluid volume excess? A. Sunken eyeballs B. Hypotension C. Poor skin turgor D. Bounding pulse

D. Bounding pulse

A nurse is beginning a therapeutic relationship with a client. Which of the following actions should the nurse take to convey empathy when using the therapeutic communication technique of active listening? A. Assume an open position B. Sit upright and lean back into the chair C. Avoid direct eye contact until the client initiates it D. Sit next to the client

A. Assume an open position

A nurse discovers that a client received the wrong medication. Which of the following actions should the nurse take first? A) Complete a medication error report B) Notify the prescribing provider C) Assess the client D) Notify the charge nurse

C) Assess the client

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, 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 monitoring a client's laboratory results. Which of the following results should the nurse report to the provider? A. Sodium 140 mEq/L B. Potassium 3.0 mEq/L C. Chloride 100 mEq/L D. Magnesium 2.0 mEq/L

B. Potassium 3.0 mEq/L

A nurse is teaching the parent of a child who is to take 10 mL of a liquid medication. The parent has a hollow medication spoon with marks to indicate teaspoons and tablespoons. How many teaspoons should the nurse instruct the parent to give the child? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero, if applicable. Do not use a trailing zero.)

2 tsp -5mL/1 tsp= 10 mL/Xtsp -5X=10 X=2

A nurse is teaching a client how to use an albuterol metered dose inhaler. After removing the cap from the inhaler and shaking the canister, identify the sequence of instructions the nurse should give the client. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) 1. Tilt his head back slightly, and then open his mouth 2. Hold the mouthpiece 1 to 2 inches in front of your mouth 3. Hold your breath for 10 seconds 4. Depress the canister while taking a slow-deep-breath

2, 1, 4, 3

A nurse is preparing to change a dressing on a client who is receiving negative pressure wound therapy (NPWT). What sequence of actions should the nurse plan to take? Place them in order 1. Apply a skin protectant or a barrier film to the skin around the wound 2. Turn off the vacuum on the NPWT device and administer the prescribed analgesic 3. Connect the tubing to the transparent film and turn on the NPWT unit 4. Place prepared foam into the wound bed and cover with a transparent dressing 5. Apply sterile or clean gloves and irrigate the wound 6. Remove the soiled dressing and perform hand hygiene

2, 6, 5, 1, 4, 3 -Turn off the vacuum on the NPWT device and administer the prescribed analgesic -Remove the soiled dressing and perform hand hygiene -Apply sterile or clean gloves and irrigate the wound -Apply a skin protectant or a barrier film to the skin around the wound -Place prepared foam into the wound bed and cover with a transparent dressing -Connect the tubing to the transparent film and turn on the NPWT unit

A nurse is calculating a client's intake for a 12-hr shift. The client had dextrose 5% in 0.45% sodium chloride infusing at 125 mL/hr, gentamicin 150 mg in 100 mL at 1400, famotidine 20 mg in 50 mL at 1000 and 1600, 250 mL of blood over 2 hr, and a nasogastric flush of 30 mL every 2 hr. What is the total intake in milliliters that the nurse should document for this client for this 12-hr period? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2130 -125 mL x 12 hr = 1500 mL + 100 mL + (50 mL x 2 = 100 mL) + 250 mL + (30 mL x 6 = 180 mL) = 2130 mL

A nurse is preparing to administer 40 mL of 0.9% sodium chloride IV to infuse over 20 min. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

30 - X gtt/min = 15 gtt/1 mL x 40 mL/20 min

A nurse is planning an in-service training session about nutrition. Which of the following statements should the nurse include in the teaching? A. "Fats provide energy." B. "Carbohydrates repair body tissue" C. "Fats regulate fluid balance" D. "Carbohydrates prevent interstitial edema"

A. "Fats provide energy."

A nurse is teaching a client who has low back pain about heat therapy. Which of the following statements by the client indicates an understanding of the teaching? A. "I need to place a towel between the heating pad and my skin." B. "I'll need to turn up the temperature if I can't feel the heat" C. "I'll sleep on top of the heating pad to increase the heat penetration" D. "Keeping the heat continuously on my back will help it heal"

A. "I need to place a towel between the heating pad and my skin."

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus? A. "Bear down" B. "Perform Kegel exercises" C. "Hold your breath" D. "Raise your head off the pillow"

A. "Bear down"

A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate? A. Airborne B. Droplet C. Contact D. Protective environment

A. Airborne

A nurse is caring for a client who is well-hydrated and has no visible evidence of nutritional deficiencies. A laboratory result within the expected reference range for which of the following substances indicates adequate protein uptake and synthesis? A. Albumin B. Calcium C. Sodium D. Potassium

A. Albumin

A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states, "It's too late for me to quit." Which of the following actions should the nurse take? A. Assist the client in finding local smoking-cessation assistance programs B. Tell the client that she will be all right after receiving medical care C. Inform the client that she must stop smoking or the provider will not be able to care for her D. Advocate for the client by supporting her statement about not quitting

A. Assist the client in finding local smoking-cessation assistance programs

A nurse is performing a focused assessment of a client's peripheral vascular system. Where should the nurse palpate the posterior tibial pulse? A. Below the medial malleoulus B. In the popliteal fossa C. In the antecubital space D. On the dorsum of the foot

A. Below the medial malleoulus

A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview? A. Client's level of comfort and ability to participate in the interview B. Previous illnesses and surgeries C. Events surrounding the client's recent illness D. Sociocultural history

A. Client's level of comfort and ability to participate in the interview

A nurse is replacing the surgical dressings on a client who had abdominal surgery. Which of the following actions should the nurse take? A. Don clean gloves to remove the old dressing B. Loosen the dressing by pulling the tape away from the wound C. Remove the entire old dressing at once D. Open sterile supplies after applying sterile gloves

A. Don clean gloves to remove the old dressing

A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger-stick blood sample. Which of the following actions by the AP requires that nurse to intervene? A. Elevating the finger above the heart level B. Rubbing the fingertip with an alcohol pad C. Puncturing the side of the fingertip D. Wrapping the finger in a warm cloth

A. Elevating the finger above the heart level

A nurse is caring for a client who has stage II pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer? A. Hydrocolloid B. Collagen C. Calcium alginate D. Proteolytic enzyme

A. Hydrocolloid

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 hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client's insomnia? A. The client watches television in her bed during the day. B. The client drinks warm milk before bedtime C. The client goes to bed at 2200 every night D. The client gets up to use the bathroom once during the night

A. The client watches television in her bed during the day.

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following pieces of information must the nurse verify with another nurse prior to the administration? Select all that apply A. The client's ID number B. The client's room number C. The client's name D. ABO compatibility E. Rh compatibility

A. The client's ID number C. The client's name D. ABO compatibility E. Rh compatibility

A nurse is preparing to assist an older adult client with ambulation following bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall? A. Use a gait belt during ambulation B. Ensure the client is wearing socks before ambulating C. Instruct the client to sit on the edge of the bed for 15 sec before ambulating D. Walk 2 ft behind the client during ambulation

A. Use a gait belt during ambulation

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home which of the following statements should the nurse identify as an indication that the client understands medical asepsis? A. "Ill wrap the old dressing in a paper bag and put it in the trash" B. "Ill wash my hands before I remove the old dressing and again before putting on the new one" C. "Ill need to take a pain pill 30 mins before I change the dressing" D. "Ill wear sterile gloves when I apply the new dressing"

B. "Ill wash my hands before I remove the old dressing and again before putting on the new one"

A nurse is assessing the pH of a client's gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect? A. 6 B. 2 C. 10 D. 8

B. 2

A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative. Which of the following clients should the nurse see first? A. A client who is 1 day postoperative following a lobectomy for small-cell carcinoma and has a chest tube with 35 mL/hr of bright red, bloody drainage B. A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage C. A client who is 2 days postoperative following the excision of an abdominal mass and has a portable wound suction device with 20 mL/hr of serosanguinous drainage D. A client who is 1 day postoperative following the excision of a bladder wall tumor and prostate and has continuous bladder irrigation with 300 mL/hr reddish-pink urine

B. A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage

A nurse is admitting a client who has tuberculosis. In addition to standard precautions, which of the following transmission-based precautions should the nurse add to the client's plan of care? A. Protective B. Airborne C. Droplet D. Contact

B. Airborne

A nurse on a medical unit is caring for a client who has difficulty sleeping. Which of the following actions should the nurse take to promote the client's ability to fall asleep? A. Encourage the client to ambulate in the hallway just before bedtime B. Allow the client to maintain the same bedtime routine as at home C. Keep room temperature warm D. Offer the client a cup of hot chocolate before bedtime

B. Allow the client to maintain the same bedtime routine as at home

A nurse is caring for an adult client who has an NG tube in place and a prescription for continuous enteral feedings. Which of the following actions should the nurse perform to reduce the client's risk of aspiration? A. Irrigate the tubing with 30 mL of sterile water B. Elevate the head of the bed to 30° or 45° C. Suggest changing the feeding to lactose-free formula D. Warm the enteral formula to room temperature before feeding

B. Elevate the head of the bed to 30° or 45°

A nurse is preparing to administer a feeding via a gastrostomy tube to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding? A. Warm the feeding in a microwave oven B. Elevate the head of the client's bed C. Flush the tube with 0.9% sodium chloride for irrigation D. Verify that the client's gastric pH is above 4

B. Elevate the head of the client's bed

A nurse on a medical-surgical unit observes smoke billowing from a client's room. Which of the following actions should the nurse take first? A. Close the door to the client's room B. Evacuate the client from the room C. Sound the fire alarm D. Activate the fire extinguisher

B. Evacuate the client from the room

A nurse is performing a physical assessment of a client. The nurse should recognize that which of the following findings places the client at risk of impaired skin integrity? A. 3+ Achilles reflex B. Faint pedal pulses C. Feet warm to the touch bilaterally D. Capillary refill of <2 sec

B. Faint pedal pulses

A nurse is communicating with a group of clients about what to expect during the postoperative phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as an evaluation of effective communication? A. The motivation for communication is evident B. Feedback is provided C. A message is communicated to the group of clients D. Multiple channels are used by the sender

B. Feedback is provided

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? A. Autonomy B. Fidelity C. Nonmaleficence D. Justice

B. Fidelity

A nurse is an emergency department is assessing a client who reports diarrhea and decreased urination for 4 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 a skin fold on the client under the clavicle, release it, and note whether it springs back C. Press the skin above the ankle for 5 seconds, release it, and not the depth of the impression D. Measure the skinfold thickness on the upper arm using a pair of calibrated skinfold calipers

B. Grasp a skin fold on the client under the clavicle, release it, and note whether it springs back

A nurse is collecting health history data from a client who is deaf and uses American Sign Language (ASL) to communicate. The nurse will be working with an ASL interpreter. Which of the following actions should the nurse take when working with the interpreter? A. Face away from the client to avoid distraction B. Pace speech to allow time for the interpreter to convey the words. C. Make eye contact with the interpreter when explaining the procedure D. Stand in the background while the interpreter translates the message

B. Pace speech to allow time for the interpreter to convey the words.

a nurse is preparing to administer a bolus feeding to a client through an NG tube and observes that the exit mark on the tube has moved since the last feeding. Which of the following actions should the nurse plan to take? A. Auscultate over the stomach while injecting air B. Request an x-ray of the client's abdomen C. Place the head of the client's bed in a flat position D. Administer the feeding if the pH of the aspirated contents is >6

B. Request an x-ray of the client's abdomen

A nurse in a provider's office is teaching a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching? (Select all that apply) A. Canned peaches B. White rice C. Black beans D. Whole-grain bread E. Tomato juice

C. Black beans D. Whole-grain bread

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

C. Temperature

A nurse is preparing to instill a vaginal medication in suppository form to a client. Which of the following actions should the nurse take during this procedure? A. Don sterile gloves B. Use the dominant hand to retract the labia C. Use the index finger to insert the suppository D. Ease the suppository along the anterior vaginal wall

C. Use the index finger to insert the suppository

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 safety. Dentures can slip and block your airway during surgery" B. "You wouldn't want your teeth to be lost or broken during surgery, would you?" C. "The anesthesiologist requires all clients to remove their dentures" D. "What worries you about being without your teeth?"

D. "What worries you about being without your teeth?"

A nurse asks a client to explain the statement, "A bird in the hand is worth two in the bush". Through this question, the nurse is evaluating the client's ability in which of the following intellectual functions? A. Judgement B. Short-term memory C. Attention span D. Abstract reasoning

D. Abstract reasoning

A nurse is preparing to administer a tuberculin skin test to a client. After performing hand hygiene, which of the following actions should the nurse take? A. Select a 23-gauge needle B. Insert the needle into the skin at a 25 degree angle C. Massage the area of injection following removal of the needle D. Circle the injection area with a pen

D. Circle the injection area with a pen

While admitting a client to the medical unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able" The nurse should identify that the client is referring to which of the following documents? A. Informed consent form B. Living will document C. Do-not-resuscitate (DNR) directive D. Durable power of attorney document

D. Durable power of attorney document

A nurse is caring for a client who has the head of his bed elevated to a 45° angle with his knees slightly flexed. Which of the following positions should the nurse document for the client? A. Sims' B. Prone C. Supine D. Fowler's

D. Fowler's

A nurse in a provider's office is collecting information form an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects? A. Constipation B. Gastric ulcers C. Respiratory depression D. Liver damage

D. Liver damage

A nurse has receiving a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the following functional classifications? A. Skeletal muscle relaxants B. Beta-adrenergic blockers C. Broad-spectrum anti-infective agents D. Plasma volume expanders

D. Plasma volume expanders

A nurse is preparing to admin an afternoon dose of ampicillin to a client. The client appears upset & refuses to take the med before throwing the pill on the floor. Which of the following entries should the nurse enter into the client's med record? A. The client refused to take the med today B. The client stated, "I will not take this pill." C. The client seemed angry & hostile D. The client threw the med on the floor

D. The client threw the med on the floor

A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family? A. Use battery-operated equipment for personal care B. Apply mineral oil to protect the facial skin from irritation C. Remove the television set from the client's bedroom D. Wear cotton clothing to avoid static electricity

D. Wear cotton clothing to avoid static electricity