ATI Master Exam Practice

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?A) Role play B) Group discussions C) Question-answer meetings D) Practice sessions

practice sessions

A nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? a. "I can concentrate best in the morning" b. "it is difficult to read the instructions because my glasses are at home" c. "i'm wondering why I need to learn this" d. "you will have to talk to my wife about this"

A

A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. a. examine personal values about the issue b. tell the parents that this is a necessary procedure c. inform the parents that the staff does not require their consent d. contact a spiritual support person to explain the imprtance of the procedure

A

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?

I can see that this is upsetting you

A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take?

Place the client in Trendelenburg's position

A nurse is providing oral care for a client who is unconscious which of the following actions should the nurse take?

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

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?

Remove the safety pin from the extinguisher

a nurse is planning care for a client who has tuberculosis. the nurse should use which of the following pieces of personal protective equipment when providing care for the client? a. gown b. N95 respirator c. shoe covers d. surgical cap

N95 respirator

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?

Romberg test

a nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. the nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? a. a client who has a history of physical abuse b. a client who has a permanent pacemaker c. a client who has ulcerative colitis d. a client who has asthma

a client who has asthma

a nurse is assessing a client who received an IV fluid bolus for dehydration. which of the following findings should the nurse identify as an indication of fluid volume excess? a. hypotension b. weak, thready pulse c. slow capillary refill d. distended neck veins

distended neck veins

A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention? A) Erythema on pressure points B) Lower-extremity pulse strength of 2+ C) Fluid intake of 3,000 mL per day D) A bowel movement every other day

erythema on pressure points

A nurse is preparing to administer 0.9%sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr?

107mL/hr

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? A. during the admission process B.as soon as the client's condition is stable C. during the initial team conference D. after consulting with the client's family

A

Inspect-Auscultate-Percuss-Palpate

A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for the assessment. (Inspection, Palpation, Percussion, Auscultation)

A. Assessment

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

B. Obtain client information.

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

C. Place the wheelchair at a 45 degree angle to the bed.

A nurse on a rehabilitation unit is preparing to transfer a client who us unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? A. Stand toward the client's stronger side. B. Instruct the client to lean backward from the hips. C. Place the wheelchair at a 45 degree angle to the bed. D. Assume a narrow stance with feet 15 cm (6in) apart.

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next? a. document the provider's statement in the medical record b. comple an incident report c. consult the facility's risk manager d. notify the nursing manager

D

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? A. bend at the waist B. keep his feel close together C. use his back muscles for lifting D. stand close to the cabinet when lifting it

D

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?

Daily weight

a nurse is discussing the use of herbal supplements for health promotion with a client. which of the following client statements indicates an understanding of herbal supplement use? a. I can take echinacea to improve my immune system b. I can take feverfew to reduce my level of anxiety c. I can take ginger to improve my memory d. I can take ginkgo blob to relieve nausea

I can take echinacea to improve my immune system

A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use?

PC for after meals

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take?

Position the client on his left side

An 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 a need for further teaching?

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

a nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection

WBC 15,000 mm3

a nurse is caring for a client who has decreased mobility. which of the following actions should the nurse take to decrease the clients risk of developing plantar flexion contractures? a. place a pillow under the clients knees b. position a trochanter roll under each of the clients hips c. advise the client to wear rubber-soled slippers d. apply an ankle-foot orthotic device to the clients feet

apply an ankle-foot orthotic device to the clients feet

a nurse is caring for a client who has a prescription for wound irrigation. which of the following actions should the nurse take? a. wear sterile gloves when removing the old dressing b. warm the irrigation solution to 40.5 Celsius/105F c. cleanse the wound from the center outward d. use a 20 mL syringe to irrigate the wound

cleanse the wound from the center outward

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?

cold extremities

a nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. which of the following documentation should the nurse include? a. client flow sheet b. acuity ratings c. current medications d. incident reports

current medications

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?

decreased calcium

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take?

fill the bag two-thirds full with ice

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? A) Place the client in high-Fowler's position. B) Increase the client's intake of carbohydrates. C) Massage reddened areas with unscented lotion. D) Have the client use a trapeze bar when changing position.

have the client use a trapeze bar when changing positions

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

ventrogluteal

a nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. which of the following types of activity should the nurse recommend? a. walking briskly b. riding a bike c. performing isometric exercises d. engaging in high-impact aerobics

walking briskly

A. Evaluate pedal pulses

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

D. Pericardial friction rub

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

A nurse on a surgical unit is receiving a client who has abdominal surgery from the post-anesthesia care unit. Which of the following assessments should the nurse make first?

Airway

a nurse is caring for a client who has recently started using a behind-the-ear hearing aid. which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device? a. this type of hearing aid does not allow for fine tuning of volume b. I shouldn't have trouble keeping the hearing aid in place during exercise c. I expect to hear a whistling sound when I first insert the hearing aid d. I will be sure to remove my hearing aid before taking a shower

I will be sure to remove my hearing aid before taking a shower

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? A. the client uses a wool blanket on their bed B. the client uses non-acetone nail polish remover C. the client stores an extra oxygen tank on its side under their bed D. the client has a weekly inspection checklist for oxygen equipment

B

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?

Have the client demonstrates the procedure

A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take

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

a community health nurse is checking blood pressures for a group of clients at a community health screening. which of the following clients is at an increased risk for hypertension? a. a client who is 52 years old b. a client who smokes one pack of cigarettes each day c. a client who walks for 30 minutes every day d. a client who drinks one glass of wine 3 times per week

a client who smokes one pack of cigarettes each day

D. Identify the client using two identifiers.

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.

B. The client reports severe pain.

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

C. Carefully remove the gloves and follow with hand hygiene.

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. Wash the 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. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart.

A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? A. Measure the pulse using a Doppler ultrasound stethoscope B. Check the client's pedal pulses. C. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. D. Take the pulse at each peripheral site and count the rate for 30 seconds.

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

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

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

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

D. "Donate autologous blood before the surgery."

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

A. The involvement of the client in planning the change

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

A. Lock the wheels on the bed and stretcher.

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

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

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

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

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

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

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

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

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

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

A nurse is planning care for a client who has had a stroke resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an AP? a. assist the client with a partial bed bath b. measure the client's BP after the nurse administers an antihypertensive medication c. test the client's swallowing ability by providing thickened liquids d. use a communication board to ask what the client wants for lunch e. irrigate the client's indwelling urinary catheter

A, B, & D

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? A. "I can place an extension cord across my living room to plug in my television" B. "I will hire someone to trim the tree that hangs low over the stairs of my front porch" C. "I will place my alarm clock on my bedroom dresser across the room" D. "I will replace the old throw rug in my kitchen with a new one"

B

A nurse is talking with an older adult client who is contemplating retirement. The client states, " I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse take? a. "you would have so much more time to spend with your family" b. " you should consider getting a part-time job or do volunteer work" c. "let's talk about how the change in your job status will affect you" d. "why wouldn't you about to retire and relax"

C

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manager household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the type of role-performance stress. a. role ambiguity b. sick role c. role overload d. role confllict

C

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? a. place the client in a side-lying position b.instill 15 mL of irrigation fluid into the catheter with each flush c. subtract the amount of irrigant used from the client's urine output d. perform the irrigation using a 20-mL syringe

C

The nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? A. insert the needle at a 15 degree angle B. aspirate for blood return prior to administration C. administer the medication into the abdomen D. massage the site following the injection

C

A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients?

A client who has a prescription for a transfusion of packed red blood cells

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "what would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make? a. "we would consult the person appointed by your health care proxy to make decisions" b. "we would give you oxygen through a tube in your nose" c. "you would be unable to change your previous wishes about your care" d."we would insert a breathing tube while we evaluate your condition"

B

A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. Which of the following responses should the nurse make?

It must be difficult to care for someone who is confined to bed

A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship?

Loss

A newly licensed nurse is preparing to administer medications to a client. Which of the following actions should the nurse take?

consult the medication reference book available on the unit

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make? A) "I'll get a blood sample from you and send it for a screening test." B) "Beginning at age 60, you should have a colonoscopy." C) "You should have a fecal occult blood test every year." D) "The recommendation is to have a sigmoidoscopy every 10 years."

you should have a fecal occult blood test every year

a nurse is caring for a client who requires a 24-hr urine collection. which of the following statements by the client indicates an understanding of the teaching? a. "I had a bowel movement, but I was able to save the urine." b. "I have a specimen in the bathroom from about 30 minutes ago." c. "I flushed what I urinated at 7:00 a.m. and have saved all urine since." d. "I drink a lot, so I will fill up the bottle and complete the test quickly."

"I flushed what I urinated at 7:00 a.m. and have saved all urine since."

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? A) "What could I have done to deserve this illness?" B) "I blame medical science for not curing me." C) "Where is my daughter at a time like this?" D) "Will I ever begin to feel in charge of my life again?"

"What could I have done to deserve this illness?"

a nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure? a. 92 mm Hg b. 102 mm Hg c. 112 mm Hg d. 122 mm Hg

122 mm Hg

A nurse is preparing a heparin infusion for a client who was hospitalized with deep-vein thrombosis. The order reads: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

8 mL/hr 250ml/25,000units = 0.01 ml/units 0.01 ml/units x 800units/hr = 8 ml/hr

D. Second intercostal space to the right of the sternum

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

a nurse is planning to insert a pheripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? a. insert the catheter at a 45 degree angle b. place the client's arm in a dependent position c. shave excess hair from the insertion site d. initiate IV therapy in the veins of the hand

B

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? a. numbness of the extremities b. bradycardia c. positive Chvostek's sign d. abdominal cramping

D

a nurse in a provider's office is assessing a client who has heart failure. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess

bounding pulse

a nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. which of the following pieces of information is the priority for the nurse to provide? a. admitting diagnosis b. breath sounds c. body temperature d. diagnostic test results

breath sounds

a nurse on a telemetry unit is caring for a client who had a myocardial infarction. Which of the following responses should the nurse make?

all of this equipment can be frightening

a nurse has just inserted an NG tube for a client. which of the following findings should the nurse expect to confirm correct tube placement? a. the tube aspirate has a pH of 7 b. an x-ray shows the end of the tube above the pylorus c. bowel sounds are present on auscultation d. the client reports relief of nausea

an x-ray shows the end of the tube above the pylorus

A nurse is providing discharge teaching to a client who is recovering from lung cancer. which of the following activities should the nurse recommend to the client?

washing dishes

A client is being discharged home with oxygen therapy via nasal cannula. Which of the following instructions should the nurse provide to the client and family

wear cotton clothing to avoid static electricity

A nurse is caring for a client with c diff. which of the following actions should the nurse take?

wear gloves when changing the client's gown

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? A) Ask the client to consider a direct donation. B) Withhold the blood transfusion. C) Request a consultation with the ethics committee. D) Ask the client's family to intervene.

withhold the blood transfusion

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take? A. turn the client every 2 hr B. administer an antiemetic every 6 hr C. hold oral care D. increase the room's temperature

A

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

A nurse in 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 chest under the clavicle, release it, and note whether it springs back. C. Press the skin in above the ankle for 5 seconds, release it, and note the depths of the impression. D. Measure the skin fold thickness at the upper arm using a pair of calibrated skinfold calipers.

B. Absent bowel sounds with distention

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

C. Temperature

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

D. Temporal

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

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? A. contact B. droplet C. airborne D. protective

B

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (select all that apply) a. lacrimal apparatus b. pupil clarity c. appearance of bulbar conjunctivae d. visual fields e. visual acuity

B, D & E

a nurse on a medical unit is preparing to discharge a client to home. which of the following actions should the nurse take as part of the medication reconciliation process? a. seal unused medications from the facility in a plastic bag b. evaluate the clients ability to self administer medications c. report an identified discrepancy to the join commission d. compare prescriptions with medications the client received while at the facility

compare prescriptions with medications the client received while at the facility

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feedings? A) assign a staff member to feed the client B) Provide small-handle utensils for the client. C) Thicken liquids on the client's tray. D) arrange food in a consistent pattern on the clients plate

arrange food in a consistent pattern on the client's plate

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?

cough deeply after each use

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.) A) Place the client in a room with negative-pressure airflow. B) Wear gloves when assisting the client with oral care. C) Limit each visitor to 2-hr increments. D) Wear a surgical mask when providing client care. E) Use antimicrobial sanitizer for hand hygiene.

-Place the client in a room with negative-pressure airflow. -Wear gloves when assisting the client with oral care. -Use antimicrobial sanitizer for hand hygiene.

a nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. how should the nurse transcribe the dosage of this medication in the clients medical record? a. .3 mg b. 0.3 mg c. 0.30 mg d. 3/10 mg

0.3 mg

C. Confirm unresponsiveness

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

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which type of dressing should the nurse use? A. alginate B. gauze C. transparent D. hydrocolloid

D

A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding?

Sit at the bedside while feeding the client

a nurse is caring for a client who requires an informed consent for a surgical procedure. which of the following actions is the nurses responsibility? a. describe the procedure to the client b. witness the clients signature on the consent form c. inform the client of alternatives to the procedure d. tell the client which team members will assist with the procedure

witness the clients signature on the consent form

a nurse is admitting a client who has been having frequent tonic-clonic seizures. which of the following actions should the nurse add to the clients plan of care? a. wrap blankets around all four sides of the bed b. apply restraints during seizure activity c. place the client in a supine position during seizure activity d. have a tongue depressor at the clients bedside

wrap blankets around all four sides of the bed

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? a. pad the client's wrist before applying the restraints b. evaluate the client's circulation every 8hr after application c. remove the restraints every 4 hr to evaluate the client's status d. secure the restraint ties to the bed's side rails

A

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

A community health nurse is preparing 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 younger children about dangers of influenza. D. Finding rehabilitation programs for older adults who have complications from influenza.

C. Sit and hold the client's hand

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

C. Raise the level of the bed

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

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

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? A. "Drink a minimum of 1,000 milliliters of fluid daily." B. "Increase your intake of refined-fiber foods." C. "Sit on the toilet 30 minutes after eating a meal." D. "Take a laxative every day to maintain regularity."

D. Perform hand hygiene.

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

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? A. regulate the flow rate by aligning the rate with the top of the ball inside the flow meter B. regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min C. make sure the reservoir bag of a partial rebreathing mask remains deflated D. use petroleum jelly to lubricate the client's nares, face, and lips

B

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complimentary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which therapy? A. biofeedback B. aloe C. feverfew D. acupuncture

D

a nurse is admitting a client who has rubella. which of the following types of transmission-based precautions should the nurse initiate? a. droplet b. airborne c. contact d. protective environment

droplet

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?

gelatin

A nurse is responding to a parents question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include?

A 10-month-old infant can pull himself to a standing position

An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make

tell me more about how your friends discourage you

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. Which of the following ethical principles is the nurse demonstrating?

Fidelity

A nurse is caring for a client who is receiving a blood transfusion. The nurse recognizes these manifestations as which of the following types of transfusion reactions?

Hemolytic

a nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. which of the following actions should the nurse take? a. Instruct the family to refrain from pushing the button for the client while she is asleep. b. Inform the client that because she is on PCA, vital signs will be taken every 8 hr. c. Teach the client to avoid pushing the button until pain is above a 7 on a scale of 0 to 10. d. Increase the basal rate and shorten the lock-out interval time if the client's pain level is too high.

Instruct the family to refrain from pushing the button for the client while she is asleep.

A nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse question? A) The medication name B) The route of administration C) The medication dose D) The frequency of administration

the medication dose

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? A) "I'm having mild pain." B) "The pain is like a dull ache in my stomach." C) "I notice that the pain gets worse after I eat." D) "The pain makes me feel nauseous."

the pain is like a dull ache in my stomach

A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take?

tie the restraint with a quick release knot

a nurse is a surgical suite notes documentation on a clients medical record that he has a latex allergy. in preparation for the clients procedure, which of the following precautions should the nurse take? a. ensure sterilization of non disposable items with ethylene oxide b. wrap monitoring cords with stockinette and tape them in place c. cleanse latex ports on IV tubing with chlorhexidine before injecting medication d. wear hypoallergenic latex gloves that contain powder

wrap monitoring cords with stockinette and tape them in place

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? A. ask another nurse to observe the medication wastage B. notify the pharmacy when wasting the medication C. lock the remaining medication in the controlled substance cabinet D. dispose of the vial with the remaining medication in a sharps container

A

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

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. "I am sure 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."

D. Notify the provider about the client's decision.

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

A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? a. Bladder distention b. Decreased Blood pressure c. Calf swelling d. Diminished bowel sounds

C

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? a. protective environment b. airborne precautions c. droplet precautions d. contact precautions

D

a middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." which of the following responses should the nurse make? a. "Most people are happy when their children grow up and leave home." b. "You should be proud that your children are becoming independent." c. "Maybe you should consider why you are feeling useless." d. "People in middle adulthood often find satisfaction in nurturing and guiding young people."

"People in middle adulthood often find satisfaction in nurturing and guiding young people."

a nurse is caring for a client who has a terminal diagnosis and whose health is declining. the client request information about advanced directives. which of the following responses should the nurse make? a. "We can talk about advance directives, and I can also give you some brochures about them." b. "You should set up a time to talk with your provider about that." c. "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better." d. "Why do you want to discuss this without your partner here to plan this with you?"

"We can talk about advance directives, and I can also give you some brochures about them."

a nurse is teaching a client whose left leg is in a cast about using crutches. which of the following statements should the nurse identify as an indication that the client understands the teaching? a. "When descending stairs, I will first shift my weight to my right leg." b. "I should place my crutches 12 inches in front and to the side of each foot." c. "As I sit down, I will hold one crutch in each hand." d. "I will make sure the shoulder rests are snug against my armpits."

"When descending stairs, I will first shift my weight to my right leg."

a nurse enters a clients room and finds her on the floor. the clients roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. which of the following statements should the nurse document about this incident? a. "incident report completed" b. "client climbed over the side rails" c. "client found lying on floor" d. "client was trying to get out of bed"

"client found lying on floor"

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1) Inject 5 units of air into the bottle of regular insulin 2) Withdraw the correct dose of NPH insulin from the bottle 3) Inject 10 units of air into the bottle of NPH insulin 4) Withdraw the correct dose of regular insulin from the bottle

1. Inject 10 units of air into the bottle of NPH insulin 2.Inject 5 units of air into the bottle of regular insulin 3.Withdraw the correct dose of regular insulin from the bottle 4) Withdraw the correct dose of NPH insulin from the bottle

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. 1. place name tag on the body 2. obtain the pronouncement of death from the provider 3. remove tubes and indwelling lines 4. wash the client's body 5. ask the client's family members if they would like to view the body

2,3,4,5,1

a nurse is calculating a clients fluid intake over the past 8 hours. which of the following items should the nurse plan to document on the clients intake and output record as 120 ml of fluid? a. 2 cups of soup b. 1 quart of water c. 8 oz of ice chips d. 6 oz of tea

8 oz of ice chips

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? a. press gently on the tragus of the client's ear b. pack a small piece of cotton deep into the client's ear canal c. move the client's auricle down and back toward her head d.tilt the client's head back for 5 min.

A

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? a. use a bed exit alarm system b. raise four side rails while the client is in bed c. apply one soft wrist restraint d. dim the lights in the client's room

A

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? a. check the client for injuries b. move hazardous objects away from the client c. notify the provider d. ask the client to describe how she felt prior to the fall

A

B. Obtaining cotton balls for the tracheostomy care

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 interventions? A. Obtaining hydrogen peroxide for the tracheostomy care B. Obtaining cotton balls for the tracheostomy care C. Obtaining sterile gloves for the tracheostomy care D. Obtaining a sterile brush for the tracheostomy care

A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex? A. Tapping the back of heel B. Tapping the knee C. Tapping the biceps D. Tapping the triceps

B

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority? a. request that a respiratory therapist discuss the technique for incentive spirometry with the client b. determine the reasons why the client is refusing to use the incentive spirometer c. document the client's refusal to participate in health restorative activities d. administer a pain medication to the client

B

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infections? A. carry a client's soiled linens out of the room in a mesh linen bag B. place a client who has tuberculosis in a room with negative-pressure airflow C. provide disposable plates and utensils for a client who is HIV-positive D. dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag

B

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? a. make sure the client's room has at least six air exchanges per hour b. make sure the client wears a mask outside her room if there is construction in the area c. place the client in a private room with negative-pressure airflow d. wear an N95 respirator when giving the client direct care

B

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? a. critical pathway b. situation, background, assessment, & recommendation (SBAR) c. transfer report d. medication administration record (MAR)

B

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? a. remove the outer cannula cautiously for routine cleaning b. use tracheostomy covers when outdoors c. use sterile technique when performing tracheostomy care at home d. cleanse irritated skin with full-strength hydrogen peroxide

B

A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching?

Bear weight on both of your legs

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the clients pain? A. "is your pain constant or intermittent?" B. "what would you rate your pain on a scale of 0 to 10?" C. "does the pain radiate?" D. "is your pain sharp or dull?"

D

A nurse is auscultating the anterior chest of a client who was newly admitted to a medical-surgical unit. Listen to the audio clip of what the nurse auscultates through the stethoscope and identify the type of breath sounds. A. crackles B. rhonchi C. friction rub D. normal breath sounds

D

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client? A. have the client wear a mask when receiving visitors B. limit the client's time with visitors to no more than 30 min per day C. assign the client to a room with negative-pressure airflow exchange D. wear a gown when caring for the client

D

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? a. discuss the risk factors for colon cancer b. focus teaching on what the client will need to do in the future to manage his illness c. provide the client with written information about the phrases of loss and grief d. reassure the client that this is an expected response to grief

D

A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says "every time you change my badge, it hurts so much." Which of the following interventions is the nurse's priority action? A. encourage the client to relax and take deep breaths during the dressing change B. educate the client about the importance of dressing change to prevent infection C. assists the client to a comfortable position for the dressing change D. administer pain medication 45 min before changing the client's dressing

D

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? a. BUN 15 mg/dL b. Creatinine 0.8 mg/dL c. Sodium 143 mEq/L d. Potassium 5.4 mEq/L

D

A nurse receives report about a client who has 0.9% sodium chloride infusing IV at 125mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80mL over the last 2 hr. Which of the following actions should the nurse take first? A. reposition the client B. document the client's IV intake in the medical record C. request a new IV fluid prescription D. check the IV tubing for obstruction

D

A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next?

Observe the rate, depth, and character of the client's respirations

A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse indicates an understanding of the teaching?

People who practice judaism stay with the body of the deceased until burial

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing?

Provide a protein intake of 1.5g/kg of body weight per day

a nurse is caring for a group of clients on a medical-surgical unit. in which of the following situations does the nurse demonstrate the ethical principle of veracity? a. A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. b. A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes. c. A client who has a do-not-resuscitate (DNR) order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family. d. A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse previously promised to administer.

a client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively

a nurse is caring for a client who has an indwelling urinary catheter. which of the following findings indicates that the catheter requires irrigation? a. urine has an unusual odor b. urine specific gravity is 1.035 c. bladder scan shows 525 mL of urine d. urine is positive for ketones

bladder scan shows 525 mL of urine

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

edema at the infusion site

a home health nurse is planning to provide health promotion activites for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?

educating clients about the recommended immunization schedule for adults

a client who is non ambulatory notifies the nurse that his trash can is on fire. after the nurse confirms the presence of the fire, which of the following actions should the nurse take next? a. activate the emergency fire alarm b. extinguish the fire c. evacuate the client d. confine the fire

evacuate the client

A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The nurse should plan care based on which of the following factors

impaired peristalsis of the intestines

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? A) Insert an implanted port. B) Close a laceration with sutures. C) Place an endotracheal tube. D) Initiate an enteral feeding through a gastrostomy tube.

initiate an enteral feeding through a gastrostomy tube

A nurse in a provider's office is collecting information from an older adult client who reports that he has been taking acetaminophen 500 mg/day for severe joint pain.

liver damage

a nurse is caring for a client who reports difficulty falling asleep. which of the following recommendations should the nurse make? a. drink a cup of hot cocoa before bedtime b. maintain a consistent time to wake up each day c. exercise 1 hour before going to bed d. watch a television program in bed before going to sleep

maintain a consistent time to wake up each day

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following? (Click on the audio button to listen to the clip.) A) Narrowed arterial lumen B) Distended jugular veins C) Impaired ventricular contraction D) Asynchronous closure of the aortic and pulmonic valves

narrowed arterial lumen

A nurse is planning care for a client who has a single-lumen nasogastric tube for gastric decompression. select all that apply

provide oral hygiene frequently is correct measure the drainage from the NG tube every shift is correct secure the ng tube to the client's gown

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect? A) Neck vein distention B) Urine specific gravity 1.010 C) Rapid heart rate D) Blood pressure 144/82 mm Hg

rapid heart rate

A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take

repeat each joint motion five times during each session

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? A) Use a resuscitation bag with 80% oxygen prior to the procedure. B) Select a suction catheter that is half the size of the lumen. C) Place the end of the suction catheter in water-soluble lubricant. D) Adjust the wall suction apparatus to a pressure of 170 mm Hg.

select a suction catheter that is half the size of the lumen

a nurse is caring for a client who is receiving fluid through a peripheral IV catheter. which of the following findings at the IV site should the nurse identify as indicating infiltration? a. purulent exudate b. warmth c. skin blanching d. bleeding

skin blanching

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?A) Rinse the feeding bag with water between feedings. B) Tell the client to keep the head of the bed elevated at least 30°. C) Make sure the enteral formula is at room temperature. D) Wipe the top of the formula can with alcohol.

tell the client to keep the head of the bed elevated at least 30°

A nurse is reviewing measures to prevent back injuries with AP. which of the following instructions should the nurse include?

when lifting an object spread your feet apart to provide a wide base of support

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?

Cover the incision with a moist sterile dressing

a nurse is preparing to delegate client care tasks to an assistive personnel (AP). which of the following tasks should the nurse delegate? a. ambulating a client who is postoperative b. inserting an indwelling urinary catheter for a client c. demonstrating the use of an incentive spirometer to a client d. confirming that a clients pain has decreased after receiving an analgesic

ambulating a client who is postoperative

A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching? A) Assign the client to a room with a negative air-flow system. B) Use alcohol-based hand sanitizer when leaving the client's room. C) Clean contaminated surfaces in the client's room with a phenol solution. D) Have family members wear a gown and gloves when visiting.

have family members wear a gown and gloves when visiting

a nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. after securing a safe environment, which of the following actions should the nurse take next? a. rock the client up to a standing position b. pivot on the foot that is the farthest from the chair c. assess the client for orthostatic hypotension d. apply a gait belt to the client

assess the client for orthostatic hypotension

A nurse is preparing to administer enoxaparin subcutaneously to a client/ Which of the following actions should the nurse take? a. administer the medication with the needle at a 45 degree angle b. administer the medication into the client's non-dominant arm c. pull the client's skin laterally or downward prior to administration d. massage tne injection site after administration

A

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? a. "use the complete name of the medication magnesium sulfate" b. "delete the space between the numerical dose and the unit of measure" c. "write the letter U when noting the dosage of insulin" d. "use the abbreviation SC when indicating an injection"

A

a nurse is planning an educational program for a group of older adults at a senior living center. which of the following recommendations should the nurse include? a. "You should have an eye examination every 2 years." b. "You should receive a tetanus booster every 5 years." c. "You should receive a shingles vaccine when you are 70 years old." d. "You should receive a pneumococcal vaccine when you are 65 years old."

"You should receive a pneumococcal vaccine when you are 65 years old."

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? A. use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain B. ensure the bladder of the blood pressure cuff surrounds 80% of the clients arm C. obtain an apical heart rate by auscultating at the third intercostal space left of the sternum D. palpate the clients abdomen before auscultating bowel sounds

B

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? A. "they allow the court to overrule an adult client's refusal of medical treatment" B. "they indicate the form of treatment a client is willing to accept in the event of a serious illness" C. "they permit a client to withhold medical information from health care personnel" D. "they allow health care personnel in the emergency department to stabilize a client's condition"

B

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understand the preoperative teaching she received about pain management? a. "I think I should take my pain medication more often, since it is not controlling my pain" b. "breathing faster will help me keep my mind off of the pain" c. "it might help me to listen to music while i'm lying in bed" d. "I don't want to walk today because I have some pain"

C

A home health nurse is performing a folow-up visit for a client who has a gastrostomy tube through which they recieve intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea? a. the client is receiving formula at room temperature b. the feedings infuse at a slow, continuous drip over 8 hr each night c. the client's caregiver washes out the feeding bag with warm water once every 24 hr d. the client's caregiver flushes the tubing with water before and after administering medications

C

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? a. position the client with the head of the bed elevated to 30 degrees prior to insertion of the NG tube b. remove the NG tube if the client begins to gag or choke c. apply suction to the Bg tube prior to insertion d. have the client take sips of water to promote insertion of the NG tube into the esophagus

D

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take? A) Dissolve each medication in 5 mL of sterile water. B) Draw up medications together in the syringe. C) Push the syringe plunger gently when feeling resistance. D) Flush the tube with 15 mL of sterile water.

flush the tube with 15mL of sterile water

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? A) Gently shake the container of medication prior to administration. B) Transfer the medication to a medicine cup. C) Place the client in a semi-Fowler's position prior to medication administration. D) Verify the dosage by measuring the liquid before administering it.

gently shake the container of medication prior to administration

a nurse is performing a Romberg test during the physical assessment of a client. which of the following techniques should the nurse use? a. touch the face with a cotton ball b. apply a vibrating tuning fork to the clients forehead c. have the client stand with their arms at their sides and their feet together d. perform direct percussion over the area of the kidneys

have the client stand with their arms at their sides and their feet together

A nurse in the emergency department 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?

tachycardia

C. Remove the restraints one at a time.

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

A nurse is administering IV fluid to an older adult client. The nurse should perform which priority assessment to monitor for adverse effects? A) Auscultate lung sounds. B) Measure urine output. C) Monitor blood pressure readings. D) Monitor serum electrolyte levels.

auscultate lung sounds

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? A. a lesion with uniform pigmentation B. new appearance of petechiae C. a mole with an asymmetrical appearance D. the presence of a papule

C

A nurse is preparing an education program for staff about advocacy. which of the following information should the nurse include? a. advocacy ensures client's safety, health, and rights b. advocacy ensures that nurses are about to explain their own actions c. advocacy ensures that nurses follow through on their promises to clients d. advocacy ensures fairness in client care delivery and use of resources

A

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? a. increased in hematocrit b. increased in respiratory rate c. decrease in heart rate d. decrease in capillary refill time

C

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? a. verify the client's name on their identification bracelet with the medication administration record b. call the pharmacy to determine wether the client's medications are available c. compare the client's home medications with the provider's prescriptions d. place the client's home medication bottles in a secure location

C

a nurse manager is overseeing the care activities on a unit. for which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines? a. A nurse who is caring for a client reviews the client's medical chart with a nursing student who is working with the nurse. b. A nurse asks a nurse from another unit to assist with documentation for a client. c. A nurse who is caring for a client returns a call to the person appointed in the health care proxy to discuss the client's care. d. A nurse discusses a client's status with the physical therapist who is caring for the client.

A nurse asks a nurse from another unit to assist with documentation for a client.

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

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 out with our children." B. "I am going to ask my husband to go to counseling with me." C. "I keep having nightmares about my upcoming surgery." D. "My girlfriends bought me a nice wig."

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

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

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

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

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

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? A. Turn on the machine every 15 min to measure the client's blood pressure. B. Record only blood pressure readings needed for the 15- min intervals. C. Obtain manual and automatic readings and compare them. D. Disconnect the machine, and measure the blood pressure manually every 15 min.

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

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

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? a. "I will return shortly after I document this in your record" b. "most men live in a long time with prostate cancer" c. "I am available to talk if you should change your mind" d. "I will make a referral to a cancer support group for you"

C

a charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. which of the following actions by the newly licensed nurse required intervention by the charge nurse? a. The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field. b. The newly licensed nurse places sterile objects 2.5 cm (1 inch) within the border of the field. c. The newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring. d. The sterile field is positioned at the level of the newly licensed nurse's waist.

The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field.

a nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first?

inspection

a nurse is caring for a client who has 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

oil retention

a home health nurse is completing an admission assessment of an older adult client who has their caregiver present. which of the following findings should the nurse identify as a potential indication of elder abuse? a. the caregiver is the clients financial power of attorney b. the client is in a wheelchair with the wheels locked c. the client reports receiving a full bath twice each week d. the caregiver insists on remaining in the room

the caregiver insists on remaining in the room

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? a. insert the suction catheter while the client is swallowing b. apply intermittent suction when withdrawn the catheter c. place the catheter in a location that is clean and dry for later use d. hold the suction catheter with her clean, non-dominant hand.

B

A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping? a. "I am not worried because I still have hope that he will be okay" b." I am relying on support from our family during this time" c. "we can plan our future reunion once he recovers and comes home" d. "we don't see any reasons to start discussing funeral arrangements right now"

B

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take? a. assist the client into a prone position b. place a sleeve over the top of each leg with the opening at the knee c. make sure two fingers can fit under the sleeves d. set the ankle pressure at 65 mm Hg

C

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? a. the top of the cane is parallel to the client's waist b. when walking, the client moves the cane 46 cm (18 in) forward c. the client holds the cane on the stronger side of her body d. the client moves er stronger limb forward with the cane

C

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? A. combine client care tasks when caring for multiple clients B. wait until the end of the shift to document client care C. use the planning step of the nursing process to prioritize client care delivery D. allow for interruptions in tasks to discuss client care with colleagues

C

a nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. which of the following instructions should the nurse provide to the client and his family? (select all that apply) a. check the cord routinely for frays or tearing b. keep the unit at least 1.2 m (4 ft) away from a gas stove c. Consider purchasing a generator for power backup. d. Observe for signs of hypoxia. e. Select synthetic clothing and bedding.

a. check the cord routinely for frays or tearing c. Consider purchasing a generator for power backup. d. Observe for signs of hypoxia.