ati proctored exam
A nurse is calculating the protein needs of a young adult client who weighs 132 lb. The RDA for protein for an adult who has no medical conditions is 0.8 g/kg. How many grams of protein per day should the nurse recommend for this client? (Fill in the blank with the numeric value only.)
48
A nurse is caring for a client who requires fluid restriction and may drink only 1 oz of water with each oral medication. How many milliliters of water should the nurse document as intake for the 3 separate medications the client receives during a 12-hr night shift? (Round the answer to the nearest whole number and fill in the blank with the numeric value only.)
90
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 community health nurse is conducting a class about body mechanics for county office workers. Which of the following instructions should the nurse include? (Select all that apply.) a. "Sit with your back supported." b. "Keep your knees at hip level." c. "Use an ergonomically designed computer keyboard." d. "Keep your elbows away from your body." e. "Adjust the monitor screen so that you have to tilt your head slightly to look at it."
a. "Sit with your back supported." b. "Keep your knees at hip level." c. "Use an ergonomically designed computer keyboard."
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 preparing to administer an otic antibiotic to an adult client who has otic media. Which of the following actions should the nurse plan to take? a. Hold the dropper 1 cm (0.5 in) above the ear canal during administration b. Apply pressure to the nasolacrimal duct following administration c. Place a cotton ball into the inner ear canal for 30 minutes following administration d. Straighten the ear canal by pulling the auricle down and back prior to administration
a. Hold the dropper 1 cm (0.5 in) above the ear canal during administration
A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take? a. Hyperoxygenate the client before suctioning b. Insert the catheter during exhalation c. Apply suction during insertion of the catheter d. Apply suction for no more than 15 sec
a. Hyperoxygenate the client before suctioning
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 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 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 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
c. Childhood
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 provide? 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 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 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. Allows 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 planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the child's temperature? a. Rectal b. Tympanic c. Oral d. Temporal
d. Temporal
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 this 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 preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following entries should the nurse enter into the client's medical record? a. The client refused to take medication today. b. The client stated, "I will not take this pill." c. The client seemed angry and hostile. d. The client threw the medication on the floor.
d. The client threw the medication on the floor.
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 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? (Move the steps into the box on the right, placing them in order of performance. Use all the steps.) Turn off the vacuum on the NPWT device and administer the prescribed analgesic. Place prepared foam into the wound bed and cover with a transparent dressing. Apply a skin protectant or a barrier film to the skin around the wound. Apply sterile or clean gloves and irrigate the wound. Connect the tubing to transparent film and turn on the NPWT unit. Remove the soiled dressing and perform hand hygiene.
1. Turn off the vacuum on the NPWT device and administer the prescribed analgesic. 2. Remove the soiled dressing and perform hand hygiene. 3. Apply sterile or clean gloves and irrigate the wound. 4. Apply a skin protectant or a barrier film to the skin around the wound. 5. Place prepared foam into the wound bed and cover with a transparent dressing. 6. Connect the tubing to transparent film and turn on the NPWT unit.
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 Fahrenheit temperature should the nurse administer acetaminophen to the client? (Fill in the blank with the numeric value only, round the answer to the nearest tenth, and use aa leading zero if applicable. Do not use a trailing zero.)
101.1
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 caring for an adult client who has dysphagia following a cerebrovascular accident. Which of the following actions should the nurse take when assisting the client at mealtime? a. Encourage the client to drink fluids before swallowing food b. Offer the client tart or sour foods first c. Tilt the client's head backward when swallowing d. Turn on the television
a. Encourage the client to drink fluids before swallowing food
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
a. Evaluate pedal pulses
A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations? a. Increased intestinal motility b. Respiratory alkalosis c. Decreased cardiac output d. Hypocalcemia
c. Decreased cardiac output
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
a. Have the client urinate 20 min before the scan
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. Sterognosis c. Proprioception d. Kinesthesia
b. Sterognosis
A nurse is caring for a client who has a stage ||| pressure ulcer on the heel. When preparing to irrigate the wound, which of the following actions should the nurse take first? a. Obtain the prescribed irrigation solution. b. Don personal protective equipment c. Check the client's pain level d. Place a waterproof pad under the client's extremity
c. Check the client's pain level
A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following findings 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
c. Decreased hematocrit
A nurse is explaining Piaget's theory of cognitive development to a group of daycare providers for employees' children at an acute care facility. Which of the following activities should the nurse include as an example of concrete operational thinking? a. Playing in the sand b. Playing dress up c. Collecting and trading game cards d. Describing interpersonal relationships
c. Collecting and trading game cards
A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to him. Which of the following actions should the nurse take? a. Consult the medication reference book available on the unit b. Ask a more experienced nurse for information about the medication c. Call the client's provider and verify the prescription d. Ask the client if she takes this medication at home
a. Consult the medication reference book available on the unit
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse perform 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 teaching a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group? a. Independent moral development b. Acceptance of body changes c. Strengthening ties with the family of origin d. Development of concrete reasoning
a. Independent moral development Explanation: According to Kohlberg's theory of moral development, making individual decisions about moral issues is a function of the highest level of moral development, the postconventional level. Young adults who have reached this level separate themselves from the rules and tenets of others and make their own decisions according to personal beliefs and principles.
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 form c. Instruct the guard to ask the inmate d. Complete an incident report.
a. Inform the guard that the warden must request this information
A nurse is caring for a client who has a dysrhythmia. 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 blood pressure 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 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 restrains within 24 hr 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 hr
a. Renew the prescription for the use of restrains within 24 hr
A nurse is preparing to administer a unit of packed RBCs to a client when she discovers that the IV line is no longer patent. The IV team informs her that someone can come to initiate a new line in 30 min. Which of the following actions should the nurse take? a. Return the blood to the laboratory b. Place the blood in the medication room c. Place the blood in the refrigerator d. Leave the blood at the client's bedside
a. Return the blood to the laboratory
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? a. Sit at the bedside while feeding the client b. Order pureed foods c. Make sure feedings are provided at room temperature d. Offer the client a drink of fluid after every bite
a. Sit at the bedside while feeding 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 planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet? a. Vitamin C and zinc b. Vitamin D c. Vitamin K and iron d. Calcium
a. Vitamin C and zinc
A nurse 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 offer? a. "You won't need the equipment for 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 in a long-term care facility is admitting a client who is incontinent n smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? a. "A lot of clients who are cared for at home have the same problem." b. "Don't worry about it. He will get a bath, and that will take care of the odor." c. "It must be difficult to care for someone who is confined to bed." d. "When was the last time that he had a bath?"
b. "Don't worry about it. He will get a bath, and that will take care of the odor."
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. "I'll wrap the old dressing in a paper bag and put it in the trash." b. "I'll wash my hands before I remove the old dressing and again before putting on the new one." c. "I'll need to take a pain pill 30 minutes before I change the dressing." d. "I'll wear sterile gloves when I apply the new dressing."
b. "I'll wash my hands before I remove the old dressing and again before putting on the new one."
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. Accommodation test
c. Corneal light reflex
a nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps relieve pain. Which of the following responses should the nurse make? a. "It provides a distraction from the pain." b. "It modulates the transmission of the pain impulse." c. "It promotes increased circulation to the painful area." d. "It elicits a relaxation response."
b. "It modulates the transmission of the pain impulse."
A nurse is providing teaching about crutches to a client who has a fracture of the right foot. Which of the following instructions should the nurse include? a. "When you go up a flight of stairs, place your right foot on the first step." b. "Keep the rubber crutch tips securely in place." c. "When standing, keep the crutches 12 inches infront of you and 12 inches to the side." d. "Place your weight on the crutch pads at your armpits."
b. "Keep the rubber crutch tips securely in place."
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 from 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 implementing cold therapy for a client who has an ankle sprain. Which of the following actions should the nurse take? a. Apply a cold pack to the edematous area b. Check capillary refill before applying an ice pack to the affected area c. Half-fill an ice pack with crushed ice d. Apply an ice pack for 60 min intervals
b. Check capillary refill before applying an ice pack to the affected area
A nurse is assessing a client. Which of the following findings 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 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 at the infusion site b. Edema at the infusion site c. Warmth at the infusion site d. Oozing of blood at the infusion site
b. Edema at the infusion site
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 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 preparing to administer a feeding via 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 INCORRECT: a. Warm the feeding tube in a microwave oven--> ROOM TEMP c. Flush the tube with 0.9% sodium chloride for irrigation--> FLUSH WITH WATER PRIOR d. Verify that the client's gastric pH is above 4--> should be BELOW 4
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
b. Glaucoma
A nurse is caring for a client who has a temperature of 38.7°C (101.7°F). 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 (40oz) of fluid per day
b. Keep the client's bed linens dry
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 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 charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? a. Obtaining hydrogen peroxide for tracheostomy care b. Obtaining cotton balls for tracheostomy care c. Obtaining sterile gloves for tracheostomy care d. Obtaining a sterile brush for tracheostomy care
b. Obtaining cotton balls for tracheostomy care Explanation: Cotton ball particles can be aspirated into the tracheostomy opening, possibly causing a tracheal abscess. The charge nurse should intervene for this action
A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a form of 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 caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following? (Select all that apply.) a. Allowing the client to speak b. Stabilizing the position of the tube c. Preventing aspiration of secretions d. Preventing air leaks e. Preventing tracheal injury
b. Stabilizing the position of the tube c. Preventing aspiration of secretions d. Preventing air leaks
A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take? a. Continue the teaching, but check afterward with the surgeon about informed consent. b. Stop the teaching and check with the surgeon about informed consent. c. Stop the teaching and ask the client to sign an informed consent form. d. Continue the teaching and check the client's medical record afterward for a signed consent form.
b. Stop the teaching and check with the surgeon about informed consent.
A nurse is providing nutritional teaching to a group of clients. Which of the following definitions for the recommended dietary allowance (RDA) should the nurse include in the teaching? a. The RDA is a comprehensive term that includes various dietary standards and scales. b. The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups. c. The RDA defines the levels of nutrients that should not be exceeded to prevent adverse health effects. d. The RDA is the daily percentage of energy intake values for fat, carbohydrate, and protein.
b. The RDA defines the level of nutrient intake that meets the needs of healthy people in various groups.
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 is caring for a semiconscious client who had 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 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."
c. "Bear down during insertion."
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 reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP indicates that further teaching is required? a. "I should not leave all 4 side rails up unless there is a prescription for restraints." b. "An alert client will be safest if I raise the 2 upper side rails at the head of the bed." c. "If the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself." d. "If a client is sedated, I should raise all 4 side rails to prevent a fall out of bed."
c. "If the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself."
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 to make the necessary changes." c. "Let's 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. "Let's set up a meeting time with the doctor to discuss your options for home care."
A nurse is assessing a client who has a sudden onset of severe back pain of unknown origin. Which of the following questions should the nurse ask to encourage discussion with the client? a. "Does the medication you're taking relieve the pain?" b. "Can you point to where the pain is the worst?" c. "What do you think caused the onset of your pain?" d. "Changing positions makes your pain worse, right?"
c. "What do you think caused the onset of your pain?"
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 on 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.
c. Administer analgesics to the child on a routine schedule throughout the day and night.
A nurse is caring for client who has terminal pancreatic cancer. When the client states, "It's devastating that I will not be here to see my child graduate," 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 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 is producing large amounts of urine. The nurse should document this finding as which of the following? a. Retention b. Oliguria c. Diuresis d. Dysuria
c. Diuresis
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 to the client? a. Make eye contact with the interpreter. b. Break sentences into shorter segments to allow time for interpretation. c. Ensure the interpreter and the client speak the same dialect. d. Speak in a loud tone of voice.
c. Ensure the interpreter and the client speak the same dialect.
A nurse is performing eye irrigation for a client who was exposed to smoke and ash. Which of the following actions should the nurse take? a. Hold the irrigator 1.25 cm (0.5 in) above the eye b. Direct the irrigation solution up toward the upper eyelid c. Exert pressure on the bony prominences when holding the eyelids open d. Direct the irrigation from the outer canthus to the inner canthus of the eye
c. Exert pressure on the bony prominences when holding the eyelids open
A nurse is teaching a group of unit nurses about the experiences of clients who are having surgery. In which phase of care is the client transferred to the surgical suite table before being transferred to the PACU? a. Preoperative b. Postoperative c. Intraoperative d. Admission
c. Intraoperative
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 Explanation: Nutrition, sensory perception, moisture, activity, mobility, and friction and shear are the parameters on the Braden scale for determining a client's risk of developing pressure ulcers.
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 planning to document care provided for a client. Which of the following abbreviations should the nurse use? a. BT for bedtime b. SC for subcutaneously c. PC for after meals d. HS for half-strength
c. PC for after meals
A hospice nurse is reviewing religious practices of a group of clients with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. People who practice the islamic faith pray over the decreased for a period of 5 days before burial. b. People who practice the Hindu faith bury the deceased with their head facing north. c. People who practice Judaism stay with the body of the deceased until burial. d. People who are practicing the Buddhist faith have the female family members prepare the body following death.
c. People who practice Judaism stay with the body of the deceased until burial.
A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? a. Maintain suction while removing the NG tube b. Instill 100 mL of air into the NG tube before removal c. Pinch the NG tube while removing the tube d. Instruct the client to breathe in and out during the removal of the NG tube
c. Pinch the NG tube while removing the tube
A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take? a. Raise the enema bag if the client experiences cramping b. Lubricate 2.54 cm (1 in) off the tip of the rectal tube prior to insertion c. Place the client in a left Sims' position d. Don sterile gloves prior to the procedure
c. Place the client in a left Sims' position
A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use? a. Stand 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 the feet 15 cm (6 in) apart.
c. Place the wheelchair at a 45-degree angle to the bed.
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 inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take? a. Remove the NG tube b. Advance the NG tube quickly c. Pull the NG tube back slightly d. Ask the client to tilt his head backward
c. Pull the NG tube back slightly
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. Raise the level of the bed.
A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for the client? a. Perform tracheostomy care using medical asepsis b. Allow enough slack under the tracheostomy ties to insert three fingers c. Soak the inner cannula of the tracheostomy in normal saline d. Cut a sterile gauze pad to place between the neck and tracheostomy tube
c. Soak the inner cannula of the tracheostomy in normal saline
A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2°C (102.6°F), a heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority? a. Heart rate of 105/min b. Soft nontender abdomen c. Temperature d. Overdue menses
c. Temperature
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 this weight on the unaffected leg when moving the cane forward d. The client keeps 2 points of support on the ground
c. The client supports this weight on the unaffected leg when moving the cane forward
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 on a medical surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical handwashing technique? a. The nurse washes each part of her hands with 5 strokes. b. The nurse washes from the elbows down to the hands. c. The nurse holds her hands higher than her elbows while washing. d. The nurse uses minimal friction when washing her hands.
c. The nurse holds her hands higher than her elbows while washing.
A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month and may 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 share with 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. "Ask a family member to donate blood for you." d. "Donate autologous blood before the surgery."
d. "Donate autologous blood before the surgery."
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 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 reviewing s 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 is changing the dressings for a client recovering from an appendectomy following a ruptured appendix. The client's surgical wound is healing by secondary intention. Which of the following observations should the nurse report to the provider? a. Tenderness when touched b. Pink, shiny tissue with a granular appearance c. Serosanguineous drainage d. Halo of erythema on the surrounding skin
d. Halo of erythema on the surrounding skin
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 2 identifiers.
d. Identify the client using 2 identifiers.
A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care-associated infections (HAIs). Which of the following routes should the manager identify as an iatrogenic HAI? a. Infection acquired from improper hand hygiene b. Infection acquired 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 client who has glaucoma of the right eye self-administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following actions should the nurse take? a. Confirm that the client performed the procedure correctly. b. Instruct the client to look at the floor while instilling the eye drop. c. Remind the client to avoid using a facial tissue after instillation. d. Instruct the client to apply pressure to the inside corner of the eye after instillation.
d. Instruct the client to apply pressure to the inside corner of the eye after instillation.
A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider? a. Respiratory alkalosis b. Metabolic alkalosis c. Respiratory acidosis d. Metabolic acidosis
d. Metabolic acidosis
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 client is being discharged home with oxygen therapy delivered through a nasal cannula. Which of the following instructions should the nurse provide to the client and family members? 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.
