ati proctored exam

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 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 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 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 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 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 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 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 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 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 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?"

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 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 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 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 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 teaching a client how to use an albuterol metered-dose inhaler. After removing the cap from the inhaler and shaking the canister, what sequence of instructions should the nurse give the client? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

"Hold the mouthpiece 1 to 2 inches in front of your mouth." "Tilt your head back slightly and open your mouth wide." "Depress the canister while taking a slow, deep breath.: "Hold your breath for 10 seconds."

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 caring for a client who is receiving dextrose 5% in water IV at 150 mL/hr and has ingested 4 oz of water and 1/2 pint of milk. What is the total 8-hr fluid intake in milliliters that the nurse should document for this client? (Round the answer to the nearest whole number and fill in the blank with the numeric value only.)

1560 (150mL/hr ... 150x8 + 4ozx30mL + 1/2(8oz)x30mL)

A nurse is preparing to administer sotalol to a client with a prescription for 320 mg/day divided equally every 12 hr. The medication is available in 80 mg tablets. How many tablets should the nurse administer per dose? (Fill in the blank with the numeric value only, round the answer to the nearest tenth, and use a leading zero if applicable. Do not use a trailing zero.)

2

A nurse is teaching the parent of a child who is to take 30 mL of a liquid medication. The parent has a hollow medication spoon that has marks to indicate teaspoons and tablespoons. How many tablespoons of medication should the nurse instruct the parent to give to the child? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

2

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

2130

A nurse is caring for a client whose intake and output flow sheet for 0700 to 1500 indicates the following:m voided x3: 350 mL, 200 mL, 150 mL; wound drainage 2 tsp; and emesis 2 oz. What total output in milliliters should the nurse document for this 8 hr period? (Fill in the blank with the numeric value only, round the answer to the nearest whole number, and use a leading zero if applicable. Do not use a trailing zero.)

770

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

a. "Bear down."

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

a. "I'll wear nonsterile gloves."

A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first? a. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask b. A client who has emphysema and is receiving oxygen at 3L/min via transtracheal oxygen cannula c. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar d. A client who has COPD and is receiving oxygen at 2L/min via nasal cannula

a. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask

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 clients' self-motivation b. Keep detailed records of each client's progress c. Test client learning after each teaching session d. Avoid discussing topics that might increase client's anxiety

a. Attempt to increase the clients' self-motivation

A nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. Which of the following actions should the nurse take? a. Change the tube feeding bag every 48 hours b. Chill the formula prior to administration c. Increase the infusion rate d. Request a prescription for an isotonic enteral nutrition formula

a. Change the tube feeding bag every 48 hours

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

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

A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? (Select all that apply.) a. Coat the tip of the tube with a water-soluble lubricant b. Ask the client to swallow water while the tube enters her throat c. Place the coiled tube in ice chips prior to insertion d. Tell the client to tilt her head backward as insertion begins e. Instruct the client to bear down during insertion

a. Coat the tip of the tube with a water-soluble lubricant b. Ask the client to swallow water while the tube enters her throat d. Tell the client to tilt her head backward as insertion begins

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

a. Daily weight

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

a. Decreased calcium

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

a. Elevating the finger above the heart level

A nurse is admitting a client who will undergo a cranotomy. During the planning phase of the nursing process, which of the following actions should the nurse take? a. Establish client outcomes. b. Collect information about past health problems. c. Determine whether the client has met specific goals. d. Identify the client's specific health problems.

a. Establish client outcomes.

A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) items should the nurse don prior to providing client care? a. Gown b. Gloves c. Mask d. Hair cover e. Goggles

a. Gown b. Gloves

A nurse is caring for a client who has a gastric ulcer. The nurse should explain that prolonged exposure of the body to stress can also cause which of the following to occur? a. Hyperglycemia b. Hypotension c. Heightened immune response d. Bleeding tendencies

a. Hyperglycemia

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

a. Inspect both breasts simultaneously

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following precautions should the nurse implement? a. Place the client in a semi-private room b. Wear a mask when providing care c. Wear a gown when in the client's room d. Dispose of all bed linens used by the client

a. Place the client in a semi-private room

A nurse is preparing to provide chest physiotherapy for a client who has let lower lobe atelectasis. Which of the following actions should the nurse plan to take? a. Place the client in the Trendelenburg position b. Perform percussions directly over the client's bare skin c. Use a flattened hand to perform percussions d. Remind the client that chest percussions can cause mild pain

a. Place the client in the Trendelenburg position

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? a. Pull suction catheter back 1 cm (0.5 in) if the client starts coughing b. Allow 30 sec between suctioning passes c. Hyperventilate the client with 50% oxygen for 30 sec d. perform a maximum of 4 passes with the suction catheter

a. Pull suction catheter back 1 cm (0.5 in) if the client starts coughing

A nurse is caring for a client who has chronic kidney disease. The kidneys regulate body fluids as well as assisting with which of the following functions? a. Regulation of acid-base balance b. Reabsorption of nutrients for cellular growth c. Regulation of body temperature d. Secretion of hormones needed for growth

a. Regulation of acid-base balance

A nurse is helping a client change his hospital gown. The client has an IV infusion via an infusion pump. Which of the following actions should the nurse take first? a. Remove the sleeve of the gown from the arm without thew IV line b. Slow the infusion using the roller clamp c. Disconnect the IV line from the pump d. Bring the IV solution and tubing from the outside to the inside of the sleeve of the gown

a. Remove the sleeve of the gown from the arm without thew IV line

A nurse is planning care for a client who is confused and requires a prescription for wrist restraints. Which of the following interventions should the nurse include in the plan of care? a. Renew the prescription for the use of 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 planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take? a. Repeat each joint motion 5 times during each session b. Move the joint to the point of considerable resistance c. Sit approximately 2 ft from the side of the bed closest to the joint being exercised d. Exercise the smaller joints first

a. Repeat each joint motion 5 times during each session

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 assessing a client's incision and observes the drainage to be blood-tinged. Which of the following terms should the nurse use to document this finding? a. Sanguineous b. Purulent c. Serous d. Hyperemia

a. Sanguineous

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

a. Sims'

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

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

A nurse is teaching a client about the use of a straight-legged cane. Which of the following client actions indicates an understanding of the teaching? a. The client holds the cane on the unaffected side. b. The client walks by stepping with the unaffected leg before the affected leg. c. The client holds the cane directly next to the foot d. The client holds the cane with a straight elbow.

a. The client holds the cane on the unaffected side.

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

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

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

a. Use a gait belt during ambulation

A nurse is planning to administer pain medication to a client following abdominal surgery. Which of the following actions should the nurse take first? a. Use the pain scale to determine the client's pain level. b. Discuss the adverse effects of pain medication with the client c. Obtain the client's vital signs d. Check the client's allergies

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

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

a. Vitamin C and zinc

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

a. Wear sterile gloves when collecting the specimen

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."

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 assessing the pH of a client's gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect? a. 6 b. 2 c. 10 d. 8

b. 2

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following pieces of information should the nurse include? a. A 2-month-old infant can turn from his abdomen to his back. b. A 10-month-old infant can pull up to a standing position. c. A 4-month old can sit up without support. d. A 6-month-old infant can crawl on his hands and knees.

b. A 10-month-old infant can pull up to a standing position.

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

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

A nurse is teaching a client who is postoperative following a knee arthroplasty about the muscles he will need to strengthen in physical therapy. Which of the following muscle groups is responsible for movement at the knee joint? a. Antigravity b. Antagonistic c. Synergistic d. Skeletal

b. Antagonistic

A nurse is assessing a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries? a. Palpation of both carotid arteries simultaneously b. Auscultation of the arteries for bruits with the bell of the stethoscope c. Palpation of the arteries for murmurs bilaterally d. Auscultation of the arteries for thrills with the diaphragm of the stethoscope

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

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

b. Choose the most proximal vein in the extremity

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

b. Cough deeply after each use

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 an older adult client who has an in-the-canal hearing aid. The client states that the hearing aid is making a whistling sound. The nurse should identify which of the following factors as the source for this sound? a. Low battery power b. Excessive wax in the ear canal c. A volume setting that is too low d. A crack in the ear tube

b. Excessive wax in the ear canal

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 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 (40 oz) 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 caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastronomy tube for enteral feedings. Which pieces of information are critical to communicate to the next nurse who will be caring for this client? (Select all that apply.) a. Room temperature b. New prescriptions c. Number of visitors d. Arterial blood gas results e. Tracheal secretion characteristics

b. New prescriptions d. Arterial blood gas results e. Tracheal secretion characteristics

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

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

A nurse is planning an in-service training session about nutrition. Which of the following pieces of information should the nurse include? a. Fat breaks down into amino acids. b. Protein serves as an energy source when other sources are inadequate. c. Glucose breaks down into ammonia. d. Carbohydrates provide 9 cal/g of energy.

b. Protein serves as an energy source when other sources are inadequate.

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) a. Set the suction machine at 120 mmHG b. Provide oral hygiene frequently c. Measure the amount of drainage from the NG tube every shift d. Secure the NG tube to the client's gown e. Apply petroleum jelly to the client's nares

b. Provide oral hygiene frequently c. Measure the amount of drainage from the NG tube every shift d. Secure the NG tube to the client's gown

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

b. Request an X-ray of the client's abdomen

A 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 preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection? a. Lower medial quadrant of the buttock near the coccyx b. Side hip between the iliac crest and anterior iliac spine c. Tissue of the posterior upper arm d. Lower inner thigh 4 finger-widths above the patella

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

A nurse is 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 caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? a. Fasten the ties on the restraint to the side rails of the bed. b. Tie the restraint with a quick-release knot. c. Allow a fingerbreadth between the restraint and the client's chest. d. Place the restraint under the client's clothing.

b. Tie the restraint with a quick-release knot.

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 performing an admission assessment for a client. Which of the following responses by the nurse reflects the communication technique of clarifying? a. "Now that we have talked about your medications, let's talk about your pain." b. "Are you having other symptoms?" c. "It sounds like your pain is intermittent." d. "It seems as though you have really had a rough time these past few weeks."

c. "It sounds like your pain is intermittent."

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

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

A nurse is teaching a client who has urinary incontinence about bladder retraining. Which of the following instructions should the nurse include? a. "Wake up every 2 hr to urinate during the night." b. "Drink citrus juices throughout the day." c. "Try to block the urge to urinate until the next scheduled time." d. "Limit fluids to no more than 1 L (34 oz) during waking hours."

c. "Try to block the urge to urinate until the next scheduled time."

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

c. Advise the client to tuck his chin downward

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

c. Avoid direct eye contact until the client initiates it

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

c. Black beans d. Whole-grain bread

A nurse is preparing to assess the function of the client's trigeminal nerve (cranial nerve V). Which of the following items should the nurse gather for the test? a. Sugar b. Coffee c. Cotton wisps d. Snellen chart

c. Cotton wisps

A nurse is planning care for a young adult client who has a terminal illness. Which of the following concepts of death should the nurse consider for this client? a. Death is unacceptable under any circumstances. b. Magical thinking helps avoid thoughts of death. c. Death is viewed as an interruption of what might have been. d. Death is a natural consequence of a deteriorating body.

c. Death is viewed as an interruption of what might have been.

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 caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary ffor entering the client's room with the lunch tray. Which of the following instructions should the nurse give to the dietary assistant? a. Don a gown before entering the room and remove it before exiting. b. Wear a mask while in the client's room. c. Don gloves when entering the room and use hand sanitizer when exiting. d. Take no special precautions engaging in direct contact with the client.

c. Don gloves when entering the room and use hand sanitizer when exiting.

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 middle-aged female client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of this client's routine health screening? a. Annual Papanicolaou (Pap) testing b. Mammogram every 2 years c. Eye examination every 2 years d. Annual colonoscopy

c. Eye examination every 2 years

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

c. Hearing aids

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

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

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

c. Lentils

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

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

A nurse is preparing to administer a partial dose of a prefilled opioid analgesic parenterally to a client. Which of the following actions should the nurse plan to take? a. Return the unused portion of the medication to the pharmacy b. Dispose of the wasted medication into a sharps container c. Record the amount of medication wasted on the controlled substance inventory record d. Ask an assistive personnel (AP) to witness the wasting of the controlled substance

c. Record the amount of medication wasted on the controlled substance inventory record

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

c. Respiratory acidosis

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

c. Respite care

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? a. Warm, dry skin b. Increased urinary output c. Tachycardia d. Bradypnea

c. Tachycardia

A nurse is caring for a client who is receiving IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? a. Redness at the IV catheter entry site b. Palpable cord along the vein for the infusion c. Taut skin around the IV catheter that is cool to the touch d. Bleeding at the IV insertion site

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

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 administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use? a. Deltoid b. Ventrogluteal c. Vastus lateralis d. Dorsogluteal

c. Vastus lateralis

A nurse is preparing to irrigate a client's wound. Which of the following actions should the nurse take? a. Use a 10 mL syringe b. Attach a 22-gauge catheter to the syringe c. Warm the irrigating solution to 37°C (98.6°F) d. Administer an analgesic 10 min before

c. Warm the irrigating solution to 37°C (98.6°F)

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

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

A nurse is performing a spiritual assessment of a client. Which of the following questions should the nurse ask? a. "When did you start to believe in your faith?" b. "How often do you perform religious rituals?" c. "Which church do you regularly attend?" d. "What is your source of strength and hope?"

d. "What is your source of strength and hope?"

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

d. Administering high-flow oxygen prior to the procedure

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

d. Ask the adolescent to sign the consent form.

A nurse is caring for a middle-aged adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks? a. Managing a home b. Establishing a sense of self in the adult world c. Forming new friendships d. Ceasing to compare personal identity with others

d. Ceasing to compare personal identity with others

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perineal area. Which of the following actions should the nurse take first? a. Apply a fecal collection system b. Apply a barrier cream c. Cleanse and dry the area d. Check the client's perineum

d. Check the client's perineum

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

d. Circle the injection area with a pen

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

d. Clean the drain site from the center outward

A nurse is performing a mental-status examination on a client who has manifestations of dementia. Which of the following directions should the nurse give the client when evaluating the client's ability to think abstractly? a. Subtract by 7 serially, starting at 100 b. Describe a previous illness c. Explain what to do if a fire happened in his bedroom d. Discuss the meaning of a common proverb

d. Discuss the meaning of a common proverb

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

d. Gait

A nurse is reviewing 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 teaching a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes? a. Identify the risks of nonadherence b. Schedule learning sessions to demonstrate the psychomotor skills the client will need c. Provide clearly written and easy-to-understand materials d. Help the client identify ways that these changes will result in positive personal outcomes

d. Help the client identify ways that these changes will result in positive personal outcomes

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 nurse is planning care for a client who has anorexia and nausea due to cancer treatment. Which of the following interventions should the nurse include? a. Serve foods at warm or hot temperatures b. Offer the client low-density foods c. Make sure the client lies supine after meals d. Limit drinking liquids with food

d. Limit drinking liquids with food

A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take? a. Provide oxygen b. Place the client in the side-lying position c. Provide privacy d. Lower the client to the floor

d. Lower the client to the floor

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

d. Medial thigh

A nurse on a medical-surgical unit is caring for a client who is at risk of experiencing seizures. Which of the following pieces of equipment must be available at the client's bedside at all times? a. Suction equipment b. Clean gloves c. Blankets d. Oxygen

d. Oxygen

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? a. Auscultate 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 (3 in) above the popliteal artery d. Place the bladder of the cuff over the posterior aspect of the thigh

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

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? a. Instruct the client to defecate 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 nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring? a. Right task b. Right circumstance c. Right person d. Right communication

d. Right communication

A nurse is caring for a client who is dehydrated. The nurse should expect that insensible fluid loss of approximately 500 to 600 mL occurs each day through which of the following organs? a. Kidneys b. Lungs c. Gastointestinal tract d. Skin

d. Skin

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 witnessing a client sign an informed consent form for surgery. What is the nurse affirming by this action? a. The client fully understands the provider's explanation of the procedure. b. The client has been informed about the risks and benefits of the procedure. c. The nurse witnessed the provider's explanation of the procedure. d. The signature on the preoperative consent form is the client's.

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

A nurse is 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 obtaining aa capillary blood sample to determine a client's blood glucose level. The nurse prepares and punctures the client's finger for the procedure but does not obtain an adequate amount of blood. Which of the following actions should the nurse take next? a. Smear the small amount of blood onto the testing strip b. Hold the finger above the heart level c. Massage the client's fingertip d. Wrap the client's finger in a warm washcloth

d. Wrap the client's finger in a warm washcloth

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

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

A nurse is caring for a 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 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 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 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 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 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.

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 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 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 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