ATI Proctored-NUR101 LPN 2020
A nurse is caring for a toddler in contact isolation. Which of the following is an appropriate toy to offer the toddler? A) plush stuffed animal B) Chapter book C) plastic building blocks D) puzzle
plastic building blocks
A nurse is monitoring the flow rate of an IV solution prescribed to infuse at 100 ml an hour using a drop factor of 15 gtt\per ml. the nurse should ensure that the flow rate is set to infuse how many gtt per min?
25 gtt\min
A nurse is caring for a toddler who is dehydrated and has an order for 100 ml of 0.9 % sodium chloride IV over 4 hours. A microdrip set with a drop factor of 60 gtt\per ml is being used. The nurse should regulate the IV to deliver how many drops per min?
25 gtt\ml
The nurse explains tot he post operative ambulatory surgery client that his discharge will be delayed because of his: A) pulse rate of 92 B) mild incisional discomfort C) inability to void D) blood pressure of 108/64
inability to void
A provider prescribes dextrose 5% in water IV to infuse at 100 ml per hour. The drop factor on the manual IV tubing is 60 gtt\per ml. The nurse should set the IV flow rate to deliver how many gtt\min.
100 ml
A 0900 the nurse begins the care of a patient who has just been transferred from the post anesthesia care unit. The patient has a new liter of D5\0.9 % NS infusing at 125 ml\per hour. The client has an indwelling urinary catheter with continuous bladder irrigation of NS infusing at 75 ml per hour, to keep the catheter free of clots. At 1500 the nurse empties 1575 ml from the urinary catheter. Consider the patient's I & O starting at 0900 and ending at 1500 and calculate the number of positive or negative mL.
375 ml
A provider prescribes 1 L of dextrose 5 % in 0.45 sodium chloride to infuse at 100 ml per hour. The nurse is using microtubing, the nurse should adjust the IV flow rate to deliver how many gtt\min?
100 ml
A nurse completes the I & O record for a client who consumed breakfast and lunch as follows: 4 oz of clear soda, 1 piece of toast, 12 oz of water, 1 cup of fruit flavored gelatin, 1/2 cup of chicken broth, 300 ml of 0.9 % sodium chloride IV output 460 ml of urine, 90 ml of drainage from the suction drainage system? What should the nurse document as the clients intake?
1140 ml
Following several episodes of vomiting with an increased temperature in a 2 year old child, the nurse plans to monitor the client for dehydration. Which of the following findings indicates the child is dehydrated? A) specific gravity of 1.034 B) irritable behavior C) blood pressure of 90/58 mmgh D) depressed fontanel
A) specific gravity of 1.034
A nurse if preparing a sterile field. Which of the following actions should the nurse perform first? A) grasp outer edge of inner most flap and lay it on the table B) center the sterile pack on the work surface C) open outer most flap away from the body while arm is outstretched D) Grasp side flap by outer edge and lay on the table
Center the sterile pack on the work surface
A nurse is creating a plan of care for a client who is receiving enteral feedings via a gastrotomy tube. Which of the following is the first action the nurse should take when administering enteral feedings? A) aspirate and measure stomach contents B) administer the bolus feeding C) elevate the head of bed at least 30 degrees D) warm the feeding to room temperature
Elevate the head of the bed at least 30 degree
A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure? A) I will urinate a little and then stop B) I will use the cleansing wipe from front to back C) I will dry the outside of the container with a paper towel D) I will use each cleansing wipe twice.
I will use the cleansing wipe from front to back
A nurse is emptying a client's urinal when she notices the urine is dark amber, cloudy and has an unpleasant odor. These findings are associated with which of the following. A) Urinary tract infection B) urinary incontinence C) urinary frequency D) urinary retention
Urinary tract infection
A nurse is caring for a client who requires catherization for a urine specimen. The client tells the nurse that she is concerned about her privacy during the procedure. Which of the following actions should the nurse take to alleviate the client's concern. A) explain the procedure to the client B) obtain assistance so the client does not become resistant to the procedure C) close the door and assure the client that she will be covered D) gather needed equipment for starting the procedure.
close the door and assure the client that she will be covered
A nurse is caring for a client who has a respiratory rate at 7 per min. Which of the following is an appropriate interruption of the clients ABGs? PH: 7.22, PaCO2: 68 mmhg, Base excess: -2, PaO2 of 78 mmhg, 02 saturation of 80 %, bicarbonate: 28 mEq\L. A) metabolic acidosis B) respiratory acidosis C) metabolic alkalosis D) respiratory alkalosis
respiratory acidosis
A nurse is caring for a client who is one day post operative following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following are appropriate nursing actions. add the amount of bladder irrigation to the total output -use sterile technique when preparing the irrigation solution -ensure the drainage tubing is patent and without obstruction -contact the surgeon if the client reports the continual need to void -notify the surgeon if the urine is bright red in appearance or has large clots
-use sterile technique when preparing the irrigation solution -ensure the drainage tubing is patent and without obstruction -notify the surgeon if the urine is bright red in appearance or has large clots
A nurse is calculating the total fluid intake for a client during a 4 hour period. The client consumes 1 cup of coffee, 4 oz of orange juice, 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth and 3 oz of water. How many ml on the clients I & O.
1170 ml
A nurse is caring for a client who has a large surgical wound healing my secondary intention. The nurse should recommend a diet high in protein and? A) vitamin C B) folate C) iron D) potassium
A) vitamin C
A client states, "why do I feel relief now that my dad is gone". Which of the following is the best response for the nurse to give? A) do you feel guilty B) tell me what you are thinking? C) you are in denial about your dads death D) your dad is not suffering anymore
B) tell me what you are thinking?
The parent of a toddler asks a nurse at a well child clinic how to handle his childs frequent temper tantrums. The nurse should suggest that the parent: A) tell the child that temper tantrums are not acceptable B) restrain the child physically C) ignore the temper tantrums D) distract the child by offering to play a game
C) ignore the temper tantrums
The nurse is working with a client pre-operatively. after the client is given a pre-operative medicine, which nursing action is appropriate? A) cover the client's eyes with a small towel B) offer the client the opportunity to ambulate to the bathroom C) raise the side rails and decrease the lighting D) cover the client with an extra blanket
C) raise the side rails and decrease the lighting
A nurse is caring for a client who has pneumonia. The client's O2 stat is 85 %. Which of the following should the nurse do first? A) administer oxygen at 2 L per min B) notify the provider C) encourage coughing and deep breathing D) raise the head of the bed
D) raise the head of the bed
A nurse is caring for a young adult client who has ulcerative colitis and is scheduled for surgery to create an ileostomy. After speaking with the surgeon, the client says to the nurse How will I ever be able to have a normal life after this? A) everybody worries about how they will manage their ileostomy at first B) are you worried that it will affect your relationship with your girlfriend C) Tell me how you think having the ileostomy will affect you D) this will cure your disease so you don't spend so much time in the hospital
Tell me how you think having the ileostomy will affect you
A nurse is checking a client's bowl sounds. The nurse understands that the bowel sounds should be auscultated: A) after palpating the abdomen B) prior to percussing the abdomen C) after checking for kidney tenderness D) prior to inspecting the abdoment
prior to percussing the abdomen
A nurse if removing an isolation gown. After caring for a client who requires contact precautions. Which of the following steps should the nurse take to properly remove the isolation gown that has ties in the front? A) untie the neck strings, remove gloves and until waist strings B) untie front waist strings, remove gloves and untie neck ties C) remove gloves, wash hands, untie waist D) remove gloves, untie neck strings, untie waist strings
untie waist strings, remove gloves, untie neck ties
A nurse is obtaining a urine specimen for culture and sensitivity via a straight catheterization. Which of the following should the nurse incorporate. A) collect urine from the catheter port B) use a sterile specimen container C) ensure only sterile water is used to inflate the balloon D)instruct the client to clean from front to back with an antiseptic solution
use a sterile specimen container
A nurse is using standard precautions while caring for a group of clients. Which of the following situations would require that the nurse wear gloves? Select all that apply. - empty urine from a dwelling urine collection bag - providing oral care - changing an ostomy pouch _ delivering a food tray to a client who has aids _ placing oral medication tablets into a clients hand
-empty urine from a dwelling urine collection bag -providing oral care -changing an ostomy pouch
A nurse is implementing strict I & O on a client. The client's output for the past 12 hours includes the following: Jackson-Pratt drain 35 ml, NG suction 120 ml, incontinence weighing 240 g, 275 g, 310 g and 270 g. Incontinence pad dry weight 90 g. What is the total output for the past 12 hours.
890 ml
A nurse is caring for a pre-operative client. The nurse understands that which of the following rationales is most important for the removal of dentures pre-operatively? A) the dentures can get lost in surgery B) the dentures can be broken during anesthesia C) the dentures can interfere with respirations D) the dentures can interfere with placement of the endotracheal tube
C) the dentures can interfere with respirations
A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following lab values should indicate to the nurse that the client is effectively responding to treatment? A) sodium 165 mEq\L B) potassium 32 mEq\L C) urine specific gravity 1.020 D) hematocrit 62%
C) urine specific gravity 1.020
A nurse is developing a plan of care for a client who has an ileostomy and application of stoma bag care. Based on the nurses understanding, which of the following are appropriate concepts. A) facilitate ring adhesion with pectin flange B) apply an aspirin to decrease odor C) limit the use of skin barriers D) expect firm fecal content
facilitate ring adhesion with pectin flange
A nurse is assessing a client who has a urine output of 250 ml in a 24 hour period. Which of the following terms should the nurse include in the documentation on the electronic record? A) dysuria B) anuria C) nocturia D) olguria
olguria
A nurse is organizing at the beginning of her shift the plan of care for two clients. The first client who is one day post op from a partial bowel resection requires a complete dressings change, total parental nutrition administration and is reporting pain at a level of 6 on a 10 point scale. The second client who has a newly inserted percutaneous gastrotomy tube requires a tube feeding, dressing change and daily weight. Which of the following nursing actions should the nurse complete first? A) weight the client requiring a daily weight B) take the vital signs on both clients C) administer pain medication to the client reporting pain D) change the dressings
take the vital signs on both clients
A nurse is performing a psychosocial assessment on an adolescents client. Which of the following should indicate to the nurse a potential risk for suicide? - a death of a parent at a young age - recent or impending move - low parental expectations - volunteers at a community center after school - sudden decline in school performance
- a death of a parent at a young age - recent or impending move - low parental expectations -sudden decline in school performance
A nurse is caring for an older adult client who was admitted to the hospital with confusion and weakness. Based on the client's laboratory findings which of the following actions should the nurse take? Select all that apply. Hematocrit 53%, BUN at 25 mg / dl, urine specific gravity at 1.032 -restrict fluid intake - monitor I & O - weigh client daily -instruct the client to sit on the side of the bed for a few mins before standing - check orientation to person, place and time regularly
-monitor I & O - weigh client daily -instruct the client to sit on the side of the bed for a few mins before standing - check orientation to person, place and time regularly
A nurse is caring for a client receiving IV dextrose 5% in 0.9 % sodium chloride at 75 ml\ hour. When the nurse checks the clients IV bag at 0700 there are 300 ml remaining in the bag. At what time does the nurse anticipate needing to hang a new bag of D5NS? A) 0900 B) 1000 C) 1100 D) 1200
11:00 am
A provider prescribes LR solution IV to infuse at 120 ml per hour for a client who has a respiratory disorder. The drop factor on the manual IV tubing is 60 gtt\per ml. The nurse should set the IV fluid rate to how man gtt per min?
120 gtt\min
A nurse is calculating a clients intake and output during the shift. The client's intake includes 1000 ml normal saline, one cup of coffee, 6 oz of water, 1 bowel of soup, 3 oz of flavored Gelatin and 3 oz of ice cream.
1780 ml
A nurse is caring for an older adult client who is Asian and is recovering from a bowel obstruction. The client is on a clear liquid diet and asks the nurse for a cup of hot Ginger tea. The nurse should recognize that this request is? A)contraindicated for this clients diet prescription B) A traditional ethnic remedy C) intended to promote sleep D) cleanse the body
A traditional ethnic remedy
A nurse is reinforcing discharge teaching with a client and his wife who will be receiving enteral feedings through a gastrotomy tube. Which of the following client statements requires further teaching by the nurse? A) I can crush and mix my medication with my formula B) My wife will be able to change the dressing around my tube C) I need to flush with 15-30 ml of water before and after each bolus feeding D) I should make sure the formula is at room temperature before instilling down my tube.
A) I can crush and mix my medication with my formula
A nurse is caring for a client receiving TPN therapy via an infusion pump. When collecting data about the client receiving this therapy. Which of he following observations by the nurse is crucial? A) IV insertion site B) height of the IV pole C) the client's oral intake D) signs of hypoglycemia
A) IV insertion site
A nurse in a clinic is preparing to administer pre-K immunizations to a 5 year old child. The child's immunizations are current. Which of the following immunizations should the nurse administer to the client at this visit? A) MMR B) Hib C) PCV D) hep B
A) MMR
A nurse unit is notified that IV pumps available for use are limited due to a high censes in the hospital. The nurse should use one of the available pumps for which of the following clients receiving IV therapy? A) a client who has diabetic ketoacidosis who is receiving IV insulin B) a client who has bronchial pneumonia who is receiving Cefuroxime IV C) a client who has a fractured left femur who is receiving LR solution IV D) a client who has acute alcohol withdrawal who is receiving thiamine IV
A) a client who has diabetic ketoacidosis who is receiving IV insulin
A nurse is caring for a client who is scheduled to receive several medications via gastrostomy tube. For which of the following should the nurse administer 15-30 ml of warm water. Select all that apply. A) after each medication B) before aspiration of gastric contents C) when the flow of the medication by gravity slows D) prior to administering each medication E) following administration of last medication.
A) after each medication D) prior to administering each medication E) following administration of last medication.
A nurse is caring for a 8 month old child who becomes upset at seeing his parents leaving. The appropriate explanation by the nurse is, "this is: A) an expected reaction for a child of this age B) a response to an over stimulating environment C) a common reaction to an over exposure to care givers D) a sign of a developmental delay
A) an expected reaction for a child of this age
A nurse is caring for a hospitalized 14 month old child. Which of the following lunch choices is appropriate? A) chicken nuggets and green beans B) commercially prepared formula C) chicken and strained beans D) hamburger and french fries
A) chicken nuggets and green beans
To promote the safe use of a cane as an assistive device for a client who is recovering from a musculoskeletal injury of the left lower extremity, which of the following instructions should the nurse provide? A) hold the cane on the right side B) remove the rubber tip from the end of the cane C) adjust the height of the cane so the arm is straight D) place the cane 18 in in front of the feet before advancing.
A) hold the cane on the right side
A nurse is caring for a hospitalized 4 year old child who had an incident of bed wetting. The child's parents expressed concern about the incident. Which of the following nursing responses is appropriate? A) hospitalized children often regress. The toileting skills will return when your child is feeling better. B) I know this can be embarrassing, I have kids myself so I understand and it doesn't bother me C) its probably due to the IV fluids and medications we are giving your child for the infection D) I will discuss your child's loss of bladder control with the physician as this may require further investigation.
A) hospitalized children often regress. The toileting skills will return when your child is feeling better
A assistive personnel says to the nurse " this client is incontinent of stool 3-4 times per day. I get angry when I think the client may be doing it just to get attention". Which of the following by the nurse is appropriate? A) its upsetting to see an adult regress B) changing the bed and cleaning the client must be tiresome for you. Next time it happens I will help you C) you are probably right soiling the bed is one way of getting attention from the nursing staff D) why don't you spend more time with the client if you think she is trying to get more attention.
A) its upsetting to see an adult regress
A nurse is caring for a 4 year old child who refuses to take his medication. Which of the following strategies should the nurse use to elicit the child cooperation? A) offer the child of crushed pills or elixir B) tell the child taste like candy C) hide the medication in ice cream or juice D) document that the child refused to take the medicine
A) offer the child of crushed pills or elixir
A nurse is caring for a client who has a fractured hip and is post op open reduction and internal fixation. The client has a closed suction drain extending out of the wound. The nurse recognized that the purpose of this device is to? A) prevent fluid from accumulating in the wound B) eliminate pain from the surgical site C) prevent the development of a wound infection D) eliminate the need for wound irrigations.
A) prevent fluid from accumulating in the wound
A nurse is caring for a client with a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture? A) wipe away puss with a gauze swab prior to culturing the wound B) irrigate the wound with prescribed antiseptic prior to culturing the wound C) include intact skin at the wound edges in the culture D) swab an area of skin away from the wound to identify normal flora for comparison with the culture.
A) wipe away puss with a gauze swab prior to culturing the wound
A nurse is reinforcing preoperative teaching to a client prior to undergoing a knee replacement. Which of the following instructions should the nurse include? A) you can drink clear liquids up to 2 hours before your surgery B) expect to remain in bed for at least the first 24 hours C) your provider will insert an NG tube during the procedure D) Do not wash your hair within 2 days of the surgery
A) you can drink clear liquids up to 2 hours before your surgery
A nurse is reinforcing discharge teaching to a client about nutrition therapy for wound healing following major surgery. Which of the following vitamins promote wound healing and should be including in the teaching? Select all that apply A)vitamin A B) vitamin B12 C) vitamin C D) vitamin D E) Vitamin E
A)vitamin A C) vitamin C
A nurse is caring for a client receiving IV therapy in the left forearm and notices that the site is red, swollen and has fluid weeping from the surrounding tissues. Which of the following actions should the nurse perform first? A) insert an IV in the opposite extremity B) discontinue the existing IV line C) apply a warm moist compress to the site D) elevate the extremity
B) discontinue the existing IV line
A client who is post operative is receiving IV fluids and a unit of whole blood. The nurse should observe the client for which of the following as an early sign of circulatory overload? A) flushing B) dyspnea C) bradycardia D) vomiting
B) dyspnea
A nurse is preparing to measure a client's level of O2 saturation and notes edema of both of the client's hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations? A) finger B) earlobe C) toe D) skin fold
B) earlobe
A nurse works in a long term care facility which will be implementing a new protocol to meet the joint commissions national safety goal of preventing health care associated pressure ulcers. When educating assistive personal about the new standard, the nurse emphasizes that it is most important to: A) turn and reposition each resident every 2 hours B) identify the residents at greatest risk for development of pressure ulcers C) use a barrier cream when delivering perineal care to residents D) supervised residents to ensure adequate nutritional intake
B) identify the residents at greatest risk for development of pressure ulcers
A nurse is caring for a 4 year old client following abdominal surgery. Which of the following statements is appropriate for the nurse to use to encourage the child to take deep breaths? A) you cant go to the playroom until you finish deep breathing B) lets play a game of blowing cotton balls across your table C) I'll leave your blow bottle hear on your table so you can use it yourself like a big kid D) ill give you a sticker each time you take a deep breath
B) lets play a game of blowing cotton balls across your table
The nurse will plan to offer the teaching session in a quite area in order to: A) ensure that the patient can hear what the nurse says B) reduce distractions C) provide absolute privacy D) make the environment like the classroom
B) reduce distractions
A nurse is caring for a hospitalized 2 year old child who has a tantrum when the parent leaves. To help the child adjust to the stress of the situation. Which of the of following therapeutic toys is most appropriate for the nurse to provide? A) set of building blocks B) toy hammer with a pounding board C) picture book about hospitals D) stuffed animal
B) toy hammer with a pounding board
A nurse is assisting a client who is post op abdominal surgery with morning care and identifies a loop of bowel through an opening in the surgical incision. After calling for help which of the following actions should the nurse take first? A) check vitals B) provide reassurance C) apply moistened sterile gauze to the site D) position client supine with knees and hips bent
C) apply moistened sterile gauze to the site
During report the nurse is informed that a client's IV has 900 ml of fluid left in the bag. The nurse makes rounds 30 mins later and notes that the IV bag is empty. Which of the following is an appropriate nursing action? A) elevate the head of the bed to high Fowlers B) request NPO status for the client C) check clients respiratory rate and lung sounds D) obtain the client's temperature, pulse and BP
C) check clients respiratory rate and lung sounds
A client who had abdominal surgery 24 hours ago suddenly reports a pulling sensation and pain at his surgical incision. The nurse checks the client's surgical wound and finds and evisceration. Which of the following interventions is appropriate? A) have the client lie flat in bed B) use sterile gauze to place pressure on the organs C) cover the area with saline soaked sterile dressings D) Apply an abdominal binder
C) cover the area with saline soaked sterile guaze
A nurse is caring for a 6 month old child. The child's provider has ordered a DTaP vaccine to be administered. Which of the following should cause the nurse to question the administration of this vaccine? A) afebrile, otitis media B) evidence of sensitivity to egg antigens C) temperature of 40.5 Celius ( 104.9 F), after last DTaP D) new onset of seizure disorder in the child's sibling
C) temperature of 40.5 Celius ( 104.9 F), after last DTaP
A client arrives at an urgent care center with a laceration of his forearm. The nurse cleanses the wound and the provider sutures it. The nurse applies a sterile dressing, administers a tetanus immunization and gives the client instructions on caring for the wound and returning for suture removal. which of the following interventions is an example of primary prevention A) wound sutures B) sterile dressing application C) tetanus immunization D) instructions for follow up care
C) tetanus immunization
A parent of an 8 year old child in the family practice clinic that she is concerned with the amount of sleep her son is getting. The nurse should explain that school aged children would get at least how many hours of sleep each night? A) 8 hours D) 10 hours C) 12 hours D) 14 hours
D) 10 hours
A nurse is reinforcing teaching about advance directives for a client admitted to the hospital for cardiac surgery. Which of the following statements made by the client indicates clarification is needed? A) the healthcare proxy does not go into effect unless I am incapable of making decisions B) I can change my healthcare proxy at any time C) I can choose to withhold life support in my living will D) My children can make changes to my living will if I am incapacitated
D) My children can make changes to my living will if I am incapacitated
A nurse begins the shift caring for a client who has just returned from the recovery room after surgery. It is most important to document: A) at the end of the shift so that the nurse can give his full attention and time to the patients needs during the shift B) a nursing care plan in the chart before assessing the patient so that the nurse can identify priorities. C) at least three times during the shift: at the beginning, in the middle, and at the end, and as needed D) an initial assessment of the patient and a plan based on the needs of the patient as assessed at the beginning of the shift.
D) an initial assessment of the patient and a plan based on the needs of the patient as assessed at the beginning of the shift.
A nurse is re-enforcing teaching for a client who is post op from having an ileostomy established. Which of the following should the nurse include in the teaching? A) empty the pouch immediately after meals B) change the entire appliance once a day C) limit fluid intake D) avoid medications in capsule or enteric form
D) avoid medications in capsule or enteric form
A nurse manager is discussing the differences between normal and maladaptive grief with nursing staff. Which of the nurse manager identify as being unique to the maladaptive grieving process? A) anorexia B) sleep disturbances C) anergia D) low self esteem
D) low self esteem
A client is having difficulty seeping related to her fear of impending surgery. Which of the following interventions is the nurses best option for helping this client get some sleep? A) allow the client to follow her usual sleep time and rituals B) use tactile stimulation to promote relaxation C) give the client a warm non caffeinated drink before bedtime D) offer the client an opportunity to discuss her concerns before surgery.
D) offer the client an opportunity to discuss her concerns before surgery
A nurse is collecting data on a healthy 6 month old infant in a well child clinic. Which of the following observations should the nurse expect to make? A) infant sits well without support B) infants birth weight has tripled C) upper and lower central incisors are present D) posterior fontanel is closed
D) posterior fontanel is closed
A nurse is caring for a post op client. The nurse understands that the rationale for repositioning the client every 90 mins is to: A) prevent muscle pain B) prevent the formation of pressure ulcers C) facilitate gastric mobility and drainage D) promote adequate ventilation of the lungs
D) promote adequate ventilation of the lungs
A client reports pain above the catheter site during a nurses attempt to flush the IV saline lock. Which of the following actions should the nurse take: A) inject the solution more slowly B) apply warm compress to the site C) ask the client to describe the pain D) remove the IV saline lock
D) remove the IV saline lock
While a nurse is starting an IV for a client her gloved hands become contaminated with the client's blood. The client has not been diagnosed with any organisms by way of the of blood stream. After completing the procedure which of the following actions should the nurse take? A) ask the client to undergo a blood test B) wash the gloved hands and then throw the glove away C) prepare an incident report D) remove the gloves carefully and complete thorough handwashing.
D) remove the gloves carefully and complete thorough handwashing.
A nurse is collecting date from a client who has respiratory insufficiency. Which of the following findings should the nurse recognize as an inadequate oxygenation? A) diaphoresis B) combativeness C) oliguria D) restlessness
D) restlessness
An example of a nurse communicating with a patient using open ended questions would be? A) is your pain less today than yesterday? B) did you sleep all night without waking? C) How many bowel movements have you had today ? D) what was your daughters reaction to your desire for hospice?
D) what was your daughters reaction to your desire for hospice?
A nurse is caring for a client who has a potassium level of 5.4 mEq\L. The nurse should assess the client for? A) Hypotension B) Polyuria C)Constipation D)ECG changes
ECG changes
Stem: a nurse in a provider's office is re-enforcing teaching for a client who is to collect a 24 hour specimen. Which of the following should the nurse include in the instructions? A) at the beginning of the collection time, void and discard the urine B) at the beginning of the collection time, void and save the urine C) at the end of the collection time, void and discard the urine D) at the end of the collection time, void and save the urine in a separate container.
at the beginning of the collection time, void and discard the urine
A client who is taking nitrofurantoin (Macrodantin) for a UTI voices a concern to the clinic nurse about voiding brown colored urine. Which of the following is an appropriate response by the nurse? A) drinking more fluid will prevent your urine from becoming brown B) the provider will change your medication because your infection is not resolving with the nitrofurantoin C) an increase of RBC destruction in your blood can result in brown colored urine D) brown colored urine is a harmless side effect of the medication.
brown colored urine is a harmless side effect of the medication
A client who is receiving magnesium sulfate has a urine output of 20 ml per hour. Which of the following should the nurse expect to administer? A) calcium gluconate B) flumazenil (Romazicone) C) naloxone (Narcan) D) protamine sulfate
calcium gluconate
A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary teaching? A) eating yogurt can help decrease the amount of gas B) I should eliminate pasta from my diet so that I don't have many loose stools C) My largest meal of the day should be in the evening D) carbonated beverages can help control odor
eating yogurt can help decrease the amount of gas
A nurse is caring for a client who is post operative. Which of the following non pharmacological interventions should the nurse use to promote bowel elimination for this client? A) increase ambulation B) decrease fluid intake C) administer a laxatives D) offer bed pan every 2 hours
increase ambulation
A nurse is implementing a bladder training program. Which of the following actions by the assistive personnel who is assisting in the clients care indicates a need for further instruction? A) assist the client to the bathroom every two hours B) encourages oral fluid, intake during waking hours C) offers the opportunity to void 15 mins before bathing D) instructs the client to void whenever the urge occurs
instructs the client to void whenever the urge occurs
A nurse on a medical unit is evaluating the 24 intake and output records for several clients, none of whom have fluid restrictions. Which of the following client findings indicate an acceptable intake and output. A) intake of 2500 ml, output 500 ml B) intake of 2400 ml, output 2500 ml C) intake of 1200 ml, output 700 ml D) intake of 800 ml , output 2100 ml
intake of 2400 ml, output 2500 ml
A nurse is preparing a sterile field. Which of the following actions by the nurse contaminates the field? A) placing a sterile dressing 2 inches from the border of the sterile field? B) holding a sterile item just above the waist level C) opening a sterile package over the middle of the sterile field D) pouring sterile normal saline into a container with the bottle label facing upwards.
opening a sterile package over the middle of the sterile field
A nurse is caring for a client who has urinary incontinence following surgery. Findings include the leakage of small amounts of urine frequently during the day and night, along with urinating frequently in small amounts. Her bladder is often distended and palpable upon examination. The nurse identifies these findings as associated with which of the following types of incontinence. A) stress incontinence B) urge incontinence C) overflow incontinence D) reflex incontinence
overflow incontinence
A client has not voided for 8 hours following the removal of an indwelling bladder catheter. Which of the following should be the nurse's priority action? A) increase fluids B) perform bladder scan C) place indwelling catheter D) provide assistance to the bathroom
perform bladder scan
A night nurse is caring for a client who is confused and has pulled the peripheral IV catheter out 3 times. Which of the following should the nurse consider? A) administer a mild sedative B) place mitten restraint's on the client's hands C) reorient ate the client to time place and person D) move client close to nurse station
place mitten restraint's on the client's hands
A nurse performs a sterile dressing change for a client. Which of the following actions should the nurse identify as a containment to the sterile field? A) keeps the sterile field in sight at all times B) places sterile supplies within the 1 cm ( 2.54 inch) border of the sterile field C) uses sterile forceps to remove the sterile items on the sterile field D) positions the sterile tray on the bedside table 1 cm ( 2.54 inch) above waist level
places sterile supplies within the 1 cm ( 2.54 inch) border of the sterile field
A nurse is planning care for a hospitalized 4 year old child. The nurse should include providing: A) plastic stethoscope B) brightly colored mobile C) jigsaw puzzle D) helium filled latex balloon
plastic stethoscope
A nurse is preparing to exit the room of a client who has a draining wound infected with MRSA and requires contact isolation precautions. identify the sequence the nurse should follow to remove PPE.
remove gloves remove protective eyewear remove gown remove mask perform hand hygiene
A nurse is caring for a client who has recently undergone a stem cell transplant. Which of the following should the nurse recognize as appropriate isolation precaution guidelines? A ) the client should be placed in a negative airflow room B) the client is not permitted to have fresh flowers or potted plants C) the client may be placed in a semi private room with another stem cell transplant client D) the client is protected by visitors who wear gloves prior to entering the room.
the client is not permitted to have fresh flowers or potted plants
A nurse is caring for a client who has a permanent ileostomy. Which of the following data should be reported immediately? A) the stool is yellow green B) the ostomy is draining frequently C) the stoma is pale in color D) the skin around the stoma is red
the stoma is pale in color
A nursing supervisor overhears a newly licensed nurse providing instructions to a female client on the proper steps to collect a midstream urine specimen. Which of the following statements made by the nurse requires the supervisor to intervene? A) it will be easier for you to use your non dominant hand to spread the labia B) use the provided the towelette to cleanse the area by moving in a back and forth motion C) start a flow of urine before passing the container under the stream to collect the specimen D) remove the specimen container before your stream completely stops.
use the provided the towelette to cleanse the area by moving in a back and forth motion
A nurse is assisting with the implementation of a bowel training program for a client. For the program to be effective the client should be taken to the bathroom at the following times? A) when the client has a urge to defecate B) every 2 hours while the patient is awake C) immediately before meals D) after client feels abdominal cramping
when the client has a urge to defecate
A nurse is caring for a client who has a suspected cholecystitis. Which of the following should the nurse find when assessing the urine? A) pale yellow B) greenish brown C) red D) yellow orange
yellow orange
