ATI-RN Assessment Level 1: Practice A
A community health nurse is planning prevention strategies for hypertension among members of her community. The nurse should identify that which of the following ethnic groups in the community is at greatest risk for hypertension A. African Americans B. Hispanic Americans C. European Americans D. Native Americans
A. African Americans
A nurse is caring for a client who has dysphagia following a stroke. Which of the following actions should the nurse take to facilitate safe swallowing and decrease the risk of aspiration? A. Delay the clients meal-time if he is fatigued B. Instruct the client to tilt his head to the side when swallowing C. Assist the client with fluid intake by inserting it into the client's mouth with a syringe D. Encourage the client to focus on a television program during mealtime
A. Delay the clients meal-time if he is fatigued
A nurse is preparing to admit a client to the hospital. Which of the following actions should the nurse take first A. Determine the need for an interpreter. B. Orient the client to the room. C. Obtain a health history. D. Perform a physical examination.
A. Determine the need for an interpreter.
A nurse is reviewing a client's new prescription that were just documented in the client's medical record by the provider. Which of the following abbreviations should the nurse clarify with the provider? A. Enoxaparin 40 mg SQ QD B. Clindamycin 500 mg IM q 8hr C. Furosemide 40 mg IV STAT D. Acetaminophen 650 mg PO q 6 hr PRN pain
A. Enoxaparin 40 mg SQ QD
A nurse is administering ophthalmic solution to a client who has bacterial conjunctivitis. Which of the following actions should the nurse take A. Have the client lie supine. B. Tell the client to look down toward the floor. C. Place a finger on the upper eyelid to pull it outward. D. Instill the drops onto the client's cornea.
A. Have the client lie supine.
A nurse in a provider's office is caring for a male client who just turned 50 years old. The client has no significant health problems or family history of health problems. Which of the following preventative health screenings should the nurse recommend? Select all that apply A. Initial screening colonoscopy B. Digital rectal examination C. Yearly glaucoma screening D. Monthly testicular self-examination E. Annual skin examination
A. Initial screening colonoscopy B. Digital rectal examination D. Monthly testicular self-examination E. Annual skin examination
A nurse in an orthopedic clinic is documenting data about several clients. Which of the following actions should the nurse take to comply with the regulations of the Health Insurance Portability and Accountability Act (HIPAA) A. Lock or log off computers whenever he leaves the area. B. Discard hard copies of client-specific data in wastebaskets in "staff only" areas. C. Place clients' flow sheets in racks outside the examination room. D. Ask the provider to log into the system and document on the provider's behalf.
A. Lock or log off computers whenever he leaves the area.
A nurse in a long-term care facility is performing a fall risk assessment on a newly admitted client using the Timed Up and Go (TUG) test. The client reports using a tripod cane for ambulation. Which of the following actions should the nurse take when using this test? A. Observe the client ambulating a distance of 3m(10 feet) during the TUG test B. Instruct the client to perform the TUG test without the use of the cane C. Assist the client to stand up from the chair when starting the TUG test D. Advise the client to use the arms of the chair to stand when starting the TUG test
A. Observe the client ambulating a distance of 3m(10 feet) during the TUG test The nurse should instruct the client to stand, ambulate to the marked spot, turn, ambulate back to the chair, and sit down. The nurse should observe the client's ability to perform the test and use a stopwatch to time the client. The nurse should identify that the client is at increased risk of falls if it takes longer than 14 seconds to complete the test
A nurse is preparing to administer intermittent enteral nutrition via a client's NG tube. In which order should the nurse take the following actions? (Move the steps into the box on the right, placing them in the order of performance. Use all steps) - Flush the NG tube with 30 mL of water - Aspirate 5 mL of gastric contents - Assist the client to an upright position - Measure the gastric residual volume - Test the pH of gastric aspirate
1. Assist the client to an upright position 2. Aspirate 5 mL of gastric contents 3. Test the pH of gastric aspirate 4. Measure the gastric residual volume 5. Flush the NG tube with 30 mL of water
A nurse is preparing to administer acetaminophen 120 mg PO to a toddler. Available is acetaminophen drops 80mg/0.8 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Using a leading zero if it applies. Do not use a trailing zero.)
1.2 mL
A nurse is preparing to administer 0.9% sodium chloride 1000mL over 8 hr IV to a client. The nurse should set the infusion pump to deliver how many mL/hr? (Round you answer to the nearest whole number
125 mL/hr
A home health nurse is providing teaching to the parent of a child who is receiving chemotherapy and experiencing nausea. Which of the following statements should the nurse make A. "Have your child rest with his head elevated after meals." B. "Administer the antiemetic at least 4 hours before chemotherapy." C. "Increase your child's intake of favorite foods when he feels nauseated." D. "Wait until your child vomits to give the antiemetic after chemotherapy."
A. "Have your child rest with his head elevated after meals."
A nurse is teaching a client about strategies to prevent recurrent constipation. Which of the following instruction should the nurse include? Select all that apply A. "Perform moderate exercises daily." B. "Add more whole grains to your diet." C. "Increase your fluid intake." D. "Consume a dose of castor oil every day." E. "Take an iron supplement every day."
A. "Perform moderate exercises daily." B. "Add more whole grains to your diet." C. "Increase your fluid intake."
A nurse Is providing teaching to a client who has chronic fatigue syndrome. Which of the following statements should the nurse make A. "Take NSAIDs for body aches and pain." B. "Report a sore throat immediately to your provider." C. "Avoid taking any herbal supplements for 6 months." D. "Exercise in 2 hour increments every day of the week."
A. "Take NSAIDs for body aches and pain."
A charge nurse is educating unit staff about the cultural aspect of client care following death. Which of the following statements by an assistive personnel indicates an understanding of the teaching A. "The body of a client who practices Islam is washed and wrapped in a cloth following death." B. "The body of a client who practices Judaism is left alone for 24 hr following death." C. "The youngest child of a client who is Chinese might want to stay with the body for 12 hr following death." D. "The body of a client who practices Buddhism is prepared by the oldest female family member."
A. "The body of a client who practices Islam is washed and wrapped in a cloth following death."
A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients should the nurse monitor for the development of reflux urinary incontinence A. A client who has a T12 spinal cord injury B. A client who has an acute bladder infection C. A client who has Alzheimer's disease D. A client who is receiving IV diuretics
A. A client who has a T12 spinal cord injury
A nurse is planning care for a client who has breast cancer and is scheduled for chemotherapy. The client reports experiencing chemothaerapy-induced nausea and vomiting (CINV) during her previous round of treatment. Which of the following interventions should the nurse include in the clients plan of care? A. Administer ondansetron to the client prior to chemotherapy administration. B. Provide the client with a small meal 30 min prior to chemotherapy. C. Offer the client an 8 oz glass of orange juice after chemotherapy administration. D. Implement NPO status for the client while the chemotherapy is infusing.
A. Administer ondansetron to the client prior to chemotherapy administration.
A nurse is admitting a client who has pulmonary tuberculosis. Which of the following transmission- based precautions should the nurse initiate A. Airborne B. Droplet C. Contact D. Protective environment
A. Airborne
A nurse in a mental health facility is preparing an educational program for a group of staff nurses about the proper use of restraints. Which of the following information should the nurse include? A. An adult client may be in a mechanical restraint for up to 4 hr. B. Documentation of the client's status should be performed hourly. C. The provider can write a client prescription for an as-needed restraint. D. The client should be offered toileting privileges every 2 hr.
A. An adult client may be in a mechanical restraint for up to 4 hr. Children who are 9 to 17 years old are limited to 2 hr Children who are younger than 9 years old are limited to 1 hr
A nurse is developing a Plan of care for an older adult who is at risk of falling. Which of the following fall prevention measures should the nurse include in the plan A. Ask the client to demonstrate how to use the call light. B. Place wool socks on the client prior to ambulation. C. Store the client's eyeglasses in the bathroom at night time. D. Keep the bed in a flat position when the client is sleeping.
A. Ask the client to demonstrate how to use the call light.
A nurse is searching electronic databases for clinical research about behavior indications of pain in an infant. Which of the following online sources should the nurse select to research this infant care issue A. Cumulative Index to Nursing and Allied Health Literature (CINAHL) B. The Nursing Minimum Data Set C. The Omaha System D. The Nursing Intervention Classification (NIC)
A. Cumulative Index to Nursing and Allied Health Literature (CINAHL)
A nurse is caring for an older adult client who has osteoarthritis and plans to go to an assistive living facility due to decreased mobility. Which of the following actions should the nurse take when acting in the role of client advocate? A. Research facilities for the client that best meet her specific needs. B. Inform the client about the discharge plan for treatment of her osteoarthritis. C. Assist the client as needed while encouraging independence with her ADLs. D. Coordinate the prescriptions from the health care team into the discharge plan.
A. Research facilities for the client that best meet her specific needs.
A community health nurse is developing a brochure about the use of smokeless tobacco. Which of the following information should the nurse plan to include? A. Smokeless tobacco provides a higher dose of nicotine than cigarettes. B. Smokeless tobacco users are at an increased risk for lung cancer. C. Smokeless tobacco is more addictive than cigarettes. D. Smokeless tobacco users have a lower risk for developing stomach cancer.
A. Smokeless tobacco provides a higher dose of nicotine than cigarettes. Smokeless tobacco is placed in the mouth, where nicotine is then absorbed sublingually. A higher dose of nicotine is delivered with the use of smokeless tobacco compared to smoking cigarettes, because heat destroys nicotine
A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following types of pain are classified as neuropathic? (Select all that apply) A. Spinal nerve pain B. Postherpetic neuralgia pain C. Phantom limb pain D. Fractured hip pain E. Osteoarthritic pain
A. Spinal nerve pain B. Postherpetic neuralgia pain C. Phantom limb pain Neuropathic pain occurs when there is damage to or impaired function of nerves due to an injury or illness
A nurse in an emergency room is caring for an infant who required emergency surgery. The infant is accompanies by his 16 year old mother and his sternal grandfather. Which of the following should the nurse take when assisting with informed consent A. Witness consent obtained from the infants mother B. Inform the family that informed consent is not needed due to the emergency surgery C. Notify the maternal grandfather that he is required to give informed consent D. Request that a court-appointed representative provide consent
A. Witness consent obtained from the infants mother The nurse should assist in obtaining informed consent from the infant's mother by witnessing her signature. Statutory guidelines indicate that a minor, even if unemancipated, can provide consent for her infant
A nurse is preparing to document care in a client's medical record. In adherence with the Joint Commission National Patient Safety Goals regarding communication errors, which of the following eateries should the nurse make. A. "Client fell to the floor." B. "Client medicated with morphine 5 mg IM for pain." C. "Physical therapy consult recommended for the client." D. "Client reported pain relief."
B. "Client medicated with morphine 5 mg IM for pain."
A nurse is teaching the parent of a toddler about home injury prevention. When discussing snacks, which of the rolling statements by the parent indicates an understanding of the teaching? A. "I can offer her grapes as long as I peel them first?" B. "I can give her watermelon pieces after I remove the seeds." C. "I should give her popcorn that is air-popped and without salt or butter." D. "I should cut hot dogs into thin, round slices before giving them to her."
B. "I can give her watermelon pieces after I remove the seeds." The nurse should inform the parent that toddlers can easily choke on seeds from fruits, such as watermelon seeds or cherry pits, because of their round shape and size. Removing the seeds and cutting the watermelon into pieces provides the toddler with a nutritious snack that does not increase the toddler's risk of foreign body obstruction
A nurse is caring for a client who has cancer and is planning discharge to home with hospice care. Which of the following statements by the client indicates that he is experiencing spiritual distress? A. "I am thankful for what I have, because things could be worse." B. "I wish God had not allowed this cancer to invade my body." C. "I will have to ask my son to read the Torah to me." D. "I would like to speak to the rabbi at my synagogue."
B. "I wish God had not allowed this cancer to invade my body."
A nurse is assessing the spiritual wellbeing and development of a preschooler. The nurse asks "why is it wrong to kick your baby sister?" Which of the following responses should the nurse expect? A. "Its not wrong because she made me mad" B. "Its wrong because my dad said I cant kick her" C. "It wrong to kick her because the gods wont like it" D. "Its wrong because she would get hurt and be sad"
B. "Its wrong because my dad said I cant kick her" The nurse should expect the preschooler to be motivated to choose right from wrong because of rules taught to him by his parents. The nurse should understand that, even though the preschooler might know the rules, he is not yet able to understand the rationale for the rules
A nurse at a provider's office is counseling a client who reports insomnia. Which of the following statements should the nurse make to include the clients preferences into sleep promotion plan? A. "If alcoholic beverages are desires, consume them in the early evening" B. "Sleep in the location of your home where you feel you rest best." C. "Turn on a favorite television show just before going to bed." D. "Allow your sleep and wake times to vary depending on how you feel each day."
B. "Sleep in the location of your home where you feel you rest best." Whether it be a bed, couch, or chair
A nurse is providing change of shift report about a group of clients to the oncoming nurse at the end of the shift. Which of the following statements should the nurse include? A. "The client received a PRN dose of pain medication this morning." B. "The client has been very tearful since finding out he has diabetes mellitus." C. "The client's routine vital signs were obtained at 0700, 1100, and 1500." D. "The client's husband visited during lunch as he has done each day."
B. "The client has been very tearful since finding out he has diabetes mellitus." The nurse should include significant information such as a new diagnosis in the change-of-shift report. The nurse should also identify changes in the client's emotional status that might indicate a need for additional client support and teaching
A newly licensed nurse asks a change nurse where to find information about scope of practice for registered nurse. Which fo the following responses should the charge nurse make A. "The National Institutes of Health website contains this information." B. "The state board of nursing can provide this information." C. "The facility's legal department writes a summary of scope of practice." D. "The Nurse Licensure Compact defines a nurse's scope of practice."
B. "The state board of nursing can provide this information." Each state develops a nurse practice act, which defines scope of practice for nurses in that state. This practice act is available on the board of nursing website for each state.
A nurse is caring for a child who has contact dermatitis due to poison ivy. The patient asks the nurse how to prevent further reactions. Which of the following responses should the nurse make? A. "Rinse your child's skin with hot water within 30 min of contact with the poison ivy plant." B. "Wash your child's exposed clothing with hot water and detergent." C. "Scrub your child's exposed skin with warm water and antibacterial soap." D. "Don't allow your child to have contact with other children who have poison ivy."
B. "Wash your child's exposed clothing with hot water and detergent." This will remove the oil, urushiol, which causes the skin reaction
A nurse is talking with a client who reports difficulty adjusting to the death of her partner. Which of the following responses by the nurse demonstrates the therapeutic communication technique of reflecting A. "I am here to listen if you'd like to talk about your current situation." B. "What do you think would help you cope with your loss?" C. "You've expressed that you are having difficulty adjusting to the loss of your partner." D. "Can you please provide an example of how you're having difficulty adjusting?"
B. "What do you think would help you cope with your loss?"
A nurse is assessing a preschooler who has a UTI. Which of the following should the nurse inspect? A. Diarrhea B. Abdominal Pain C. Increased Thirst D. Skin Rash
B. Abdominal Pain Other manifestations include constipation, dysuria, foul-smelling urine, fever
A nurse is caring for a client who is 2 days postoperative following an above-the- knee amputation. The client states he is experience in a dull, burning pain in the leg that was amputated. Which of the following should the nurse take to treat the client's neuropathic pain A. Inform the client that phantom limb pain is not real B. Administer a beta-blocking medication to the client C. Place the client on a soft mattress D. Loosen the bandage on the client's residual limb
B. Administer a beta-blocking medication to the client This classification of medication has been shown to relieve the phantom limb pain manifestations of constant dull and burning type pain
A nurse is planning care for a newly admitted school age child who has rubeola. Which of the following isolation precautions should the nurse plan to initiate A. Droplet B. Airborne C. Contact D. Protective environment
B. Airborne Airborne precautions include a private room with negative pressure airflow, with 6 to 12 air exchanges/hr via a high-efficiency particulate air (HEPA) filtration system
A nurse is preparing to administer enoxaparin subcutaneously to a client who is postoperative following orthopedic surgery. The nurse should plan to administer this medication in which of the following locations (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer A. The outer posterior aspect of the upper arm B. Anterolateral aspect of the client's abdomen C. Abdomen
B. Anterolateral aspect of the client's abdomen
A nurse is asked by a provider to preform an invasive procedure for which he has nor received training. Which of the following actions should the nurse take to ensure that it is within his legal scope of practice to perform this procedure A. Ask the provider for instructions on how to perform the procedure. B. Check the state's nurse practice act before performing the procedure. C. Request that the charge nurse assist him to perform the procedure. D. Obtain informed consent from the client before performing the procedure.
B. Check the state's nurse practice act before performing the procedure.
A nurse in a long-term care facility is admitting a new client following a brief stay in acute care. In adherence with the Joint Commission National Patient Safety Goals regarding medication administration, which of the following actions should the nurse take? A. Inform the client that he will not be receiving medications he took prior to his hospitalization B. Compare a list of the clients current medications with the ones he will take in long-term care C. Eliminate any OTC products from the clients current medication list D. Omit the medication indications when listing the clients medication dose information
B. Compare a list of the clients current medications with the ones he will take in long-term care The Joint Commission National Patient Safety Goals regarding medication reconciliation includes maintaining and communicating accurate client medication information. The nurse should complete a medication reconciliation to identify and resolve any discrepancies by comparing the client's list of current medications with the medications he will take in the long-term care facility and addressing any duplications, omissions, or interactions
A nurse is preparing to administer three medications to a client who has an NG tube: a levothyroxine tablet, and ibuprofen gel cap, and a delayed release omeprazole capsule. Which of the following actions should the nurse take A. Dissolve all three medications in 30 mL of warm water and instill them through the NG tube. B. Crush the levothyroxine tablet into a powder and dissolve it in 30 mL of warm sterile water. C. Ask the provider to prescribe a different formulation of ibuprofen. D. Open the omeprazole capsule and dissolve it in 30 mL of warm sterile water.
B. Crush the levothyroxine tablet into a powder and dissolve it in 30 mL of warm sterile water
A nurse is caring for a client who is morbidly obese and is 3 days postoperative following variations surgery. Which of the following dietary recommendations should the nurse make A. Restrict fluid intake to no more than 1,000 mL (34 oz) each day. B. Eat foods that are high in protein. C. Avoid drinking fluids that contain sodium. D. Begin adding soft foods one to two times a day.
B. Eat foods that are high in protein.
A nurse is planning to use an interpreter to assist her when interviewing a client who does not speak the same language as the nurse. Which of the following actions should the nurse plan to take A. Direct the interview questions to the interpreter. B. Ensure the client and the interpreter are compatible. C. Ask the client's partner to act as the interpreter. D. Ask the interpreter to translate questions word for word.
B. Ensure the client and the interpreter are compatible.
A nurse is counseling a client who has a family history of colorectal cancer about management of nutrition to help prevent GI cancers. Which of the following images indicated a food or beverage the nurse should encourage? A. Wine B. Fruit C. Fried Chicken D. Bread
B. Fruit Consume at least 2.5 cups of fruit and vegetables per day to help reduce the risk of cancers of the GI system
A nurse is providing discharge teaching about nutrition management to a client who has COPD. Which of the following instructions should the nurse include the teaching? A. Limit the use of gravy or sauces on foods. B. Have a high-calorie protein drink between meals. C. Increase intake of beverages during meals. D. Use a bronchodilator 15 min after each meal.
B. Have a high-calorie protein drink between meals. Anorexia is a manifestation of COPD and this added nutritional intake promotes weight gain
A nurse is caring for an adolescent client who is in critical condition following a motor vehicle crash in which he was the passenger. The client's parent shouts at the nurse, asking why her son is dying instead of the driver. Which of the following actions should the nurse take to provide emotional support to The parent? A. Encourage the parent to speak with the family of the driver of the car. B. Inform the parent that anger is a natural response when dealing with loss. C. Ask the parent to leave and come back later after she has calmed down. D. Contact a clergy member to come and speak with the parent.
B. Inform the parent that anger is a natural response when dealing with loss.
A nurse is caring for a 47-year- old female client who has urinary incontinence. Which of the following actions should the nurse take first? A. Teach the client how to perform pelvic exercises. B. Obtain a specimen from the client for culture. C. Instruct the client to keep a daily record of episodes. D. Provide nutritional education for the client.
B. Obtain a specimen from the client for culture.
A nurse is planning care to prevent a catheter-related blood stream infection for a client who is receiving IV fluid therapy. Which of the following interventions should the nurse include in the plan A. Change bags of IV solution every 72 hours B. Perform hand hygiene before touching the IV tubing C. Use hydrogen peroxide to cleanse the IV insertion site D. Assess the IV insertion site every 12 hours for redness
B. Perform hand hygiene before touching the IV tubing
A nurse is reviewing the medication administration record of a client who is 2 days postoperative following abdominal surgery. The nurse should identify that which of the following medications can result in delayed wound healing? A. Metoprolol B. Prednisone C. Vitamin C D. Ropinirole
B. Prednisone Prednisone is a corticosteroid used in the treatment of inflammatory disorders. It can mask the manifestations of infection due to its ability to impair the inflammatory response
A nurse is administering enoxaparin subcutaneously to a client who is postoperative and is at risk for thromboembolic events. Which of the following actions should the nurse take? A. Insert the needle at a 15º angle after cleansing the site. B. Pull up a small amount of skin using the thumb and forefinger of the nondominant hand. C. Insert about half of the needle length into the tissue. D. Pull back on the plunger to check for blood return before administering the medication.
B. Pull up a small amount of skin using the thumb and forefinger of the nondominant hand.
A home health nurse manager is assisting in the implementation of an electronic medical record (EMR) system for client care. Which of the following actions should the nurse manager take to promote interoperability? A. Scan each client's prescribed medications into the individual EMR. B. Recommend a single coding system for each department to use. C. Seek reimbursement opportunities for the use of an EMR system. D. Establish a personal health record (PHR) for each client.
B. Recommend a single coding system for each department to use.
A nurse is planning the menu for a client who practices Seventh-day Adventist. Which of the following food selections should the nurse make? A. Shellfish B. Scrambled eggs C. Pork chop D. Tuna fish
B. Scrambled eggs Most clients who practice Seventh-Day Adventistism are lacto-ovo vegetarians who consume vegetables, eggs, and dairy, but not meat. Clients who practice this religion also do not consume caffeine or alcohol
A community health nurse is participating in a task force initiative to reduce the incidence of disease from injection drug use among the city's homeless population. Which of the following plans should the nurse recommend as part of tertiary prevention A. Offer HIV testing. B. Start a needle-exchange program. C. Screen clients who are homeless for drug use. D. Provide community education about needle sharing.
B. Start a needle-exchange program.
A nurse is beginning nutrition counseling with a client who has a BMI of 34.2. Which of the following questions should the nurse ask first to address the client's excessive nutrition and obesity? A. "What are some strategies you use to reduce the portion sizes of the foods you eat?" B. "Should we begin with a discussion of healthy versus unhealthy food choices?" C. "Are you ready to make a lifelong commitment to a healthier lifestyle?" D. "Did you know that you need to consume 500 fewer calories every day to lose a pound per week?"
C. "Are you ready to make a lifelong commitment to a healthier lifestyle?"
A nurse in a community health clinic is screening a 10 year-old-girl for scoliosis. Which of the following instructions should the nurse five the child for this examination A. "Walk across the room with the heel of one foot against the toes of your other foot." B. "Lie on your back on the examination table." C. "Bend forward at the waist and let your arms hang down." D. "Close your eyes and stand with your heels together."
C. "Bend forward at the waist and let your arms hang down."
A nurse is performing a focused assessment on a client who has chronic pain due to fibromyalgia. Which of the following questions should the nurse ask to assess the quality of the client's pain? A. "How long do your episodes of pain typically last?" B. "Do you have nausea when you're in pain?" C. "Can you describe what your pain feels like?" D. "Could you rate your pain on a scale of 0 to 10?"
C. "Can you describe what your pain feels like?"
A nurse is providing teaching to the parent of a 6-year old girl about preventing urinary tract infections. Which of the following statement by the parent indicates understanding of the teaching A. "I will have her wear panties made of nylon." B. "I will teach her how to wipe from back to front." C. "I will increase her intake of foods high in fiber." D. "I will limit her fluid intake in the evenings."
C. "I will increase her intake of foods high in fiber."
A nurse is providing dietary teaching to a client who has diarrhea. Which of the following instructions should the nurse include A. "Decrease your intake of soluble fiber while you are experiencing diarrhea." B. "Decrease your intake of sodium while you are experiencing diarrhea." C. "Increase your intake of potassium-rich foods while you are experiencing diarrhea." D. "Increase your intake of caffeinated beverages while you are experiencing diarrhea."
C. "Increase your intake of potassium-rich foods while you are experiencing diarrhea."
A nurse is using therapeutic communication to attempt de-escalation with a client who is yelling at staff members. Which of the following statements should the nurse make A. You need to stop yelling at the staff, okay?" B. "If you don't calm down, you will lose your privileges." C. "Tell me what is causing your anger at this moment." D. "Why do you feel it is acceptable to take out your anger on staff?"
C. "Tell me what is causing your anger at this moment."
A nurse is teaching an older adult client about accessing electronic resources for health care information on the internet. Which of the following statements should the nurse include in the teaching? A. "Websites that are evidence-based avoid placing direct links to other evidence-based websites on their home pages." B. "Websites that market products are credible as long as the products are beneficial for health care." C. "Websites ending in 'dot-gov' are reliable sites for obtaining health information from government agencies." D. "Website forums with the opinions of other clients provide factual and trustworthy information."
C. "Websites ending in 'dot-gov' are reliable sites for obtaining health information from government agencies."
A hospice nurse is planning care for a client who has terminal cancer. The client tells the nurse that she practices the Hindu religion. Which of the following interventions should the nurse include in the plan of care to support the client's religious beliefs. A. Position the client's bed in her home so that she faces east. B. Arrange for the Sacrament of the Sick when the client nears death. C. Allow time for a family member to perform a ritual bath after the client dies. D. Coordinate with the funeral home for burial within 24 hr of the client's death.
C. Allow time for a family member to perform a ritual bath after the client dies. The nurse should recognize a client who practices the Jewish, Muslim, or Hindu religions might want a ritual bath after death
A nurse enters a client's room to find the client lying on the floor. The client states that on the way to the bathroom her "knee locked" causing her to fall. Which of the following actions should the nurse take first A. Ask an assistive personnel to help return the client to her bed. B. Complete an incident report. C. Check the client for injuries. D. Document objective details about the client's condition in the medical record.
C. Check the client for injuries.
A nurse in a mental health facility is caring for a client who is exhibiting violent behavior and has been placed in seclusion. Which of the following actions should the nurse take? A. Provide the client with food every 3 hr. B. Ensure the provider evaluates the secluded client within 8 hr. C. Document the client's status every 15 min. D. Explain to the client that seclusion is punishment for violent behavior
C. Document the client's status every 15 min.
A nurse on a pediatric unit is admitting an infant who has pertussis. Which of the follow isolation precautions should the nurse initiate? A. Protective environment B. Airborne C. Droplet D. Contact
C. Droplet
A nurse is planning to implement bladder retraining for a client who has urge urinary incontinence. Which of the following actions should the nurse plant to take? A. Assist the client to the toilet as soon as the urge to void is reported. B. Apply an adult diaper to the client during nighttime hours. C. Gradually lengthen the time between the client's scheduled voids. D. Decrease the client's fluid intake beginning at 2000
C. Gradually lengthen the time between the client's scheduled voids
A nurse is preparing to administer morphine 5 mg IM from a 10 mg/mL vial to help manage a client's acute pain. Which of the following actions should the nurse plant take after administering a controlled substance? A. Crush the vial between paper towels and discard it in a sharps container. B. Lock the remaining medication in the vial in a secure location for future use. C. Have a second nurse witness and initial the disposal of the remaining medication. D. Return the unused portion of the medication in its original vial to the pharmacy.
C. Have a second nurse witness and initial the disposal of the remaining medication.
A nurse is teaching a client who is postpartum about preventing injury when using a car seat for her newborn. Which of the following instructions should the nurse include? A. Place the retainer clip at the level of the newborn's abdomen. B. Keep the air bag on if the car seat must be placed in a front seat. C. Install the car seat so that it is facing the rear of the vehicle. D. Position the newborn at a 60º angle in the car seat.
C. Install the car seat so that it is facing the rear of the vehicle.
A nurse is planning care for a client who has bacterial meningitis caused by Haemophilus influenza. Which of the following infection control interventions should the nurse include in the plan A. Stand at least 0.3 m (1 foot) from the client unless wearing a mask. B. Apply a N95 respirator before entering the client's room. C. Place a mask on the client during transport out of the room D. Assign the client to a room with negative air flow.
C. Place a mask on the client during transport out of the room
A nurse is assessing a client who has fibromyalgia. Which of the following treatment modality prescriptions should the nurse expect for the client's mixed pain. A. Referral for a nutritional consult B. PCA infusion pump with morphine C. Pregabalin PO twice daily D. Progressive exercise plan leading to running three times per week
C. Pregabalin PO twice daily
A nurse in a long term care facility discovers a small fire in a client's trash can. After moving the client to safety, which of the following actions should the ruse take next A. Return to the room to extinguish the fire. B. Close the doors and windows on the unit. C. Pull the alarm to notify emergency services. D. Turn off oxygen and electrical equipment.
C. Pull the alarm to notify emergency services.
A nurse is planning care for a client who has an indwelling urinary catheter. Which of the following interventions should the nurse include in the plan to prevent the development of a Cather associated urinary tract infection A. Ensure that the catheter tubing has a dependent loop. B. Empty the urinary collection bag when it is 75% full. C. Secure the catheter tubing to the client's leg. D. Use an open method for catheter irrigation.
C. Secure the catheter tubing to the client's leg.
A nurse is planning meals for a client who practices Judaism and reports that he strictly adheres to orthodox dietary laws. The nurse should recognize that which of the fallowing dietary practices applies to the client's beliefs A. The client should avoid honey or products that contain honey. B. The client needs to wait 15 min after eating meat before consuming a dairy product. C. The client is permitted to eat fish that have scales. D. The client can eat chicken but should avoid eating their eggs.
C. The client is permitted to eat fish that have scales.
A charge nurse is observing a newly licensed nurse prepare medications for a client. Which of the following actions by the newly licensed nurse adheres to safe medications administration practices A. The nurse breaks a non-scored caplet in half to administer a prescribed dose. B. The nurse uses the client's room number as an identifier for medication administration. C. The nurse compares the medication label with the client's medication administration record. D. The nurse prepares to administer an antibiotic 1 hr prior to the scheduled time.
C. The nurse compares the medication label with the client's medication administration record.
A nurse is preparing to administer a unit of packed RBCs to a client. In adherence with the Joint Commission National Patient Safety Goals Regarding blood administration, which of the following actions should the nurse plan to take? A. Review the client's medical record for previous transfusion information. B. Administer premedication to the client as prescribed by the provider. C. Verify the client and blood component using a two-person process. D. Educate the client about manifestations to report to the nurse immediately.
C. Verify the client and blood component using a two-person process.
A nurse is caring for a client who has a Clostridium difficile infection that is incontinent of stool following long-term antibiotic therapy. Which of the following actions should the nurse take? A. Place the client in a room with a client who has Shigella. B. Clean hands with alcohol-based hand rub after caring for the client. C. Wear a gown when providing care for the client. D. Remain within 1 m (3 ft) while caring for the client.
C. Wear a gown when providing care for the client.
A nurse is teaching sleep hygiene to a client who has insomnia. Which of the following statements should the nurse make? A. "Plan to catch up on sleep during the weekend." B. "Limit watching television in bed to 1 hour." C. "Get out of bed if you are unable to fall asleep within 10 minutes." D. "Exercise in the morning after arising."
D. "Exercise in the morning after arising
A nurse is teaching a young adult female client about health screening for breast cancer. Which of the following statements by the client indicates an understanding of breast self-examination (BSE) A. "I should perform a BSE about 1 week before my period each month." B. "I should use the fingers of my right hand to feel for lumps in my right breast." C. "I should report a lump in my breast if it remains for two consecutive BSEs." D. "I should expect to feel a firm ridge along the bottom curve of each breast."
D. "I should expect to feel a firm ridge along the bottom curve of each breast."
A nurse is teaching a client who has rheumatoid arthritis about chronic pain management. Which of the following statements by the client indicates an understanding of the teaching? A. "I should stop participating in my bowling league." B. "I should take a cool shower in the morning to relieve stiffness." C. "I should decrease my intake of foods containing purine." D. "I should use a warm paraffin dip for my hands and feet."
D. "I should use a warm paraffin dip for my hands and feet." dip her hands and feet in warm paraffin to alleviate pain and stiffness. The client can more easily perform hand and finger exercises following the treatment
A nurse is talking with a client who has major depressive disorder. The client states, "Nobody cares if I'm around or not." Which of the following responses should the nurse make? A. "Let's talk about the medications you're taking." B. "You know you really shouldn't talk like that." C. "You will feel much better after group therapy." D. "It sounds as though you're feeling hopeless."
D. "It sounds as though you're feeling hopeless."
A nurse is preparing to contact a client's provider regarding the need for a prescription for pain medication. When using the Situation, Background, Assessment, Recommendation (SBAR) communication tool, the nurse should provide which of the following information in the assessment portion of the tool A. "The client is a 75-year-old female who has a hip fracture and is reporting pain." B. "The client is in need of a prescription for pain medication at this time." C. "The client was admitted this afternoon and is scheduled for surgery in the morning." D. "The client is in audible distress and rates her pain as an 8 on a scale from 0 to 10."
D. "The client is in audible distress and rates her pain as an 8 on a scale from 0 to 10."
A nurse is preparing a client for an elective vaginal hysterectomy when the client states, "My doctor said there are more conservative ways to treat my problem. I realize now that I don't want this surgery, but I already signed that consent form." Which of the following responses should the nurse make? A. "Why would you question yourself when it is clear that you've weighed the risks and benefits already?" B. "Perhaps you should talk with your family about this issue. They might be able to help you decide what's best for you." C. "I think you made the best decision you could and should go ahead with the surgery." D. "You have the right to refuse this and any other procedure, even after you have signed the consent form."
D. "You have the right to refuse this and any other procedure, even after you have signed the consent form."
A nurse is teaching about advance directives with an older adult client who has a terminal illness. Which of the following statements should the nurse make? A. "Having advance directives means that you don't want to receive CPR." B. "Your next of kin can amend your advance directives for you if you are unconscious." C. "Advance directives are verbal or written instructions." D. "Your advance directives can designate a friend to make your health care decisions."
D. "Your advance directives can designate a friend to make your health care decisions."
A nurse is planning a community health program about substance use disorders. Which of the following information should the nurse include when discussing the guidelines for safe limits of alcohol consumption? A. A healthy man under the age of 65 years should consume no more than five drinks each day. B. A healthy woman of any age should consume no more than four drinks each day. C. A healthy man over the age of 65 years should consume no more than 14 drinks in a week. D. A healthy woman of any age should consume no more than seven drinks in a week.
D. A healthy woman of any age should consume no more than seven drinks in a week.
A nurse is developing a care for a client who has urinary incontinence. Which of the following actions should the nurse include? A. Gently massage reddened areas of the client's skin. B. Inspect the client's skin every other day. C. Change the client's position every 4 hr. D. Apply a moisture barrier cream to the client's skin.
D. Apply a moisture barrier cream to the client's skin.
A nurse is providing teaching about nutrition management to the parent of an 18- month-old toddler who has phenylketonuria. Which of the following foods should the nurse recommend? A. Strawberry yogurt B. Refried beans C. Cheddar cheese D. Baked potato
D. Baked potato The nurse should recommend low-protein foods to the parent of a toddler who has phenylketonuria. The nurse should also recommend the parent offer the toddler fruits, juices, and cereals with limited phenylalanine
A nurse is preparing to collect a stool specimen from a client who has had diarrhea for 3 days, with fever and abdominal cramping. When reviewing the client's recent medication administration record, the nurse should recognize that treatment which which of the following medications increases the client's risk for developing a Clostridium difficile infection A. Fidaxomicin B. Metronidazole C. Vancomycin D. Ciprofloxacin
D. Ciprofloxacin
A community health nurse is planning interventions to promote Healthy People 2020 initiatives in the community. Which of the following actions should the nurse plant to take first A. Collaborate with community environmental resources to decrease pollutants. B. Educate adolescents in the community about diseases caused by tobacco use. C. Promote healthy development of infants and toddlers in the community. D. Determine the level of health equity among groups in the community
D. Determine the level of health equity among groups in the community
A nurse is caring for an older adult client who has a leg wound following a fall on the stairs. The nurse should identify which of the following factors as an expected, age-related change in older adults that can impair wound healing A. Collagen tissue expands and is more flexible. B. Antibody formation increases. C. Skin capillaries enlarge. D. Elastin fibers separate and thicken.
D. Elastin fibers separate and thicken.
A nurse is caring for a child who has celiac disease. Which of the following items should be removed from the meal tray? A. Corn-flake cereal B. Orange juice C. Scrambled eggs D. Oatmeal with raisins
D. Oatmeal with raisins Celiac disease is the intolerance to dietary gluten, which is a protein in wheat, rye, oats, and barley. This intolerance causes diarrhea, weight loss, abdominal pain, and fatigue
A nurse is creating a plan of care for a client who is non ambulatory and is bladder and bowel incontinence. Which of the following interventions should the nurse include to prevent skin breakdown A. use a sheepskin device to pad the client's pressure points. B. Apply cornstarch to the perineal area after bathing the client. C. Massage the client's skin and pressure points every 12 hr. D. Offer the client a glass of water every 2 hr when repositioning.
D. Offer the client a glass of water every 2 hr when repositioning.
A nurse is developing a plan of care for an older adult client who is experiencing functional incontinence following hip arthroplasty. Which of the following should the nurse include? A. Dress the client in pants with a zipper. B. Measure residual after each void. C. Insert a urinary catheter. D. Place grab bars by the toilet.
D. Place grab bars by the toilet.
A nurse is assessing for acute pain in a client who is postoperative. The client has dementia and is nonverbal. Which of the following funding's should the nurse identify as a need for administration of a PRN pain medication? A. Hypoactive reflexes B. Increased sleep time C. Pupils constricted bilaterally D. Rapid breathing
D. Rapid breathing This change in breathing is a sympathetic nervous system response to acute pain. The nurse should further assess the client's respiratory status and administer a PRN pain medication. Other nonverbal indicators of pain include muscle tension, restlessness, and moaning
A nurse is preparing to leave the room of a client who is on isolation precautions. Which of the following actions should the nurse take when removing a tied surgical mask? A. Take the mask off immediately after leaving the client's room. B. Perform hand hygiene prior to removing the mask. C. Untie the top strings of the mask and then untie the lower strings. D. Remove the mask by securely holding the ties and moving it away from the face
D. Remove the mask by securely holding the ties and moving it away from the face
A nurse is documenting an assessment in a clients electronic health record when an assistive personnel (AP) asks to enter the morning blood glucose for the client. Which of the following actions should the nurse take. A. Allow the AP to use the computer while the nurse is still logged in. B. Enter the data in the computer for the AP. C. Instruct the AP to come back later to use the computer. D. Request that the AP use another computer to enter the data.
D. Request that the AP use another computer to enter the data.
A nurse is preparing to administer an immunization via IM injection into an adult client's deltoid muscle. Which of the following actions should the nurse take? A. Limit the volume of fluid injected to 3 mL. B. Aspirate and check for blood prior to injection of the vaccine. C. Pinch the client's skin with the nondominant hand while inserting the needle. D. Select a 1-inch needle for the injection
D. Select a 1-inch needle for the injection
A nurse is preparing to extinguish a small fire in a client's room. Which of the following actions should the nurse take? A. Aim the extinguisher at the top of the flames B. Pump the handles of the extinguisher up and down three times C. Sweep the fire extinguisher in a circular motion until fire is extinguished D. Slide the pin on the top of the fire extinguisher straight out
D. Slide the pin on the top of the fire extinguisher straight out
A nurse is preparing to administer a medication via intermittent IV bolus to a client who is receiving a continuous infusion via an infusion pump. The client's IV fluid solution is incompatible with the bolus. Which of the following actions should the nurse plan to take first A. Flush the injection port with 10 mL of 0.9% sodium chloride solution. B. Administer the intermittent IV bolus medication through the injection port. C. Clamp the intravenous tubing proximal to the injection port. D. Stop the continuous IV infusion.
D. Stop the continuous IV infusion.
A nurse manager is developing a faculty policy about using a fax machine to communicate information from a client's electronic medical record (EMR). Which of the following actions should the nurse include in the policy A. Disable the speed-dial keys on the fax machine. B. Fax the client's entire EMR for consultations. C. Save the printed copies of the EMR used for faxing for at least 30 days. D. Use a cover sheet when sending a fax from the health care unit.
D. Use a cover sheet when sending a fax from the health care unit.
A charge ruse is teaching a group of newly licensed nurses how to prevent errors during administration of blood transfusions. Which of the following actions should the nurse include A. Complete the administration of 1 unit of packed RBCs within 6 hr of initiation of the transfusion. B. Infuse 500 mL of lactated Ringer's when administering whole blood. C. Vigorously massage the blood bag to mix the cells prior to administration. D. Use a new blood administration tubing set for each blood bag infused.
D. Use a new blood administration tubing set for each blood bag infused.
A nurse is caring for a 2 year old toddler who is immediately postoperative. Which of the following pain scales should the nurse use to assess the toddler's pain level? A. FACES scale B. COMFORT scale C. Visual analog scale D. FLACC scale
The FLACC scale assesses facial expression, leg movement, activity, cry, and consolability in children 2 months to 7 years of age. The nurse assigns a score of 0 to 2 for each area
