Final

The LPN/LVN is obtaining a blood glucose level on a client with diabetes mellitus, and notes that the blood glucose level is 280 mg/dL. Knowledge of which condition prompts the LPN/LVN to report the finding to the RN?

Hyperglycemia

A physician has ordered "Clear liquids, advance as tolerated." Which factors indicate to the nurse the advancement of the client's diet should be delayed? Select all that apply.

Hypoactive bowel sounds Nausea and vomiting Reports of indigestion

A patient arrives at a clinic with a knee joint that is noticeably swollen, warm to the touch, and painful. The HCP plans to perform an arthrocentesis. Given the patient's symptoms, which is the least likely reason for the procedure?

To mechanically inhibit the production of synovial fluid

Which of the following procedures involves removal of something? Select all that apply.

Tonsillectomy Hysterectomy

The nurse is caring for a high school football player who is diagnosed with a serious sprain to the ankle. Which part of the anatomy does the nurse associate with this type of injury?

Torn ligaments

The nurse provides care to a patient who is able to do very little to nothing for self. Which type of care does the nurse include in the patient's plan of care?

Total care

The nurse provides care to a patient who is terminally ill. Which nursing action is the priority when providing care to this patient at the end of life?

Touching the patient to show caring

The nurse is caring for a patient admitted with chest pain and suspected myocardial infarction (MI). Which laboratory value should the nurse expect to see an elevation?

Troponin

Electrolytes sodium, chloride, potassium, calcium magnesium, phosphorus, and bicarbonate must be maintained in homeostasis.

True

For the care of a patient being infused. You should monitor his or her Vital Signs and sure he or she is not showing signs of fluid overload.

True

Hypervolemia or fluid volume excess can result from renal failure, congestive heart failure, or retention of sodium and water in the ECF spaces.

True

In order to successfully teach your patient you must consider and resolve any factors that can delay or impede learning.

True

Many electrolyte imbalances can cause irregular heart rhythms some of which can be fatal.

True

The nurse is attempting to insert a standard urinary catheter in a female client who is unable to separate her legs because of severe contractures. Which adjustment will the nurse make?

Try to insert the catheter with the client lying on her side.

The nurse is providing discharge teaching to a client with COPD who is being discharged on supplemental oxygen for home use. Which information should the nurse exclude from the client teaching?

Turn up the oxygen flow rate at night to avoid shortness of breath during sleep.

A nurse requires supplies and equipment that have been prepared for surgery. Which preparation method does the nurse recognize as being inadequate for surgical asepsis?

Ultrasound

The nurse is caring for a patient whose troponin I level is elevated due to experiencing a myocardial infarction. Which nursing action would be appropriate?

Up as desired

The nurse is preparing teaching for a client ordered on long-term treatment with corticosteroids. As part of the teaching about side effects, the nurse should inform the client that which body function is primarily affected?

Metabolism

While caring for a client taking tetracycline, the nurse recognizes that teaching has been effective if the client avoids which of the following? Select all that apply.

Milk Cottage cheese Ice cream

The nurse uses the five techniques for obtaining objective data when performing the physical assessment of a client. Which technique provides assessment information through the use of the nurse's hands?

Palpation

A nurse is caring for a client whose primary language is different from the nurse. The client needs preoperative. The nurse best demonstrates a caring demeanor through which of the following actions?

Arranging for an interpreter or translator to be present

The nurse is caring for an older adult client who is experiencing anxiety related to a new diagnosis of cancer. Which action by the nurse is mosthelpful in alleviating the client's anxiety?

Ascertaining which family member can stay with the client

The nurse is preparing a patient for an angiogram. What should be included in data collection for this patient?

Ask if the patient is allergic to eggs.

A client from a non-English speaking culture is dying. Which should the nurse do to ensure that this client receives culturally specific care?

Ask if there are any specific cultural interventions at this time.

Which actions should the nurse perform when performing a neurovascular check on a client? Select all that apply.

Ask the client about numbness, burning, or tingling in the affected limb. Compare sensations by touching an affected and unaffected limb with a paper clip. Ask the client to move the fingers or toes of the affected extremity. Test capillary refill of the fingers or toes distal to the surgical site or cast.

The nurse, working in a pediatric clinic, is caring for a preschool client. The client presents with vomiting and diarrhea. The client's parent reports poor appetite and sleeplessness. The nurse suspects a urinary tract infection (UTI). Which additional assessment will help confirm the nurse's suspicion? Select all that apply.

Ask which direction the client wipes after using the toilet. Ascertain the method by which the client bathes. Determine if the client has recently been incontinent.

A physician has ordered 5 grains of aspirin. Aspirin is available in 300-mg tablets. How many tablets should the nurse give?

1

The nurse is caring for a client with a newly placed plaster leg cast. Which actions by the nurse are part of the nursing care for this client? Select all that apply.

Assess for capillary refill of the toes. Elevate the casted limb on pillows. Handle the cast with the palms of the hand.

The nurse is providing care for a client who is four days postoperative for a lower limb amputation. The nurse wraps the stump with an elastic bandage. Which additional actions will the nurse perform? Select all that apply.

Assess for the presence of pain or numbness. Slip two fingers under the proximal end of the wrap.

While providing care for an older adult client, the nurse learns that the client has had only small, watery stools for several days. Which is the nurse's priority in providing care for this client?

Assess the client for an impaction.

The nurse is preparing to administer a medication by the sublingual route. Which should the nurse determine prior to administering the medication? Select all that apply.

Assess the client's mouth for lesions. Assess the client for gum disease.

A client with coronary artery disease complains of substernal chest pain, After checking the client's heart rate and blood pressure, the vocational nurse administers nitroglycerin, 0.4mg sublingual. After 5 minutes the client states, "My chest still hurts." Select the appropriate actions that the nurse should take. (Select all that apply)

Assess the client's pain level Contact the registered nurse Administer a second nitroglycerin, 0.4 mg sublingually Check the client's blood pressure

The nurse is completing the placement of a nasogastric (NG) tube. Which is the most reliable way for the nurse to initially confirm the placement of the tube?

After placement of a radiopaque tube confirm the location of the tube by x-ray.

The nurse identifies the diagnosis of "spiritual distress" for a client. Which interventions should the nurse plan for this client? Select all that apply.

Allow the client to express concerns about dying. Solicit an appropriate member of the clergy with the client's consent. Provide comfort by sitting quietly at the client's bedside.

The nurse is caring for a 7-year-old client. The nurse is providing education to the client about receiving vaccinations. Which is an appropriate action for the nurse to take when teaching the client?

Allow the client to model giving vaccinations on a teddy bear.

The nurse is admitting a client into the hospital with a diagnosis of dehydration related to vomiting. Which symptom of dehydration will the nurse expect during physical assessment?

Alteration in body temperature

The nurse provides care to a patient who is lethargic and unable to tolerate standing for long periods. The patient experiences dyspnea on exertion. Which type of bath is best for the nurse to implement with this patient?

Bed bath

The nurse provides care to a terminally ill patient. Upon entering the patient's room, the nurse notes the patient is not breathing. The patient does not have a do-not-resuscitate (DNR) prescription. Which action does the nurse implement based on the current data?

Begin cardiopulmonary resuscitation (CPR) because a DNR prescription is not written.

The nurse strives to provide culturally competent care. Which areas that influence the patient's health should the nurse understand? Select all that apply.

Behavior Perceptions Expectations Decision-making process

The nurse established a sterile field for a dressing change. Which location is outside of the boundaries when considering the location of the safety zone for the sterile field?

Below the draped surface

A client makes an appointment at the health clinic to receive an annual influenza vaccination. Which health belief is this client demonstrating?

Biomedical

The nurse reviews a client's electrolyte levels on a laboratory report and notes the client has hyponatremia. Which symptoms will the nurse expect to find during assessment?

Blood pressure of 100/58 mm Hg

A client reports having a sore jaw and tooth pain in the mornings. Which sleep disorder should the nurse suspect this client is experiencing?

Bruxism

The nurse gently squeezes a client's nailbed and counts the number of seconds until color returns to the nailbed. What is the nurse assessing in this client?

Capillary refill

A client has a critical pathway to be used for providing care. Which should the nurse keep in mind when following this plan of care?

Care is based upon the day of hospitalization

The dietician explains that when food metabolizes, complex substances become simpler substances and sometimes energy is released. The nurse is aware that the process is referred to as __________________.

Catabolism

The nurse is working in a long-term facility. A client complains to the nurse about the lighting in the facility. Which condition will the nurse check for related to aging?

Cataracts

The nurse is providing care for a client who becomes short of breath when ambulating to the bathroom. Which documentation should the nurse enter on the client's medical record?

Dyspnea noted after walking 15 feet

A homeless client reports having foot pain for several months, but is just now seeking medical attention because he did not have access to health insurance. For which reason has this client delayed seeking care?

Economics

The nurse provides education to a client who needs to increase intake of complete proteins. The nurse recognizes that teaching is effective if the client selects which food?

Eggs

Match the following

Elastic bandages- helps compress the area to depress edema Amputee Compression sock- helps to shape to fit in the prosthesis immobilizer- protects an injured limb, keeps its joints from flexing Splint- firm plastic molded from, keep from joint or joints from flexing Traction- use of ropes, pulleys, and weights to align bone ends

A patient just had an arthrogram performed for pain in a synovial joint. Which nursing care is inappropriate following this procedure?

Elevate the limb that was tested.

The nurse is caring for a client admitted with fluid volume deficit. Which diagnostic test results does the nurse identify as supporting the client's diagnosis? Select all that apply.

Elevated urine specific gravity High hematocrit level Elevated blood urea nitrogen (BUN)

The nurse observes that although several clients are experiencing pain, the pain response and tolerance are different. Which factors about pain perception should the nurse keep in mind when assessing for pain? Select all that apply.

Emotions Individual values Developmental stage Ethnic and cultural beliefs

While caring for a client with pneumonia, the nurse notes that the client is having difficulty expectorating thick, rust-colored sputum. Which nursing intervention is the priority?

Encourage increased fluid intake.

The nurse is providing care for a client after abdominal surgery. Which interventions should the nurse include in the client's plan of care to help prevent respiratory complications? Select all that apply.

Encourage the client to use the incentive spirometer. Closely monitor the client's oral fluid intake every shift. Teach the client to cough and deep breathe with a pillow splint

The nurse is caring for a patient recovering from a cardiac catheterization. Which action should the nurse take?

Encourage the patient to drink plenty of liquids.

The nurse provides care to a terminally ill patient who has barely eaten anything for several days. Which nursing action is appropriate for this patient?

Encourage the patient to eat whatever foods he or she thinks sound and look appealing.

When a client has an intact digestive system but has difficulty with swallowing, digestion, or the absorption of food, the nurse can expect the client to be ordered on ____________________ feedings.

Enteral

The nurse works in a rehabilitation facility. Which action by the nurse will help promote mobility so a client can be discharged home? Select all that apply.

Evaluate the client's mobility deficits. Diligently follow the physician's activity orders.

The nurse is caring for a client admitted with a diagnosis of bulimia nervosa. Which assessment finding will the nurse expect? Select all that apply.

Evidence of dental caries Verbal reports of indigestion Frequent bouts of sore throat Poor skin turgor and sunken eyes

The nurse is caring for a client who has fecal incontinence. The symptoms include intermittent periods when small amounts of liquid stool are passed, followed by periods of severe constipation requiring the use of enemas to resolve. Which intervention should the nurse perform first?

Examine the client and check for the possibility of fecal impaction.

A client has received nutrition teaching from the RN. Which client statement will prompt the LPN/LVN to reinforce teaching about the functions and importance of water in the body?

Exercise does not affect my water intake unless I sweat."

A client is prescribed to have core body temperature measurements twice a day. For which client situation should the nurse discuss this measurement with the health-care provider?

Experiencing diarrhea

The nurse is assessing an 82-year-old client who has diabetes mellitus. Based on the individual's age, which assessment is considered essential?

Feet

A client from a non-English speaking culture becomes visibly upset when the phlebotomist arrives to draw a blood sample, and he changes clothes to leave the hospital. What should the nurse do at this time?

Find an interpreter to help with communication.

While assessing a client's surgical incision, the nurse notes that it is dry, clean, and intact, with edges approximated. The nurse is aware that which type of healing is taking place?

First intention

The nurse administers a liquid medication via the oral route. While documenting that the medication was administered, the nurse realizes it was ordered to be administered via the parenteral route. Which action should the nurse take?

Report it as a medication error.

The nurse is caring for a patient who has possible kidney damage from high blood pressure. Which action should the nurse take?

Review creatinine level.

While preparing to provide medications, the nursing student correctly recognizes that which of the following safety checks are part of the Six Rights of Medication Administration? Select all that apply.

Right dose Right time Right medication Right documentation

A client has been vomiting without relief from medications. The physician orders the client on NPO status. Which action by the nurse violates the physician's order?

Gives ice chips when the client indicates mouth dryness

The nurse is providing information to a patient recently diagnosed with type 1 diabetes mellitus (DM). The patient expresses a desire to understand the disease. Which information provided by the nurse is accurate?

Glucose is carried into cells when glucose transporters are activated in the membrane

The nurse is monitoring laboratory BG levels for a patient diagnosed with type 2 DM. Which test result does the nurse use to evaluate the patient's compliance with treatment?

Glycohemoglobin testing

The RN provides teaching to a client with newly diagnosed diabetes mellitus. Which method will the LPN/LVN reinforce as the bestindicator of long-term glycemic control?

Glycosylated hemoglobin

A patient with type 1 DM expresses concern about developing retinopathy due to a chronic disease. Which information does the nurse provide to give the patient the best reassurance?

Good control of BG and blood pressure can reduce the risk.

The nurse is providing care for a client with an Ilizarov frame. Which entry will the nurse document in this client's medical record?

Rod, wires, and screw ring intact

During an assessment, a client states, "I'm religious. I go to church twice a week." Which characteristics might the nurse expect this client to demonstrate? Select all that apply.

Hope Purpose of Life Empowerment Sense of control

A client has hyperactive bowel sounds, diarrhea, nausea, vomiting, and has lost five pounds over the last week. Which type of nursing diagnostic statement should be created for this client?

Three-part

A patient is admitted to the hospital with hyperosmolar hyperglycemia. The patient is 40 percent overweight and has a blood glucose value of 987 mg/dL. Which is the priority focus while planning nursing care for this patient?

Hydration status

After rating pain as an 8 on a scale from 1 to 10, the nurse finds the client sleeping when bringing pain medication. Which action should the nurse take?

Wake the client up gently and provide the medication

A client is prescribed warm moist heat application four times a day. Which should the nurse apply directly to the skin area?

Warm moist towel

To prevent complications from intramuscular injections, a nurse should do which of the following? Select all that apply.

Wash hands before preparing injections. Apply a bandage after giving the injection. Document the site of the injection. Wash hands when entering a client's room.

A patient with diabetes has peripheral neuropathy. What should the nurse do to prevent related complications?

Wash, dry, and inspect feet daily.

A client is prescribed a cold compress to the forehead. Which items should the nurse use to make this compress?

Washcloth and zip-type plastic bag

The nurse applies the principles of anatomy and physiology to client care. Which factor does the nurse understand as having the most affect on fluid movement in the body?

Water intake

The nurse is obtaining a health history from an older adult client. The client tells the nurse that a bowel movement occurs about every 2 to 3 days. Which question should the nurse ask to determine if this is normal functioning for the client?

What is the consistency of your stool?

The nurse verifies the client, medication, dose, and route several times when preparing medications for administration. These required safety checks occur:

When the nurse removes the medication from the cart.

The nurse prepares to address a client's spirituality concerns. Which should the nurse assess first?

Whether the client practices a religion

While caring for a client in the surgical center, which of the following preoperative laboratory values would a nurse expect to be included in the orders? Select all that apply.

White blood cell (WBC) count Hemoglobin (Hgb) Platelet count (PLT) Urinalysis (UA)

The nurse reviews the food diary of a client who is on a weight reduction plan. Which entry listed in the food diary provides the nurse with an idea why the client has not lost weight?

Whole milk and cheese

As the nurse is giving an intramuscular injection, she notes blood returning into the syringe with aspiration. Which actions should the nurse take? Select all that apply.

Withdraw the needle Dispose of the medication-filled syringe Try again with a new dose and needle

The nurse is providing care for a client after an above-the-knee amputation one day ago. Which nursing care is most important during the initial postoperative period?

Wrapping the stump with an elastic bandage

While documenting in a client's chart, the nurse realizes that it is the wrong chart. What should the nurse do?

Write "mistaken entry" and place initials just above incorrect entry.

A nurse is caring for a client who received spinal anesthesia. The client reports having a bad headache later that day. Which is the best response from the nurse?

You might have lost some spinal fluid during anesthesia.

The nurse is preparing a client for a routine colonoscopy. The client asks if the procedure will be painful. Which response by the nurse is accurate?

You will have conscious sedation during the procedure, so it will be like you're sleeping.

The nurse is preparing to measure a client's blood pressure. Which should the nurse explain that blood pressure measures?

he amount of force being placed on arteries by blood

You are educating your patient on the purposes of and correct application of (select all that apply)

his or her treatments his or her medication/s empowering your patient to best care for him or herself.

A mother asks how much sleep a 4-year-old child needs. Which response should the nurse make?

"A 4-year-old should sleep approximately 12 hours a day."

The nurse provides care to a patient who is actively dying. The patient's spouse is upset about her husband's respirations. Which response by the nurse is appropriate when providing education to the spouse about Cheyne-Stokes respirations?

"As your husband approaches end of life, breathing will be a cycle of shallow and deep respirations."

A female patient is prescribed glyburide for control of blood glucose. What precaution does the nurse teach the patient about this medication?

"Avoid drinking alcohol."

The nurse wakes the client during evening shift for a focused assessment. The client, trying to rest, tells the nurse, "I really need to sleep. Can you tell me why you need to wake me up so often?" Which response by the nurse explains the purpose of the assessment?

"Because you were just started on a medicine, I need to check your blood pressure more frequently."

The nurse provides care to a terminally ill patient. The patient's family asks the nurse what should be expected during the dying process. Which response by the nurse is accurate and appropriate?

"Breathing will stop, and then the heart will cease beating within a few minutes."

The nurse reviews a care plan written for a client. Which nursing diagnosis should the nurse delete from this plan?

"Chronic fatigue syndrome related to poor diet"

A client with a sprained wrist is prescribed cold therapy. Which should the nurse explain about this treatment as compared to heat therapy?

"Cold therapy decreases swelling and pressure on nearby nerves, which helps decrease pain."

The nurse is leading orientation for a newly hired nurse. The newly hired nurse states, "I worry about getting all the information documented after an assessment. How do I remember everything?" Which advice by the orienting nurse will be most helpful?

"Document in the same order you gather data by working from head to toe."

In response to a nurse's question about bowel function, a client shares that sometimes the feces are greenish black in color. Which answer by the nurse is correct?

"Eating green foods, such as spinach, can cause your stools to have greenish black streaks."

The nurse discovers a client lying on the floor. Which should the nurse write when completing an incident report?

"Found client lying face down on the floor beside the bed."

The nurse is teaching a patient with hypertension about the DASH diet. Which statement made by the patient indicates a need for further teaching?

"I ate a hamburger with a small order of fries last night."

The LPN/LVN is reinforcing instructions to a client for the use of an incentive spirometer. Which statement by the client will prompt the LPN/LVN to notify the RN that additional teaching is necessary?

"I blow into the mouthpiece 10 times a day just as instructed."

The nurse is reinforcing teaching to a patient about to undergo angiography. Which statement made by the patient indicates a need for further teaching?

"I cannot have anything to eat or drink for 4 hours before the test."

The nurse is offering support to a family member who is caring for a client diagnosed with Alzheimer disease. Which comment by the family member does the nurse recognize as a possible contributor for client abuse?

"I feel like I am caring for a stranger; I don't relate to this person at all."

The nurse is evaluating the knowledge of a patient recently diagnosed with type 1 DM. Which statement by the patient indicates a need for additional information?

"I know that I am obese and can reduce my need for insulin with weight loss."

The nurse is providing discharge teaching to an older adult client. The nurse is concerned about the client being able to safely manage multiple prescriptions. Which comment by the client indicates that the nurse's concern requires follow-up?

"I know that I take one pink, one blue, and two white pills every morning."

The nurse is interviewing a client during a wellness visit in a physician's office. Which comment by the client during a discussion about nutrition will cause the nurse the most concern?

"I make sure to follow my extensive vitamin regimen."

The nurse is caring for a client with urinary stress incontinence. Which statement by the client indicates that teaching has been effective?

"I need to do Kegel exercises to help strengthen the muscles that control the urine."

The nurse is teaching a patient about furosemide (Lasix). Which statement made by the patient indicates an understanding of the teaching?

"I should take the medication in the morning so I am not up all night going to the bathroom."

The nurse is teaching a client newly diagnosed with diabetes mellitus about the eating and nutrition parameters required with the client's diagnosis. Which comment by the client indicates that teaching is understood?

"I will find a new method for cooking besides frying."

The nurse is providing care for a client after joint replacement surgery. The nurse delivers a lunch tray with a cheeseburger, French fries, slaw, and fresh fruit. After the meal, the nurse picks up an empty tray. Which comment is more important for the nurse to make if the client states, "My husband ate part of my lunch because I'm just not that hungry"?

"I will need to know which foods you actually ate."

A nurse reinforces discharge instructions to a post-operative client who is taking warfarin (Coumadin). Which statement, if made by the client, reflects the need for further teaching?

"I will take Ecotrin (enteric coated aspirin) for my headaches because it is coated."

A patient tells the nurse he has started experiencing impotence since beginning treatment for hypertension. Which statement by the nurse is most appropriate?

"I will talk to your doctor and see about referring you for sexual counseling."

A nurse would include which of the following questions in a presurgical assessment? Select all that apply.

"Is there a possibility you may be pregnant?" "Are you taking any medications at this time?" "Do you smoke or use tobacco in any form?" "What surgery is planned? Why are you having surgery?"

The nurse's coworker states, "All old people are the same—cranky and needy." Which response by the nurse is most appropriate?

"It is important that we treat all clients as individuals."

The nurse provides care for a patient who is actively dying. The patient's spouse tells the nurse, "I am worried that my husband is not getting enough fluids." Which response by the nurse is appropriate?

"It is natural to become dehydrated before death. It will actually make him more comfortable."

A patient asks the nurse what the doctor meant by the phrase, "hypertensive emergency." Which explanation should the nurse provide?

"It refers to an episode of very high blood pressure."

The LPN/LVN is providing medication administration instructions to the parents of a 4-year-old girl with an ear infection under the supervision of an RN. Which statement made by the parents indicates teaching has been successful? Select all that apply.

"It will be best if we lay her down on one side to administer the medication." "I will position the dropper so that the drop rolls down the wall of the canal, to prevent it from landing on her eardrum."

A client experiencing pain rated as a 7 on a scale from 1 to 10 continues to have pain despite having medication 2 hours ago. Which response should the nurse make when the client requests additional medication?

"Let me reposition you and rub your back to help relieve the pain"

A client asks why a moist cold pack is prescribed for an injury. What should the nurse respond to this client?

"Moist cold penetrates faster and deeper than dry cold."

The nurse is presenting nutrition information to a client. The client states, "I know my diet is not the healthiest, but I never remember to take vitamin supplements." Which response by the nurse reinforces good information for the client?

"Most people get sufficient vitamins from plants, animal sources, or supplements."

The nurse is providing care for a patient with diabetes who experiences frequent periods of hyperglycemia. Which comment by the patient is indicative to the nurse of a major cause of this BG imbalance?

"My job is really busy in tax season."

The nurse reinforces education to a terminally ill patient and family regarding the senses. Which statement by a family member indicates correct understanding of the information presented?

"My loved one's ability to hear is the last sense to go at end of life."

A client tells the nurse, "I have been using a decongestant nasal spray for 3 months, but I still have terrible nasal congestion." Which response by the nurse is appropriate?

"Nasal decongestant sprays can cause rebound congestion with long-term use."

Under the supervision of a registered nurse (RN), an LVN/LPN is providing parents with instructions for administering eye drops to their young child, who has been diagnosed with pink eye. The nurse correctly tells the parents:

"Place the drop in the middle part of the space created when you pull down the lower lid."

The nurse reinforces education for the family of a terminally ill patient. When discussing respite care with the family, which statement by a family member indicates correct understanding of the information?

"Respite care means that I will be given an opportunity to have time away from my spouse without worrying about his care."

The nurse is reinforcing teaching for a patient with hypertension. If a patient states, "I understand that if I do not eat or cook with salt, my hypertension will go away." What is the nurse's best response?

"Some patients' blood pressure may not respond to salt restriction alone."

A client reports that chronic pain is usually tolerable until under stress and then the pain becomes unbearable. Which should the nurse respond to this client?

"Stress causes the thalamus to open the gateway to pain, increasing the pain."

The nurse manager recognizes that a nurse requires further teaching about infection prevention when which comment is made by the nurse?

"Surgical asepsis is based on maintaining a clean client environment."

A patient asks the nurse what the action of the arteries is. Which response by the nurse is most appropriate?

"The arteries carry blood from the heart to capillaries."

The nurse is asked to explain the difference between core temperature and the temperature measured through the tympanic route. Which response should the nurse make?

"The core temperature is more reflective of the environment the internal organs are being exposed to."

The nurse is providing care to a client with colorectal cancer who typically takes sustained-release morphine (MS Contin), furosemide (Lasix), and metoprolol (Lopressor). The client's wife reports that because the client has bad mouth sores and has a hard time swallowing pills, she has crushed the pills and given him his medications in ice cream. Which statement by the nurse reflects the nursing priority?

"The morphine tablets shouldn't be crushed because that releases all of the medication at once."

While taking a shower, a patient becomes light-headed and dizzy. When reporting this occurrence to the health-care provider, which statement is accurate from the nurse

"The patient became light-headed and dizzy in the shower due to hypotension."

The RN teaches a group of LPN/LVNs about sterile technique in long-term care facilities. Which comment by an attending LPN/LVN indicates understanding of the teaching?

"The presence of pathogens in a long-term facility is just as concerning as in a hospital."

A patient diagnosed with curvature of the spine asks the nurse why breathing is so much more difficult. Which answer by the nurse best answers the question?

"The thoracic cage has lost some flexibility."

The nurse is caring for a client who has an order for a 24-hour urine specimen collection. The client asks, "Why do I have to collect my urine for 24 hours?" Which answer by the nurse is best?

"This test is done to evaluate how your kidneys function."

A client is using two types of inhalers—a bronchodilator and a steroid. Which statements made by the nurse accurately describe how to take these medications? Select all that apply.

"Wait 5 minutes between taking the inhalers." "Rinse out your mouth after using the steroid inhaler." "Use the bronchodilator first."

The nurse is caring for a client who has been prescribed morphine to help manage postoperative pain. Which of the following statements made by the nurse is true?

"We must monitor your intake of this medication closely because it is highly addictive."

The nurse is providing care for a 32-year-old with suspected bowel obstruction who is receiving intramuscular injections of narcotic pain medication. The client states, "I hate shots. Why can't I just take a pill?" The nurse could best respond with:

"We want to avoid giving you medication that you have to digest."

A client seeks medical attention for a burn located on the lower back. Which question should the nurse ask to determine how the burn occurred?

"Were you lying on a heating pad?"

The nurse provides care to a terminally ill patient. Which patient response indicates to the nurse a readiness to talk about dying?

"What do you think death feels like?"

A nurse is supervising a student nurse. When providing client teaching, the nurse intervenes when the student nurse states which of the following?

"Why didn't you do it the way that I showed you?"

The nurse is providing care for a marathon runner who is recently diagnosed with DM. Which explanation regarding exercise is best for the nurse to provide?

"You always need to take some emergency glucose with you when you are running."

The LPN/LVN prepares to assist the RN in teaching a client how to perform in-home self-catheterization. The client asks, "Will you be sending a crate of sterile gloves home with me?" Which reply is correct?

"You will not need sterile gloves to do this at home."

The nurse is caring for a client who just had a plaster cast applied for a lower leg fracture. The client states, "Why this kind of cast? My friend got a fiberglass cast." The nurse will make which comment to address the client's statement?

"You will probably have a fiberglass cast in a couple of weeks."

The nurse is assisting with nutrition teaching for a patient who voices concern over coping with a diabetic diet. Which response by the nurse about medical nutrition therapy is correct?

"Your diet will be a well-balanced, individualized meal plan that is healthy for your whole family."

An emergency department nurse admits an adult client for a drug overdose. The physician writes an order for the nurse to instill charcoal through a nasogastric (NG) tube. Which size tube will the nurse select?

16 French

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The client tells the nurse they feel short of breath and are having difficulty breathing. Which supplemental oxygen is correct for this client?

2 L/min

The nurse is documenting information collected about a patient's pulses. How should the nurse document that a peripheral pulse was normal?

2+

A client is prescribed a heating pad to be placed on the lower back. When should the nurse teach the client to remove the heating pad to prevent rebound phenomenon?

25 to 30 minutes

The nurse is reinforcing teaching for a patient who is on four injections of regular insulin daily. About how many hours after each injection of insulin does the nurse teach the patient to be alert for symptoms of hypoglycemia?

3 hours

The nurse is preparing to provide an intramuscular injection to a newborn client. Which size needle is appropriate for this client?

3/8-inch

A client has an order for miconazole nitrate (Monistat) vaginal cream to treat a yeast infection. Place the following actions in the order in which the nurse would perform them to correctly administer the vaginal cream (1-5). (Enter the number of each step in the proper sequence without spaces; do not use commas). 1. Squeeze the tube to fill the applicator. 2. Depress the plunger until all of the cream is inserted. 3. Attach the applicator to the end of the tube containing the cream. 4. Detach the applicator from the tube of medication. 5. Wearing gloves, insert the applicator into the client's vagina along the posterior wall for approximately 3 inches.

31452

A client reports waking up frequently during the night and not getting restful sleep. Which response should the nurse make?

Drinking alcohol can cause you to wake up during the night

The nurse is assessing the heart rate for a person who plays basketball and runs track. Which heart rate can the nurse expect to document?

50 beats/min

The nurse is collecting data for a patient with osteoporosis. Which serum calcium result indicates the typical changes that occur in serum calcium levels with osteoporosis?

6.5 mg/dL

The nurse is planning to auscultate a patient's apical pulse. How long should the nurse listen to the patient's heart?

60 seconds

Match the following

7 vertebrae- cervical 12 vertebrae- thoracic 5 vertebrae- lumbar 5 fused vertebrae- sacrum 4 fused vertebrae- coccyx

Which of the following pH values indicates the presence of alkalosis?

7.47

The nurse is caring for multiple clients. The nurse recognizes which clients as being at greatest risk for development of pressure injuries? Select all that apply.

A 32-year-old client who is quadriplegic A 66-year-old with diabetes mellitus A 40-year-old with bilateral leg casts An 80-year-old with thin and inelastic skin

Which of the following clients would likely receive preoperative anticholinergics? Select all that apply.

A 4-year-old client having tubes placed in his or her ears A 60-year-old client with Parkinson's disease A 70-year-old client who previously had a stroke A 6-year-old client having his or her tonsils removed

The nurse is contributing to a teaching session about hypertension. Which patient should the nurse identify as having the greatest risk for hypertension?

A 40-year-old man whose brother has hypertension

A nurse would most appropriately administer medication via the rectal route to which of the following clients? Select all that apply.

A 40-year-old with severe nausea. A 30-year-old with severe vomiting who is unable to keep anything down.

A nurse recognizes that which of the following clients may receive spinal anesthesia?

A 48-year-old scheduled for a hemorrhoidectomy

While providing care and medications to a number of clients during the shift, the nurse correctly recognizes that which of the following clients has the greatest risk for an adverse drug reaction?

A 55-year-old man with a liver infection

The nurse is planning care for a group of patients. Which individual should the nurse identify as being at the highest risk for developing hypertension?

A 56-year-old African American woman

The nurse is caring for a group of clients. For which client should the nurse monitor more closely when using hot or cold therapy? Select all that apply.

A 58-year-old with appendicitis A 79-year-old with prostate cancer A 1-year-old with an ear infection A 62-year-old with heart disease

The nurse works in an extend care facility and recognizes that some residents are likely experiencing frequent loss of friends, family members, and physical capabilities. Which client does the nurse identify as likely to fall within this category?

A 77-year-old woman who lives alone in her own home

The nurse is reviewing clients scheduled for a whirlpool bath. For which clients should the nurse take special precautions? Select all that apply.

A client who has been sedated to undergo a procedure A 70 year old client An 8 year old client

The nurse is caring for multiple adult clients in an acute care setting. The nurse should consider which client to be the most unlikely for an electrolyte imbalance?

A client with an estimated blood loss of 500 mL due to a traumatic injury

The nurse is caring for clients on an orthopedic unit. Which client will be the nurse's immediate concern after receiving report?

A client with redness and purulent drainage at an external pin site

A nurse correctly recognizes that administration of medication via the rectal route is appropriate for which client?

A client with severe hemorrhoids

When conducting an admission assessment, the nurse correctly recognizes which information as objective data?

A client's fruity-smelling breath

When performing a client assessment, the nurse will correctly recognize which assessment finding as subjective data?

A client's statement of discomfort

The nurse is caring for a client with diabetes mellitus who has a non-healing wound on the bottom of the foot. Which assessment finding causes the nurse to conclude that the wound is likely infected with Clostridia?

A crackling sensation under the skin can be felt when palpating around the wound.

An older adult client is admitted to the hospital for a bowel obstruction, and part of the client's duodenum was surgically removed. Which condition does the nurse recognize as a potential problem for the client?

A decreased ability to absorb nutrients

A client arrives at a clinic with a wound received by an ax two days ago while cutting firewood. The client states that initial wound care was performed at home. The nurse assesses a deep open wound on the lower leg, which will need surgical closure. Which complication does the nurse recognize is a probability for this client?

A high risk for infection from Staphylococcus aureus contamination

The nurse is preparing for the discharge of a client from the hospital to an extended care facility. Which information is most important for the nurse to include for the new facility? Select all that apply.

A list of the medications ordered for the client at the time of transfer A description of the client's condition and vital signs at the time of discharge Instructions regarding the client's diet, activity, and follow up appointments

Which client does the nurse expect to need teaching about the American Heart Association recommendation to limit salt intake to 1,500 mg/d?

A middle-age client with hypertension

The nurse assesses a client 24 hours after abdominal surgery. The client is experiencing nausea, anorexia, and is vomiting foul-smelling emesis. Physical assessment reveals an extended abdomen and hypoactive bowel sounds. Which order does the nurse expect from the client's physician?

A nasogastric tube inserted for gastric decompression

The nurse is collecting data on a patient who is experiencing hip pain. Which data does the nurse consider to be subjective?

A pain level of 7 on a 0-to-10 scale

A patient is scheduled for arthroscopic surgery on a knee. The patient is to receive light general anesthesia and will be discharged home. Which action will cause the nurse to contact the HCP or registered nurse (RN)?

A pain level of 8 on a 0-to-10 scale after mild analgesia

The nurse prepares to perform a sterile dressing change. Which finding will cause the most concern for the nurse when gathering supplies?

A partial bottle of sterile saline is open in the client's room

The nurse is caring for a group of patients. Which patient should the nurse see first?

A patient with a blood pressure of 180/120 mm Hg reporting a nosebleed

The nurse is caring for a client in the hospital. On assessment, the nurse discovers the client's hands and feet are swollen. A review of the client's past medical history reveals a history of cardiac problems. Which diet does the nurse expect the physician to order for this client?

A sodium-restricted diet

The nurse is caring for a client with incontinence who has an order for a catheterized urine specimen to evaluate the presence of a urinary tract infection. Which catheter will the nurse select to obtain the specimen?

A straight catheter

A piece of indicator tape has been applied to the outer wrapper of a set of surgical instruments. Which finding causes the nurse to reject the instruments?

A strike-through line is present on the tape.

The nurse puts on a pair of sterile gloves. Which situation would require the nurse to obtain a different set of sterile gloves? Select all that apply.

A tear is noted on the left ring finger. The gloves are wrinkled in the palm. The package is wet from water on the bedside table.

Which of the following would be classified as elective surgeries? Select all that apply.

A tonsillectomy for a 10-year-old with a history of frequent pharyngitis A colectomy with colostomy for an 18-year-old with Crohn disease A mastectomy for a 56-year-old with recently diagnosed breast cancer

The LPN/LVN is assigned to care for a client who is in skin traction. Which condition does the LPN/LVN expect to observe? Select all that apply.

A trapeze in place over the bed A rope attached to a frame on the limb An elastic bandage wrap on the limb A suspended weight at the foot of the bed

While bathing a client, the nurse finds that the client's previous IV site is tender, and the vein feels hard upon palpation, indicating inflammation. Which should the nurse apply to the site?

A warm compress using a washcloth dipped in hot water

A nurse is caring for a number of clients on a medical unit. Which client will the nurse identify as the highest priority?

A young-adult client with pneumonia who is restless and confused

The nurse is performing an assessment of the client's eyes, and tells the client, "Focus on my pencil and follow it as I move it away from you and then back toward you." Which specific function is the nurse assessing?

Accommodation response

The nurse provides care to a patient who is actively dying. When planning care for this patient and the family, the nurse prioritizes interventions to address which physical change associated with the dying process to ease the family's anxiety?

Accumulation of secretions in the trachea

The nurse is preparing to instruct a client on how to change an ostomy appliance. What should be addressed prior to beginning this teaching session to ensure optimal learning occurs?

Address lower level needs

A nurse is admitting a client to a hospital unit. Which does the LPN/LVN recognize that the nurse should do to demonstrate respect for the client?

Address the client by the correct title and last name.

The nurse is providing meperidine (Demerol) to a client who reports postsurgical pain 8 of 10. The order is for 50 mg to be orally administered to the client in tablet form every 4 hours, but each tablet contains 100 mg. Which is the best action for the nurse to take?

Administer half the tablet to the client and dispose of the other half in a chemical waste container with another licensed nurse as a witness, recording the narcotic drug wastage on the narcotic record and having the witness cosign.

The nurse recognizes that a client develops an impression of the nurse during which process?

Admission

The nurse recognizes that a 22 g × 1.5-inch needle would be most appropriate for a(n):

Adult intramuscular (IM) injection.

The nurse is caring for a client who is postoperative for abdominal surgery. On assessment, the nurse notes the presence of hypoactive bowel sounds. Which nursing intervention does the nurse need to include on the client's plan of care? Select all that apply.

Ambulation four times a day in the hall Movement to a chair for meals Encouragement to pass flatus

Which client is the nurse most likely to screen for a mineral deficiency?

An adult client who is a strict, life-long vegetarian

The nurse works in an orthopedic unit in the hospital and is providing care for four clients. Which client does the nurse identify as having a potential need for amputation?

An adult client with gangrene of the left foot due to decreased circulation

The nurse is providing care for multiple clients in an extended care facility. Which client does the nurse identify for being at the most risk for the development of pressure injuries?

An elderly client with diabetes mellitus who is immobile

The nurse is assigned to provide client care to multiple clients. Which client does the nurse recognize as being at greatest risk for a fecal impaction?

An older adult client with poor fluid intake and a history of laxative abuse.

The nurse is aware that good nutrition is essential for __________________, the process when the body uses components to build or reconstruct new components or tissue.

Anabolism

The nurse provides care to a terminal patient who states, "I don't need anything from you. Leave me alone!" Based on this information, the nurse documents that the patient is likely experiencing which stage of grief?

Anger

A nurse is providing preoperative care to a client with a history of congenital heart disease. Which preoperative medication does the nurse expect will be administered prophylactically?

Antibiotics

Which reaction by the hospitalized client should the nurse consider to be most realistic?

Anxiety related to the cost and ability to pay for care

The nurse is providing care for a female client who was admitted due to a stroke. The client becomes frustrated because of an inability to respond verbally to the nurse's questions. Which terminology should the nurse use to document this complication?

Aphasic

The nurse works in a long-term care facility. The nurse notices that many clients with bowel and bladder incontinence have developed skin breakdown. Which actions will the nurse initiate to minimize skin breakdown? Select all that apply.

Apply a barrier ointment to the perineal area as needed. Change soiled incontinence pads as quickly as possible. Assess each client for incontinence every 1 to 2 hours. Turn and reposition clients in beds or chairs every 1 to 2 hours.

A client is prescribed a heat pack to be applied to an area of inflammation on the lower leg. What should the nurse do before placing the pack on the client's skin?

Apply a cloth barrier

Which are the nurse's immediate priorities when a client enters the postanesthesia care unit (PACU)? Select all that apply.

Apply a pulse oximeter. Apply an electrocardiogram (EKG) monitor. Apply a blood pressure monitor. Observe client respiration rate.

An older client with hip pain reports that continuous heat has been the most effective means of relieving pain. After confirming that the client has an order for heat therapy, which method should the nurse select?

Aquathermia K-pad

During the admission procedure, the nurse learns that a new client is from a culture that requires men to keep their head covered at all times by wearing a turban. The client's roommate in the double room is recovering from detoxification and has episodes of using racial slurs. Which action by the nurse is best?

Arrange to have the client assigned to a different room, without the probability of a verbally offensive roommate.

A female client has been admitted with ulcerative colitis. Which appearance of the client's stools will the nurse expect with the exacerbation of this condition?

Contain pus, mucus, and blood

The nurse is providing care for an individual admitted with an acute asthma attack. Arterial blood gas (ABG) results indicate pH = 7.33; CO2= 49; HCO3 = 26; and oxygen saturation is 87%. After initiating treatment with IV fluids, bronchodilators, and oxygen therapy at 4 L via nasal cannula (NC), the client's repeat ABG results are pH = 7.35; CO2 = 47; HCO3 = 26; and oxygen saturation is 89%. Which action should the nurse take next?

Assess the function of the client's oxygen delivery system.

A client has been using a TENS unit for one hour to help relieve back pain. Which action should the nurse take after removing the unit from the client?

Assess the pain level

While caring for a newly admitted client, the registered nurse (RN) gathers information by interviewing the client to obtain a health history and reviewing the results of laboratory and diagnostic tests. Which step in the nursing process did this nurse complete?

Assessment

Match the following Assessment Diagnosis Planning Expected outcomes Evaluation

Assessment- Gathering of information through signs and symptoms patient history and objective findings Diagnosis- using the assessment information and statements describing problems that patient is experiencing Planning- step of the nursing process involves several areas setting long and short term goals planning outcomes Expected outcomes- specific measurable actions by the patient within an explicit time frame Evaluation- when the nurse reflects on the interventions he or she has performed and decides if the patient is closer to achieving the set goals

The nurse is caring for a male client with a recent total hip replacement who cannot ambulate to the bathroom without difficulty. The client has a urinal but reports a continued inability to void. Which intervention by the nurse will assist the client with toileting?

Assist the client to stand at the bedside and void into the urinal.

Which type of care does the nurse include in the plan of care for a patient who requires assistance bathing the lower extremities?

Assisted care

The nurse is collecting data on a patient with manifestations of osteoarthritis. Which method of physical examination is unnecessary?

Auscultating for joint deformity

The nurse is preparing to administer insulin that was drawn up in the medication room. The nurse uses a one-handed scoop method to:

Avoid a needle stick.

The nurse is caring for a patient recovering from a cardiac catheterization with a right femoral artery entry site. Which action should the nurse take?

Avoid movement of right leg as ordered.

The nurse is preparing to document care provided in the client's electronic medical record. Which should the nurse keep in mind when entering the data?

Avoid using abbreviations within the note.

Match the following

Axial- flat or irregular bones and contain hematopoietic tissue Appendicular- consist of long bones Skull- eight cranial bones and 14 facial bones Vertebral column- made of 33 individual bones thoracic Cage- consists of 12 pairs of rib and the sternum

The nurse is admitting a client for a diagnosis unrelated to nutrition; however, the client states, "I don't eat gluten, but I don't have celiac disease." Which meal will the nurse expect the client to order?

Baked chicken breast, mashed potatoes with butter, and ice cream

The nurse provides care to a patient who is dying of colon cancer who states, "I know I can beat this cancer if I just change the things that I eat." Based on Kübler-Ross' stages of grief, which stage does the nurse document in the medical record that the patient is experiencing?

Bargaining

The nurse provides care to a patient who has died. Which action does the nurse implement when preforming postmortem care?

Bathe the patient's body and remove all tubes, unless an autopsy is prescribed.

The charge nurse notes a client's blood pressure at 8:00 a.m. was 124/80 mm Hg. It is now 12:00 p.m., and the client's blood pressure is 152/94 mm Hg. Which suggestion about the plan of care will the charge nurse make to the newly hired nurse?

Because the blood pressure has become elevated, it should be rechecked in 1 to 2 hours.

The nurse thoughtfully plans care for an assigned client. What should the nurse do to provide culturally competent care?

Become familiar with any facet of the client's culture that may have an impact on the care.

If a nurse commits a medication error, which actions should be taken? Select all that apply.

Check for adverse reactions to the erroneous medication. Report the error to the prescriber. Fill out an incident report per facility procedures. Document the medication error in the medication administration record.

The nurse is caring for clients on a busy cardiac unit. Following morning assessment, the nurse would notify the physician with which of the following symptoms?

Chest pain at rest

The nurse is caring for a client who crushes medications and administers them via a gastrostomy tube. Which medication could safely be included in the client's plan of care?

Chewable antacids

The nurse is obtaining a health history from an individual at a blood pressure screening clinic. Which information in the patient's history should the nurse identify as a modifiable risk factor for hypertension?

Cigarette smoking

The nurse is planning to review information with a patient diagnosed with diabetes. Which information does the nurse include regarding an increased risk for and treatment of infection?

Circulation may not be adequate to heal a wound or fight infection.

Match the Contamination of Wound Categories

Clean- Not infected Clean-Contaminated- Surgically made, not infected Contaminated- Surgical wound or trauma wound Infected- High numbers of microorganisms Colonized- High numbers of microorganisms, without sign of infection

A health-care organization is preparing for a site visit from The Joint Commission. What should the organization ensure about addressing client's culture?

Clients have the right to receive care that is considerate of culture, religion, and spiritual being.

Which medication will require that the nurse open two separate layers of locks?

Codeine

The nurse meets with the physical and occupational therapist to plan care for a client with nerve damage caused by a back injury. Which type of intervention will be listed on the plan of care?

Collaborative

A client who is 3 days postoperative states a slight increase in pain level from the day before. Which additional assessment will the nurse make to determine the condition of the client's wound? Select all that apply.

Color of drainage Type of closure Odor of drainage Closed or open

The nursing instructor is reviewing documentation with a group of students. Which should the instructor include as the purpose of written documentation? Select all that apply.

Communicate pertinent data to the health-care team Serve as a record of accountability for accreditation Serve as a record of accountability for quality assurance and reimbursement purposes Provide a permanent record of medical and nursing diagnoses

The nurse brings a dinner tray to a client on a regular diet. The nurse notes that the client has been blind since birth. Which intervention by the nurse is most helpful in assisting this client to eat?

Compare the location of the food on a plate with the face of a clock.

The nurse at a long-term care facility takes care of multiple residents. Which action by the nurse is aimed at helping the resident feel comfortable in the environment?

Consider the residents' right to privacy and always knock on the door.

Which fact should the nurse teach a client about the American Heart Association (AHA) recommendation regarding dietary fat?

Consume 25% to 35% of total daily calories from fat.

Match the following Wounds.

Contusion- bruise Abrasion- Superficial open wound Puncture- Open wound from sharp object Penetrating- Object remains embedded in tissue Lacerations- Made by accidental cutting/tearing of tissue Pressure Injuries- Wound resulting from pressure or fiction

While assessing a client's apical heart rate, the nurse detects a different radial pulse rate. Which should the nurse do?

Count the apical rate for a full minute and ask another nurse to count the radial pulse at the same time.

The nurse is providing postoperative care to a client with a large wound. The nurse removes the dressing and notes that the wound has dehisced. Which actions should the nurse take? Select all that apply.

Cover the wound with a large sterile dressing. Notify the surgeon immediately.

The nurse instructs a patient on beverages to avoid when taking the prescribed medication warfarin (Coumadin). Which beverage should the patient state that indicates teaching has been effective?

Cranberry Juice

The nurse recognizes that teaching has been effective if a client selects which beverage while undergoing treatment for a urinary tract infection (UTI)?

Cranberry juice

A nurse is caring for a client who is newly diagnosed with Graves disease. The nurse selects the nursing diagnosis "Readiness for enhanced knowledge." What should the nurse do next?

Create a written teaching plan.

When preparing a plan of care, the nurse uses skillful reasoning and logical thought to determine the merits of an action. Which action is the nurse performing?

Critical thinking

Match the following

Crutches- used when unable to bear full weight on a lower limb Canes- used when can bear weight on affected leg Walkers- used who can bear full weight on both legs and assist with balance Knee Scooter- used to propel forward who cannot bear weight on foot or ankle Common crutch-walking gaits- two point, three point, four point, swing to or swing through

The nurse provides care to the whole client, incorporating within that care the cultural context of the client's beliefs and values. Which type of care is the nurse providing?

Culturally competent

Before creating a plan of care, the nurse assesses a client's rituals, values, customs, and beliefs. What is the nurse assessing?

Culture

The nurse is preparing to teach a class on nutrition. The focus of the class is on the nutrition food label facts found on all processed food products. Which information will the nurse identify that each food label must include? Select all that apply.

Daily Reference Value Vitamin and mineral content Health claims Macronutrient content

The nurse is collecting data on a new patient in a HCP's office. Data includes the following: 65-year-old male, abdominal obesity with waist circumference of 42 inches, blood pressure 140/88 mm Hg, and fasting glucose of 120 mg/dL. Which health concerns by the HCP is least expected?

Damage to weight bearing joints

A health-care organization is considering focus charting. Which categories are commonly documented using this approach?

Data, action, response

The home-care nurse is visiting a client diagnosed with chronic obstructive pulmonary disease (COPD). The client is routinely cared for by the client's spouse, who states, "It takes forever to do all the morning care." Which suggestion will the nurse make to the spouse?

Decide if some care activities can be done later in the day.

The nurse prepares a handout about the nursing process for an orientation class of new colleagues. Which should the nurse use to explain this process?

Decision-making framework used by nurses to determine the needs of clients

A client reports feeling pain "only when I move." Which type of pain is this client experiencing?

Deep somatic

A nurse is caring for a client who is newly diagnosed with type 2 diabetes mellitus. The client requires teaching about antidiabetic medications, including when to take them, what effects are expected, and negative side effects to report if they occur. Which nursing diagnosis does the LPN/LVN expect to be used for this client?

Deficient knowledge.

During standard preoperative testing, a nurse notices that a client's urine has an elevated specific gravity. This finding is an indication that this client is at risk for which of the following?

Dehydration

A patient is diagnosed with diabetic ketoacidosis. Which manifestations should the nurse expect to observe in this patient? (Select all that apply.)

Dehydration Flu like symptoms Kussmaul's respirations

When asked by family members of a terminally ill patient what benefit their loved one would experience as a result of dehydration, a nurse explains that which of the following is true? Select all that apply.

Dehydration will contribute to less edema and discomfort from ascites. Urinary output decreases, which results in less discomfort from toileting. Dehydration increases endorphin production and decreases perception of pain.

An older adult client is going through drug and alcohol withdrawal and experiencing hallucinations followed by loud emotional outbursts. Which condition does the nurse recognize?

Delirium

A client with diabetes is being treated for an infected foot wound. Which would be an appropriate short-term goal for this client?

Demonstrates correct technique for self-injection of insulin

When providing care to a patient diagnosed with a terminal illness, which traditional first stage of grief does the nurse not anticipate the patient will exhibit?

Denial

A client expresses understanding about the role dietary fiber has in the prevention of constipation. Which other reasons should the nurse present about the importance of fiber in the diet? Select all that apply.

Dietary fiber will decrease the LDL cholesterol level. Adequate intake of dietary fiber will contribute to weight loss. Fiber supports normal flora in the GI tract by providing a food source. Adequate dietary fiber increases the absorption of minerals.

Which term should the nurse recognize for the process in which food is broken down in the gastrointestinal (GI) tract, releasing nutrients for the body to use?

Digestion

The nurse is performing a physical assessment on a client and notes that the client has a large number of dental caries and is missing numerous teeth. The nurse voices concern about the client's nutritional status. Which is the most likely concern?

Digestion begins in the mouth with the process of chewing.

The nurse has determined that a client's pain is acute and plans to administer pain medication. Which signs and symptoms of acute pain did the nurse use to make this clinical determination? Select all that apply.

Dilated pupils Syncope Increased heart rate Reduced attention span

A critically ill client may have difficulty in getting the restorative sleep necessary for healing. Which action should the nurse take to help this client?

Dim the lights and close the door

When preparing to administer medication through a feeding route, the nurse takes which appropriate action?

Dissolves and administers each medication separately

The nurse is discussing ways to help prevent constipation. Which information is most important for the nurse to share?

Do not ignore the defecation reflex.

The nurse takes the BP of a patient with a result of 120/80 mm Hg. Which action should the nurse take?

Document the finding as normal.

A nurse is providing care to a 32-year-old who returned from a thyroidectomy 6 hours ago. The nurse notes that the client's temperature is 99.5°F and that the client has been taking sips of clear liquids. The client reports mild nausea and is using client-controlled anesthesia to manage pain, which the client rates as a 3 out of 10. Which action should the nurse take?

Document the findings.

A nurse is caring for a client with a kidney infection. Output is tallied at the end of the shift, and the nurse notes that the client has voided 240 mL in the past 8 hours. Which action should the nurse take next?

Document the output amount.

The nurse prepares to perform postmortem care on a patient who passed away. Which step does the nurse implement for safety during this procedure?

Donning gloves

The nurse notices that there is no room at the end of a written note to sign the note. What should the nurse do?

Draw a line through the space on the next line and sign at the end.

A patient with orthostatic hypotension asks why the health problem is occurring. What should the nurse include when explaining the causes of orthostatic hypotension to the patient? (Select all that apply.)

Experiencing pain Insufficient fluid volume in the body Use of narcotic pain medication Use of medication that takes fluid out of the body

A client refuses to take a medication for depression. Which action should the nurse take next?

Explain the desired effect of the medication.

A patient is prepared for a nuclear medicine scan of the skeleton, using gallium and thallium as the radioisotopes. Which nursing care will the nurse provide if the scan reveals high thallium concentrations?

Extend a willingness to sit and talk with the patient.

The nurse is providing care for a client diagnosed with chronic obstructive pulmonary disease (COPD). The nurse applies knowledge of anatomy and physiology to understand the client's condition. Which physiological function does the nurse recognize as being defective in a client with COPD?

External respiration

The nurse is reinforcing teaching provided to a patient about the complications of hypertension. Which organ should the patient state is at risk of damage from hypertension?

Eyes

The nurse is approached by a resident in a long-term care facility. The client is considered to be middle-old, walks with a cane, has notable facial droop, and takes a long time to formulate verbal expression. Which is the best response by the nurse?

Face the individual and directly ask, "What can I do for you?"

Severe electrolyte imbalances like slightly deficient potassium or slightly excess sodium can be corrected through diet.

False

After completing a family history, the nurse is concerned that a patient is at risk for developing high blood pressure. What information did the nurse obtain to come to this conclusion? (Select all that apply.)

Father died with morbid obesity at age 55. Mother had type 2 diabetes mellitus.

The nurse is concerned that a client is experiencing chronic pain. Which psychological symptoms did the nurse assess to make this clinical determination? Select all that apply.

Fatigue Depression Low self esteem

The nurse is counseling a client about weight loss. The client states, "I am just going to eliminate all fats from my diet." Which information provided by the nurse is correct?

Fats from animal sources form all the cell membranes in the body.

The nurse is teaching a class about nutrition to parents of toddlers and preschool-age children. Which information is appropriate for the nurse to include in this class? Select all that apply.

Fats should account for 30% to 35% of the daily caloric intake. Peanut butter on whole grain bread supplies both protein and iron. Provide one serving of milk or other dairy product with each meal.

The nurse is aware that admission to the hospital setting can be stressful for clients. Which conditions does the nurse recognize as causes of stress? Select all that apply.

Fear related to unknown diagnostic or treatment procedures Anxiety about interruption of daily routines and responsibilities Loss of control of activities and schedules in the hospital setting

A nurse is providing care for an elderly client who has not had a bowel movement in 3 days. Which factor related to aging is contributing to the client's problem? Select all that apply.

Feces may remain in the large intestines for a longer period. The individual takes multiple medications. Decreased activity is common in the elderly.

While caring for a client who recently took a new anticonvulsant medication, the nurse correctly contacts the physician immediately if the client reports which of the following?

Feeling short of breath

The nurse notices that a client experiences dizziness, blurred vision, weakness, numbness in the left arm, and difficulty swallowing that lasts for about 10 minutes. The nurse suspects an interruption of oxygen supply to the client's brain. Which conclusion will the nurse draw regarding the client's experience?

Fits the symptoms of a transient ischemic attack

A nurse explains to a client that it is wise to avoid taking a laxative every day because of the problems it can cause. The client demonstrates understanding by saying laxative abuse can result in which condition? Select all that apply.

Fluid and electrolyte imbalances The need for increasing dosages of laxative Loss of natural contractility in the bowel Increased risk for an impaction

While reviewing laboratory results, the nurse notes that one of the clients has a low blood urea nitrogen (BUN) level. Which cause is the most likely related to the result?

Fluid volume excess

The student is preparing a concept map prior to caring for a client during the next clinical day. Which should the student do when creating this map?

Follow the nursing process

A client tells the nurse of experiencing minor gastrointestinal pain, flatulence, and diarrhea several times after meals. Which possible cause should the nurse identify?

Food intolerance

The nurse is providing care for a client admitted to the hospital due to a renal stone. The physician orders that all urine be strained. Which reason does the nurse recognize as the primary purpose of straining the client's urine?

For analysis to help identify cause and treatment

A client accidentally receives an entire liter of intravenous fluid over 3 hours. Which should the nurse expect when assessing this client's pulse?

Full and bounding

The nurse assists a client to the bathroom, and notices that the client's stool is clay colored. The client tells the nurse that this has occurred off and on for the last month or two. Which condition does the nurse suspect?

Gallstones or liver problems

A client's stomach contents will be removed by inserting a double-lumen nasogastric (NG) tube through the nose into the stomach and then connecting the tube to a suction. The nurse identifies this procedure as ____________________.

Gastric Decompression

The nurse is caring for an older adult client who expresses displeasure by "the inability to do what I used to." The nurse understands that the changes are related to the client's neurological functioning. Which change is expected to accompany aging?

Gradual inability to process information from the neurologic and sensory systems

A client with chronic pain reports that pretending to be lying on a beach with the sun warming the legs helps relieve the chronic hip and leg pain caused by arthritis. Which nonpharmacological method is this client using to control pain?

Guided imagery

Information about the Health Insurance Portability and Accountability Act (HIPAA) is being prepared for a group of new nurses to review during orientation. Which should be emphasized about this act? Select all that apply.

HIPAA guarantees a client the right to view and obtain a copy of his or her medical record HIPAA asks a client to specify who can obtain personal health data. HIPAA ensures the right of a client to amend personal health information HIPAA requires hospitals to disclose the way in which a client's health data will be used.

The nurse reviews problems identified for a client. Which problem should the nurse list as a priority?

Has irregular heart rhythm

The LPN/LVN needs to reinforce teaching for a client who speaks a limited amount of English. Which action will the RN suggest to the LPN/LVN to best assure that the client understands the information presented?

Have an interpreter translate for the client and nurse.

Before placing antiembolism stockings on a client for the first time, a nurse should do which of the following?

Have the client lie supine for 15 minutes.

Which safety steps should the nurse take prior to administering a heparin injection? Select all that apply.

Have two other nurses verify the strength and dosage. Assess PT, INR, and APTT results. Check the heparin label against the medication administration record at least 4 times

A nurse is caring for a 30-year-old man who returned from the repair of a broken jaw 3 hours earlier. The client reports an urge to urinate and tried to use the urinal in the bed without success. The nurse assesses the client and notes the bladder is distended. Which actions should nurse to take? Select all that apply.

Help the client stand to urinate. Run water to encourage voiding. Help the client to the bathroom.

A patient is recovering from a biopsy of the right femur and was given pain medication 1 hour ago. Which symptom does the nurse report and closely monitor in this patient? (Select all that apply.)

Hematoma formation Pain reported as 7 on a 0-to-10 scale

The nurse who is performing a physical assessment is preparing to auscultate breath sounds. Which position is most favorable position for performing the assessment of breath sounds?

High Fowler position

The spouse of a dying patient states to the nurse, "I believe remorse for the dead leads to more suffering of the soul and will increase the soul's difficulty in leaving the earthly plane. I prefer to think only happy thoughts to facilitate the journey." Which culture does the nurse identify for the couple based on the spouse's statement?

Hindu

Match the following

Hip Arthroplasty- head and neck of femur are replaced with a titanium implant Abductor pillow- wedge-shape, used to prevent leg going beyond midline Knee-Arthroplasty- top of tibia and lower end of femur replaced with titanium or other metal implants Partial Kee Replacement- unicompartmental knee replacement Continuous passive motion machine- gently flex knee according to degree of flexion

The circulating nurse is assisting in the operating room and is asked to open a sterile pack and give the contents to the surgeon. Which action should the nurse perform?

Hold the contents by the opened outer wrapper for the surgeon to grasp.

During an assessment, a client reports performing self-care techniques to balance the hot disease state of diabetes. Which health belief should the nurse realize that this client practices?

Holistic

A nurse is providing preoperative teaching to the client. During this teaching the nurse notes that the client should be sure to cough, breathe deeply, and turn from side to side every few hours. The nurse provides this teaching to help prevent which of the following? Select all that apply.

Hypoventilation Atelectasis Pneumonia

The nurse is admitting a bed-ridden older adult client to an extended care facility. During the initial assessment, the nurse notices the client's bone to be visible in a sacral pressure injury. Which staging will the nurse document in the client's record?

IV

The nurse is providing preoperative teaching to a client and the client's family. Which statements made by the nurse are accurate regarding preoperative teaching? Select all that apply.

If you all know what to expect, you'll all be able to support optimal healing. Having a thorough understanding of the procedure is conducive to the shortest recovery period. My goal is to help you feel more comfortable and calm any anxiety you might have.

The nurse teaches a client about the availability of systems that can activate flashing lights for smoke detectors, ringing telephones, and doorbells. The nurse is addressing which functioning deficit?

Impaired hearing

The nurse is caring for a client who had a motor vehicle accident resulting in a comminuted fracture of the right fibula. After healing, the client's right leg is shorter than the left. Treatment to correct the defect involves the placement of an Ilizarov frame. Which process does the nurse expect with the treatment?

In small increments, the right leg will become longer.

The nurse assesses a client's wound. Which documentation will the nurse make to indicate a possible infection?

Incision intact, moderate amount of purulent drainage, foul odor

The nurse working on a surgical unit is aware that surgical clients need an increased amount of dietary protein. Which is the correct reason for the increase in protein?

Increased dietary protein intake is essential for new cells and wound healing.

An older-adult client expresses concern to a home health-care nurse about the ability to afford groceries along with all of the new medications prescribed after discharge from the hospital. Which action will the nurse add to the client's plan of care?

Initiating a referral with a social worker

The nurse is preparing discharge teaching for a client who is going home after a total knee replacement. Which home safety assessment should the nurse make?

Inquire whether the client needs to go up steps for sleeping and the bathroom.

The nurse is preparing to administer an ordered enema to a client. Which intervention by the nurse is correct for this procedure?

Insert the tip of the enema tube approximately 3 to 4 inches into the rectum.

The nurse is providing care for a client with a stage III pressure injury on the right trochanter area. The physician has ordered the use of hydrocolloid dressings. Which action will the nurse perform in the maintenance of the prescribed dressing?

Inspect the dressing for escaping drainage, wrinkling, and excessive exudate.

The nurse is performing an initial physical assessment on a client. Which sequence does the nurse apply to correctly assess a client's abdomen?

Inspection, auscultation, and palpation

During the admission process, which actions will the nurse take to make the client feel comfortable and welcome? Select all that apply.

Introduce self and shake the client's hand. Make eye contact and speak directly to the client. Share the nurse's credentials with the client.

The nurse becomes concerned that a male patient's blood pressure is 168/98 mm Hg after 6 months on antihypertensive medication. What question should the nurse ask after measuring this blood pressure?

Is the patient taking the medication?

The nurse prepares a presentation for parents of adolescents with eating disorders. The parents have expressed an interest in understanding the causes and effects of the disorders. Which information will the nurse include? Select all that apply.

It can cause a client's health to be severely affected. It generally occurs during adolescence or early adulthood. It is evidenced by extreme disturbances in eating habits. It may result from either physical or psychological causes

The nurse is helping a patient understand all of the functions of the skeleton. Which function is incorrect?

It is the main system responsible for body movement.

The nurse provides care to a patient who is prescribed palliative care. The patient asks, "What is the difference between hospice care and palliative care?" Which does the nurse include in the response to the patient regarding palliative care?

It may be aggressive and is directed at eliminating discomfort.

Which of the following statements is made by the nurse in preoperative teaching to help prevent postsurgical blood clot formation?

It's important to move your ankles in circles with toes extended. You will wear postsurgical compression stockings. You should alternate ankle flexion and extension for a total of 10 times each.

The nurse is preparing material for a presentation about the musculoskeletal system. Which information is inaccurate in regard to the functioning of this system?

Joint articulations are maintained by moisture from the lymph system.

Match the following

Joint- articular Cushions joints and reduces friction- cartilage Connect bone to bone- ligaments Connect muscle to bone- tendon Strong membranes enclosing individual muscles- fasciae

The nurse provides care for a client who is emaciated and exhibits a severely enlarged abdomen and liver. The health-care provider also diagnoses the client with skin infections, small for age stature, and notably delayed mental development. Which condition does the nurse expect the health-care provider to diagnose?

Kwashiorkor disease

The nurse is caring for a patient who had a cardiac catheterization using the left femoral site for entry. Which data is most important for the nurse to monitor?

Left pedal pulse

The nurse is administering an intradermal injection for tuberculin testing. Unless contraindicated, the nurse will use the client's:

Left ventral forearm.

After an initial assessment, a nurse documents that a client, admitted for abdominal pain, has hyperactive bowel sounds. Which type of bowel movement will the nurse expect this client to have?

Liquid or semi-liquid

A client who underwent a carotid endarterectomy asks a nurse about care for his neck incision. The client informs the nurse that he is an auditory learner. The nurse determines that the client will learn best by:

Listening to the nurse's verbal instructions about care of the incision.

A patient being treated with rosiglitazone for type 2 DM is receiving a routine follow-up assessment. In addition to HbA1c and a fasting plasma glucose test, which other laboratory test should the nurse expect to be monitored in this patient?

Liver function tests

The nurse provides care to a patient who has a written document containing medical decisions should the patient be unable to make them as the illness progresses. Which end-of-life documentation does the patient have based on the current information?

Living will

The nurse completes documentation on an electronic medical record. What should the nurse do next?

Log out of the system.

The nurse is preparing to administer medication to treat a client's irregular heartbeat. Which of the following would require that the nurse withhold the medication?

Low pulse

A client is prescribed the medication lithium as a mood-stabilizing agent. Which laboratory report indicates the client may be retaining higher than prescribed levels of lithium?

Low sodium levels

Match the following

MRI- view soft tissue condition External fixators- wires, pins, tongs, and rods fixed in the bone of the limb illizarov frame- composed of metal rings, helps stabilize small bone pieces Casts- made of plaster, fiberglass or polymers Spica- often used to correct hip dysplasia in young children

When providing a bed bath, the nurse monitors the patient's skin. The nurse observes an area of skin on the buttocks that is softened from continuous exposure to urine. Which term does the nurse use when documenting this finding?

Maceration

During an admission physical assessment, a nurse questions a client about bowel elimination habits. Which client care goal is the nurse attempting to identify?

Maintain the client's normal elimination habit.

The nurse provides care to an obese client who is at risk for pressure injuries. The client's plan of care places the client on pressure injury prevention. Which actions should the nurse be implementing? Select all that apply.

Maintaining a bed with clean, dry linens that are free of wrinkles Encouraging an adequate fluid intake and a nutritious diet Assessing the client's skin every 2 hours for indications of breakdown

The nurse is caring for a client immediately after surgery. During assessment the nurse notes sanguineous drainage on the client's dressing. Which action by the nurse is most correct?

Mark and initial the edges of the drainage, including the date and time.

During a staff education meeting, the nurse explains that it is important to use four senses (sight, touch, hearing, and smell) to determine whether a client is exhibiting signs of illness or injury. Which description defines the assessment findings from these methods?

Measurable

The LPN/LVN is assigned to feed a client who was admitted with the diagnosis of a cerebral vascular accident (CVA). The client's ability to swallow is intact, but chewing remains difficult. Which type of food will most likely cause the LPN/LVN to consult with the RN?

Mechanical soft

A nurse enters a room to assist a client who has used the bedside commode. The nurse washes the client's hands, puts on clean gloves, assists the client in cleaning the genital area, and then assists the client into bed. The nurse then empties, rinses, and replaces the pan of the bedside commode. The nurse removes the gloves and washes his or her hands. Which is the nurse practicing?

Medical asepsis

While inspecting a client's stool, a nurse notices a small amount of black, tarry blood with a distinctive old-blood odor that appears to have been partially digested. Which term does the nurses use to describe the client's stool?

Melena

The nurse is providing care for a client whose arterial blood gas results are pH = 7.48; CO2 = 44; NaHCO3 = 29. Which conclusion about the client's condition will the nurse draw from the testing results?

Metabolic alkalosis

The nurse needs to be aware of the functions of water in the body. Which presented function is untrue?

Prevents replication and growth of pathogens

The nurse sees that the health-care provider has ordered a subcutaneous heparin injection for a client. Which actions should the nurse take to administer this medication safely?

Monitor the client for blood in the stools Inject into the abdomen Monitor the client for bleeding gums Monitor the client for excessive bruising

The nurse is providing care for a client admitted with fluid volume overload. Which nursing care will the nurse implement for this client? Select all that apply.

Monitor the effects of diuretic therapy. Obtain a daily weight on the same scale. Teach about foods naturally high in sodium. Assess intake and output results for imbalances.

The nurse is caring for a patient who is having an exercise treadmill test. What interventions would be appropriate for the test? (Select all that apply.)

Monitor vital signs throughout the test. Monitor electrocardiogram before, during, and after the test.

The plan of care for a client at risk for cardiac complications during the immediate postoperative period would include which of the following? Select all that apply.

Monitoring the client's heart rate continuously Administering intravenous fluids as ordered Assessing the client's skin color and capillary refill frequently Assessing the client's peripheral pulses bilaterally

The nurse is researching the current information available regarding the long-term complications for patients diagnosed with diabetes. Which finding is accurate?

Most complications involve either the large or tiny vessels of the body.

The nurse is reviewing laboratory values for a patient and notes a potassium level of 6.4 mEq/L. Which clinical manifestation can the nurse expect the patient to report?

Muscle cramps

The nurse is caring for a client taking the diuretic furosemide. The nurse will be most concerned about which assessment finding?

Muscle spasms

A patient's daughter approaches a nurse to explain that upon the death of a male, female nurses should not touch the body. The family also asks that the body remain completely covered with the feet turned toward Mecca. Based on the family's request, the nurse concludes that the family identifies with which faith?

Muslim

The nurse instructs a client to apply heat to an infected hangnail. Which client statement indicates teaching has been effective?

My body's ability to fight off infection will be enhanced by allowing more white blood cells to get to the wound."

The nurse is reviewing complications of hypertension with a patient. Which should the nurse include in the teaching? (Select all that apply.)

Myocardial infarction Kidney Failure Stroke Heart failure

The nurse is performing a physical assessment at the change of shift on an older adult client. Assessment indicates a breathing rate of 20 breaths per minute, breath sounds are clear to auscultation in all five lobes, and the client denies dyspnea. Which finding does the nurse expect with assessment of the client's capillary refill?

Nail beds blanched, capillary refill 3 seconds

While reviewing new orders for client medications, the nurse recognizes that the order is complete if which of the following is included? Select all that apply.

Name of the medication Route of administration Physician signature Client name

The nurse is aware that specific areas of the hospital are considered restricted in order to reduce the introduction of pathogens. Which areas within a hospital are commonly restricted? Select all that apply.

Neonatal unit Intensive care unit Surgical suite

A client recovering from an amputation asks why the foot that was removed is still causing pain. Which type of pain should the nurse explain that the client is experiencing?

Neuropathic

A client reports having difficulty sleeping. What should the nurse teach this client about restorative sleep?

Non-rapid eye movement (NREM) sleep is the most restful cycle.

The nurse provides care to a terminal patient who is approaching end of life. Which information does the nurse reinforce with the family members as indicating death is very near? Select all that apply.

Nonresponsiveness Slow and thready pulse Mottling of feet and legs Edema of lower extremity

The nurse is receiving a client who is being admitted through the emergency department. The client is a roofer who became confused and disoriented while on a roof during the heat of the day. The nurse anticipates that which IV fluid may be included in the treatment plan?

Normal saline (NS)

After any patient teaching remember to (select all that apply)

Notify caregivers of completed patient education. document your instruction and the patient's response.

The nurse is assessing a patient and notices the radial pulse has fewer beats than the apical pulse. Which action should the nurse take?

Notify the health care provider (HCP).

The nurse is preparing to administer atenolol (Tenormin) to a patient with hypertension. The patient's blood pressure is 72/40 mm Hg. Which action should the nurse take?

Notify the healthcare provider

Who is responsible for completing the preoperative checklist? Select all that apply.

Nursing unit nurse Circulating nurse

The nurse shares information with a client about essential nutrients. Which fact is important for the nurse to emphasize?

Nutrients are important, but too much of certain nutrients is problematic

The nurse provides dietary teaching for a client diagnosed with hypomagnesemia. The nurse determines the teaching has been effective if the client discusses including which foods in the daily diet? Select all that apply.

Oatmeal Flax seed Broccoli Bananas

The nurse is providing care for a patient who is diagnosed with rhabdomyolysis from a crushing injury. Laboratory results indicate elevated levels of CK, myoglobin, and serum potassium. Which nursing care is most important for the nurse implement?

Observe the color and amount of urine.

Under the appropriate supervision of the RN, the LPN/LVN is teaching a 40-year-old client how to self-administer insulin. The client also has impaired vision. Which actions are appropriate for this client? Select all that apply.

Obtain small insulin syringes that the client can use to draw up the insulin. Demonstrate how to inject a volume of air into insulin prior to removing insulin. Let the client practice rolling a vial of insulin.

The nurse is preparing to provide a dose of liquid oral antibiotic to a 2-year-old whose mother reports, "She doesn't like the taste of that and won't take it without a fight." To successfully provide the medication, the nurse could appropriately do which of the following? Select all that apply.

Offer the child a frozen juice bar before medication administration. Discuss the addition of a flavoring with the pharmacist. Place the dose in a plastic medicine cup and encourage the child to "drink it like a big girl."

The nurse is performing a physical assessment on an older adult client. Which is the best reason for the nurse to ask this client about experiences with constipation?

Older adult clients commonly experience slower intestinal peristalsis, creating issues with constipation.

The nurse correctly recognizes that separation anxiety is particularly common in children and which additional population?

Older adults

A nurse encounters a client who is depressed about getting older. The nurse explains that there are many positive aspects of aging. Which positive aspects will the nurse share with the client? Select all that apply.

Older people have learned from their own mistakes. Older people have so much knowledge to share with younger generations. Older people have experienced many things that others have yet to experience.

A client with severe dehydration is experiencing minimal urine production. Which terminology does the nurse use to document the client's urinary output?

Oliguria

The LPN/LVN is a recent hire in a long-term care facility. The RN explains that long-term care is very different from acute care. The RN explains that unless a client is symptomatic or injured, head-to-toe assessments are not usually performed. Which timeline is the LPN/LVN given for performing routine head-to-toe assessments?

Once a month

The nurse is providing information to a patient recently diagnosed with type 2 DM. The health care provider (HCP) prescribes an oral hypoglycemic medication for blood glucose (BG) control. Which information is the best comparison the nurse can give the patient between insulin and an oral hypoglycemic?

Oral hypoglycemic agents stimulate a partially working pancreas.

The nurse is caring for a client taking furosemide. The nurse recognizes that dietary teaching is successful if the client chooses which food?

Oranges

The LPN/LVN is assisting the nurse during the admission process of a new client. Which task focused on client safety will the LPN/LVN perform?

Orienting the client about location and use of the call light.

The nurse provides preoperative teaching for a client who is scheduled for surgery due to a diagnosis of sigmoid cancer. The nurse explains that the client's digestion process will not change. Which organ will the nurse indicate as a source of digestive enzymes? Select all that apply.

Pancreas Gallbladder Small intestine Liver

The nurse is assessing the feet of an adult client who is hospitalized with uncontrolled diabetes mellitus. Assessment findings indicate an absence of cuts, cracks, or blisters. The client states, "I don't have as much feeling in my feet as I used to." Which condition does the nurse correctly identify for this client?

Paresthesia

The nurse is caring for a client recently admitted to the unit after a right knee replacement. Which assessment finding is most concerning to the nurse?

Pedal pulses on the operative foot are weak compared to the non-operative side.

The nurse is caring for a client admitted after plaster cast placement for a comminuted fracture of the lower leg. Which nursing intervention is most important for the nurse to perform?

Perform neurovascular checks every 2 hours for the first 24 hours.

Which term does the nurse recognize as the process that gently propels the food bolus into the small intestine?

Peristalsis

A client has undergone diagnostic tests of the gastrointestinal (GI) system. The client, who has chronic constipation, tells the nurse the physician is concerned about peristalsis, and asks why it is important. Which information will the nurse include?

Peristalsis is contractions of circular and longitudinal muscles that propels food through the GI tract.

A client with a known history of diverticulosis who is experiencing severe cramping and diarrhea is admitted to the hospital during the night with a diagnosis of diverticulitis. The client's pain increases, and the abdomen is distended and hard. The client has spiked a fever of 102.4°F. The nurse concludes the client may be developing a life-threatening complication and notifies the physician. Which possible complication concerns the nurse?

Peritonitis

The RN on an orthopedic unit is working with the LPN/LVN. Which instruction to the LPN/LVN from the RN is inappropriate?

Place the client with a left hip replacement one day ago onto the left side.

After sending a client to have a bowel resection, a nurse prepares the room for the client's return. Which of the following preparations should be included?

Placing a lift sheet on the bed

A nurse handling a syringe before administering an injection correctly keeps which parts of the syringe sterile?

Plunger Inside of the barrel Syringe tip Needle cannula

The nurse is collecting data on an older adult patient. Which finding is indicative of normal changes in the musculoskeletal system of this patient?

Presence of pain in knees joints in the morning

The nurse is contributing to a dietary presentation for patients in a multicultural community with diabetes. Which intervention will be least likely to meet the needs of the attendees?

Presentation of the standard diabetic diet

The nursing instructor is teaching a student nurse appropriate medication administration procedure. Which actions indicate that teaching has been successful? Select all that apply.

Prior to administration, the student asks the client "When is your birthday?" The student reads the original prescriber's orders to confirm route, dosage, and medication prior to administration.

An older adult patient becomes progressively more confused. The patient begins talking to long-gone loved ones about places and events that do not make any sense to the family. Which is the priority nursing action based on the current information?

Protect the patient from injury by bed rails or equipment.

A nurse is providing care to a client newly diagnosed with AIDS. Which behavior by the nurse demonstrates a caring demeanor toward the client?

Protecting the client's diagnosis from visitors and staff members

The nurse is planning interventions for a client experiencing nausea and vomiting after receiving chemotherapy. Which intervention is individualized for this client?

Provide 8 ounces enriched milkshake mid-morning and mid-afternoon

A nurse is caring for a visually impaired client who requires discharge instructions. When speaking with the client, the nurse should do which of the following?

Provide the client with larger-print handouts.

The LPN/LVN is caring for a client with diabetes mellitus and obtains a morning blood glucose level of 60 mg/dL. The LPN/LVN reports the finding to the RN. Which intervention does the LPN/LVN expect?

Provide the client with one-half cup of orange juice.

The LPN/LVN is working in a long-term care facility. A client is having difficulty managing urinary continence, and the LPN/LVN begins a program of bladder training with the client. Which part of the bladder training program should the LPN/LVN reconsider?

Provide the client's favorite beverages, which are coffee and iced tea.

The nurse receives a report on a client who just returned from surgery following a transurethral prostatectomy (TURP). The nurse is told that the client has a three-way urinary catheter. The nurse associates the catheter selection based on which client need?

Provides continuous bladder irrigation to control clot formation.

The nurse observes an unlicensed assistive personnel (UAP) providing assistance to clients during dinner. The nurse is confident of the UAP's ability to perform this task if which behavior is included? Select all that apply.

Providing supplemental nutrition as ordered. Ensuring that dentures are in place before meals. Recording the amount of food eaten at each meal. Promoting that fluid is offered routinely during the day.

Which of the following are examples of wellness strategies? Select all that apply.

Providing tips on how to quit smoking Emphasizing how to reduce the amount of unhealthy foods consumed Providing tips on changing how much alcohol one consumes

A patient was an unrestrained passenger in a motor vehicle accident and hit the windshield. In addition, the patient's leg was fractured. Which areas should be included in this patient's neurovascular checks? (Select all that apply.)

Pulses Sensation Movement

Which of the following locations is an appropriate place to store a metered-dose inhaler (MDI)? Select all that apply.

Purse or bag that the client always carries Drawer in the client's kitchen Drawer in the client's bedroom

Which certified nursing assistant (CNA) action while making a bed for a patient who is out receiving therapy requires an intervention by the nurse?

Puts soiled linens on the floor

The nurse provides care to a patient who experiences dyspnea. The patient states, "I don't want to take any more medication." Which nonpharmacological intervention does the nurse implement for this patient?

Putting a fan near the bed to circulate the air

The mother of a preschool-age child reports having difficulty getting the child to go to sleep at night. Which suggestion should the nurse provide this mother?

Read a bedtime story to the child.

The nurse is checking to be sure the medication that is being administered is correct. Which actions will help the nurse determine this? Select all that apply.

Read the original prescriber's order. Ask the client to confirm his or her name. Read the label on the medication and compare it with the MAR.

Your patient may learn best by (select all that apply)

Reading Performing a task while you watch Watching a video

The student nurse is preparing to provide 25 mg meperidine (Demerol) IM for pain. The Pyxis is loaded with prefilled 50 mg meperidine syringes. The supervising nurse appropriately intervenes if the student nurse:

Recaps the needle after the injection.

While being admitted to the unit, a client reports, "I'm allergic to Vicodin; it makes me sick to my stomach." Which is the best action for the nurse to take?

Record Vicodin under allergies, along with the client's reported symptoms.

The nurse assesses the skin of a client receiving a heat pack and decides to remove the pack. What skin color did the nurse assess to make this clinical determination?

Red

A client is prescribed a cold pack to be placed over several arm wounds. Which should the nurse expect to occur after applying this therapy? Select all that apply.

Reduced pain Muscle relaxation Decreased bleeding Prevention of edema

A patient on antihypertensive medication has no insurance, three children, and reports feeling great and exercising daily. What should the nurse include in this patient's teaching plan to promote compliance?

Refer the patient for financial assistance.

A client asks why the shoulder is hurting when the problem is in the abdomen. Which type of pain should the nurse explain this client is experiencing?

Referred

An LPN/LVN is caring for a pediatric client who appears anxious. Which actions should the LPN/LVN take to help decrease the client's anxiety? Select all that apply.

Refrain from using medical terminology. Encourage the parent to stay with the client.

A nurse correctly recognizes that which of the following types of syringe is calibrated in milliliters?

Regular syringe

A nurse is caring for a client who returned from abdominal surgery 6 hours ago. The nurse notes that the abdominal dressing is nearly saturated with serosanguineous drainage and that a small amount of drainage is leaking from the lower edge of the dressing. Which action should the nurse take first?

Reinforce the dressing with additional gauze pads.

The LPN/LVN listens to the RN provide discharge teaching to a client about newly prescribed nitroglycerine. Which action is within the LPN/LVN's scope of practice? Select all that apply.

Reinforces the client teaching provided by the RN Listens to the client tell a spouse how the medication is taken Tells the RN the client does not know the purpose of the medication

A client receiving a cold pack complains of the skin feeling cold. Which action should the nurse take?

Remove the pack

When the nurse inserts a nasogastric (NG) tube, the client becomes cyanotic, coughs incessantly, and is unable to speak. Which action should the nurse take immediately?

Remove the tube completely.

The nurse is providing care for a client with cervical skeletal traction following surgery. Which action is contraindicated when caring for this client?

Remove weights when turning the client and then replace.

The nurse reviews pertinent laboratory data and assesses the response to pain medication. Where should the nurse write this information until able to document it in the medical record?

Report form

The nurse is friendly with an older neighbor. The neighbor tells the nurse, "I am so afraid of getting sick. My spouse died after getting a cold." Which suggestion will the nurse make to help the neighbor maintain good respiratory health?

Seek medical attention for symptoms that are serious or last more than a few days.

The nurse who is working in a long-term care facility recognizes that safety concerns in the elderly population are most often related to normal changes in which physiologic system?

Sensory

A client is approved to use a heating pad at home. Which should the nurse emphasize when teaching the client about the use of this devic

Set a timer for no longer than 20 to 30 minutes

The nurse uses a cheat sheet to jot down pertinent client data while providing care. What should the nurse do with the sheet after documenting all client care?

Shred the paper.

A nurse provides oral care to an unconscious patient. Which patient position enhances the patient's safety during this procedure

Side-lying

The nurse is helping a patient understand why the heart beat can change in speed. When doing so, what should the nurse explain as being the pacemaker of the heart?

Sinoatrial node

The nurse is providing care for a client readmitted to the hospital following a modified mastectomy. The nurse notes that the primary surgical wound is inflamed, painful, and edematous. Under the client's arm, the nurse notices a small open area draining a moderate amount of green drainage. Which condition does the nurse identify?

Sinus tract between infected and healthy tissue

A nurse finds a resident in a long-term care facility crying in her room. The nurse knows that the resident's husband recently passed away. Which is the best action for the nurse to take?

Sit quietly with the resident to offer support.

Match the following

Skeleton- protects organs and tissue from injury Calcium- in the blood, helps blood clotting and proper functioning of nerves and muscles Periosteum- covers all outer bone surfaces expect joints Osteoblasts- produces bone matrix during growth Osteoclasts- resorb bone matrix when more calcium is needed

The nurse is caring for a client admitted with chronic venous insufficiency. The nurse assesses the client's lower extremities, which are edematous and discolored. Which additional finding should the nurse expect to find during assessment?

Skin wounds known as stasis ulcers

Which behavior does the LPN/LVN expect the admitting nurse to demonstrate during the admission process?

Smiling and speaking kindly

The nurse is explaining the regulation of blood pressure (BP) to a patient newly diagnosed with hypertension. What tissues within the artery wall that helps maintain diastolic BP should the nurse identify for the patient?

Smooth muscle and elastic connective tissue

The nurse is reviewing laboratory values of multiple clients with fluid and electrolyte imbalance. Which laboratory value does the nurse identify as representing a therapeutic response to treatment?

Sodium = 136 mEq

The nurse is providing dietary teaching to a client who is a vegetarian. Which is a single source of complete protein that the nurse should recommend to the client?

Soy

The nurse is providing care for a client from an Asian culture. Which foods does the nurse recognize as commonly occurring in the client's cultural diet?

Soy products, fish, and legumes

Match the following

Sprain- injury results to damage to muscles or ligaments fractures- breaks in the bone Joint replacement- arthroplasty Limb after amputation- stump Gangrene- death of tissue

The nurse finds a client who is sleeping difficult to arouse to provide routine prescribed medications. Which stage of sleep was this client most likely experiencing?

Stage IV

The LPN/LVN approaches and asks the RN to check and make sure the continuous passive motion (CPM) machine is set up correctly before it is turned on. Which assessment by the RN is most important?

Stand at the foot of the bed to inspect the alignment.

You are explaining the procedure to your patient while you are attaching her to an electrocardiogram (EKG) machine. As the test is running you notice you notice there is no electrographic complexes on the tracing paper. The nurse would first,

Stay with the patient and call a code blue

A client reports not having a gynecologic examination or Pap smear for five years since the health-care provider made a comment about her body weight. Which barrier to health care did this client experience?

Stereotyping

In order to develop a sterile conscience, the nurse needs to be aware of the conditions that impact sterility. Which equation is helpful to the nurse?

Sterile + sterile = sterile

The nurse explains to a client with chronic pain that exercise may relieve some pain. What should the nurse explain about the role of exercise on the gate control theory of pain?

Stimulates the broad nerve fibers to shut the gate

A client with terminal cancer asks how massage can decrease pain. Which should the nurse explain about massage in pain control?

Stimulates the release of endorphins, which are thought to block the transmission of pain

The nurse is called to the room of a client who is having audible, high-pitched crowing sounds. For which reason should the nurse notify the health-care provider?

Stridor

The nurse understands the importance of sterile technique during certain client care procedures. Which procedure will require sterile technique?

Subcutaneous injection given

Match the following

Subjective data collection- health history Observe ROM and muscle tone during ADL- physical examination Grating sound as joint or bones moves- crepitation What activities do you participate in, and how often?- subjective data palpate all pulses below involved area- objective data

The nursing instructor is reviewing the different types of charting methods with the class. Which should the instructor explain for the acronym SOAPIER?

Subjective data, Objective data, Assessment data, Plan, Intervention, Evaluation, Revision

The nurse is reviewing medication orders for a client. Which routes would indicate medications that should be administered by mouth? Select all that apply.

Sublingual route Buccal route

The nurse is providing care to a client with chronic pain. Which action should the nurse take when caring for this client? Select all that apply.

Suggest a variety of nonpharmacological methods Accept the client as an expert Verbalize acknowledgment of the client's pain

The nurse provides care for a patient after a lumbar puncture. Which position does the nurse place the bed for this patient?

Supine

The nurse is preparing a patient with type 2 DM for surgery. The patient expresses concern about the use of insulin at this time. Which reason does the nurse understand that insulin therapy is appropriate in regard to surgery?

Surgery is a stressor causing counter-regulatory hormones to increase blood glucose.

A nurse encounters a bed made up with the top linens fanfolded to the side of the bed. The nurse documents this as which type of bed?

Surgical

A nurse correctly recognizes that a liquid medication with undissolved particles is a(n):

Suspension and should be shaken before use.

The nurse is counseling a young female client who is a long-distance runner. Which factor does the nurse recognize as the greatest risk for this client to develop dehydration?

Sweating and hard breathing will cause fluid loss.

The nurse is transferring a client to the intensive care unit (ICU) and reports the client is experiencing "third spacing." Which manifestation will the ICU nurse expect to see?

Swelling in the extremities

The staff members at a hospital are preparing for a visit from The Joint Commission (TJC). Which should be explained to the staff about the purpose of this visit? Select all that apply.

TJC seeks to improve the safety and quality of care that health care organizations provide to the public TJC offers accreditation when a facility practices in a manner meets TJC standards TJC sends a team of reviewers to visit the facility and assess its policies, procedures, and actual performance TJC sets the standards by which the quality of health care is managed nationally and internationally

During a home visit, the nurse notes that a client experiencing chronic pain manages the pain better when sitting quietly holding a small kitten. Which type of distraction is this client using for pain control?

Tactile

The nurse is caring for a patient with hypertension who is being discharged home with a prescription of propranolol (Inderal). Which topics should the nurse include in the teaching? (Select all that apply.)

Talk to the doctor before the medication is stopped. Check the heart rate and blood pressure before taking the medication. Get up slowly to avoid dizziness.

A terminally ill patient refuses to take adequate pain medication. The patient expresses worry that the use of pain medication may result in addiction. Which response by the nurse is appropriate?

Teach the patient that addiction is not a concern during the terminal stages of illness.

Older adults are considered easy prey for scams and crime, as they are less skeptical about solicitors and telemarketers than younger individuals. Which information should the nurse present to protect older adults from becoming victims? Select all that apply.

Teach them not to allow anyone they are not expecting into their home. Teach them that they should never give out personal information over the telephone.

The nurse is providing care for an older, sedentary female client. The client admits a lack of knowledge regarding a healthy diet. Which nutrition information is correct for the nurse to share?

The FDA suggests minimum daily intake of nutrients to prevent disease.

The nurse caring for residents of a skilled nursing facility wants to quickly check on the latest orders and medications for one client. Where should the nurse locate this information?

The Kardex

The RN is observing a LPN/LVN perform open tracheostomy suctioning. The RN would stop the LPN/LVN if which behavior is observed?

The LPN/LVN suctions the client's mouth and then the tracheostomy with the same catheter.

The RN is observing an LPN/LVN perform a sterile procedure. Which observed behavior requires the RN to intervene?

The LPN/LVN turns away from the sterile field.

A client tells the LPN/LVN, "I am going home. I am not getting better, and I cannot afford to stay here." After informing the RN, which action will the LPN/LVN anticipate happening first?

The RN will attempt to explain why it is not in the client's best interest to leave without physician permission.

The LPN/LVN understands that alterations in the characteristics of urine can be an important indication of a client's condition. Which urine characteristic does the LPN/LVN expect an unlicensed assistive personnel (UAP) to report?

The UAP notices a distinctly sweet odor.

A nurse is caring for a client with a high blood level of carbon dioxide. Which response by the body's respiratory system will the nurse expect?

The breathing rate increases.

Which member of the surgical team is the primary client advocate responsible for ensuring that everything done in the operating room is in the best interest of the client?

The circulating nurse

A nurse is preparing to administer an elixir to the client. Under which circumstances should the nurse withhold the medication and notify the prescribing health-care provider? Select all that apply.

The client has a history of alcoholism. The client is receiving disulfiram.

A nurse is caring for a client with compromised respiratory function. The client has a productive cough, and sputum appears frothy and pink-tinged. Which conclusion by the nurse causes the greatest concern?

The client has life-threatening pulmonary edema.

The nurse is assessing an older adult client who was brought into the emergency department for an undetermined illness. The client lives with an adult child and grandchildren. Which assessment finding will cause the nurse to consider the possibility of elder abuse?

The client has multiple bruises in various stages of healing.

The nurse enters the room of a client who is taking a nebulizer treatment set up by the respiratory therapist. Which observation by the nurse would be cause for intervening with the treatment?

The client is breathing in and out through the nose.

The home-care nurse is visiting a client who performs self-catheterization. The nurse observes the client's technique as a plan to decrease the possibility of urinary tract infection (UTI). Which observation of the client's techniques will the nurse correct?

The client puts on clean gloves without washing the hands.

The RN asks the LPN/LVN to orient a client arriving for admission to the unit. Which client orientation will the LPN/LVN directly connect to a safety need?

The client reports vomiting for 24 hours.

The LPN/LVN works at a physical rehabilitation clinic. The LPN/LVN is aware of many clients who use assistive devices for mobilization. Which client is the LPN/LVN aware to be unsuitable for the use of a knee walker?

The client who is one week postoperative for a total knee replacement.

The nurse is providing care for multiple clients in the hospital who are ordered on intake and output (I&O) measurement. Which client does the nurse anticipate will need extra assistance in obtaining accurate data?

The client who is vomiting with an intake only of ice chips

The nurse assesses a client just admitted from the emergency department with pain in the lower right quadrant of the abdomen. The physician's order reads, "Diet as tolerated." Which conclusion will impact the nurse's decision regarding the client's diet?

The client will be NPO due to the probability of surgery.

The nurse is inserting a nasogastric (NG) tube. Which conclusion does the nurse make if a client coughs continually?

The client's airway is compromised.

A nurse is notified that a new admission is expected to the unit. The nurse is told that the client is 101 years old and is being admitted from a nearby extended care facility. Which assumption about the client's need is appropriate?

The client's risk for falls will be high.

The nurse is using a stethoscope to listen to a patient's heart sounds. The nurse recognizes that the "dub" of the characteristic "lub-dub" heart sound indicates what part of the cardiac cycle?

The closure of the aortic and pulmonary semilunar valves

The nurse shares information about the Mediterranean Diet with colleagues. Which fact about this diet is correct? Select all that apply.

The diet promotes poultry, pork, and fish in low to moderate amounts. The diet consists of a healthier, low consumption of saturated fats. The diet is common in the French, Spanish, Greek, and Italian cultures. The diet focuses on foods from plant sources, such as fruit and vegetables.

The nurse is discussing the management of an older adult client recently diagnosed with type 2 DM. Which information is least helpful?

The family can promote healthy eating by supplying meals.

The nurse is deciding about how to determine what size of sterile gloves fit properly. Which information will help the nurse make a correct decision?

The gloves should fit closely to the skin.

The experienced nurse in an intensive care unit is orienting a new nurse. Which action by the new nurse requires the experienced nurse to intervene immediately? Select all that apply.

The new nurse rearranges items in a sterile pack before donning gloves. The new nurse turns toward the client, with the back toward the sterile field The new nurse places a sterile pack with the first flap facing toward the right.

The nurse prepares to count a client's breathing rate. Which should the nurse count when completing this assessment?

The number of times the client breathes in and breathes out

The nurse needs to add sterile dressings in peel-open packages to an established sterile field. Which method will the nurse use to prevent contamination of the field or the added items?

The nurse approaches from the side to drop the items on the sterile field.

A client is demonstrating signs of spiritual distress. In which way would the nurse fail to provide spiritual care to this client?

The nurse does not understand the relationship between mind, body, and spirit.

A nurse is caring for a female client who is scheduled for an abdominal hysterectomy. The nurse obtains the client's signature on the consent form and then signs the form himself. What does the nurse's signature indicate?

The nurse has verified that it was the client who signed the form.

A client received a dose of intravenous pain medication before change of shift. After receiving the report, the oncoming nurse notes that the medication was not documented, provides another dose, and the client has a respiratory arrest. Who is most liable for this situation?

The nurse who gave the first dose of medication

The nurse is employed at a clinic for patients diagnosed with diabetes. Which patient does the nurse identify as being at greatest risk for needing dialysis?

The older adult with type 2 DM, unstable BG, and hypertension

The nurse is preparing a sterile field using a drape provided inside a sterile pack. Which area of the sterile drape can the nurse touch in order to maintain sterility?

The outer 1-inch border of the drape

The newly hired surgery nurse is preparing to open a sterile pack for the first time. Which principle will the nurse apply to maintain the sterile field?

The pack is placed unopened on top of a surgery table.

The nurse is providing care for a patient with type 2 DM who has been treated with an oral hypoglycemic agent. The HCP prescribes for the addition of insulin. Which situation does the nurse recognize as being the least valid reason for giving this patient insulin?

The patient is unable to effectively follow a diabetic diet.

A patient with type 1 diabetes has frequent episodes of hypoglycemia, even with multiple daily blood glucose self-monitoring throughout the day. Which method of self-monitoring does the nurse recognize as being more effective for this patient?

The patient will benefit from continuous monitoring.

The nurse is preparing to measure a patient's blood pressure. What should the nurse do to ensure that the reading obtained is accurate? (Select all that apply.)

The patient's arm is at the level of the heart. The patient is seated

The nurse is assessing a patient who has been taking prazosin (Minipress) for 3 months. Which indicates treatment is effective?

The patient's blood pressure is 114/66 mm Hg.

The nurse in a rehabilitation facility attends a meeting to discuss client status. For which reason does the nurse recognize attendance by the physical therapist?

The physical therapist assesses for musculoskeletal deficiencies and makes a recovery plan.

A client is being directly admitted to the hospital from the physician's office. Which component of the admission process should the nurse expect?

The physician's office staff will give the client instructions for admission.

The nurse is providing care for a client with a history of cardiac problems. The nurse notes the client's potassium level is 3.6 mEq/L. The nurse understands that which reason supports the physician's order for a daily dose of potassium?

The potassium is ordered in an attempt to prevent cardiac arrhythmias.

The nurse witnesses a terminally ill patient telling the health-care provider, "I don't want my life prolonged, as stated in my living will." Which action does the nurse anticipate from the health-care provider based on the patient's statement?

The provider will speak to the patient's family before writing a DNR prescription.

The nurse is preparing for a client with severe chronic obstructive pulmonary disease (COPD) to be discharged home. Which discharge teaching is important for the nurse to provide? Select all that apply.

The safety reasons why the client will need a shower chair The importance for alternating activity with rest periods The rationale for the client to eat small, frequent meals The symptoms that will require the client to contact the physician

The nurse is preparing to irrigate a client's wound with a syringe and sterile saline. Which action by the nurse demonstrates correct procedure?

The solution flow is directed from the least contaminated to the most contaminated area.

The nurse is preparing education material for adults regarding nutrition. Which fact will the nurse address about the anatomy and physiology of digestion?

The stomach is a reservoir where little absorption occurs except for alcohol.

The nurse educator is teaching the student how to apply a transdermal patch. Which actions taken by the student would indicate teaching has been effective? Select all that apply.

The student nurse removed a patch that was applied yesterday before applying the new patch. The student nurse wrote the date and time on the patch before applying it. The student nurse placed the new patch on the client's right shoulder because the last patch was on the left shoulder. The student nurse shaves an area prior to application.

The nurse recruiter at a large hospital researched the projected need for nurses by the year 2020. Which finding best supports the nurse recruiter's need to recruit and retain more nurses?

The supply of nurses will fall more than one million below the need.

The nurse applies a cooling blanket to a client with a temperature of 105.4°F. Which should the nurse recognize as an indication of therapeutic effectiveness?

The temperature slowly falls to 100°F

The nurse is caring for a client with mild left-sided weakness who is using a walker for the first time. Which assessments indicate to the nurse that the client is using the walker correctly? Select all that apply.

The walker is the height of the client's hip joint. The hand brakes are set before the client sits in the seat if provided. The client moves the affected leg forward with the walker.

The nurse provides care to a patient with an infected leg wound. Which type of bath does the nurse anticipate will be included in the patient's plan of care?

Therapeutic bath

The nurse is caring for a client who was involved in a motor vehicle accident. The client was thrown from the vehicle and has several areas where skin appears to have been scraped away. The nurse identifies the wounds as abrasions. Which statement is true about this type of wounds?

They are generally superficial and will heal quickly if kept clean.

The nurse is evaluating the potential presence of a urinary tract infection (UTI). In which laboratory value will the nurse be most interested?

Urine pH

A nurse is caring for a client who can speak and understand some English but is not fluent. The nurse should:

Use a professional or certified interpreter from the hospital's list of available interpreters.

A client is prescribed to apply cold therapy to an inflamed area on the leg. Which should the nurse instruct the client to do to prepare a cold pack at home? Select all that apply.

Use a refillable bag Expel any air from the bag Place ice and water in the bag Fill the bag one-half to two-thirds full

The nurse is preparing to clean a surgical wound that is closed with staples. Assessment reveals that the incision is clean, dry, well approximated, and without redness or tenderness. Which wound cleaning procedure will the nurse use?

Use forceps with a sterile antiseptic swab and move from the superior to the inferior end.

Which assessment activities should the nurse include when performing a respiratory assessment on a client admitted with a diagnosis of bilateral pneumonia? Select all that apply.

Use of accessory muscles Skin color Respiratory rate Cough

The nurse is caring for a client who is 75 years old. When teaching the client, the nurse should:

Use plenty of repetition.

The nurse is admitting a client and performs a focused assessment. Which techniques will result in the nurse acquiring objective data related to bowel function?

Use the diaphragm of a stethoscope to hear bowel sounds.

Which of the following is considered an essential step for the nurse to follow while withdrawing medication from an ampule?

Using a filtered needle to withdraw medication

The nurse is reinforcing teaching for a female client with a history of recurrent urinary tract infections (UTIs). Which behavior, if shared by the client, indicates the client understands the necessary behaviors to avoid another UTI? Select all that apply.

Using a method of birth control other than a diaphragm or spermicides Using a method of birth control other than a diaphragm or spermicides Being sure to void after having sexual intercourse

The nurse correctly recognizes that which of the following medications may cause toxicity? Select all that apply.

Valproic acid Gentamicin

The nurse is reviewing orders for a patient taking digoxin (Lanoxin). Which additional medication should the nurse question?

Verapamil (Calan SR)

A client is prescribed isoniazid (INH), a medication that treats tuberculosis (TB). Which condition will prompt the nurse to remind the physician that the client will need a specific vitamin during the therapy?

Vitamin B6 excretion will increase with INH.

Nurses who use critical thinking (select all that apply)

avoid jumping to conclusions. avoid making decisions based on assumptions.