final exam review

A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? (Select all that apply) a. bathtub with rails b. electric cords behind furniture c. raised toilet seats d. water heater temperature 130 degrees e. throw rubs

D and E

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply) a. excessive laxative use b. ignoring the urge to defecate c. inadequate fluid intake d. increased fiber in diet e. increased activity

a b c

A charge nurse is antiipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses' station? a. a client who suffered a head injury and is having periods of confusion b. a client who reports a severe migraine headache c. a client who has a suspected diagnosis of tuberculosis (Tb) d. a client who has a history of atrial fibrillation and is on continuous ECG monitoring

a. a client who suffered a head injury and is having periods of confusion

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse? a. observe the client's respiratory status b. elevate the head of the client's bed 30-45 degrees c. monitor intake and output every 8 hours d. check residual volume every 4 to 6 hours

a. observe the clients respiratory status

A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply) a. report of feeling pressure b. tenderness over the symphysis pubis c. distended bladder d. voiding 30 mL frequently e. dysuria

a. report of feeling pressure b. tenderness over the symphsis pubis c. distended bladder d. voiding 30 mL frequently

a newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take? a. secure the restraints using a quick release tie b. ensure four fingers fit under the restraints to prevent constriction c. secure the restrains to the lower bar of the side rail d. anticipate removing the restraints every 4 hour

a. secure the restraints using a quick release tie

A nurse is preforming tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take? a. suction two to three times with a 60 second pause between passes b. perform chest physiotherapy prior to suctioning c. lubricate the suction catheter tip with sterile saline d. hyperventilate the client on 100% oxygen prior to suctioning

a. suction two to three times with a 60 second pause between passes

A nurse provides a back massage as a palliative care measure to a client who is unconscious, grimacing, and restless. Which of the following findings should the nurse identify indicating a therapeutic response? (Select all that apply?) a. the shoulders droop b. the facial muscles relax c. the respiratory rate increases d. the pulse is within the expected range e. the client draws his legs up into a fetal position

a. the shoulders droop b. the facial muscles relax d. the pulse is within normal range

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to maintain the integrity of the client? a. use a transfer device to lift the client up in bed b. apply cornstarch to keep sensitive skin areas dry c. massage the skin over the client's bony prominences d. elevate the head of the bed no more than 45 degrees

a. use a transfer device to lift the client up in bed

A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times? a. when the client has the urge to defecate b. every 2 hours while the client is awake c. immediately before the client has a meal d. after the client feels abdominal cramping

a. when the client has an urge to defecate

A nurse is caring for a client who has an NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. Which of the following readings should the nurse expect? a. 6.0 b. 4.0 c. 7.0 d. 8.0

b. 4.0

A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. I will walk briskly for 30 minutes before bedtime b. I will no longer have a glass of wine before bedtime c. i will have a cup of hot cocoa immediately before bedtime d. I will do my muscle relaxation techniques each afternoon

b. I will no longer have a glass of wine before bedtime

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take? a. adjust the water temperature to feel hot b. apply 4 to 5 mL of liquid soap to the hands c. hold the hands higher than the elbows d. rub hands together to dry

b. apply 4 to 5 mL of liquid soap to the hands

A client receives a wrong medicaiton. The nurse who made the medication error should take which of the following actions first? a. call the client's provider b. assess the client c. notify the nurse manager d. complete an incident report

b. assess the client

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances? a. steatorrhea b. blood c. bacteria d. parasites

b. blood

A nurse is receiving change of shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process? a. critically analyze client data to determine priorities b. collect and organize client data c. set client centered, measurable and realistic goals d. determine effectiveness of interventions

b. collect and organize data

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take? a. place the wheelchair at a 90 degree angle to the bed b. lock the wheels of the bed and the wheelchair c. acquire the help of several people to lift the client d. elevate the bed to a position of comfort for the nurse

b. lock the wheels of the bed and the wheelchair

A nurse is caring for an older adult client who was alert and oriented at admission, but now sees increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs? a. call the family and ask them to stay with the client b. move the client to a room closer to the nurses station c. apply wrist and leg restraints to the client d. administer medication to sedate the client

b. move the client closer to the nurses station

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TPN) solution is not infusing. The nurse should monitor the client for which of the following conditions? a. excessive thirst and urination b. shakiness and diaphoresis c. fever and chills d. hypertension and crackles

b. shakiness and diaphoresis

A nurse is caring for a client who is postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the client's pain? a. vital sign measurement b. the client's self-report of pain severity c. visual observation for nonverbal signs of pain d. the nature and invasiveness of the surgical procedure

b. the clients self report of pain severity

A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? a. hypotension b. numbness c. shivering d. reduced blood viscosity

c, shivering

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions? a. an upper respiratory infection b. pulmonary edema c. atelectasis d. delayed gastric emptying

c. atelectasis

a nurse is caring for a client who is postoperative following abdominal surgery. the surgeon initially prescribes a clear liquid diet. which of the following items should the nurse include on the client's lunch tray. a. lemon sherbet b. plain yogurt c. cranberry juice d. carrot juice

c. cranberry juice *clear liquid diet = any liquid you hold up to the light that you can see through

A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field? a. Placing a sterile dressing 5 cm (2 in) from the border of the sterile field b. holding a sterile item at just above waist level c. opening a sterile package over the middle of the sterile field d. opening the sterile tray by first unfolding the flap farthest from his body

c. opening the sterile package over the middle of the sterile field

a nurse is admitting a client who is arriving back to the unit from the PACU following hip arthoplasty. which of the following tasks should the nurse assign to the assistive personnel (AP)? a. obtain vital signs b. determine if the client is in need of pain medication c. record the amount of urine in the catheter drainage bag d. instruct the client on the use of the incentive spirometer

c. record the amount of urine in the catheter drainage bag

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take? a. use a stiff toothbrush to clean the client's teeth b. use the thumb and index finger to keep the client's mouth open c. turn the client on his side before starting oral care d. apply petroleum jelly to the client's lips after oral care

c. turn the client on his side before starting oral care

A nurse is caring for a client who has MRSA in an abdominal wound. The nurse enters the room to check the client's pulse. Which of the following actions should the nurse take? a. wear an N95 respirator mask b. wear sterile gloves c. wear clean gloves d. wear protective eyewear

c. wear clean gloves

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? a. creatine kinase b. troponin c. total bilirubin d. albumin

d. albumin

A nurse is ready to insert an indwelling urinary catheter for a female client. Which of the following instructions should the nurse give the client as the catheter is inserted? a. contract the pelvic muscles b. take a sip of water c. exhale slowly d. bear down

d. bear down

A nurse is caring for a client who has an indwelling urinary catheter notes blood-tinged urine in the catheter bag. The nurse recognizes that this finding can be a manifestation of which of the following urinary alterations? a. pernicious anemia b. dehydration c. prostate enlargement d. bladder infection

d. bladder infection

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take? a. mix the three medications together prior to administering b. dilute each medication with 10 mL of tap water c. maintain the head of the bed in a flat position for 30 min following medication administration d. flush the NG feeding tube with 30 mL of water immediately following medication administration

d. flush the NG feeding tube with 30 mL of water immediately following medicaiton administration

A nurse is caring for a client who reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene? a. closes the door to the client's room b. measures the client's vital signs routinely c. asks a group of nurses in the hall to speak quietly d. flushes the client's toilet after emptying the urinary catheter's drainage bag

d. flushes the client's toilet after emptying the urinary catheter's drainage bag

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures? a. trochanter roll b. sheepskin heel pad c. abduction pillow d. footboard

d. footboard

a nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first? a. administer oxygen at 2 L/min b. administer prescribed analgesic medication c. encourage coughing and deep breathing d. raise the head of the bed

d. raise the head of the bed

A nurse is caring for a client who needs a stool specimen collected. Which of the following actions should the nurse take when obtaining the specimen? a. use a sterile swab to obtain the specimen b. place the specimen in a sterile container c. label the paper bag in which specimen container is placed d. send specimen container immediately to the lab

d. send specimen container immediately to lab

A nurse is caring for a client who has fallen while getting out of bed and states, "I'm okay! I guess I should have called for help to the bathroom." After assessing the client, the nurse notifies the provider. Which of the following documentation should the nurse include in the client's medical record? a. "There were no injuries reported" b. "An incident report was completed" c. "An incident report was forwarded to risk management" d. "The provider was notified"

d. the provider was notified

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes? a. to confirm the placement of the NG tube b. to remove gastric acid that might cause dyspepsia c. to determine the client's electrolyte balance d. to identify delayed gastric emptying

d. to identify delayed gastric emptying

A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use? a. one nurse lifting as the client pushes with his feet b. two nurses lifting the client under the shoulders c. one nurse lifting the client's legs as the client uses a trapeze bar d. two nurses using a friction-reducing device

d. two nurses using a friction reducing device