Fundamentals CMS

Evacuate the client. According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area.

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next? Activate the emergency fire alarm. Extinguish the fire. Evacuate the client. Confine the fire.

A client who smokes one pack of cigarettes each day A client who smokes one pack of cigarettes each day is at an increased risk for hypertension.

A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension? A client who is 52 years old A client who smokes one pack of cigarettes each day A client who walks for 30 min every day A client who drinks one glass of wine three times per week

Witness the client's signature on the consent form. The nurse is responsible for witnessing the client sign the consent form. The nurse should confirm that the client appears competent to give consent and that the client understands the procedure.

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? Describe the procedure to the client. Witness the client's signature on the consent form. Inform the client of alternatives to the procedure. Tell the client which team members will assist with the procedure.

8 oz of ice chips The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. The nurse should understand that 4 oz of liquid water is equal to 120 mL of fluid.

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid? 2 cups of soup 1 quart of water 8 oz of ice chips 6 oz of tea

Assess the client for orthostatic hypotension. The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair.

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next? Rock the client up to a standing position. Pivot on the foot that is the farthest from the chair. Assess the client for orthostatic hypotension. Apply a gait belt to the client.

Select a suction catheter that is half the size of the lumen. The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take? Use a resuscitation bag with 80% oxygen prior to the procedure. Select a suction catheter that is half the size of the lumen. Place the end of the suction catheter in water-soluble lubricant. Adjust the wall suction apparatus to a pressure of 170 mm Hg.

0.3 mg The use and placement of a decimal point can potentially cause a medication error if documented incorrectly. A zero should precede a decimal point, as in 0.3 mg, but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg.

A nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? .3 mg 0.3 mg 0.30 mg 3/10 mg

"You should have a fecal occult blood test every year." Colorectal cancer screening for clients who are at average risk begins at age 50. One option for screening is a fecal occult blood test annually.

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make? "I'll get a blood sample from you and send it for a screening test." "Beginning at age 60, you should have a colonoscopy." "You should have a fecal occult blood test every year." "The recommendation is to have a sigmoidoscopy every 10 years."

Wrap monitoring cords with stockinette and tape them in place. Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them.

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? Ensure sterilization of nondisposable items with ethylene oxide. Wrap monitoring cords with stockinette and tape them in place. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication. Wear hypoallergenic latex gloves that contain powder.

Current medications The nurse should include the client's medications in the discharge summary to ensure client safety and continuity of care.

A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include? Client flow sheet Acuity ratings Current medications Incident reports

Breath sounds When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds.

A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide? Admitting diagnosis Breath sounds Body temperature Diagnostic test results

Have the client stand with their arms at their sides and their feet together. A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance.

A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use? Touch the face with a cotton ball. Apply a vibrating tuning fork to the client's forehead. Have the client stand with their arms at their sides and their feet together. Perform direct percussion over the area of the kidneys.

Narrowed arterial lumen Blowing sounds resulting from blood flowing through occluded or narrowed arteries are known as a bruit.

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, the nurse hears the following sound. This sound indicates which of the following? (Click on the audio button to listen to the clip.) Narrowed arterial lumen Distended jugular veins Impaired ventricular contraction Asynchronous closure of the aortic and pulmonic valves

"You should receive a pneumococcal vaccine when you are 65 years old." The nurse should instruct older adult clients to receive one of the two pneumococcal vaccines when they are 65 years old. The vaccines can be given to clients who are 19 years of age and older and have certain conditions, such as chronic heart, lung, or liver disease, diabetes mellitus, and alcohol disease, or to those who smoke cigarettes.

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include? "You should have an eye examination every 2 years." "You should receive a tetanus booster every 5 years." "You should receive a shingles vaccine when you are 70 years old." "You should receive a pneumococcal vaccine when you are 65 years old."

N95 respirator The nurse should wear an N95 respirator when providing care for a client who requires droplet precautions as a result of tuberculosis to prevent the transmission of bacteria.

A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client? Gown N95 respirator Shoe covers Surgical cap

Arrange food in a consistent pattern on the client's plate. Consistency in preparing the client's plate helps to facilitate self-feeding for clients who have vision loss. Staff can describe the location of the food on the plate by using a clock pattern, allowing the client to have greater independence during meals.

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding? Assign a staff member to feed the client. Provide small-handled utensils for the client. Thicken liquids on the client's tray. Arrange food in a consistent pattern on the client's plate.

8mL/hr

A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Gently shake the container of medication prior to administration. The nurse should gently shake the liquid medication to ensure that the medication is mixed.

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? Gently shake the container of medication prior to administration. Transfer the medication to a medicine cup. Place the client in a semi-Fowler's position prior to medication administration. Verify the dosage by measuring the liquid before administering it.

Ambulating a client who is postoperative Ambulating a client is within the range of function of an AP. The nurse can delegate tasks to the AP that do not require special skills, assessment, or teaching.

A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate? Ambulating a client who is postoperative Inserting an indwelling urinary catheter for a client Demonstrating the use of an incentive spirometer to a client Confirming that a client's pain has decreased after receiving an analgesic

122 SBP To obtain an accurate blood pressure measurement, the nurse should inflate the cuff 30 mm Hg beyond the point at which the nurse was last able to palpate the pulse. If the nurse last palpated the pulse at 92 mm Hg, then this would be the correct pressure to which the nurse should inflate the cuff.

A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. Which of the following images displays the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure?

Medication dose In the prescription, the medication dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer.

A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify with the provider? Medication name Route of administration Medication dose Frequency of administration

Initiate an enteral feeding through a gastrostomy tube. It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes.

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? Insert an implanted port. Close a laceration with sutures. Place an endotracheal tube. Initiate an enteral feeding through a gastrostomy tube.

"When descending stairs, I will first shift my weight to my right leg." To descend stairs, the client should first shift his body weight to his right, unaffected leg.

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? "When descending stairs, I will first shift my weight to my right leg." "I should place my crutches 12 inches in front and to the side of each foot." "As I sit down, I will hold one crutch in each hand." "I will make sure the shoulder rests are snug against my armpits."

A client who has asthma Some essential oils can cause bronchospasm; therefore, the nurse should consult the client's provider before using this therapy for a client who has asthma.

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? A client who has a history of physical abuse A client who has a permanent pacemaker A client who has ulcerative colitis A client who has asthma

A nurse asks a nurse from another unit to assist with documentation for a client. Only health care professionals directly caring for a client should have access to the client's medical information; therefore, this is a violation of HIPAA guidelines.

A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines? A nurse who is caring for a client reviews the client's medical chart with a nursing student who is working with the nurse. A nurse asks a nurse from another unit to assist with documentation for a client. A nurse who is caring for a client returns a call to the person appointed in the health care proxy to discuss the client's care. A nurse discusses a client's status with the physical therapist who is caring for the client.

Compare prescriptions with medications the client received while at the facility. When performing medication reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking. Part of the process is comparing the medications the client received at the facility with those the provider has prescribed for the client to take after discharge.

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? Seal unused medications from the facility in a plastic bag. Evaluate the client's ability to self-administer medications. Report an identified discrepancy to The Joint Commission. Compare prescriptions with medications the client received while at the facility.

The caregiver insists on remaining in the room. A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment.

A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse? The caregiver is the client's financial power of attorney. The client is in a wheelchair with the wheels locked. The client reports receiving a full bath twice each week. The caregiver insists on remaining in the room.

"People in middle adulthood often find satisfaction in nurturing and guiding young people." According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore opportunities for mastering the developmental tasks of this stage with the client, such as volunteering and mentoring young people.

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make? "Most people are happy when their children grow up and leave home." "You should be proud that your children are becoming independent." "Maybe you should consider why you are feeling useless." "People in middle adulthood often find satisfaction in nurturing and guiding young people."

Rapid heart rate Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? Neck vein distention Urine specific gravity 1.010 Rapid heart rate Blood pressure 144/82 mm Hg

Practice sessions Practice sessions require psychomotor skills when learning.

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? Role play Group discussions Question-answer meetings Practice sessions

Flush the tube with 15 mL of sterile water. The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication.

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take? Dissolve each medication in 5 mL of sterile water. Draw up medications together in the syringe. Push the syringe plunger gently when feeling resistance. Flush the tube with 15 mL of sterile water.

Weight-bearing exercises Weight bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis.

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? Walking briskly Riding a bicycle Performing isometric exercises Engaging in high-impact aerobics

Assist the client to a left side-lying position with the right knee flexed is correct. The nurse should place the client in a left side-lying position with the right knee flexed prior to administering an enema. Because the provider prescribed a cleansing enema for the client, the nurse should prepare the client for the procedure. Prepare the client for a chest x-ray is incorrect. A chest x-ray is typically performed for a client who has an impairment of the upper thorax or lungs, not the abdomen. The client has already received an abdominal x-ray; therefore, a chest x-ray is not necessary. Administer a cleansing enema is correct. The nurse should administer a cleansing enema for the client as a result of the provider's prescription. A cleansing enema is intended to assist with bowel elimination and remove any impacted fecal matter indicated by the abdominal x-ray. Auscultate the client's bowel sounds is correct. The nurse should auscultate the client's bowel sounds to determine the status of the client's peristalsis. This is a necessary part of determining the presence of bowel sounds, which are an indication of the status of the client's gastrointestinal tract. Perform a manual digital examination of the client's rectum is correct. The nurse should perform a manual digital examination of the client's rectum to determine if impacted stool is present. This is a part of the necessary evaluation of the status of the client's gastrointestinal tract. Administer oxycodone extended-release tablets is incorrect. Although the client has a prescription for oxycodone to treat pain related to pancreatic cancer, opioid medications can cause the adverse effect of constipation. Because the client reports not having experienced a bowel movement for an extended period of time, the nurse should withhold further opioids until the cause of the client's constipation is determined. Prepare the client for NG tube placement is incorrect. The nurse should not prepare the client for placement of an NG tube because there is no indication or prescription to do so. Placement of an NG tube is required when there is an obstruction of the gastrointestinal tract and peristalsis is absent.

A nurse in the emergency department (ED) is caring for a client who reports abdominal pain. Based on the client's clinical findings, which of the following actions should the nurse take? Select all that apply. Assist the client to a left side lying position with the right knee flexed Prepare the client for chest xray Administer a cleansing enema Auscultate the clients bowel sounds Perform a manual digital examination of the clients rectum is correct Administer oxycodone ER tablet Prepare the client for NG tube replacement

Cachectic Skin dry and scaly... Pulse Rate Abdomen distended BMI 17 Cachectic, with flaccid muscle tone is correct. The client's lack of energy, flaccid muscle tone, and wasting appearance can be an indication of malnutrition. Skin dry and scaly with bruises on extremities is correct. The client's dry, scaly, and bruised skin can be an indication of malnutrition. Oriented x 3, able to move all extremities is incorrect. The client's neurological status is within expected parameters. Pulse rate 118/min is correct. The client's tachycardia can be an indication of malnutrition. Respiratory rate 18/min is incorrect. The client's respiratory rate is within the expected reference range. Abdomen distended is correct. The client's abdominal distention can be an indication of malnutrition. Temperature 39.2° C (102.6° F) is incorrect. An elevated temperature is not an indication of malnutrition. BMI 17 is correct. A BMI of 17 is considered underweight and can be an indication of malnutrition.

A nurse in the emergency department (ED) is caring for a client. Click to highlight the findings that indicate the client is malnourished. To deselect a finding, click on the finding again. Cachectic, with flaccid muscle tone. Skin dry and scaly with bruises on extremities. Oriented x 3, able to move all extremities. Pulse rate 118/min Respiratory rate 18/min Abdomen distended Temperature 39.2° C (102.6° F) BMI 17

Auscultate lung sounds. The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and shortness of breath.

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority? Auscultate lung sounds. Measure urine output. Monitor blood pressure readings. Monitor electrolyte levels.

Request a prescription for an antibiotic medication Initiate droplet precautions Wear a mask within 1m(3 ft) of the client Apply a mask on the client when they leave their room Request a prescription for an antibiotic medication is correct. The nurse should identify that the client has streptococcal pharyngitis due to the client's manifestations and a positive throat culture. Therefore, the nurse should request an antibiotic medication, such as penicillin, to treat the client's infection. Apply oxygen at 2 L/min via nasal cannula is incorrect. The client's oxygen saturation is greater than 95% on room air. Therefore, no further action is required by the nurse. Initiate droplet precautions is correct. The nurse should identify that the client has streptococcal pharyngitis, which is transmitted through droplets greater than 5 microns in the air. Therefore, the nurse should initiate droplet precautions for the client. Wear a mask within 1 m (3 feet) of the client is correct. The nurse should identify that the client has streptococcal pharyngitis. Therefore, the nurse should wear a mask when within 1 m (3 feet) of the client to prevent the spread of the infection. Place the client in a negative airflow room is incorrect. The nurse should initiate droplet precautions, which do not require a negative airflow room. A negative airflow room is indicated for clients who require airborne precautions. Apply a mask on the client when they leave their room is correct. The nurse should identify that the client has streptococcal pharyngitis. Therefore, the nurse should apply a mask on the client when they leave their room to prevent transmission of the infection.

A nurse is admitting a client who reports experiencing a sore throat, productive cough, and fever for the past 3 days. The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply. Request a prescription for an antibiotic medication Apply oxygen at 2L/min via nasal cannula Initiate droplet precautions Wear a mask within 1m(3 ft) of the client Place the client in a negative airflow room Apply a mask on the client when they leave their room

Place the client on droplet Place the client on droplet isolation precautions is correct. The nurse should identify that the client has pneumonia, which is transmitted through droplets greater than 5 microns in the air. Therefore, the nurse should place the client on droplet isolation precautions. Apply oxygen at 2 L/min via nasal cannula is correct. The nurse should identify that the client's oxygen saturation is less than 95% on room air, indicating a decrease in oxygen in the client's blood, which can lead to hypoxia. Therefore, the nurse should apply oxygen at 2 L/min via nasal cannula to the client. Request a prescription for an antipyretic medication is correct. The nurse should identify that the client has a temperature of 36.6° C (101.5° F), indicating a fever. Therefore, the nurse should request an antipyretic medication to treat the client's fever. Wear an N-95 mask when providing care to the client is incorrect. The nurse should wear an N-95 mask when providing care to clients who have an airborne infection and are in a negative air pressure room. Request a prescription for an antihypertensive medication is incorrect. The client's blood pressure is within the expected reference range. Therefore, a request for a prescription for an antihypertensive medication is not indicated. Remain 1 m (3 feet) from the client is correct. The nurse should identify that the client has pneumonia. Therefore, the nurse should wear a sterile mask and remain within 1 m (3 feet) from the client.

A nurse is admitting a client. The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply.

Distended neck veins Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess? Hypotension Weak, thready pulse Slow capillary refill Distended neck veins

"I can take echinacea to improve my immune system." Echinacea is taken to promote immunity and reduce the risk of infection.

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use? "I can take echinacea to improve my immune system." "I can take feverfew to reduce my level of anxiety." "I can take ginger to improve my memory." "I can take ginkgo biloba to relieve nausea."

Stoma, Skin around the stoma Stoma color is correct. The greatest risk to the client is the necrosis of the bowel. The nurse should identify that the color of the stoma indicates the client is at greatest risk for necrosis of the bowel; therefore, the nurse should notify the provider immediately about the color of the client's stoma. Hemoglobin level is incorrect. The nurse should report the client's hemoglobin level because it is greater than the expected reference range. However, there is another finding that is a greater risk to the client and that the nurse should address first. Ostomy leakage is incorrect. The nurse should address the leakage around the client's stoma because it can cause irritation to the skin surrounding the stoma. However, there is another finding that is a greater risk to the client and that the nurse should address first. Dropdown 2: Ostomy pouch seal is incorrect. The nurse should address the ostomy pouch seal because it can cause irritation to the skin surrounding the stoma. However, there is another finding that is a greater risk to the client and that the nurse should address next. Skin around the stoma is correct. The nurse should identify that the skin condition around the stoma is the next priority finding to address because it places the client at risk for infection. Amount of stool in the pouch is incorrect. The nurse should address the amount of stool in the client's pouch to avoid further leakage, which can cause irritation. However, there is another finding that is a greater risk to the client and that the nurse should address next.

A nurse is caring for a client who has a newly placed ileostomy. Complete the following sentence by using the lists of options.

The nurse should first inject air into the vial of NPH insulin without touching the needle to the solution. Next, the nurse should inject air into the vial of regular insulin and withdraw the correct amount of the regular insulin. Finally, the nurse should insert the needle into the NPH insulin vial and withdraw the correct amount of NPH insulin. The nurse should follow these steps to prevent contaminating the regular insulin with NPH insulin.

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Temperature WBC count Prealbumin Pain lvl Odor Temperature is correct. The nurse should identify that the client has a fever, which is a manifestation of an infection. Therefore, the nurse should report this finding to the provider. WBC count is correct. The nurse should identify that the client has a WBC count that is greater than the expected reference range, which is a manifestation of an infection. Therefore, the nurse should report this finding to the provider. Prealbumin level is correct. The nurse should identify that the client has a prealbumin level that is lower than the expected reference range. This is a manifestation of malnutrition, which contributes to delayed wound healing. Therefore, the nurse should report this finding to the provider. Hemoglobin level is incorrect. The client's hemoglobin is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider. Blood pressure is incorrect. The client's blood pressure is within the expected reference range. Therefore, the nurse does not need to report this finding to the provider. Pain level is correct. The nurse should identify that the client's pain level has increased over 3 days and is an indication of complications associated with wound healing. Therefore, the nurse should report this finding to the provider. Odor of wound is correct. The nurse should identify that a foul odor of a wound is a manifestation of an infection. Therefore, the nurse should report this finding to the provider. Bowel sounds is incorrect. The client's bowel sounds are present in all four quadrants. Therefore, the nurse does not need to report this finding to the provider.

A nurse is caring for a client who has a pressure injury. Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again. Temperature WBC count Prealbumin level Hemoglobin level Blood pressure Pain level Odor of wound Bowel sounds

"We can talk about advance directives, and I can also give you some brochures about them." With this statement, the nurse offers to provide the information the client needs in a direct and simple way.

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make? "We can talk about advance directives, and I can also give you some brochures about them." "You should set up a time to talk with your provider about that." "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better." "Why do you want to discuss this without your partner here to plan this with you?"

Tell the client to keep the head of the bed elevated at least 30°. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula into the esophagus.

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first? Rinse the feeding bag with water between feedings. Tell the client to keep the head of the bed elevated at least 30°. Make sure the enteral formula is at room temperature. Wipe the top of the formula can with alcohol.

Apply an ankle-foot orthotic device to the client's feet. The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress.

A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? Place a pillow under the client's knees. Position a trochanter roll under each of the client's hips. Advise the client to wear rubber-soled slippers. Apply an ankle-foot orthotic device to the client's feet.

"What could I have done to deserve this illness?" The client's terminal illness might prompt the client to review their life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to them.

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? "What could I have done to deserve this illness?" "I blame medical science for not curing me." "Where is my daughter at a time like this?" "Will I ever begin to feel in charge of my life again?"

Place client... Wear.. Use antimicrobial.. Place the client in a room with negative-pressure airflow is correct. The nurse should place the client in a room with negative-pressure airflow to meet the requirements of airborne precautions.Wear gloves when assisting the client with oral care is correct. The nurse should wear gloves when assisting the client with oral care to meet the requirements of standard precautions, which the nurse must adhere to for all clients regardless of their diagnosis. The nurse should wear gloves whenever their hands might come in contact with a client's bodily fluids, such as saliva, and the mucous membranes in the mouth.Limit each visitor to 2-hr increments is incorrect. The nurse does not need to limit the client's visitors. However, the nurse should limit the client's presence outside the room and the client should wear a surgical mask when outside of the room.Wear a surgical mask when providing client care is incorrect. The nurse should wear an N95 respirator during client care to meet the requirements of airborne precautions.Use antimicrobial sanitizer for hand hygiene is correct. The nurse should use antimicrobial sanitizer for routine hand hygiene when caring for a client who has tuberculosis. Nurses should also wash their hands with soap and water when their hands are visibly soiled.

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? (Select all that apply.) Place the client in a room with negative-pressure airflow. Wear gloves when assisting the client with oral care. Limit each visitor to 2-hr increments. Wear a surgical mask when providing client care. Use antimicrobial sanitizer for hand hygiene.

Skin blanching Skin blanching, edema, and coolness at the IV site indicate infiltration.

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration? Purulent exudate Warmth Skin blanching Bleeding

Instruct the family to refrain from pushing the button for the client while she is asleep. The nurse should instruct family members not to activate the button for the client while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain.

A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take? Instruct the family to refrain from pushing the button for the client while she is asleep. Inform the client that because she is on PCA, vital signs will be taken every 8 hr. Teach the client to avoid pushing the button until pain is above a 7 on a scale of 0 to 10. Increase the basal rate and shorten the lock-out interval time if the client's pain level is too high.

Withhold the blood transfusion. The principle of autonomy ensures that a client who is competent has the right to refuse treatment.

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? Ask the client to consider a direct donation. Withhold the blood transfusion. Request a consultation with the ethics committee. Ask the client's family to intervene.

"Maintain a consistent time to wake up each day." The client should maintain a consistent time for waking up and going to sleep. This helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client.

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make? "Drink a cup of hot cocoa before bedtime." "Maintain a consistent time to wake up each day." "Exercise 1 hour before going to bed." "Watch a television program in bed before going to sleep."

"The pain is like a dull ache in my stomach." The client is describing the quality of the pain, which is how the pain feels in the client's own words.

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? "I'm having mild pain." "The pain is like a dull ache in my stomach." "I notice that the pain gets worse after I eat." "The pain makes me feel nauseous."

"I flushed what I urinated at 7:00 a.m. and have saved all urine since." For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings.

A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? "I had a bowel movement, but I was able to save the urine." "I have a specimen in the bathroom from about 30 minutes ago." "I flushed what I urinated at 7:00 a.m. and have saved all urine since." "I drink a lot, so I will fill up the bottle and complete the test quickly."

Dysrhythmias is incorrect. The client's potassium level is within the expected reference range. Therefore, the client is not at an increased risk for dysrhythmias. Bleeding is correct. The client's platelet count is less than the expected reference range. Therefore, the client is at risk for bleeding. Infection is incorrect. The client's WBC count is within the expected reference range. Therefore, the client is not at an increased risk for infection. Drop Down 2: Platelet count is correct. The client's platelet count is less than the expected reference range. Therefore, the client is at risk for bleeding. WBC count is incorrect. The client's WBC count is within the expected reference range. Therefore, the client is not at an increased risk for infection. Potassium level is incorrect. The client's potassium level is within the expected reference range. Therefore, the client is not at an increased risk for dysrhythmias.

A nurse is caring for a client. Exhibit 1 Client is receiving chemotherapy for treatment of breast cancer. (Fill in the blank)

A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others.

A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity? A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes. A client who has a do-not-resuscitate (DNR) order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family. A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse previously promised to administer.

Passive ROM Plantar flexion contractures Left heel Client is repositioned every 2 hr is incorrect. The nurse should reposition the client every 2 hr to reduce the risk for skin breakdown. Therefore, this finding does not require intervention at this time. Passive range-of-motion exercises to lower extremities performed once each day is correct. The nurse should perform passive range-of-motion exercises to the client's lower extremities two to three times each day to reduce the risk for contractures. Feet warm. Pedal pulses 2+ bilaterally is incorrect. The nurse should identify that the client has adequate circulation to their feet. Therefore, this finding does not require intervention at this time. Plantar flexion contractures noted bilaterally is correct. The nurse should place a footboard at the end of the client's bed or apply foot boots to the client's feet to protect the client's heels and decrease the contractures. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact is correct. The client has a stage 1 pressure injury on the heel. The nurse should apply foot boots to the client's feet to protect the client's heels and promote healing.

The nurse is reviewing the client's medical record. Click to highlight the findings that require intervention by the nurse. To deselect a finding, click on the finding again. Client is repositioned every 2 hr. Passive range-of-motion exercises to lower extremities performed once each day. Feet warm. Pedal pulses 2+ bilaterally. Plantar flexion contractures noted bilaterally. Left heel with 1.3 cm x 1.3 cm (0.5 in x 0.5 in) area of nonblanchable erythema, skin intact.