Fundamentals practice test 2020 spring

A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of following physiological responses to prolonged immobility should the nurse expect?

Increased calcium excretion

A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Which of the following of eriksons developmental stages should the nurse consider in the planning?

Industry vs. inferiority

A nurse is reviewing information about the health insurance probability and accountability act (HIPAA), with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

Information about a client can be disclosed to family members at any time

A nurse is providing preoperative teaching by demonstrating diaphragmatic breathing to a client who is scheduled for surgery in the morning. Which of the following actions should the nurse include in the demo?

Inhale slowly and evenly though her nose

A nurse is developing a therapeutic relationship with a client. The nurse should preform which of the following actions during the working phase of a therapeutic relationship?

Instruct the client about methods to achieve goals

A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should preform isometric exercises every 2 hrs. Which of hte following actions should the nurse take as directed by the plan of care?

Instruct the client to tighten muscle groups for a short period, then Relax

A nurse is caring for several clients who are at various developments stages. The nurse should explain that, according to Erickson, acceptance of death is a primary task of which of the following stages of psychological development?

Integrity vs. despair

A nurse is instructing clients in the community about relationship development. The nurse should explain that according to Erickson, establishing relationships with commitment is a primary task of which of the following stages of psychological development?

Intimacy vs. isolation

A nurse intercepts a messenger at the nurses station who has a flower delivery for a client on the unit. As the nurse accepts the flowers, the messenger says "I know mrs. Welch from the neighborhood. What happened to her?" Which of the following response should the nurse provide?

It's my responsibility to remind you that we have to respect our clients privacy

A nurse is talking with a client who is about to start using transcutaneous Electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

It's unfortunate that I have to be in the hospital for this treatment

A nurse is asking an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client?

Kyphosis

A nurse is caring for a client who requires cold application with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?

Apply the bag for 30 mins at a time

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the clients level of strength?

Ask the client to push her feet against the nurses palms

A nurse is caring for aclinet who is 1 day post-op following gynecologic surgery and reports incisional pain. Which of hte following actions should the nurse take first?

Ask the client to rate her pain on a scale from 0-10

Before administering a medication to a client, the nurse must identify the client which of hte following methods of idenificaiton should the nurse use?

Ask the clients full name and date of birth

A nurse is caring for a client who has mental health disorder. The client asks about his medications and their effects. The nurse asks the client why he needs to know this. Which of the following nontherapeutic communication techniques is the nurse using?

Asking for an explanation

A nurse is assessing a clients radial pulse and determines that hte pulse is irregular. Which of the following actions should the nurse take?

Asses the apical pulse for a full minute

A client recieves a wrong medication. The nurse who made the medications error should take which of the following actions first?

Asses the client

A nurse in a clinical is interviewing a client who will undergo diagnostic testing. The nurse should ask about a clients pote tío al allergies during which phase of the nursing process?

Assessment

A client tells the nurse that he suspects that he grinds his teeth at night. The nurse should explain that the client should see a dentist for this problem, which she should document as which of the following disorders?

Bruxism

A nurse notices an assistive personnel (AP) preparing to deliver a food tray to a client who practices the orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?

Call the dietary department and ask for a kosher tray

A nurse is assessing a client circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

Carotid

A nurse is teaching a client about crutch walking use the three point gait. Which of the following statements by the nurse should be included in the teaching?

Move both crutches forward while standing on the unaffected leg, then lift and swing your body past the crutches

A nurse Is caring for an older adult client who was alert and orientated at admission, but now seems increasingly restless and intermittently confused. Which of hte following actions should the nurse take to address the clients Safety needs??

Move the client to a room closer to the nurses station

A nurse asks a client to share personal stories. Which of the following types of interventions is the nurse use instagram to promote the development of nurse-client relationship?

Narrative interaction

A nurse is complete in a clients history and physical examination. Which of the following information should the nurse consider subjective data?

Nausea

A nurse is providing care to a client who is on strict bed rest following surgery. The nurse assist the patient to the bedside commode and the client sustains an injury to the operative area. Which of the following types of torts has the nurse committed?

Negligence

A client is smoking in his bathroom has dropped a cigarette butt into a waste paper basket, which begins to smolder. Which of the following actions is the nurses priority?

Move any clients in the immediate vicinity

A nurse is preparing a sterile field. Which of the following actions should the nurse preform when opening the sterile pack?

Reach around the pack and open the top flap away from the body

A nurse is preparing to administer an intramuscular (IM) injection of meperidine to a client. Which of the following is the priority assessment the nurse should complete?

Respiratory rate

A nurse is caring for client who sustained blood loss. Which of hte following is a manifestation of hypovolemia?

Weak pulse

A nurse is discussing indication for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include?

-relief of urinary retention -measurement of residual urine after urination -an open perineal wound

A nurse is rehearsing assertive communication approaches to use when declining leadership of a nursing department committee. Which of the following statements should the nurse make?

"I decline the opportunity at this time."

A nurse is preparing to administer naproxen 500 mg PO BID for a client who has osteoarthritis. The amount available is naproxen 125 mg/5 mL oral suspension. How many mL should the nurse administer per dose?

20 mL

A nurse is caring for a client within the intimate zone of the clients personal space. The nurse should perform which of the following activities in this space?

-auscultating heart sounds - changing a dressing

A charge nurse is making client care assignments. Which fo the following tasks should the nurse delegate to assistive personnel (AP)? (Select all)

-bathe a client who had an amputation 2 days ago -assist a client to ambulante using a gait belt -feed a client who had a stroke 3 months ago

A nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the client?

-broth -grape juice -lemon gelatin

A nurse is providing hygiene care for a client who is immobile. Which of hte following actions should the nurs take?

-check for personal items when changing the bed linens -keep the bath water temperature between 110-115 degrees F -shave the clients hair in the direction of the hair growth

A nurse is assessing a client who is experiencing complications due to immobility. Which of following finding should the nurse expect?

-contractures of the extremities -crackles in the lungs -pressure ulcers

A nurse is working with a team of nursing personnel within a facility. Which of the following are necessary tasks performance roles that members of the group or the leader must preform? (Select all)

-coordinator -evaluator -energizer

A nurse is having difficulty caring for a client due to variables affecting the communication process. Which of the following should the nurse identify as an interpersonal variable? (Select all)

-education -gender -perception

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following situations requires that the nurse wear gloves?

-emptying urine from an in dwelling urine collection bag -providing oral care -changing an ostomy pouch

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation?

-excessive laxatives -ignoring the urge to defecate -inadequate fluid intake

A nurse is assessing a client who has DM and reports foot pain the nurse evaluates the client for which of the following alterations as indications that the client has an infection?

-increase in neutrophils -localized edema

A nurse is adhering to standard precautions while caring for a group of clients. For which of hte following tasks should the nurse wear protective eye equipment?

-irrigating a clients abdominal wound -suctioning a client s new tracheostomy tube

a nurse is adhering to standard precautions while caring for a group of clients. for which of the following tasks should the nurse wear protective eye equipment?

-irrigating a clients abdominal wound -suctioning a clients new tracheostomy tube

A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion?

-more difficulty seeing due to a greater sensitivity to glare -decreased cough reflex -decreased bladder capacity -dehydration of intervertebral discs

A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which fo the following actions should the nurse take?

-offer the client a back rub -remind the client to use incisional splinting -identify the clients pain level -change the clients position

A nurse is caring for a client who requires isolation for active TB. Which of the following precautions should the nurse include when creating a sign to post outside the clients room?

-protective mask -closed door -puncture proof sharps container -hand hygiene

A nurse is preforming care activities for a client in the zone of touch that requires his consent. Which of the following actives shoul the nurse perform in this zone?

-removing the clients dentures -palpating for pedal edema -counting a radial pulse

A nurse is receiving a providers prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription?>

-repeat the order back to the provider -question any part of hte Order that is unclear or inappropriate -transcribe the Order into the clients health record

A nurse is asssessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect?

-report of feeling pressure -tenderness over the symphysis pubis -distended bladder -voiding 30 mL frequently

A nurse is assessing a client who has narcolepsy. Which of the following findings should the nurse expect (select all)

-sudden attacks of sleep -hallucinations at the onset of sleep

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take?

-teaching the client to use the call light -keep the clients bed in the lowest position -place a fall risk identification band on the clients wrist

A home health nurse is conduction a home safety assessment for an older adult client. Which of the following finding should the nurse identify as a safety risk for hte client?

-water heater temperature 130 degrees F -throw rug

A nurse is caring for a client who has hypernatermia and requires IV fluid therapy due to his NPO status. Which of hte following solutions should the nurse prepare to infuse for this client?

0.45% sodium chloride

A nurse is preparing to administer meperidine 35 mg IM to a client every 6 hr PRN for pain. available is meperidine injection 75 mg/mL. How many mL should the nurse administer per dose?

0.5 mL

A nurse is preparing to administer methylnaltrexone 12 mg subcutaneously to a client who has opioid induced constipation. Available is methylnaltrexone 8 mg/0.4 mL. How many mL should the nurse administer?

0.6 mL

A nurse is preparing to insert an IV catheter for a client and has selected the insertion site. Place the following steps in the order in which the nurse should preform them

1) apply a tourniquet or BP cuff 2) cleanse the site with an antiseptic swab 3) dilate the vein 4) insert the catheter 5) flush the catheter (the answer is incorrect but it does not tell me the right order)

A nurse is preparing to exit the room of a client who has MRSA in a draining wound. Identify the sequence the nurse should follow before leaving the clients room (move the steps into the box on the right by placing them in order of performance)

1) gloves 2) eyewear 3) gown 4) mask 5) hygiene

A nurse in a long term care facility enters the day room and finds the window curtains on fire. Clients are panicking and the room is filling with smoke . Indicate the emergency actions the nurse must take

1) remove the clients from the room 2) activate the fire alarm 3) close the door 4) extinguish the fire

A nurse is documenting the intake for a client who is scheduled for an abdominal computed axial tomography (CT) CSF a. Prior to the scan, the client consumes 12 oz of sodium diatriozate and meglumine diatrizoate. The client has an IV of D 5 1/2 NA running at 75mL/hr form 0700 until 1200. The IV runs at 30 mL/hr from 1200 to 1500. At 1500, the client has an 6 oz juice. How many mL should the nurse document as the clients intake for the shift?

1,005 mL

A nurse is calculating the total fluid intake for a client during a 4 hr period. The client consumes 1 cup of coffee, 4 oz of orange juice, 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth, and 3 oz of water. The nurse should record how many mL of intake on this clients record?

1,170 mL

A nurse is calculating a clients intake and output for an 8-hr shift. The clients intake included 1,000 mL 0.9% sodium chloride IV , onc 6-oz cup of coffee, 6 oz of water ,one 180 mL bowl of soup, 3 ox of flavored gelatin, and 3 oz of ice cream. How many mL should the nurse document as the clients total intake for the shift?

1,720 mL

A nurse is preparing to administer levothyroxine 0.175 mg PO once a day. The amount available is levothyroxine 88 mcg/tablet. How many tablets should the nurse administer per dose?

1.9886 = 2

A nurse is preparing to administer moxifloxacin 400 mg by intermittent IV bolus over 60 mins. Available is moxifloxacin 400 mg in 250 mL dextrose 5% (DSW). The drop factor of the manual IV tubing is 15gtt/mL. The nurse should set the manual IV infusion to deliver how many get/min?

63 get/min

A nurse is preparing to administer 0.9% sodium chloride 1,000 mL IV to infuse over 8 hrs. The nurse should set the IV pump to deliver how many mL/hr?

125 mL/hr

A nurse is Devin a clients prescription for 1,000 mL of 5% dextrose in water IV to infuse over 8 hr. At 1400, the nurse observes that there is 500 mL of solution remaining in the clients current IV bag. At what time should the nurse administer the next bag of IV solution?

1800

A nurse in the ED is preparing to administer naloxone 0.4 mg IV bolus to a client who has opioid-induced respiratory depression. Available is halo one injection 02.mg/mL. How many mL should the nurse administer per dose?

2 mL

A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x ray, and a positive Mantoux test. Room 208 is a private, negative pressure airflow room; 212 is a semi positive pressure airflow room; 214 is a negative pressure semi private room and room 216 is a private positive airflow room. To which of the following rooms should the nurse assign the client

208

A nurse is calculating the intake of a client during the past 9 hr. The clients intake includes lactated ringers IV at 150 mL/hr, cefazolin 2 g IV intermittent bolus in 100 mL of 0.9% sodium chloride two units of packed RBC of 275 mL and 250 mL; two IV bolus infusion of 250 mL of 0.9% sodium chloride, ranitidine 50 mg IV intermittent bolus in 50 mL of destroce 5% in water. How many mL of intake should the nurse record?

2525 mL

A nurse is preparing to administer 1,000 mL of lactated Ringer's IV over 6 hrs. The drop factor of the manual IV tubing is 10 gtt/min. The nurse should set the manual IV infusions to devlier how many gtt/min?

28 gtt/min

A nurse is preparing to administer gabapentin 900 mg PO once daily for a client who has neuropathic pain. The amount available is gabapentin 300 mg/capsule. How many capsules should the nurse administer per dose?

3 capsules

A nurse is preparing to administer digoxin 12 mcg/kg/day PO to divide equally every 12 hr to a school age child who weighs 66 lbs. available is digoxin elixir 0.05 mg/mL. How many mL should the nurse administer per dose?

3.6 mL

A nurse is preparing is infuse a 250-mL unit of packed RBC over 2 hrs. The drop factor of manual IV tubing is 15 gtt/mL. The nurse should adjust the flow rate to deliver how many drops per minute?

31 gtt/min

A nurse is preparing to instill 840 mL of enteral nutrition via a clients gastrostomy tuve over 24 hr using an infusion pump. The nurs should set the infusion pump to deliver how many mL/hr?

35 mL/hr

A nurse is preparing ato administer amoxicillin 320 mg PO every 12 hrs to an infant. The amount available is amoxicillin suspension 200 mg/5mL. How many mL should the nurse administer per dose?

4 mL

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 reading should the nurse expect?

4.0

A nurse is caring for a client who has DVT and is receiving IV fluid that contains 10,000 units of heparin in 500 mL infusing at 1,000 units/hr. When calculating the clients intake and output, how much should the nurse document as intake form this infusion in an 8-hr shift?

50 mL (how to do it: 10,000units/ 500mL = 1,000units/ X mL)

A nurse is completing an 8-hr I&O record for a client who consumed 4 oz of juice, 6 oz of hot tea, 100 mL ice chips, an IV bolus 150mL, and an 8 oz broth. The nurse should record how many mL of intake on the clients record?

790 mL

A nurse is preparing to administer 5% dextrose in 0.45% sodium chloride 1,000 mL IV to infuse over 12 hrs. The nurse should set the IV pump to deliver how many mL/hr?

83 mL/hr

A nurse is preparing to administer an IV fluid bolus of 500 mL 0.9% sodium chloride over 60 mins. The drop factor of the manual IV tubing is 10 get/mL. The nurse should set the manual IV infusion to deliver how many get/mins?

83.33= 83 gtt/min

A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection into the clients ventrogluteal muscle?

90 degrees

A charge nurse is anticipating he admission of four clients and plannning their room assignments. Which of hte following client should the nurse assign to the room closest to the nurses station?

A client who sustained a head injury and is having periods of confusion

A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Which of the following should the nurse include as a criterion for applying restraints?

A nurse has already considered alternatives to restraints

While auscultating a clients heart sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this findings as which of the following?

A systolic murmur

A provider prescribes a sublingual medication for a client who has an NG tube in place. Which of the following actions should the nurse take?

Administer the mediation under the clients tongue

A nurse assumes a variety of roles while working with clients. Which of the following describes the nursing role of protecting the client and supporting the clients decisions?

Advocate

A nurse is admitting a client who has TB and a productive cough. Which of the following types of isolation precaution should the nurse initiate for the client?

Airborne

A nurse is admitting a client who reports anorexia and is experiencing malnutrion. Which of the following lab findings should the nurses expect to be altered?

Albumin

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?

An older adult who has a hip fracture and is buck traction

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?

Apply 4-5 mL of liquid soap to the hands

A nurse is implementing direct nursing care for a group of clients in an acute care facility. Which of the following actions by the nurse is considered an indirect nursing care activity?

Assigning tasks to an assistive personnel (AP)

A nurse is assessing a clients peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse?

At the ankle

A nurse is preparing to administer a pre-packaged oral medication to a client and complete the final medication check. At which of the following times or places should the nurse preform this final check?

At the clients bedside before administration

A nurse is caring for a client who experienced a lacerated sleepy and has been on bedrest for several days. The nurse ausculatates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this findings is most likely an indication of which of the following?

Atelectasis

A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include I the clients plan of care?

Ausculate breath sounds at least ever 2 hrs

An assistive personnel (AP) reports a clients vital signs as tympanic temperature 98.8 degrees F, pulse 92/min, RR 18/min, BP 95/58 mmHg. Which of the following vital signs should the nurse re-measure?

BP

A nurse is ready to inset an in dwelling urinary catheter for a female client. Which of the following instruction should the nurse give the client as the catheter is inserted?

Bear down

A nurse is teaching a client who has strained her back muscles while preparing to move to a new apartment. Which of the following instructions should the nurse include?

Bend at the knees when picking up an object

A nurse is caring for a client who has an in dwelling urinary catheter and notes blood tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

Bladder infection

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?

Blood

A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walk and Saftey of hte client, which of the following actions should the nurse take?

Check that the clients lifts the walker and then places it down in front of her

A nurse is caring for a client who came to the ED with abdominal distensión and is now on the medical-surgical unit with an NG tube in place to low gastric suction. The client is reporting anxiety, discomfort, and a feeling of bloating. Which of the following actions is the nurse's priority?

Check to see if the suction equipment is working

A nurse is assessing a clients cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

Checking the pupillary response to light

A nurse is caring for a client who is about to have a colonoscopy. The client states "I am so nervous about what the doctor might find during the test". The nurse asks the client "are you feeling anxious about the results of your colonoscopy?" With this question, the nurse is using which of the following communication techniques?

Clarification

A nurse is providing nail care for a client. Which of the following actions should the nurse take?

Clean under the nail with an orange stick

A nurse is caring for a client who has a wound infection. Which of the rolling actions should the nurse take when obtaining a wound drainage specimen for culture?

Cleanse the wound with a 0.9% sodium chloride saline irrigation before obtaining the specimen

A nurse is asssisiting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse rely on for accurate information about eh client?

Client concern

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?

Collect and organize client data

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mmHg, and temp 98.2 degrees F. Which of the following actions should the nurse preform?

Complete a neurological check

A nurse is preparing a clients evening dose of risperidone when the tablet falls on the countertop. Which of hte following actions should the nurse take?

Discard he tablet and obtain another dose of medication

The family of an older adult client brings him to the ED after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the clients behavior?

Confusion

A nurse is assessing for cyanosis in client who has dark skin. Which of following sites should the nurse examine to identify cyanosis in this client?

Conjuntivitis

A nurse is discussing the norming stage of the group development process with a student nurse. Which of the following statements by the nurse indicates understanding of the discussion?

Consensus evolves in this stage

When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take?

Contact the provider to question the dosage

A nurse is caring for a client who is post-op following an abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the clients lunch tray?

Cranberry juice

A nurse is caring for a client in the ED who, 2 hr earlier, severed the tip of a finger in an accident. During the assessment the nurse detects a strong smell of alcohol form the clients breath. For which of the following findings should the nurse assess first?

Date of the clients last tetanus immunizations

A nurse in the ED is caring for a client who collapsed after playing football on a hot day. After reviewing the admission laboratory findings, the nurse recognizes that these findings are consistent with which of the following conditions?

Dehydration

A nurse in a dialysis center is caring for a client who has a new diagnosis of end stage kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, "I decided to come today, but I am not sure if i will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again". The nurse should identify that this client is demonstrating which of the following Kubler-Ross stages of grieving?

Denial

A nurse is admitting a cleat who has a partial hearing loss. Which of the following is the priority action by the nurse?

Determine if the client uses hearing aids

A nurse is developing the plan of care for a client who does not speak the same language as the nurse. Which of the following Interventions should the nurse include?

Determine the clients level of fluency in his primary language

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse preform first?

Determine the location of the pain

A nurse is planning preoperative care for a client who will undergo surgery. Which of the following is the priority action by the nurse?

Determine what the client knows about the surgery

A nurse prepares to replace the nearly empty container of total parenteral nutrient (TPN) for a client when she finds that ether has been a delay in receiving hte new container of solution form the pharmacy. Which of the following solutions should the nurse infuse until the next container of TPN solution becomes available?

Dextrose 10% in water

A nurse i orienting a newly licensed nurse about documentation of a clients information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?

Documentation is a communication tool for the inter professional health care team

A nurse is inserting an IV catheter for a client in preparation for an outpatient procedure. Which of hte following vein should the nurse select?

Dorsal metacarpal vein

A nurse is admitting a client who has pertussis. Which of the following types of transmission based precautions should the nurse indicate?

Droplet

A nurse is assessing an IV infusion site on an infants left hand. Which of the following finding should the nurse identify as an indie I AOTA of an infiltration?

Edema in the palm of the hand

A nurse is planning to car for a client who has decreased level of consciousness. The client is receiving continuous enteral feeding via a gastronomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Elevate the head of the clients bed 30-45 degrees

A nurse is caring for a client in the orientation phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase?

Elicit information from the client

A nurse is caring for a client who expresses anxiety his impending surgery. Which of the following actions should the nurse take?

Explore the clients feelings

A nurse is caring for a client who has a new diagnosis of type 1 DM. To focus on effective learning with this client, which of the following interventions should the nurse use?

Explore the clients feelings about dietary modifications

A nurse is caring for a client who refuses treatment and asks to be discharged fro meh hospital against medical advice. The nurse notifies the clients provider, who tells the nurse to restrain the client, if necessary, to keep her from leaving the hospital. The nurse understands that restraining this client would be considered which type of civil action by the nurse?

False imprisonment

A nurse is teaching a client about the physical effects of chemotherapy. Following the teaching, the nurse asks the client to describe one physical effect. The nurse if focusing on which of the following elements of the communication process?

Feedback

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 flex action contractures?

Footboard

A nurse is assisting an older adult client who sometimes loses her balance while walking. Which of hte following decides should the nurse use when helping the client ambulate?

Gait belt

A nurse has just finished a wound irrigation for a client who requires contact precaution. Which of hte following pieces of PPE should the nurse remove first?

Gloves

A nurse is removing PPE after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?

Gloves

A nurse is caring for a client who has a prescription for a clear liquid diet. Which of te following foods should the nurse allow the client to have?

Grape juice

A nurse i caring for a client who has an electrical burn. With the clients permission the nurse is answering questions form the family about his status. Which of the following responses should the nurse make?

He has an electrical burn. He is stable, and we will update you with any changes

A nurse is preparing an educational program for a group of newly licensed nurses about client confidentiality. The nurse should explain that nurses may share a clients protected health information with which of the following groups?

Health care team members caring for the client

A nurse is caring for a client who has active pulmonary TB. The client requires airborne precaution and is receiving multidrug therapy. Which of the following preucations should the nurse take to transport the client safely to the radiology department for an x-ray?

Heave the client wear a mask

A nurse is preparing to administer a cleaning enema to a client. Which of the following actions should the nurse take?

Hold the container of solution 30 cm (12 in) above the anus

A nurse is preparing to administer ophthalmic solution to a client. Which of the following actions should the nurse take?

Hold the ophthalmic solution 2 cm (3/4in) above the lower conjunctival sac

A nurse is teaching a client about carbon monoxide poisoning. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

I can detect the presence of carbon monoxide by a metallic odor

A nurse is assisting a client who has received crutches in an urgent caer center following a foot injury. Which of the following stamens should the nurse identify as an indication that the client needs further teaching?

I have a set of my brothers crutches in my basement i can also use

A nurse is caring for a client who has a new diagnosis of chronic kidney disease. Which of the following statements should the nurse identify as an indication of anticipatory grieving?

I just can't believe that this dialysis is going to ruin my whole life

A nurse is instructing a young adult about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

I watch TV until I fall asleep at night

A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understand when discharge planning should be implemented?

I will begin upon the clients admission to the facility

A nurse is reinforcing teaching with a client about using transdermal patches at home. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

I will clean and dry the area before applying hte patch

A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. The client says "go away; no one can help me". Which of the following responses should the nurse make?

I will come back later and we can talk

A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of te following response should the nurse make?

I will cover the catheter so he cannot see it

A nurse is teaching a client who has a history of falls about home Saftey. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

I will place a bath seat in my shower to use when I bathe

A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations .which of the following client statements should indicate to the nurse the need for additional teaching?

I will take my medications at the first sign of an attack

A nurse is providing teaching to an assistive personnel (AP) about caring for clients with restraints. Which of the following statements by the AP indicates an understanding of the teaching?

I will tie a restraint to the portion of the bed that moves when the head of the bed is moved

A nurse is teaching an assistive personnel (AP) about using PPE while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions?

I will wear gloves and a gown when bathing a client who has open skin lesions

A nurse is providing discharge teaching for a client who requires home O2 therapy. Which of the following statement should the nurse identify as an indication that he client needs further teaching?

I will wear synthetic clothing and woolen socks when using my O2

a nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

I will wear synthetic clothing and woolen socks when using my oxygen

A nurse receives a client care assignment form the charge nurse that he believes is unfair. The nurse voices his concern to the charge nurse. The nurse is using which level of communication at this time?

INTERpersonal

A nurse is discharging a client who came to the outpatient clinical with an ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands the discharge instructions?

Ill apply ice to my ankle today and tomorrow

A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. Which of hte following statement should the nurse identify as an indication that he client requires further classification?

Ill sit with my knees lower than my hips

A nurse instructs a female client about collecting a midstream urine sample. Which of hte following client stamens indicates an understanding of the procedure?

Ill use the cleaning wipe from front to back

A nurse identifies a pressure ulcer after a client had a long extensive recovery following a surgical procedure. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions?

Include any relevant statements the client made about the ulcer

A nurse is caring for an older adult client who states "I am afraid that I may fall while talking to the bathroom during the night". Which of the following actions should the nurse take?

Leave a nightly on in the clients room

A nurse is preparing to obtain a blood specimen from a client by venipuncture. The client is receiving IV fluids through an IV catheter inserted in the basilic vein of the right forearm. Which of the following sites should the nurse plan to use to obtain the blood specimen?

Left forearm

A nurse is preparing medication for a client when another client has an emergency. Which of the following actions should the nurse take?

Lock the medication in a room and finish preparing it after returning form the emergency

A nurse is assisting with transferring a client from the bed to a wheelchair. Which of the following actions should the nurse take?

Lock the wheels of the bed and the wheelchair

A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to ausculatet the clients apical pulse.

Lowest end on the left side of patient

A nurse accidentally administers the wrong mediation to a client which results in a severe allergic reaction and prolongs the clients hospitalization. The client could rightfully sue the nurse for which of the following?

Malpractice

A nurse is caring for a client who requires droplet precautions. Which of the following PPE should the nurse wear when settin up the clients meal tray?

Mask

A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of hte following actions should the nurse take?

Measure from the heel to the popliteal space

A nurse has completed an informed consent form with a client. The client then states, "I have changed my mind and do not want to have the procedure done". Which of the following actions should the nurse take?

Notify the surgeon that the client wishes to withdraw informed consent for the procedure

A nurse is caring for a client who has RA and is experiencing difficulty feeding herself using adaptive devices. The nurse should initiate a referral with which of the following members of the interprofessional health care team?

OT

A nurse is caring for a client who has peripheral vascular disease and report difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take tp promote the clients comfort?

Obtain a pair of slipper socks for the client

A nurse is caring for a client who states, "i have got to get out of this hospital! They have found my address and are coming for my family!" The nurse responds, "dont worry, no one will harm your family". Which of the following types of communication breakdown does this response represent?

Offering false reassurance

A nurse is preparing a sterile field. Which of the following actions should the nurse identify has contaminating the field?

Opening a sterile package over the middle of the sterile field

An nurse in a clinical is caring for a client who report pain, crepitus and a popping sound in his temporomandibular joint. Based on these findings, to which of the following provider should the nurse request a referral for the client?

Oral surgeon

A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Pain

A nurse is attending a social even when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which of hte following actions should the nurse take?

Perform the heimlich maneuver

A newly licensed nurse is seeking advise from her preceptor about the need to purchase personal professional liability insurance. Which of hte following statements should the preceptor make?

Personal liability coverage is not mandatory, but you should consider purchasing you own coverage

A nurse is preparing to administer three liquid medications to a client who has an NG tube with intermittent suction. Which of the following actions should the nurse take?

Pinch the tube prior to attaching the mediation syringe

A nurse is preparing to administer the hepatitis B vaccine to a client. Which of the following techniques should the nurse use to located the deltoid muscle?

Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspects of upper arm

A nurse in a long term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control?

Places clean linen that touches the floor in the soiled linen bag

A nurse is caring for a client who is not cooperating with his care and demonstrations defiant behavior. The nurse chooses to confront this client. Which of the following approaches should the nurse use when using confrontation?

Point out inconsistencies in the clients behavior

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the clients infections?

Preforming hand hygiene before, during and after direct contact with the client

A nurse is teaching a newly hired group of assistive personnel (AP) about infection control measures on the unit. It is crucial for the nurse to remind that APs that which of the following is the most effective way to prevent the spread of pathogens during client care?

Preforming hand hygiene frequently and consistently

A nurse is assessing a clients bowel sounds. At which of the following points in the assessment should the nurse auscultate the clients abdomen?

Prior to percussion the abdomen

A nurse is caring for a client who has an also genetic hematopoietic stem-cell transplant. Which of the following infection-control precautions should the nurse use while caring for this client?

Protective

A nurse is caring for a client who has limited hand movement. Which of the following actions should the nurse take to assist the client with feeding?

Provide an adaptive feeding device for the client

A nurse I s caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the clients skin?

Provide the client with a diet high in protein

A nurse is caring for a client who is discussing his PTSD and states: "everyone thinks you should be able to put it out of your mind. It happened so long ago- just get over it!" The nurse responds, "it must be very frustrating to encounter this kind of attitude?" The nurse is using which of hte following therapeutic techniques?

Reflection

As part of an annual physical examination, a nurse is preparing a client to undergo chest X-Ray. Which of the following instructions should the nurse give the client prior to the procedure?

Remove all metal necklaces

A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?

Remove the catheter and insert another into a different area

A nurse is working with an AP while caring for a surgical client who is 1 day post-op. Which takes should the nurse take responsibly for completing?

Removing the abdominal dressing

A nurse is auscultations a clients lung sounds and identifies crackles in the left lower lobe. Which of the rolling interventions should the nurse take?

Repeat auscultation after asking the client to breath deeply and cough

A nurse finds an open vial of morphine lying on top of the cabinet in a clients room. Which of the following actions should the nurse take?

Report the discrepancy immediately

A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the folllwing actions is an example of a violation of confidentiality ?

Reporting laboratory findings to a member of the clients family

A nurse is developing a plan of care for a client who practices Islam. Which of the following actions should the nurse include in the plan?

Request a meal tray without pork

A nurse is planning to discharge a client who has quadriplegics to his home. The nurse suggests that the family might need respite care services. When a family member asks how respite care can help, which of the following responses should the nurse provide?

Respite care allows the primary caregiver time away from day to day responsibilities

A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following statements should the nurse include?

Rub all surface of you hands with an alcohol rub for 20 to 30 seconds

A nurse in a long term care facility is planning care for several clients. Which of the following activities should the nurse delegate to the licensed practice nurse (LPN)?

Scheduling a diagnostic study for a client

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Secure the restraints using a quick release tie

A nurse is caring for a client who needs a stool specimen collected. Which of the following actions should the nurse take when obtaining he specimen?

Send specimen container immediately to the lab

A nurse is assessing a client and discovers the infusion pump with the clients TPN solution is not infusing. The nurse should monitor the client for which of hte following conditions?

Shakiness and diaphoresis

A nurse is documenting information in a computerized health record. Which of hte following nursing actions jeopardizes client confidentiality?

Sharing computer passwords with coworkers

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?

Shivering

A nurse is caring for a client who is at 36 weeks of gestation and is on the antepartum unit for continuous close observation. The client confides to the nurse that she doesn't think she will ever be a mother and begins to cry. Which of the following response should the nurse make?

Sit quietly With the client and follow her cues

A nurse is caring for a client who is receiving heat applications ushering an aquathermia pad. Which of the following actions should the nurse take when applying the pad?

Stop the treatment if the clients skin becomes red

A nurse is preforming tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

Suction two to three times with a 60-second pause between passes

A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care professionals is responsible for obtaining informed consent form the client for the procedure?

Surgeon

A nurse in a long term care facility is caring for an older adult client who has dementia and being so have frequent episodes of urinary incontinence. After the provider determines no medical cause for hte clients incontinence, which of hte following interventions should the nurse initiate to mange this behavior?

Take hte client to the bathroom every 2 hrs

A nurse is re-admitting a client to the medical unit after a transfer to ICU following self-administration of an overdose of medication. The client looks down at the flood and mumbles, "hello". Which of the following responses should the nurse make?

Tell me a little more about what happened

A nurse is assisting with the admission of a client who is about to have elective surgery. The client tells the nurse she fells anxious. Which of the following responses should the nurse make?

Tell me about your concerns

A nurse is administering nasal decongestant drops fro a client which of the following actions should the nurse take?

Tell the client to blow her nose gently before the instillation

A nurse removes an indwelling urinary catheter than an older adult client had had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

Temporary urinary retention

A nurse is caring for a client in a long term care facility who is reviewing enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?

Test the pH of gastric aspirate

A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reports by the LPN indicated to the nurse the client has phlebitis at the IV insertion site?

The area surrounding the insertion site feels warm to the touch

A nurse is reviewing the goals of the nurse client therapeutic relationship with a client who is seeking counseling. Which of the following information should the nurse include in his discussion?

The client achieves optimal personal growth

A nurse is assessing a client at a follow up clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that he client is meeting this goal?

The client faces the direction of movement when sliding an object across the floor

A nurse is filling out an incident report after finding a client lying on the floor. Which of hte following information should the nurse include?

The client was lying on the floor next to his bed

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?

The client who has an NG tube to suction

A nurse is caring for a client whose postoperative. The nurse should base her pain management interventions primarily on which of the following methods of determining the intensity of the clients pan?

The clients self-report of pain severity

A nurse is observing a clients nonverbal behavior. When evaluating this behavior, the nurse should facto in which of the following principles influencing nonverbal communication?

The clients sociocultural background influences nonverbal communication

A nurse is assessing a clients cardiovascular system. To palpate for unexpected pulsations In the pulmonic area, at which anatomical location should the nurse place her finger?

The left second intercostal space

A nurse is preparing an educational presentation about organ donation for a group of newly licensed nurses. Which of the following information should the nurse include?

The nurse may serve as a witness to informed consent for organ donation

A nurse is caring for a client who has fallen while getting out of bed and states "Im ok! 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 clients medical record?

The provider was notified

A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The clients family asks the nurse for information about this type of care. Which of the following explanations should the nurse provide?

The service began with the clients admission to the hospital

A nurse is engaging in relationship counseling with a male client. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse client relationship?

They are more direct when discussing issues

A nurse on a medical unit is teaching a group of assistive personnel about handling clients bed linen es safely. Which of the following instructions should the nurse include?

Tie linen bags securely at the top

A nurse is caring for a client who recieves intermittent enteral feedings through and NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

To identify delayed gastric emptying

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Turn the client on his side before staring oral care

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?

Two nurses using a friction reducing device

A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider?

Urine output of 175 mL in the past 8 hr

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 help maintain the integrity of the clients skin?

Use a transfer device to lift the client up in bed

A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take?

Use attentive listening with the client

A nurse caring for a client is using active listening skills. Which of the following actions should the nurse take?

Use intermittent eye contact

A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include?

Use soap and water to wash the catheter after each use

A nurse administers an incorrect medication to a client. Following an assessment of the client, the nurse determines that the client has experienced no untoward effects San a result of the medication. The nurse does no complete an incident report because no harm came to the client. Which of the following ethical principles did the nurse violate?

Veracity

A nurse arrives for her shift and is preparing to count the controlled substances in the secure cabinet. Which of the following actions should the nurse take?

Verify that the amounts of each medication she counts matches the amount on the inventory record

A nurse is reviewing the lab results of a client who has a pressure ulcer. The nurse hold identity an elevation in which of the following lab values as an indication that the client has developed an infection?

WBC count

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?

Wash the area of the puncture throughly with soap and water

A nurse is orienting a new assistive personnel (AP) to the unit. For which of the following actions should the nurse intervene?

Washes and rinses her hands for 10 seconds

A nurse is caring for a client who has MRSA in an abdominal wound. The nurse enters the room to check the clients pulse. Which fo the following actions should the nurse take?

Wear CLEAN gloves

A nurse is planning care for a client who requires airborne precautions. Which of the following actions should the nurse take?

Wear an N95 respirator mask

A nurse is caring for a client whose partner asks to speak with the nurse. The partner relates her concerns about her spouse abusing alcohol and having difficult maintaining employment. Which of the following responses should the nurse make?

What have you done in the past to cope with this issue?

A nurse is admitting a client from a long term care facility. The nurse should use closed-ended questions when assessing which of hte following factors?

When asking if the client took his meds this morning

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?

When the client has the urge to defecate

A nurse at an extended care facility is instructing a class of assistive personnel (AP) about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about he clients use of cane?

When the client moves, he should move the cane forward first

A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should the nurse take regarding informed consent?

Witness the clients signature

A nurse enters an older adult clients room to insert a saline lock. The client asks the nurse, "why do I need that? I am drinking plenty of fluids." Which of the following response should the nurse provide?

Your provider has prescribed antibiotics therapy to be administered intravenously every 6 hrs

A nurse asks a client how he is feeling the client states "im feeling a bit nervous today". Which of the following responses should the nurse make?

please explain what you mean by the word nervous

a nurse is reviewing the goals of the nurse-patient therapeutic relationship with a client who is seeking counseling. which of the following information should the nurse include in the discussion?

the client achieves optimal personal growth

a nurse administers an incorrect medication to a client. Following an assessment of the client, the nurse determines that the client has experienced no untoward effects as a result of the medication. The nurse does not complete an incident report because no harm came to the client. Which of the following ethical principles did the nurse violate?

veracity