Fundamentals Reprint ATI
A nurse is caring for a client who weighs 80 kg (176 lbs.) and is 1.6 m (5ft 3in) tall. Calculate her body mass index (BMI) and determine whether this client's BMI indicates that she is of a healthy weight, overweight, or obese.
31.25 obese
A nurse is assessing a client as part of an admission history. The client reports drinking an herbal tea every afternoon at work to relieve stress. The nurse should suspect the tea includes which of the following ingredients? a. chamomile b. ginseng c. ginger d. echinacea
a
A client who has an indwelling catheter reports a ned to urinate. Which of the following actions should the nurse take? a. check to see whether the catheter is patent b. reassure the client that it is not possible for her to urinate c. recatheterize the bladder with a larger-gauge catheter d. collect a urine specimen for analysis
a
A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. Which of the following pain characteristics is the nurse attempting to determine? a. presence of associated manifestations b. location of the pain c. pain quality d. aggravating and relieving factors
a
A nurse in an outpatient clinic is caring for a client who has a new prescription for an antihypertensive medication. Which of the following instructions should the nurse give the client? a. "Get up and change positions slowly." b. "Avoid eating aged cheese and smoked meat." c. "Report any usual bruising or bleeding to the doctor immediately." d. "Eat the same amount of foods that contain vitamin K every day."
a
A nurse is caring for a client scheduled for abdominal surgery. The client reports being worried. Which of the following actions should the nurse take? a. offer information on a relaxation technique and ask the client if he is interested in trying it b. request a social worker see the client to discuss meditation c. attempt to use biofeedback techniques with the client d. tell the client many people feel the same way before surgery and to think of something else
a
A nurse is caring for a client who has a prescription for a 24-hr urine collection. Which of the following actions should the nurse take? a. discard the first voiding b. keep the urine in a single container at room temperature c. ask the client to urinate and pout the urine into a specimen container d. ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container
a
A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make? a. "Water helps clear the tube so it doesn't get clogged." b "Flushing helps make sure the tube stays in place." c. "This will help you get enough fluids." d. "Adding water makes the formula less concentrated."
a
A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse anticipate including in the plan of care? a. infuse hypotonic IV fluids b. implement a fluid restriction c. increase sodium intake d. administer sodium polystyrene sulfonate
a
A nurse is planning care for a client who is on bed rest. Which of the following interventions should the nurse plan to implement? a. encourage the client to perform anti embolic exercises every 2 hrs. b. instruct the client to cough and deep breathe every 4 hrs. c. restrict the client's fluid intake d. reposition the client every 4 hrs.
a
A nurse is preparing to admit a client who is suspected to have pulmonary tuberculosis. Which of the following actions should the nurse plan to perform first? a. implement airborne precautions b. obtain a sputum culture c. administer prescribed antituberculosis medications d. recommend a screening test for family members
a
A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as risk factors for the development of this electrolyte imbalance? a. Crohn's disease b. postoperative following appendectomy c. history of bone cancer d. hyperthyroidism
a
A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include? a. "Flush the tube before and after each medication." b. "Mix your medications with your enteral feeding." c. "Push tablets through the tube slowly." d. "Mix all the crushed medications prior to dissolving them in water."
a
A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? a. a client who has nasogastric suctioning b. a client who has chronic constipation c. a client who has syndrome of inappropriate antidiuretic hormone d. a client who took an overdose of sodium bicarbonate antacids
a
A nurse prepares an injection of morphine to administer to a client who reports pain. Prior to administering the medication, the nurse assist another client onto a bedpan. She asks a second nurse to give the injection. Which of the following actions should the second nurse take? a. offer to assist the client who needs the bedpan b. administer the injection the other nurse prepared c. prepare another syringe and administer the injection d. tell the client who needs the bedpan she will have to wait for her nurse
a
A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (select all that apply) a. review a signal the client can use if feeling any distress b. lay a towel across the client's chest c. administer oral pain medication d. obtain a Dobhoff tube for insertion e. have a petroleum-based lubricant available
a b
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (select all that apply) a. auscultate bowel sounds b. assist the client to an upright position c. test the pH of gastric aspirate d. warm the formula to body temperature e. discard any residual gastric contents
a b c
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (select all that apply) a. apply the oxygen source loosely if the SpO2 decreases during the procedure b. use surgical asepsis to remove and clean the inner cannula c. clean the outer surfaces in a circular motion from the stoma site outward d. replace the tracheostomy ties with new ties e. cut a slit in gauze squares to place beneath the tube holder
a b c
A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? (select all that apply) a. increase in incisional pain b. fever and chills c. reddened wound edges d. increase in serosanguineous drainage e. decrease in thirst
a b c
A nurse is assessing a client who has an acute respiratory infection that puts her at wrist for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? (Select all that apply) a. restlessness b. tachypnea c. bradycardia d. confusion e. pallor
a b d e
A nurse is teaching a client who has a new prescription for oxybutynin about managing the medication's anticholinergic effects. Which of the following instructions should the nurse include? (select all that apply) a. take sips of water frequently b. wear sunglasses when outdoors in sunlight c. use a soft toothbrush when brushing teeth d. take the medication with an antacid e. urinate prior to taking the medication
a b e
A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (select all that apply). a. older adults are more prone to dehydration than younger adults are b. older adults need the same amount of most vitamins and minerals as younger adults do c. many older men and women need calcium supplementation d. older adults need more calories than they did when they were younger e. older adults should consume a diet low in carbohydrates
a b c
A nurse is preparing a wellness presentation for families about health screening for adolescents. Which of the following information should the nurse include? (select all that apply) a. obtain a periodic mental status evaluation b. discuss prevention of sexually transmitted infections c. regularly screen for tuberculosis d. provide education about drug and alcohol use e. teach monthly breast examinations for girls
a b c d
A nurse is teaching a group of nursing students on complementary and alternative therapies they can incorporate into their practice without the need for specialized licensing or certification. Which of the following should the nurse encourage the students to use? (select all that apply) a. guided imagery b. massage therapy c. meditation d. music therapy e. therapeutic touch
a c d
A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining raid eye movement (REM) sleep, which of the following characteristics should the nurse include? (select all that apply) a. REM sleep provides cognitive restoration b. REM sleep lasts about 90 mins c. It is difficult to awaken a person in REM sleep d. sleep walking occurs during REM sleep
a c e
A nurse is reviewing complementary and alternative therapies which a group of nursing students. The nurse should classify which of the following interventions as a mind-body therapy? (select all that apply) a. art therapy b. acupressure c. yoga d. therapeutic touch e. biofeedback
a c e
A client who had abdominal surgery 24 hrs ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (select all that apply) a. cover the area with saline-soaked sterile dressings b. apply an abdominal binder snugly around the abdomen c. use sterile gauze to apply gently pressure to the exposed tissues d. position the client supine with his hips and knees bent e. offer the client a warm beverage, such as herbal tea
a d
A nurse is caring 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 client's skin? (select all that apply) a. keep the head of the bed elevated 30º b. massage the client's bony prominences frequently c. apply cornstarch liberally to the skin after bathing d. have the client sit on a gel cushion when in a chair e. reposition the client at least every 3 hrs while in bed
a d
A nurse is preparing to administer a 0900 medication to a client. Which of the following are acceptable administration times for this medication? (select all that apply) a. 0905 b. 0825 c. 1000 d. 0840 e. 0935
a d
A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? (select all that apply) a. apply suction while withdrawing the catheter b. perform suctioning on a routine basis, every 2 to 3 hrs. c. maintain medical asepsis during suctioning d. use a new catheter for each suctioning attempt e. limit total suctioning time to 5 minutes
a d e
A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary inanition? (select all that apply) a. stage III pressure ulcer b. sutured surgical incision c. casted bone fracture d. laceration sealed with adhesive e. open burn area
a e
A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications, that the client currently takes, should alert the nurse to a further risk for ototoxicity? (select all that apply) a. furosemide b. ibuprofen c. cimetidine d. simvastatin e. amiodarone
a b
A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? (select all that apply) a. warm the enema solution prior to instillation b. position the client on the left side with the right leg flexed forward c. lubricate the rectal tube or nozzle d. slowly insert the rectal tube about 5 cm (2in) e. hang the enema container 61cm (2in) above the client's anus
a b c
A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? (Select all that apply) a. repeat the details of the prescription back to the provider b. have another nurse listen to the telephone perscription c. obtain the provider's signature on the prescription within 24 hrs d. decline the verbal prescription because it is not an emergency situation e. tell the charge nurse that the provider has prescribed morphine by telephone
a b c
A nurse is instructing a client, who has an injury of the left lower extremity, about the use of a cane. Which of the following instructions should the nurse include? (select all that apply) a. hold the cane on the right side b. keep two points of support on the floor c. place the cane 38cm (15in) in front of the get before advancing d. after advancing the cane, move the weaker leg forward e. advance the stronger leg so that it aligns evenly with the cane
a b d
A nurse is determining a client's ability to learn self-monitoring of blood glucose using a glucometer. Which of the following abilities should the nurse confirm that the client has before proceeding with instruction? (select all that apply) a. finger dexterity b. visual acutiy c. color vision d basic literacy e. demonstration ability
a b e
A nurse is reviewing a client's medication history. The client has an admission blood glucose of 260mg/dL and no documented history of diabetes mellitus. Which of the following types of medications should alert the nurse to the possibility that the client has developed an adverse effect of pharmacological therapy? (select all that apply) a diuretics b. corticosteroids c. oral anticoagulants d. opioid analgesics e. antipsychotics
a b e
A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should recognize which of the following findings is a manifestation of dehydration? (select all that apply) a. Hct 55% b. serum osmolarity 260 mOsm/kg c. serum sodium 150mEq/L d. urine specific gravity 1.035 e. serum creatinine 0.6 mg/dl
a c d
A nurse in a residential care facility is assessing an older adult client. Which of the following findings should the nurse identify as atypical indications of infection? (select all that apply) a. urinary incontinence b. malaise c. acute confusion d. fever e. agitation
a c e
A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (select all that apply) a. Weber test showing lateralization to the right ear b. light reflex at 10 o'clock in the left ear c. indications of obstruction in the left ear canal d. Rinne test showing less time for air and bone conduction e. Rinne test showing air conduction less than bone conduction in the left ear
a d
A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a client who has recurrent UTIs. Which of the following factors should the nurse include? (select all that apply) a. frequent sexual intercourse b. lowering of testosterone levels c. wiping from front to back d. location of the urethra in relation to the anus e. frequent catheterization
a d e
A nurse is discussing direct and indirect contact modes of transmission of infection at a staff education session. Which of the following incidents are examples of direct mode of transmission? (select all that apply) a. a client vomits on a nurse's uniform b. a nurse has a needle stick injury c. a mosquito bites a hiker in the woods d. a nurse finds a hole in his glove while handling a soiled dressing e. a person fails to wash her hands after using the bathroom
a e
A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? a. give the client thin liquids b. instruct the client to tuck her chin when swallowing c. have the client use a straw d. encourage the client to lie down and rest after meals
b
A nurse is caring for a client who is having difficult breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? a. increase the oxygen flow b. assist the client to Fowler's position c. promote removal of pulmonary secretions d. obtain a specimen for aerial blood gasses
b
A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? a. auscultate breath sounds b. stop the feeding c. obtain a chest x-ray d. initiate oxygen therapy
b
A nurse is evaluating teaching on a client who has a new prescription for a sequential compression device. Which of the following client statements should indicate to the nurse the client understands the teaching? a. "This device will keep me from getting sores on my skin." b. "This thing will keep the blood pumping through my leg." c. "With this thing on, my leg muscles won't get weak." d. "This device is going to keep my joints in good shape."
b
A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? a. administer antihypertensive on schedule b. check on the client's weight each morning c. notify the provider of a urine output greater than 30mL/hr. d. encourage independent ambulation four times a day
b
A nurse is planning to use healing intention with a client who is recovering from a lengthy illness. Which of the following is the priority action the nurse should take before attempting this particular mind-body intervention? a. tell the client the goal of the therapy is to promote healing b. ask whether the client is comfortable with using prayer c. encourage the client participate actively for best results d. instruct the client to relax during the therapy
b
A nurse is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the nurse take? a. use a 22-guage needle b. select a site on the client's abdomen c. spread the skin with the thumb and index finger d. observe for bleb formation to confirm proper placement
b
A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure? a. check how long the feeding container has been open b. verify the placement of the NG tube c. confirm that the client does not have diarrhea d. make sure the client is alert and oriented
b
A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? a. pull down and out at the back of the upper denture to remove b. brush the dentures with a toothbrush and denture cleaner c. rinse the dentures with hot water after cleaning them d. place the dentures in a clean, dry storage container
b
A nurse is reviewing a client's medications. They include cimetidine and imipramine. Knowing that cimetidine decreases the metabolism of imipramine, the nurse should identify that this combination is likely to result in which of the following effects? a. decreased therapeutic effects of cimetidine b. increased risk of imipramine toxicity c. decreased risk of adverse effects of cimetidine d. increased therapeutic effects of imipramine
b
A nurse is reviewing car seat safety with the parents of a 1-month-old infant. When reviewing car seat use, which of the following instructions should the nurse include? a. use a car seat that has a three-point harness system b. position the car seat so that the infant is rear-facing c. secure the car seat in the front passenger seat of the vehicle d. convert to a booster seat after 12 months
b
A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? a. macaroni and cheese b. fresh fruit and whole wheat toast c. bread pudding and yogurt d. roast chicken and white rice
b
A nurse is teaching an adult client how to administer ear drops. Which of the following statements should the nurse identify as an indication that the client understands the proper technique? a. "I will straighten my ear canal by pulling my ear down and back. b. "I will gently apply pressure with my finger to the front part of my ear after putting in the drops." c. "I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in." d. "After the drops are in, I will place a cotton ball all the way into my ear canal."
b
A nurse is working with a newly licensed nurse who is administering medications to clients. Which of the following actions should the nurse identify as an indication that the newly hired nurse understands medication error prevention? a. taking all medications out of the unit-dose wrappers before entering the client's room b. checking with the provider when a single dose requires administration of multiple tablets c. administering a medication, then looking up the usual dosage range d. relying on another nurse to clarify a medication prescription
b
A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse anticipate a prescription for fluid restriction? a. a client who has a new diagnosis of adrenal insufficiency b. a client who has heart failure c. a client who is receiving treatment for diabetic ketoacidosis d. a client who has abdominal ascites
b
A young adult client in a provider's office tells the nurse that she uses fasting for several days each week to help control her weight. The client takes several medications for various chronic issues. The nurse should explain to the client that which of the following mechanisms that results from fasting puts her at risk for medication toxicity? a. increasing the metabolism of the medication over time b. increasing the protein-binding response c. increasing medications' transit time through the intestines d. decreasing the excretion of medications
b
A nurse is caring for an adolescent client who is 2 days postoperative following an appendectomy and has type 1 diabetes mellitus. The client is tolerating a regular diet. He has ambulated successfully around the unity with assistance. He requests pain medication every 6 to 8 hrs while reporting pain at a 2 on a scale of 0 to 10 after receiving the medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? (select all that apply) a. extremes in age b. impaired circulation c. impaired/suppressed immune system d. malnutrition e. poor wound care
b c
A nurse is preparing medications for a preschooler. Which of the following factors should the nurse identify as factors should the nurse identify as altering how a medication affects children? (select all that apply) a. increased gastric acid production b. lower blood pressure c. higher body water content d. increased absorption of topical medications e. increased gastric emptying time
b c d
To promote adherence with medication self-administration, a nurse is making recommendations for an older adult client. Which of the following instructions should the nurse include? (select all that apply) a. adjust dosages according to daily weight b. place pills in daily pill holders c. ask for liquid forms if the client has difficulty swallowing pills d. ask a relative to assist periodically e. request child-resistant caps on medication containers
b c d
A nurse is collecting data from a client who takes haloperidol to treat schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms (EPSs)? (select all that apply) a. orthostatic hypotension b. tremors c. acute dystonia d. decreased level of consciousness e. restlessness
b c e
A nurse is caring for a client who is postoperative. Which of the following interventions should the nurse take to reduce the risk of thrombus development? (select all that apply) a. instruct the client not to perform the Valsalva maneuver b. apply elastic stockings c. review laboratory values for total protein level d. place pillows under the client's knees and lower extremities e. assist the client to change position often
b e
A nurse is caring for a client who has had diarrhea for 4 days. When assessing the client, the nurse should expect which of the following findings? (select all that apply) a. bradycardia b. hypotension c. elevated temperature d. poor skin turgor e. peripheral edema
b c d
A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (select all that apply) a. establish a schedule of urinating prior to meal times b. have the client record urination times c. gradually increase the urination intervals d. remind the client to hold urine until the next scheduled urination time e. provide a sterile container for urine
b c d
A nurse is preparing the discharge summary for a client who has had knee arthroplasty and is going home. Which of the following information about the client should the nurse include in the discharge summary? (select all that apply) a. advance directives status b. follow-up care c. instructions for diet and medications d. most recent vital sign data e. contact information for the home health care agency
b c e
A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen safety? (select all that apply) a. family members who smoke must be at least 10 ft from the client when oxygen is in use b. nail polish should not be used near a client who is receiving oxygen c. a "no smoking" sign should be placed on the front door d. cotton bedding and clothing should be replaced with items made from wool e. a fire extinguisher should be readily available in the home
b c e
A nurse in a provider's office is evaluating a client who reports losing control of urine whenever she coughs, laughs, or sneezes. The client relates a history of three vaginal births, but no serious accidents or illnesses. Which of the following interventions should the nurse suggest for helping to control or eliminate the client's incontinence? (select all that apply) a. limit total daily fluid intake b. decrease or avoid caffeine c. take calcium supplements d. avoid drinking alcohol e. use the Crede maneuver
b d
A nurse is caring for a client who recently had a cerebrovascular accident and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? (select all that apply) a. increase the volume of your voice b. make sure only one person speaks at a time c. avoid discouraging the client by saying that you do not understand him d. allow plenty of time for the client to respond e. use brief sentences with simple words
b d e
A nurse is collecting data from a client who has hypercalcemia as a result of long-term use of glucocorticoids. Which of the following findings should the nurse expect? (select all that apply) a. hyperreflexia b. confusion c. positive Chvostek's sign d. bone pain e. nausea and vomiting
b d e
A nurse is receiving the CDC's immunization recommendations with the parents of an adolescent. Which of the following recommendations should the nurse include in this discussion? (select all that apply) a. rotavirus b. varicella c. herpes zoster d. human papilloma virus e. seasonal influenza
b d e
A charge nurse is teaching about the care of a client who has methicillin-resistant Staphylococcus aureus (MRSA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a. "I should obtain a specimen for culture and sensitivity after the first does of an antimicrobial." b. "MRSA is usually resistant to vancomycin, so another antimicrobial will be prescribed." c. "I will need to monitor the client's serum antimicrobial levels during the course of therapy." d. "To decrease resistance, antimicrobial therapy is discontinued when the client is no longer febrile."
c
A nurse attempts to collect a capillary blood specimen via finger stick for a blood glucose monitoring from a client who has diabetes mellitus. The nurse is unable to obtain an adequate drop of blood for the reagent strip. Which of the following actions should the nurse take first? a. puncture another finger to obtain a capillary specimen b. test the urine with a urine reagent strip c. wrap the hand in a warm, moist cloth d. perform a venipuncture to obtain a venous sample
c
A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering the medication, which of the following actions is the nurse's priority? a. teaching the client about the purpose of the medication b. giving the medication at the administration time the provider prescribed c. identifying the client's medication allergies d. documenting the client's anxiety level
c
A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement? a. immediately complete a through assessment b. put the client in a room with a client who has a hearing loss c. provide a private room, and limit stimulation d. speak at a higher volume to the client, and encourage ambulation
c
A nurse is caring for a client who has been sitting in a chair for 1 hr. Which of the following complications is the greatest risk to the client? a. decreased subcutaneous fat b. muscle atrophy c. pressure ulcer d. fecal impaction
c
A nurse is caring for a client who is 1 day postoperative following a total knee arthroplasty. The client states his pain level is 10 on a scale of 0 to 10. After reviewing the client's mid cation administration record, which of the following medications should the nurse administer? a. meperidine 75 mg IM b. fentanyl 50 mcg/hr transdermal patch c. morphine 2 mg IV d. oxycodone 10mg PO
c
A nurse is caring for a client who is receiving morphine via a patient-controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? a. "I'll wait to use the device until it's absolutely necessary." b. "I'll be careful about pushing the button too much so I don't get an overdose." c. "I should tell the nurse if the pain doesn't stop while I am using this device." d. "I will ask my adult child to push the dose button when I am sleeping."
c
A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray? a. cooked barley b. pureed broccoli c. vanilla custard d. lentil soup
c
A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain? a. ask the lucent what precipitates the pain b. question the client about the location of the pain c. offer the client a pain scale to measure his pain d. use open-ended questions to identify the client's pain sensation
c
A nurse is preparing information for change-of-shift report. Which of the following information should the nurse include in the report? a. input and output for the shift b. blood pressure from the previous day c. bone scan scheduled for today d. medication routine from the medication administration record
c
A nurse is providing preoperative education for a client who will undergo a mastectomy the next day. Which of the following statements should the nurse identify as an indication that the client is ready to learn? a. "I don't want my spouse to see my incision." b. "Will you give me pain medicine after the surgery?" c. "Can you tell me about how long the surgery will take?" d. "My roommate listens to everything I say."
c
A nurse is teaching a client who is lactating about taking medications. Which of the following actions should the nurse recommended to minimize in the entry of medication into breast milk? a. drink 8 oz milk with each dose of medication b. use medications that have an extended half-life c. take each dose right after breastfeeding d. pump breast milk and freeze it prior to feeding to the newborn
c
A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/L. When notify the provider, the nurse should anticipate which of the following actions? a. starting an IV infusion of 0.9% sodium chloride b. consulting with dietitian to increase intake of potassium c. initiating continuous cardiac monitoring d. preparing the client for gastric lavage
c
A nurse is teaching self-monitoring of blood glucose (SMBG) to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (select all that apply) a. perform SMBG once daily at bedtime b. wipe the hand with an alcohol swab c. hold the hand in a dependent position prior to the puncture d. place the puncturing divide perpendicular to the site e. prick the outer edge of the fingertip for the blood sample
c d e
A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (select all that apply) a. apply petroleum jelly around and inside the nares b. remove the nasal cannula during mealtimes c. check the position of the cannula frequently d. report any nasal stuffiness nausea, or fatigue e. post "no smoking" signs in a prominent location
c d e
A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? (select all that apply). a. urinary incontinence b. diarrhea c. bradypnea d. orthostatic hypotension e. nausea
c d e
A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (select all that apply) a. distended neck veins b. hyperthermia c. tachycardia d. syncope e. decreased skin turgor
c d e
A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) since his last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? (select all that apply) a. "Eat three large meals a day." b. "Eat your meals in front of the television." c. "Eat foods that are easy to eat, such as finger goods." d. "Invite family members to eat meals with you." e. "Exercise every day to increase appetite."
c d e
A nurse in a primary care clinic is assessing a client who has a history of herpes zoster. Which of the following findings suggest the client is experiencing postherpetic neuralgia? a. linear clusters of vesicles present on the right shoulder b. purulent drainage from both eyes c. decreased white blood cell count d. report of continued pain following resolution of rash
d
A nurse in an outpatient clinic is teaching a client who is in her first trimester of pregnancy. Which of the following statements should the nurse make? a. "You will need to get a rubella immunization if you haven't had one prior to pregnancy." b. "You can safely take over-the-counter medications." c. "You should avoid any vitamin preparations containing iron." d. "Your provider can prescribe medication for nausea if you need it."
d
A nurse is caring for a client ho will perform fecal occult blood testing at him. Which of the following information should the nurse include when explaining the procedure to the client? a. eating more protein is optimal prior to testing b. one stool specimen is sufficient for testing c. a red color change indicates a positive test d. the specimen cannot be contaminated with urine
d
A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? a. a client who has a broken femur and reports hip pain b. a client who has incisional pain 72 hrs. following pacemaker insertion c. a client who has food poisoning and reports abdominal cramping d. a client who has episodic back pain following a fall 2 years ago
d
A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy? a. fat b. protein c. glycogen d. carbohydrates
d
A nurse is providing education for a client who has severe hypomagnesemia due to alcohol use disorder. The client is to receive magnesium sulfate. Which of the following information should the nurse include in the teaching? a. "You will receive magnesium in a series of intramuscular injections." b. "You should receive a prescription for a thiazide diuretic to take with the magnesium." c. "You should eliminate whole grains from your diet until your magnesium level increases." d. "You will have your deep-tendon reflexes monitored while you are receiving magnesium."
d
A nurse is providing education on how to check blood glucose levels to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should include which of the following instructions about transferring blood onto the reagent portion of the test strip? a. smear the blood onto the strip b. squeeze the blood onto the strip c. touch the puncture to stimulate bleeding d. hold the test strip next to the blood on the fingertip
d
A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the interactions? a. "I use a damp cloth to clean the outside part of my hearing aids." b. "I clean the ear molds of my hearing aids with rubbing alcohol." c. "I keep the volume of my hearing aids turned up so I can hear better." d. "I take the batteries out of my hearing aids when I take them off at night."
d
A nurse is teaching a client about taking multiple oral mediations at home to include time-release capsules, liquid medications, enteric-coated pills, and opioids. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "I can open the capsule with the beads in it and sprinkle them on my oatmeal." b. "If I am having difficulty swallowing, I will add the liquid medication to a batch of pudding." c. "I can crush the pills with the coating on them." d. "I will eat two cravers with the pain pills."
d
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? a. have the client hold his breath briefly and bear down b. discontinue the fluid instillation c. remind the client that cramping is common at this time d. lower the enema fluid container
d
A nurse is preparing to administer medications to a preschooler. Which of the following strategies should the nurse implement to increase the child's cooperation in taking medications? (select all that apply) a. reassure the child an injection will not hurt b. mix oral medications in a large glass of milk c. offer the child choices when possible d. have the parents bring in a favorite toy from home e. engage the child in pretend play with a toy medical kit
d e
