NURS 306 - exam 2 ATI

A nurse is caring for a client who requires assistance with ADLs. Which of the following referrals should the nurse recommend for this client?

Occupational therapist

A charge nurse is reviewing routes of medication administration with a newly licensed nurse when providing care to a client. Which of the following routes of administration should the charge nurse include as having the slowest onset of action?

Oral

A nurse is performing a medication reconciliation for a client who is being transferred to a long-term care facility. Which of the following actions should the nurse take? (Select all that apply.)

Place the medication reconciliation form with the client's transfer documents. Reinforce teaching about the medications to the client upon discharge. Include over-the-counter medications in the medication reconciliation. Compare the client's home medications with prescribed discharge medications.

A wound, ostomy and continence nurse (WOCN) is providing an in service to a group of nurses about documentation of pressure injuries. Which of the following statements by one of the group members indicates an understanding of the teaching?

Pressure injury documentation includes location, stage, measurements and condition of the wound bed and any drainage present

A nurse is caring for a client who has pneumonia. In which of the following positions should the nurse place the client to promote postural drainage?

Prone

A nurse is caring for a nondiabetic client who has a new prescription for a fasting blood glucose check. The nurse checks the client's blood glucose and it is 67 mg/dL. Which of the following actions should the nurse take next?

Provide the client with a 15-g carbohydrate snack.

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

Remind the client to use the incentive spirometer.

A nurse is completing the Mobility Assessment Tool (MAT) for a client and determines that the client is at Level 1 Mobility. The nurse should identify that the client is unable to perform which of the following tasks?

Sit on the edge of the bed for 1 min

A nurse is caring for a client who requires maximum assistance to transfer from the bed to a chair. Which of the following pieces of equipment should the nurse use?

Slide board

A nurse is performing an admission skin assessment on a client and notes that the client has a stage 3 pressure injury to the coccyx. How should the nurse document the appearance of this pressure injury?

Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue

A nurse is preparing to lift a heavy object off the floor. In which order should the nurse perform the following steps to demonstrate the proper use of body mechanics? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Stand as close to the object as possible Keep abdominal muscles contracted and the lower back straight Look straight ahead with shoulders raised up Bend hips slightly and squat Push up from the knees when lifting the object

A nurse is collecting data on a client who is receiving vancomycin IV. The nurse observes the client has a rash on their neck, chest, and back. Which of the following actions should the nurse take first?

Stop the infusion of the vancomycin.

A nurse is providing teaching for a client who injured their ankle. Which of the following information should the nurse include?

Tendons connect muscle to bone.

A nurse is observing an assistive personnel (AP) care for a client. Which of the following actions by the AP places the client at risk for alterations in skin integrity?

The AP places the client in high-Fowler's position

A nurse is assessing a client's hair and notes that it is brittle. Which of the following should the nurse determine about the client's nutritional intake?

The client has insufficient protein in their diet.

A nurse is evaluating a client who has a broken leg and is using crutches. Which of the following actions by the client demonstrates proper use of the crutches?

The client has the crutches resting 5 cm (2 in) below their axilla.

A nurse is caring for a client who routinely eats a regular diet and is scheduled to have surgery with sedation in the morning. The nurse receives a new NPO diet prescription for the client. Which of the following should the nurse identify as the rationale for the provider's prescription?

The client is at risk for aspiration due to the upcoming surgery.

A nurse is reviewing a client's medical record and notes that their BMI is 25.5. How should the nurse interpret this finding?

The client is overweight.

A nurse is preparing a presentation for a group of clients who are scheduled for joint replacement surgery. Which of the following information should the nurse plan to include regarding flexion of a joint?

The contraction of a muscle results in flexion of a joint.

A nurse is reviewing information about the structure and function of the nails with a client. Which of the following information should the nurse include?

The cuticle of the nail forms a barrier to prevent infections.

A nurse is preparing to administer medications to a preschooler. Which of the following information should the nurse keep in mind when administering medications to this client?

The deltoid muscle can be used to administer intramuscular injections.

A nurse in a dermatology clinic is developing a skin anatomy poster to display for clients. Which of the following information should the nurse plan to include on the poster?

The dermis contains blood vessels that help nourish the epidermis

A nurse is reviewing the anatomy of the skin with a newly licensed nurse. Which of the following information should the nurse include as a characteristic of the epidermis?

The epidermis consists of squamous epithelial cells.

A charge nurse is reviewing oral care and hygiene practices with another nurse for a client who has glaucoma. Which of the following information should the charge nurse include?

The nurse should educate the client and caregivers about the importance of routine dental visits to maintain oral health.

A nurse is caring for a client who has right-sided hemiplegia following a stroke. Which of the following should the nurse consider when caring for this client?

The nurse should have the client remove clothing from the unaffected side first.

A nurse is reviewing a list of client care tasks with another nurse. In which of the following scenarios should the nurse plan to use soap and water to perform hand hygiene? (Select all that apply.)

The nurse's hands become visibly soiled. The nurse removes the meal tray of a client who has infectious diarrhea. The nurse empties the urinal of a client who has Clostridium difficile.

A nurse is providing teaching to a newly licensed nurse about the functions of the skin. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching

The skin assists in the regulation of body temperature

A nurse is teaching assistive personnel (AP) about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching?

The skin of older adults is thinner and has less subcutaneous padding over bony prominences

A nurse is teaching an in-service about the use of ergonomics to a group of staff members. Which of the following information should the nurse include?

The use of ergonomics increases job satisfaction.

A nurse is planning care for an older adult clients who is bedridden. Which of the following actions should the nurse include in the plan to prevent skin breakdown?

Tilt the client on their side at 30 degrees

A nurse is reviewing measurement systems to perform dosage calculations with a newly licensed nurse. Which of the following instructions should the nurse include?

To convert g to mg, move the decimal point 3 places to the right.

A nurse is teaching a newly hired assistive personnel (AP) about working with clients who require assistance with ADLs. Which of the following activities should the nurse include as an ADL?

Toileting

A nurse is performing nail hygiene on a client. Which of the following actions should the nurse take?

Trim the nails straight across.

A nurse is planning care for a client who has incontinence. Which of the following information should the nurse consider when providing skin care for the client?

Urinary incontinence can cause a yeast infection.

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

Use a towel to completely dry between the toes.

A nurse is performing a bed bath for a client. Which of the following should the nurse remember when preparing to bathe the client?

Washing the client in bed is less effective than taking a shower.

A nurse is assisting with teaching a newly licensed nurse about administering a transdermal nitroglycerin patch to a client. Which of the following instructions should the nurse include?

Wear clean gloves to apply the transdermal medication.

A nurse is reviewing handwashing skills with a newly licensed nurse. In which order should the nurse plan to perform this task using soap and water? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Wet hands with warm water is the first step. Apply the amount of soap recommended by the manufacture Rub hands together vigorously for at least 15 seconds is the third step. Rinse hands with water Use a disposable towel to dry Use a towel to turn off the faucet

A nurse is providing teaching to a client who is in a wheelchair about measures to avoid skin breakdown. Which of the following instructions by the nurse is related to preventing skin breakdown?

You should shift your weight off your buttocks at intervals throughout the day

A nurse is providing teaching to a client about staple removal. Which of the following statements should the nurse include in the teaching?

Your staples will be removed in about 2 weeks

A nurse is providing information to a client about what may happen if their urinary tract infection (UTI) is not treated. Which of the following statements by the client indicates an understanding of the information? a. "I can develop a kidney infection called pyelonephritis." b. "I might have urinary retention." c. "I might become incontinent." d. "I can develop functional incontinence."

a. "I can develop a kidney infection called pyelonephritis."

A nurse is caring for a female client who has a prescription for clean catch urine specimen. Which of the following statements by the client demonstrates an understanding of how to prove a urine specimen? a. "I need to wipe from front to back with a sanitary wipe." b. "I should place the urine sample cup in the refrigerator." c. "I will begin the urination process in the specimen cup." d. "I will urinate in the urine tray for the nurse to collect."

a. "I need to wipe from front to back with a sanitary wipe."

A nurse is teaching a client about diagnostic urinary testing. Which of the following should the nurse include in the teaching about cystometric testing? a. Cystometric testing measures bladder capacity, pressure, and final capacity when the urge to urinate begins b. Cystometric testing measures urine speed and volume c. Cystometric testing measures bladder pressure when urinary leakage occurs d. Cystometric testing measure electrical activity of the muscles and nerves of the bladder and spincters

a. Cystometric testing measures bladder capacity, pressure, and final capacity when the urge to urinate begins

A nurse is preparing to collect a urine sample for urinalysis using a reagent strip. The nurse should identify that the reagent strip can detect substances that are consistent with which of the following conditions? a. Diabetes b. Colon cancer c. Pancreatitis d. Pregnancy

a. Diabetes

A nurse is planning care for a client who reports blood in their stool. Which of the following tests should the nurse anticipate the provider ordering? a. Fecal occult blood test b. Stool culture c. Flexible sigmoidoscopy d. Endoscopic retrograde cholangiopancreatography (ERCP)

a. Fecal occult blood test

A nurse is planning care for a client who has a new colostomy. Which of the following complications should the nurse plan to monitor for? a. Hernia b. Gastroesphoageal reflux disease c. Crohn's disease d. Ulcerative colitis

a. Hernia

A nurse is reviewing the medical record of a client who has persistent diarrhea. Which of the following findings should the nurse identify as risk factors? (Select all that apply.) a. History of irritable bowel syndrome b. A shortened urethra c. Cardiovascular disease d. Consumes large amount of dairy in their diet e. Currently taking antibiotics for an infection

a. History of irritable bowel syndrome d. consumes large amount of dairy e. Currently taking antibiotics for an infection

A nurse is caring for a group of clients who are at risk for an alteration in urinary elimination. Which of the following groups should the nurse identify as being at an increased risk? (Select all that apply.) a. Uncircumcised infants b. School-age children c. Middle adults d. Older adults e. Young adults

a. Uncircumcised infants b. School-age children d. Older adults

A nurse is planning care for a client who has an order for urinalysis. Which of the following tests should the nurse anticipate being ordered if the presence of white blood cells in detected on urinalysis? a. Urine culture b. Bladder scan c. 24-hour urine d. Stool culture

a. Urine Culture

a nurse is caring for a client who has a traumatic injury to a lower extremity. Which of the following actions should the nurse take?

apply compression to the injured area of the extremity

a nurse is preparing to perform palpation on a client's knees. In which order should the nurse perform the following steps?

assist client to a sitting position with legs dangling at edge of examination table; palpate quadriceps muscle above knee; palpate hollows on either side of patella with thumbs; follow lower edge of the patella and locate tibiofemoral joint; palpate tibiofemoral joint where femur and tibia meet

A nurse is teaching a client about foods that can irritate the bladder. Which of the following statements by the client indicates an understanding of the teaching? a. "I will be able to drink chocolate milk" b. "I should avoid fruits that are acidic" c. "I will need to switch from regular soda to diet soda" d. "I can still use jalapeño peppers when cooking"

b. "I should avoid fruits that are acidic"

A nurse is educating a client about a new temporary ileostomy. Which of the following statements by the client indicates an understanding of the teaching? a. "My ileostomy has an internal reservoir that collects waste." b. "My ileostomy is allowing my colon time to heal from the surgery." c. "My ileostomy must be accessed with a catheter to drain the waste." d. "My ileostomy is designed to be a permanent solution."

b. "My ileostomy is allowing my colon time to heal from the surgery."

A nurse it is caring for a client who has constipation and requires an enema. Which of the following actions should the nurse take when administering the enema solution? a. Instruct the client to lie on their right side with their left leg pulled to their chest b. Instruct the client to lie on their left side with their right leg pulled to their chest c. Instruct the client to lie on their side with both legs pulled up to their chest d. Instruct the client to lie on their right side with both legs pulled to their chest

b. Instruct the client to lie on their left side with their right leg pulled to their chest

A nurse is assessing a client who has stress incontinence. Which of the following findings should the nurse expect with this client? a. Urine leakage prior to reaching the toilet b. Urine leakage following coughing c. Urine leakage as a result of nerve damage d. Urine leakage due to not reaching the toilet in time from physical impairment

b. Urine leakage as a result of coughing

A nurse is caring for client who reports occasionally having dark, tea-colored urine at home. The nurse identifies that which of the following activities can contribute to this finding? a. Attending a yoga class b. Consuming alcohol c. Drinking 2,000 mL of a fluid in a day d. Consuming fish for dinner

b. consuming alcohol

A nurse is assessing a client who has an indwelling urinary catheter and determines that the catheter is in place and functioning properly. The nurse should expect which of the following findings. a. dark yellow, cloudy urine b. pale yellow, clear urine c. Urine with a strong odor d. Urine with a slight red tint

b. pale yellow, clear urineE

A nurse is caring for a client who has a prescription for a vitamin K injection. The nurse should identify that vitamin K is naturally produced in which of the following locations in the body? a. The small intestine b. The large intestine c. The esophagus d. The stomach

b. the large intestine

A nurse is teaching a newly licensed nurse about urinary retention. Which of the following clients should the nurse include as having an increased risk of this condition? a. A client who has an enlarged uterus b. A client who experiences frequent urinary tract infections c. A client who has an enlarged prostate d. A client who has chronic hypertension

c. A client who has an enlarged prostate

a nurse is caring with suspected dehydration. For which of the following findings should the nurse monitor this client? a. Oral temperature of 36.4 C (97.5F) b. Light yellow urine c. Dry mucous membranes d. Diaphoresis

c. Dry mucous membranes

A nurse is caring for a client who has constipation. Which of the following diets should the nurse encourage the client to follow? a. Low fat b. High protein c. High fiber d. Low carbohydrate

c. High Fiber

A nurse is reviewing a client's list of medications and supplements. Which of the following medication classifications increases the risk of constipation? a. Magnesium-containing antacids b. Antibiotics c. Narcotic pain medications d. Beta blockers

c. Narcotic pain medication

A nurse is caring for a client who has a colostomy and does not wear a colostomy pouch. Which of following actions should the nurse anticipate performing on this client to maintain expected bowel function? a. Administer an enema b. Administer a laxative c. Perform colostomy irrigation d. Insert a rectal tube

c. Perform colostomy irrigation

A nurse is caring for a client who is receiving antibiotic treatment for a urinary tract infection and is experiencing diarrhea. Which of the following should the nurse identify as a potential cause for diarrhea? a. The antibiotic dose is not correct, and the provider should be alerted b. The antibiotic interferes with the client's ability to absorb nutrient c. The antibiotic eliminates the healthy gastrointestinal bacteria, allowing harmful bacteria to grow d. The antibiotic decreases a client's immunity Lebel, result in diarrhea

c. The antibiotic eliminates the healthy gastrointestinal bacteria, allowing harmful bacteria to grow

A nurse is caring for a client who has a stone in the right ureter that is obstructing the flow or urine. Which of the following urinary diversions should the nurse anticipate the client will need? a. Urostomy b. Continent cutaneous reservoir c. Ureteral stent d. Neobladder

c. Ureteral stent

A nurse is evaluating a client's bladder training program. Which of the following statements by the client indicates the bladder training was successful? a. "I am having accident daily." b. "I am voiding a small amount when I visit the bathroom." c. "I continue to visit the bathroom every hour." d. "I am experiencing less than one urinary accident per week."

d. "I am experiencing less than one urinary accident per week."

A nurse is providing postoperative instructions for a client who had kidney stone removal and placement of a nephrostomy tube. Which of the following statements by the client indicates an understanding of the instructions? a. "This tube will keep my ureters open in case of another stone." b. "This tube will remain permanently because I can't empty my bladder." c. "This tube goes directly into my bladder." d. "This tube is only temporary."

d. "This tube is only temporary."

A nurse is caring for a client who has a history of irritable bowel syndrome and repots that their last bowel movement was 5 days ago. The nurse should identify this was which of the following types of altered elimination pattern? a. Encopresis b. Diarrhea c. Fecal incontinence d. Constipation

d. Constipation

A nurse is preparing to insert a nasogastric tube into a client for decompression. Which of the following actions should the nurse perform first? a. Measure the tube from the client's ear to the xiphoid b. Insert the tube while the client takes sips of water c. Connect the nasogastric tube to suction d. Ensure the client is in a sitting position

d. Ensure the client is in a sitting position

A nurse is educating a client who has paraplegia about urinary catheter use. Which of the following catheter types should the nurse include in the teaching to help facilitate urinary elimination for this client? a. Suprapubic catheter b. Indwelling catheter c. Condom catheter d. Intermittent catheter

d. Intermittent Catheter

A nurse is caring for an older adult client who is experiencing urinary leakage. Which of the following is an expected age-related change that can contribute to this occurrence? a. Reduced blood supply b. Loss of kidney tissue c. Loss of nephrons d. Loss of bladder tone

d. Loss of bladder tone

A nurse is reviewing the primary function of the urinary tract with a group of newly licensed nurses. Which of the following information should the nurse include? a. The urinary tract regulate the production of red blood cells b. The Urinary tract produces hormones for blood pressure regulation c. The urinary tract keeps bones strong d. The urinary tract eliminates waste and excess fluid from the body

d. The urinary tract eliminates waste and excess fluid form the body

a nurse is preparing a community program about injury prevention for a group of adults. Which of the following information should the nurse include?

do not text and drive; maintain spinal alignment when working at a desk; remove loose rugs from the home; wear a helmet when riding a bicycle

the nurse is assessing the spinal curvature of a client who has a diagnosis of kyphosis. Which of the following images should the nurse identify as kyphosis?

exaggerated posterior curvature of the thoracic spine.

a nurse is preparing to perform palpation of client's shoulder. In what order should the nurse perform the following steps?

face client and palpate along clavicle; face client and palpate the acromioclavicular joint; from the back palpate scapula; from the back palpate greater tubercle of the humerus

a nurse is performing range-of-motion exercises on a client's hips. The nurse is assessing which of the following motions by instructing the client to bend the knee and bring it up toward the chest?

flexion of the hip

a nurse is taking a health history from a client. Which of the following statements by the client requires further questioning by the nurse?

for some reason I have been experiencing falls

a nurse is assessing a client's spinal range of motion. Which of the following motions is the nurse assessing by asking the client to bend backward as far as they can go?

hyperextension

a nurse is performing a musculoskeletal and neurological assessment. Which of the following actions should the nurse take?

inspect for symmetry on both sides of the body

a nurse is recommending sources of food with high calcium content to a client. Which of the following foods should the nurse recommend?

milk, mustard greens, and legumes

a nurse is assessing a client's wrist and hands. Which of the following findings indicates the client might have arthritis?

nodules on the joints; fingers deviate toward the ulnar

a nurse is performing range-of-motion exercises on a client's feet. the nurse should provide which of the following instructions to the client to assess plantar flexion of the feet

point your toes toward the floor

a nurse is assessing the range of motion of a client's hands. The nurse should provide which of the following instructions to assess abduction and adduction of the client's fingers?

spread the fingers apart and then move them back together

a nurse is assessing flexion of a client's elbows. The nurse should provide which of the following instructions to the client?

start with your arms straight out in front of you and then bend your elbows up and bring your fingers toward your shoulders

A nurse is caring for a client who states, "I feel like I don't have to eat a varied diet when I take my multivitamin." Which of the following responses should the nurse make?

"A multivitamin should not be used in place of a nutritious diet."

A nurse is caring for a client who states, "I only eat a diet high in protein and carbohydrates." Which of the following responses should the nurse make?

"A nutritious diet should include carbohydrates, protein, fiber, and healthy fats."

A nurse is reviewing information about performing oral hygiene with an assistive personnel (AP). Which of the following information should the nurse include?

"Clean the tongue with the toothbrush or tongue scraper during oral hygiene."

A nurse is caring for a client who states, "I have been getting a lot of cavities lately, but I don't know what is causing them." Which of the following responses should the nurse make?

"Drinking sugary beverages can make you prone to cavities."

A nurse is teaching the importance of handwashing to a client. Which of the following statements should the nurse make about hand hygiene in a health care setting?

"Effective handwashing can decrease hospital infection rates."

A nurse is reinforcing teaching with a client who has a new prescription for an antibiotic to treat a urinary tract infection. Which of the following statements should the nurse make?

"Finish the entire course of the prescription."

A nurse is caring for an older adult client whose caregiver reports that the client is resistant to bathing at home. Which of the following statements should the nurse make?

"Give the client choices regarding their bathing preferences to encourage them to bathe."

A nurse is teaching a client who has a pressure injury on their leg about proper nutrition to facilitate wound healing. Which of the following client statements indicates an understanding of the teaching?

"I should increase my protein intake."

A nurse is reviewing strategies to reduce the risk of wound dehiscence with a client following abdominal surgery. Which of the following responses by the client indicates an understanding of the information?

"I should report pain at my wound site".

A nurse is discussing macronutrients with a client. Which of the following statements should the nurse make?

"Macronutrients include carbohydrates, proteins, and fats, which make up the majority of a person's diet."

A nurse is caring for a client who is prescribed a low glycemic index diet. The client states, "I don't understand what this means." Which of the following responses should the nurse make? (Select all that apply.)

"The glycemic index of a food relates to its ability to increase the blood glucose level." "You should eat foods such as whole grains, fruits, and vegetables." "Try to limit or avoid potatoes due to their high glycemic index." "Foods with a high glycemic index will cause your blood glucose to increase rapidly."

A nurse is teaching a client about the function of mucous membranes in protecting the body from pathogens. Which of the following statements should the nurse include?

"The mucous membranes in the nose contain cilia that trap particles, preventing them from invading the body."

A nurse is teaching a client who has a new diagnosis of a skin infection about the function of the skin in the body. Which of the following statements should the nurse include?

"The skin contains Langerhans cells that kill pathogens."

A nurse is teaching a client who has an unsteady gait about how to use a walker. Which of the following instructions should the nurse include?

"The top of the walker should be at the level of your wrist."

A nurse is providing teaching for a client who has a prescription for alginate dressing for a wound. Which of the following statements by the client indicates an understanding of alginate dressing?

"This type of dressing will need a secondary dressing for reinforcement".

A nurse is teaching a newly licensed nurse about wound healing by secondary intention. Which of the following statements by the newly licensed nurse indicates an understanding of healing by secondary intention?

"This type of healing begins in the wound bed with the generation of granulation tissue".

A nurse is caring for a client who has a new prescription for parenteral nutrition. The client states, "I am scared that I will be on this therapy for the rest of my life." Which of the following responses should the nurse make?

"This type of nutrition can be lifelong, but it can also be temporary depending on how your nutritional needs change."

A nurse is caring for a client who has a high phosphorus level. Which of the following instructions regarding food should the nurse provide?

"You should eat white bread."

A nurse is caring for a client whose provider prescribed a heart-healthy diet. Which of the following information should the nurse include for the client regarding heart-healthy diets? (Select all that apply.)

"You should limit saturated fats in your diet." "Eat foods with whole grains in your new diet." "It's important to eat larger portions of fruits and vegetables." "Limiting high-calorie food intake will promote adherence to your new diet."

A nurse is a caring for a client who has a new prescription for a clear liquid diet. The client asks the nurse, "How long will I have to be on this type of diet?" Which of the following responses should the nurse make?

"You should not be on this diet for more than a few days."

a nurse is providing teaching to a client who has osteoporosis about the adequate intake of calcium. Which of the following intake amounts should the nurse recommend?

1,000 to 1,200 mg daily

A nurse is preparing to perform light palpation of a client's abdomen. In which order should the nurse perform the following steps?

1. Place the client's arms at their sides 2. Use the finger pads of one hand to palpate 3. Depress the client's abdomen using dipping motion 4. Move fingers across client's abdomen moving clockwise 5. Palpate painful areas

A nurse is preparing to administer acetaminophen 320 mg oral solution to a school-age child. The amount available is acetaminophen oral solution 160 mg/5 mL. How many mL should the nurse administer? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

10

A nurse is preparing to administer an intradermal injection to a client. At which of the following degree angles should the nurse insert the needle?

10° angle

A nurse is preparing to administer phenytoin suspension 300 mg PO, twice per day. The amount available is phenytoin suspension 125 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

12

A nurse is preparing to administer clindamycin 0.3 g IM to a client. Available is clindamycin 150 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2

A nurse is preparing to administer amikacin 7 mg/kg/day IM to a client who weighs 165 pounds. Available is amikacin 250 mg/mL solution for injection. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

2.1

A nurse is helping a client calculate how many net carbohydrates they consumed in their last meal. The client's food had a total of 72 g of carbohydrates and 9 g of fiber. How many net carbohydrates did the client consume?

63

a nurse is providing teaching about adequate daily intake of vitamin D to a client. Which of the following intake amounts should the nurse recommend?

800 IU daily

A nurse in an outpatient clinic is assessing the incision site of a client who is 7 days postoperative. Which of the following findings should the nurse expect?

A bright pink incision site that is absent of exudate

A nurse is caring for a group of clients. Which of the following clients should the nurse identify is at the greatest risk of developing medication toxicity?

A client who has impaired kidney function

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having the highest risk for developing alterations in tissue integrity?

A client who is incontinent and taking a prescribed diuretic

A nurse has completed the Braden scale on four clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity?

A clients who has a Braden scale score of 9

A nurse is reviewing oral hygiene practices with an assistive personnel. Which of the following should the nurse include? (Select all that apply.)

A fluoride mouthwash should be used to promote oral health. The teeth should be brushed twice daily for 2 min. Poor oral hygiene can lead to gingivitis. Use a soft-bristled toothbrush for brushing the teeth.

a nurse is assessing an older adult client while they walk. Which of the following findings should the nurse report to the provider?

the client walks with a shuffling gait

A nurse is discussing proper body mechanics with a group of assistive personnel. Which of the following information should the nurse include? (Select all that apply.)

A stable center of gravity increases stability and balance. A wide base lowers the center of gravity. Proper body alignment involves tightening the abdomen.

A nurse is caring for a client who has dime-sized stage 1 pressures injury located on the sacrum. Which of the following dressing types should the nurse use?

A transparent film

a nurse is assessing a client's head and neck. Which of the following findings should the nurse report to the provider?

there is locking of the jaw joint

a nurse is assessing the range of motion of a client's head and neck. The nurse should provide which of the following instructions to assess hyperextension?

tilt the head back and look up at the ceiling

A nurse is caring for a client who had a stroke and is immobile. The nurse should identify that the client is at risk for which of the following conditions?

Deep vein thrombosis

A nurse is assisting with the care of a client following abdominal surgery. The nurse removes the client's surgical dressing and notes a separation of the wound edges. The nurse should identify that the client is experiencing which of the following complications?

Dehiscence

A nurse is caring for a 6-month old infant who has diarrhea. The nurse should monitor the infant for which of the following alterations in tissue integrity?

Dermatitis

A nurse is caring for a client who had a stroke and reports having difficulty with proprioception. The nurse should plan to assess the client for which of the following?

Diminished awareness of body position and balance

A nurse is caring for a client who practices a religion the nurse is not familiar with. Which of the following actions should the nurse take

Discuss with the client their individual perspective on health and illness.

A nurse is caring for a client who has a portable wound bulb suction device and notes that the drainage bulb is three-fourths full. Which of the following actions should the nurse take?

Empty and measure the drainage

A nurse is discussing the role of tooth enamel with a client. Which of the following information should the nurse include in the discussion?

Enamel protects the teeth from pathogens.

A nurse is providing discharge teaching to a client. Which of the following strategies should the nurse include?

Encourage the client to ask questions.

A nurse is providing discharge teaching to the caregiver for a client who has a stage 1 pressure injury to the sacrum. Which of the following instructions should be included to the caregiver to prevent further skin breakdown?

Flex the client's knees while in bed

A nurse is assessing a client's mobility and notes one of the client's feet drags behind them when ambulating. Which of the following conditions should the nurse suspect the client is experiencing?

Foot drop

A nurse is planning care for a client who is postoperative. In which of the following positions should the nurse place the client to prevent atelectasis?

Fowler's

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

Have a second nurse confirm the insulin dose.

A nurse is preparing to administer medications to a client who is not wearing an identification bracelet. Which of the following actions should the nurse take before administering the medications?

Have the client confirm their name and date of birth.

A nurse is assisting with teaching a client about self-administration of insulin. Which of the following actions should the nurse take?

Have the client perform a return demonstration of the procedure.

A nurse is discussing health promotion programs with a client. Which of the following information should the nurse include?

Health promotion programs emphasize behavior changes in relation to prevention of illness.

A nurse is caring for a client who has a deep foot wound with minimal exudate and necrotized tissue. For which of the following dressing types should the nurse anticipate a prescription to cover the wound?

Hydrogel

A nurse is monitoring a client following a cholecystectomy. Which of the following findings should the nurse identify as a potential manifestation of sepsis?

Increased blood glucose

A nurse is performing a focused assessment on an older adult client's mobility. Which of the following findings should indicate to the nurse that the client is experiencing an age-related change to their musculoskeletal system?

Increased curvature of the thoracic spine

A nurse is caring for client who reports having daily constipation. Which of the following information should the nurse provide to the client regarding fiber intake? (Select all that apply.)

Increasing daily fiber intake can help alleviate the issue of constipation. Eating more whole grains can promote regular bowel movements.

A nurse is caring for a client who is receiving tube feedings via PEG. Which of the following actions should the nurse implement in order to help prevent the client from aspirating?

Keep the client's head elevated to at least 30° for a minimum of 1 hr after a feeding.

A nurse is providing teaching for a client who has kyphosis. Which of the following information should the nurse include?

Kyphosis is a rounded upper back with the pelvis tilted forward.

A nurse is preparing to transfer a client from a bed to a wheelchair. Which of the following actions by the nurse demonstrates proper use of body mechanics?

Looking at the client face-to-face when transferring the client

A nurse is participating in a committee to reduce medication errors on a medical unit. Which of the following interventions should the nurse recommend? (Select all that apply.)

Mark the area around the automated medication dispensing system. Provide the nurse administering medications with a vest. Double check dosages of high-alert medications.

A nurse is preparing to measure a nasogastric tube for insertion. The nurse recalls that the client's xyphoid process should be used as the last place of measurement. Which of the following landmarks should the nurse measure before the xyphoid process?

Measure from the tip of the nose to the earlobe.

A nurse is caring for a client who requires total assistance with mobility. When using the Mobility Assessment Tool (MAT), which of the following pieces of equipment should the nurse use to transfer the client?

Mechanical lift

A nurse is preparing a poster presentation about the musculoskeletal system. The nurse should include that which of the following is responsible for body posture?

Muscles

A nurse is preparing a presentation about muscle function for a group of newly licensed nurses. Which of the following information should the nurse plan to include?

Muscles assist with thermoregulation in the body.

A nurse is assessing a client who is experiencing digestive issues. Which of the following findings should the nurse expect? (Select all that apply).

Nausea Abdominal pain Diarrhea Reports of bloating

A nurse is preparing to obtain information regarding a client's abdominal health history. Which of the following questions should the nurse ask? Select all that apply. A. "Are you experiencing abdominal pain?" B. "Do you take any medication?" C. "Have you noticed a change in your appetite?" D. "When was your last bowel movement?" E. "Have you had any changes in your urinary output?"

A. "Are you experiencing abdominal pain?" B. "Do you take any medication?" C. "Have you noticed a change in your appetite?" D. "When was your last bowel movement?" The nurse should ask the client to locate the pain, describe it, rate the intensity of the pain on a scale from 0 to 10, and report how long they have been experiencing the pain. The nurse should ask the client about any medications they are taking because medications can affect a client's abdomen, such as distention, discomfort, nausea or vomiting. This can confirm weight loss or gain along with irritation of the bowel if the client is experiencing decreased hunger, nausea, or vomiting. This allows the nurse to collect information on the client's bowel habits. The nurse can also ask about color and consistency of the client's stool at this time. The nurse can also ask about color and consistency of the client's stool at this time.

A nurse is preparing to inspect a client's abdomen who has liver disease. Which of the following manifestations should the nurse expect? A. Dilated veins B. Stretch marks C. Purple striae D. Rash

A. Dilated veins The nurse should identify that dilated veins and spider angiomas on the client's abdomen are manifestations of liver disease.

A nurse is preparing to inspect a male client's abdomen. Which of the following findings should the nurse identify is an unexpected finding? Select all that apply. A. Everted umbilicus B. Purple Striae C. Rash D. Healed Scars E. Mole

A. Everted umbilicus B. Purple Striae C. Rash The nurse should identify that eversion of the umbilicus is an unexpected finding when inspecting a client's abdomen, which can indicate conditions such as an abdominal mass or obesity. The nurse should identify that purple striae is an unexpected finding when inspecting a client's abdomen, which can be an indication of weight gain or loss, abdominal distention, or a manifestation of Cushing syndrome. The nurse should identify that a rash is an unexpected finding when inspecting a client's abdomen, which can be an indication of an allergic reaction or a manifestation of a condition the client may have.

A nurse is providing teaching to a client about screening prevention for colorectal cancer. Which of the following tests should the nurse include? Select all that apply A. Fecal occult test B. Flex sigmoidoscopy C. Colonoscopy D. Barium enema with contrast E. Bronchoscopy

A. Fecal occult test B. Flex sigmoidoscopy C. Colonoscopy D. Barium enema with contrast A fecal occult test screens for blood in the stool, which can detect ulceration in the colon. A flex sigmoidoscopy is performed to visualize the rectum and descending. A colonoscopy is performed to visualize the rectum and large intestines. A barium enema with contrast is performed to visualize the large intestines using x-ray and contrast dye.

A nurse is preparing to auscultate a client's abdomen for the presence of bowel sounds. Which of the following quadrants should the nurse listen to first? A. Right lower quadrant B. Left lower quadrant C. Right upper quadrant D. Left upper quadrant

A. Right lower quadrant According to evidence-based practice, the nurse should first auscultate the client's right lower quadrant to determine the presence of bowel sounds. The presence of bowel sounds is typically found in the right lower quadrant, which is located at the ileocecal valve because bowel sounds are transmitted through the abdomen.

A nurse is preparing to inspect a client's abdomen. Which of the following variations should the nurse expect to find? Select all that apply. A. Silver striae B. Rash C. Taut skin D. Healed scars E. Mole

A. Silver striae D. Healed scars E. Mole The nurse should identify that silver striae is an expected finding when inspecting a client's abdomen, which can be an indication of a previous pregnancy.

A nurse is preparing to perform an assessment on a client's abdomen. Which of the following piece of equipment should the nurse use? Select all that apply. A. Stethoscope B. Watch C. Tape measure D. Reflex hammer E. Tuning fork

A. Stethoscope B. Watch C. Tape measure The nurse should use a stethoscope to auscultate the client's abdominal area to listen for bowel and vascular sounds. The nurse should use a watch or clock to time the intervals of bowel sounds detected. The nurse should use a tape measure to measure the client's abdominal circumference if their abdomen is distended.

A nurse is preparing to inspect the umbilicus of a client's abdomen. Which of the following findings should the nurse identify as an unexpected finding? A. Swelling B. Mole C. Extraversion D. Scar

A. Swelling The nurse should identify that swelling of the umbilicus can be an indication of a hernia, which is a protrusion of the abdominal viscera through an abnormal opening in the client's muscle wall.

A nurse is preparing to administer a medication to a client who has an enteral feeding tube. Which of the following actions should the nurse take?

Administer the medication to the client in a liquid form.

A nurse has received a prescription to administer a medication STAT to a client. Which of the following actions should the nurse take?

Administer the medication within 30 min of the health care provider prescribing the medication.

A nurse is preparing to administer medications to a client. The nurse should identify that which of the following factors contributes to medication errors? (Select all that apply.)

Administering medication outside of prescribed time intervals Failing to administer a medication Incorrect dose of the prescribed medication administered to the client

A nurse is reviewing the pharmacokinetics of medications with a newly licensed nurse. The nurse should include that which of the following factors can affect the rate of absorption? (Select all that apply.)

Age of the client Lipid solubility of a medication Route of administration

A nurse is planning to use the teach-back method to educate a client about a new antihypertensive medication. Which of the following should the nurse include to demonstrate this method?

Ask the client to explain the information using their own words.

A nurse is assisting with teaching a client who has a new prescription for a nitroglycerin patch. Which of the following actions should the nurse take? (Select all that apply)

Ask the client what they know about the nitroglycerin patch. Determine the client's ability to apply the patch. Check the client's reading comprehension level.

A nurse is caring for a client who has bariatric care needs and has a rash between skinfolds. Which of the following actions should the nurse take?

Assist the client as needed to ensure proper hygiene is performed.

A nurse in a long-term care facility is caring for an older adult client and notes their muscles have become smaller and weaker. Which of the following should the nurse suspect the client is experiencing?

Atrophy

A nurse is providing dietary teaching to a client about the purpose of incorporating fiber in their diet. Which of the following information should the nurse include? A. Fiber can be found in most dairy products. B. Fiber allows larger stool to soften and pass easier. C. Fiber decreases peristalsis to prevent diarrhea. D. Fiber promotes the growth of good bacteria in the intestinal tract.

B. Fiber allows larger stool to soften and pass easier. Fiber absorbs water in the intestinal tract, which allows larger stool to soften and pass more easily.

A nurse is preparing to assess a client's abdomen. Upon palpation, which of the following findings should the nurse report to the provider? A. Nontender B. Involuntary Rigidity C. Relaxed Muscles D. Adipose Tissue

B. Involuntary Rigidity Involuntary ridigity might be present when the client's abdomen feels boardlike, hardness, or pain along with muscle rigidty. This could be an indication that the client has an abdominal mass or an acute inflammation of the peritoneum, and should be reported to the provider.

A nurse is caring for a client who has renal disease and must limit potassium intake. Which of the following foods should the nurse instruct the client to avoid because they are high in potassium? (Select all that apply).

Bananas Dried beans Spinach Tomatoes

A nurse is preparing to auscultate a client's abdomen. Which of the following should the nurse expect if the client is experiencing borborygmus? A. Hypoactive bowel sounds B. Absent bowel sounds C. Hyperactive bowel sounds D. Normative bowel sounds

C. Hyperactive bowel sounds The nurse should identify that borborygmi bowel sounds are hyperactive bowel sounds that are auscultated about every 3 sec due to increased peristalsis of the bowels, as with diarrhea. Borborygmi bowel sounds are louder and have a rushing, rumbling, or tinkling sound.

A nurse is teaching a client about the purpose of probiotics and incorporating them in their diet. Which of the following information should the nurse provide? A.Probiotics increase peristalsis to prevent constipation. B. Probiotics allow larger stool to soften to pass. C. Probiotics promote the growth of good bacteria in the client's intestinal tract. D. Probiotics remove fats and waste products from the body.

C. Probiotics promote the growth of good bacteria in the client's intestinal tract. The nurse should include that probiotics promote the growth of good bacteria in the intestinal tract to balance with the bad bacteria. This can relieve intestinal discomfort, such as diarrhea or constipation.

A nurse is preparing to obtain a wound culture from a client who has a suspected wound infection. Which of the following actions should the nurse take?

Clean the wound with 0.9% sodium chloride

A nurse is scheduled to administer a medication to a client who is currently in the bathroom. Which of the following actions should the nurse plan to take?

Come back in a few minutes to administer the medication.

A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6 hr postoperative. The nurse notices protrusion of the client's organs from the incision site and call for help. Which of the following actions should the nurse take?

Cover the client's wound with a sterile saline dressing

A nurse is preparing to assist with feeding a client who is at risk for aspiration. Which of the following actions should the nurse take?

Cut the client's food into small bites.

A nurse is providing teaching to a client about health promotion to prevent constipation. Which of the following instructions should the nurse include? A. "Limit vegetables to 10% of your daily intake." B. "Drink 32 ounces of water per day." C. "Eliminate legumes from your diet." D. "Consume foods that are high in whole grains."

D. "Consume foods that are high in whole grains." The nurse should instruct the client to consume foods that are high in whole grains, such as high-fiber cereals and legumes.

A nurse is auscultating a client's abdomen for the presence of bowel sounds. Which of the following findings should the nurse expect for hypoactive bowel sounds? A. Bowel sounds absent after 5 min B. Bowel sounds auscultated every 5 to 30 seconds C. Bowel sounds auscultated every 3 seconds D. Bowel sounds heard after 2 min

D. Bowel sounds heard after 2 min The nurse should identify that hypoactive bowel sounds are auscultated after 1 min and up to 5 min for presence of bowel sounds. This can be related to decreased peristalsis due to constipation, adverse effects of medication, anesthesia, or an intestinal obstruction.

A nurse is preparing to palpate a client's abdomen. Which of the following findings should the nurse expect? A. Involuntary rigidity B. Voluntary guarding C. Boardlike D. Nontender

D. Nontender The nurse should expect the client's abdomen to be nontender, and muscles relaxed upon palpation.

A nurse is performing a skin assessment on a client who has a wound on their heel that is blistered and lighter in color than the client's skin tone. The nurse should identify that the wound is in which of the following stages of damage?

Damage into the skin layer