NURS101 Proctored exam
A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered? a. Creatine kinase b. Troponin c. Total bilirubin d. Albumin
D. Albumin A low albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time
A nurse is teaching an assistive personnel (AP) about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions a. "I will wear gloves whenever I am in contact with clients." b. "I will wear gloves and a gown when bathing a client with open skin lesions." c. "I will wear gloves to minimize the number to times I have to wash my hands." d. "I will wear gloves when measuring a blood pressure."
b. "I will wear gloves and a gown when bathing a client with open skin lesions." The AP should wear PPE when in direct contact with a client's bodily fluids, such as gloves and a gown when coming in contact with wound exudate is possible.
A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include? a. "Hold the cane with your left hand." b. "When walking, move your left foot forward first." c. "Move the cane forward 18 inches with each step." d. "Keep your elbow straight when you hold the cane."
b. "When walking, move your left foot forward first." The client should move her weaker (left) foot with the cane first, then bring her stronger leg forward ahead of the cane and the weaker foot.
A nurse is assessing a client for pitting edema and notes an indentation of 6 mm at the point of pressure. Which of the following notations should the nurse use to document the severity of the client's edema? a. 4+ b. 3+ c. 2+ d. 1+
b. 3+ The nurse should document pitting edema of 5 to 7 mm as 3+
A nurse is caring for a client who requires droplet precautions. Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray? a. Gloves b. Goggles c. Gown d. Mask
D. Mask A nurse should follow droplet precautions for clients who have infections that spread by droplets larger than 5 microns. The nurse should wear a mask whenever she is within 1m (3ft) of the client.
A nurse is reviewing a client's lab results. Which of the following lab results should the nurse report to the provider? a. Sodium 126 mEq/L b. Potassium 3.6 mEq/L c. Magnesium 1.9 mEq/L d. Chloride 99 mEq/L
Sodium 126 mEq/L Therapeutic range is 136-145 mEq/L. Low sodium values can be seen with dehydration, use of diuretics, adrenal insufficiency, and water toxicity. Sodium is essential for maintaining acid-base balance and conduction of nerve and muscles tissue. Hyponatremia is a net gain of water or loss of sodium that results in a sodium level less than 136 mEq/L. Manifestations of hypoatremia include headache, confusion, lethargy, muscle weakness, fatigue, decreased deep-tendon reflexes, and seizures
A nurse is completing an 8-hr I&O record for a client who consumed 4 oz juice, 6 oz hot tea, 100 mL ice chips, an IV bolus of 150 mL, and 8 oz broth. The nurse should record how many mL of intake on the client's record?
(4oz=120 mL) + (6oz=180mL) +50 mL(ice chips) + 150(IV) + (8oz=240mL) = 740 mL in total
A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include? a. " The client attempted to climb over the side rails and fell" b. "The client was lying on the floor next to his bed." c. "the client was restless and trying to get out of bed all evening." d. "The presence of a bed alarm could have prevented the client from falling."
B. "The client was lying on the floor next to his bed." In an incident report, the nurse should only document what she actually witnessed, along with the date, time, place, and any other actual facts about the incident.
A nurse is preparing to administer methlynaltrexone 12 mg SQ to a client who has opioid-induced constipation. Available is 8mg/0.4 mL. How many mL should the nurse administer
0.6 mL
A nurse is assisting a provider with a sterile procedure and prepares to pour a solution onto a piece of gauze. Identify the sequence of steps the nurse should follow when pouring the solution.
1. Remove the bottle cap 2. Place the bottle cap face up on a clean surface. 3. Pick up the bottle with the label facing his palm 4. Pour 1 to 2 ml into the receptacle 5. Pour the solution onto the gauze
A nurse is preparing to administer naproxen 500 mg PO BID for a client who has osteoarthritis. The amount available is naproxen 125 mg/5mL oral suspension. How many mL should the nurse administer per dose?
20 mL
The nurse is providing teaching to a group of assistive personnel (AP) about hand hygiene. Which of the following statements by one of the APs indicates a need for further teaching? a. "As long as I change gloves between clients, it is not necessary to wash my hands." b. "I should wash my hands before I provide client care." c. "I will not wear artificial nails when providing client care." d. "It is acceptable to use alcohol-based hand products after client contact."
a. "As long as I change gloves between clients, it is not necessary to wash my hands." While the use of gloves does reduce contamination, it is still necessary to perform hand hygiene between clients. This statement by one of the APs indicates a need for further teaching.
A nurse is discharging a client who come to the outpatient clinic with an ankle sprain. Which of the following statements should the nurse identify as an indication that the client understands the discharge instructions? a. "I'll apply ice to my ankle today and tomorrow" b. "I'll rewrap my ankle starting from the knee down." c. "I'll bear weight on my ankle for 10 minutes every hour." d. "I'll put a heating pad on my ankle at bedtime tonight."
a. "I'll apply ice to my ankle today and tomorrow" The RICE acronym outlines how to treat an ankle sprain: rest, ice, compression, elevation. The client should apply ice for the first 24 to 48 hours after the injury.
A nurse in a clinic is teaching a group of clients about preventing low back pain and injury. Which of the following statements should the nurse identify as an indication that the client requires further clarification? a. "I'll sit with my knees lower than my hips." b. "I'll do exercises that strengthen my abdominal muscles." c. "I'll wear low-heeled shoes from now on." d. "I'll carry heavy objects close to my body."
a. "I'll sit with my knees lower than my hips." To prevent back injuries, the client should sit with their knees slightly higher than their hips.
A nurse is reviewing information about HIPAA with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? a. "Information about a client can be disclosed to a family member at any time." b. "HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form." c. " A client's address would be an example of personally identifiable information." d. "HIPAA is a federal law, not a state law."
a. "Information about a client can be disclosed to a family member at any time." Privacy relates to the client's rights over the use and disclosure of his or her own personal health information.
A nurse is planning to discharge a client who has quadriplegia to his home. The nurse suggests that the family might need respite care services. When a family member asks how respite care can help. Which of the following responses should the nurse provide? a. "Respite care allows the primary caregiver away from day-to-day care responsibilities" b. "Respite care provides holistic support and care for a client who is terminally ill" c. "Respite care helps relieve pain and promote comfort" d. "Respite care is a continuation of psychological support after the family member dies."
a. "Respite care allows the primary caregiver away from day-to-day care responsibilities" A client who has quadriplegia requires support for many activities of daily living. Primary caregivers need time to meet their own personal needs as well. Respite care allows primary caregivers time away from their day-to-day care responsibilities for the client.
A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. Room 208 is a private, negative-pressure airflow room; room 212 is a semi-private, positive-pressure airflow room; 214 is a negative-pressure, semi-private room; and room 216 is a private, positive-pressure airflow room. To which of the following rooms should the nurse assign the client? a. 208 b. 212 c. 214 d. 216
a. 208 A client who has or might have tuberculosis requires airborne precautions. That means a private room with negative-pressure airflow. Room 208 is the only one of these options that fits these requirements.
A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurses assign to the room closest to the nurses station? a. A client who sustained a head injury and is having periods of confusion b. A client who reports a severe migraine headache c. A client who has a suspected diagnosis of Tuberculosis (TB) d. A client who has a history of atrial fibrillation and is on continuous ECG monitoring
a. A client who sustained a head injury and is having periods of confusion A client who sustained a head injury and is confused is at risk for seizures. The nurse should place this client in a room near the nurses' station so that he can be closely monitored to prevent injury if a seizure occurs.
A nurse on the med-surg unit is conducting a fall risk assessment for four clients. The nurse should identify that which of the following clients is the greatest risk for a fall? a. An older adult client who is confused and has urinary frequency. b. A client with diabetes mellitus who has a leg ulcer c. A client who is 1 day postoperative and has a nursing assistant helping him out of bed. d. An adolescent client who has a leg fracture and has been using crutches for the past 2 days.
a. An older adult client who is confused and has urinary frequency The client might attempt to go to the bathroom without assistance. The nurse should implement interventions to prevent a fall, such as using a bed alarm, and placing the client close to the nurses station
A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? a. Apply a moisture barrier ointment to the client's skin. b. Clean the client's skin and perineum with hot water after each episode of incontinence c. Check the client's skin every 8 hours for signs of breakdown d. Request a prescription for the insertion of an indwelling urinary catheter.
a. Apply a moisture barrier ointment to the client's skin Skin that remains in contact with urine for prolonged periods is at risk for maceration and breakdown. After cleansing and drying the client's skin, the nurse should apply a moisture barrier ointment to prevent further contact of the skin with urine.
Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse take? a. Ask the client's full name and date of birth b. Verify the client's room number c. Check the client's name on the medication administration record (MAR) d. Ask a family member to verify the client's identity
a. Ask the client's full name and date of birth The nurse must use two identifiers before administering medications. Acceptable identifiers include the client's name, date of birth, identification number within the facility or system, telephone number, and photo identification card or badge.
A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take? a. Assess the apical pulse for a full minute b. Assess the apical pulse with a Doppler device. c. Assess the pedal pulses for a full minute d. Assess the pedal pulses with a Doppler device.
a. Assess the apical pulse for a full minute For clients who have a regular pulse and no cardiovascular problems, the nurse should count the apical pulsations for 30 seconds and multiply by 2. For this client, the nurse should count for 60 seconds. This will help the nurse determine the regularity or irregularity of the heart.
A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use help maintain the integrity of the client's skin? a. Use a transfer device to lift the client up in bed. b. Apply cornstarch to keep sensitive skin areas dry c. Massage the skin over the client's bony prominences d. Elevate the head of the bed no more than 45 degrees
a. Use a transfer device to life the client up in bed Using a lifting device prevents dragging the client's skin across the bed linens, which can cause abrasions.
A nurse is assessing a client who is 2 days postoperative and auscultates bilateral breath sounds, but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications? a. Atelectasis b. Pneumonia c. Pulmonary embolism d. Arterial thrombus
a. Atelectasis Is an incomplete alveolar expansion or collapse. Breath sounds are dull or absent over areas of alveolar collapse.
A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care? a. Auscultate breath sounds at least every 2 hours. b. Perform range-of-motion exercises at least 2 to 3 times daily. c. Make sure the client has an intake of 2 to 3 L of fluid per day. d. Apply antiembolic stockings.
a. Auscultate breath sounds at least every 2 hours. The priority action the nurse should contribute to the plan of care when using the airway, breathing, and circulation approach to client care is auscultating breath sounds to determine the client's need for suctioning. With inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea.
An assistive personnel reports a client's vital signs as tympanic temperature 37.1, pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-assess? a. BP b. Respiratory rate c. Pulse rate d. Temperature
a. BP A nurse is supervising an AP's work is accountable for the work that the AP completes. Therefore, the nurse should verify anything that seems unusual. The BP the AP reported is low; therefore, the nurse should verify that his result is accurate before taking any other actions.
A nurse is helping an older adult client ambulate in the hallway for the first time since admission. the client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client. Which of the following actions should the nurse take? a. Check that the client lifts the walker and then places it down in front of her. b. Walk in front of the client to guide her in moving the walker. c. Have the client move one leg forward with the walker. d. Make sure that the upper bar of the walker is level with the client's waist.
a. Check that the client lifts the walker and then places it down in front of her. The client should lift the walker and advance it about 15 cm, then set it down, this allows her a wide base of support while she moves forward.
A nurse is caring for a client who ingested a poison and is now experiencing a seizure. Which of the following is the priority action the nurse should take? a. Check the patency of the client's airway b. Determine the poison that was ingested c. Identify the amount of poison that was ingested d. Position the client side-lying.
a. Check the patency of the client's airway The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is checking the patency of the client's airway.
A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8 degrees C. Which of the following actions should the nurse perform? a. Complete a neurological check. b. Administer the prescribed PRN antihypertensive medication. c. Increase the client's fluid intake d. Hold the client's evening dose of digoxin
a. Complete a neurological check Neurological assessment is an appropriate nursing intervention when a client displays sudden confusion. Sensory alterations can occur when a client is experiencing multiple sensory stimuli and can result in inappropriate sensory responses. Tolerance to stimuli may be affected by fatigue and emotional and physical well-being.
A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? a. Document restraints checks and client status every 2 hours b. Educate the client's family about restraint use c. Obtain the provider's prescription renewal every 72 hours d. Implement passive range-of-motion exercises. e. Release the restraint and reposition the client every 4 hours.
a. Document restraints checks and client status every 2 hours b. Educate the client's family about restraint use d. Implement passive range-of-motion exercises -promotes circulation and prevents skin breakdown and contractures
A nurse is preparing an older adult for a physical examination the provider is about to perform. Which of the following actions should the nurse take? a. Explain to the client what is about to happen. b. Make sure the room temperature is cool. c. Provide music as an environmental distraction. d. Inform the client that the provider will examine sensitive areas first.
a. Explain to the client what is about to happen Explaining assessment techniques can decrease stress and anxiety. It also increases trust and promotes a therapeutic nurse-client relationship
A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of personal protective equipment should the nurse remove first? a. Gloves b. Gown c. Face shield d. Mask
a. Gloves The greatest risk to safety is pathogen transmission. The gloves are the most contaminated item of PPE, so the nurse should remove them first. Failing to remove the most contaminated item first increases this risk.
A nurse is planning to administer an IM injection into a client's deltoid muscle. Which of the following actions should the nurse take? a. Inject the medication at a 90 degree angle b. Inject a volume less than 2 mL c. Inject the medication 12.7 cm below the client's acromion process d. Use a 21-gauage needle for the injection
a. Inject the medication at a 90 degree angle To reduce the risk of injecting the mediation into subcutaneous tissue.
A nurse is caring for a client who requires isolation for active pulmonary tuberculosis. Which of the following precautions should the nurse include when creating a sign to post outside of the client's room? (select all that apply) a. Mask b. Closed door signs c. Gown d. sharps container e. Hand hygiene
a. Mask b. Closed door sign d. Sharps container e. Hand hygiene Clients who have active pulmonary tuberculosis require airborne precautions. Everyone entering the room requires respiratory protection, in the form of an appropriate filtration mask and everyone who enters or leaves the room should close the door behind them. Nurses must always dispose of needles and sharp instruments in puncture-proof sharps containers. Hand hygiene is essential before and after all contact with clients.
A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session? a. Pain b. Hearing loss c. The client's culture d. Motor impairment
a. Pain If the client reports pain, the nurse should address managing the client's pain and postpone the learning session until the client reports pain relief.
A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take? a. Repeat auscultation after asking the client to breathe deeply and cough. b. Instruct the client to limit fluid intake to less than 2 L/day c. Prepare to administer antibiotics d. Place the client on bed rest in semi-Fowler's position.
a. Repeat auscultation after asking the client to breathe deeply and cough. Although crackles often indicate fluid in the alveoli, they can also be the result of positioning or decreased ventilation. They sometimes clear after a deep breath or a cough.
A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect a. Report of feeling pressure b. Tenderness over the symphysis pubis c. Distended bladder d. Voiding 30 mL frequently e. Dysuria
a. Report of feeling pressure -Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include a report of feeling pressure. b. Tenderness over the symphysis pubis - Clinical findings of urinary retention include tenderness over the symphysis pubis c. Distended bladder d. Voiding 30mL frequently - Urinary retention includes frequent voiding 25 to 60 mL of urine
A nurse is monitoring a client who is postoperative and unable to respond to questions. Which of the following nonverbal behaviors should the nurse identify as an indication that the client has pain? a. Restlessness b. Grimacing c. Moaning d. Clenching e. Drowsiness
a. Restlessness b. Grimacing d. Clenching
A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal? a. Temporary urinary retention b. Urinary frequency for several days c. Blood-tinged urine d. Highly concentrated urine
a. Temporary urinary retention Until the bladder regains its full tone, it is common for clients to develop urinary retention. If a client does not urinate for 6 to 8 hours after catheter removal, reinsertion might become necessary.
A nurse is assessing a client at a follow-up visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting this goal? a. The client faces the direction of movement when sliding an object across the floor. b. When pushing an object, the client moves his front foot backward. c. When moving an object to one side, the client puts his weight on his heels. d. The client stands with his feet close together when lifting an object.
a. The client faces the direction of movement when sliding an object across the floor. Sliding an object across the floor rather than lifting it prevents strain on the lower back muscles. Facing the direction of movement prevents twisting his back.
A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following explanation should the nurse provide? a. This service began the client's admission to the hospital. b. This service focuses on teaching the primary caregiver to meet the client's needs. c. The emphasis is on the client's complete recovery from the illness of injury d. Services are centered in long-term care facilities.
a. This service began the client's admission to the hospital Rehabilitation is a process that assists an ill person or a person with a disability or impairment to achieve the highest possible level of functioning. The process of rehabilitation begins with the client's admission to the heath care facility for treatment.
A nurse is caring for a client who has a stage 1 pressure ulcer. Which of the following dressings should the nurse plan to apply? a. Transparent dressing. b. Wet-to-dry dressing c. Hydrogel dressing d. Alginate dressing
a. Transparent dressing A stage 1 pressure ulcer involves only the epidermal skin. A transparent dressing protects the ulcer from moisture and bacteria while allowing oxygen to reach the skin. The dressing also minimizes friction and shear on the ulcerated area.`
A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider? a. Urine output is 175mL in the past 8 hours. b. Urine output of 2,200 in the past 24 hours c. First-voided urine in the morning has a strong odor d. Urine is cloudy after sitting in the urinal for 6 hours.
a. Urine output is 175mL in the past 8 hours. The nurse should notify the provider if the client's urinary output is less than 30mL/hour. This finding indicates a fluid imbalance, decreased circulating fluid volume, and possibly inadequate renal perfusion.
A nurse is implementing direct nursing care for a group of clients in an acute care setting. Which of the following actions by the nurse is considered an indirect nursing care activity? a. Determining the client's length of stay. b. Assigning tasks to an assistive personnel (AP) c. Providing anticipatory guidance to a client in crisis d. Establishing the client's secondary medical diagnosis
b. Assigning tasks to an assistive personnel (AP) Delegation of nursing care to an AP is considered indirect care. To meet the client's needs, activities of daily living such as ambulation, bathing, and vital signs may be assigned to an AP, but the nurse is responsible for verifying that the tasks have been completed according to standards of care.
A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take? a. Put on sterile gloves b. Assist the client to the left Sims' position c. Hang the enema container 60 cm above the anus d. Insert the tubing about 15 cm into the anus
b. Assist the client to the left Sims' position This position makes it easier for the enema solution to flow by gravity into the sigmoid and descending colon. The nurse should also have the client's right leg flexed to facilitate insertion.
A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances? a. Steatorrhea b. Blood c. Bacteria d. Parasites
b. Blood A guaiac test detects the presence of occult or hidden blood in the stool. The guaiac test is an extremely useful diagnostic screening test for the presence of colon cancer and gastrointestinal ulcers.
A nurse is receiving a change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process? a. Critically analyze client data to determine priorities. b. Collect and organize client data. c. Set client-centered, measurable, and realistic goals. d. Determine effectiveness of interventions.
b. Collect and organize client data The steps in the nursing process include assessment, analysis/diagnosis, planning, implementation and evaluation. The nurse should first collect client data, and then critically analyze the data to determine the client's priorities. This if followed by the nurse planning client-centered, measurable, and realistic goals. The nurse implements care, which involves putting the plan into action, followed by evaluation to determine the effectiveness of the interventions.
A nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci. Which of the following types of precautions should the nurse plan to initiate? a. Droplet b. Contact c. Airborne d. Protective
b. Contact Contact precautions are a type of transmission-based precautions for clients who have an infection, such as VRE, which spreads either by direct or indirect contact.
A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toenails. The nurse should apply the pulse oximeter probe to which of the following locations? a. Finger b. Earlobe c. Toe d. Skin fold
b. Earlobe The earlobe is rarely edematous, is the least affected by decreased blood flow, and has greater accuracy when measuring oxygen saturation.
A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take? a. Keep the container of solution at a level to maintain client comfort. b. Hold the container of solution 30 cm above the anus. c. Hold the container of solution level with the client's upper hip. d. Hold the container 15 cm above the anus, then lower it 15 cm below the anus.
b. Hold the container of solution 30 cm above the anus The nurse should hold the container of solution 30-45 cm above the anus when administering a cleansing enema to allow for a continuous, slow instillation of solution to promote evacuation of feces in the bowel.
A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? a. Document what the nurse believes was the cause of ulcer development. b. Include any relevant statements the client made about the ulcer. c. Document in the client's medical record that she completed an incident report. d. Question the charge nurse about care deficits that might have contributed to the ulcer's development.
b. Include any relevant statements the client made about the ulcer. The nurse should document any relevant statements the client makes about the ulcer and use quotation marks to indicate that they are in the client's words and not the nurse's.
A nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client who has diabetes mellitus. When mixing the two types of insulin, which of the following actions should the nurse take first? a. Inject 10 units of air into the regular insulin vial. b. Inject 20 units of air into the NPH insulin vial c. Withdraw 10 units of insulin from the regular insulin vial d. Replace the needle for withdrawal with a safety needle.
b. Inject 20 units of air into the NPH insulin vial This is the first action because the NPH insulin is the intermediate-acting insulin, which will be drawn up last in order to avoid contaminating the regular insulin with NPH insulin. -Clear before cloudy-
A nurse is caring for an older adult client who was alert and oriented at admission but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs? a. Call the family and ask them to stay with the client b. Move the client to a room closer to the nurse's station c. Apply wrist and leg restraints to the client d. Administer medication to sedate the client.
b. Move the client to a room closer to the nurse's station This will make it easier for the staff to observe the client, should the client behave in an unsafe manner.
A nurse is caring for a client who has not voided for 8 hrs. following a removal of an indwelling catheter. Which of the following actions should the nurse take first? a. Increase fluids b. Perform a bladder scan c. Insert a straight catheter d. Provide assistance to bathroom
b. Perform a bladder scan The first action the nurse should take using the nursing process is to assess the client. The nurse should assess the post void residual (PVR) using a bladder scanner.
A nurse is planning care for a client who has manifestations of C. difficile infection. Which of the following actions should the nurse plan to take? a. Place a surgical mask on the client during transport. b. Place the client on contact precautions c. Use an alcohol-based agent to perform hand hygiene when caring for the client. d. Obtain a blood specimen to test for C. difficile
b. Place the client on contact precautions Clients who have manifestations of C. difficile should be placed on contact isolation until proven otherwise to prevent cross-transmission to uninfected and potentially susceptible clients.
A nurse is observing an assistive personnel performing postmortem care for a client who is Muslim. Which of the following actions should prompt the nurse to intervene? a. Leaves dentures in the mouth b. Prepares to cleanse the body c. Disconnects the cardiac monitor d. Removes soiled linens from the room.
b. Prepares to cleanse the body Following the death of a client who followed the Muslim faith, a Muslim of the same gender must ritualistically wash and wrap the body.
A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen? a. After palpating the abdomen b. Prior to percussing the abdomen c. After assessing for kidney tenderness d. Prior to inspecting the abdomen
b. Prior to percussing the abdomen According to evidence-based practice, the nurse should auscultate the abdomen prior to percussing it to prevent altering the bowel sounds. Both percussing and palpation can stimulate the intestines, increase their motility, and intensify the bowel sounds
A nurse is caring for a client who has limited hand movement. Which of the following actions should the nurse take to assist the clients when feeding? a. Place the client in a lateral position b. Provide an adaptive feeding device for the client c. Initiate a liquid diet for the client d. Arrange the food groups clockwise on the client's plate
b. Provide an adaptive feeding device for the client Adaptive devices, such as utensils with bent or angled/wide/ or foam handles, are helpful for clients whose hand mobility is limited because these devices promote independence.
A nurse is preparing a sterile field. Which of the following actions should the nurse perform when opening the sterile pack? a. Place the pack on a sterile work surface. b. Reach around the pack and open the top flap away from the body. c. Open the right flap with the left-hand d. Move to the opposite side of the pack to open the fourth flap.
b. Reach around the pack and open the top flap away from the body The nurse should pull the uppermost flap away from her body, grasping it from the side to avoid reaching over the sterile field and contaminating it.
A nurse is working with an assistive personnel while caring for a surgical client who is 1 day postoperative. Which task should the nurse take responsibility for completing? a. Measuring vital signs b. Removing the abdominal dressing c. Helping the client into the shower d. Ambulating the client in the hallway
b. Removing the abdominal dressing The nurse cannot delegate assessment, diagnosis, planning, or evaluation because these are the steps of the nursing process that require nursing judgement. When removing an abdominal dressing, the nurse should assess the surgical wound and determine if any further action is needed. This could include notifying the provider and using sterile technique to complete a dressing change.
A nurse finds an open vial of morphine lying on top of the cabinet in a client's room. Which of the following actions should the nurse take? a. Return the medication to the unit's stock for future use. b. Report the discrepancy immediately c. Administer the medication to other clients to avoid waste. d. Independently dispose of the remaining medication.
b. Report the discrepancy immediately. Because this medication is a controlled substance, the nurse should remove the medication from the client's bedside and report the incident according to the facility's policy. After that, she may dispose of it which another nurse witnessing the discard.
A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of violation of confidentiality? a. Discussing a client's surgical procedure with the nurse manager b. Reporting laboratory findings to a member of the client's family c. Notifying the provider of physical examination findings d. Identifying the client by name when making a referral for home health services.
b. Reporting laboratory findings to a member of the client's family Confidentiality is the nondisclosure of information except to an authorized person, that is, someone involved in the client's care or someone the client has given permission to inform. Reporting laboratory findings to a family member without the client's permission violates client confidentiality.
A nurse is preparing to transfer a client who has left-sided weakness from the bed to a chair. Which of the following actions should the nurse plan to take? a. Raise the client's bed to the nurse's waist level. b. Use a gait belt to stand and pivot the client. c. Instruct the client to place his hands around the nurse's neck during the transfer d. Place the chair on the client's weak side.
b. Use a gait belt to stand and pivot the client The nurse should stand and pivot the client using a gait belt to reduce the risk for injury to the client or the nurse.
A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take? a. Insert the needle into a needless port at a 60 degree angle b. Withdraw 3 to 5 mL of urine from the port c. Wipe the area of needleless port with sterile water d. Don sterile gloves
b. Withdraw 3 to 5 mL of urine from the port The nurse should withdraw the required amount of urine which would be approximately 3 to 5 mL for a urine culture or 30 mL for a routine urinalysis.
A charge nurse is observing a nurse performing a Mantoux tuberculin skin test for a client. Which of the following actions should prompt the charge nurse to intervene? a. Creating a 6 mm bleb in the intradermal space of the forearm b. Withdrawing the needle and massaging the site gently. c. Stretching the skin tightly before injection d. Visualizing the tip of the needle under the skin
b. Withdrawing the needle and massaging the site gently. The nurse should apply gentle pressure, not massage, after the injection. Massage can disperse the testing substance beyond the bleb or cause it to leak out of the puncture site.
A nurse is teaching a client about crutch walking using the three-point gait. Which of the following statements by the nurse should be included in the teaching? a. "look down at your feet before moving the crutches." b. "Place one crutch forward with the opposite foot and then place the second crutch forward followed by the second foot." c. "Move both crutches forward while standing on the unaffected leg, and then lift and swing your body past the crutches." d. "Support your body weight on the underarm crutch pads."
c. "Move both crutches forward while standing on the unaffected leg, and then lift and swing your body past the crutches."
A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the client's partner should indicate to the nurse that the teaching was effective? a. "My partner should cough while swallowing food." b. "My partner should place their food on the weaker side of their mouth when eating." c. "My partner should tilt their head forward when swallowing." d. "My partner should sit at a 30-degree angle while eating their meals."
c. "My partner should tilt their head forward when swallowing." Tilting the head forward when swallowing decreases the risk for aspiration in a client who has dysphagia.
A niurse is providing preoperative teaching for a client who will undergo surgery. The nurse explains that the client will wear antiembolism stockings during and after the surgery. When the client asks what the stockings do. Which of the following responses should the nurse make? a. "They protect your legs and heels from skin breakdown" b. "They help keep you warm after your surgery" c. "They improve your circulation to keep blood from pooling in your legs" d. "They make it easier for you to do leg exercises after your surgery"
c. "They improve your circulation to keep blood from pooling in your legs" Antiembolism stockings promote venous return from the legs, thus helping to prevent venous thrombosis, also known as clot formation and peripheral edema.
A nurse is preparing a client's evening dose of risperidone when the tablet falls on the countertop. Which of the following actions should the nurse take? a. Use the tablet's packaging to pick it up from the counter b. Wash the tablet off with alcohol and place it in a clean medication cup. c. Discard the tablet and obtain another dose of medication. d. Place the tablet directly into a medication cup.
c. Discard the tablet and obtain another dose of medication The nurse must adhere to medical asepsis when preparing and administering medications. If the nurse drops a tablet, she cannot be sure that the tablet is not contaminated; therefore, she must discard it.
A nurse is preparing to administer an ophthalmic solution to a client. Which of the following actions should the nurse take? a. Instill the drops into the inner canthus b. Approach the client's eye from below it c. Hold the ophthalmic solution 2cm (3/4 in) above the lower conjunctival sac. d. Ask the client to look down when instilling the solution
c. Hold the Ophthalmic solution 2cm (3/4in) above the lower conjunctival sac.
A nurse receives a client care assignment from the charge nurse that he believes in unfair. The nurse voices his concern to the charge nurse. The nurse is using which level of communication at this time? a. Transpersonal b. Intrapersonal c. Interpersonal d. Public
c. Interpersonal Interpersonal communication is face-to-face interactions with another person. It results in an exchange of ideas, problem-solving, expression of feelings, decision making, and personal growth.
A nurse is instructing clients in the community about relationship development. The nurse should explain that, according to Erikson, establishing relationships with commitment is a primary task of which of the following stages of psychosocial development? a. Generativity vs. stagnation b. Identity vs. role diffusion c. Intimacy vs. isolation d. Trust vs. mistrust
c. Intimacy vs. isolation During this stage, young adults (18-25 years) transition form childhood to adulthood.
A nurse is caring for a client who has a Clostridium difficile infection. Which of the following cleansing agents should the nurse use for hand hygiene? a. Chlorohexidine b. Povidone-iodine c. Nonantimicrobial soap d. Alcohol-based hand rub
c. Nonantimicrobial soap The CDC recommends that hands should be washed with nonantimicrobial soap and water if in contact with spore-forming organisms such as Clostridium difficile or Bacillus anthracis. Proper hand hygiene includes using soapy lather and friction under running water for at least 15 seconds.
A nurse is assessing a client's ability to ambulate with crutches using a three-point gait. Which of the following actions should the nurse identify as a risk to the client's safety? a. The client pushes downward on the handgrips. b. the client stands in a tripod position prior to walking. c. The client places partial weight on the affected leg. d. The client keeps the elbows in a flexed position.
c. The client places partial weight on the affected leg. The three-point gait requires the client to bear all the weight on the unaffected leg because this is a non-weight-bearing gait. The client should move both crutches and the affected leg forward and then move the unaffected leg forward if the client applies weight to the affected leg it places the client at risk for injury.
A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take? a. Use a stiff toothbrush to clean the client's teeth b. Use the thumb and index finger to keep the client's mouth open. c. Turn the client on his side before starting oral care. d. Apply petroleum jelly to the client's lips after oral care.
c. Turn the client on his side before starting oral care Placing the client on his die helps fluid run out of his mouth by gravity, thus preventing aspiration and choking.
A nurse is orienting a new assistive personnel (AP) to the unit. For which of the following actions should the nurse intervene? a. Wears a gown when entering the room of a client who requires contact precautions b. Dons gloves to empty a urinary drainage device c. Washes and rinses her hands for 10 seconds d. Wears a respirator mask when entering the room of a client who requires airborne precautions
c. Washes and rinses her hands for 10 seconds The nurse should intervene because the AP should wash her hands for a least 20 seconds.
A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretion? a. Encourage client to ambulate frequently b. Encourage coughing and deep breathing c. Encourage the client to increase fluid intake d. Encourage regular use of the incentive spirometer
c. encourage the client to increase fluid intake Increasing fluid intake to 1.5 to 2.5 L per day promotes liquefaction and thinning of pulmonary secretions, which improves the client's ability to cough and remove the secretions.
A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching? a. "I don't take naps throughout the day." b. "I go to bed and get up routinely at the same time each day." c. "I have a small snack and take a bath before going to bed each day." d. "I watch TV until I fall asleep each night."
d. "I watch TV until I fall asleep each night." The client should minimize environmental stimuli just before bedtime because it can interfere with sleep.
A nurse is teaching a client's adult son about how to position the client when administering enteral feedings at home. Which of the following statements by the son indicates an understanding of the teaching? a. "I will allow him to be in the position where he is most comfortable during the feeding." b. "I will elevate the head of the bed 10 degrees during the feeding." c. "I will turn him on his left side during the feeding." d. "I will have him sit in his chair during his feeding."
d. "I will have him sit in his chair during his feeding." The client should be placed in a Fowler's position or in a sitting position in a chair, which is the normal position for eating, this is the position that will prevent aspiration of fluid into the lungs and promote a gravitational flow.
A nurse intercepts a messenger at the nurses' station who has a flower delivery for a client on the unit. As the nurse accepts the flowers, the messenger says, "I know Mrs. Welch from the neighborhood. What happened to her?" Which of the following responses should the nurse provide? a. "You know it is not appropriate for you to ask me that." b. "It's my responsibility to remind you that we have to respect our clients' privacy." c. "It's a minor injury. I'm sure you'll see her back in the neighborhood soon." d. "Oh, what lovely flowers, she will enjoy these."
d. "It's my responsibility to remind you that we have to respect our clients' privacy." This therapeutic response provides clarification to the messenger that the hospital staff cannot disclose information about clients.
A nurse is caring for four clients. The nurse should identify which of the following clients as having a contraindication to receiving moist heat. a. A client who has osteoarthritis and has pain of lower extremity joints b. A client who has a spinal cord injury and muscle spasms of the lower back. c. A client who is 1 day postoperative and had deep vein thrombosis d. A client who broke his ankle 2 hours ago and has swelling of the lower extremity.
d. A client who broke his ankle 2 hours ago and has swelling of the lower extremity A client who had a traumatic injury should not receive heat application for the first 24 hrs. due to increased bleeding and swelling. The client's leg should be kept elevated and ice should be applied during the first 24 hours to decrease swelling.
A clinical nurse educator is preparing an educational program about transmission of methicillin-resistant Staphylococcus aureus (MRSA) in hospitalized clients. Which of the following information should the nurse include in the program? a. Place clients who have MRSA on airborne precautions. b. MRSA can be effectively treated with an antiviral medication. c. MRSA can live on the hands for 1 hour. d. Bathe clients with water and chlorhexidine gluconate
d. Bathe clients with water and chlorhexidine gluconate Bathing hospitalized clients with premoistened clothes or warm water that is mixed with chlorhexidine gluconate significantly decreases infection with MRSA.
A nurse is providing dietary teaching for a client who is Asian-American and is gazing at the floor during the instructions. Which of the following actions should the nurse take to demonstrate culturally sensitive nursing care? a. Stop the instructions to see what is on the floor. b. Emphasize the significance of the information. c. Move closer to the client for eye contact d. Continue with the discussion
d. Continue with the discussion A client from this culture might consider direct eye contact, close personal space, and touching to be impolite, aggressive, or disrespectful. By remaining silent and avoiding eye contact, the client could be demonstrating respect for the nurse. The nurse should continue with the dietary teaching while also avoiding eye contact and assess comprehension throughout the discussion.
A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse? a. Speak using his usual tone of voice. b. Stand directly in front of the client. c. Rephase statements the client does not hear d. Determine if the client uses hearing aids
d. Determine if the client uses hearing aids The first action the nurse should take using the nursing process is to assess the client. The nurse should find out if the client has hearing aids and whether they are in place and functioning.
A nurse withdraws morphine 2 mg from a 4 mg/mL vial to inject IM for a client. Which of the following actions should the nurse take for wasting the excess medication? a. Place the excess medication in the sharps container b. Save the excess medication for the next administration. c. Return the excess medication to the secure cabinet d. Have a second nurse witness the disposal of the excess medication.
d. Have a second nurse witness the disposal of the excess medication. Morphine is a controlled substance. Policies vary with the facility, but the nurse must have another nurse witness the disposal of unused portions of doses of controlled substances.
A nurse is caring for a client who has emphysema and has difficulty with mobility. The client receives home health care and spends most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should the nurse expect? a. Increased insulin production b. Decreased RBC production c. Decreased sodium excretion d. Increased calcium excretion
d. Increased calcium excretion Prolonged immobility leads to the breakdown of bone tissue. This results in increased calcium excretion.
A nurse is caring for several clients who are at various developmental stages. The nurse should explain that, according to Erikson, acceptance of death is a primary task of which of the following stages of psychosocial development? a. Autonomy vs. shame and doubt b. Generativity vs. stagnation c. Identity vs. role diffusion d. Integrity vs. despair
d. Integrity vs. despair According to Erikson, integrity vs. despair is the developmental task of late adulthood, when adults must accept the worth and uniqueness of one's life and eventual death.
A nurse is preparing to discontinue a client's indwelling catheter. Which of the following actions should the nurse take first? a. Deflate the catheter balloon using a sterile syringe b. Measure and document the urine in the drainage bag. c. Remove the tape or device securing the catheter to the client's thigh d. Position the client supine
d. Position the client supine This permits adequate visualization and assessment of the perineal area and promotes the client comfort and relaxation.
A nurse is observing an AP changing the linens on the bed of a client who is immobile. Which of the following actions by the AP should the nurse identify as an indication of the need to intervene? a. Raises the bed to waist level b. Rolls the client to one side of the bed. c. Lowers the side rail on the side of the bed closest to the AP d. Reaches over the bed to straighten the fitted sheet.
d. Reaches over the bed to straighten the fitted sheet. Stretching over the bed demonstrates poor body mechanics. Fitting the sheet one side at a time will allow the AP to reach each part of the bed without straining her back. The AP should make sure the sheet fits securely on one side of the bed before going to the other side.
A nurse is preparing to administer an IM injection of meperidine to a client. Which of the following is the priority assessment the nurse should complete? a. Apical pulse rate b. Blood pressure c. Level of consciousness d. Respiratory rate
d. Respiratory rate Airway, breathing, and circulation are the priority focus of the nurse at this time. Meperidine can cause respiratory depression and the client's respiratory rate should be monitored prior to administering this medication.
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 take prior to administering the tube feeding? a. Warm the feeding solution to body temperature b. Place the client in low Fowler's position c. Discard any residual gastric contents d. Test the pH of gastric aspirate
d. Test the pH of gastric aspirate Before administering enteral feedings, the nurse should verify the placement of the NG tube. The only reliable method is x-ray confirmation, which is impractical prior to every feeding. Testing the pH of gastric aspirate is an acceptable method between x-ray confirmations.
A nurse in a long-term care facility is assisting a client with eating during meal time and recognizes another client indicating he is choking. Which of the following situations requires the nurse to perform the Heimlich maneuver? a. The client has a high-pitched inspiratory stridor b. The client is able to whisper c. The client is coughing only d. The client is not making any sounds
d. The client is not making any sounds When the airway is totally blocked, the client is not able to make any sounds. This finding, along with the client grasping his neck, comprise the universal sign of distress. This requires immediate action and the nurse should perform the Heimlich maneuver at this time.
A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint? a. The client has a capillary refill of less than 2 seconds b. The client has full range of motion in her wrist c. The client is attempting to remove the restraint d. The client's hand is cool and pale
d. The client's hand is cool and pale This finding indicates a decrease in blood flow to the client's hand, which can be caused by applying a restraint too tightly. This is the finding that indicates a complication of the restraint, and the nurse should loosen the restrain and exercise the limb.
A nurse is using the communication principle of presence when establishing a collaborative relationship with a client. Which of the following actions should the nurse take? a. Focus on the client's present circumstances instead of his personal stories. b. Verbalize understanding of how the client feels. c. Offer the client personal thoughts and beliefs d. Use attentive listening with the client
d. Use attentive listening with the client When establishing presence, eye contact, body language, voice tone, listening, and reflection convey openness and understanding
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection? a. BUN b. Potassium c. RBC count d. WBC count
d. WBC count An elevation is the WBC count (leukocytosis) indicates that the client's immune system is defending him against the pathogens causing an infection.
A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia? a. Decreased heart rate b. Dyspnea c. Increased blood pressure d. Weak pulse
d. Weak pulse A decreased volume of circulating blood and less pressure within the vessels result in weak peripheral pulses (rated as +1), which can be described as thready.
A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds? a. Crackles b. Rhonchi c. Stridor d. Wheezes
d. Wheezes Wheezes are continuous, high-pitched squeaking sounds, first evident on expiration, but possibly evident on inspiration as the airway obstruction of asthma worsens. Wheezes are often audible without a stethoscope.
A nurse is admitting a client from a long-term care facility. The nurse should use closed-ended questions when assessing which of the following factors? a. When determining if the client is eating a well-balanced diet. b. When asking the client about his receptiveness to the transfer. c. When asking the client how he completes his ADLs. d. When asking if the client took his medications this morning.
d. When asking if the client took his medications this morning. A "yes" or "no" response is sufficient when asking if a client took his morning medications. If he did not take them and should have, the nurse might want to explore this issue further.
A nurse is preparing an in-service presentation for a group of newly licensed nurses about the use of restraints. Which of the following should the nurse include as a criterion for applying restraints? a. The provider must renew a restraint prescription every 8 hours. b. The client must understand the need for the restraints. c. the restraints should promote the client's safety and prevent injuries. d. The nurse has already considered alternatives to restraints
d. the nurse has already considered alternatives to restraints Restraints physically prevent a client form moving freely in the environment. However, they are a last resort. The nurse must consider other alternatives before implementing a restraint device.
A nurse is assessing a client's peripheral circulation. In which of the following location should the nurse palpate to assess the posterior tibial pulse?
inside the ankle bone The posterior tibial pulse is located on the inner ankle, 1/3 of the way along a line between the tip of the medial malleolus (end of the tibia) and the point of the heel. It is most easily palpated about 2.5 cm higher, where it runs behind the medial malleolus.