NURS210 Unit 2 Exam
A client drinks 8 oz of water. Which of the following is a correct conversion of the client's intake? A) 1 pint B) 4 Tbsp C) 2 cups D) 240 mL
D) 240 mL
A nurse is preparing to administer acetaminophen 320 mg oral solution to a school-aged child. The amount available is acetaminophen oral suspension 160 mg/5 mL. How many mL should the nurse administer? (Round to the nearest whole number)
10 mL
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 answer to nearest whole number)
12 mL
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 answer to the nearest whole number)
2 mL
A nurse is preparing to administer amikacin 7 mg/kg/day IM to a client who weights 165 pounds. Available is amikacin 250/mg/mL solution for injection. How many mL should the nurse administer per dose? (Round answer to the nearest tenth)
2.1 mL
A nurse is teaching a newly licensed nurse about urinary retention. Which of the following client should the nurse include as having an increased risk for this condition? A client who has an enlarged uterus A client who experiences frequent urinary tract A client who has an enlarged prostate A client who has chronic hypertension
A client who has an enlarged prostate
A nurse is assisting with teaching a class about events that require an occurrence report. Which of the following events should the nurse include? (SATA) A) A client's visitor falls int eh hallway B) A nurse forgets their computer password C) A client develops an unexpected reaction to a med D) A client's denture are lost E) An antibiotic was administered to a client 30 min after the scheduled time
A) A client's visitor falls int eh hallway C) A client develops an unexpected reaction to a med D) A client's denture are lost
Which of the following actions demonstrates correct use of one of the Ten Rights of Medication Administration? A) Administering a client's med by route the provider has prescribed B) Adhering as closely as possible to the med schedule the client follows at home C) Gathering a med history from the client before administering any meds D) Insisting that the client take all meds prescribed
A) Administering a client's med by route the provider has prescribed
A nurse is reviewing the pharmacokinetics of medication with a newly licensed nurse. The nurse should include that which of the following factors can affect the rate of absorption (SATA) A) Age of the client B) First pass effect C) Lipid solubility of a medication D) Route of administration E) Metabolism of the medication
A) Age of the client C) Lipid solubility of a medication D) Route of administration
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? (SATA) A) Ask the client what they know about the nitroglycerin patch. B) Find out whether the client is able to pay for medication C) Determine the client's ability to apply the patch D) Check the client's reading comprehension level E) Use the medical terminology to instruct the client about the patch.
A) Ask the client what they know about the nitroglycerin patch. C) Determine the client's ability to apply the patch D) Check the client's reading comprehension level
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse instruct the client to perform during the insertion procedure? A) Bear down B) Take deep breaths C) Sip water D) Tighten the perineum
A) Bear down This relaxes the sphincter and aids in the insertion
A nurse is assisting with teaching a class about hospital-acquired injuries. The nurse should include that which of the following is a hospital-acquired injury? (SATA) A) Blood transfusion incompatibility B) Wring site injury C) Ineffective insulin usage D) Dysphagia following a stroke E) Dehydration due to diarrhea
A) Blood transfusion incompatibility B) Wring site injury C) Ineffective insulin usage
A nurse is preparing to administer medications to a client. Which of the following information should the nurse use to identify the client? (SATA) A) Client's full name B) Client's date of birth C) Client's telephone number D) Client's diagnosis E) Client's room number
A) Client's full name B) Client's date of birth C) Client's telephone number
A nurse is inserting a NG tube for a client and asks the client to flex their head toward their chest after the tube passes through the nasopharynx. This action facilitates proper insertion of the tube by achieving which of the following? A) Closing off the glottis B) Preventing curling of the tube in the mouth C) Allowing the client to breath through the mouth D) Opening the lowed esophageal sphincter
A) Closing off the glottis Prevents tube from entering the trachea
A client who lives in a long-term care facility is receiving intermittent enteral feedings and is experiencing social isolation. Which of the following interventions should the nurse recommend? A) Encourage the client to go to the dining room at meal times to talk with other clients B) Suggest that the client watch television while feeding are being administered C) Remind the client that they can have visitors after feeding administration times D) Ask the facility chaplain to speak with the client
A) Encourage the client to go to the dining room at meal times to talk with other clients
A nurse is preparing to conduct a fall risk screening on a client. Which of the following variables will the nurse use to evaluate the client? A) Fall history B) Medical diagnosis C) Use of assistive devices D) Mental status E) Do-not-resuscitate status
A) Fall history B) Medical diagnosis C) Use of assistive devices D) Mental status
A nurse is caring for a client who is receiving a medication that typically causes drowsiness. While assessing the client, the nurse nothes that the medication has caused the client to become hyperactive. Which of the following terms describes the client's unexpected response to the medication? A) Idiosyncratic effect B) Allergic response C) Toxic effect D) Synergistic effect
A) Idiosyncratic effect An uncommon, unexpected, or individual medication response thought to result from a genetic predisposition.
A nurse is caring for a client who reports having daily constipation. Which of the following information should the nurse provide to the client regarding fiber intake? (SATA) A) Increasing daily fiber intake can help alleviate the issue of constipation B) Eating more whole grains can promote regular BM C) Consume 10 g of fiber per day D) Food such as white rice increase fiber intake E) Decreasing daily fiber intake can help alleviate digestive discomfort.
A) Increasing daily fiber intake can help alleviate the issue of constipation B) Eating more whole grains can promote regular BM **Daily recommendation Women = 25g/day Men = 38g/day
Which of the following routes of medication administration has no barriers to absorption? A) Intravenous B) Intramuscular C) Subcutaneous D) Oral
A) Intravenous
A nurse is caring for a client who is receiving tube feeding via PEG. Which of the following actions should the nurse implement in order to help prevent the client from aspirating? A) Keep the client's head elevated to at least 30° for a minimum of 1 hr after feeding B) Verify the initial tube placement with an x-ray after the first feeding C) Check the client's tube feeding tolerance every 12 hours D) Check the pH of the gastric contents each day.
A) Keep the client's head elevated to at least 30° for a minimum of 1 hr after feeding
A nurse is preparing to administer a continuos enteral tube feeding to a client. The nurse should take which of the following actions to prevent a complication of the tube feeding? A) Limit the time the formula hangs to 8 hours B) Flush the tube every 8 hours C) Deliver the formula at a brisk rate D) Allow the feeding bag to empty before refilling it
A) Limit the time the formula hangs to 8 hours ***Formula hangs no longer than 12 hours
A nurse is assisting with teaching a newly licensed nurse about using a lift device to transfer a client. Which of the following actions by the nurse indicated an understanding of the teaching? (SATA) A) Locks the brakes on the clients bed B) Checks the maximum weight of the lift before using it C) Places the client on the edge of the sling D) Uses the lift without assistance from another team member E) Performs a safety check before lifting the client
A) Locks the brakes on the clients bed B) Checks the maximum weight of the lift before using it E) Performs a safety check before lifting 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? (SATA) A) Mark the area around the automated medication dispensing system B) Encourage the use of cell phones while dispensing medications C) Override the automated medication dispensing system during emergencies D) Provide the nurse administering medications with a vest E) Double check dosages of high-alert meds
A) Mark the area around the automated medication dispensing system D) Provide the nurse administering medications with a vest E) Double check dosages of high-alert meds
A nurse is assessing a client who is experiencing digestive issues. Which of the following findings should the nurse expect? (SATA) A) Nausea B) Abdominal pain C) Diarrhea D) Reports of bloating E) Reports of excessive salivation
A) Nausea B) Abdominal pain C) Diarrhea D) Reports of bloating
A nurse is checking a client's allergy braceley before administering a medication and finds the client is allergic to that medication. The nurse does not administer the medication to the client. This is an example of which of the following unexpected events? A) Near-miss event B) Client safety event C) Adverse event D) Sentinel event
A) Near-miss event
A nurse is reviewing a client's medical record and notes that their BMI is 25.5. How should the nurse interpret this finding? A) Overweight B) Underweight C) Normal D) Obese
A) Overweight Obese = >30 Overweight = 25-29.9 Normal = 18.5-24.9 Underweight = <18.5
A nurse is assessing a client's thyroid gland as part of a comprehensive physical examinations. Which of the following findings should the nurse expects. (Select all that apply) A) Palpating the thyroid in the lower half of the neck B) Visualizing the thyroid on inspection of the neck C) Hearing a bruit while auscultating that thyroid D) Feeling the thyroid ascend as the client swallows E) Finding symmetric extension off the trachea on both sides of the midline
A) Palpating the thyroid in the lower half of the neck D) Feeling the thyroid ascend as the client swallows E) Finding symmetric extension off the trachea on both sides of the midline
A nurse is preparing to administer a premixed medication to a client. The nurse should check the label for which of the following information? (SATA) A) The date the med was mixed B) Client's age C) Client's room number D) The dose of the mixed med E) The time the med was mixed
A) The date the med was mixed D) The dose of the mixed med E) The time the med was mixed
A nurse is preparing to administer a cleansing enema to a client who has poor sphincter control. Which of the following actions should the nurse take? A) Place the client in the dorsal recumbent position on a bedpan B) Administer the enema while the client sits on the toilet C) Administer an antidiarrheal med 3 hrs prior to the enema D) Instill 200 mL of fluid over an ouse at 15 min intervals
A) Place the client in the dorsal recumbent position on a bedpan
A nurse is caring for a client who is at risk for suicide. Which of the following actions should the nurse take? (SATA) A) Place the client on round-the-clock surveillance B) Remove objects from the room that the client could use to harm themselves C) Search items brought into the client's room by visitors D) Refrain from asking the client if they intend to hurt themselves E) Screen the client for suicidal ideation
A) Place the client on round-the-clock surveillance B) Remove objects from the room that the client could use to harm themselves C) Search items brought into the client's room by visitors E) Screen the client for suicidal ideation
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? (SATA) A) Place the medication reconciliation form with the client's transfer documents B) Reinforce teaching about the medications to the client upon discharge C) Add medications the client is no longer taking in the medication reconciliation D) Include OTV meds in the medication reconciliation E) Compare the client's home meds with prescribed discharge meds
A) Place the medication reconciliation form with the client's transfer documents B) Reinforce teaching about the medications to the client upon discharge D) Include OTV meds in the medication reconciliation E) Compare the client's home meds with prescribed discharge meds
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? A) Record the time and length of the seizure B) Restrain the client's extremities C) Place the client in the prone position D) Monitor the client's hemoglobin level.
A) Record the time and length of the seizure
A nurse is assisting with emergency care of a client who has been exposed to a chemical toxin. Which of the following actions should the nurse take? A) Rinse the client's skin with water B) Remove the client's clothing by pulling it over their head C) Dispose of the client's clothing in a single biohazard bag D) Prepare to administer potassium iodide to the client
A) Rinse the client's skin with water
A nurse is caring for a client who routinely eat a regular diet and is scheduled to have surgery with sedation in the morning. The nurse receives a new NPO dies prescription for the client. Which of the following should the nurse identify as the rationale for the provider's prescription? A) The client is at risk for aspiration due to the upcoming surgery B) The client is at risk for dysphagia due to the upcoming surgery C) The nutrients consumed as a part of the regular diet will interact with the sedation used in the procedure D) The client reports having to drink a few sipd of water before the procedure.
A) The client is at risk for aspiration due to the upcoming surgery
A nurse is caring for a client who is prescribed a low glycemic index diet. The client states, "I dont understand what this mean." Which of the following responses should the nurse make? (SATA) A) The glycemic index of a food relates to its ability to increase the blood glucose B) You should eat foods such as whole grains, fruits, and veggies C) Consuming white bread will increase your blood glucose level slowly D) Try to limit or avoid potatoes due to their high glycemic index E) Foods with high glycemic index will cause your blood glucose to increase rapidly
A) The glycemic index of a food relates to its ability to increase the blood glucose B) You should eat foods such as whole grains, fruits, and veggies D) Try to limit or avoid potatoes due to their high glycemic index E) Foods with high glycemic index will cause your blood glucose to increase rapidly
A nurse is reviewing measurement systems to perform dosage calculations with a newly licensed nurse. Which of the following instructions should the nurse include? A) To convert g to mg, move the decimal point 3 places to the right. B) Liters is a unit of measurement for distance C) The metric system uses fractions rather than decimals D) Grains is used as a measurement of weight in the metric system
A) To convert g to mg, move the decimal point 3 places to the right. B) Liters is a unit of me
A nurse is a providers office is preparing to auscultate and percuss a client's abdomen. Which of the following findings should the nurse expect? (Select all that apply) A) Tympany B) High-pitched clicks C) Borborgymi D) Friction rubs E) Bruits
A) Tympany - indicates air in stomach B) High-pitched clicks - clicks and gurgles occurring 35x/min
A nurse is preparing to administer the first of two large-volume, cleansing enemas prescribed for a client in preparation for a diagnostic procedure. Which of the following actions should the nurse take? A) Warm the enema solution prior to instillation B) Prepare 1,500 mL of enema fluid C) Use tap water as the enema fluid D) Hang the enema container 24 inches about the anus
A) Warm the enema solution prior to instillation
A nurse is caring for a client who has high phosphorus level. Which of the following instructions regarding food should the nurse provide? A) You should eat white bread B) You can drink 2 cups of milk per day C) You should limit broccoli to 3 cups per week D) You can have four servings of oatmeal per week
A) You should eat white bread ***Whole grain are high in phosphorus
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? (SATS) A) You should limit saturated fats in your diet B) You should increase sodium intake to your taste C) Eat foods with whole grains in your new diet D) Its important to eat larger portions of fruits and veggies E) Limiting high-calorie intake will promote adherence to your new diet F) Continue to avoid skim milk and lean meats
A) You should limit saturated fats in your diet C) Eat foods with whole grains in your new diet D) Its important to eat larger portions of fruits and veggies E) Limiting high-calorie intake will promote adherence to your new diet
Which of the following describes a medication's generic name? A) The chemical name for a medication B) Same as its nonproprietary name C) Name under which a med is marketed D) Formal name of a particular med
B) Same as its nonproprietary name
A nurse is helping a client calculate how many net carbs they consume in their last meal. The client's food had a total of 72 g of carbs and 9 g of fiber. How many net carbs did the client consume? A) 81 B) 63 C) 8 D) 72
B) 63 ***Total Carb - (Fiber + Alcohol sugar) = Net carbs
Which of the following clients is exhibiting medication tolerance? A) A client who continues to take a medication despite harmful effects B) A client who requires an increased dose of meds to achieve continued therapeutic benefit C) A client who exhibits signs of withdrawal when a med is discontinued D) A client who develops an intense craving for a med
B) A client who requires an increased dose of meds to achieve continued therapeutic benefit
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? (SATA) A) Apples B) Bananas C) Dried beans D) Spinach E) Tomatoes
B) Bananas C) Dried beans D) Spinach E) Tomatoes
A nurse has a handwritten prescription that is difficult to read. Which of the following actions should the nurse take to avoid an error in med admin? A) Ask another nurse to decipher the prescription B) Call the provider for clarification of the prescription C) Rely on their knowledge of the client to get the prescription right D) Inquire at the facility pharmacy about the prescription.
B) Call the provider for clarification of the prescription
A nurse is assisting with teaching a class about evidence-based protocols establish by the CDC to prevent healthcare-associated infections (HAIs). Which of the following infections should the nurse include? (SATA) A) Influenza infection B) Catheter-associated urinary tract infection C) Mycobacterium tuberculosis infection D) Central line-associated bloodstream infection E) Surgical site infection
B) Catheter-associated urinary tract infection D) Central line-associated bloodstream infection E) Surgical site infection
A nurse is preparing to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take? A) Pull the catheter out as quickly as possible B) Deflate the balloon completely before the removal C) Cut the inflation port to deflate the balloon D) Tell the client to expect the feel a tugging sensation on removal
B) Deflate the balloon completely before the removal
A nurse is caring for a client who has a dysfunctional GI tract and requires enteral feeding. Which of the following formulas should the nurse administer to the client? A) Modular B) Elemental C) Polymeric D) Specialty
B) Elemental Modular - Single nutrients Elemental - Contain predigested nutrients that are east for a partially functional GI tract to absorb Polymeric - Whole-nutrient Specialty - Meet specific needs for client who have conditions such as HIV, liver failure, or clients who have pulmonary disease
A nurse is assisting with teaching a client about self-administration of insulin. Which of the following actions should the nurse take? A) Repeat the least important information to the client B) Have the client perform a return demonstration of the procedure C) Provide the client with educational materials written at an 8th grade reading level D) Dim the lights in the client's room before beginning the teaching
B) Have the client perform a return demonstration of the procedure
A nurse is preparing a male client for intermittent urethral catheterization. Which of the following actions should the nurse take? A) Grasp the penis at its base B) Lift the penis perpendicular to the body C) Hold the penis parallel to the client's body D) Lift the penis to a 45° angle to the client's body
B) Lift the penis perpendicular to the body 90°
A nurse is administering a return-flow enema to a client. After instilling 100 mL of enema fluid, which of the following actions should the nurse take? A) Instruct the client to retain the fluid B) Lower the container to allow the solution to flow back out C) Help the client to the toilet or bedside commode D) Wait 5 minutes and instill another 100 mL of fluid
B) Lower the container to allow the solution to flow back out
A nurse is discussing macronutrients with a client. Which of the following statements should the nurse make? A) Macronutrients include vitamins and minerals, which your body needs a large amount of B) Macronutrients include carbs, proteins, and fats, which make up the majority of a person diet C) Macronutrients include carbs and fats, which your body needs very little of D) While essential, macronutrients should be limited to weekly consumption
B) Macronutrients include carbs, proteins, and fats, which make up the majority of a person diet
A nurse is caring for a client who has a significant risk of aspiration and requires nutritional support for about 2 weeks because they are unable to consume adequate nutrients orally. Which of the following types of feeding tubed should the nurse anticipate the provider to prescribe? A) NG tube B) Nasointestinal tube C) Percutaneous endoscopic gastronomy tube D) Percutaneous endoscopic jejunostomy tube
B) Nasointestinal tube Recommended for short term feeding of less than 4 weeks for aspirations
A charge nurse is reviewing routes of med admin with a newly licensed nurse when providing care to a client. Which of the following routes of admin should the charge nurse include as having the slowest onset of action? A) IM B) Oral C) Buccal D) IV
B) Oral ***Buccal bypasses first pass effect
A nurse is providing teaching about risk for aspirations with a client who is receiving intermittent bolus nasogastric feedings. Which of the following findings should the nurse instruct the client to report? A) A feeling of fullness B) Persistent coughing C) Discomfort in the naris D) Post feeding belching
B) Persistent coughing Can indicate that the distal end of the NG tube has moved into the resp tract
A nurse is palpating a tender aread of a client's abdomen. The nurse slowly applies pressure over the area with their fingertips, then quickly releases it. The client reports increased pain on the release of pressure. Which of the following findings should the nurse document? A) Borborygmi B) Rebound tenderness C) Tympany D) Abdominal guarding
B) Rebound tenderness When deep palpation over a tender are is released
A nurse is caring for a a client who has a prescription for wrist restraints. Which of the following actions should the nurse take? A) Tie the restraints to the siderails on the client's bed B) Remove the restraints with each vital sign check C) Use a square knot to secure the restraints D) Make sure one finger can fit under the restraints
B) Remove the restraints with each vital sign check **Assess skin integrity and circulation periodically***
A client who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should expect the provider to prescribe which of the following types of enemas? A) Cleansing B) Return-flow C) Medicated D) Oil-retention
B) Return-flow aka Flush enemas
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? A) Notify the client's provider B) Stop the infusion of the vancomycin C) Administer diphenhydramine to the client D) Document the incident int eh client's chart
B) Stop the infusion of the vancomycin
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? A) The client is not getting enough vitamin ! B) The client has insufficient protein in their diet C) The client needs more vitamin D from sun exposure D) The client needs to eat five servings of fruits and veggies daily
B) The client has insufficient protein in their diet
A nurse is assisting with conducting a home hazard assessment for a client who has dementia. Which of the following findings indicates an understanding of home safety? A) An extension cord is secured under a rug B) The edges of the stairs are marked with brightly colored tape C) A toaster is plugged in when not in use D) The water heater is set to 55° C (131°F)
B) The edges of the stairs are marked with brightly colored tape
A nurse is assisting with teaching a newly licensed nurse about electrical safety. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching? A) The nurse plugs in a sequential compression device with wet hands B) The nurse holds onto the plug to unplug a clients electronic BP machine C) The nurse rolls the clients bed over an electrical cord D) The nurse uses an extension cord to plug in a clients smart infusion pump.
B) The nurse holds onto the plug to unplug a clients electronic BP machine
During a cardiovascular examination, a nurse in a provider's office places the diaphragm of the stethoscope on the left midclavicular line at the fifth intercostal space. Which of the following heart sounds is the nurse attempting to auscultate? (Select all that apply.) A. Ventricular gallop B. Closure of the mitral valve C. Closure of the pulmonic valve D. Apical heartrate E. Murmur
B. Closure of the mitral valve D. Apical heartrate
A nurse is administering an enema medicated with sodium polystyrene sulfonate to an adult client who has hyperkalemia. To which of the following lengths shoudl the nurse insert the rectal tube? A) 2.5 cm - 3.75 cm (1-1.5 inches) B) 5 cm- 7.5 cm (2-3 inches) C) 7.5 cm -10 cm (3-4 inches) D) 10 cm - 12.5 cm ( 4-5 inches)
C) 7.5 cm -10 cm (3-4 inches)
A nurse is performing a cardiovascular assessment on a client. Which of the following findings should the nurse expect? A) A continuous sensation of vibration felt over the second and third left intercoastal spaces B) A high-pitched, scraping sound heard in the third intercostal space to the left of the sternum C) A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line D) A whooshing or swishing sound over the second intercostal space along the left sternal border.
C) A brief thump felt near the fourth or fifth intercostal space near the left midclavicular line Point of maximal impulse or apical pulsation
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) A client who has respiratory infection B) A client who has rheumatoid arthritis C) A client who has impaired kidney function D) A client who has hyperthyroidism
C) A client who has impaired kidney function Many meds are exerted through the kidneys. A decrease in function of the kidneys can result in a buildup of med metabolites.
A nurse is caring for a group of newly admitted clients. For which of the following clients should the nurse expect to receive a prescription for urinary catheterization? A) A client who has a persistent UTI B) A client who has urge incontinence C) A client who is in the ICU for GI bleed D) A client who has incontinence due to cognitive decline
C) A client who is in the ICU for GI bleed Precise measurement of urinary output is crucial for managing fluid balance in clients who are critically ill.
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) If taken four or more days a week, a multivitamin provides all the nutrients you need. B) As long as you take a multivitamin daily, you do not need to eat a varied diet each day C) A multivitamin should not be used in place of a nutritious diet D) As long as the multivitamin isn't generic, it can replace unhealthy dietary choices.
C) A multivitamin should not be used in place of a nutritious diet
A nurse is preparing to administer a medication to a client who has an enteral feeding tube. Which of the following actions should teh nurse take? A) Mis the med with the client's feeding infusion B) Flush the feeding tube with 10 mL of water prior to administration of the med C) Administer the med to the client in a liquid form D) Place the client in a supine position prior to administering the med.
C) Administer the med to the client in a liquid form
A nurse is preparing to administer meds to a client. The nurse should identify that which of the following factors contributes to med errors? (SATA) A) The use of automated dispensing system B) Administering a generic med C) Administering meds outside of prescribed time intervals D) Failing to administer a med E) Incorrect dose of the prescribed med administered to the client
C) Administering meds outside of prescribed time intervals D) Failing to administer a med E) Incorrect dose of the prescribed med administered to the client
Which of the following represents the correct administration of the prescribed medication? A) Acetaminophen 650 mg PO prescribed; 5 tsp of 325 mg/ 10 mL liquid given B) Levothyroxine 100 mcg PO prescribed; three 0.025 mg tablets given C) Amoxicillin 1 g PO prescribed; two 500-mg tablets given D) Diphenhydramine 40 mg IM prescribed; 1.25 mL of 50 mg/1 mL for injection given
C) Amoxicillin 1 g PO prescribed; two 500-mg tablets given
A nurse is preparing to administer an oral medication to a client. Which of the following actions is the nurse's priority? A) Have another nurse check the does to be administered B) Teach the client about possible adverse effects. C) Confirm the client's identity using two methods D) Confirm that the client can swallow adequately
C) Confirm the client's identity using two methods
A nurse is preparing a poster about fire safety for a community health fair. THe nurse should include on the poster that which of the following components contains needed elements for fire to occur? (SATA) A) Carbon Dioxide B) Nitrogen C) Cooking Oil D) Oxygen E) Heat
C) Cooking Oil D) Oxygen E) Heat **Carbon dioxide and nitrogen are nonflammable
A nurse is performing an integumentary assessment for a group of clients. Which of the following should the nurse recognize as requiring immediate attention? A) Pallor B) Jaundice C) Cyanosis D) Erythema
C) Cyanosis - indication of hypoxia ABCs - Airway and breathing
A nurse is preparing to administer insulin to a client. Which of the following actions should the nurse take first? A) Document the insulin administration B) Assist with teaching the client about insulin C) Have a second nurse confirm the insulin dose D) Monitor the client for adverse effects of the insulin.
C) Have a second nurse confirm the insulin dose
A nurse is applying a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse take? A) Stretch the sheath portion of the condom catheter along the length of the penis B) Secure the sheath portion with adhesive C) Leave a space between the penis and sheath portion tip D) Reposition the foreskin after application
C) Leave a space between the penis and sheath portion tip
While the nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? A) Measure the client's vital signs B) Notify the primary care provider C) Lower the enema fluid container D) Stop the enema instillation
C) Lower the enema fluid container
A nurse is inserting a small bore feeding tube. Before initiating the feeding, the nurse should take which of the following actions to verify placement? A) Measure the pH of gastric aspirate. B) Auscultate the epigastric area while injecting air C) Obtain an xray D) Place the open end of the tube in a cup of water
C) Obtain an xray Always verify placement before initial feeding
A nurse is caring for a client who has an indwelling urinary catheter in place. Which of the following actions is the priority for the nurse to take to reduce the client's risk of developing a healthcare-associated infection? A) Wipe down the clients bedside table with an antiseptic wipe B) Conduct informal audits of medical records to identify the number of healthcare-associated infections C) Perform hand hygiene D) Instruct the client on ways to reduce risk for infection.
C) Perform hand hygiene
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? A)Document the client's blood glucose level B) Report the client's blood glucose level to the provider C) Provide the client with a 15-g carbohydrate snack D) Recheck the blood sugar in 15 min
C) Provide the client with a 15-g carbohydrate snack *** According to evidence-based practice, the nurse should first provide the client with a 15-g carb snack to help bring their blood glucose level to the expected reference range. <70 mg/dL is low, hypoglycemic
A nurse is preparing to administer several PO medications to a client. The client states they can only take one pill at a time. Which of the following actions should the nurse take? A) Ask the pharmacy to change the formulation of each medication B) Crush the pills and mix them in applesauce C) Remain at the bedside until the client has tken all of the medications D) Leave the pills at the bedside for the client to take
C) Remain at the bedside until the client has tken all of the medications
A nurse is planning to use the ISBARR tool to communicate with a provider about a client. Which of the following information is included in the assessment component is ISBARR? A) The clients admitting diagnosis B) The clients medical history C) The clients lab test results D) The clients response to treatment
C) The clients lab test results
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? A) There is a good chance you will have to be on this therapy for the rest of your life B) Parenteral nutrition is very common and should not interfere with your daily activities C) This type of nutrition can be life-long, but it can also be temporary depending on how your nutritional needs change. D) I am sure you will need parenteral nutrition temporarily
C) This type of nutrition can be life-long, but it can also be temporary depending on how your nutritional needs change.
A nurse is performing a head and neck examination for an older adult. Which of the following findings should the nurse expect. (Select all that apply) A) Reddened gums B) Lowered Vocal Pitch C) Tooth Loss D) Glare Intolerance E) Thickened eardrums
C) Tooth Loss D) Glare Intolerance - Older adults tend to become intolerant of glaring lights and ability to distinguish colors E) Thickened eardrums - they tend to accumulate cerumen in ear canals
A nurse is caring for a client who has a new prescription for a clear liquid diet. The client ask the nurse, "How long will I have to be on this type of diet?" Which of the following responses should the nurse make? A) You will be on this diet as long as the provider feels you need to be B) You might be on this diet for a week or two C) You should not be on this diet for more than a few days D) You should speak with the provider about your concern
C) You should not be on this diet for more than a few days ***The nurse should identify that a clear liquid diet should be limited to a few days because this type of diet has inadequate nutritional value
A nurse is caring for a group of clients. The nurse should identify that which of the following clients requires an enteral tube feeding? A) who has paralytic ileus B) who has recently experiences facial trauma C) who has dysphagia D) who has decreased appetite
C) who has dysphagia unable to swallow oral nutrition
A nurse is caring for a client who has a history of irritable bowel syndrome and reports that their last bowel movement was five days ago. The nurse should identify this as which of the following types of altered elimination pattern.? Encopresis Diarrhea Fecal incontinence Constipation
Constipation
A nurse is caring for a 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? Attending a yoga class Consuming alcohol Drinking 2000 mL of fluid in a day Consuming fish for dinner
Consuming alcohol
A nurse is reinforcing teaching with a client who has a new prescription for an antibiotic to treat a urinary infection. Which of the following statements should the nurse make? A) "You can expect to experience a rash while taking this medication" B) "Natural supplements do not interact with antibiotics" C) "This medication is used to treat a viral infection" D) "Finish the entire course of the prescription"
D) "Finish the entire course of the prescription"
A nurse is preparing to administer an ID injection to a client. At which of the following degree angles should the nurse insert the needle? A) 60° angle B) 90° angle C) 45° angle D) 10° angle
D) 10° angle
A nurse is caring for a client who states, "I only eat a diet high in protein and carbs." Which of the following responses should the nurse make? A) Make sure you get enough servings of red meat in your diet B) Your diet is varied but should also be high in calorie intake C) A varied diet should be high in protein and carb consumption D) A nutritious diet should include carbs, protein, fiber, and healthy fats
D) A nutritious diet should include carbs, protein, fiber, and healthy fats
A nurse discovers a small fire in a client's room. After removing the client to safety, which of the following actions should the nurse take next? A) Extinguish the fire B) Close the window in the client's room C) Close the client's door D) Activate the fire alarm
D) Activate the fire alarm
A nurse has received a prescription to administer a medication STAT to a client. Which of the following actions should the nurse take? A) Administer the medication whenever the client reports specific manifestations, such as pain B) Administer the medication at specific times until directed by HCP C) Administer the medication at regular intervals of 4 hr D) Administer the medication within 30 min of the HCP prescribing the med.
D) Administer the medication within 30 min of the HCP prescribing the med.
A nurse is planning to use the teach-back methos to educate a client about a new antihypertensive medication. Which of the following should the nurse include to demonstrate this method? A) Provide the client with an internet link to research the meds B) Refer the client to the American Heart Association C) Give the client written educational material about the medication D) Ask the client to explain the information using their own words
D) Ask the client to explain the information using their own words
A nurse is preparing to administer an oil retention enema to a client who has constipation. The nurse should instruct the client to retain he solution for which of the following durations? A) the duration of the procedure B) 10-15 minutes C) Until the client feels the urge to defecate D) At least 30 min
D) At least 30 min
A nurse is assessing a client's indwelling urinary catheter drainage at the end of the shift and notes the output is considerably less than the fluid intake. Which of the following actions should the nurse take first? A) Irrigate the catheter B) Assess for peripheral edema C) Palpate for bladder distention D) Check the catheter for kinks
D) Check the catheter for kinks
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? A) Leave the medication at the client's bedside B) Prepare the medication to administer later C) Document the medication was given prior to administration D) Come back in a few minutes to administer the medication
D) Come back in a few minutes to administer the medication
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? A) Position the client upright at a 45° B) Turn on the television per the client's request C) Avoid allowing the client to drink until meal is finished D) Cut the client's food into small bites
D) Cut the client's food into small bites
A nurse is reviewing a group of prescriptions. Which of the following should the nurse identify as an example of a complete prescription? A) Aspirin PO 1 tablet daily B) Ferrous sulfate 624 mg PO C) Hydrocodone/acetaminophen 5/325 mg PRN D) Digoxin 1.25 mg PO daily
D) Digoxin 1.25 mg PO daily Dose, route, and frequency or admin
A nurse is caring for a client who states, "I have been gettign a lot of cavitied lately, but I don't know what is causing them." Which of the following responses should the nurse make? A) A lack of protein can cause a problem with cavities B) Cavities can be caused by a diet low in Vitamin C C) Increasing your consumption of leafy green veggies and tomatoes can help with this D) Drinking sugary beverages can make you prone to cavities
D) Drinking sugary beverages can make you prone to cavities
A nurse is providing discharge teaching to a client. Which of the following strategies should the nurse include? A) Use closed-ended questions B) Provide written meterial at a 9th-greade reading level C) Use passive listening skills D) Encourage the client to ask questions
D) Encourage the client to ask questions
A nurse is assiting with teaching a class about warning signs from a co-worker that might indicate future workplace violence. Which of the following behaviors should the nurse include? A) Legitimate absenteeism B) Strict adherence to facility policies C) Consistent adequate work performance D) Frequent reports of not being treated fairly
D) Frequent reports of not being treated fairly
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 med? A) Verify the client's identity using their diagnosis B) Use one of the identifier to confirm the client's identity C) Use the client's room number to identify the client D) Have the client confirm their name and DOB
D) Have the client confirm their name and DOB
A nurse is preparing an adult client for an enema. The nurse should assist the client into which of the following positions? A) Prone B) Dorsal recumbent C) Right lateral with both knees at chest D) Left lateral with the right leg flexed
D) Left lateral with the right leg flexed
A nurse is preparing to measure a NG tube for insertion. The nurse recalls that the client xyphoid process should be used as the last place of measurement. Which of the following landmarks should the nurse measure before the xyphoid process? A) Measure from the bottom of the ear B) Measure from the tip of the chin C) Measure from the bottom of the jawline D) Measure from the tip of the nose to earlobe
D) Measure from the tip of the nose to earlobe
A nurse is administering an enteral tube feeding to a client. Which of the following actions should the nurse take to prevent aspiration? A) Flush the feeding tube with 30 mL of water B) Add blue food coloring to the enteral formula C) Ensure the formula is at room temp D) Place client in Fowlers position
D) Place client in Fowlers position
A nurse is documenting a client's response to a pain medication. Which of the following is an example of correct documentation regarding the client's response to pain? A) The client states, "I feel better 10 minutes after med admin" B) The client is sleeping 1 hr after med admin C) The client is up and walking in the hall 2 hr after med admin D) The client reports pain decreased 30 min after med admin to a 3 on a scale of 0-10
D) The client reports pain decreased 30 min after med admin to a 3 on a scale of 0-10
A nurse is preparing to administer medications to a preschooler. Which of the following should the nurse keep in mind when administering meds to this client? A) The dosage is calculated by height B) The preschooler is unable to take capsules C) Preschoolers receive the same amount of meds as adults D) The deltoid muscle can be used to administer IM injections
D) The deltoid muscle can be used to administer IM injections
A nurse is planning to implement the Transforming Care at the Bedside plan on a med-surg unit. Which of the following interventions should the nurse include in the plan? A) Require nurses to spend 50% of their time at the bedside of clients. B) Perform change-of-shift report at the nurses' station. C) Complete client rounds every 4 hours. D) Use a standardized communication tool
D) Use a standardized communication tool
A nurse is assisting with teaching a newly licensed nurse about administering a transdermal nitroglycerin patch to a client. Which of the following instruction should the nurse include? A) Place a new transdermal patch over the same site as an old patch B) Apply no more than two transdermal patched at a time C) Expect the transdermal med to absorb rapidly. D) Wear clean gloves to apply the transdermal med
D) Wear clean gloves to apply the transdermal med
A nurse is providing perineal care for a female client who has an indwelling catheter. Which of the following areas should the nurse cleanse last? A) Urethral meatus B) Labia minora C) Perineum D) Anus
D) anus
To determine the length of a nasointestinal tube to insert, a nurse should measure the distance from the tip of the client's nose to the earlobe and from the earlobe to the A) umbilicus B) xiphoid process C) manubrium plus 10-20 cm more D) xiphoid process plus 20-30 cm more
D) xiphoid process plus 20-30 cm more ***for duodenal or jejunal placement, an additional 20-30 cm is needed
A nurse is preparing to collect a urine sample for a urinalysis using a regents trip. The nurse should identify that the regent strip contact substances are consistent with which of the following conditions? Diabetes Colon cancer Pancreatitis Pregnancy
Diabetes Urine concentration, proteins, glucose, ketones, bilirubin, leukocytes, nitrates, and blood can also be tested with urinalysis
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? Hernia Gastroesophageal reflux disease Crohn's disease Ulcerative colitis
Hernia Complications of fecal diversions include hernia, electrolyte imbalance, blockage, prolapse, diarrhea, and infection
A nurse is caring for a client with suspected dehydration. For which of the following findings, should the nurse monitor the client? Oral temperature of 36.4°C. 97.5°F. Light yellow urine Dry, mucous membranes Diaphoresis
Dry, mucous membranes
A nurse is preparing to insert a nasogastric tube into a client for decompression. Which of the following action should the nurse perform first? Measure the tube from the clients here to the xiphoid Insert the two by the client take sips of water Connect to nasogastric tube to suction Ensure the client is in a sitting position
Ensure the client is in a sitting position
A nurse is planning care for a client who reports blood in their stool. Which of the following test should the nurse anticipate the provider ordering? Fecal occult blood test Stool culture Flexible sigmoidoscopy Endoscopic retrograde cholangiopancreatography (ERCP)
Fecal occult blood test
A nurse is caring for a client who has constipation. Which of the following diet should the nurse encourage the client to follow? Low fat Hi protein High-fiber Low carbohydrate
High fiber
What happens when the pancreas releases insulin?
Glucose is moved out of the bloodstream into cells in order to meet energy needs
A nurse is reviewing the medical record of a client who has persistent diarrhea. Which of the following findings should the nurse identify as a risk factors? SATA History of irritable bowel syndrome A shortened urethra Cardiovascular disease Consuming large amounts of dairy in their diet Currently taking antibiotics for an infection
History of irritable bowel syndrome Consuming large amounts of dairy in their diet Currently taking antibiotics for an infection
Kyphosis
Hunchback curvature of the spine, usually a result of osteoporosis. Most common in older adults and increases with ago
A nurse is evaluating a clients bladder training program. Which of the following statements by the client indicates the bladder training was successful? I am having accidents daily I am waiting a small amount when I visit the bathroom I continue to visit the bathroom every I am experiencing less than one urinary accident per week
I am experiencing less than one urinary accident per week
A nurse is providing information to a client about what may happen if their urinary tract infection is not treated. Which of the following statements by the client indicates an understanding of the information? I can develop a kidney infection called pyelonephritis I might have urinary retention I might become incontinent I can develop functional incontinence
I can develop a kidney infection called pyelonephritis If left untreated, UTIs can result in a more serious kidney infection. Clients be present with severe lower back pain, fevers, nausea, vomiting, or blood in their urine.
A nurse is caring for a female client who has a prescription for a clean, catch urine specimen. Which of the following statements by the client demonstrates an understanding of how to provide a urine specimen? I need to wipe from front to back with a sanitary wipe I should place the urine sample cup in the refrigerator I will be in the urination process in the specimen cup I will urinate in the urine tray for the nurse to collect
I need to wipe from front to back with a sanitary wipe
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? I will still be able to drink chocolate milk I should avoid fruits that are acidic I will need to switch from regular soda to diet soda I can still use jalapeño peppers when cooking
I should avoid fruits that are acidic
A nurse 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? Instruct the client to lie on the right side, with her left leg pulled up to their chest Instruct the client to lie on the left side with her right leg, pulled up to their chest Instruct the client to lie on their left side with both legs pulled up to the test Instruct the client to lie on the right side, with both legs pulled up to their chest
Instruct the client to lie on the left side with her right leg pulled up to the test?
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? Suprapubic catheter Indwelling catheter Condom catheter Intermittent catheter
Intermittent catheter Clients who have paraplegia will often utilize in German catheters in conjunction with bladder training to avoid urinary accidents, due to the lack of bladder sensation from paralysis
Scoliosis
Lateral curvature of the thoracic spine. Typically detected in adolescence
What organ convert fructose and galactose into glucose?
Liver
A nurse is caring for an older adult client who is experiencing urinary leakage. Which of the following is an expected age related changes I can contribute to this occurrence? Reduced blood supply Loss of kidney tissue Loss of nephrons Loss of bladder tone
Loss of bladder tone
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? My ileostomy has an internal Reservoir that collects waste My ileostomy is allowing my colon time to heal from the surgery My ileostomy must be access with a catheter to drain the waste My ileostomy is designed to be a permanent solution
My ileostomy is allowing my colon time to heal from the surgery
A nurse is reviewing the client list of medication and supplements. Which of the following medication classifications increases the risk of constipation? Magnesium containing antacids Antibiotics Narcotic pain medications Beta blockers
Narcotic pain medication Can slow gastric motility an increased risk of constipation
A nurse is assessing a client who has an indwelling urinary catheter in determines that the catheter is in place and functioning properly. The nurse should expect which of the following findings? Dark yellow, cloudy urine Pale, yellow, clear urine You're in with a strong odor Urine with a slight red tint
Pale, yellow, clear urine In a healthy person you're in his late yellow, clear and without cloudiness
A nurse is caring for a client who has a colostomy and does not wear a colostomy pouch. Which of the following actions should the nurse anticipate performing on this client to maintain expected bowel function? Administer an enema Administer a laxative Perform colostomy irrigation Insert a rectal tube
Perform colostomy irrigation
If there is an absence of breath sounds when auscultating the lungs, what would that indicate?
Pneumothorax (collapsed lung) or atelectasis (complete or partial collapse of lung or lobe)
A nurse is teaching a client about diagnostic urinary testing. Which of the following should the nurse include in the teaching about cystometric testing? Cystometric, testing, measures bladder, capacity, pressure, and final capacity when the urge to urinate begins Cystometric testing measures urine speed in volume Cystometric testing measures bladder pressure when urinary leakage occurs Cystometric testing measures electrical activity of the muscles and nerves of the bladder and sphincters
Sisto metric testing measures bladder, capacity, pressure and final capacity when the urge to urinate begins
Lordosis
Swayback Exaggerated lumbar curvature of the lumbar spine Common in pregnant or obese clients
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 of diarrhea? The antibiotic dose is not correct, and the provider should be alerted The antibiotic interferes with the clients ability to absorb The antibiotic eliminates the healthy GI bacteria, allowing harmful bacteria to grow That antibiotic decreases a clients immunity level, resulting in diarrhea
The antibiotic elements to healthy, G.I. bacteria, allowing harmful bacteria to grow
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? The small intestine The large intestine The esophagus The stomach
The large intestine Bacteria within the large intestine produce vitamin K, a nutrient important for blood, clotting and strong bones
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? The urinary tract regulates the production of red blood cells The urinary tract produces hormones for blood pressure regulation The urinary tract keeps bones, strong The urinary tract eliminates waste and excess fluid from the body
The urinary tract eliminates waste and excess fluid from the body
A nurse is providing post operative 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? This, too, will keep my ears open in case of another stone This, too, will remain permanently, because I can't empty my bladder This tube goes directly into my bladder This tube is only temporary
This tube is only temporary It is removed once the kidney has healed
Three main factors that influence the body's requirement for protein?
Tissue growth need Quality of dietary protein Added need due to illness
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? SATA Uncircumcised infants School age children Middle adults Older adults Young adults
Uncircumcised infants School age children Older adults
A nurse is caring for a client who has a stone in the right ureter that is obstructing the flow of urine. Which of the following urinary diversions should the nurse anticipate the client will need? Urostomy Continent cutaneous reservoir Ureteral stent Neobladder
Ureteral stent
A nurse is planning care for a client who has an order for urinalysis. Which of the following test should the nurse anticipate being ordered in the presence of white blood cells detected on urinalysis? Urine culture Bladder scan 24 hour urine Stool culture
Urine culture Used to evaluate urine for the presence of bacteria and yeast
A nurse is assessing a client who has stress incontinence. Which of the following findings should the nurse expect with this client? Urine leakage prior to reaching the toilet Urine leakage, following coughing Urine leakage as a result of nerve damage You're only can you do to not reaching the toilet in time for my physical impairment
Urine leakage, following coughing
What are three different types of carbohydrates?
monosaccharides (simple carb/basic energy for cells/glucose, fructose, galactose) disaccharides (simple carb/energy, aids in calcium and phosphorus absorption/sucrose, lactose, maltose) polysaccharides (complex carb/energy storage-starch, digestive aid-fiber, glycogen)
