Practice Assessment A med sure

A nurse is admitting a client who has influenza. Which of the following types of transmission precautions should the nurse initiate?

droplet precautions because a client who has infections that spread via droplet nuclei that are larger than 5 microns in diameter, including influenza

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.

1. Inject 10 units of air into the bottle of NPH insulin. .2. Inject 5 units of air into the bottle of regular insulin. .3. Withdraw the correct dose of regular insulin from the bottle. .4. Withdraw the correct dose of NPH insulin from the bottle. Cloudy insulin (NPH, Humulin N, Novolin N) should NOT enter clear insulin (regular, Humulin R, Novolin R)

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

Flush the tube with 15 mL of sterile water. The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication

A nurse is caring for a client who has had his diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?

Fried egg Soft fruits, such as bananas or cooked fruits, are acceptable for a client who requires a mechanical soft diet. Fried eggs are not a part of a mechanical soft diet. Eggs that are poached or scrambled are an acceptable replacement for this item.

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

Have the client use a trapeze bar when changing position because using a trapeze bar to assist with repositioning and transferring avoids the friction and shearing that result from sliding up and down in bed

A nurse is caring for a client who require a 24-hour urine collection. Which of the following statements by the client indicates an understanding of the teaching?

I flushed what I urinated at 7:00 a.m. and have save all urine since. The client should discard the first voiding and save all subsequent voidings.

A nurse is giving discharge instructions to a client who will require oxygen therapy at home. Which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home?

I'll check the wires and cables on my TV to make sure they are in good working order. need to make sure any electrical equipment in the room where the client is using supplemental oxygen is functioning so that it does not create sparks.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take?

Place the client's arm in a dependent position because the veins will dilate due to gravity.

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.)

Pupil clarity Visual fields Visual acuity Cloudy pupils mean that the pt has cataracts, which can increase his risk for falls Visual fields are tested by the use of a finger test by moving it out of range and then back into his visual field to determine when he sees the finger Visual acuity should be assessed using a Snellen chart

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following assessment findings should the nurse expect?

Rapid heart rate Tachycardia indicated fluid-volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?

Select a suction catheter that is half the size of the lumen. The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

Subtract the amount of irrigant used from the client's urine output The nurse should calculate the fluid used for irrigation and subtract it from clients total output.

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

Tell the client to keep the head of the bed elevated at least 30 degrees. the first action the nurse should take when using the ABC approach to pt care is to prevent aspiration of the enteral formula.

A nurse is teaching an older adult who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity would the nurse recommend?

Walking briskly because weight bearing excercises are essential for maintaining bone mass which will prevent osteoporosis.

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

Wrap monitoring cords with stockinette and tape them in case. Many monitoring devices and cords contain latex

A nurse is assessing a client who has been on bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?

Calf swelling Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility.

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse indicate?

Contact precautions Clients who have an immune-system compromise require a protective environment.

A nurse is assessing an adult client who has been immobile for the past 3 weeks. The nurse should identify that which of the following findings requires further intervention?

Erythema on pressure points Erythema on pressure points requires prompt relief of pressure and additional measure to protect the skin from further breakdown

A nurse if performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following?

Narrowed arterial lumen Arterial bruits are blowing sounds resulting from blood flowing through occluded or narrowed arteries