RN Fundamental Adaptive Quizzes

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month and may require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse share with the client?

"Donate autologous blood before the surgery."

A nurse is caring for a client who has injuries resulting from a monitor-vehicle crash. Which of the following client statements should the nurse address first?

"I can't sleep well because whenever I move in my sleep, the pain wakes me up"

A nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student should the nurse identify as a potential problem with achieving Erikson's developmental task for his age group?

"I go home on the weekends to be with my family because I do not have any good friends here on campus."

A nurse is teaching a client who has low back pain about hear therapy. Which of the following statements by the client indicates an understanding of the teaching?

"I need to place a towel between the heating pad and my skin."

A nurse is teaching a group of older adults about expected age-related changes. Which of the following statements by a group member indicates that the teaching has been effective?

"I should expect my heart rate to take longer to return to normal after exercise as I get older"

A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular-sized cuff for a client who is obese. Which of the following explanations should the nurse give the AP?

"Using a cuff that is too small will result in an inaccurately high reading."

A nurse is performing a spiritual assessment of a client. Which of the following question should the nurse ask?

"What is your source of strength and hope?"

A nurse is caring for a client who is receiving dextrose 5% in water IV at 150ml/hr and has ingested 4oz of water and 1/2 pint of milk. What is the total 8-hr fluid intake in milliliters that the nurse should document for this client? (Round the answer to the nearest whole number and fill in the blank with the numeric value only.)

1560ml

A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following pieces of information should the nurse include?

A 10-month-old infant can pull up to a standing position

A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect?

Absent bowel sounds with distention

A nurse is caring for a client who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?

Administer analgesics to the child on a routine schedule throughout the day and night

A nurse is admitting a client who has tuberculosis. In addition to standard precautions, which of the following transmission-based precautions should the nurse add to the client's plan of care?

Airborne

During a client care staff meeting, a nurse manager discuss potential problems with data security that affect confidential client information. Which of the following environments should the nurse identify as an acceptable place for discussing client information?

Areas with no public access

A nurse in an urgent-care center is caring for a 15-year-old client whose symptoms suggest a sexually transmitted infection (STI). The client's parent is unavailable, but the client's grandmother accompanied the client to the clinic. Which of the following actions should the nurse take?

Ask the adolescent to sign the consent form

A nurse is performing an admission assessment for a client who has asthma and reports several food allergies. Which of the following actions should the nurse take first?

Ask the client to identify the specific food allergies

A nurse discovers that a client received the wrong medication. Which of the following actions should the nurse take first?

Assess the client

A nurse in a provider's clinic is taking a client's age, height, weight, and vital signs. The nurse should identify this action as part of which of the following components of the nursing process?

Assessment

A nurse is using the I-SBAR communication tool to give a client's provider information about the client. The nurse should convey this client's pain status in which portion of the report?

Assessment

A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

Carefully remove the gloves and proceed with hand hygiene

A nurse is caring for a middle-aged adult client. The nurse should evaluate the client for progress toward which of the following developmental tasks?

Ceasing to compare personal identify with others

A nurse is conducting an admission interview with a client. Which of the following pieces of assessment information should the nurse collect during the introductory phase of the interview?

Client's level of comfort and ability to participate in the interview

A nurse is explaining Piaget's theory of cognitive development to a group of daycare providers for employees' children at an acute care facility. Which of the following activities should the nurse include as an example of concrete operational thinking?

Collecting and trading game cards

A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?

Confirm unresponsiveness

A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing?

Cranial nerve XII

A nurse is caring for a client who has a BMI of 29 and expresses a desire to lose weight. Which of the following actions should the nurse take first?

Determine the client's intention to change current eating habits

A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals, and the readings are inconsistent. Which of the following actions should the nurse take?

Disconnect the machine and measure the blood pressure manually every 15 mins

A nurse is admitting a client who will undergo a crainotomy. During the planning phase of the nursing process, which of the following actions should the nurse take?

Establish client outcomes

A nurse is discussing fire safety with newly hired nurses. Which of the following actions is the priority if a fire occurs in the health care facility?

Evacuate clients from the unit

A nurse on a medical surgical unit observes smoke billowing from a client's room. Which of the following actions should the nurse take first?

Evacuate the client from the room

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first?

Evaluate pedal pulse

A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating?

Fidelity

A nurse is performing a comprehensive physical assessment of a client. The nurse should use inspection to assess which of the following?

Gait

A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first?

Gloves

A nurse is preparing a sterile field for a procedure the provider will perform at the client's bedside. Which of the following actions should the nurse take?

Hold the sterile drape above the waist and away from the body

A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?

Identify the client using 2 identifiers

A nurse is teaching a group of young adults. Which of the following should the nurse identify as an expected developmental task for this age group?

Independent moral development

A nurse is performing a breast examination for a female client. Which of the following techniques should the nurse use first?

Inspect both breasts simultaneously

A nurse is presenting an in-service training session about nutrition. Which of the following simple sugars should the nurse identify as the carbohydrate found in milk?

Lactose

A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse perform to transfer the client from the stretcher to the bed?

Lock the wheels on the bed and stretcher

A nurse in a rehabilitation facility is observing an assistive personnel (AP) help a client transfer from a bed to a wheelchair. Which of the following actions indicates to the nurse that the AP understands how to perform this task?

Locking the brakes on the bed and the wheelchair before moving the client

A nurse is performing a physical examination of a client. The nurse should use percussion to evaluate which of the following parts of the client's body?

Lungs

A nurse is changing the dressing for a client who has 2 Penrose drains near an abdominal incision. Which of the following adhering devices is the best choice for the nurse to use to decrease skin irritation?

Montgomery straps

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastrostomy tube for enteral feedings. Which pieces of information are critical to communicate to the next nurse who will be caring for this client? (Select all that apply)

New prescriptions Arterial blood gas results Tracheal secretion characteristics

A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse prioritize when using the nursing process?

Obtain client information

A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks both the client's native language and the nurse's, arrives to drive the client home. Which of the following actions should the nurse take?

Obtain the services of an interpreter

A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use?

PC for after meals

A nurse is performing a physical examination for a client. To evaluate the client's skin moisture, the nurse should use which of the following techniques?

Palpation

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse perform first?

Perform hand hygiene

A nurse is assessing the heart sounds of a client who has developed chest pain that worsens with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal boarder. Which of the following heart sounds should the nurse document?

Pericardial friction rub

A nurse is employing a thorough, systematic, method while obtaining objective data about a client. Through which of the following methods should the nurse collect this information?

Physical examination

A nurse is leading an education session about disposing of biohazardous materials. Which of the following instructions should the nurse include in the teaching?

Place soiled linen in a single linen bag

A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take?

Place the bladder of the cuff over the posterior aspects of the thigh

A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?

Remove the safety pin from the extinguisher

A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a form of secondary prevention?

Screening groups of older adults in nursing care facilities for early influenza manifestations

A nurse is examining a client for signs of costovertebral angle tenderness. The nurse should place the client in which of the following positions for evaluation?

Sitting

A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take?

Stop the teaching and check with the surgeon about informed consent

A nurse on a medical-surgical unit is caring for a client who is at risk of experiencing seizures. Which of the following pieces of equipment must be available at the client's bedside at all times?

Suction equipment

A nurse is performing an abdominal assessment of a client. Which of the following positions should the nurse tell the client to assume for this examination?

Supine

A nurse is caring for an adult client in the terminal stages of lung cancer who refuses any further treatment. The nurse should provide care that facilitates which of the following outcomes?

Supports self-determination

A nurse is providing nutritional teaching to a group of client. Which of the following definitions for the recommended dietary allowance (RDA) should the nurse include in the teaching?

The RNA defines the level of nutrients intake that meets the needs of healthy people in various groups

A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who is scheduled for emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?

The client reports severe pain

A nurse is providing nutrition counseling to a middle-aged adult client who has a sedentary job. Which of the following factors should the nurse consider?

The client's basal metabolic rate could decrease

A nurse is caring for an adult client who is grieving following the death of a loved one. Which of the following factors increases the client's risk of developing complicated grief?

The death was sudden

A nurse on a medical-surgical unit is washing her hands prior to assisting with a surgical procedure. Which of the following actions by the nurse demonstrates proper surgical handwashing techniques?

The nurse holds her hands higher than her elbows while washing

A nurse is witnessing a client sign an informed consent form for surgery. What is the nurse affirming by this action?

The signature on the preoperative consent form is the client's

A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take?

Tie the restraint with a quick-release knot

A nurse is assessing a client's respiratory system. Which of the following breath sounds should the nurse expect to hear over the periphery of the major lung fields?

Vesicular

A nurse is caring for a client who has Clostridium difficile infection and is in contact isolation. Which of the following actions should the nurse take?

Wear gloves when changing the client's gown

A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include?

When lifting an object, spread your feet apart to provide a wide base of support

A nurse is evaluating the development of a group of clients. According to Erikson, the developmental task of intimacy vs. isolation occurs during which of the following stages of development?

Young adulthood

A client has 1 L of dextrose 5% in 0.45% sodium chloride infusing IV at 125mL/hr. How many hours will it take for the liter to infuse?

8

A nurse is assessing a client who is experiencing stress and anxiety regarding a recent diagnosis. Which of the following findings should the nurse expect?

Increased blood pressure

A nurse is assessing a client who reports nausea and vomiting for 2 days. Which of the following should indicate to the nurse that the client is experiencing fluid volume deficit?

Increased heart rate

A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first?

Inspection

A client who has glaucoma if the right eye self-administers timolol eye drops by looking at the ceiling, instilling a drop onto the center of the conjunctival sac, and applying gentle pressure to the lower lid with a facial tissue. After observing this process, which of the following actions should the nurse take?

Instruct the client to apply pressure to the inside corner of the eye after instillation

A nurse in the emergency department is caring for an inmate who has a laceration and is bleeding. The client was brought to the facility by a guard who asks the nurse about the client's HIV infection status. Which of the following actions should the nurse take?

Instruct the guard to ask the inmate

A nurse is caring for a group of clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?

Provide oral care to a client who cannot take oral fluids

A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?

Raise the level of the bed

A nurse is caring for a client in a long-term care facility. Which of the following findings should alert the nurse to the possibility that the client has developed delirium?

Reduced level of consciousness

A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?

Remove the restraints one at a time

A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes the following values: pH 7.25, PaCO2 40, and HCO3 -18. Which of the following acid-base imbalances should the nurse identify and report to the provider?

Respiratory acidosis

A nurse is preparing to administer a unit of packed RBCs to a client when she discovers that the IV line is no longer patent. The IV team informs her that someone can come to initiate a new line in 30 min. Which of the following actions should the nurse take?

Return the blood to the laboratory

A nurse is caring for a client who has breast cancer. The client has been receiving radiation therapy for several months and now refuses to undergo further treatment. Which of the following actions should the nurse take?

Support the client's decision

A nurse is teaching range-of-motion exercises to a client who has osteoarthritis. Which of the following client positions demonstrates an understanding of supination of the hand?

The client hold the hand with the palm up

A nurse is assisting a client who has right-sided weakness while ambulating using a cane. Which of the following client actions should indicate to the nurse that the client understands the procedure of cane walking?

The client keeps 2 points of support on the ground

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following pieces of information must the nurse verify with anouther nurse prior to the administration? (Select all that apply)

The client's ID number The client's name ABO compatbility Rh compatibility

A nurse is planning care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and minerals should the nurse plan to increase in the client's diet?

Vitamin C and zinc

A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?

Tachycardia

A nurse is evaluating a client's use of crutches. The nurse should identify that which of the following actions by the client indicates safe usage of the equipment?

The client has slightly flexed elbows when ambulating with the crutches

A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use?

Vastus lateralis

A nurse is caring for a semiconscious client who has a small-bore NG tube placed yesterday for the administration of enteral feeding. Which of the following methods should the nurse use to verify correct tube placement? (Select all that apply)

Verify the initial X-ray examination Measure the length of the exposed tube Determine the pH of aspirated fluid

A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication of an infection?

WBC 15,000 mm^3

A client is being discharged home with oxygen therapy delivered through a nasal cannula. Which of the following instructions should the nurse provide to the client and family members?

Wear cotton clothing to avoid static electricity

A nurse is obtaining a capillary blood sample to determine a client's blood glucose level. The nurse prepares and punctures the client's finger for the procedures but does not obtain an adequate amount of blood. Which of the following actions should the nurse take next?

Wrap the client's finger in a warm washcloth

A community health nurse is conducting a class about body mechanics for county office workers. Which of the following instructions should the nurse include? (Select all that apply)

"Sit with your back supported" "Keep your knees at hip level" "Use an ergonomically designed computer keyboard"

While in the hospital, a client who has a terminal illness tells the nurse, "I can't believe I'm dying. A lot of bad people in the world are health, and here I am dying!" Which of the following responses should the nurse provide?

"Tell me more about how you feel about dying"

A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?

"There are times I should use soap and water rather than an alcohol-based rub to clean my hands"

A nurse is assessing a client's thyroid gland. Which of the following instructions should the nurse give the client before inspecting and palpating this gland?

"Tilt your head back and swallow."

A middle-aged adult client is discussing future plans with the nurse. Which of the following statements should the nurse identify as an indication that the client is having difficulty achieving Erikson's developmental task for this age group?

"We miss our daughter so much that we are going to move closer to her."

A nurse is assessing a client for conductive hearing loss. When using the Rinne test, which of the following results should the nurse identify as an indication that the client has conductive hearing loss of the left ear?

Air conduction is less than bone conduction in the left ear

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

Airborne

A nurse is an emergency department is caring for a client who reports developing severe right eye pain with a gritty sensation while sawing wood. Which of the following actions should the nurse take first?

Ask the client about first aid performed at the scene

A nurse is supervising a newly licensed nurse who is administering a controlled substance. Which of the following action by the newly licensed nurse indicates an understanding of the procedure?

Asking another nurse to observe the disposal of an unused portion of the medication

A nurse is caring for a client who has emphysema. The client has not stopped smoking cigarettes and states, "It's too late for me to quit." Which of the following actions should the nurse take?

Assist the client in finding local smoking-cessation assistance programs

A nurse is caring for a client who has a hearing impairment. Which of the following interventions should the nurse use when speaking with the client?

Face the client when speaking

A nurse in a provider's office is teaching a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching? (Select all that apply)

Black beans Whole-grain bread

A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions actions should the nurse take?

Fill the bag 2/3 full with ice

A nurse is beginning her shift and reviewing the medication administration records (MARs) for her clients. She notes a dosage of a medication above the safe range and sees that a nurse administered the dosage during the previous shift. Which of the following actions should the nurse take?

Call the provider to clarify the dosage

A nurse is caring for a client who is having difficulty with muscle coordination following a head injury. The nurse should suspect injury to which of the following areas of the brain?

Cerebellum

A nurse enters a client's room and finds the client sitting on the floor and leaning against the side of the bed. The client states she slipped while getting out of bed. Which of the following actions should the nurse take first?

Check the client for injuries

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first?

Check the client's perineum

A nurse is teaching a newly licensed nurse about pain management in clients age 65 and older. Which of the following pieces of information should the nurse include in the teaching?

Clients who are aged 65 or older are reluctant to report pain

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse perform first after discovering that the client's wound has eviscerated?

Cover the incision with a moist sterile dressing

A nurse is planning care for a young adult client who has a terminal illness. Which of the following concepts of death should the nurse consider for this client?

Death is viewed as an interruption of what might have been

A nurse is reviewing the laboratory values of a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect?

Decreased calcium

A nurse is teaching a middle-aged adult about health promotion and disease prevention. The nurse should inform the client that which of the following changes could occur?

Decreased estrogen and testosterone production

A nurse is caring for a client who has terminal cancer. The client is proceeding with plans to build a new home. The nurse should identify this behavior typically indicates which of the following stages of grief?

Denial

A nurse is preparing to administer eye drops to a client following surgery. Which of the following actions should the nurse take when instilling the eye drops?

Drop the eye medication into the lower conjunctival sac

While admitting a client to the medical unit, the nurse asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able." The nurse should identify that the client is referring to which of the following documents?

Durable power of attorney document

A nurse is admitting a client who is experiencing an exacerbation of heart failure. At which of the following times should the nurse initiate discharge planning?

During the admission process

A nurse is communicating with a group of clients about what to expect during the postoperative phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as an evaluation of effective communication?

Feedback is provided

A nurse is teaching an assistive personnel (AP) how to obtain a capillary finger-stick blood sample. Which of the following actions by the AP requires that nurse to intervene?

Elevating the finger above the heart level

A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take?

Encourage the client to express thoughts about death and dying

A nurse is providing discharge teaching to a client who has a prescription for daily wound care via home health services. Which of the following statements by the client indicates an understanding of the teaching?

"A nurse will show me how to care for my wound."

A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse offer?

"All of this equipment can be frightening"

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus?

"Bear down"

A nurse is teaching a client with lower extremity weakness how to use a 4-point crutch gait. Which of the following instructions should the nurse include in the teaching?

"Bear weight on both of your legs"

A nurse is caring for a middle-aged adult client. The nurse should identify which of the following statements as an indication that the client has completed Erikson's developmental task for her age group?

"I think I have done a good job with my children since they are all independent now."

A nurse is preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements should the nurse identify as an indication that the client understand medical asepsis?

"I'll wash my hands before I remove the old dressing and again before putting on the new one."

A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP indicates that further teaching is required?

"If the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself."

A nurse is teaching the parent of a child who is to take 10mL of a liquid medication. The parent has a hollow medication spoon with marks to indicate teaspoons and tablespoons. How many teaspoons should the nurse instruct the parent to give the child?

2

A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients?

A client who has a prescription for a transfusion of packed red blood cells

A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative. Which of the following clients should the nurse see first?

A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage

A nurse on a medical-surgical unit is admitting a client. Which of the following pieces of information should the nurse document in the client's record first?

Assessment

A nurse is supervising a newly licensed nurse who is caring for a client with streptococcal pharyngitis and is on transmission-based precautions. Which of the following actions by the newly licensed nurse indicates an understanding of droplet precautions?

Assigning another client with the same infection to share the room with the client

A nurse is planning weight-loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the clients commitment to a long term goal of weight loss?

Attempt to increase the clients self-motivation

A nurse is assessing a client who is undergoing a physical examination. Following the inspection, which of the following techniques should the nurse use next when assessing the client's abdomen?

Auscultation

A nurse rates a client's biceps as 2+. Which of the following characteristics should the nurse document about the client's reflexes?

Average

A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?

Obtaining cotton balls for tracheostomy care

A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent?

Cold extremities

A nurse is planning care for a client who has a prescription for collection of a sputum specimen for culture and sensitivity. Which of the following actions should the nurse take when obtaining the specimen?

Collect the specimen when the client rises in the morning

A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to him. Which of the following actions should the nurse take?

Consult the medication reference book available on the unit

During a physical examination of a client, the nurse suspects strabismus. Which of the following tests should the nurse use to collect additional data?

Corneal light reflex

A nurse is measuring a client's vital signs and notices an irregularity in the pulse. Which of the following actions should the nurse take?

Count the apical pulse rate for 1 full min and describe the rhythm in the chart

A nurse in a provider's office is measuring a client and notes a loss in height from the previous year. The nurse should identify this finding as a manifestation of which of the following musculoskeletal system disorders?

Osteoporosis

A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of primary prevention?

Educating clients about the recommended immunization schedule for adults

A new resident provider asks the charge nurse for an access code to review the client's online records. The resident is not scheduled to attend the facility's orientation computer class until next week. Which of the following actions should the nurse take?

Explain that it is against policy to share access codes and refer the resident to his supervisor

A nurse is teaching a middle-aged female client about disease prevention and health maintenance. Which of the following diagnostic tests should the nurse recommend as part of this client's routine health screening?

Eye examination every 2 years

A nurse is collecting health history data from a client who is deaf and uses American Sign Language (ASL) to communicate. The nurse will be working with an ASL interpreter. Which of the following actions should the nurse take when working with the interpreter?

Pace speech to allow time for the interpreter to convey the words

A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) items should the nurse don prior to providing client care? (Select all that apply)

Gown Gloves

A nurse is reviewing a client's 24 hr dietary recall. The client reports eating a slice of toasted white bread with butter, a banana, a glass of milk, and a cup of coffee for breakfast; grilled chicken, a baked potato, and a glass of milk for lunch; an apple and cheddar cheese for a snack; and 2 servings of chicken, 2 cups of steamed broccoli, and a glass of milk for dinner. This client's diet is deficient in which of the following food groups?

Grains

A nurse is an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?

Grasp a skin fold on the client under the clavicle, release it, and note whether it springs back

A nurse is teaching a client about lifestyle changes to manage a chronic illness. Which of the following strategies should the nurse use first to help the client make a commitment to these lifestyle changes?

Help the client identify ways that these changes will result in positive personal outcomes

A nurse manager is providing teaching to a group of newly licensed nurses about ways that clients acquire health care associated infections (HAIs). Which of the following routes of infection should the manager identify as an iatrogenic HAI?

Infection acquired from a diagnostic procedure

A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this techniques?

Keeping microorganisms from entering the wound

A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first?

Lower the client to the floor

A nurse is preparing a client who is scheduled for a hysterectomy for transport to the operating room. The client states she no longer wants to have the surgery. Which of the following actions should the nurse take?

Notify the provider of the client's decision

A client who reports shortness of breath requests the nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next?

Observe the rate, depth, and character of the client's respirations

During the insertion of a urinary catheter for a client, the tip of the catheter brushes against the nurse's arm. Which of the following actions should the nurse take?

Obtain a new catheter and reattempt insertion

A home health nurse enters a client's home and finds a used insulin syringe without a cap on the table. Which of the following actions should the nurse take?

Place the syringe in a puncture-proof disposal container

A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from a bed to a wheelchair. Which of the following techniques should the nurse use?

Place the wheelchair at a 45-degree angle to the bed

A nurse has receiving a prescription for dextran to administer to a client. The nurse should recognize that dextran belongs in which of the following functional classifications?

Plasma volume expanders

A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing?

Provide a protein intake of 1.5g/kg of body weight per day

A nurse is caring for a client who has chronic kidney disease. The kidneys regulate body fluid as well as assisting with which of the following functions

Regulation of acid-base balance

A nurse is caring for a client who requires wrist restraints. Which of the following actions should the nurse take?

Remove the restraints at least every 2 hours

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume?

Sodium

A nurse delegated the task of emptying an indwelling urinary catheter drainage bag to an assistive personnel (AP). The nurse later observes the AP emptying the bag without wearing gloves. Which of the following actions should the nurse take?

Talk with the AP about the technique used

A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2C (102.6F), a hear rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority?

Temperature

A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and may have a right ear infection. Which of the following routes should the nurse use to obtain the child's temperature?

Temporal

A nurse is preparing to administer an afternoon dose of ampicillin to a client. The client appears upset and refuses to take the medication before throwing the pill on the floor. Which of the following entries should the nurse enter into the client's medical record?

The client threw the medication on the floor

A nurse is providing teaching to a client with heart failure about reducing his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?

The involvement of the client in planning the change

A nurse is caring for a client who was admitted to a long-term care facility for rehabilitation after a total hip arthroplasty. At which of the following times should the nurse begin discharge planning?

Upon the client's admission to the care facility

A nurse is caring for a client who reports using several herbal medicines. Which of the following actions should the nurse take?

Verify the herbal supplements do not interact do not interact with medications the provider has prescribed

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps relieve pain. Which of the following responses should the nurse make?

"It modulates the transmission of the pain impulse."

A nurse is caring for a client who has cancer and refuses visitors because of his debilitated physical appearance. Which of the following comments should the nurse make?

"Would you like to talk about how you feel?"

A nurse is performing an otoscopic examination of a client's right ear. The light reflex is visible in the right lower quadrant of the tympanic membrane. Which of the following actions should the nurse take in response to this finding?

Document this as an expected finding

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the follow instructions should the nurse give to the dietary assistant?

Don gloves when entering the room and use hand sanitizer when exiting

A nurse is assessing a client's pulses of the lower extremities. The nurse should identify which of the following as the location of the most distal pulse?

Dorsalis pedis

A nurse is assessing a client. Which of the following finding should the nurse identify as an indication of protein-calorie malnourishment? (Select all that apply)

Dry, brittle hair Edema Poor wound healing

A nurse is caring for a client who has stage II pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer?

Hydrocolloid

A nurse is providing teaching about nutritious diets to a group of adult women. Which of the following statements should the nurse include?

"Include 2.5 cups of vegetables in your daily diet"

A nurse is caring for a client who is scheduled to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The client asks the nurse how a TENS unit helps to relieve pain. Which of the following responses should the nurse make?

"It modulates the transmission of the pain impulse."

A nurse is talking with the parent of a preschool-aged child who tells the nurse "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make?

"Keep a diary of the foods your child eats each day."

A nurse is caring for a client who has a temperature of 38.7C (101.7F). Which of the following actions should the nurse take?

Keep the client's bed linens dry

A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?

Airway

A nurse on a medical unit is caring for a client who has difficulty sleeping. Which of the following actions should the nurse take to promote the client's ability to fall asleep?

Allow the client to maintain the same bedtime routine as at home

A nurse is assessing a client's vascular system. Which of the following techniques should the nurse use when evaluating the carotid arteries?

Auscultation of the arteries for bruits with the bell of the stethoscope

A nurse in an acute care facility is planning care for a client who is alert but temporary immobile due to a total hip arthroplasty. Which of the following interventions should the nurse plan to take to prevent a complication of immobility?

Instruct the client to perform foot and leg exercises every 1-2 hours while awake to help prevent thrombophlebitis

A nurse is teaching a group of unit nurses about the experiences of clients who are having surgery. In which phase of care is the client transferred to the surgical suite table before being transferred to the PACU?

Intraoperative

A nurse is caring for a client who is postoperative following vascular surgery on the left femoral artery. The nurse should identify that the surgical wound should be cleansed in which of the following directions?

From the wound toward the surrounding skin

A nurse is working with the facility's language interpreter to explain a wound-care procedure to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take when describing the procedure to the client?

Ensure the interpreter and the client speak the same dialect

A nurse is caring for a client who has a dysrhythmia. Which of the following techniques should the nurse to use to assess for a pulse deficit?

Obtain the apical and radial rates simultaneously

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply)

Provide oral hygiene frequently Measure the amount of drainage from the NG tube every shift Secure the NG tube to the client's gown

A home health nurse is visiting an older adult client with severe dementia. The client's son, who serves as her primary caregiver, reports being "exhausted" from working part-time and caring for his mother at home. Which of the following options should the nurse suggest to the caregiver?

Respite care

A nurse is screening a client who has an S-shaped spinal column with unequal should heights. The nurse should identify these findings as manifestations of which of the following abnormalities?

Scoliosis

A nurse is at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

Second intercostal space to the right of the sternum

A nurse is assessing a client who is unconscious. Family members are present and answer the nurse's questions about the client's medical history. The nurse should document this information as which of the following types of data?

Secondary-source data

A nurse is caring for a client who is in the terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?

Sit and hold the client's hands

A nurse is proving teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?

Sit on the toilet 30 min after eating a meal

A nurse on a medical unit is caring for a client who has been coughing intermittently during meals, attempting to clear her throat repeatedly, and eating only a small portion of each meal. The nurse should recommend a referral to which of the following members of the interprofessional team to evaluate the client for dysphagia?

Speech-language pathologist