RN Fundamentals Online Practice 2019 A with NGN

A nurse is preparing to administer an injection of an opiod medication to a client. The nurse draws out 1 mL of medication from a 2 mL vial. Which of the following actions should the nurse take? A. ask another nurse to observe the medication wastage B. notify the pharmacy when wasting the medication C. lock the remaining medication in the controlled substances cabinet D. dispose of the vial with the remaining medication in a sharps container

A. ask another nurse to observe the medication wastage

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? A. insert the catheter at a 45 degree angle B. place the client's arm in a dependent position C. shave excess hair from the insertion site D. initiate IV therapy in the veins of the hand

B. place the client's arm in a dependent position

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? A. "Is your pain constant or intermittent?" B. "What would you rate your pain on a scale of 0 to 10?" C. "Does the pain radiate?" D. "Is your pain sharp or dull?"

D. "Is your pain sharp or dull?"

A nurse prepare to apply dressing for client with stage 2 pressure injury. WHat types of dressing should the nurse use? A. Alginate B. Gauze C. Transparent D. Hydrocolloid

D. Hydrocolloid

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? A. BUN 15 B. Creatinine 0.8 C. Sodium 143 D. Potassium 5.4

D. Potassium 5.4

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies? A. biofeedback B. aloe C. feverfew D. acupuncture

D. acupuncture

A nurse is caring for a child who has a prescription for blood transfusion. The child's parents have refused the treatment due to their religious belief. Which of the following actions should the nurse take? A. Examine personal values about the issue B. Tell the parents that this is a necessary procedure. C. Inform the parents that the staff does not require their consent. D. Contact a spiritual support person to explain the importance of the procedure.

Examine personal values about the issue. Rationale: The nurse should examine personal values about the issue in order to provide unbiased care.

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following action should the nurse take? A. pad the client's wrist before applying the restraints B. evaluate the client's circulation every 8 hr after application C. remove the restraints every 4 hr to evaluate client's status D. secure the restraint ties to the bed's side rails

Pad the client's wrist before applying the restraints.

A nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. To prevent self-injury, which of the following actions should the nurse take when lifting this object? A. Bend at the waist. B. Keep his feet close together. C. Use his back muscles for lifting. D. Stand close to the cabinet when lifting it.

Stand close to the cabinet when lifting it.

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Put the following steps in order: -obtain the pronouncement of death from the provider -wash the client's body -ask the client's family members if they would like to view the body -place a name tag on the body -remove tubes and indwelling lines

The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer.

A nurse is admitting a new client. Which of the following action should the nurse take while performing medication reconciliation? 1. verify the client's name on his ID bracelet with the MAR 2. call the pharmacy to determine if the client's medications are available 3. compare the client's home medications with the provider's prescriptions 4. place the client's home medication bottles in a secure location

compare the client's home medications with the provider's prescription. reconciliation is the process of creating the most accurate list possible of all meds a patient is taking.

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? A. "Use the complete name of the medication magnesium sulfate." B. "Delete the space between the numerical dose and the unit of measure." C. "Write the letter U when noting the dosage of insulin." D. "Use the abbreviation SC when indicating an injection."

A. "Use the complete name of the medication magnesium sulfate."

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? A. Check the client for injuries. B. Move hazardous objects away from the client. C. Notify the provider. D. Ask the client to describe how she felt prior to the fall.

A. Check the client for injuries.

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? A. advocacy ensures clients' safety, health, and rights. B. advocacy ensures that nurses are able to explain their own actions. C. advocacy ensures that nurses follow through on their promises to clients. D. advocacy ensures fairness in client care delivery and use of resources.

A. advocacy ensures clients' safety, health, and rights.

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take? A. turn the client every 2 hr B. administer and antiemetic every 6 hr C. hold oral care D. increase the room temp

A. turn the client every 2 hr

A nurse is caring for a client with dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? A. use a bed exit alarm system B. raise four side rails while the client is in bed C. apply one soft wrist restraint D. dim the lights in the client's room

A. use a bed exit alarm system Rationale: The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at a risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance.

A nurse is providing teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? A. Insert the needle at a 15° angle. B. Aspirate for blood return prior to administration. C. Administer the medication into the abdomen. D. Massage the site following the injection.

Administer into the abdomen.

Older adult with fall risk. Which assessments should the nurse use to identify the client's safety need? Select all that apply. A. Lacrimal apparatus B. Pupil clarity C. Appearance of bulbar conjunctivae D. Visual fields E. Visual acuity

B. Pupil clarity D. Visual fields E. Visual acuity

client who is postoperative is verbalizing pain as a 2 out of 10. Which statement should the nurse identify as an indication that the client understands the preop teaching she received about pain management? A. "I think I should take my pain meds more often since it is not controlling my pain." B. "Breathing faster will help me keep my mind off the pain." C. "It might help me to listen to music while lying in bed." D. "I don't want to walk today because I have some pain."

C. "It might help me to listen to music while lying in bed."

A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make? A. "You would have so much more time to spend with your family." B. "You should consider getting a part-time job or doing volunteer work." C. "Let's talk about how the change in job status will affect you." D. "Why wouldn't you want to retire and relax?"

C. "Let's talk about how the change in job status will affect you."

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? A. combine client care tasks when caring for multiple clients B. wait until the end of the shift to document client care C. use the planning step of the nursing process to prioritize client care delivery D. allow for interruptions in tasks to discuss client care issues with colleagues

C. use the planning step of the nursing process to prioritize client care delivery. Rationale: Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management.

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 initiate? A. Protective environment B. Airborne precautions C. Droplet precautions D. Contact precautions

Contact precautions

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? A. discuss the risk factors for colon cancer B. focus teaching on what the client will need to do in the future to manage his illness C. provide the client with written information about the phases of loss and grief D. reassure the client that this is an expected response to grief

D. reassure the client that this is an expected response to grief

A nurse is admitting a client who is having an exacerbation of heart failure. In the planning this client's care, when should the nurse initiate discharge planning? A. During the admission process B. As soon as the client's condition is stable C. During the initial team conference D. After consulting with the client's family

During the admission process

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh- length sequential compression sleeves. Which of the following actions should the nurse take? a. assist the client into a prone position b. place a sleeve over the top of each leg with the opening at the knee c. Make sure two fingers can fit under the sleeves. D. Set the ankle pressure at 65 mm Hg.

Make sure two fingers can fit under the sleeves.

A nurse is reviewing evidence-based practice principles about administering oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. B. Regulate oxygen via nasal canal at a flow rate of no more then 6L/ min C. Make sure the reservoir bag of a partial rebreathing mask remains deflated. D. Use petroleum jelly to lubricate the client's nares, face, and lips.

Regulate oxygen via nasal canal at a flow rate of no more then 6L/ min

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? A. Remove the outer cannula cautiously for routine cleaning. B. Use tracheostomy covers when outdoors. C. Use sterile techniques when performing tracheostomy care at home. D. Cleanse irritated skin with full-strength hydrogen peroxide.

Use tracheostomy covers when outdoors. -Tracheostomy covers protect the client airway from cold air, dust, and other airborne particles.

A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take? A. Administer the medication with the needle at a 45° angle. B. Administer the medication with the needle at a 45° angle. C. Pull the client's skin laterally or downward prior to administration. D. Massage the injection site after administration.

A. Administer the medication with the needle at a 45° angle.

The nurse provides discharge teaching for a patient who will be using a walker. Which of the following client statements indicates an understanding of the teaching? A. "I can place an extension cord across my living room to plug in my television." B. "I will hire someone to trim the tree that hangs low over the stairs of my front porch." C. "I will place my alarm clock on my bedroom dresser across the room." D. I will replace the throw rug in my kitchen with a new one."

B. "I will hire someone to trim the tree that hangs low over the stairs of my front porch."

A nurse is caring for a client who asks about the purpose of advanced directives. Which of the following statements should the nurse make? A. "They allow the court to overrule an adult client's refusal of medical treatment." B. "They indicate the form of treatment a client is willing to accept in the event of a serious illness." C. They permit a client to withhold medical information from healthcare personnel." D. "They allow healthcare personnel in the ED to stabilize a client's condition."

B. "They indicate the form of treatment a client is willing to accept in the event of a serious illness."

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make? A. "We would consult the person appointed by your health care proxy to make decisions." B. "We would give you oxygen through a tube in your nose." C. "We would be unable to change your previous wishes about your care." D. "We would insert a breathing tube while we evaluate your condition."

B. "We would give you oxygen through a tube in your nose."

Client has terminal illness and is at the end of life. Which one of the following statements by the client's partner indicates effective coping? A. I am not worried because I still have hope that he will be okay B. I am relying on support from our family during this time C. We can plan our family reunion once he recovers and comes home D. We don't see any reason to start discussing funeral arrangements right now

B. I am relying on support from our family during this time

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? A. critical pathway B. SBAR C. transfer report D. MAR

B. SBAR

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? A. The client uses a wool blanket on their bed. B. The client identifies the location of a fire extinguisher. C. The client stores an extra oxygen tank on it's side under their bed. D. The client has a weekly inspection checklist for oxygen equipment.

B. The client identifies the location of a fire extinguisher.

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority? A. request that a respiratory therapist discuss the technique for incentive spirometry with the client B. determine the reasons why the client is refusing to use the incentive spirometry. C. document the client's refusal to participate in health restorative activities D. administer a pain med

B. determine the reasons why the client is refusing to use the incentive spirometry.

A nurse is caring for a client who pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? A. contact B. droplet C. airborne D. protective

B. droplet

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? A. FLACC pain scale B. ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm C. obtain an apical heart rate by auscultating at the third intercostal space left of the sternum D. palpate the client's abdomen before auscultating bowel sounds

B. ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm

A nurse is talking with the partner of an older adult male client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. The nurse should identify that he is going through which of the following types of role-performance stress? A. Role ambiguity B. Sick role C. Role overload D. Role conflict

C. Role overload Rationales the partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can perform.

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? A. a lesion with uniform pigmentation B. new appearance of petechiae C. a mole with an asymmetrical appearance D. the presence of a papule

C. a mole with an asymmetrical appearance

A nurse is administering 1 L of NS to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? A. increase in hematocrit B. increase in respiratory C. decrease in heart rate D. decrease in capillary refill time

C. decrease in heart rate

A nurse is using an open irrigation technique to irrigate a client's indwelling catheter. Which of the following actions should the nurse take? A. place the client in a side-lying position B. instill 15 mL of irrigation fluid into the catheter with each flush C. subtract the amount of irrigant used from the client's urinary output D. perform the irrigation using a 20-mL syringe

C. subtract the amount of irrigant used from the client's urinary output

Nurse evaluates a client's use of cane. Which of the following actions is the indication of correct use of cane? A. The top of the cane is parallel to the client's waist. B. When walking, the client moves the cane 46 cm (18 in) forward. C. The client holds the cane on the stronger side of her body. D. The client moves her stronger limb forward with the cane.

C. the client holds the cane on the stronger side

Nurse initiates protective environments for client with allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this patient? A. Make sure the client's room has at least six air exchanges per hour. B. Make sure the client wears a mask when outside her room if there is construction in the area. C. Place the client in a private room with negative-pressure airflow. D. Wear an N95 respirator when giving the client direct care.

D. Wear an N95 respirator when giving the client direct care.

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next? A. document the provider's statement in the medical record B. complete an incident report C. consult the facility's risk manager D. notify the nursing manager

D. notify the nursing manager Rationale: The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care.

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? a. "I will return shortly after I document this in your record" b. "most men live in a long time with prostate cancer" c. "I am available to talk if you should change your mind" d. "I will make a referral to a cancer support group for you"

c. "I am available to talk if you should change your mind"

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following action should the nurse take when inserting the NG tube? a. position the client with the head of the bed elevated to 30 degrees prior to insertion of the NG tube. b. removes the NG tube if the client begins to gag or choke. c. apply suction to the NG tube prior to insertion. d. has the client take sips of water to promote insertion of the NG tube into the esophagus..

d. have the client take sips of water to promote insertion of the NG tube into the esophagus Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube's passage into the trachea.