RN Funds A&B
A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?
"Client found lying on floor"
A nurse is caring for a client who requires 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 AM and have saved all urine since."
A nurse is teaching a client who left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indiction that the client understands the teaching?
"When descending the stairs, I will first shift my weight to my right leg"
A nurse is preparing to obtain a lower extremity blood pressure from a client and no longer palpates the popliteal pulse after 92 mm Hg. Which of the following images displayed the measurement in mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure.
(picture with 122 mm Hg)
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? Select all that apply.
- Place the client in a room with negative-pressure airflow - Wear gloves when assisting the client with oral care - Use antimicrobial sanitizer for hand hygiene
A nurse has accepted a verbal prescription "for three tenths of a milligram of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?
0.3 mg
A nurse is preparing a heparin infusion for a client who was admitted to the facility with sep-vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump?
8 mL/hr
A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid?
8 oz of ice chips
A nurse is teaching a group a staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?
A client who has asthma
A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines?
A nurse asks a nurse from another unit to assist with documentation for a client
A nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. I can concentrate best in the morning B. it is difficult to read the instructions because my glasses are at home C. I'm wondering why I need to learn this D. You will have to talk to my wife about this
A. I can concentrate best in the morning (indicates a readiness to learn b/c he is verbalizing the best time for him to learn)
A nurse is preparing to administer enoxaparin sub-cut to a client. Which of the following actions should the nurse take? A. administer the medicaiton with the needle at a 45* angle B. administer the medication into client's nondominant arm C. pull the client's skin laterally or downward prior to administration D. massage the injection site after administration (never!)
A. administer the medicaiton with the needle at a 45* - 90* angle b/c this is SC range (not C b/c this technique is for IM injections)
A nurse is caring for a client who has 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 client is out of bed C. apply one soft wrist restraint D. dim the lights in the client's room
A. use a bed exit alarm system
A nurse is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tests should the nurse delegate?
Ambulating a client who is postoperative
A nurse has just inserted an NG for a client. Which of the following findings should the nurse expect to confirm correct tube placement?
An x-ray shows the end of the tube above the pylorus
A nurse is caring for a client who has decreased mobility. which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures?
Apply an ankle foot orthotic device to the clients feet
A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding?
Arrange food in a consistent pattern on the client's plate
A nurse is preparing to transfer a client who can bear weight on one leg from the bed to the chair. After securing a safe environment, which of the following actions should the nurse take next?
Assess the client for orthostatic hypotension
A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?
Auscultate lung sounds
A nurse is providing discharge instructions to a client 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 TV B. I will hire someone to trim the treat 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 old throw rug in my kitchen with a new one
B. I will hire someone to trim the treat that hangs low over the stairs of my front porch
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. I-SBARR C. transfer report D. medication administration record (MAR)
B. I-SBARR
A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should nurse take? A. contact B. droplet C. airborn D. protective
B. droplet (DIPtheria = DRoplet)
A nurse is planning to insert a peripheral IV catheter for an older client. Which of the following actions should the nurse plan to take? A. insert the cath at 45* angle B. place client's arm in a dependent position C. shave excess hair from insertion site D. initiate IV therapy in the veins of the hand
B. place client's arm in a dependent position (b/c veins will dilate d/t gravity and make it easier to find and correctly insert-- think of video)
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation?
Bladder scan shows 525 mL of urine
A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves client's room. When 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 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 providing discharge teaching to a client about self-administering heparin. Which fo the following instructions should nurse include in teaching? A. insert needle at 15* angle B. aspirate for blood return prior to administration C. administer medication into abdomen D. massage the site following injection
C. administer medication into abdomen
A nurse is using open irrigation technique to irrigate a client's indwelling urinary cath. Which of the following actions should nurse take? A. place client in side-lying position B. instill 15 mL of irrigation fluid into cath with each flush C. subtract the amount of irrigant used from client's urine output D. perform the irrigation using a 20-mL syringe
C. subtract the amount of irrigant used from client's urine output Not #A b/c client should be in supine or dorsal recumbent position. Not #B b/c should be 30-40 mL of irrigation fluid, not #D b/c should use 30-50 mL syringe to perform irrigation
A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as indication of correct use? A. the top of the cane is parallel to client's waist B. when walking, the client moves the cane 18 inches forward C. the client holds the cane on the stronger side of her body D. client moves her stronger limb forward with the cane
C. the client holds the cane on the stronger side of her body (to increase support and maintain alignment)
A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should nurse implement? A. combine client care tasks when caring for multiple clients B. wait until end of shift to document client care C. use planning step of nursing process to prioritize client care delivery D. allow for interruptions in tasks to discuss client care issues with colleagues
C. use planning step of nursing process to prioritize client care delivery
A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?
Cleanse the would from the center outward
A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?
Compare prescriptions with medications the client received while at the facility.
A nurse is an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include?
Current medications
A nurse is reviewing a client's F/E status. Which of the following should the nurse report to the provider? A. BUN 15 mg/dL B. Creatinine 0.8 mg/dL C. Na+ 143 mEq/L D. K+ 5.4 mEq/L
D. K+ is high (N = 3.5 - 5) Na+ 136-145 (143 WNL) Creatinine 0.5-1.1 women ; 0.6-1.3 men (0.8 WNL) BUN 10-20 mg/dL (15 WNL)
A nurse receives report about a client who has 0.9% NaCl infusing IV at 125 mL/hr. When nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hours. Which of following actions should nurse take first? A. reposition client B. document client's IV intake in the medical record C. request a new IV fluid prescription D. check IV tubing for obstruction
D. check IV tubing for obstruction
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
D. contact precautions (private room, nurses wear gown and gloves)
A nurse is preparing to apply a dressing for a client who has stage 2 pressure injury. Which of the following types of dressing should client use? A. alginate B. gauze C. transparent D. hydrocolloid
D. hydrocolloid dressing promote healing by creating a moist wound bed. Stage 2 is partial-thickness skin loss into but no deeper than dermis and no drainage. Some may have a blister)
A nurse is lifting a bedside cabinet to move it closer to a pt 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 feet close together C. use back muscles for lifting D. stand close to cabinet when lifting
D. stand close to cabinet when lifting
A nurse is assessing a client who received an IV fluid bolus for dehydration. which of the following findings should the nurse identify as an indiction of fluid volume excess?
Distended neck veins
A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?
Droplet
A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene?
Erythema on pressure points
A client who is non ambulatory notifies the nurse that his tracheostomy's can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?
Evacuate the client
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
A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?
Gently shake the container of medication prior to administration
A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching?
Have family members wear a gown and gloves when visiting
A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use?
Have the client stand with their arms at their sides and their feet together
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
A nurse is caring for a client who has terminal illness and is at the end of life. THe nurse should recognize that which of the following statements by the client's partner indicates effective coping?
I am relying on support from our family during this time
A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use?
I can take echinacea to improve my immune system
A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indiction that the client understands the use of this assistive device?
I will be sure to remove my hearing aid before taking a shower
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?
Initiate an enteral feeding through a gastrostomy tube.
A nurse is caring for a client who is receiving pain medication through a patient-controlled analgesia (PCA) pump. Which of the following actions should the nurse take?
Instruct the family to refrain from pushing the button for the client while she is asleep.
A nurse is caring for ac client who reports difficulty falling asleep. Which of the following recommendations should the nurse?
Maintain a consistent time to wake up each day
A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify with the provider?
Medication dose
A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use a psychomotor approach to learning?
Practice sessions
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?
Rapid Heart Rate
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?
Reassure the client that this is an expected response to grief
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
A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicting infiltration?
Skin blanching
A nurse is caring for a client who has a 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.
A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as potential of elder abuse?
The caregiver insists on remaining in the room
A charge nurse is observing a newly license nurse prepare a sterile field for a dressing change. Which of the following actions by the newly license nurse requires intervention by the charge nurse?
The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field
A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?
The pain is like a dull ache in my stomach
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 should the nurse recommend?
Walking Briskly
A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?
We can talk about advance directives, and I can also give you some brochures about them
A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?
What could I have done to deserve this illness?
A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?
Withhold the blood transfusion
A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurses responsibility?
Witness the clients signature on the consent form
A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?
Wrap blankets around all four sides of the bed
A nurse in s surgical suite notes documentation on a 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 place
A nurse is preparing to administer 0.9% NaCl 750mL IV to infuse over 7 hours. The nurse should set the infusion pump to deliver how many mL/hr? Round answer to nearest whole number
X mL/hr = (Volume mL) / time (hours) 750/7 = 107.14 = 107 mL/hr
A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?
You should have a fecal occult blood test every year.
A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?
You should receive a pneumococcal immunization every 10 years.
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 skin malignancy? A. a lesion with uniform pigmentation B. new appearances of petechiae C. a mole with asymmetrical appearance D. presence of papule
a asymmetrical mole
A nurse is admitting a client who is having an exacerbation of HF. In planning this client's care, when should the nurse initiate discharge planning?
duh-- during the admission process
A nurse is caring for a client who asks about the purpose of advanced directives. How should nurse respond?
they indicate the form of treatment a client is willing to accept in the event of a serious illness
The nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? Select all that apply.
- Check the cord routinely for frays or tearing - Consider purchasing a generator for power backup is correct - Observe for signs of hypoxia
A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?
A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively
A community health nurse is checking blood pressures for a group of clients at a community health screening. Which of the following clients is at an increased risk for hypertension?
A client who smokes one pack of cigarettes each day.
A nurse is planning care for a client who has had a stroke, resulting in aphasia and dyshagia. Which of the following tasks should the nurse assign to an AP (SATA)? A. assist the client with a partial bed bath B. measure the client's bp after the nurse administers an antihypertensive medication C. test the client's swallowing ability by providing thickened liquids D. use a communication board to ask what the client wants for lunch E. irrigate the client's indwelling urinary catheter
A. assist the client with a partial bed bath B. measure the client's bp after the nurse administers an antihypertensive medication (APs can take VS?) D. use a communication board to ask what the client wants for lunch
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 pt for injuries B. move hazardous objects away from the clinet C. notify the provider D. ask the client to describe how she felt prior to the fal
A. check the pt for injuries
A nurse is administering an otic medication to an older adult. To make sure it reaches inner ear, nurse should... A. press gently on tragus of client's ear B. pack a small piece of cotton deep into client's ear canal C. move client's auricle dwon and back toward her head D. tilt client's head backward for 5 minutes
A. press gently on tragus of client's ear (think of when you are swimming and have water in your ear)
A nurse is giving change-of-shift report about a client they admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?
Breath Sounds
A nurse is caring for a client who has a Na+ level of 125 mEq/L (LOW). Which of the following findings should the nurse expect? A. numbness of the extremities B. bradycardia C. positive Chvostek's sign D. abdominal cramping
D. abdominal cramping (manifestations of hyponatremia include abdominal cramping, weakness, confusion, lethargy, HA, and nausea-- think about feelings when losing a lot of sweat)
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. ale C. feverfew D. acupuncture
D. acupuncture. (an open portal on skins surface could increase the risk of further enfection).
A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2mL 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 the sharps container
ask another nurse to observe the medication wastage
A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? A. position the client with the HOB elevated 30* prior to insertion of the NG tube B. remove the NG tube if the client begins to gag or choke C. apply suction to the NG tube prior to insertion D. have the client take sips of water to promote insertion of NG tube into esophagus
#A incorrect b/c pt should be in high-Fowler's position and HOB 90* #B incorrect b/c NG tube should be withdrawn slightly not removed if pt is choking #C incorrect b/c should not apply suction until NG is in correct body cavity placement #D is CORRECT because sipping water will close epiglottis over trachea and make sure N-gastric tube ends up in stomach
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.
- Inject 10 units of air into the bottle of NPH insulin. - Inject 5 units of air into the bottle of regular insulin. - Withdraw the correct dose of regular insulin from the bottle Withdraw the correct dose of NPH insulin from the bottle
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 child who has a prescription for a blood transfusion. The child's parents have refused the treatment d/t religious beliefs. Which of the following actions should 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
A. examine personal values about the issue (nurses should examine their own personal values about the issue in question in order to provide care that is without bias) - it is not #D because spiritual support people are there to help families' spiritual needs not physiological
A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps:
A. obtain the pronouncement of death from provider B. remove tubes and indwelling lines C. wash client's body D. ask client's family members if they would like to view the body (wash and remove before so they can have positive memory of loved one) E. place name tag on body (for the morgue)
A nurse on a med-surg unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? A. pad the client's wrist before applying the restraints B. evaluate the client's circulation q8hr after application C. remove the restraints q4hr to evaluate client's status D. secure the restraints ties to the bed's side rails
A. pad the client's wrists before applying the restraints (w/o can cause abrasion of skin resulting in client injury)
A nurse is caring for a client who has 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 q2hrs B. administer an antiemetic (prevents N/V) q6hrs C. hold oral care D. increase room temperature
A. turn client q2hr to break up secretions in lungs not B b/c pt not struggling with N/V. Not C b/c oral care should help moisten mouth from SOB (and don't withhold care just because someone is dying). Not D b/c should be palliative to lower room temp
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 dosage of insulin D. use abbreviation SC when indicating an injection
A. use the complete name of the medication magnesium sulfate ( avoided misinterpretation as MgSO4 and MSO4 (morphine) could be mixed up)
A nurse is caring for a client who has respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? A. insert the suction catheter while the client is swallowing B. apply intermittent suction when withdrawing the catheter C. place the catheter in a location that is clean and dry for later use D. hold the suction catheter with her clean, non-dominant hand
B. apply intermittent suction when withdrawing the catheter
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 the respiratory therapist discuss the technique for incentive spirometry with the clinet B. determine the reasons why the client is refusing to use the incentive spirometer C. document the client's refusal to participate D. administer a pain medication first
B. determine the reasons why the client is refusing to use the incentive spirometer
A nurse is assessing four adult clients. Which of the following assessment techniques should the nurse use? A. use the face, legs, activity, cry, and consolability pain rating scale for a clinet who is experiencing pain B. ensure the bladder of the bp culf surrounds 80% of client's arm C. obtain a apical heart rate by ausculating at the third (should be 5th) intercostal space left on the sternum D. palpate the client's abdomen before ausculating bowel sounds
B. ensure the bladder of the bp culf surrounds 80% of client's arm #D should ausculate bowel sounds prior to palpation
A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? A. make sure the client's room has at least 6 air exchanges/hr B. make sure the client wears a mask when outside her room if their is construction in the area C. place the client in a private room with negative-pressure airflow D. wear a N95 respirator when giving the client care
B. make sure the client wears a mask when outside her room if their is construction in the area (allogeneic stem cell transplant helps suppress disease and restore immune system)
A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? A. carry a client's soiled linens out of the room in a mesh linen bag B. place a client who has tuberculosis in a room with negative-pressure airflow C. provide disposable plates and utensils for a client who is HIV-positive D. dispose of a client's blood-saturated dressing in a trash bag inside a second trashbag
B. place a client who has tuberculosis in a room with negative-pressure airflow (#A should be fluid-resistant bag #C is not transmitted via contact but by body fluids #D should dispose in biohazard bag)
A nurse is performing a home safety assessment for a client who is receiving supplemental O2. Which of the following observations should the nurse identify as proper safety protocol? A. client uses a wool blanket on their bed B. pt uses nonacetone nail polish remover C. pt stores an extra O2 tank on its side under their bed D. pt has weekly inspection checklist for O2 equipment
B. pt uses nonacetone nail polish remover (is nonflammable material) Not #D b/c should check equipment daily
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 (SATA)? A. lacrimal apparatus (tears) B. pupil clarity C. appearance of bulbar conjuctivae (for presence of infection not fall risk) D. visual fields E. visual acuity
B. pupil clarity (with pen light) D. visual fields (tracking finger movement) E. visual acuity (use eye chart to measure) INNCORECT: A. Impairment in ability to make tears shouldn't affect ther fall risk. C. Condition of conjuctivae will not impede clients safety.
A nurse is reviewing EBP principles about administration of O2 therapy with a newly licensed nurse. Which of the following actions should nurse include? A. regulate the flow rate by aligning the rate with the top of the ball inside the flow meter B. regulate O2 via nasal cannula at a flow rate of no more than 6 L/min C. make sure the reservoir bag of a partial rebreathing mask remains deflated D. use petroleum jelly to lubricate client's nares, face, and lips
B. regulate O2 via nasal cannula at a flow rate of no more than 6 L/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 technique when performing tracheostomy care at home D. cleanse irritated skin with full-strength hydrogen peroxide
B. use tracheostomy covers when outdoors (to protect from dust, cold air, and other airborne particles)
A nurse is educating a client who has terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the ER and 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 O2 through a tube in your nose C. you 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 O2 through a tube in your nose (Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers in via nasal cannula)
A nurse is assessing a client who has required bed rest for the past month. Which of the findings should nurse identify as an indication that client has developed thrombophlebitis (inflammation of the wall of the vein) A. bladder distension B. decreased blood pressure C. calf swelling D. diminished bowel sounds
C. calf swelling
A home health nurse is performing a follow-up visit for a client who has a gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should nurse identify as a possible cause of diarrhea? A. client is receiving formula at room temp B. feedings infuse at a slow, continuous drip over 8hr each night C. client's caregiver washes out the feeding bag with warm water once q24hr D. client's caregiver flushes tubing with water before administering
C. client's caregiver washes out the feeding bag with warm water once q24hr. (feeding bags should be washed out after each feeding and replaced with a new dressing bag Q24H to prevent bacterial contamination).
A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? A. verify client's name on their ID bracelet with medication administration record B. call the pharmacy to determine whether the client's medications are available C. compare the client's home medications with the provider's prescriptions D. place the client's home medication bottles in a secure location
C. compare the client's home medications with the provider's prescriptions
A nurse is administering 1 L of 0.9% NaCl to pt who is post-op and has fluid volume deficit. Which of the following changes should nurse identify as an indication that the treatment was successful? A. increased hematocrit B. increased resp rate C. decreased hr D. decrease in cap refill time
C. decrease in hr (b/c tachycardia is common sx of low fluids). Not #D because fluid volume deficit slows cap refill but correction should keep in WNL (<3 seconds)
A client who is post-op is verbalizing pain as a 2/10. Which of the following statements should nurse identify as an indication that the client understands the pre-op teaching she received about pain management? A. I think I should take my pain medication 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 I'm 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 family B. you should consider getting a part-time job or doing volunteer work C. let's talk about how the change in your job status will affect you D. why wouldn't you want to retire and relax
C. let's talk about how the change in your job status will affect you
A nurse is caring for pt who is post-op following knee arthroplasty and requires the use of a thigh-length sequential compression sleeves. Which of the following actions should the nurse take? A. assist the pt to 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 mmHg
C. make sure two fingers can fit under the sleeves (any less space can inhibit circulation when the sleeves begin to inflate)
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 > partner's frustration refers to having more responsibilities within a role than one person can imagine). Role Ambiguity= occurs when people are unclear about the expectations of their role in given situation. Sick Role= refers to the expectations placed on an individual who has the alteration in health, rather than the caregiver. Role Conflict= develops when a person must assume multiple roles that have opposing expectations.
A nurse is caring for a client who is post-op. When the nurse prepares to change her dressing, she says, "Every time you change my bandage, it hurts so much!" Which of the following interventions is the nurse's priority action? A. encourage the pt to relax and take deep breaths during the dressing change B. educate the pt about the importance of the dressing change to prevent infection C. assist the pt to a comfortable position for the dressing change D. administer the pain med 45 minutes prior to changing the client's dressing
D. administer the pain med 45 minutes prior to changing the client's dressing
A nurse is assessing a client who reports increased pain following PT. 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 0-10? C. does the pain radiate D. is your pain sharp or dull?
D. is your pain sharp or dull (asking pt this question helps determine quality of pain)
A nurse is caring for a client who is post-op and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's VS q15min and report back in 1 hour. Which of the folloiwng 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 (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 the client receives the necessary care). #A is not correct because the client is in shock and documentation should be done after intervention/stabilization
A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client? A. have the client wear a mask when receiving orders B. limit the client's time with visitors to <30 min/d C. assign the client to a room with negative-pressure airflow exchange D. wear a gown when caring for the client
D. wear a gown when caring for the pt (to avoid contact with body fluids and contaminated surfaces). Shigella is an bacterial intestinal disease causing GI upset and pt can have diarrhea/vomiting/etc.
A nurse is planning care for a client who has tuberculosis. The nurse should use which of the following pieces of personal protective equipment when providing care for the client
N95 respirator
A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, the nurse hears the following sound. This sound indicates which of the following?
Narrowed arterial lumen
A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?
People in middle adulthood often find satisfaction in nurturing and guiding young people