RN VATI Fundamentals Assessment

44. A nurse is providing teaching about cough etiquette to a client who has influenza. Which of the following instructions should the nurse include in the teaching?

"Cover your nose and mouth with a tissue when coughing." DROPLET The nurse should instruct the client to cover their nose and mouth with a tissue when coughing. The client should discard the tissue promptly in the nearest trash container. The nurse should instruct the client to wash their hands before and after meal time. The nurse should instruct the client to remain at least 0.9 m (3 ft) away from others when coughing. This helps prevent the transmission of microorganisms. Turning the head away when coughing can transmit microorganisms into the air.

22. A nurse is evaluating preoperative teaching with a client who is to undergo surgery with general anesthesia. Which of the following statements by the client indicates an understanding of the teaching?

"I should remove nail polish from my fingers before surgery." The nurse should instruct the client to remove nail polish for accurate pulse oximetry monitoring and for a clear view of the nail beds when assessing capillary refill.

39. A home health nurse is performing a home assessment for an older adult client. which of the following statements by the client should alert the nurse to suggest additional safety measures?

"I use space heaters to keep warm in the winter." A common environmental hazard in the home is the use of space heaters, which can increase the risk of fire. The use of a handheld shower head, along with secure grab bars and colored adhesive tape on the bottom of the bathtub, are important safety measures that can help reduce the risk for falls.

54. A nurse is providing discharge teaching about bathtub safety to an older adult client. Which of the following statements by the client indicates an understanding of the teaching?

"I will place a bath mat in front of the tub." The client should place a bath mat in front of the tub because it decreases the risk for falls. The client's wet feet could become slippery & slide on the floor without a bath mat

6. A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy utilizing a compressed oxygen system. Which of the following statements by the client indicates an understanding of the teaching?

"I will store oxygen tanks in an upright position" This statement by the client indicates an understanding of the teaching. The nurse should instruct the client to store oxygen tanks in an upright position in a holder to prevent damage to the tank and injury to the client and the client's family. The nurse should instruct the client to check the oxygen equipment at least once daily to determine if it is set to the prescribed oxygen rate. The nurse should instruct the client to place the oxygen equipment 2.4 m (8 ft) from a heat source to prevent injury from accidental combustion.

19. A nurse is teaching a client to manage stress by using progressive relaxation techniques. Which of the following statements by the client indicates an understanding of the teaching?

"I'll compare the sensations I feel when I tense my muscles to what I feel when I relax them." Progressive relaxation involves tensing and relaxing specific muscles, moving progressively through the body's muscle groups. The key is to distinguish sensations during tension from those during relaxation. Stretching can be used with yoga and is not a form of progressive muscle relaxation. This form of relaxation is using imagery through visualization and is not a form of progressive muscle relaxation. Deep breathing is required to reach a relaxed state.

7. A nurse is caring for a client who has terminal cancer. The client begins to cry and says, "I am afraid of dying." Which of the following responses should the nurse make?

"It must be a very difficult time for you." The nurse is using the therapeutic communication technique of verbalizing the implied. This technique puts into words what the client has said indirectly and creates a more positive nurse-client relationship.

37. A school RN is teaching a group of parents about measures to prevent firearm injuries in the home. Which of the following instructions should the nurse include in the teaching?

"Keep ammunition and guns in separate, locked locations." The nurse should instruct the parents to keep ammunition in a locked cabinet separate from the firearms to reduce the risk for injury. This action will prevent access to the firearm and also prevents injury from accidental discharge because the firearm does not contain ammunition. Also, the keys to the cabinet should not be accessible to children.

17. A home health nurse is making an initial assessment visit to an older client who has type 1 diabetes mellitus. Which of the following statements should the nurse make to evaluate the client's ability to measure blood glucose accurately?

"Please use your glucometer and show me the results." Asking for a return demonstration is an effective way to assess a client's ability to complete a psychomotor activity. The nurse should carefully observe the client using the glucometer to validate the client's understanding of the procedure and evaluate whether or not the method is accurate.

4. A nurse is planning teaching for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following actions should the nurse take prior to performing the teaching? (select all that apply)

- Establish the client's learning needs - Determine the client's literacy level - Evaluate the client's readiness for learning - Identify the client's learning style

31. A home health RN is teaching a client who has a latex allergy about items typically found in the home that can trigger an allergic reaction. Which of the following items should the RN instruct the client to avoid? (Select all that apply)

-Dishwashing gloves -Adhesive tape -Bananas -Rubber bands Dishwashing gloves is correct. Many kinds of dishwashing gloves contain latex. Therefore, it places the client at risk for an allergic reaction. Adhesive tape is correct. Adhesive tape contains latex. Therefore, it places the client at risk for an allergic reaction. Bananas is correct. Certain foods such as kiwi, avocados, and bananas can trigger latex allergies. Rubber bands is correct. Rubber bands contain latex. Therefore, they place the client at risk for an allergic reaction.

36. A RN is completing a pre-admission interview for a client who is to undergo surgery the following day. The client reports a latex allergy. Which of the following interventions should the RN include when planning care for the client's surgery?

-Notify ancillary department of the client's allergy -Label the surgical suite as latex-free -Ensure a latex allergy care is available Notify ancillary departments of the client's allergy is correct. Notifying ancillary departments of the client's sensitivity to latex allows the staff to take appropriate measures to ensure that medications and surgical items are not contaminated by latex. Label the surgical suite as latex-free is correct. This helps keep personnel from bringing rubber products into the room. Ensure a latex allergy cart is available is correct. A latex allergy cart should be kept in the operating room at all times. All of the contents must be latex-free.

1. A nurse is preparing to mix short-acting and intermediate-acting insulin in one syringe to administer to a client who has type 1 diabetes mellitus. Identify the sequence the nurse should follow.

1: Draw up the volume of insulin from the intermediate-acting insulin vial. 2: Inject the volume of air equal to the amount of insulin to withdraw from the intermediate-acting insulin vial. 3: Inject the volume of air equal to the insulin dose form the short-acting insulin vial 4: Withdraw the prescribed amount of insulin form the short-acting insulin vial. 5: Withdraw the prescribed amount of insulin form the intermediate-acting insulin vial. To mix insulin from two vials in the same syringe, the nurse should first draw up a volume of air equal to the volume of insulin from the intermediate-acting insulin vial. The nurse should then inject the volume of air equal to the amount of insulin to withdraw from the intermediate-acting insulin vial, making sure the needle does not touch the insulin. Next, the nurse should inject the volume of air equal to the insulin dose from the short-acting insulin vial. Then, the nurse should withdraw the prescribed amount of insulin from the short-acting insulin vial. Lastly, the nurse should withdraw the prescribed amount of insulin from the intermediate-acting insulin vial. The insulins are now mixed and ready to administer.

51. A nurse is caring for a client who is at risk for pressure ulcer formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?

30° lateral The 30° lateral position, along with positioning devices, can prevent pressure directly over the client's most vulnerable bony prominences. This position can, however, cause pressure on the shoulder, ankle, anterior iliac spine, and trochanter. Therefore, the nurse should ensure the client's head is midline and supported, rotation of the spine is avoided, and position changes are implemented every 1 to 2 hr

10. A nurse has administered 5 mL of medication to a client via NG tube. Then used 30 mL of water to flush the tue both before and after the instillation. the nurse should document which of the following amounts as liquid intake for the client?

65 mL A client who has an NG tube can receive numerous liquid medications, plus water to flush the tube before and after medications. Over a 24-hr period, these liquids can amount to a significant intake. The nurse should document them on the intake and output record. A value of 65 mL accounts for 5 mL of medication and two 30-mL flushes.

40. A nurse is preparing to administer an intramuscular injection to a client. at which of the following angles should the nurse plan to insert the needle

90 The nurse should plan to insert the needle at a 90° angle when administering medication via the intramuscular route. The intramuscular route promotes quicker medication absorption into the muscle than the other routes of medication administration.

24. RN in a rehab unit is assessing a group of clients who have a TBI. The RN should identify that which of the following clients requires a priority referral?

A client who consistently coughs after drinking liquids The greatest risk to this client is injury from aspiration. Therefore, this is the client the nurse should address first. The priority referral the nurse should make is to a speech-language pathologist because a client who coughs after drinking liquids is at risk for aspiration. Manifestations of dysphagia include changes in voice tone, coughing, delayed swallowing, pocketing of food, and occasional silent aspiration, which can occur if a client is experiencing a decrease in sensation.

45. A nurse in a rehabilitation unit is assessing a group of clients who have a traumatic brain injury. The nurse should identify that which of the following clients requires a priority referral?

A client who consistently coughs after drinking liquids The greatest risk to this client is injury from aspiration. Therefore, this is the client the nurse should address first. The priority referral the nurse should make is to a speech-language pathologist because a client who coughs after drinking liquids is at risk for aspiration. Manifestations of dysphagia include changes in voice tone, coughing, delayed swallowing, pocketing of food, and occasional silent aspiration, which can occur if a client is experiencing a decrease in sensation.

15. A nurse in a long-term care facility is planning to use therapeutic touch for a group of selected clients who have chronic pain. The nurse should identify that the use of therapeutic touch is CONTRADICTED for which of the following patients?

A client who has chronic back pain and a history of physical maltreatment Therapeutic touch consists of using the nurse's hands to harmonize energy fields and to facilitate relief of pain or anxiety, such as for a client who has chronic back pain. The nurse can touch the client with their palms or move the palms near, but not touching the client's body. Prior physical maltreatment and some mental health disorders are contraindications for therapeutic touch, because touch or near touch could cause severe anxiety.

67. A nurse is assessing four clients. Which of the following clients should the nurse identify as a potential candidate for a prescription for mitten restraints?

A client who has dementia and has removed their enteral feeding tube repeatedly Clients who have confusion and repeatedly remove or try to remove medical devices might require mitten restraints to protect themselves from injury. However, the nurse should exhaust alternative methods prior to requesting a restraint prescription.

50. A nurse is receiving change-of-shift report from a group of clients. which of the following clients should the nurse plan to see first?

A client who has dysphagia and has a scheduled feeding Using the airway, breathing, and circulation approach to client care, the priority action the nurse should take is to monitor the feeding of the client who is at risk for choking and aspiration. Therefore, the nurse should plan to see this client first.

2. A nurse is assessing a client who wears partial dentures and reports mouth pain. Which of the following actions should the nurse take?

Advise the client to rinse their mouth and dentures after each meal. The nurse should advise the client to rinse their mouth and dentures after each meal to remove food and particles and to promote healing of gums and oral mucosa. The nurse should instruct the client to rinse their mouth four times each day with mild rinses, such as normal saline or sodium bicarbonate solution. The nurse should inform the client that mouthwashes containing alcohol dry the oral mucosa and can irritate tissue. The nurse should instruct the client to brush their remaining teeth with a soft toothbrush at least twice each day to reduce the risk for gum abrasions. The nurse should avoid using lemon-glycerin sponges because they can cause erosion of the client's tooth enamel, dry the mucous membranes, and increase the client's current discomfort.

57. A nurse is preparing to administer an opioid medication to a client who is experiencing pain. Which of the following actions should the nurse take?

Ask a second nurse to witness the discarding of unused opioid medication. The nurse should ask a second nurse to witness the discarding of unused opioid medication and sign the designated form.

41. A nurse is admitting a client who is to undergo a surgical procedure. Under the Patient Self-Determination Act (PSDA), which of the following actions is the nurse's responsibility regarding the client's advance directives?

Ask the client whether they have created advance directives. The PSDA requires facilities to provide information to clients about their rights under state law to make decisions, including the right to refuse treatment and formulate advance directives. Under the act, staff should ask the client if they have advance directives, and the nurse should document the client's response in the medical record. When the legal competency of the client requires clarification for advance directives under the PSDA, the determination is made by a judge. The provider and family members also collaborate to determine if the client has the ability to make health care decisions. All members of a health care team should be aware of the existence of a client's advance directives. However, it is not the nurse's responsibility to notify the provider of the client's wishes or the health care proxy designated in the client's durable power of attorney for health care. Personal decisions about the need for life support should be made by the client. The nurse should assess the client's understanding of life support, but should not take part in decision making.

16. A nurse is preparing to delegate task for multiple clients at the beginning of the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Assist a client with ambulation When delegating client care activities to an AP, the delegating nurse should follow the five rights of delegation, which include right task, right circumstance, right person, right direction, and right evaluation. Assisting a client with ambulation is within the range of function of an AP.

46. A nurse is assessing a client who is postoperative following a cholecystectomy. Which of the following techniques should the nurse use to assess for peristalsis of the abdomen?

Auscultate each of the four quadrants for 5 min before determining sounds are absent. Although it usually takes only 5 to 20 seconds to hear bowel sounds, the nurse might have to listen in all four abdominal quadrants for at least 5 min before determining that bowel sounds are absent. Palpation of each quadrant determines abdominal distension or tenderness, not the presence of peristalsis. Percussion does not determine the presence or absence of peristalsis. However, percussion of the abdomen can help reveal the presence of air in the stomach and intestines and maps out underlying organs, bones, and masses. Observation for distention does not determine the presence or absence of peristalsis. When inspecting the abdomen for distention, the nurse should observe for bloating, a shiny appearance, as well as tight-looking skin for ascites. Bruising can indicate a bleeding disorder or injury to the abdomen.

64. A nurse discovers a fire in a client's room in a wastebasket where some isopropyl alcohol was discarded. Which of the following types of fire extinguisher should the nurse use to put out the fire?

B A type B fire extinguisher is appropriate for putting out flammable liquid & gas fires. Disinfectant solutions, such as isopropyl alcohol, are highly flammable liquids.

26. RN is preparing to assess a client's cardiac function by auscultating heart sounds at the pulmonic landmarks. Which of the following areas should the RN identify as the pulmonic area? (hotspot question)

C (left sternal border, second intercostal space) The nurse should identify that this is the pulmonic area of the cardiac landmarks, which is located at the left second intercostal space, near the sternum.

58. A nurse is planning care for a client who is receiving an IV fluid infusion. Which of the following interventions should the nurse implement to maintain asepsis?

Change the primary IV infusion set every 96 hr. The nurse should change the primary IV infusion set every 96 hr to minimize the risk of contamination and infection. Change bag every 24 hrs

65. A nurse is reviewing a medical administration record for a client and discovers that an incorrect medication was just administered. Which of the following actions should the nurse take first?

Check the client's vital signs. The first action the nurse should take when using the nursing process is to assess the client for any adverse effects of receiving the incorrect medication.

18. A nurse is caring for a client who has an ankle sprain and a prescription for an aquathermia pad. Which of the following actions should the nurse take?

Cover the pad with a pillowcase before application. The nurse should cover the aquathermia pad with a thin towel or pillowcase before use because applying the pad directly to the skin could cause a burn injury. Monitor condition of skin every 5 minutes during application, and question patient regarding sensation of burning. Remove pad after 20 min.

21. A nurse is creating a plan of care for a client who requires suture removal. Which of the following actions should the nurse plan to take?

Cut the sutures as close to the skin as possible. The nurse should cut the sutures as close to the skin as possible, away from the knot. The exposed part of the suture contains bacteria, so cutting close to the skin prevents bacteria from entering the clean wound, decreasing the risk for infection.

25. A RN is assessing a client who has hypokalemia. Which of the following findings should the RN expect?

Decreased bowel sounds Decreased bowel sounds are an indication of hypokalemia because of decreased excitability of cells, resulting in less responsiveness to normal stimuli in nerves and muscles.

69. A nurse at a health fair is performing screening assessments for older adults clients. Which of the following is the priority mental health assessment that the nurse should include?

Depression The greatest mental health risk for older adult clients is depression. Therefore, this is the priority assessment to include.

11. A nurse is performing a family assessment for a client who has recently developed paraplegia following a stroke. Which of the following actions should the nurse take first?

Determine how the client views the concept of family According to evidence-based practice, the nurse should first determine how the client views the concept of a family. This will influence the nurse's decision on how or whether to move forward in including the family into the client's plan of care.

12. A nurse is caring for a client who reports having insomnia due to increased stress. Which of the following actions should the nurse take first?

Determine the source of the client's stress The first action the nurse should take when using the nursing process is to assess or determine what is causing the client to experience increased stress. The nurse should instruct the client to eliminate distracting noise, such as television, a clock chiming, or a phone that can disrupt sleep. However, there is another action the nurse should take first.

56. A nurse receives a telephone call from a client's family member who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

Encourage the family member to contact the client directly for information Nurses are legally & ethically obligated to maintain the confidentiality of client information, including the client's current health status. Therefore, the nurse should encourage the family member to contact the client directly for more information.

62. A nurse is planning care for a client who has a history of seizures. Which of the following interventions should the nurse include in the plan of care?

Ensure oral suction equipment is at the bedside The nurse should ensure that oral suction equipment is available at the client's bedside to prevent aspiration of oral secretions during a seizure.

34. A nurse is providing teaching to a client who has a new dx of type 1 DM. The client expresses feelings of hopelessness about managing the disease. Which of the following actions should the RN take first?

Explore the client's past coping mechanisms The first action the nurse should take when using the nursing process is to assess the methods that the client used to successfully cope with other issues in the past and then reinforce them. This will help encourage the client to begin to learn self-care.

8. A nurse is assessing a client's coping skills. Which of the following should the nurse identify as an internal stressor?

Fear of medical test results Fear of medical test results is an internal stressor that originates within the body and mind of a client. Internal stressors are pressures that the client places upon themselves and are often the most common causes of stress. These stressors often force clients to deal with conflicting inner values and interactions with others. When a client manages internal stressors, it enhances their ability to deal with external stressors.

60. A nurse is caring for a client who is recovering from a bronchoscopy. Select the area the nurse should assess before giving the client ice chips or fluids. (You will find "hot spots" to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Flexible fiberoptic scope used for diagnosis, biopsy, specimen collection, or assessment of changes. It may be done to suction mucous plugs, lavage lungs, or remove foreign objects.

38. A nurse is caring for a client who has a terminal illness. The client requests a do-not-resuscitate (DNR) order, but their family opposes the decision. Which of the following actions should the nurse take first?

Gather information to support the client's request for a DNR order Using the nursing process, the first action the nurse should take is to assess the situation by gathering information to support the client's request for a DNR order. This information should include the client's current clinical status, factors such as the client's spirituality, culture, and family dynamics, and evidence from literature about the client's condition. The nurse should verbalize the client's request to have DNR status with the family members and maintain open communication about the client's situation. However, there is another action the nurse should take first.

61. A nurse is admitting a client who is at risk for falls. Which of the following interventions should the nurse include in the client's plan of care?

Have the client demonstrate how to use the call light. The nurse should demonstrate use of the call light for the client and ask for a return demonstration to confirm the client's understanding. This ensures the client will be able to request assistance quickly and reduces the risk for falls.

9. A nurse is performing postmortem care for an older client who had just died. Which of the following actions should the nurse take?

Identify the client using 2 identifiers The nurse should identify the deceased client using two identifiers, such as name and birth date, or name and account number, and then compare the identifiers to the information in the client's medical records

A nurse is planning an in-service about foot care for a group of clients who have peripheral neuropathy. Which of the following information should the nurse include?

Inspect the feet daily with a mirror The nurse should include in the program to inspect the feet daily with a mirror for dryness, redness, lesions, orlacerations, which can place the client at risk for infection.

63. A nurse is preparing to move a client who is immobile up in bed with the assistance of another nurse. Which of the following actions should the nurse plan to take?

Keep the back, pelvis, feet, and neck in alignment. To reduce the risk of injury to their lower back, the nurse should align their neck, back, pelvis, and feet when lifting an object or moving a client.

33. A RN is reviewing data in a client's medical record. Which of the following info should the RN expect to find in the discharge summary section?

List of community resources The nurse should expect to find a list of community resources provided to the client in the discharge summary section. Other information the nurse should expect to find in the discharge summary section includes unresolved problems, a list of complications to report to the provider, the mode of transportation used, and who accompanied the client at discharge.

35. A nurse manager is teaching a group of newly licensed nurses about which procedures are within their scope of practice. Which of the following examples should the nurse include in the teaching?

Monitoring a continuous intra-arterial infusion of a thrombolytic medication Monitoring the infusion of a clot-dissolving agent is within a nurse's scope of practice. In addition, the nurse should inspect the IV line for a disconnection, check the infusion site for bleeding, and maintain site integrity.

14. A nurse receives a telephone prescription form the provider, who states, "four milligrams of morphine diluted with 5 milliliters of sterile water intravenous each morning at nine o'clock before client dressing changes." Which of the following entries by the nurse indicates correct transcription of the prescription? MSO4 4 mg IV bolus daily before dressing changes and dilute with 5 cc of water Morphine 4 mg IV bolus daily at 0900 before dressing changes, dilute medication with 5 mL of sterile water Morphine 4 mg IV bolus Q.D. before dressing changes and dilute with 5 cc of sterile water MSO4 4 mg IV bolus daily @ 9 AM, dilute with 5 mL of sterile water

Morphine 4 mg IV bolus daily at 0900 before dressing change, dilute medication with 5 mL of sterile water This entry by the nurse indicates correct transcription of the prescription. This transcription contains acceptable abbreviations according to The Joint Commission and includes complete information from the provider.

49. A nurse is assessing a client for hearing acuity by performing the Rinne test. Which of the following actions should the nurse take when performing this test?

Move a vibrating tuning forks prongs in front of the client's left or right ear canal. The nurse should perform the Rinne test by placing the handle of a vibrating tuning fork on the client's mastoid process and then moving the vibrating prongs 1 to 2 cm (0.4 to 0.8 in) in front of the client's left or right ear canal. The Rinne test compares bone conduction with air conduction. The client is expected to hear sound conduction by air for twice as long as bone conduction.

48. A nurse is inserting an NG tube for a client who has a new prescription for enteral feedings. Which of the following actions should the nurse take to verify the placement of the client's tube? (Select all that apply.)

NO - Measure the amount of aspirate in the NG tube is incorrect. The nurse should measure the amount of aspirate in the NG tube when the client is receiving tube feedings to evaluate absorption. However, measuring the aspirate in the NG tube does not confirm placement. Placement of the NG tube must be confirmed prior to initiating feedings. NO - Flush the tube with 50 mL of tap water is incorrect. The nurse should not instill fluid into an enteral tube until placement is confirmed. Examine the color of aspirated secretions is correct. Gastric secretions are typically cloudy, green, or tan in color. Intestinal secretions are bile-stained and therefore, typically appear yellow in color. Measure the pH of the client's aspirate is correct. Stomach contents are usually acidic, with a pH less than 5.5. A pH of 6 is an indication that the distal end of the tube is located in the intestines. A pH above 7 is an indication that the distal end of the tube is located in the respiratory tract. Obtain an x-ray of the client's chest and abdomen is correct. Radiological examination is the most reliable method of verifying the placement of a client's NG tube.

29. A RN is reviewing the medical record of a client is postoperative. Based on the info in the medical record, which of the following actions should the RN take first?

Obtain a RX for IV fluids The greatest risk to this client is injury from fluid volume deficit. Therefore, the first action the nurse should take is to contact the provider for a prescription to initiate IV fluid infusion. The client has assessment findings that indicate fluid volume deficit, such as an increased urine specific gravity, a decreased blood pressure, an increased temperature, and a weak pulse. The client also has increased fluid output with decreased intake as well as concentrated urine. To prevent further fluid volume deficit, the nurse's priority action is to administer IV fluids to the client.

68. A nurse is assessing a female client for a possible breast mass. Which of the following actions should the nurse take?

Palpate the breasts using finger pads while the client is supine. The nurse should use their finger pads to palpate the breasts while the client is supine.

20. A home health nurse is teaching about oral care to the family of a client who is in a coma. Which of the following task should the nurse instruct the family to perform first?

Place the client in a side-lying position The greatest risk to this client is injury from aspiration. Therefore, the first action the nurse should instruct the family to perform is to place the client in a side-lying position. If the client should not be placed in a side-lying position, then the nurse should instruct the family to turn the client's head to the side to allow fluid to run out of the client's mouth.

52. A nurse is providing teaching to a client following a thoracentesis. Which of the following actions should the nurse take?

Position the client on the unaffected side. The nurse should position the client on the unaffected side to help facilitate expansion of the affected lung. Some facility protocols recommend that the nurse should raise the head of the bed to 30° for at least 30 min to facilitate expansion of the affected lung & ease of breathing. INCORRECT: Measure the client's abdominal girth at the level of the umbilicus. The nurse should measure the client's abdominal girth following an abdominal paracentesis, rather than a thoracentesis. Leave the puncture site open to air. The nurse should apply a small, sterile dressing over the puncture site.

27. RN is assessing a client who has an NG tube and is receiving continuous enteral feedings. The nurse auscultates coarse crackles in the client's lungs. After discontinuing the feeding, which actions should the RN take next?

Position the client on their side The greatest risk to this client is aspiration from possible dislodgment of the NG tube and aspirated stomach contents into the respiratory tract. Therefore, the priority nursing action to decrease exacerbation of the condition is to position the client on their side.

23. A nurse is moving a client up in bed with assistance of another nurse. Which of the following actions should the nurse take?

Positions the client's arms across their chest. The nurse should position the client's arms across their chest to minimize friction during movement and prevent injury.

5. A nurse is preparing to notify the provider about a change in a client's status. Which of the following information should the nurse plan to include in the "background" portion of the SBAR communication tool?

Previous treatments The nurse should include previous treatments in the "background" portion of the SBAR communication tool. Other information the nurse should include in the "background" portion is the client's admission history, diagnosis, pertinent medical history, and code status. The nurse should include physical findings in the "assessment" portion of the SBAR communication tool. The nurse should include questions regarding client care in the "recommendation" portion of the SBAR communication tool. The nurse should include the client's present condition in the "situation" portion of the SBAR communication tool.

32. A charge nurse is providing an in-service about client advocacy to a group of newly licensed nurses. Which of the following examples should the nurse include?

Requesting a social services consult for a client who states they cannot afford their medications Requesting a social services consult for a client is an example of advocacy. The nurse is protecting the client's health by providing resources that will assist the client to receive their prescribed medications. Ensuring that all clients receive equal treatment is an example of justice. Other examples of justice include discussion about hospital location, services provided, and health insurance. Another example of justice is ensuring fairness related to organ transplants. Instructing a client about how to apply antiembolic stockings is a form of teaching rather than advocacy. Witnessing informed consent is a legal responsibility of the nurse rather than an example of advocacy. The nurse must verify that the client is competent and understands the procedure being performed.

47. A nurse is preparing to administer ophthalmic drops to a client. Which of the following actions should the nurse take?

Rest the dominant hand on the client's forehead while instilling the drops. Ask patient to look at ceiling. Rest dominant hand on patient's forehead This action stabilizes the nurse's hand & ensures that the hand will move with the client if they move suddenly. This simple precaution reduces the risk of striking the client's eye with the dropper and injuring it. The nurse should hold the medication dropper 1 to 2 cm (0.4 to 0.8 in) above the conjunctival sac. With this distance, the client is less likely to blink. Therefore, the eye drop is instilled more efficiently. It is also important to not touch the conjunctival sac or cornea. The nurse should never instill an eye medication directly onto the cornea due to the high risk for injury. Instead, the nurse should expose the lower conjunctival sac by drawing down the skin over the client's cheekbone. The nurse should then instill the prescribed number of drops onto the lower conjunctival sac. The nurse should help the client assume a comfortable position, either sitting or lying, with their head tilted backward & looking up at the ceiling.

3. A nurse is planning care for a client who has dysphagia and is at risk for aspiration. Which of the following referrals should the nurse make?

Speech-language pathologist The nurse should recommend a referral for a client who has dysphagia to a speech-language pathologist. Clients who have dysphagia have difficulty swallowing and are at risk for aspiration. The speech-language pathologist can perform a swallow study to determine the extent of the client's dysphagia and work with the client to develop new swallowing techniques.

53. Thoracentesis procedure

Thoracentesis is the insertion of a large-bore needle through the chest wall into the pleural space to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication. The patient is positioned sitting upright, leaning on an overbed table with feet supported. The skin is cleansed & a local anesthetic (lidocaine) is injected subcutaneously. A percutaneous catheter may be left in to allow further drainage of fluid. Chest x-ray or ultrasound images are used to determine the optimal puncture site. The skin is cleansed with an antiseptic solution & injected with a local anesthetic. The thoracentesis needle is inserted into the intercostal space. Usually no more than 1000 to 1200 mL of pleural fluid is removed at one time. Rapid removal of a large volume can result in hypotension, hypoxemia, or reexpansion pulmonary edema. A chest x-ray may be done after the procedure to assess for complications, such as pneumothorax. During & after the procedure, monitor vital signs & pulse oximetry. Observe the patient for respiratory distress.

70. A nurse is performing a health screening for a client. Which of the following findings should indicate to the nurse that the client is at risk for coronary artery disease?

Triglyceride 180 mg/dL A triglyceride level of 180 mg/dL is outside the expected reference range of 40 to 160 mg/dL for a male client and 35 to 135 mg/dL for a female client, which places the client at risk for coronary artery disease.

30. A RN is assessing an older adult client who has become increasingly confused and agitated in the last 48 hrs. Which of the following conditions should the nurse expect?

UTI According to evidence-based practice, the nurse should expect the client who has a urinary tract infection to become increasingly confused and agitated. Confusion and agitation in older adult clients often result from a systemic infection, such as a urinary tract infection or pneumonia.

66. A nurse in an operating room is performing surgical hand hygiene. Which of the following actions should the nurse take?

Use a nail pick to clean the fingernails under running water. Large amounts of microorganisms can collect in dirt and organic material under fingernails. Scraping out this material and ensuring its disposal via running water is essential for surgical hand hygiene.

42. A nurse is caring for a client who has suspected clonus. Which of the following actions should the nurse take to assess for this condition?

Use a reflex hammer. Clonus, an abnormal response, is a continued rhythmic contraction of the muscle with continuous application of the stimulus. The nurse should use a reflex hammer to assess the client for clonus. The reflex hammer causes the muscle to immediately contract due to a two-neuron reflex arc involving the spinal or brainstem segment that innervates the muscle. Administering magnesium sulfate is not a test for clonus. Magnesium sulfate is administered for convulsions, hypomagnesemia, and hypertension. A Romberg test assesses balance, gross-motor function, and equilibrium. Testing the client's gait gives the nurse information about symmetry, walking ability, posture, and balance.

59. A nurse is preparing to transfer a client who weighs 136 kg (300 lb) from a bed to a stretcher with the aid of an assistive personnel (AP). Which of the following actions should the nurse take?

Use an air-assisted transfer device to move the client. The nurse should place an air-assisted device under the client prior to transfers to prevent injury. An air assisted transfer device is an inflatable mattress that minimizes friction to smoothly and efficiently move the client from the bed to the stretcher. In addition, at least two caregivers should assist with the transfer of a client who weighs 136 kg (300 lb).

13. A nurse is caring for a client who had a stroke and is immobile. Which of the following actions should the nurse take to maintain the client's skin integrity?

Use an alcohol-free barrier product The nurse should apply an alcohol-free barrier film to keep the client's skin dry and protect it from the collection of moisture. This action will help to maintain the integrity of the client's skin.

28. A RN is applying a new transdermal patch to a client. Which of the following actions should the RN take?

Wear gloves when applying the patch The nurse should apply the patch while wearing clean gloves to prevent transfer of the medication through the skin.

43. A nurse is caring for a client who is pulling at their abdominal wound drains. The provider prescribes wrist restraints for the client's safety. To which of the following parts of the bed should the nurse secure the restraints?

moveable portion of the bed frame Attaching the wrist restraints to the moveable portion of the bed frame allows the head of the bed to be raised or lowered without causing injury to the client.