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A nurse is calculating the intake of a client during the past 9 hr. The client's intake includes lactated Ringer's IV at 150 mL/hr, cefazolin 2 g IV intermittent bolus in 100 mL of 0.9% sodium chloride, two units of packed RBCs of 275 mL and 250 mL; two IV bolus infusions of 250 mL of 0.9% sodium chloride, famotidine 20 mg IV intermittent bolus in 50 mL of 0.9% sodium chloride. How many mL of intake should the nurse record?

2525 mL

A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection into the client's ventrogluteal muscle?

90° Rationale: With this angle, the nurse will deposit the medication deeply into the muscle to ensure rapid absorption of the medication due to the vascularity of muscle tissue.

Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?

Ask the client's full name and date of birth. Rationale: The nurse must use two identifiers before administering medications. Acceptable identifiers include the client's name, date of birth, identification number within the facility or system, telephone number, and photo identification card or badge.

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

Droplet Rationale: The nurse should initiate droplet precautions for clients who have infections that spread by droplets larger than 5 microns, including mumps, streptococcal pharyngitis, and pertussis.

A nurse is preparing to administer an intramuscular (IM) injection of meperidine to a client. Which of the following is the priority assessment the nurse should complete?

Respiratory rate Rationale:Airway, breathing, and circulation are the priority focus of the nurse at this time. Meperidine can cause respiratory depression and the client's respiratory rate should be monitored prior to administering this medication.

A nurse caring for a client is using active listening skills. Which of the following actions should the nurse take?

Use intermittent eye contact. Rationale: The nurse should establish intermittent eye contact and maintain it during active listening. It demonstrates interest is what the client is saying.

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?

Wash the area of the puncture thoroughly with soap and water. Rationale: The greatest risk to this client is injury from any bloodborne pathogens on the needle; therefore, the first action the nurse should take is to provide immediate first aid by scrubbing the area thoroughly with soap and water.

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

"Information about a client can be disclosed to family members at any time." Rationale: This statement reflects a need for further teaching. Privacy relates to the client's rights over the use and disclosure of his or her own personal health information.

A nurse intercepts a messenger at the nurses' station who has a flower delivery for a client on the unit. As the nurse accepts the flowers, the messenger says, "I know Mrs. Welch from the neighborhood. What happened to her?" Which of the following responses should the nurse provide?

"It's my responsibility to remind you that we have to respect our clients' privacy." Rationale: This therapeutic response provides clarification to the messenger that the hospital staff cannot disclose information about clients.

A nurse is readmitting a client to the medical unit after a transfer to ICU following self-administration of an overdose of medication. The client looks down at the floor and mumbles, "Hello." Which of the following responses should the nurse make?

"Tell me a little more about what happened." Rationale: This response is an example of the therapeutic communication technique of providing general leads. It encourages the client to express his feelings and gives the nurse additional data about what is troubling him.

A nurse is preparing to administer naproxen 500 mg PO BID for a client who has osteoarthritis. The amount available is naproxen 125 mg/5 mL oral suspension. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

20 mL

A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and a positive Mantoux test. Room 208 is a private, negative-pressure airflow room; room 212 is a semi-private, positive-pressure airflow room; 214 is a negative-pressure, semi-private room; and room 216 is a private, positive-pressure airflow room. To which of the following rooms should the nurse assign the client?

208 Rationale:A client who has or might have tuberculosis requires airborne precautions. That means a private room with negative-pressure airflow. Room 208 is the only one of these options that fits these requirements.

A nurse is caring for a group of clients on a medical-surgical unit. Which of the following situations requires that the nurse wear gloves? (Select all that apply.)

A. Emptying urine from an indwelling urine collection bag B. Providing oral care C. Changing an ostomy pouch D. Delivering a food tray to a client who has AIDS E. Placing oral medication tablets into a client's hand Answer A,B,C

A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective eye equipment? (Select all that apply.)

A. Providing hygiene care to a client who is HIV-positive B. Emptying a urinary drainage bag for a client who has pneumonia C. Irrigating a client's abdominal wound D. Transporting a cerebrospinal fluid specimen to the laboratory E. Suctioning a client's new tracheostomy tube Answer C,E

A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)

A. Repeat the order back to the provider. B. Question any part of the order that is unclear or inappropriate. C. Transcribe the order into the client's health record. D. Obtain the provider's signature within 8 hr. E. Implement a recorded order message if the nurse can hear and understand it clearly. Answer A,B,C

A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?

An older adult who has a hip fracture and is in Buck's traction Rationale:According to evidenced-based practice, this client has multiple risk factors for skin breakdown: the aging process (decreased muscle mass, thin and fragile skin) and the limitation of movement due to traction. Therefore, this client is at the greatest risk for skin breakdown.

A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?

Apply 4 to 5 mL of liquid soap to the hands. Rationale: The nurse should apply 4 to 5 mL of liquid soap to the hands to ensure an adequate amount is available to produce lather and kill microorganisms.

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

Assess the apical pulse for a full minute. Rationale: For clients who have a regular pulse and no cardiovascular problems, the nurse should count the apical pulsations for 30 seconds and multiply by 2. For this client, the nurse should count for 60 seconds. This will help the nurse determine the regularity or irregularity of the heart.

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?

Atelectasis Rationale:Atelectasis is the collapse of part or all of a lung by blockage of the air passages (bronchus or bronchioles) or by hypoventilation. Prolonged bedrest with few changes in position, ineffective coughing, and underlying lung disease are risk factors for the development of atelectasis.

A nurse is caring for a client in the emergency department who, 2 hr earlier, severed the tip of a finger in an accident. During the assessment, the nurse detects a strong smell of alcohol from the client's breath. For which of the following findings should the nurse assess first?

Date of the client's last tetanus immunization Rationale: The greatest risk to this client is injury from infection with Clostridium tetani; therefore, the priority assessment the nurse should perform is to determine whether the client will require a tetanus immunization by identifying the date the client last received one. An adult should have a tetanus booster immunization every 10 years and after any severe or dirty wound.

A nurse is removing personal protective equipment (PPE) after giving direct care to a client who requires isolation. Which of the following PPE items should the nurse remove first?

Gloves Rationale:According to evidence-based practice, the nurse should remove the most contaminated item, the gloves, first.

A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client?

Kyphosis Rationale:Kyphosis, a forward "stooping" posture with a loss of height, is an angulation of the posterior curve of the thoracic spine, usually a result of osteoporosis. It is most common in older adults and increases with aging and vertebral fractures.

A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?

Move the client to a room closer to the nurses' station. Rationale: This will make it easier for the staff to observe the client, should the client behave in an unsafe manner.

A nurse is preparing a sterile field. Which of the following actions should the nurse perform when opening the sterile pack?

Reach around the pack and open the top flap away from the body. Rationale: The nurse should pull the uppermost flap away from her body, grasping it from the side to avoid reaching over the sterile field and contaminating it.

A nurse is working with an assistive personnel (AP) while caring for a surgical client who is 1 day postoperative. Which task should the nurse take responsibility for completing?

Removing the abdominal dressing Rationale: The nurse cannot delegate assessment, diagnosis, planning, or evaluation because these are steps of the nursing process that require nursing judgment. When removing an abdominal dressing, the nurse should assess the surgical wound and determine if any further action is needed. This could include notifying the provider and using sterile technique to complete a dressing change.