505 ATI Final Prep
A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure?
"Are you able to help with your hygiene care?"
A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate?
"Have a seat and let me tell you what has happened."
A nurse is providing teaching to a client who is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching?
"I will disinfect my toothbrush weekly ____________________________________ -Avoid fresh fruits due to acidity -Avoid crowds and contact with ill ppl -Bathe daily
A nurse is educating a family member of a client who is immobile about how to prevent back injury associated with moving the client up in bed. Which of the following statements by the family member should indicate to the nurse that he understands the teaching?
"I will leverage my weight against my wife and shift it as I move her."
A nurse is caring for a client who asks about the purpose of advance directives. Which of the following is an appropriate response by the nurse?
"It indicates the form of treatment a client is willing to accept in the event of a serious illness."
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. The nurse understands that the preoperative teaching regarding pain control has been effective when the client states which of the following?
"It may help me to listen to music while I'm lying in bed."
A client demonstrates anger when the nurse does not respond within 5 min of ringing for the nurse. Which of the following is an appropriate response by the nurse?
"It must be frustrating. I have a few minutes now."
A nurse is preparing to administer oral medications to a client who has dysphagia. Which of the following is an appropriate action by the nurse?
- Offer one medication at a time __________________________________ - Do not use a straw - Bend Chin Downwards
A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedematous coma. How should the nurse transcribe the dosage of this medication in the client's medical record?
0.3mg
A nurse is caring for a client who has an NG tube that is irrigated every 8 hr. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance?
0.9% sodium chloride
A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number.)
107
A nurse is preparing to administer ampicillin 40 mg/kg/day PO divided in equal doses every 6 hr to a toddler who weighs 10 kg. Available is ampicillin oral suspension 125 mg/ 5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number.)
4 mL
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 unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. *Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others.
A nurse is conducting a respiratory assessment for four clients. Which of the following should the nurse recognize as an abnormal respiratory assessment finding?
An adolescent who has visible accessory muscle movement when breathing.
A nurse has just inserted an NG tube for a client. Which of the following assessment findings indicates that the tube is properly positioned?
An x-ray shows the end of the tube above the pylorus.
A nurse is caring for a client who is at risk for hypokalemia. Which of the following foods should be included in the client's diet?
Avocados
A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?
Compare the client's home medications with the provider's prescriptions.
A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?
During the admission process
A nurse is caring for a client who has a terminal illness and is approaching death. The client's respirations are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take?
Elevate the head of the client's bed. *This action promotes postural drainage and also allows maximal chest expansion, which makes it easier for the client to breathe and decreases noisy respirations
A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?
Evaluate electrolytes. *The first action the nurse should take when using the nursing process is to assess the client's electrolytes; therefore, the nurse should evaluate the client's laboratory results, including sodium, potassium, BUN, Hgb, Hct, and protein, to guide the planning of interventions to correct the imbalances.
A nurse is performing a Romberg's test during the physical assessment of a client. Which of the following techniques should the nurse use?
Have the client stand with arms at side and feet together.
A nurse is caring for a client for whom a nasogastric tube is ordered for stomach decompression. Which of the following actions is appropriate when inserting the NG tube?
Have the client take sips of water to promote insertion of the NG tube into the esophagus. ______________________________________ -Place in High Fowlers -Withdraw slightly when pt gags or chokes -Suction should be applied once NG tube placement is verified
A nurse is implementing a plan of care for an older adult client who is at risk for falls. Which of the following is an appropriate nursing action?
Implement a regular toileting schedule. *The nurse should toilet the client every 1 to 3 hr to reduce the risk of falls due to the client ambulating to the bathroom without assistance.
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions falls within the RN scope of practice?
Initiate an enteral feeding through a PEG tube.
Which of the following is the responsibility of a nurse who is caring for a client receiving PCA?
Instruct the family to refrain from pushing the button for the client while she is asleep.
A nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg weakness. Which of the following should the nurse include in the teaching?
Maintain two points of support on the floor. _______________________________________ -Place cane on stronger side of the body -Advance cane while balancing weight on both legs -Advance cane 15-25cm
A client is scheduled for surgery. The intraoperative nurse finds a necklace on the client after anesthesia has been administered. Which of the following interventions should be initiated?
Notify security for placement of the necklace.
A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid?
Orange Sherbet
A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider?
Potassium 5.4 mEq/L
A nurse is reviewing laboratory data for a client who has contusions to the chest wall following a motor vehicle crash. Which of the following values should the nurse report?
SaO2 86%
A nurse is planning care for a client who has dysphagia following a stroke. The nurse should initiate a referral for which of the following therapies?
Speech Therapy
A charge nurse is observing a newly hired nurse prepare a sterile field. Which of the following indicates to the charge nurse that the sterile field is contaminated?
Sterile field is opened on a wet surface. *Opening a sterile field on a wet surface contaminates it because capillary action can wick bacteria through the dressing.
A nurse is caring for a client who is postoperative following colostomy placement. Which of the following findings should the nurse report to the provider?
Stoma appears purple in color.
A nurse is teaching a client about self-administering NPH insulin. Which of the following actions by the client indicates a need for further teaching?
The client inserts the needle at a 30°-angle. *Should be inserted at a 45 to 90 degree angle ____________________________________ -Roll vial between both hands -Hold syringe in place for 5 seconds
A nurse is caring for a client who is refusing a scheduled 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 scheduled blood transfusion.
A nurse is providing instructions for an older adult client who has a prescription for an electric heating pad to his lumbosacral area. Which of the following client statements indicates a correct understanding of the teaching?
"I will remove the heating pad in 30 minutes." *The client should apply the heating pad periodically and for no more than 30 to 45 min at a time to prevent reflex vasoconstriction. Continuous heat application can result in tissue damage.
A nurse is providing discharge instructions to a client who will be using a walker. Which of the following statements by the client indicates a need for further instruction by the nurse?
"I will replace the old throw rug in the kitchen with a new one."
A nurse on an oncology unit is caring for a client who has tears in his eyes and states, "The doctor just told me that I don't have long to live." Which of the following is an appropriate response by the nurse?
"Tell me more about how you're feeling."
Who is at risk of secondary hypertension?
-Pregnant women -Those taking birth control -Those with kidney disease
A nurse is preparing to transfer a client who has right sided weakness from the bed to a chair. Which of the following actions should the nurse take to assist the client? (Order the steps of the process by placing the letters in the correct sequence.)
1) Ask the client if he can bear weight 2) Position the chair on the left side of the bed 3) Have the client sit and dangle his feet at the bedside 4) Use the stand and pivot techniques to move the client to the chair
A nurse is caring for a client who has taken in 2,600 mL of fluids in 24 hr. Which of the following is an expected output for the client?
2,500 mL *The client's output should approximate the daily fluid intake. Therefore, an output close to 2,600 mL is expected.
A nurse is transcribing new orders for insulin based on a client's blood glucose readings. The nurse notes that the provider did not write the frequency for checking blood glucose levels on the order sheet. Which of the following is the appropriate action by the nurse?
Call the health care provider to determine the frequency of blood glucose checks.
A nurse is caring for a young child who is prescribed a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take?
Examine personal values about the issue.
A nurse contacts the facility's interpreter to explain a therapeutic procedure for a client who does not speak English. Which of the following guidelines should the nurse follow when working with the interpreter?
Explain the purpose of the communication to the interpreter. __________________________________ -Speak in a clear and normal voice at a normal speed -Look at the patient while speaking -Avoid using gestures in place of words
A nurse is preparing to transfer a client from the bed to the stretcher using a slide board. Which of the following actions should the nurse take?
Lower the head of the bed. _______________________________________ -Cross arms over chest -Position bed slightly higher than stretcher -Flex neck during transfer to avoid head injury
A nurse is performing assessments on clients of various ages. Which of the following is an appropriate physical assessment technique?
Measurement of an adult's blood pressure with a cuff whose bladder surrounds 80% of the client's arm circumference
A nurse is caring for a client who has left-sided paralysis after a cerebrovascular accident. The client is unable to bear his own weight. Which of the following actions is an appropriate method to move the client from his bed to his wheelchair?
Use a hydraulic lift and have an AP help move the client.
A nurse is providing teaching to a client about techniques to promote sleep. Which of the following instructions should the nurse include in the teaching?
Consume a light snack of carbohydrates at bedtime.
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?
Make sure the client wears a mask when outside her room if there is construction in the area. *An allogeneic stem cell transplant compromises the client's immune system, putting her at high risk for infection. The client will need protection from breathing in any pathogens in the environment.
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 negative pressure room. -Wear gloves when assisting the client with oral care. -Wear a surgical mask when providing client care. -Use antimicrobial sanitizer for hand hygiene.
A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. After which of the following observations should the nurse remove the IV catheter?
Swelling and coolness are observed at the IV site. *Swelling and coolness are indications of IV infiltration, which warrant removing the catheter and restarting the IV infusion with a new catheter at a different site.
A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?
"I am available to talk if you should change your mind." *When a client does not wish to share his feelings with the nurse, it is important for the nurse to convey a willingness to be available when he needs her.
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 caring for a client who cannot bear weight on his fractured ankle. Which of the following client statements indicates a need for further teaching regarding three-point gait crutch walking?
"When I get out of a chair, I'll hold both crutches on the side next to my weak leg." *When getting out of a chair, a client should hold both crutches on the unaffected side.
A nurse is caring for a client who has recently started using a hearing aid worn behind the ear. Which of the following client statements indicates to the nurse that he understands the use of this assistive device?
- "I will be sure to remove my hearing aid before taking a shower." _______________________________________ - Can be easily dislodged during exercise - Whistling during insertion can be caused by improper fit and build up of cerumen
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
Administer the medication with the needle at a 45° angle. *The nurse should insert the needle for a subcutaneous injection at a 45° to 90° angle.
A nurse is working with an Orthodox Jewish client who has just given birth to a stillborn infant. Which of the following interventions is appropriate?
Ask the family if there are any special rituals that they would like to follow at this time. *The nurse should ask the family if there are any special rituals because culture can influence rituals people follow when a death occurs.
Which of the following should indicate to a nurse the need to suction a client's tracheostomy?
Irritability _________________ -Hypertension -Pallor -Tachycardia
A nurse is completing an admission assessment of an older adult client. Which of the following findings is a potential indication of abuse?
Presence of bruises on the arms in various stages of healing
A nurse is caring for a client and performing blood glucose monitoring. Which of the following is an appropriate nursing intervention?
Wipe away the first drop of blood from the client's finger. _______________________________________ -Massage figer in a proximal to distal direction -Puncture the lateral side of the client's finger -Hold finger in dependent position
A nurse is performing a spiritual assessment on a client newly admitted to the unit. The nurse recognizes that the purpose of performing a spiritual assessment is to
identify the client's religious and spiritual beliefs, affiliations, and practices.
A nurse is caring for a client who is receiving medication intramuscularly. The nurse should recognize that this route
increases infection rates.
A nurse is caring for a client with a diagnosis of terminal cancer. The nurse understands that the client is ready to hear information regarding palliative care when the client states which of the following?
"I want you to tell me about measures available to keep me comfortable."
A nurse is preparing to administer morphine 4 mg IV bolus to a client. Available is morphine 5mg/mL. Which of the following is an appropriate nursing intervention?
Have a second nurse witness the disposal of remaining medication.
A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the following locations should the nurse place the bell of the stethoscope?
Second intercostal space at the left sternal border *This is the area over the pulmonary valve. The nurse should listen over this, the apex, and the other valve areas for rate and rhythm, as well as gallops and murmurs.
A nurse is preparing a change-of-shift report. Which of the following is an appropriate method to communicate continuity of care?
Situation, Background, Assessment, and Recommendation (SBAR)
A nurse is planning to delegate client care to an assistive personnel (AP). Which of the following factors is most important for the nurse to consider before delegating care?
The facility's job description for the AP
A nurse is planning to insert a peripheral IV catheter in an older adult client. Which of the following actions should the nurse plan to take?
- Position the client's arm in the dependent position _____________________________________ - Insert Iv at 15-30 degree angle - Clip hair around site, do not shave it
A nurse manager is overseeing the care of a unit. Which of the following should the nurse manager identify as a violation of HIPAA guidelines?
A nursing student consults a former classmate to assist with her documentation.
A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?
"Is your pain sharp or dull?"
A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy?
A client who has asthma *Some essential oils can cause bronchospasm; therefore, the nurse should consult the client's provider before using this therapy.
A nurse is giving an end-of-shift report about a client admitted earlier that day with pneumonia. Which of the following pieces of information is most essential to provide?
Breath Sounds *When using the airway, breathing, circulation approach to client care the nurse determines the priority information to provide are the client's breath sounds.
A nurse is reviewing the medication documentation of a newly hired nurse. Which of the following images shows correct documentation?
Guidelines for Safe Medication Practices - No zeros afters decimal point -Do not use U and sq -Write zero before a decimal point
A nurse is transcribing new prescriptions for a client. Which of the following prescriptions is accurately transcribed by the nurse?
Morphine 4 mg IV bolus every 2 hr PRN for incisional pain
A nurse is checking a client's blood pressure to assess for orthostatic hypotension. Which of the following actions should the nurse take?
Obtain blood pressure 2 min after assisting the client to a sitting position. *The nurse should obtain the blood pressure with the client in first the supine, then the sitting and finally the standing positions. The nurse should wait 1 to 3 min after each position change.
A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions is appropriate for the client and family?
Use tracheostomy covers when outdoors. *Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles.
A nurse is caring for a client who needs a 24-hr urine collection initiated. Which of the following client statements indicates an understanding of the procedure?
"I flushed what I urinated at 7 a.m. and have saved all urine since." *For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings. ______________________________________ -Collect urine that is free of feces -Place urine in container immediately and keep on ice or in fridge
A hospice nurse is providing end-of-life care to a client who has terminal lung cancer. The client states, "I am so tired and afraid of not being able to catch my breath." Which of the following is an appropriate response by the nurse?
"I will be able to give you a medication to help your breathing." *The nurse can administer bronchodilators, inhaled steroids, or opiates to promote comfort and ease breathing, air hunger, and apprehension for clients who are terminally ill and are experiencing shortness of breath.
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." *According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore with the client opportunities for mastering the developmental tasks of this stage, such as volunteering and mentoring young people.
A nurse is speaking with the parent of an infant who has a cardiac defect. After the parent expresses concern, which of the following is an appropriate response?
"Tell me a about your baby while I bathe her." *Open-ended statements prompt clients to describe situations and express what is important to them.
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." *With this statement, the nurse offers to provide the information the client needs in a direct and simple way.
A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give the client?
"We need to document the exact medication you were taking because you might be allergic to it." *If there is any possibility that a client had an allergic reaction to a medication, it is imperative that the provider be aware and does not prescribe that same medication again. Subsequent allergic reactions could be life-threatening.
A nurse receives report on a client who is receiving 0.9% sodium chloride at 125 mL/hr. When the nurse performs the initial assessment she notes that the client has received 80 mL for the last 2 hr. Which of the following actions should the nurse take first?
- Check the IV tubing for occlusion ______________________________________ After... - Reposition the client - Document the IV intake - Request new IV fluid
A 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 give to the client and his family?
- Check the cord routinely for frays or tearing. -Consider purchasing a generator for power backup. -Monitor for signs of hypoxia. _________________________ -Keep 8ft away from heat source -Choose clothing and bedding that does not produce static electricity (cotton)
A nurse in a clinic is providing teaching to an older adult client about nutritional considerations associated with aging. Which of the following should the nurse include in the teaching?
- Protein intake is often inadequate in older adults _____________________________________ - Vitamin and mineral requirements increase -Thirst declines resulting in dehydration
A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an AP? (Select all that apply.)
-Assist the client with a partial bed bath -Measure the client's BP after the nurse administers an antihypertensive medication -Use a communication board to ask what the client wants for lunch
A nurse is monitoring an older adult client who is receiving IV fluid therapy. Which of the following assessment findings should the nurse recognize as an adverse effect of excess fluid therapy? (Select all that apply.)
-Edema -Crackles in lungs -Elevated BP -Jugular Venous Distention
A nurse is caring for a client with an order for 5 units of Regular insulin and 10 units of NPH insulin to be mixed together and administered subcutaneously. List the correct order of steps for this procedure. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.)
1) Inject 10 units of air into the bottle of NPH insulin 2) Inject 5 units of air into the bottle of Regular insulin 3) Withdraw the correct dose of Regular insulin from the bottle 4) Withdraw the correct dose of NPH insulin from the bottle
A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?
8 oz of ice chips *The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. Four oz of liquid water equals 120 mL of fluid.
A nurse working in the emergency department is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following individuals' signatures may the nurse legally witness? (Select all that apply.)
A 16-year-old client who is married is correct. A minor who is married is emancipated and can give consent for his own treatment. A 27-year-old client who has schizophrenia is correct. An adult client who requires psychiatric care can give consent for her own care unless the court has determined the client to be incompetent. An adoptive parent who brings in his 8-year-old son is correct. The adoptive parent of a child is a parent and legal guardian and can sign to give consent for the child's care. A 17-year-old mother who brings in her toddler is correct. A custodial parent who is a minor can legally give consent for the medical treatment of her child.
A nurse is checking blood pressures at a community health screening. Which of the following clients is at high risk for primary hypertension?
A client who has an elevated LDL
A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
Allow the adolescent to make decisions regarding his daily routine.
A nurse is performing a skin assessment of a client who has a lesion on his anterior thigh and expresses concern about skin cancer. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy?
An uneven shape *An uneven shape is a possible indication of a cutaneous malignancy. Each half of the lesion looks different from the other half.
A nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following foods should the nurse suggest that the client add to his diet?
Avocados *Avocados contain no cholesterol. Plant foods contain no cholesterol; foods from animals contain cholesterol.
A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?
Apply intermittent suction when withdrawing the catheter. *The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. Suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise.
Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client?
Apply intermittent suction when withdrawing the catheter. _______________________________________ -Insert while pt is inhaling -Discard after use -Hold with dominant hand with sterile glove
A nurse is caring for a client with cancer who lives at home with her spouse. The spouse tells the nurse that the client is in pain "all of the time." Which of the following actions is most important for the nurse to take?
Ask the client to rate her pain.
A client is receiving continuous tube feeding via NG tube. The client has 3 episodes of vomiting in 12 hr. Which of the following actions should the nurse take?
Aspirate for residual. *The nurse should aspirate for residual if vomiting occurs, as this can indicate the client is not absorbing the nutrients.
A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?
Assess the client for orthostatic hypotension. *The first action the nurse should take using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting her to sit and dangle her feet on the side of the bed. The nurse should assess her for dizziness and a significant drop in blood pressure before assisting her to stand and transfer into the chair.
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter should be irrigated?
Bladder scan reveals 525 mL of urine. *A client who has an indwelling urinary catheter should have continuous urine flow without an accumulation of urine in the bladder; therefore the nurse should irrigate the catheter to resolve a blockage.This finding may indicate a blockage of the catheter and would require irrigation.
A nurse is caring for a preschooler who has heart disease. The provider prescribes digoxin at the maximum adult dose. Which of the following actions should the nurse take?
Call the provider to discuss concerns regarding the dosage for the child.
A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein?
Cheddar cheese *Complete proteins contain enough of all nine of the essential amino acids that help maintain and promote nitrogen balance. Cheese, poultry, and fish are examples of foods that are good sources of complete protein.
A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?
Clean sutures along with the incision site.
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 wound from the center outwards. _______________________________________ -Use clean gloves to remove dressing -Use body temperature irrigation solution -Use 30-60mL syringe
A nurse finds a client on the floor upon entering the client's room. The roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following is correct documentation of this incident?
Client found lying on the floor *Documentation must contain descriptive, objective information about what the nurse actually observes, without any opinions or judgment about motive or cause.
A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile. Which of the following information should the nurse include in the teaching?
Have family members wear a gown and gloves when visiting. _______________________________________ - Must wash hands with soap and water
A nurse is planning teaching for a client who has a new diagnosis of type 1 diabetes mellitus about insulin self-administration. Which of the following actions should the nurse take first?
Determine the client's learning style.
A nurse is caring for a postoperative adult client who refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action?
Determine the reasons why the client is refusing to use the incentive spirometer.
A client is reporting pain at the insertion site of his IV catheter. The nurse observes a red line extending outward from the insertion site. Which of the following actions should the nurse take first?
Discontinue the infusion *A red line extending outward from the insertion site indicates the client is at greatest risk to the client is further injury to the vein; therefore the first action the nurse should take is to discontinue the infusion.
Following administration of levothyroxine 125 mcg at 0800, the nurse discovers the medication was given to a client for whom it was not prescribed. Which of the following is the correct way to document this error in the medical record of the client who received the medication?
Levothyroxine 125 mcg given at 0800. Provider notified.
A client who is nonambulatory notifies the nurse to tell her that his trash can is on fire. After confirming the fire, which of the following actions should the nurse take next?
Evacuate the client. *According to the RACE mnemonic, the first action in response to a fire is to rescue the client, moving to a safe area.
A nurse is preparing to care for a client who has methicillin-resistant Staphylococcus aureus (MRSA) in the lungs. In addition to a gown and gloves, the nurse will need which of the following equipment in order to provide care?
Face Shield
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 displays the appropriate mm Hg to which the nurse should inflate the cuff when obtaining the blood pressure?
For accurate blood pressure measurement, the nurse should inflate the cuff 30 mm Hg beyond the last measurement on the manometer at which she was able to palpate a pulse.
A nurse is preparing to administer meperidine 80 mg IM from a 100 mg prefilled syringe. After the injection, which of the following is an appropriate action by the nurse?
Have another nurse witness the disposal of the excess medication. *A second nurse should witness disposal of the unused medication because meperidine is a controlled substance.
A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take?
Insert the IV catheter without using a tourniquet. *The nurse should insert the IV catheter using the tourniquet minimally or not at all to avoid injury of fragile skin or veins.
A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence?
Instruct the client to focus on gradually resuming self-care tasks.
A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. Which of the following actions should the nurse take?
Make sure two fingers can fit under the sleeves. *Less space than two fingers between the sleeves and the legs can inhibit circulation when the sleeves inflate.
A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following should the nurse suggest to promote neck rotation?
Move her head from side to side
A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to take the client's vital signs every 15 min and call him back in 1 hr. From a legal perspective, which of the following actions should the nurse take next?
Notify the nursing manager *The greatest risk to the client is not receiving timely intervention for this deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure the necessary care. ______________________________________ Afterwards you can: - document the provider's statement -Complete an incident report - Consult the facility's risk manager
A nurse is preparing to perform nasopharyngeal suctioning for a client who is unable to cough up excessive secretions. Which of the following actions is appropriate?
Perform suctioning while removing the catheter. ----------------------------- -Use sterile technique -Insert catheter when the pt takes a deep breath -Apply suction for up to 15 seconds
A nurse is caring for four clients. Which of the following actions should the nurse take to prevent the spread of infection?
Place a client who has tuberculosis in a room with negative-pressure airflow.
A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next?
Place a warm compress over the IV site. ____________________________________ -Document after -Contact the provider -Prepare to insert a new IV
A nurse is caring for a client who is having difficulty voiding following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take?
Pour warm water over the client's perineum. ______________________________________ -Increase fluids
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. *Evidence-based practice supports a flow rate of 1 to 6 L/min via nasal cannula. Rates above 6 L/min force clients to swallow air excessively without increasing their fraction of inspired oxygen (FiO2).
A nurse is caring for a client who is combative in the emergency department. The provider orders wrist restraints after the client attempts to assault the admitting nurse. Which of the following actions is appropriate for the nurse to take?
Remove each restraint one at a time every 2 hr. _____________________________________ - 2 fingers widths -Quick release tie -Secure to stationary part of the bed frame
A nurse is obtaining a health history from a client who has hearing loss. Which of the following actions by the nurse is appropriate?
Rephrase rather than repeat misunderstood information.
A nurse is caring for a client who had a fasting blood sugar drawn at 0600. The client tells the nurse, "All I have had since midnight is water and some juice." Which of the following nursing actions is appropriate?
Reschedule this lab test for the next morning. *The nurse will need to reschedule this lab test because in order to ensure accuracy of a fasting blood sugar, the client should fast for 8 to 12 hr before the sample is drawn.
A nurse is reviewing a protocol in preparation for suctioning a client who has a new tracheostomy. Which of the following is an appropriate action for the nurse to take?
Select a suction catheter that is half the size of the lumen ______________________________________ -Pre oxygenate with 100% -Lubricate catheter with sterile water or NS -Suction should be set at 80-120 mmHg
A nurse is caring for a client in the immediate postoperative period. The nurse should recognize that which of the following positions maximizes the effectiveness of incentive spirometry?
Semi-Fowler's (30 degrees)
A nurse is reviewing the medical records for a client who has a pressure ulcer. Which of the following is an expected finding?
Serum albumin level of 3 g/dL *A serum albumin level below 3 g/dL indicates protein deficiency, putting the client at risk for pressure ulcer formation and poor wound healing.
A nurse is developing a plan of care for an African-American child who is preschool-age and experiencing pain. Which of the following is the best way for the nurse to assess the child's pain?
Show the child the Oucher Pain Scale
A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse recognize as infiltration?
Skin Blanching
A nurse in a long-term care facility notes that a client coughs frequently during meals and suspects dysphagia. The nurse should assess the client for which of the following behavioral signs of dysphagia?
Storing food in the mouth *Clients who have dysphagia tend to have incomplete emptying of the food from their mouth. This can lead to collections or "pockets" of food left in the mouth, which they tuck in front of the buccal surfaces of the gums. ______________________________________ -Drool or leak food
A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?
The family member washes out the feeding bag with warm water once every 24 hr. *The family member should wash out the feeding bag at each refilling throughout the day (every 4 to 8 hr) and replace it with a new feeding bag every 24 hr to prevent bacterial contamination. Therefore, the nurse should reinforce this information with the family member.
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. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer.
The nurse is observing a newly licensed nurse who is preparing a sterile field for a dressing change. Which of the following actions by the newly licensed nurse should cause the nurse to intervene?
The newly licensed nurse places the cap of the sterile saline bottle on the sterile field. *The newly licensed nurse should place the cap with the sterile side up on a clean surface because the outer edges are unsterile and will contaminate the sterile field.
A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection?
Thread the IV catheter so that the hub rests at the insertion site.
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 this client?
Use a bed exit alarm system
A nurse is planning care to promote improved self-feeding for a client who has a visual impairment. Which of the following interventions should the nurse include in the plan of care?
Use a clock pattern to describe food on the plate to the client. ______________________________________ - Use large handled adaptive utensils
A nurse is planning to teach a preschool child how to properly use a metered dose inhaler. Which of the following methods is appropriate for this child?
Use role play and imitation when explaining.
A nurse is evaluating a client who has right leg weakness and is learning to use a rubber-tipped standard walker. Which of the following actions by the client indicates proper use of the walker?
Uses a lifting motion to move the walker _______________________________ -Advance walker then take steps -Keep elbows flexed
Which of the following precautions is important to take when a nurse is caring for a client who has diarrhea due to Shigella?
Wash hands before and after client contact
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. *The nurse should affix linens or blankets around the head, foot, and side rails of the bed to pad them and prevent injury for a client who has been having frequent tonic-clonic seizures.
To prevent foot drop in a client who has decreased mobility, the nurse should
place the client's feet against a foot board perpendicular to the mattress. _______________________________________ -Place pillow under client's lower legs, not the knees -Place a trochanter roll under the butt and alongside hips to reduce external rotation of hips