ATI Challenge 2
A nurse is caring for a client who is taking naproxen (Naprosyn) following an exacerbation of rheumatoid arthritis. Which of the following comments by the client requires further discussion by the nurse? a. "I signed up for a swimming class." b. "I've been taking an antacid to help with indigestion." c. "I've lost 2 pounds since my appointment 2 weeks ago." d. "The naproxen is easier to take when I crush it and put it in applesauce."
"I've been taking an antacid to help with indigestion." NSAIDs, like naproxen, can cause serious adverse gastrointestinal reactions such as ulceration, bleeding, and perforation. Warning manifestations such as nausea or vomiting, gastrointestinal burning, and blood in the stool reported by the client require further investigation by the nurse. The client might be taking an antacid because he is experiencing one or more of these manifestations.
a clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). which of the following findings should the nurse expects?
A dry, red rash across the bridge of the nose and on the cheeks. A "butterfly" rash that is dry, red, and raised is characteristic of SLE.
A nurse is caring for a client who is receiving oxygen at 2 L per minute via nasal cannula. The nurse recognizes the client is receiving which of the following inspired oxygen concentration? A. 28% B. 36% C. 70% D. 50%
A. 28%
A nurse in a clinic is talking with a client who has a new diagnosis of osteoarthritis. The nurse should anticipate that the client will require teaching about which of the following medications? A. Acetaminophen B. Celecoxib C. Cyclobenzaprine D. Ibuprofen
A. Acetaminophen According to the American Pain Society, acetaminophen is the primary drug of choice for treating osteoarthritis. The provider would likely begin with this medication.
A nurse is teaching a client who is to begin long-term therapy with prednisone to treat rheumatoid arthritis. The nurse should instruct the client take which of the following supplements while taking this medication? A. Calcium and vitamin D B. Biotin in vitamin B2 C folic acid and vitamin C D. Pantothenic acid and vitamin B6
A. Calcium and vitamin D Long-term use of glucocorticoids, such as prednisone, places the client at risk for osteoporosis. The nurse should instruct the client to take calcium and vitamin D supplements to reduce this risk.
A nurse is providing discharge teaching for a client who is postoperative following a simple mystic to me. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include? A. Do not apply heat to the area of radiation B. Do not wash the area of radiation C. Use an antibiotic appointment to prevent skin breakdown D. Lubricate the skin with hypo allergenic lotion
A. Do not apply heat to the area of radiation
A nurse is orienting a newly licensed nurse about documentation of a clients information in electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of the documentation.? A. Documentation is a communication tool for the interprofessional healthcare team B. Documentation provided information to the client about financial charges for care provided C. Documentation provides information for the client audit D. Documentation allows providers to monitor the nurses activities
A. Documentation is a communication tool for the interprofessional healthcare team
A nurse is reviewing the laboratory results of a client who has a key radiation syndrome and notes the client has leukopenia. Which of the following assessment findings should the nurse identify as being consistent with leukocytosis? A. Fever B. Bruising C. Pallor D. Petechiae
A. Fever
A nurse in a mental clinic is providing teaching to an older adult client who has osteoarthritis that is affecting her knees. Which of the following statements by the client indicates an understanding of the teaching? A. I can use either heat or ice to help relieve my discomfort B. Ibuprofen is the first step in medication therapy for osteoarthritis C. I should limit physical activity to prevent further injury D. I will elevate my legs by placing two pillows under my knees when I go to bed
A. I can use either heat or ice to help relieve the discomfort The nurse should reinforce that different treatment modalities, such as heat or cold therapy, can be tried to determine which one is more effective for the client. Heat application can help with muscle relaxation in the area around the affected joint. The application of cold numbs nerve endings and decreases joint inflammation.
A charge nurse is supervising a newly licensed nurse provided care for a client who has a PCA pump. Which of the following statements made by the nurse requires further action by the charge nurse? A. I discarded the remaining 2 mg of morphine from the PCA pump. Please document that you witnessed it. B. I noted that my client push the PCA button six times in the past hour, and the PCA lockout is set for 10 minutes C. I gave my client a bolus dose of morphine when I initiated the PCA pump D. I told the clients family that they must not push the PCA button for the client
A. I discarded the remaining 2 mg of morphine from the PCA pump. Please document that you witnessed it.
A nurse is providing teaching to a group of adult athletes about prevention the effects of hydration on the body. Which of the following manifestations should the nurse include in the teaching? A. Impaired motor control B. Drop in body temperature during exercise C . Increase in appetite D. Decreased resting heart rate
A. Impaired motor control
A nurse is discussing culturally competent care and a nursing staff in-service. Which of the following information should the nurse include when discussing clients cultures? A. Nurses should focus on clients cultures, rather than their ethnic city, when providing care B. Nonverbal communication is important in a few cultures C. Culture plays no role in determining when I client will seek medical care D. Nurses should expect clients to adapt to the care provided regardless of culture
A. Nurses should focus on clients cultures, rather than their ethnic city, when providing care
A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive devices. Which of the following members of the interprofessional healthcare team should the nurse initiate a referral to? A. Occupational therapist B. Social worker C. Registered dietitian D. Speech pathologist E. Physical therapist
A. Occupational therapist An occupational therapist assists clients who have physical challenges to use adaptive devices and strategies to help with self-care activities such as feeding.
A nurse is teaching a client who has rheumatoid arthritis about self-care strategies for managing the disease. Which of the following activities should the nurse include in the teaching? A. Press water from a sponge rather than ringing it out B. Turn door knobs in a clockwise motion C. Finish weekly household tasks within 1 to 2 days D. Engage in repetitive tasks, even when joints are inflamed, to keep the joints mobile
A. Press water from a sponge rather than ringing it out The nurse should instruct the client to modify fine motor activities, such as wringing out a sponge, by using larger joints or body surfaces, such as the palm of the hand, to substitute for smaller ones.
A nurse is auscultating a client from lung sounds and identifies crackles in the left lower lobe. Which of the following intervention should the nurse take? A. Repeat auscultation after asking the client to deep breathe and cough B. Instruct the client to limit fluid intake to less than 2000 mL a day C. Prepare to administer antibiotics D. Place the client on bed rest in semi Fowler's position
A. Repeat auscultation after asking the client to breathe deeply and cough
A nurse is receiving a providers 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 clients health record D. Obtain the provider signature within eight hours E. Implement a recorded order message if the nurse can hear and understand it clearly
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 clients health record
A newly licensed nurse is applying prescribed her wrist restraints on a patient. Which of the following action should the nurse take? A. Secure the restraints with a quick release tie B. Esure four fingers fit under the restraints to prevent construction C. Secure the restraints to the lowest bar of the side rail D. Anticipate removing the restraints every four hours
A. Secure the restraints with a quick release tie
A nurse is reviewing laboratory values for a client who has lupus. Which of the following values should give the nurse the best indication of the clients renal function? A. Serum creatinine B. Blood urea nitrogen BUN C. Serum sodium D. Urine specific gravity
A. Serum creatinine A renal function disorder reduces the excretion of creatinine, resulting in increased levels of blood creatinine. Creatinine is a specific and sensitive indicator of renal function.
I nurse is performing tracheostomy care for client and suctioning to remove copious secretions. Which of the following action should the nurse take? A. Suction 2 to 3 times with a 60 second pause between passes B. Perform chest physiotherapy prior to suctioning C. Lubricate the suction catheter tip with sterile saline D. Hyperventilate the client on 100% oxygen prior to suctioning
A. Suction 2 to 3 times with a 60 second pause between passes
A staff nurse has applied for a promotion. The hiring manager insinuates that if there was a sexual relationship between the two of them, the nurses promotion request would get increased consideration. Which of the following action should the nurse take first? A. Tell the hiring manager in clear terms at this conduct causes feelings of discomfort and that this behavior should stop immediately B. Report the behavior to the nurse manager C. Create a written document of the incident store the documentation in a safe place D. Seek help from a trustworthy friend
A. Tell the hiring manager in clear terms at this conduct causes feelings of discomfort and that this behavior should stop immediately Sexual harassment is unwanted sexual advances made in the context of a relationship of unequal power or authority. It is experienced as offensive in nature. The nurse should first start by taking the most direct measure: confronting the hiring manager and insisting the harassment stop.
I nurse is teaching a client who has asthma about how to use an albuterol inhaler. Which of the following actions by client indicates an understanding of the teaching? A. The client hold his breath for 10 seconds after inhaling the medication B. The client takes a quick inhalation after releasing the medication from the inhaler C. The client exhales as the medication is released from the inhaler D . The client wait 10 minutes between inhalations
A. The client hold his breath for 10 seconds after inhaling medication
A nurse and a providers office is providing teaching to a client who is taking chemotherapy and losing weight. Which of the following should the nurse recommend to increase calorie and protein intake? (select all that apply) A. Top fruits with yogurt B. Add cream to soups C. Use milk instead of water in recipes D. Increase fluids during meals D. Dip meats and eggs and breadcrumbs before cooking
A. Top fruits with yogurt B. Add cream to soups C. Use milk instead of water in recipes D. Dip meats and eggs and breadcrumbs before cooking
I nurse is reviewing the diagnostic results of an older adult client who is post op. The nurse should notify the surgeon of which of the following results? A. WBC count 20,000 B. Hematocrit 40% C. Creatinine 0.9 D. Potassium 3.8
A. WBC count 20,000
A nurse is teaching a client how to follow a low-purine diet as prescribed by the provider for the management of gout. Which of the following statements indicates the client understands the teaching? A. "I will need to limit the number of fruit servings each day." B. "I should avoid eating liver and other organ meats." C. "I can drink only white wine." D. "I should choose red meat instead of poultry."
B. "I should avoid eating liver and other organ meats." The nurse should encourage the client who has gout to avoid organ meats, such as liver, due to high levels of purine. - Clients who have gout should avoid alcohol intake, which can trigger an exacerbation. - Clients who have gout should limit the intake of red meats.
A nurse is caring for a client who is receiving a unit of packed red blood cells. The nurse should prime the blood administration to being with which of the following IV solutions? A. Lactated ringer's solution B. 0.9% sodium chloride C. Dextrose 5% in water D. Dextrose 5% and 0.45% sodium chloride
B. 0.9% sodium chloride
I nurse is caring for a group of older adult clients. What should the following manifestations indicates what is the clients is experiencing delirium? A. My client wants to know the current time while the clock is on the wall B. I client repeatedly attempts to climb out of bed and repeatedly states that she wants to get home C. A client request extra blankets one a thermostat in the room indicates 78°F D. Client refuses to get out of bed and has no motivation to attend to daily hygiene
B. A client attends to get out of bed and repeatedly states she must go home Delirium is characterized by a change in cognition that occurs over a short period of time. It results from a secondary physiological condition (e.g., infection, surgery, prolonged hospitalization, hypoxia, fever, medications) and is a transient disorder. Although delirium can occur with any age, it is more common in older adults. It frequently progresses in the evening hours and is sometimes called "sundown syndrome." Delirium is characterized by alterations in memory, agitation, restlessness, illusions, or hallucinations. A client who becomes acutely confused and agitated may be showing manifestations of delirium.
A nurse manager received a client request not to have a specific staff nurse care for her while attic acute care facility. Which of the following is an appropriate action by the nurse manager? A. Ask other staff nurses about the level of care that the specific nurse provide B. Address the concern with specific staff nurse C. Recommend a specific staff nurse be transferred to another unit D. Notify the human resource department about the request
B. Address the concern with specific staff nurse
A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the long area. She states that she started taking birth control pills three weeks ago and that she smokes. Her heart rate is 110, respiratory rate 40, blood pressure 140/80. Her ABG states pH 7.50, PAC02 29, PaO2 60, HCO3 20, and SAO2 is 86%. Which of the following is the priority nursing intervention? A. Prepare for mechanical ventilation B. Administer oxygen via facemask C. Prepare to administer a sedative D. Assess for indications a pulmonary embolism
B. Administer oxygen via face mask
I nurse is caring for a client who develops and airwaves Truxion from a foreign body but remains conscious. Which of the following action should the nurse take first? A. Insert an oral airway B. Administer the abdominal thrust maneuver C . Turn the client on their side D. Preform a blind finger sweep
B. Administer the abdominal thrust maneuver
A nurse notices an AP preparing to deliver a food tray to a client who practices the Orthodox Jewish faith. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take? A. Allow the AP to delver the food tray to the client B. Call the dietary department and ask for a kosher tray C. Replace the nonfat milk with apple juice D. Explain to the patient that he needs the protein in the milk and beef
B. Call the dietary department and ask for a kosher tray
A nurse is caring for a client who is receiving Hydro morphine HCl viaPCA pump and reports continuous pain of six on a scale of 0 to 10. Which of the following action should the nurse take first? A. Administer a bolus of medication B. Check the display on the PCA pump C. Obtain an order for another pain medication for breakthrough pain D. Encourage the client to administer a demand dose
B. Check the display on the PCA pump
A nurse is admitting a client who has a wound infected with Bank of myosin resistant entrococci. Which of the following types of precautions should the nurse plan to initiate? A. Droplet B. Contact C. Airborne D. Protective
B. Contact
A nurse is teaching a client who has a new prescription of prednisone to treat rheumatoid arthritis. The nurse should inform the client that which of the following is a therapeutic effect of this medication? A. Reduce his risk of infection B. Decreases inflammation C . Improves Peripheral blood flow D. Increases bone density
B. Decreases inflammation Prednisone is used to treat rheumatoid arthritis because it produces anti-inflammatory and immunosuppressive effects, which reduces inflammation, decreases pain, and increases mobility.
A nurse is assessing a client for early manifestations of rheumatoid arthritis. Which of the following changes is an early manifestation of RA? A. Morning stiffness B. Fatigue C. Baker cysts D. Temporomandibular joint pain
B. Fatigue Fatigue, weakness, and anorexia are early manifestations of RA.
A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer. The patient has neutropenia. Which of the following should the nurse include in the restrictions in the clients plan of care? A. All visitors from entering the room B. Fresh flowers and potted plants in the room C. Oral fluid intake to between meals only D. Activities that could result in bleeding
B. Fresh flowers and potted plants in the room
A nurse is caring for a client who is dying. The client says my mother died in the hospital but I did not get there before she died. Which of the following statements should the nurse make? A. We will call your family in time for them to get here B. I wonder if you are fearful of dying alone C. I will make sure a staff member is in your room at all times D. I will tell your family of your concerns so that they can be here
B. I wonder if you are fearful of dying alone
A nurse observes that a client who is depressed is sitting alone in the room crying. As a nurse approaches, the client states, I'm feeling really down and I don't want to talk to anyone right now. Which is the following responses should the nurse take? A. It might help you feel better if you talk about it B. I'll just sit here for a few minutes with you then C. I understand. I've felt like that before, too D. Why are you feeling so down
B. I'll just sit here for a few minutes with you then
A nurse is collaborating on care for a client who has COPD. Which of the following tasks should the nurse recommend me for referred to an occupational therapist for assistance? A. Instructing how to measure oxygen saturation B. Instructing how to use kitchen tools to prepare a meal C. Instruction on how to plan a diet based on the individual caloric needs D. Instruction how to perform pursed lip breathing
B. Instructing how to use kitchen tools to prepare a meal
A nurse intercepts a message at the nurses station who has a flower delivery for a client on the unit. As a nurse accepts the flowers, the messenger says, "I know Miss Welch from the neighborhood. What happened to her?" Which of the following responses should the nurse provide? A. You know it's not appropriate for you to ask me that B. It is my responsibility to remind you that we have to respect our client's privacy C. It's a minor injury. I'm sure you'll see her back in the neighborhood soon D. Oh what lovely flowers she will enjoy these
B. It is my responsibility to remind you that we have to respect our client's privacy
A nurse is talking to a client who is about to start using transcutaneous electrical nerve stimulation to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching? A. I wish I didn't have to attach these electrodes to my skin B. It's unfortunate that I have to be in the hospital for this treatment C. I'll need to shave the hair off my skin where I place the electrodes D. I hope I don't have to take as many pain pills
B. It's unfortunate that I have to be in the hospital for this treatment
A nurse is caring for an older adult client who is alert and oriented admission, but now seems increasingly restless and intermittently confused. What are the following actions should the nurse take to address the client safety needs? A. Call the family and ask them to stay with a client B. Move the client to a room closer to the nurses station C. Apply wrist and leg restraints to the client D. Administer medication to sedate the client
B. Move the client to a room closer to the nurses station This will make it easier for the staff to observe the client, should the client behave in an unsafe manner.
I charge nurse has access to the facilities electronic client records. Is appropriate for the charge nurse to share her personal password with whom? A. The nurse manager B. No one C. A nursing student who is completing a preceptor ship on the unit D. The unit clerk
B. No one
A nurse is caring for a patient who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take? a. Review laboratory tests for low hemoglobin b. Observe for signs of infection c. Monitor the mouth for signs of xerostomia d. Examine the skin for generalized urticaria
B. Observe for signs of infection
A nurse is caring for a client who is confused and has pulled out her peripheral IV catheter three times. Which of the following actions should the nurse consider? A. Administering a mild sedative to the client B. Placement in restraints on the clients hands C. Reorient the client to time, person, and place D. Move the client close to the nurses station
B. Placement in restraints on the clients hands
A public health nurse is assessing an older adult client who lives with a family member. The nurse had an affair several bruises in various stages of healing. The client and family member explained that the bruises a result of cleanliness. However, based on the distribution of the bruises, the nurse suspect abuse. which of the following actions should the nurse take first? A. Document the bruise in the chart B. Report the findings to the supervisor C. Provide the client with a crisis hotline number D. Discuss respite care with the patient and family
B. Report the findings to the supervisor
A nurse is performing a pain assessment for a client who is alert. The nurse recognizes that which of the following measures is the most reliable indicator of pain? A. Vital signs B. Self report a pain C. Severity of the condition D. Nonverbal behavior
B. Self-report a pain
A nurse is caring for an older adult client who has a white blood cell count of 2000 after three rounds of chemotherapy. Which of the following actions should the nurse take? A. Humidify the clients room B. Serve cooked fruit with meals C. Clean dentures in a denture cup D. Replace the water in the flower vases with freshwater daily
B. Serve cooked fruit with meals
A nurse is planning to use the SPA our communication tool when calling a provider. Would you following statement should the nurse include in the B step? A. The client should be seen by a neurologist B. The client was found unconscious on the floor in her home C. There are no providers prescriptions available D. The client is disoriented. Pupils are slow to respond to light
B. The client was found unconscious on the floor in her home
A nurse is caring for a female client who has rheumatoid arthritis and a new prescription of methotrexate. The client tells the nurse she is planning a pregnancy. Which of the following instructions should the nurse give to the client? A. Dietary modifications of her during pregnancy when taking this medication B. This medication should be discontinued three months prior to planned pregnancy C. Dosage of the medication will be reduced during pregnancy D. The client can breast-feed while taking this medication
B. This medication should be discontinued three months prior to planned pregnancy Methotrexate should be discontinued 3 months prior to planning a pregnancy because of the risk of birth defects.
I nurse is caring for a client who has chemotherapy induced Paris Friel neuropathy. The nurse should expect the client to report having experience which of the following symptoms? A. Extremities that turn blue when exposed to cold B. Tingling feeling in extremities C. Jerking movements in the extremities D. Spasms of the extremities
B. Tingling feeling in extremities
I nurse is monitoring an older adult client immediately following a bronchoscope be. The nurses priority is to monitor the client for which of the following? A. Observing for confusion B. Auscultating breath sounds C. Assessing the gag reflex D. Monitor blood pressure
C. Assessing the gag reflex
A nurse on the medical surgical unit is preparing to contact a provider about a clients condition. The client is six hours postop from a total hysterectomy. The nurse notes for clients postoperative oxygen saturation is 94% and her apical heart rate is 110. The nurse should include information about the clients oxygen saturation level and heart rate in which component of the SBAR report? A. Situation B. Background C. Assessment R. Recommendation
C. Assessment
I nurse is caring for a client who has a fungal infection and has a new prescription of penicillin G. Which of the following laboratory values should the nurse report to the provider before initiating this medication? A.Sodium 140 B.Potassium 4.5 C.BUN 55 D. Glucose 120
C. BUN 55
I nurse is caring for a client who has a prescription for potassium chloride 20 mEq PO daily. The nurse reviews the clients most recent laboratory results and fines the clients potassium level of 5.2. Which of the following actions should the nurse take? A. Give the ordered potassium as prescribed B. Omit the potassium dose and document it was not given C. call the prescribing physician and inform her of the client's serum potassium level results D. Call lab to verify the clients results
C. Call the prescribing physician and inform her of the clients serum potassium level results
A nurse is giving change of shift report using the SBAR to the oncoming nurse on a client who has a Traumatic brain injury. Which of the following information should the nurse include in the background segment of SPIR? A. Glasgow results B. Intracranial pressure readings C. Code status D. Plan of care changes for upcoming shift
C. Code status
When reviewing the mini prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following action should the nurse take? A. Contact the pharmacy and confirm that the dosage is safe to administer B. Ask another nurse verify that the dosage is appropriate for the client C. Contact the provider to question the dosage D. Inform the charge nurse and administer the dose of the medication provided by the prescriber
C. Contact the provider to question the dosage
A nurse is caring for a client who is receiving oxygen therapy via nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following? A. Delivers a constant rate of a specific concentration of oxygen B. Delivers a high concentration of oxygen C. Delivers a low concentration of oxygen D. Restricts the clients ability to eat speak or drink
C. Delivers a low concentration of oxygen
A nurse manager is preparing to confront a staff nurse who is abusing alcohol. Which of the following defense mechanisms should the nurse manager expect the staff nurse to use.? A. Projection B. Rationalization C. Denial D. Repression
C. Denial
A nurse is caring for a client who request prescription pain medication. Which of the following actions should the nurse perform first? A. Reposition the client B. Administer medication C. Determine the location of pain D. Review the effects of the pain medication
C. Determine the location of pain
A nurse is working for a home health agency and is assessing an older adult male client. What should the following findings is the priority of the nurse to address? A. Swollen gums B. Urinary hesitancy C. Dysphagia D. Pruritus
C. Dysphagia Dysphagia poses the greatest safety risk to the client because it can cause choking, or result in aspiration of food or liquids leading to pneumonia and respiratory compromise. This is the priority finding for the nurse to address.
A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? A. Encourage the client to ambulate frequently B. Encourage coughing and deep breathing C. Encourage the client to increase fluid intakes D. Encourage regular use of an incentive Spirometer
C. Encourage client to increase fluid intake
A nurse is caring for a client who is postoperative following hip arthroplasty. The nurse should anticipate which of the following prescriptions for this client? A. Aspirin B. Clopidogrel C. Enoxaparin D. Alteplase
C. Enoxaparin The nurse should anticipate a prescription for enoxaparin as prophylaxis therapy for venous thromboembolism. Clients following hip arthroplasty are usually on anticoagulants for 3 to 6 weeks after surgery. - Although aspirin has anticoagulant effects, clients generally take it for ongoing primary prevention of cardiovascular and cerebrovascular events, not for the immediate anticoagulant effects a client who is postoperative hip arthroplasty requires. - Clopidogrel is an oral antiplatelet drug clients take to prevent stenosis of coronary stents and for some secondary prevention indications, not for the immediate anticoagulant effects a client who is postoperative hip arthroplasty requires. - Alteplase is a thrombolytic agent used in clients experiencing an acute MI, acute ischemic stroke, or acute massive PE.
A nurse is caring for several clients. For which of the following situation should the nurse complete an incident report? A. The nurse identifies a broken piece of equipment B. I staff member does not show up to work for her assigned shift C. I client discovers that his dentures are missing D. A nurse has a disagreement with the nursing supervisor about inadequate staffing
C. I client discovers that his dentures are missing
A nurse is teaching a newly licensed nurse about methods to reduce costs of client care. Which of the following statements by the newly not licensed nurse indicates understanding of the teaching? A. I should wait to empty my clients drainable colostomy until it is 3/4 full B. I should delegate providing closed irrigation to an assistive personnel C. I should encourage clients to receive an annual flu immunization D. I should recommend that my clients who have an established tracheostomy use sterile techniques at home to provide ostomy care
C. I should encourage clients to receive an annual flu immunization
I nurse is caring for an adult client who states I am afraid that I may fall while walking to the bathroom during the night. Which of the following actions should the nurse take? A.Limit the clients fluid intake in the evening B. Obtain a bedside commode for the clients use C. Leave a night light on in the clients room D. Put the side rails up and tell the client to call the nurse before voiding
C. Leave a night light on in the clients room This is an appropriate action for keeping the client safe. Night vision may be impaired in older adult clients. If the client awakens in the night, a nightlight may help the client to recognize the surroundings, decreasing the likelihood of disorientation. It will also help to decrease the possibility of a fall on the way to the bathroom because the path will be illuminated and the client will be less likely to trip over objects in the room.
A nurse is caring for a client with Clostridium diffcile infection. Which of the following cleansing agent should the nurse use for hand hygiene? A. Chlorhexidine B. Iodine C. Non-antimicrobial soap D. Alcohol-based hand rub
C. Non-antimicrobial soap The Centers for Disease Control recommends that hands should be washed with nonantimicrobial soap and water if in contact with spore-forming organisms such as Clostridium difficile or Bacillus anthracis. Proper hand hygiene includes using soapy lather and friction under running water for at least 15 seconds.
A nurse is teaching a client about risk factors for osteoarthritis. Which of the following factors should the nurse include in the teaching?( select all that apply) A. bacteria B. Diuretics C. Obesity D. Aging E. Smoking
C. Obesity D. Aging E. Smoking - Aging is a risk factor for osteoarthritis, as the joints bear the load of the body's weight over time. - Obesity is a risk factor for osteoarthritis, as it increases the load of the body's weight over time. - Smoking is a risk factor for osteoarthritis, as smoking predisposes people to the loss of cartilage in the knees.
A nurse is caring for a client with a tracheostomy. The client partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the clients discharge? A. Attending a class given about tracheostomy care B. Verbalizing all steps in the procedure C. Performing the procedure independently D. Asking appropriate questions about suctioning
C. Performing the procedure independently
A nurse is developing a plan of care for a client who practices islam. Which of the following actions should the nurse include in the plan? A. Sever foods that have a hot/cold balance B. Serve milk products separately from meals C. Request a meal tray without pork D. Remove tea and coffee from meal trays
C. Request a meal tray without pork
A nurse is caring for a client who is postoperative following abdominal surgery and reports incisional pain. The surgeon has prescribed morphine for milligrams IV bolus every six hours as needed. Before administering the medication, the nurse should complete which priority assessment? A. Blood pressure B. Apical heart rate C. Respiratory rate D. Temperature
C. Respiratory rate
A nurse is caring for a client who has a tracheostomy. Which of the following intervention should the nurse implement when performing tracheostomy care? A. Use aseptic technique B. Clean the inner cannula with mild soap and water C. Secure new tracheostomy tires before removing old ones D. Apply suction when inserting the catheter
C. Secure new tracheostomy ties before removing the ones
I nurse is caring for a client who has receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment? A. Sodium 165 B. Potassium 5.2 C. Urine specific gravity 1.020 D. Hematocrit 62%
C. Urine specific gravity 1.020
I nurse is assessing for cyanosis in a client who is dark skinned. where would the nurse assess for cyanosis in this client?
Conjunctiva
A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had an increase the dose of morphine this week to obtain pain relief. Which of the following scenarios should the nurse document as the explanation of the situation? A. The client has not been taking the medication properly B. The client is experiencing episodes of confusion C. The client has become addicted to the medication D. The client has developed a tolerance to the medication
D
A nurse is completing discharge instructions with a client following hospitalization for an acute onset of gout. Which of the following client statements should indicate to the nurse that the client understands the treatment regimen? A. "I will closely follow a high-purine diet" B. " I will limit my fluid intake to 1 liter per day" C. " I will take one enteric-coated aspirin every day" D. " I will drink only one beer, at most, a night"
D. " I will drink only one beer, at most, a night" A client who has gout should limit alcohol consumption, which is known to cause a gouty attack by inhibiting excretion of uric acid and leading to its buildup. However, clients should be encouraged to increase their fluid intake to help prevent formation of urinary stones.
A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurses highest priority? A. Initiating oxygen therapy B. Providing immediate rest for the client C positioning a client high Fowlers D. Administering a Nebula as beta adrenergic
D. Administering a Nebula as beta adrenergic
A nurse is caring for a client scheduled to receive radiation to the neck for cancer of the larynx. During the pre-treatment exam, the nurse explained to the client that the most likely side effect would be A. Infertility B. Diarrhea C. Dyspnea D. Dysphasia
D. Dysphasia
A nurse in a public clinic is planning a health fair for older adult client in the community. In teaching medication safety, which of the following foods should the nurse advise the client to avoid when taking their prescriptions? A. Carbonated beverages B. Milk C. Orange juice D. Grapefruit juice
D. Grapefruit juice There is a high rate of food-drug interactions between grapefruit juice and many medications frequently taken by older adults, especially lipid-lowering agents. It is thought that one or more of the chemicals (most likely flavonoids) in grapefruit juice alter the activity of specific enzymes (such as CYP3A4 and CYP1A2) in the intestinal tract. These enzymes decrease the rate at which medications enter the systemic circulation. This could allow a larger amount of these drugs to reach the bloodstream, resulting in increased drug levels and possibly toxicity.
A nurse is preparing to administer morphine for milligrams IV bolus to a client who reports pain. Available is morphine 10 mg/mL. Which of the following actions should the nurse take.? A. Discard the extra medication in the sharps container B. Save the extra medication for later dosing C. Send the waste amount to the pharmacy D. Have another nurse witness the disposal of the extra medication
D. Have another nurse witness the disposal of the extra medication
A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block? A. Vomiting B. Tachycardia C. Respiratory depression D. Hypotension
D. Hypotension
A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of Niley apneic episodes. Which of the following client statements indicates an understanding of the teaching? A. It might help if I tried sleeping on my back B. I'll sleep better if I take sleeping pills at night C. I'll get a humidifier to run at my bedside at night D. If I could lose about 50 pounds, I might stop having so many apneic episodes
D. If I could lose about 50 pounds, I might stop having so many apneic episodes
A nurse is developing a plan of care for client who has COPD. The nurse should include which of the following interventions in the plan? A. Restrict the clients fluid intake to less than 2 L per day B. Provide the client with a low protein diet C. Have a client use the early morning hours for exercise and activity D. Instruct the client to use pursed lip breathing
D. Instruct the client to use pursed lip breathing
A home health nurse is visiting an older adult client who tells the nurse that she is feeling tired, is on able to shop for groceries, and would like the nurse to shop for her. Shopping and performing personal errands for the client is prohibited in the nurses job description. Which of the following is an appropriate nursing response? A. I won't be able to shop for you today because I have to get home to my family Baby. I would be happy to do whatever I can for you C. What I think you should do is wait for the days when you feel better and do your grocery shopping D. Let's look at some other resources to solve this problem
D. Let's look at some other resources to solve this problem Acknowledging that the client needs assistance on certain days and encouraging the formulation of an action plan regarding community resources for that problem is an appropriate nursing response. The nurse should work within her job description and collaborate with others, making appropriate referrals within the community.
I nurse is planning care for a client who has immunosuppression following chemotherapy. Which of the following intervention should the nurse include in the plan of care? A. Insert an indwelling catheter to monitor the sentiment of the urine B. Take the clients temperature once per shift C. Provide the client with fresh fruits to avoid constipation D. Limit the number of healthcare workers entering the room
D. Limit the number of healthcare workers entering the room
A nurse manager is providing an educational program on antibiotic sensitivity to bacterial infections. The nurse should include in the teaching that Vancomycin is indicated for which of the following infections? A. Pseudomonas aeruginosa B. Klebsiella C. Candida D. Methicillin-resistant staphylococcus aureus
D. Methicillin-resistant staphylococcus aureus The nurse should teach that vancomycin is sensitive to the infection methicillin-resistant Staphylococcus aureus and Clostridium difficile infections, and should be the antibiotic of choice to treat this organism.
A nurse on the medical surgical unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer? A. Delivering mail trays to a client in their room B. Assisting a client who has difficulty seeing the foods on the tray while eating C. Delivering a routine urine specimen to the laboratory D. Observing a postoperative client who is confused
D. Observing a postoperative client who is confused
A nurse is teaching a newly hired group of assistive personnel about infection control measures only unit. It is critical for the nurse to reminder assistive personnel that which of the following is the most effective way to prevent the spread of pathogens during client care? A. Properly disposing of contaminated equipment B. Discarding used syringe is inappropriate containers C. Changing soiled linens daily for clients who have draining wounds D. Performing hand hygiene frequently and consistently
D. Performing hand hygiene frequently and consistently The greatest risk to all clients and staff on the unit is infection from cross contamination; therefore, the priority action is hand hygiene. It is one of the most important and effective ways to prevent pathogen transmission. It applies to every health care setting and is a consistent imperative during client care.
A nurse is caring for a client who has cancer and is scheduled for immediate chemotherapy. The client tells the nurse that she wants to try nontraditional treatments first. Which of the following responses should the nurse take? A. Using non-traditional treatments is not a good idea. I'd rather you avoid that route. B. A lot of people think nontraditional treatments work, and they found out too late that they made the wrong choice C. Your provider is very knowledgeable. If he prescribes chemotherapy, it's the best treatment for you D. Tell me more about your concerns about chemotherapy
D. Tell me more about your concerns about chemotherapy
A nurse is caring for for hospitalize clients. Which of the following should the nurse identify as being at risk for fluid volume deficit? A. The client who is NPO since midnight for endoscopy B. The client who has left-sided heart failure and has a BNP level of 600 C. The client who has end-stage renal failure and is scheduled for dialysis today D. The client who has Gastroenteritis and ferbile
D. The client who has Gastroenteritis and is febrile
I nurse is caring for a client who has fallen out of bed. The patient states I'm OK I guess I should have called to get help to go to the bathroom. After assessing a client, the nurse notifies the provider. Which of the following documentation should the nurse include in the clients medical record? A. There were no injuries sustained B. An incident report was completed C. An incident report was forwarded to risk management D. The provider was notified
D. The provider was notified
A home health nurse is conducting a home safety assessment for an older adult client. Which of the following findings should the nurse identify as a safety risk for the client? Select all that applyA. Bathtub with railsB. Electric cords behind the furnitureC. Raised toilet seatsD. Water heater temperature 54.4 C (130F)E. Throw rugs
D. Water heater temperature 54.4 C (130F) E. Throw rugs - The nurse should recommend setting the water heater's temperature no higher than 49°C (120° F). - The nurse should recommend removing or securing any rugs or mats that could move and cause the client to slip, slide, or trip.
An older adult client is scheduled to have an elective surgical procedure and informs the nurse that she wants to be designated as a do not resuscitate case. Which of the following responses should the nurse provide? A. This is a minor procedure; there is no need for this request B. You need to let the provider know your wishes after the procedure C. You need to discuss your request with the hospital chaplain D. Your provider needs to talk with you concerning this request
D. Your provider needs to talk with you concerning your request The nurse should inform the client that the provider is responsible for consulting with the client and writing a DNR order.
a chargen nurse is teaching a group of healthcare workers about hand hygiene to prevent infection. Which of the following information should the charge nurse include in the teaching? A. Keep artificial nails trimmed. B. Use alcohol-based hand rubs before administering eyedrops to a patient C. Wash hands with alcohol-based hand rubs when caring for a patient who has C diff D. Use Chlorohexidine to wash hands if the client is immunocompromised
D. use chlorohexedine to wash hands if the client is immunocompromised The CDC recommends health care workers use chlorhexidine for hand washing when providing care to a client who is immunosuppressed.
A nurse is caring for a client who has an infection and a prescription for gentamicin intermittent IV bolus every 8hr. A peak and trough is required with the next dose. Which of the actions should the nurse take to obtain an accurate gentamicin serum level. a. Draw a trough level at 0900 and a peak level at 2100. b. Draw a peak level 90 min prior to administering the medication and a trough level 90 min after the dose. c. Draw a trough level immediately prior to administering the medication and a peak level 30 min after the dose. d. Draw a peak level at 0900 and a trough level at 2100.
Draw a tough level immediately prior to administering the medication and a peak level 30 min after the dose
A nurse is preparing to measure a clients oxygen saturation level and observes Adema in both hands and thickened toenails. Where should the nurse apply the pulse oximeter probe?
Earlobe
A nurse is preparing an in-service for an annual skills fair at a community medical facility about fire safety. Place the steps in the order in which they should be performed in the case of a fire emergency.
Rescue Clients Pull Fire Alarm Confine the Fire Extinguish the Fire
A client is admitted to the emergency room with the respiratory rate of seven breaths per minute. Which of the following is an appropriate analysis of the ABGs?
Respiratory acidosis
A nurse is caring for a client who is ABG results show pH of 7.3 and PaCO2 a 50. The nurse should identify that the client is experiencing which of the following acid-base imbalances?
Respiratory acidosis
A nurse is reviewing an arterial blood gas for a client. The pH is 7.32, PaCO248, HCO323. The nurse should recognize that these findings indicate which of the following acid-base imbalances?
Respiratory acidosis
I nurse is caring for a client who is post operative and he's respite rations are shallow at nine per minute. Which of the following acid-base balance says should the nurse identify the client being at risk for developing initially.?
Respiratory acidosis
I nurse is assessing a client who is receiving one unit of packed red blood cells to treat intraoperative blood loss. The client reports chills and back pain and the clients blood pressure is 80/64. Which action should the nurse take first?
Stop the infusion of blood
A nurse is reviewing the diagnostic test results of an older adult female client who is preoperative for a knee arthroplasty. The nurse should notify the surgeon of which of the following results? WBC count 20,000/mm3 Hematocrit 40% creatinine 0.9 Potassium 3.8 mEq/L
WBC count 20,000/mm3 This result exceeds the expected reference range for WBC of 5,000 to 10,000/mm3. The client's elevated WBC count indicates infection. The nurse should notify the surgeon. - This result is within the expected reference range for women of 37 to 47% - This result is within the expected reference range for older adult women of 0.5 to 1.2 mg/dL. - This result is within the expected reference range of 3.5 to 5.0 mEq/L.
a nurse is providing teaching for a client who has a new diagnosis of fibromyalgia. which of the following client statements indicates the need for further teaching? a. "Fibromyalgia causes joint inflammation." b. "Fibromyalgia may cause me to feel chest pain." c. "Fibromyalgia commonly causes migraine headaches." d. "Fibromyalgia symptoms may worsen depending upon the weather."
a. "Fibromyalgia causes joint inflammation." Clients who have fibromyalgia may report joint discomfort. However, fibromyalgia is a noninflammatory disorder and does not cause joint inflammation.
a nurse is caring for a client who has rheumatoid rthritis and tells the nurse that she wears a copper bracelet to help her feel better. which of the following responses should the nurse make? a. "Yes, I understand that you feel better wearing your bracelet." b. "Why do you think the copper helps with your arthritis?" c. "Believing objects have powers to make you feel better has no scientific basis." d. "I think you should rely more on your medication therapy than on your bracelet."
a. "Yes, I understand that you feel better wearing your bracelet." The nurse illustrates the therapeutic communication technique of accepting. The nurse demonstrates the knowledge that the bracelet is harmless for the client and shows respect for the client's beliefs.
A nurse has just finished a wound irrigation for a patient who requires contact precautions. which piece of personal protective equipment should the nurse remove FIRST? a. gloves b. gown c. face shield d. mask
a. Gloves The greatest risk to safety is pathogen transmission. The gloves are the most contaminated item of PPE, so the nurse should remove them first. Failing to remove the most contaminated item first increases this risk.
a nurse is teaching a group of clients about tick-borne illnesses. which of the following information should the nurse include in the teaching regarding ticks? a. Grasp the tick as close to the skin as possible. b. Use a twisting motion when removing the tick. c. Apply a pediculicide lotion to the area surrounding the tick. d. Use the hot ember from the tip of a match to remove the tick.
a. Grasp the tick as close to the skin as possible. The nurse should instruct the clients to grasp the tick as close to the skin as possible to remove the entire tick body.
A nurse is planning care for a client who is postoperative from a total hip arthroplasty. which of the following is appropriate to include in the plan of care? a) instruct the client to avoid movement of the affected leg b) prevent hip flexion of the affected extremity c) position the lower extremities so that they are touching d) ensure that the client's heels are touching the bed
b) prevent hip flexion of the affected extremity The nurse should implement measures to prevent hip flexion of the affected extremity beyond 90 degrees due to the risk of dislocation. Raised toilet seats and reclining chairs help prevent hyper-flexion.
A nurse is admitting a client who has a wound infected with vancomycin-resistant enterococci(VRE). Which of the following types of precautions should the nurse plan to initiate? a. Droplet b. Contact c. Airborne d. Protective
b. Contact Contact precautions are a type of transmission-based precaution for clients who have an infection, such as VRE, which spreads either by direct or indirect contact.
A public health nurse is visiting an older adult client who lives with a family member. The nurse assesses the client and identifies several bruises in various stages of healing. The client explains that the bruises are a result of "clumsiness," and the client's family member agrees. However, based on the location and distribution of the bruises, the nurse suspects the client may be abused. Which of the following actions should the nurse should take first? a. Document the bruises in the client's chart. b. Report the findings to a supervisor. c. Provide the client with a crisis hotline number. d. Discuss respite care with the client's family.
b. Report the findings to a supervisor. The greatest risk to this client is further injury from continued abuse; therefore, the first action the nurse should take is to report the findings to a supervisor. Nurses are required to report suspected cases of child and older adult abuse.
a nurse is providing discharge teaching to a client who has systemic lupus erythematosus (sle). which of the following instructions should the nurse include? a. Avoid using moisturizing lotions on the skin. b. Wash the hair with a mild protein shampoo. c. Apply powder liberally to sensitive skin areas. d. Use a sun-blocking agent with a sun protection factor of at least 15.
b. Wash the hair with a mild protein shampoo. Clients who have SLE are prone to hair loss. They should use a mild protein shampoo and avoid treatments that can damage the hair and scalp, such as dyes and permanents. - SLE should apply non-perfumed moisturizing lotions liberally to the skin. - SLE should not use powder or other drying skin products on their skin. - SLE should use a sun-blocking agent with a sun protection factor of at least 30.
a nurse is caring for a client who has osteoarthritis and asks about the use glucosamine. which of the following statements should the nurse make? a. hospice care b. meals on wheels c. a rehab facility d. temporary assistance for needy families
b. meals on wheels Meals on Wheels is a service that delivers meals daily to older adults who need them, either at senior centers or directly to their homes. It is appropriate for the nurse to recommend this service for this client.
a nurse is assisting an older adult client who is sedentary plan a new exercise regimen, Which of the following activities should the nurse recommend? a. tennis b. walking c. running d. jumping rope
b. walking The nurse should recommend low impact exercises, such as yoga or walking, to maintain and increase strength and flexibility.
a nurse is caring for an older adult client whose provider will discharge him to an extended-care nursing facility the following morning. the client asks the nurse why he has to go to "that place.' which of the following responses should the nurse make? a. "Your doctor feels that this is the best place for you right now." b. "Why don't you ask your doctor about that when she comes in to see you?" c. "Did your doctor or anyone else talk to you about going to the nursing home?" d. "Your family can't take care of you at home, so you will need to go there."
c. "Did your doctor or anyone else talk to you about going to the nursing home?" It is important to identify what the client thinks he has heard about his discharge. Clarification of information can proceed after this.
a nurse is providing teaching for a client who has osteoarthritis. which of the following instructions should the nurse include in the teaching? a. "Apply a heat pack at a temperature below your body temperature." b. "Elevate the affected joint on large pillows." c. "Take acetaminophen as the primary medication to treat the pain." d. "Decrease foods high in purines."
c. "Take acetaminophen as the primary medication to treat the pain." The nurse should instruct the client to take acetaminophen to treat osteoarthritis.
a nurse is caring for a client who has a fungal infection and has a new prescription for amphtericin b. which of the following laboratory values should the nurse report to the provider before initiating the medication? a. Sodium 140 mEq/L b. Potassium 4.5 mEq/L c. BUN 55 mg/dL d. Glucose 120 mg/dL
c. BUN 55 mg/dL This BUN level is above the expected reference range (10-20 mg/dL). Amphotericin B is nephrotoxic and is contraindicated if BUN is > 40mg/dL. The nurse should report this laboratory value to the provider before initiating the medication.
A nurse is caring for a client who has an infection and a prescription for gentamicin intermittent IV bolus every 8hr. A peak and trough is required with the next dose. Which of the actions should the nurse take to obtain an accurate gentamicin serum level. a. Draw a trough level at 0900 and a peak level at 2100. b. draw a peak level 90 min prior to administering the medication and a trough level 90 min after the dose. c. Draw a trough level immediately prior to administering the medication and a peak level 30 min after the dose. d. Draw a peak level at 0900 and a trough level at 2100.
c. Draw a trough level immediately prior to administering the medication and a peak level 30 min after the dose. Timing of the peak and trough is based on the pharmacokinetics of absorption and the half-life of the medication. The trough level is the lowest serum level after pharmacokinetic effects have taken place. For divided doses, correct timing for the trough is just before administering the next dose. The peak is the highest serum level of the medication; if this level is too low, then the medication will not be effective. Correct timing for the peak is between 30 and 60 min after the dose has finished infusing.
A nurse is assessing a client who has had systemic scleroderma for 5 years to document the diseases progression. In addition to skin changes, which of the following findings should the nurse expect? a. Periorbital edema b. Excessive salivation c. Finger contractures d. Thinning of the skin
c. Finger contractures Scleroderma is a chronic disease that can cause thickening, hardening, or tightening of the skin, blood vessels, and internal organs. Manifestations include skin changes, Raynaud's phenomenon, arthritis, muscle weakness, and dryness of the mucous membranes. Contractures occur with advanced systemic scleroderma unless the client follows a regimen of range-of-motion and muscle-strengthening exercises, pain management, and joint protection. - edema of the hands, fingers, and sometimes the lower extremities. - will experience decreased salivation, which increases the risk of dental caries and gum disease. - Thickening and hardening of the skin
a nurse is reviewing the prescriptions for a client who had a total hip arthroplasty. which of the following prescriptions should the nurse vefrify with the provider? a. Administer enoxaparin 30 mg subcutaneous every 12 hr. b. Place a wedge or pillow between the client's legs when turning. c. Instruct the client to restrict flexion of the hip past 120°. d. Encourage the client to perform foot and calf exercises every 2 hr.
c. Instruct the client to restrict flexion of the hip past 120°. The nurse should verify this prescription with the provider. The nurse should instruct the client to restrict flexion of the hip past 90° to avoid dislocation of the hip. - Enoxaparin is recommended for a client who had a total hip arthroplasty to prevent deep venous thrombosis. The prescription does not need verification. - The nurse should place an abductor wedge or pillow between the client's legs when turning and at rest to prevent adduction of the affected leg and dislocation of the hip. - The nurse should encourage the client to do foot and calf exercises every 2 hr to help prevent deep venous thrombosis.
a nurse is assessing a client who has systemic lupus erythematosus (sle). which of the following findings ia the highest priority for the nurse to report to the provider? a. Client report of feelings of depression. b. Dry, raised rash on the face. c. Presence of peripheral edema. d. Joint pain in hands and knees.
c. Presence of peripheral edema. The client who has SLE is at greatest risk for death from lupus nephritis. Therefore, according to the safety and risk reduction priority setting framework, findings that indicate an impairment of renal function are the highest priority to report.
A nurse is providing teaching to a client who has a new prescription for hydroxychloroquine to treat mild manifestations of rheumatoid arthritis. Which of the following information should the nurse include in the teaching? a. This medication should be taken between meals. b. This medication can turn skin an orange color. c. Wear sunglasses when out in bright sunshine. d. Avoid crushing the medication.
c. Wear sunglasses when out in bright sunshine. The nurse should instruct the client to wear sunglasses to decrease photophobia when taking hydroxychloroquine. Clients should have an ophthalmologic examination before treatment because the medication can cause retinopathy.
A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the clients infection? A. Changing the clients bed linens every day B. Encouraging the client to consume a high protein diet C. Performing hand hygiene before during and after contact with a client D. Placing the client in a positive pressure air room
c. performing hand hygiene before, during, and after contact with the patient The nurse can help prevent the transmission of micro-organisms by washing her hands frequently before, during, and after client care procedures.
A nurse is caring for a client who requires droplet precautions Which of the following personal protective equipment should the nurse wear when setting up the client's meal tray? a. Mask b. Goggles c. Gown d. Gloves
d. Gloves The nurse should follow droplet precautions for clients who have infections that spread by droplets larger than 5 microns. The nurse should wear a mask whenever she is within 1 m (3 ft) of the client.
A nurse is planning care for a client who requires airborne precautions. Which of the following actions should the nurse take? a. Provide a positive-pressure airflow room. b. Stand 1.8m (6 feet) away from the client. c. Allow the client to ambulate in the hall. d. Wear an N95 respiratory mask.
d. Wear an N95 respiratory mask The nurse should wear an N95 respirator mask or a high-efficiency particulate air (HEPA) filter mask when caring for a client who has an infection that requires airborne precautions, such as disseminated varicella zoster, rubeola, or tuberculosis.
a nurse is caring for a client who has developed gout. which of the following a. zolpidem b. alprazolam c. spironolactone d. allopurinol
d. allopurinol Allopurinol is a xanthene oxidase inhibitor that reduces uric acid synthesis. The medication is prescribed to treat gout.
A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions? a. scabies b. pertussis c. streptococcal pharyngitis d. measles
d. measles A client who has measles requires airborne precautions as well as a negative pressure room.
a nurse is preparing to exit the room of a client who has methicillin-resistant staphylococcus aureus (MRSA) in a draining wound. Identify the sequence the nurse should follow BEFORE LEAVING the client's room.
glove eyewear gown mask hand hygiene
PPE sequence
gloves goggles gown mask hand hygiene
A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? (Select all that apply) More difficulty seeing due to a greater sensitivity to glare Decreased cough reflex Decreased bladder capacity Decreased systolic blood pressure Dehydration of intervertebral discs
more difficulty seeing due to a greater sensitivity to glare decreased cough reflex decreased bladder capacity dehydration of interverebral diss - Older adults have an increased susceptibility to glare, greater difficulty in seeing at low levels of illumination, and alterations in color perception. - Older adults have a decreased cough reflex, increased airway resistance, fewer alveoli, and a greater risk for respiratory infections. - Older adults have a decreased bladder capacity and a reduction in renal blood flow. - Older adults have increased systolic blood pressure, thickening of blood-vessel walls, and decreased peripheral circulation. - Older adults have dehydration of intervertebral discs, decreased muscle strength and mass, and decalcification of bones.
