ATI Fundamentals Practice A

A nurse is preparing to administer 0.9=% NaCl 750 mL IV to infuse over 7 hrs. The nurse should set the infusion pump to deliver how many mL/hr? Round the answer to the nearest whole number.

107 mL/hr 750/7= 107

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress? A. "What could I have done to deserve this illness?" B. "I blame medical science for not curing me." C. "Where is my daughter at a time like this?" D. "Will I ever begin to feel in charge of my life again?"

A. "What could I have done to deserve this illness?"

A nurse has accepted a verbal prescription for three tenths of a milligram of levothyroxine IV stat for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record? A. .3 mg B. 0.3 mg C. 0.30 mg D. 3/10 mg

B. 0.3 mg

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use? A. Alginate B. Gauze C. Transparent D. Hydrocolloid

D. Hydrocolloid

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? A. Discuss the risk factors for colon cancer. B. Focus teaching on what the client will need to do in the future got manage his illness. C. Provide the client with written information about the phases of loss and grief. D. Reassure the client that this is an expected response to grief.

D. Reassure the client that this is an expected response to grief.

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. Determine the correct order of steps for this procedure.

Inject 10 units of air into the bottle of NPH insulin. Inject 5 units of air into the bottle of regular insulin Withdraw correct dose of regular insulin from the bottle Withdraw the correct dose of NPH insulin from the bottle.

A nurse is preparing a heparin infusion for a client who was admitted to the facility with deep-vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium chloride 250 mL to infuse at 800 units/hr. At what rate should the nurse set the infusion pump?

8 mL/hr

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? A) Check the client for injuries. B) Move hazardous objects away from the client. C) Notify the provider .D) Ask the client to describe how she felt prior to the fall.

A) Check the client for injuries. The first action the nurse should take when using the nursing process is to assess the client for injuries. B) Move hazardous objects away from the client. Moving hazardous objects away from the client can prevent further injury; however, there is another action the nurse should take first. C) Notify the provider The nurse should notify the provider of the client's fall; however, there is another action the nurse should take first. .D) Ask the client to describe how she felt prior to the fall. Determining the facts that surrounded the fall is important to help prevent subsequent falls; however, there is another action the nurse should take first

A nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn? A. " I can concentrate best in the morning." B. "It is difficult to read the instructions because my glasses are at home." C. "I m wondering why I need to learn this." D. "You will have to talk to my wife about this."

A. " I can concentrate best in the morning."

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. A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. B. A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes. C. A client who has a do-not-resuscitate order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family. D. A client who is about to undergo a painful procedure receives pain medication 30 minutes before the procedure that the nurse previously promised to administer.

A. A client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively.

A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include? A. Advocacy ensures clients' safety, health, and rights. B. Advocacy ensures that nurses are able to explain their own actions. C. Advocacy ensures that nurses follow through on their promises to clients. D. Advocacy ensures fairness in client care delivery and use of resources.

A. Advocacy ensures clients' safety, health, and rights. Advocacy is a key component of professional nurses' code of ethics. As a client advocate, the nurse ensures clients' safety, health, and rights, including the right to privacy, confidentiality, and refusal of care.

A nurse is preparing to delegate the client care tasks to an assistive personnel. Which of the following tasks should the nurse delegate? A. Ambulating a client who is postoperative. B. Inserting an indwelling urinary catheter for a client. C. Demonstrating the use of an incentive spirometer to a client. D. Confirming that a client's pain has decreased after receiving an analgesic.

A. Ambulating a client who is postoperative.

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate? A. Droplet B. Airborne C. Contact D. Protective environment

A. Droplet

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? A. During the admission process B. As soo as the client's condition is stable. C. During the initial team conference D. After consulting with the client's family.

A. During the admission process Discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility.

A nurse is caring for a child who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. Which of the following actions should the nurse take? A. Examine personal values about the issue. B. Tell the parents that this is a necessary procedure. C. Inform the parents that the staff does not require their consent. D. Contact a spiritual support person to explain the importance of the procedure.

A. Examine personal values about the issue. Nurses should examine their own personal values about the issue in question in order to provide care that is without bias. B. Tell the parents that this is a necessary procedure. The nurse should provide the parents with information about the procedure. However, telling the parents that this is a necessary procedure disregards the parents' religious beliefs and their right to refuse treatments. C. Inform the parents that the staff does not require their consent. Parents must give consent for a child to receive a blood transfusion. D. Contact a spiritual support person to explain the importance of the procedure. The nurse or the provider should provide information about the procedure. Spiritual support people attend to clients' and families' spiritual needs, not their physiological needs

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? A. Gently shake the container of medication prior to administration B. Transfer the medication to a medicine cup. C. Place the client in a semi-Fowler's position prior to medication administration D. Verify the dosage by measuring the liquid before administering it.

A. Gently shake the container of medication prior to administration

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? A. Use a bed exit alarm system. B. Raise four side rails while the client is in bed. C. Apply one soft wrist restraint. D. Dim the lights in the client's room.

A. Use a bed exit alarm system.The nurse should identify that a client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at a risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance. B. Raise four side rails while the client is in bed. Raising four side rails when the client is in bed is a form of restraint and increases the risk for falls and injury. Raising four side rails when the client is in bed is a form of restraint and increases the risk for falls and injury. C. Apply one soft wrist restraint. Applying one soft wrist restraint is a physical restraint requiring a prescription. Other forms of distraction or intervention to maintain client safety should be attempted for clients who have dementia. Applying one soft wrist restraint is a physical restraint requiring a prescription. Other forms of distraction or intervention to maintain client safety should be attempted for clients who have dementia. D. Dim the lights in the client's room. Dimming the lights in the room for a client who has dementia can reduce visibility and increase the risk for injury.

A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching? A. Use the complete name of the medication magnesium sulfate. B. Delete the space between the numerical dose and the unit of measure. C. Write the letter U when noting the dosage of insulin D. Use the abbreviation SC when indicating an injection.

A. Use the complete name of the medication magnesium sulfate.

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? A. Walking briskly B. Riding a bicycle C. Performing isometric exercises. D. Engaging in high-impact aerobics

A. Walking briskly

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? A. Carry a client's soiled linens out of the room in a mesh linen bag. B. Place a client who has tuberculosis in a room with negative-pressure airflow C. Provide disposable plates and utensils for a client who is HIV-positive. D. Dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag.

B. Place a client who has tuberculosis in a room with negative-pressure airflow A. Carry a client's soiled linens out of the room in a mesh linen bag. The nurse should place soiled linens in a fluid-resistant bag to reduce the risk of infection transmission. C. Provide disposable plates and utensils for a client who is HIV-positive. People transmit HIV mainly by blood and sexual activity; therefore, a client who is HIV-positive does not require disposable plates and utensils. Standard precautions are sufficient. D. Dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag.

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? A. Critical pathway B. SBAR C. Transfer report D. MAR

B. SBAR A. Critical pathway- A critical pathway is an interprofessional approach to planning all phases of client care. C. Transfer report- The nurse should use a transfer report when the client is moving from one health care area or facility to another. D. MAR- to document medication administration.

a nurse is reviewing protocol in preparation for suctioning secretions from a client who has new tracheostomy. Which of the following actions should the nurse plan to take? A. Use a resuscitation bag with 80% oxygen prior to the procedure. B. Select a suction catheter that is half the size of the lumen. C. Place the end of the suction catheter in water-soluble lubricant D. Adjust the wall suction apparatus to a pressure of 170 mm Hg

B. Select a suction catheter that is half the size of the lumen.

A nurse is perfuming a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? A. The client uses a wool blanket on their bed. B. The client uses non-acetone nail polish remover. C. The client stores an extra oxygen tank on its side under their bed. D. The client has a weekly inspection checklist for oxygen equipment.

B. The client uses non-acetone nail polish remover.

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility? A. Describe the procedure to the client. B. Witness the client's signature on the consent form. C. Inform the client of alternatives to the procedure. D. Tell the client which team members will assist with the procedure.

B. Witness the client's signature on the consent form.

A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching? A. "I had a bowel movement, but I was able to save the urine." B. "I have a specimen in the bathroom from about 30 minutes ago." C. "I flushed what I urinated at 7 AM and have saved all urine since." D. "I drink a lot, so I will fill up the bottle and complete the test quickly. "

C. "I flushed what I urinated at 7 AM and have saved all urine since."

A nurse is talking with an older adult client who is contemplating retirement. The client states, "I keep thinking about how much I enjoy my job. I'm not sure I want to retire." Which of the following responses should the nurse make? A. "You would have so much more time to spend with your family." B. "You should consider a part-time job or doing volunteer work." C. "Let's talk about how the change in your job status will affect you." D. Why wouldn't you want to retire and relax?"

C. "Let's talk about how the change in your job status will affect you." A. "You would have so much more time to spend with your family." This response is nontherapeutic because the nurse is minimizing the client's feelings and making assumptions about the client's relationships. B. "You should consider a part-time job or doing volunteer work." This response is nontherapeutic because the nurse is minimizing the client's feelings and offering personal advice. D. Why wouldn't you want to retire and relax? This response is nontherapeutic because the nurse is asking a "why" question, which can provoke a defensive response from the client.

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? A. Rock the client up to a standing position. B. Pivot on the foot that is the farthest from the chair. C. Assess the client for orthostatic hypotension. D. apply a gait belt to the client.

C. Assess the client for orthostatic hypotension.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation? A. Urine has an unusual odor. B. Urine specific gravity is 1.035. C. Bladder scan shows 525 mL of urine. D. Urine is positive for ketones.

C. Bladder scan shows 525 mL of urine.

A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? A. Bladder distention B. Decreased blood pressure C. Calf swelling D. Diminished bowel sounds

C. Calf swelling

A nurse is administering 1 L of 0.9% NaCl to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? A. Increase in hematocrit. B. Increase in respiratory rate. C. Decrease in heart rate. D. Decrease in capillary refill time.

C. Decrease in heart rate.

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take? A. Assist the client into a prone position. B. Place a sleeve over the top of each leg with the opening at the knee. C. Make sure two fingers can fit under the sleeves. D. Set the ankle pressure at 65 mm Hg.

C. Make sure two fingers can fit under the sleeves.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? A. Neck vein distention B. Urine specific gravity 1.010 C. Rapid heart rate D. Blood pressure 144/82 mm Hg

C. Rapid heart rate

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration? A. purulent exudate. B. Warmth. C. Skin blanching. D. Bleeding.

C. Skin blanching

A nurse is evaluating a client's use of a cane. Which of the following actions should the nurse identify as an indication of correct use? A. The top of the cane is parallel to the client's waist B. When walking, the client moves the cane 46 cm (18 in) forward. C. The client holds the cane on the stronger side of the body D. The client moves her stronger limb forward with the cane.

C. The client holds the cane on the stronger side of the body

A home health nurse is performing a follow-up visit for a client who has gastrostomy tube through which they receive intermittent feedings and medications. The client has recently developed diarrhea. Which of the following findings should the nurse identify as a possible cause of the diarrhea? A. The client is receiving formula at room temperature. B. The feedings infuse at a slow, continuous drip over 8 hr each night. C. The client's caregiver washes out the feeding bag with warm water once every 24 hr. D. The client's caregiver flushes the tubing with water before and after administering medications.

C. The client's caregiver washes out the feeding bag with warm water once every 24 hr.

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients? A. A client who has a history of physical abuse. B. A client who has a permanent pacemaker. C. A client who has ulcerative colitis. D. A client who has asthma

D. A client who has asthma.

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess? A. Hypotension B. Weak, thready pulse C. Slow capillary refill D. Distended neck veins

D. Distended neck veins

A nurse is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? A. Position the client with the head of the bed elevated to 30 degrees prior to insertion of the NG tube. B. Remove the NG tube if the client begins to gag or choke. C. Apply suction to the NG tube prior to insertion. D. Have the client take sips of water to promote insertion of the NG tube into the esophagus.

D. Have the client take sips of water to promote insertion of the NG tube into the esophagus. Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea. A. Position the client with the head of the bed elevated to 30 degrees prior to insertion of the NG tube. The client should be sitting in high-Fowler's position with the head of the bed elevated to 90° to reduce the risk for aspiration. B. Remove the NG tube if the client begins to gag or choke. The nurse should withdraw the NG tube slightly, not remove it, if the client gags or chokes to reduce the risk of injury to the client. C. Apply suction to the NG tube prior to insertion. The nurse should not apply suction until the NG tube is in place with x-ray verification of its position in order to reduce the risk of injury to the client.

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next? A. Document the provider's statement in the medical record. B. Complete an incident report. C. Consult the facility's risk manager. D. Notify the nursing manager.

D. Notify the nursing manager. The greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action the nurse should take is to activate the chain of command to ensure that the client receives the necessary care. A. Document the provider's statement in the medical record. The nurse should document the provider's directions in the medical record for later reference; however, another action is the nurse's priority. B. Complete an incident report. The nurse should prepare an incident report detailing the delay in treatment for later review and action for prevention of future occurrences; however, another action is the nurse's priority. C. Consult the facility's risk manager. The nurse should discuss the situation with the facility's risk management department to help determine the need for preventive actions; however, another action is the nurse's priority.

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? A. BUN is 15 mg/dL B. Creatinine 0.8 mg/dL C. Sodium 143 mEq/L D. Potassium 5.4 mEq/L

D. Potassium 5.4 mEq/L expected reference range of 3.5 to 5 mEq/L A. BUN is 15 mg/dL expected reference range of 10 to 20 mg/dL. B. Creatinine 0.8 mg/dL expected reference range of 0.5 to 1.1 mg/dL for women 41 to 60 years of age and 0.6 to 1.3 mg/dL for men 41 to 60 years of age C. Sodium 143 mEq/L expected reference range of 136 to 145 mEq/L.

A nurse is planning teaching for group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? A. Role play B. Group discussions C. Question-answer meetings D. Practice sessions

D. Practice sessions

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client? A. have the client wear a mask when receiving visitors. B. Limit the client's time with visitors to no more than 30 minutes. C. Assign the client to a room with a negative-pressure airflow exchange. D. Wear a gown when caring for the client.

D. Wear a gown when caring for the client. The nurse should implement contact precautions for a client who has shigella to prevent the transmission of the bacteria. The nurse should wear a gown when providing care for a client who requires contact precautions due to the risk of contact with bodily fluids and contaminated surfaces A. have the client wear a mask when receiving visitors. The client does not need to wear a mask to prevent the spread of the infection because shigella does not require airborne or droplet precautions. B. Limit the client's time with visitors to no more than 30 minutes. Limiting the client's time with visitors will not decrease the risk of spreading shigella. Clients who require isolation precautions are at risk for depression and loneliness; therefore, the nurse should encourage visitation. C. Assign the client to a room with a negative-pressure airflow exchange. The nurse should assign a client who has shigella to a private room; however, negative-pressure airflow is not necessary because shigella is not airborne.

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take? A. Ask another nurse to observe the medication wastage. B. Notify the pharmacy when wasting the medication C. Lock the remaining medication in the controlled substances cabinet. D. Dispose of the vial with the remaining medication in a sharps container.

A. Ask another nurse to observe the medication wastage. A second nurse must witness the disposal of any portion of a dose of a controlled substance. B. Notify the pharmacy when wasting the medication Pharmacies do not require notification of the disposal of a portion of a dose of a controlled substance. C. Lock the remaining medication in the controlled substances cabinet. The nurse should not lock the remaining controlled substance in the cabinet because this is a violation of the Controlled Substances Act. D. Dispose of the vial with the remaining medication in a sharps container The nurse should not dispose of the remaining controlled substance in the sharps container because this is a violation of the Controlled Substances Act.

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take? A. Turn the client every 2 hr. B. Administer an antiemetic every 6 hr. C. Hold oral care D. Increase the room's temperature

A. Turn the client every 2 hr.

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? A. Wrap blankets around all 4 sides of the bed. B. Apply restraints during seizure activity. C. Place the client in a supine position during seizure activity. D. Have a tongue depressor at the client's bedside.

A. Wrap blankets around all 4 sides of the bed.

A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says " Every time you change my bandage, it hurts so much". Which of the following interventions is the nurse's priority? A. Encourage the client to relax and take deep breaths during the dressing change. B. Educate the client about the importance of the dressing change to prevent infection. C. Moving the client to a comfortable position for the dressing change is important because it can help the client relax and can also reduce strain on the wound. However, there is another intervention that is the priority. D. Administer pain medication 45 min before changing the client's dressing

Administer pain medication 45 min before changing the client's dressing The priority action the nurse should take when using Maslow's hierarchy of needs is to meet the client's physiological need for comfort and pain relief. Therefore, the priority intervention is to administer an analgesic 30 to 60 min before changing the client's dressing.

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? A. Insert the suctions catheter while the client is swallowing. B. Apply intermittent suction when withdrawing the catheter. C. Place the catheter in a location that is clean and dry for later use. D. Hold the suction catheter with her clean, nondominant hand.

B. 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. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise. A. Insert the suctions catheter while the client is swallowing. The nurse should insert the suction catheter while the client is inhaling to avoid inserting the catheter into the esophagus. B. Apply intermittent suction when withdrawing the catheter. C. Place the catheter in a location that is clean and dry for later use. The nurse should discard the suction catheter after use to eliminate the risk of reintroducing pathogens into the respiratory tract. D. Hold the suction catheter with her clean, nondominant hand. The nurse should hold the suction catheter with her dominant hand after donning a sterile glove.

A nurse is imitating a protective environment for a client who has had a n allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? A. Make sure the client's room has at least 6 air exchanges per hour. B. Make sure the client wears a mask when outside her room if there is construction in the area. C. Place the client in a private room with negative-pressure airflow. D. Wear an N95 respirator when giving the client direct care.

B. Make sure the client wears a mask when outside her room if there is construction in the area.

A nurse is planning to insert a peripheral IV catheter for an older adult client. Which of the following actions should the nurse plan to take? A. Insert the catheter at a 45 degree angle. B. Place the client's arm in a dependent position. C. Shave excess hair from the insertion site. D. Initiate IV therapy in the veins of the hand.

B. Place the client's arm in a dependent position.

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? A. Wear sterile gloves when removing old dressing. B. Warm the irrigation solution to 40.5 degrees C (105 degrees F). C. Cleanse the wound from the center outward. D. Use a 20-mL syringe to irrigate the wound.

C. Cleanse the wound from the center outward.

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? A. Verify the client's name on their identification bracelet with the medication administration record. B. Call the pharmacy to determine whether the client's medications are available. C. Compare the client's home medications with the provider's prescriptions. D. Place the client's home medication bottles in a secure location.

C. Compare the client's home medications with the provider's prescriptions.

A nurse 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. Remove tubes and indwelling lines. Obtain the pronouncement of death from the provider. Ask the client's family members if they would like to view the body. Place a name tag on the body. Wash the client's body.

Obtain the pronouncement of death from the provider. Remove tubes and indwelling lines. Wash the client's body. Ask the client's family members if they would like to view the body. Place a name tag on the body.

A nurse is on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? A. Pad the client's wrist before applying the restraints. B. Evaluate the client's circulation every 8 hr after application. C. Remove the restraints every 4 hr to evaluate the client's status. D. Secure the restraint ties to the bed's side rails.

A. Pad the client's wrist before applying the restraints. The use of restraints without padding can abrade the client's skin, resulting in client injury. B. Evaluate the client's circulation every 8 hr after application. C. Remove the restraints every 4 hr to evaluate the client's status. D. Secure the restraint ties to the bed's side rails

A nurse is administering an otic medication to an older adult client. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? A. Press gently on the tragus of the client's ear B. Pack a small piece of cotton deep into the client's ear canal. C. Move the client's auricle down and back toward her head. D. Tilt the client's head backward for 5 minutes.

A. Press gently on the tragus of the client's ear

A nurse is providing discharge instructions to a client who will be using a walker. Which of the following client statements indicates an understanding of the teaching? A. "I can place an extension cord across my living room to plug in my television" B. "I will hire someone to trim the tree that hangs low over the stairs of my front porch" C. "I will place my alarm clock on my bedroom dresser across the room" D. "I will replace the old throw rug in my kitchen with a new one"

B. "I will hire someone to trim the tree that hangs low over the stairs of my front porch" Clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls. A. "I can place an extension cord across my living room to plug in my television" Extension cords should be securely fastened to the floor and should be run along the edge of the wall, if possible, to avoid the risk for tripping. C. "I will place my alarm clock on my bedroom dresser across the room" Frequently used items like an alarm clock, glasses, or disposable tissues should be placed within reach, such as on the client's night stand. This helps to prevent the client from needing to get up and potentially falling in the night. D. "I will replace the old throw rug in my kitchen with a new one" Using throw rugs increases the client's risk for falls because they create a tripping and slipping hazard for the client

A nurse is educating a client who has a terminal illness about declining resuscitation in a living will. The client asks, "What would happen if I arrived at the emergency department and I had difficulty breathing?" Which of the following responses should the nurse make? A. "We would consult the person appointed by your health care proxy to make decisions." B. "We would give you oxygen through a tube in your nose." C. You would be unable to change your previous wishes about your care." D. We would insert a breathing tube while we evaluate your condition."

B. "We would give you oxygen through a tube in your nose." Oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula. A. "We would consult the person appointed by your health care proxy to make decisions." The staff must honor the client's wishes as stated in their living will; therefore, it would not be necessary to consult the person appointed by the client's health care proxy to make decisions about the client's care. C. You would be unable to change your previous wishes about your care." Clients determine advance directives ahead of time to guide decision-making at the time of an emergency event. If the client initiates a change, the staff must honor it. Otherwise, staff must honor the decisions the client has documented in the advance directives. D. We would insert a breathing tube while we evaluate your condition." Intubation is a resuscitative measure. The staff should not implement this intervention for a client who declines resuscitation in their living will.

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority? A. Request that a respiratory therapist discuss the technique for incentive spirometry with the client. B. Determine the reasons why the client is refusing to use the incentive spirometer. C. Document the client's refusal to participate in health restorative activities. D. Administer a pain medication to the client.

B. Determine the reasons why the client is refusing to use the incentive spirometer. The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action for the nurse to take is to determine why the client is refusing the treatment. A. Request that a respiratory therapist discuss the technique for incentive spirometry with the client. The nurse can request that another team member discuss the use of the incentive spirometer with the client to encourage the client to use it; however, this is not the priority action for the nurse to take. C. Document the client's refusal to participate in health restorative activities. If other interventions to promote the client's use of the incentive spirometer are unsuccessful, the nurse must document the client's refusal; however, this is not the priority action for the nurse to take. D. Administer a pain medication to the client. Pain or incisional complications might make the client refuse spirometry; however, administering medication is not the priority action for the nurse to take.

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? A. Contact B. Droplet C. Airborne D. Protective

B. Droplet Droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 1 m (3 feet) of the client who has a disorder requiring droplet precautions. A. Contact Contact precautions are a requirement for clients who have infections that spread via direct contact or from environmental contact. Examples are vancomycin-resistant enterococci and herpes simplex infections. C. Airborne Airborne precautions are a requirement for clients who have infections that spread via droplet nuclei that are smaller than 5 microns in diameter, including varicella, tuberculosis, and measles. D. Protective Clients who have a compromised immune system, such as those who have received an allogeneic stem cell transplant, require a protective environment. This precaution keeps them from acquiring infections from others.

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take? A. Rinse the feeding bag with water between feedings. B. Tell the client to keep the head of the bed elevated at least 30 degrees. C. Make sure the enteral formula is at room temperature. D. Wipe the top of the formula can with alcohol.

B. Tell the client to keep the head of the bed elevated at least 30 degrees.

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? A. Remove the outer cannula cautiously for routine cleaning. B. Use tracheostomy covers when outdoors. C. Use sterile technique when performing tracheostomy care at home. D. Cleanse irritated skin with full-strength hydrogen peroxide.

B. Use tracheostomy covers when outdoors. Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles. A. Remove the outer cannula cautiously for routine cleaning. The outer cannula stabilizes the airway; therefore, the client should never remove it for cleaning. C. Use sterile technique when performing tracheostomy care at home. In the home environment, medical asepsis with clean technique is appropriate. D. Cleanse irritated skin with full-strength hydrogen peroxide. Hydrogen peroxide can irritate the skin; therefore, the nurse should instruct the client and family to use 0.9% sodium chloride irrigation to cleanse the site and prevent further irritation.

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 discuss any concerns, the client declines. Which of the following statements should the nurse make? A. I will return shortly after I document this in your record." B. "Most men live a long time with prostate cancer." C. "I am available to talk if you should change your mind." D. "I will make a referral to a cancer support group for you."

C. "I am available to talk if you should change your mind." 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 for the client. A. I will return shortly after I document this in your record." - is likely to sound dismissive of his profound needs at this time. B. "Most men live a long time with prostate cancer."- provides false reassurance D. "I will make a referral to a cancer support group for you."- Dismissing the client's concerns by referring him elsewhere without specific intervention by the nurse is a nontherapeutic response.

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management? A. "I think I should take pain medication more often since it is not controlling my pain." B. Breathing faster will help me keep my mind off of the pain." C. "It might help me to listen to music while I'm lying in bed." D. I don't want to walk today because I have some pain. "

C. "It might help me to listen to music while I'm laying in bed." Listening to music is an effective nonpharmacological intervention for the management of mild pain. A. "I think I should take pain medication more often, since it is not controlling my pain." As a 2 on a scale of 0 to 10, this client's pain is mild. Additional analgesic medication is unnecessary at this time. B. Breathing faster will help me keep my mind off of the pain." Rapid breathing can lead to hyperventilation, while slow, focused breathing helps induce relaxation, which can help with managing pain. C. I don't want to walk today because I have some pain. " Postoperative clients need to ambulate even if they are having mild pain.

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid? A. 2 cups of soup B. 1 quart of water C. 8 oz of ice chips D. 6 oz of tea

C. 8 oz of ice chips

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? A. Place the client in a side-lying position. B. Instill 15 mL of irrigation fluid into the catheter with each flush. C. Subtract the amount of irritant used from the client's urine output. D. perform the irrigation using a 20-mL syringe.

C. Subtract the amount of irritant used from the client's urine output.

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? A. Combine client care tasks when caring for multiple clients. B. Wait until the end of the shift to document client care. C. Use the planning step of the nursing process to prioritize client care delivery. D. Allow for interruptions in tasks to discuss client care issues with colleagues.

C. Use the planning step of the nursing process to prioritize client care delivery.

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? A. "Is your pain constant or intermittent?" B. "What would you rate your pain on a scale of 1-10?" C. "Does the pain radiate?" D. "Is your pain sharp or dull?"

D. "Is your pain sharp or dull?" Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain. A. "Is your pain constant or intermittent?"- pattern of the pain. B. "What would you rate your pain on a scale of 1-10?"- intensity of the pain. C. "Does the pain radiate?"- pain's location.

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include? A. "You should have an eye exam every 2 years." B. "You should receive a tetanus booster every 5 years." C. "You should have a fecal occult blood test every 2 years." D. "You should receive a pneumococcal immunization every 10 years."

D. "You should receive a pneumococcal immunization every 10 years."

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? A. Numbness of the extremities. B. Bradycardia. C. Positive Chvostek's sign D. Abdominal cramping

D. Abdominal cramping A. Numbness of the extremities. - Hyperkalemia B. Bradycardia.- hyponatremia C. Positive Chvostek's sign- hypomagnesemia/hypocalcemia

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies? A. Biofeedback B. Aloe C. Feverfew D. Acupuncture

D. Acupuncture The nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk of further infection.

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown? A. Place the client in high-Fower's position. B. Increase the client's intake of carbohydrates. C. Massage reddened areas with unscented lotion. D. Have the client use a trapeze bar when changing position.

D. Have the client use a trapeze bar when changing position.

A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? Place the client in a room with negative-pressure airflow. Wear gloves when assisting the client with oral care. Limit each visitor to 2 hr increments Wear a surgical mask when providing client care Use antimicrobial sanitizer for hand hygiene

Place the client in a room with negative-pressure airflow. Wear gloves when assisting the client with oral care. Use antimicrobial sanitizer for hand hygiene

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply). Lacrimal apparatus Pupil clarity Appearance of bulbar conjunctivae Visual fields Visual acuity

Pupil clarity Cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because clients cannot see items in their path clearly. Visual fields The nurse should use a finger to test the client's peripheral vision by moving the finger out of range and then back into the visual field to determine when the client sees the finger. Clients who have a visual field impairment are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall. Visual acuity The nurse should use a Snellen chart to assess distance vision and a handheld card to assess near vision. Clients who wear eyeglasses should wear them during the assessments. Clients who have impaired visual acuity are at an increased risk for falls because they might not see objects in their path and trip over them or bump into them and fall Lacrimal apparatus is incorrect. If clients have an impairment in the ability to produce tears, it should not affect their fall risk. The nurse tests this by palpating the tear duct at the lower eyelid to see if any tears emerge. Appearance of bulbar conjunctivae is incorrect. The nurse should examine the bulbar conjunctivae by gently retracting the lower and upper lids to evaluate color and texture and assess for the presence of infection. However, the condition of the conjunctivae will not impede the client's safety.