ATI fundamentals test A

The nurse should instruct older adult clients to receive a pneumococcal immunization every __________ years to a group of senior citizens

10

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 0 to 10?" C) "Does the pain radiate?" D) "Is your pain sharp or dull?"

D WHY: Asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain.

rubella is under what kind of precautions

droplet

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take? A) Have the client wear a mask when receiving visitors .B) Wash her hands before and after contact with the client. C) Assign the client to a room with negative-pressure airflow exchange .D) Instruct all visitors to limit their time with the client.

B WHY: Shigella requires the nurse to perform contact precautions to prevent the transmission of the bacteria. The nurse should also use standard precautions, which require the nurse to perform hand hygiene before and after direct contact with every client, regardless of their diagnosis.

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 WHY:Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles.

a nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. which of the following assessment 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 WHY:Tachycardia indicates fluid-volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.

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 action? 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) Assist the client to a comfortable position for the dressing change. D) Administer pain medication 45 min before changing the client's dressing.

D WHY: 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 reviewing practice guidelines with a group of newly licensed nurses. which of the following interventions should the nurse include that is within the RN scope of practice? A. insert an implanted port B. close a laceration with sutures C. place an endotracheal tube D. initiate an enteral feeding though a gastrostomy tube

D WHY:It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes.

fluid volume excess symptom

Indications of fluid volume excess include distended neck veins, edema, tachycardia, crackles in the lungs, dyspnea, a bounding pulse, and an increase in blood pressure.

nurses job during surgical procedure

The nurse is responsible for witnessing the client sign the consent form. The nurse should confirm that the client appears competent to give consent and that the client understands the procedure.

what should you remind the patient what when having a PCA?

The nurse should instruct family members not to activate the button for the client while they are sleeping. Even though PCA pumps minimize the risk of overdose, toxic effects could still occur if the client receives more medication than necessary to control pain.

The nurse should instruct older adult clients to receive an eye exam every __________ year to a group of senior citizens

every year

A nurse is preparing to apply a dressing for a patient who has a stage 2 pressure injury. Which of the following dressings should the nurse use? A)Alginate B)gauze c)transparent D)hydrocolloid

D WHY:Hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed.

nurse is planning teaching for a 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 WHY: Practice sessions require psychomotor skills when learning.

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 soon as the client's condition is stable C) During the initial team conference D) After consulting with the client's family

A WHY: Discharge planning should begin as soon as the client is undergoing admission. The nurse should begin to assess the client's needs and plan for care during and after hospitalization.

nurse is assessing a client's readiness to learn about insulin 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 WHY: The client's statement indicates a readiness to learn because he is verbalizing the best time for him to learn.

The nurse should instruct older adult clients to receive fecal occult every __________ year(s) to a group of senior citizens

every year

RACE

rescue, alarm, contain, extinguish

A nurse 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 once per shift after application C) Remove the restraints every 4 hr to evaluate the client's status D) Secure the restraint ties to the client's bed side rails.

A WHY:Restraints without padding can abrade the client's skin.

A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to 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 WHY:The nurse should examine her own personal values about the issue to help her provide care that is without bias.

A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. Which of the following actions should the nurse take? 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 WHY: Less space than two fingers between the sleeves and the legs can inhibit circulation when the sleeves inflate.

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-flowers position B. increase the client's intake of carbohydrates C. massage the reddened areas with unscented lotion D. have the client use a trapeze bar when changing positions

D WHY: By using a trapeze bar to assist with repositioning and transferring, the client avoids the friction and shearing that result from sliding up and down in bed. Shearing is a risk factor for pressure-ulcer development.

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 15 mg/dL B. Creatinine 0.8 mg/dL C. Sodium 143 mg/dL D. Potassium 5.4 mg/dL

D WHY: he value is above the expected reference range and the nurse should report this finding. This client is at risk for dysrhythmias.

A nurse is performing a skin assessment of a client who has a lesion on his anterior thigh and expresses concern about skin cancer. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy? A) Uniform pigmentation B) new appearance of petechiae C) a mole with an asymmetrical appearance D) presence of a papulae

C WHY:An uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part.

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 suction 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.

D WHY: The nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. Suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise.

a nurse is reviewing protocol in preparation for suctioning secretions from client who has a 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 of the size of the lumen C. place the end of the function catheter in water-soluble lubricant D. adjust the wall suction apparatus to a pressure of 170 mm Hg

B WHY: The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.

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 WHY: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 ft) of the client who has a disorder requiring droplet precautions.

a nurse is giving discharge instructions to a client who will require oxygen therapy at home. which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home? A. the client uses a wool blanket on their bed B. the client uses non acetone nail polish C. The client stores an extra oxygen tank on its side under the bed D. the client has a weekly inspection checklist for oxygen supplies

B WHY:he client should use nonflammable materials, such as nonacetone nail polish remover, while using supplemental oxygen.

A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex? A) Back of foot (heel) B) Knee cap C) Elbow D) Back of elbow

B WHY:he nurse should identify this image as assessing the client's patellar reflex. To elicit the expected response of lower leg extension, the nurse should allow the client's legs to hang freely over the side of the examination table while seated and quickly tap the patellar tendon just below the kneecap using a reflex hammer.

a nurse is performing a Romberg's test during the physical assessment of a client. which of the following techniques should the nurse use? A. touch the face with a cotton ball B. apply a vibrating tuning fork to the clients forehead C. have the client stand with her arms at her side and her feet together D. perform direct percussion over the area of the kidneys

C WHY: A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance.

a nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. which of the following actions should the nurse plan to take? A. dissolve each medication in 5 mL of sterile water B. draw up medication together in the syringe C. push the syringe plunger gently when feeling resistance D. flush the tube with 15 mL of sterile water

D WHY: The nurse should flush the feeding tube with 15 to 30 mL of sterile water before administration and between each medication. The nurse should flush the feeding tube with 30 to 60 mL of sterile water following the administration of the last medication.

a nurse is caring for a client who has tuberculosis. which of the following actions should the nurse take? (Select all that apply) A. place the client in a rom with negative pressure airflow B. wear gloves the assisting the client with oral care C. limit each visitor to 2 hour increments D. wear a surgical mask when providing client care E. use antimicrobial sanitizer for hand hygiene

A,B,E

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 other at a 45º angle B. place the client's arm in a dependent position C. shave excess hair from the insertion site D. initiative IV therapy in the veins of the hand

B WHY:The nurse should place the client's arm in a dependent position because the veins will dilate due to gravity.

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 move the cane 46 cm (18 in) forward C. the client holds the cane on the stronger side of her body D. the client moves her stronger limb forward with the cane

C WHY:The client should hold the cane on the stronger side of her body to increase support and maintain alignment.

a nurse is lifting a bedside cabinet to move it closer to a client who is sitting in a chair. to prevent self-injury, which of the following actions should the nurse take when lifting this object? A. bend at the waist B. keep his feet close together C. use his back muscles for lifting D. stand close to the banner when lifting it

D WHY: This action keeps the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching.

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) 1) Place a name tag on the body 2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body

2) Obtain the pronouncement of death from the provider 3) Remove tubes and indwelling lines 4) Wash the client's body 5) Ask the client's family members if they would like to view the body 1) Place a name tag on the body WHY:The first step is to obtain the death pronouncement from the provider. Next, the nurse should remove tubes and indwelling lines prior to cleansing the client's body. After cleansing, the nurse should ask the family members if they wish to view the body. Finally, the nurse should place a name tag on the body before transfer.

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 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 with a do-not-resuscitate (DNR) status 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 min before the procedure that the nurse promised she would give her.

A WHY: Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others.

A nurse is preparing an education program for staff about advocacy> which of the following information should the nurse include? A) advocacy ensures clients health, safety, and rights B)Advocacy ensures the 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

A WHY: 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 manager is preparing to review medication documentation with a group of newly licensed nurses. which of the following statements should the nurse manger 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 WHY: The Institute for Safe Medication Practices designates that nurses and providers write the complete medication name for magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate.

a nurse is caring for a client who has terminal live 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 WHY: The client's terminal illness might prompt him to review his life and question its meaning. A manifestation of the client's spiritual distress is asking why this illness is happening to him.

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 WHY: The first action the nurse should take when using the nursing process is to assess the client for injuries.

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-fowlers position to medication administration D. verify the dosage by measuring the liquid before administering it

A WHY: The nurse should gently shake the liquid medication to ensure the medication is mixed.

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk of inure to this client? A) use a bed exit alarm system B) raise 4 side rails while client is in bed C) apply one soft wrist restraint D) dim the lights in the clients room

A WHY: 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.

A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take? A) Administer the medication with the needle at a 45° angle. B) Administer the medication into the client's nondominant arm. C) Pull the client's skin laterally or downward prior to administration. D) Massage the injection site after administration.

A WHY: The nurse should insert the needle for a subcutaneous injection at a 45° to 90° angle.

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

A WHY: The nurse should turn the client at least once every 2 hr to break up the secretions in the client's lungs and prevent noisy respirations.

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A) "When descending stairs, I will first shift my weight to my right leg." B) "I should place my crutches 12 inches in front and to the side of each foot." C) "As I sit down, I will hold one crutch in each hand." D) "I will make sure the shoulder rests are snug against my armpits.

A WHY: To descend stairs, the client should first shift his body weight to his right (unaffected) leg.

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 WHY: Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy.

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.) A) Assist the client with a partial bed bath. B) Measure the client's BP after the nurse administers an antihypertensive medication. C) Test the client's swallowing ability by providing thickened liquids. D) Use a communication board to ask what the client wants for lunch. E) Irrigate the client's indwelling urinary catheter.

A,B,D Assist the client with a partial bed bath is correct. Assisting a client with a bed bath poses minimal risk to the client and fits within the AP's range of function. Measure the client's BP after the nurse administers an antihypertensive medication is correct. Measuring a client's BP poses minimal risk to the client and fits within the AP's range of function. Use a communication board to ask what the client wants for lunch is correct. Using a communication board poses minimal risk to the client and fits within the AP's range of function.

A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? (Select all that apply.) A) Check the cord routinely for frays or tearing. B) Keep the unit at least 4 feet away from a gas stove. C) Consider purchasing a generator for power backup. D) Observe for signs of hypoxia. E) Select synthetic clothing and bedding.

A,C,D

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 A client who has tuberculosis requires airborne precautions, which include placing the client in a room that has negative-pressure airflow to reduce the risk of infection transmission.

A nurse has just inserted an NG tube for a client. Which of the following assessment findings should the nurse expect to confirm correct tube placement? A) The tube aspirate has a pH of 7. B) An x-ray shows the end of the tube above the pylorus. C) Bowel sounds are present on auscultation. D) The client reports relief of nausea

B WHY: An abdominal x-ray showing the end of the tube above the pylorus indicates gastric placement.

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? 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 WHY: An allogeneic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment.

a nurse is caring for a client who is terminally ill. which of the following statements should the nurse identify as an indication that the client's family member is coping effectively with the situation? A. "we are not worried. we still have hope that everything will be ok." B. "this is a difficult time, but we are helping each other though this." C. "after he comes home, we can plan out family reunion." D. "we don't need to talk about funeral arraignments at this time."

B WHY: An effective coping strategy is talking with others in the family and supporting each other. This statement displays effective coping skills because the family is using social supports to assist them throughout the grief process.

urse is providing discharge instructions to a client who will be using a walker. Which of the following statements by the client indicates a need for further instruction by the nurse? A. I will tape electrical cords to the baseboards in each room B. I will hire someone to trim that tree that overhangs the front porch stairs C. I will remove the table from the hall D. I will replace the old throw rug in the kitchen with a new one

B WHY: 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 nurse is administering 1 L of 0.9% sodium chloride 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

B WHY: Fluid-volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range.

a nurse is preparing a change-of-shift report. which of the of the following tools or documents should the nurse use to communicate continuity of care? A. critical pathway B. SBAR C. transfer report D. medication administration record (MAR)

B WHY: SBAR is a communication tool nurses use to relate a client's status during a change-of-shift report.

a nurse is caring for a client who report pain. when documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? A. "I'm having mild pain." B. "the pain is like a dull ache in my stomach." C. "I notice that the pain gets worse after I eat." D. "the pain makes me feel nauseous."

B WHY: The client is describing the quality of the pain, which is how the pain feels in her own words.

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 first? A. rinse the feeding bag with water between feedings B. tell the client to keep the head of the bed elevated at least 30º C. make sure the enteral formula is at room temperature D. wipe the top of the formula can with alcohol

B WHY: The first action the nurse should take when using the airway, breathing, circulation approach to client care is to prevent aspiration of the enteral formula; therefore, the priority intervention is to keep the head of the bed elevated at least 30° to prevent reflux of the formula backward into the esophagus.

a nurse is caring for a client who is refusing a blood transfusion for religious reasons. the client's partner wants the client to have the blood transfusion. which of the following actions should the nurse take? A. ask the client to consider a direct donation B. withhold the blood transfusion C. request a consolation with the ethics committee D. ask the client's family to intervene

B WHY: The principle of autonomy ensures that a client who is competent has the right to refuse treatment.

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 on the client's medical record? A. .3 mg B. 0.3 mg C. 0.30 mg D. 3/10 mg

B WHY: The use and placement of a decimal point can potentially cause a medication error if documented incorrectly. A zero should precede a decimal point, as in 0.3 mg, but should not follow a decimal point unless a whole number follows the zero, as in 2.05 mg.

A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide? A) Admitting diagnosis B) Breath sounds C) Body temperature D) Diagnostic test results

B WHY: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority information to provide is the current status of the client's breath sounds.

a nurse is caring for a client who asks about the purpose of advance directives. which of the following statements should the nurse make? A. "they allow the court to overrule an adult client's refusal of medical treatment." B. "they indicate the form of treatment a client is willing to accept in the event of a serious illness." C. "the permit a client to withhold medical information from heath care personnel." D. "they allow heath care personnel in the emergency department to stabilize a client's condition."

B WHY:Advance directives include a living will, which permits the client to direct treatment in the event of a terminal illness.

A nurse is educating a client who has a terminal illness about her request to decline resuscitation in her living will. The client asks what would happen if she arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide? A) "We will determine who the durable power of attorney for health care form has designated." B) "We will apply oxygen through a tube in your nose." C) "We will ask if you have changed your mind." D) "We will insert a breathing tube while we evaluate your condition."

B WHY:Oxygen can provide comfort and is not resuscitative when the nurse delivers it via nasal cannula.

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 is the nurse's priority action? A. request that a respiratory therapist discuss the technique for incentive spirometer B. determine the reasons why the client is refusing to use the onetime spirometer C. document the client's refusal to participate in health restorative activities D. administer a pain medication to the client

B WHY:The first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action is for the nurse to determine why the client is refusing the treatment.

A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vital signs every 15 min and call him back in 1 hr. From a legal perspective, which of the following actions should the nurse take next? A) Document the provider's statement in the medical record. B) Notify the nursing manager. C) Consult the facility's risk manager. D) Complete an incident report.

B WHY: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 nurse is assessing four adult clients. Which of the following physical assessment techniques would the nurse use? A) Use the face, Leg, activity, cry, and consolability (FLACC) pain rating scale for a client who is experiencing pain B)Ensure the bladder of the blood pressure cuff surrounds 80% of the clients arm C)Obtain an apical heart rate by osculating the third intercostal space left of the sternum D) palpate the clients abdomen before osculating bowel sounds

B WHY:The nurse should use a blood pressure cuff with a bladder that surrounds 80% of the client's arm circumference to give an accurate reading.

a nurse is assessing an older adult client's risk for falls. which of the following assessments would the nurse use to identify the cent's safety needs? (Select all that apply). A. lacrimal apparatus B. pupil clarity C. appearance of bulbul conjuctivae D. visual fields E. visual acuity

B,D,E WHY: 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.

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 getting a part time job or doing volunteer work c)lets talk about how the change in your job status will affect you D) why wouldn't you want to retire and relax?

C WHY: this response is therapeutic because the nurse is encouraging the client to verbalize feelings about the life transition of retirement

a nurse is assessing a client who has been on 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 WHY:Swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility.

A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene? 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 family member washes out the feeding bag with warm water once every 24 hr. D) The family member flushes the tubing with water before and after giving medications.

C WHY:The family member washes out the feeding bag with warm water once every 24 hr.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment 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 WHY: A client who has an indwelling urinary catheter should have continuous urine flow without an accumulation of urine in the bladder; therefore, the nurse should irrigate the catheter to resolve a blockage.

A nurse in a clinical is caring for a middle age adult who states, "the doctor says that since I am at an average risk for colon cancer, I should have a routine screening. what does that involve?" which of the following responses should the nurse make? A. "I'll get a blood sample from you and send it for a screening test." B. "beginning at age 60, you should have a colonoscopy." C. "you should have a decal occult blood test every year." D. "the recommendation is to have a sigmoidoscopy every 10 years."

C WHY: Colorectal cancer screening for clients at average risk begins at age 50. One option for screening is a fecal occult blood test annually.

a nurse is caring for a client who requires a 24-hour urine collection. which of the following statement 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 flushes 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 txt quickly."

C WHY: For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings.

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 WHY: Setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management.

a nurse is caring for a client receiving fluid through a peripheral IV catheter. which of the following filings at the IV site should the nurse identify as infiltration? A. purulent exudate B. warmth C. skin blanching D. bleeding

C WHY: Skin blanching, edema, and coolness at the IV site indicate infiltration.

a nurse is caring for a client who is reporting difficulty falling asleep. which of the following measures should the nurse recommend? A. drink a cup of hot cocoa before bedtime B. exercise 1 hr before going to bed C. maintain a consistent time to wake up each day D. reflect on the day's activities before going to bed

C WHY: The client should maintain a consistent time for waking up and going to sleep. This helps to establish an internal sense of sleep and waking on a daily basis and helps to maintain it over time. This will help promote sleep for the client.

a nurse is reviewing a client's medication prescription, which reads, "digoxin 0.25 by mouth every day." which of the following components of the prescription should the runs question? A. the medication B. the route C. the dose D. the frequency

C WHY: The dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer.

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 WHY: The nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output.

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 the old dressing B. warm the irrigation solution of 40.5ºc (105ºF) C. cleanse the wound from the center outward D. use a 20 mL syringe to irrigate the wound

C WHY: The nurse should clean the wound from the center outward to prevent introduction of micro-organisms from the outer skin surface.

A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about this incident? A) "Incident report completed." B) "Client climbed over the bedrails." C) "Client found lying on floor." D) "Client was trying to get out of bed."

C WHY: he nurse should include documentation that is descriptive, objective information about what she actually observed, without any opinions or judgment about motive or cause.

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 tarsus of the client's ear B. pack a small piece of cotton deep into the cent's ear canal C. move the client's auricle down and back toward her head D. tilt the client's head backward for 5 min

C WHY:Pressing gently on the tragus of the ear will help the medication get into the inner ear.

a nurse is providing discharge teaching to a client about self administering heparin. Which of the following instructions should the nurse include in the teachings? A)insert the needle at 15 degrees B)Aspirate for blood return prior to administration C)administer the medication in the abdomen D)massage the site following the injection

C WHY:The nurse should instruct the client to administer the medication into the abdomen at least 5.08 cm (2 in) from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subcutaneous tissue.

a nurse is talking with the partner of an older adult male client who has dementia. the client's partner expresses frustration about finding time to manage household responsibilities while caring for his partner. the nurse should identify that he is going through which of the following types of role-performing stress? A. role ambiguity B. sick role C. role overload D. role conflict

C WHY:The partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can perform.

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? 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 WHY:When a client does not wish to share his feelings with the nurse, it is important for the nurse to convey a willingness to be available when he needs her.

A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 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 my 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."

D WHY: Listening to music is an effective nonpharmacological intervention for the management of mild pain.

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? A) Seal unused hospital medications in a plastic bag. B) Evaluate the client's ability to self-administer medications .C) Report an identified discrepancy to The Joint Commission. D) Compare prescriptions with medications the client received during hospitalization.

D WHY: The nurse should compare the client's home medications with the provider's prescriptions when performing medication reconciliation.

a nurse is caring for a client who has herpes zoster and asks the runs about the use of complementary and alternative therapies for pain control. the nurse should inform inform the client that his condition is a contraindication for which of the following therapies? A. biofeedback B. aloe C. feverfew D. acupuncture

D WHY: 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 auscultating the anterior chest of a client newly admitted to a medical-surgical unit. Listen to the audio clip of what the nurse auscultates through his stethoscope and identify the type of breath sounds he hears. A) Crackles B) Rhonchi C) Friction rub D) Normal breath sounds

D WHY: These are normal bronchovesicular breath sounds, characteristically of moderate intensity and sounding like blowing as air moves through the larger airways on inspiration and expiration.

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make? A) "Most people are happy when their children grow up and leave home." B) "You should be proud that your children are becoming independent." C) "Maybe you should consider why you are feeling useless." D) "People in middle adulthood often find satisfaction in nurturing and guiding young people."

D WHY: According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore with the client opportunities for mastering the developmental tasks of this stage, such as volunteering and mentoring young people.

a nurse is caring for a client who is expressing anger over 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 to 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 WHY: During the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and ensure him that this is an expected reaction to a cancer diagnosis.

a nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. which of the following types of transition precautions hold the nurse initiate? A. protective environment B. airborne precautions C. droplet precautions D. contact precautions

D WHY: Major wound infections require contact precautions, which mean the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client.

a charge nurse is discussing the responsibility of nurses caring for clients who have a clostridium difficile infection. which of the following information should the nurse include in the teaching? A. assign the client to a room with a negative air-flow system B. use alcohol-based hand sanitizer when leaving he client's room C. clean contaminated surfaces in the client's room with a phone solution D. have family members wear gown and gloves when visiting

D WHY: Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Caregivers must also wear gowns and gloves.

A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy? A) 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 WHY: Some essential oils can cause bronchospasm; therefore, the nurse should consult the client's provider before using this therapy.

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 30º prior to insertion of the NG tube B. remove the NG tube if the client begins to gag of 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 WHY: Taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube's passage into the trachea.

A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that she understands the use of this assistive device? A) "This type of hearing aid does not allow for fine tuning of volume." B) "I shouldn't have trouble keeping the hearing aid in place during exercise." C) "I expect to hear a whistling sound when I first insert the hearing aid." D) "I will be sure to remove my hearing aid before taking a shower."

D WHY: The client should remove any hearing device before showering because exposure to water can damage the hearing aid.

a nurse is planning care to improve self-feeding for a client who has vision loss. which of the following interventions should the nurse include in the plan of care? A. tell the client which food she should eat first B. provide small-handle utensils for the client C. thicken liquids on the client's tray D. use a clock pattern to describe food on the client's plate

D WHY: se a clock pattern to describe food on the client's plate.MY ANSWERDescribing the location of the food on the plate by using a clock pattern allows the client to have greater independence during meals.

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include? A) Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter. B) Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. C) Make sure the reservoir bag of a partial rebreathing mask remains deflated D) Use petroleum jelly to lubricate the client's nares, face, and lips.

D WHY:Evidence-based practice supports the use of a water-soluble lubricant to protect the client's skin from the drying effects of oxygen.

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures? a. Trochanter roll b. Sheepskin heel pad c. Abduction pillow d ankle foot orthotic device to the clients feet

D WHY:The nurse should use a device to maintain dorsiflexion, such as an ankle-foot orthotic device or a foot board placed perpendicular to the mattress.

The nurse should instruct older adult clients to receive a tetanus booster every __________ years to a group of senior citizens

10

a nurse is preparing a herparing infusion for a client who was hospitalized with deep-vein thrombosis. the orders read: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. at what rate should the nurse set the infusion pump? (round to the nearest whole number)

8

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 four 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 WHY: The nurse should affix linens or blankets around the head, foot, and side rails of the bed to pad them and prevent injury for a client who has been having frequent tonic-clonic seizures.

a nurse is administering IV fluid to an older adult client. the nurse should perform which priority assessment to monitor for adverse effects? A. auscultate lung sounds B. masure urine output C. monitor blood pressure readings D. monitor serum electrolyte levels

A WHY: The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid-volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles heard in lung fields, dyspnea, and shortness of breath.

A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make? A) "We can talk about advance directives, and I can also give you some brochures about them." B) "You should set up a time to talk with your provider about that." C) "Let's discuss how you are feeling today, and we'll save the planning for when you are feeling a little better." D) "Why do you want to discuss this without your partner here to plan this with you?"

A WHY:With this statement, the nurse offers to provide the information the client needs in a direct and simple way.

a nurse is assessing an adult client who has been immobile for the past 3 week. the nurse should identify that which of the following findings requires further intervention? A. erythema on pressure points B. lower-extremity pulse strength on 2+ C. fluid intake of 3,000 mL per day D. a bowel movement every other day

A. WHY: Erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from breakdown.

a nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. in preparation for the client's procedure, which of the following precautions should the nurse take? A. ensure sterilization of non disposable items with ethylene oxide B. wrap monitoring cords with stockinette and tape them in place C. cleanse latex pots on IV tubing with chlorohexidine before injection medication D. wear hypoallergenic latex gloves that contain powder

B WHY: Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them.

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next? A) Activate the emergency fire alarm. B) Extinguish the fire. C) Evacuate the client. D) Confine the fire.

C WHY: According to the RACE mnemonic, the first action in response to a fire is to rescue the clients, moving them to a safe area.

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 WHY: he first action the nurse should take using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting her to sit and dangle her feet on the side of the bed. The nurse should assess her for dizziness and a significant drop in blood pressure before assisting her to stand and transfer into the chair.

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

C WHY:The nurse should document half of the volume of ice chips when calculating fluid intake to account for the air in between the chips. Four oz of liquid water equals 120 mL of fluid.

sign of potential elderly abuse?

Caregiver refuses to leave the room A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment.

Ginkgo biloba can be taken to improve

memory and reduce stress.

Echinacea is taken to

promote immunity and reduce the risk of infection.

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 eating the medication C. lock the remaining medication in the controlled substance cabinet D. dispose of the vial with the remaining medication in a sharps container

A WHY:A second nurse must witness the disposal of any portion of a dose of a controlled substance.

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 WHY:The client has hyponatremia, a low sodium level. Manifestations include abdominal cramping, weakness, headache, and nausea.

UAPs cannot

Teach, Assess, Plan, Evaluate

Feverfew is taken to

promote wound healing and decrease inflammation associated with arthritis.

Valerian and chamomile can be taken to

reduce anxiety.

Ginger is taken to

relieve nausea and vomiting and aid in digestion