ATI MIDTERM
A nurse is caring for a client who is experiencing tachypnea due to an exacerbation of asthma. Which of the following medications should the nurse anticipate administering? a) nicotine product b) opioid antagonist c) antihypertensive d) bronchodilator
bronchodilator
A nurse is caring for a client who is scheduled for an emergency appendectomy and reports increasing anxiety. Which of the following statements should the nurse make to implement a complementary health strategy?
"Try to take slow, deep breaths in and out."
A nurse is teaching about the Affordable Care Act. What should she include?
A focus of the ACA is disease prevention.
A nurse is assisting with teaching a class about U.S. Food and Drug Administration (FDA) regulation of nutritional supplements. Which of the following information should the nurse include in the teaching?
A nutritional supplement contains at least one nutritional component.
A nurse is washing their hands with soap and water prior to repositioning of a client in bed. During the handwashing procedure, it is important to take which of the following actions?
WASH FOR at least 15 seconds
A nurse is teaching a group of AP about techniques used to obtain BP. For which of the following clients should the nurse to instruct the AP to obtain an electronic BP measurement? a) a client who has a BP lower than the expected reference range b) a school-age client c) a client recovering from extensive abdominal surgery d) a client who has stabilized BP measurements
a client who has stabilized BP measurements
A nurse is planning care for a group of clients. For which of the following clients should the nurse direct an AP to obtain a rectal temperature? a) a toddler who has diarrhea b) a client who is 1 day post op from hemorrhoid surgery c) an infant who is receiving IV fluids d) a client who is diaphoretic and frequently chewing ice to relieve dry mouth
a client who is diaphoretic and frequently chewing ice to relieve dry mouth
A nurse is caring for a group of clients. Which of the following clients is experiencing an alteration in their RR that requires intervention? a) an adolescent who has a RR of 20/min b) an older adult with RR of 16/min c) an infant with RR of 52/min d) a school-age child who has a RR of 14/min
a school-age child who has a RR of 14/min
a nurse is caring for a client who requires total assistance with mobility. when using the Mobility Assessment Tool (MAT), which of the following pieces of equipment should the nurse use to transfer the client? - gait belt- mechanical lift- cane- sit-to-stand lift
mechanical lift
a nurse is preparing a poster presentation about the musculoskeletal system. the nurse should include that which of the following is responsible for body posture? - center of gravity - bones - muscles - synovial joints
muscles
A nurse is caring for a client who has bariatric care needs and has a rash between skinfolds. Which of the following actions should the nurse take?
Assist the client as needed to ensure proper hygiene is performed.
A nurse is discussing the FLACC scale with a newly licensed nurse. Which of the following categories should the nurse include? (Select all that apply.) Face Legs Alert Circulation Consolability
Face Legs Consolability
A nurse is hired to be a case manager in a facility. Which of the following services should the nurse expect to perform?
Facilitate transfer of clients to meet the required level of care.
A nurse at a community health center is providing an in-service for a group of residents about the Healthy People program. Which of the following information should she include?
Initiatives to reduce health care disparities. Activities to improve social determinants of health. Improving access to health care.
A nurse is assisting with an in-service for staff members about culturally competent care. Which of the following information should the nurse include about traditional Native American beliefs?
Music can produce healing energy.
A nurse is reviewing information about the structure and function of the nails with a client. Which of the following information should the nurse include?
The cuticle of the nail forms a barrier to prevent infections.
A nurse is caring for a client who has right-sided hemiplegia following a stroke. Which of the following should the nurse consider when caring for this client?
The nurse should have the client remove clothing from the unaffected side first.
A nurse is reviewing a list of client care tasks with another nurse. In which of the following scenarios should the nurse plan to use soap and water to perform hand hygiene? (Select all that apply.)
The nurse's hands become visibly soiled. The nurse removes the meal tray of a client who has infectious diarrhea. The nurse empties the urinal of a client who has Clostridium difficile.
After assisting a newly admitted client with removing their shoes and outerwear, the nurse notices what appears to be soil or grime on their hands. Which of the following actions should the nurse take?
Wash their hands with soap and water.
A nurse is reviewing the vitals for a group of clients obtained by an AP. The nurse should identify that which of the following clients requires a follow-up assessment due to bradycardia? a) a school-age child who has an apical pulse of 78/min b) a young adult who has a radial pulse of 56/min c) an adolescent who has a radial pulse of 76/min d) an older adult with apical pulse of 62/min
a young adult who has a radial pulse of 56/min
A nurse is reviewing the vital signs for a group of clients. Which of the following clients should the nurse identify as exhibiting tachycardia? a) an infant who has an apical pulse rate of 132/min b) a preschooler who has an apical pulse rate of 108/min c) a young adult who has an apical pulse rate of 104/min d) an older adult who has an apical pulse rate of 96/min
a young adult who has an apical pulse rate of 104/min
A nurse is caring for a client who has a sunburn. The nurse should identify that which of the following herbal supplements is used to treat sunburns?
aloe vera
A nurse is obtaining vital signs for a group of clients. Which of the following findings requires intervention? a) a 17 year old who has a RR of 16/min b) a young adult who has a pulse rate of 98/min c) an 11 year old who has a RR of 34/min d) an older adult who has a pulse rate of 62/min
an 11 year old who has a RR of 34/min
A nurse is explaining the practice of Ayurveda to a newly licensed nurse. The nurse should include that Ayurveda is based on establishing a balance between the body, mind, and spirit with which of the following elements? (Select all that apply.)
earth sky water
A nurse is caring for a client who reports that they have lost their job and do not have insurance. Which of the following social determinants of health is challenging for this client?
economic stability
A nurse is assessing a client who has orthostatic hypotension. Which of the following actions should the nurse take?a) encourage the client to change positions slowly b) restrict the client's oral intake of fluids c) encourage the client to take a short walk d) discontinue IV fluids
encourage the client to change positions slowly
A nurse is reviewing the scope of nursing practice. Which of the following is the purpose of the nursing scope of practice?
specifies the actions a nurse can perform
a nurse is planning care for a client who is postoperative. in which of the following positions should the nurse place the client to prevent atelectasis - Fowler's- lateral- prone- supine
Fowler's
A nurse is assisting with teaching a class about using holistic nursing interventions to care for clients. Which of the following information should the nurse include?
Holistic nurses empower clients to actively participate in their own care.
A nurse is about to irrigate a client's open wound. Besides gloves, which of the following protective equipment should the nurse wear?
a face shield
A nurse is caring for a client who practices a religion the nurse is not familiar with. Which of the following actions should the nurse take
discuss with the client their individual perspective on health and illness
a nurse is providing teaching for a client who injured their ankle. which of the following information should the nurse include? - cartilage is always remodeling and changing - tendons connect muscle to bone - ligaments are flexible connective tissue that coat bony areas - synovial joints attach the skeleton to maintain posture
tendons connect muscle to bone
A nurse is teaching a client who has a new diagnosis of a skin infection about the function of the skin in the body. Which of the following statements should the nurse include?
the skin contains Langerhans cells that kill pathogens
A nurse is performing nail hygiene on a client. Which of the following actions should the nurse take?
trim the nails straight across
A nurse is teaching about Medicaid to a client who is concerned about paying for health care. Which of the following statements should the nurse make?
your income will determine if you are eligible for medicaid
A nurse is caring for an older adult client whose caregiver reports that the client is resistant to bathing at home. Which of the following statements should the nurse make?
"Give the client choices regarding their bathing preferences to encourage them to bathe."
A nurse is performing the role of case manager for a client. Which of the following actions demonstrates this nursing role? A) Coordinating and overseeing the care the client is receiving B) Helping to develop nursing knowledge for clinical interventions C) Providing knowledgeable and compassionate care to promote health and address illness D) Instructing the client on specialized topics such as diabetes care
Coordinating and overseeing the care the client is receiving
a nurse is caring for a client who had a stroke and is immobile. the nurse should identify that the client is at risk for which of the following conditions? - deep vein thrombosis - asthma- hernia - hypertension
deep vein thrombosis
A nurse is evaluating the effectiveness of interventions provided to a client who was admitted fr decreased circulation. Which of the following findings require further intervention by the nurse? a) pulse deficit of 0 b) left radial pulse is nonpalpable c) peripheral pulse +2 bilateral d) brachial pulses are symmetrical
left radial pulse is nonpalpable
A nurse is providing client care using the nursing process. The nurse should identify that which of the following standards or guidelines includes this criterion?
standards of practice
A newly licensed nurse is reviewing the standards of care when performing client care. Which of the following describes a standard of care?
the level of care a nurse provides that is the same for all nurses who have comparable education, competency, and experience
A nurse is assisting with providing an in-service for staff members about complementary and integrative health. Which of the following statements by a staff member indicates an understanding of the teaching?
"Scented oils might decrease discomfort."
A nurse is assisting with providing end-of-life care for a client who is unresponsive and near death. The client's family asks the nurse about managing the client's pain. Which of the following statements should the nurse make to the client's family? a. "Your family member will not require pain medication." b. "Your family member can inform the provider about their decision for pain management." c. "Your family member has the right to receive effective pain management." d. "Your family member will not be able to tolerate the effects of pain medications."
"your family member has the right to receive effective pain management."
A nurse in a provider's office is speaking with a client who needs a refill for a prescription that has expired. The nurse should identify that which of the following team members can assist the client with the refill?
Advanced practice registered nurse (APRN)Physician Assistant (PA)Physician
A nurse is teaching a patient about extended-wear skin barriers. Which of the following strategies should the nurse instruct the patient to use for maximal adherence? A. Use an oil-based lotion on the peristomal area .B. Apply the skin barrier while the skin is slightly moist .C. Leave the residue from the previous appliance on the skin. D. Press gently around the barrier for 30 seconds to 1 min.
D. Press gently around the barrier for 30 seconds to 1 min. Rationale: The nurse should instruct the client to press gently around to barrier for 30 seconds to 1 min because the pressure-sensitive tackifiers and heat-sensitive polymers of the skin barrier require adequate pressure and warmth (from the fingers) to ensure adherence.
A nurse is caring for a client who asks about naturopathy. The nurse should include that which of the following is a component of naturopathy? (Select all that apply.)
Dietary supplements Exercise Traditional Chinese medicine Homeopathy
A nurse educator is planning a presentation for nurses about the opioid epidemic. Which of the following is a strategy promoted by the U.S.Department of Health and Human Services to address this epidemic? A)Continue to evaluate to determine if the use of opioids improves on its own. B) Educate nurses and other health care personnel about naloxone C) Keep the issue private to avoid embarrassment. D) Reduce efforts to explore alternative pain management practices until the opioid epidemic is over.
Educate nurses and other health care personnel about naloxone
A nurse is collecting data from a client who is nonverbal to determine the presence of pain. Which of the following assessment findings indicates an increased level of discomfort? (Select all that apply.) Grimacing Restlessness' Elevated temperature Increased diaphoresis Bradycardia
Grimacing Restlessness Increased diaphoresis
A nurse is contributing to a plan to teach staff about the ethical principle of justice and how it relates to pain management for clients. Which of the following statements should the nurse make? a. "Justice allows the client the freedom of choice." b. "Justice allows the client the opportunity to be treated fairly." c. "Justice is causing no harm to the client." d. "Justice is doing good for the client."
Justice allows the client the freedom of choice
A nurse resides in a state that recently enacted the Nurse licensure Compact (NLC). Which of the following information should the nurse identify as a part of the NLC?
NLC allows a nurse to practice in their primary state of residence and in other compact states under one multistate license
A nurse is assisting with the care of a client who is postoperative following abdominal surgery and has a morphine PCA pump. Which of the following medications should the nurse ensure is available in case the client develops respiratory depression? a. Naloxone b. Lidocaine c. Prednisone d. Amitriptyline
Naloxone
A nurse is caring for a client who has severe pain and repeatedly asks for pain medication. The nurse is busy and forgets to collect data about the client's pain and administer prescribed pain medication. Which of the following can the nurse be charged with? a. Malpractice b. Negligence c. Nonmaleficence d. Beneficence
Negligence
A nurse is caring for a client who asks about using aromatherapy for nausea. Which of the following scents should the nurse recommend? (Select all that apply.)
Peppermint Ginger Orange
A nurse is caring for a Parkinson's patient and needs assistance for their ADLs. Which of the following referrals should the nurse anticipate the provider to prescribe?
Physical therapist Occupation therapist Dietician
A nurse is caring for a client who has mycoplasma pneumoniae. The client has been placed on droplet precautions. Which of the following actions should the nurse take when caring for the client?
Protect their eyes.
A nurse who completed their shift realized they forgot to take a client's vital signs as frequently as prescribed. Which of the following actions should the nurse take to uphold the American Nurses Association's Code of Ethics for Nurses with Interpretive Statements? A) Take the client's vital signs now and document them as being completed 8 hr earlier. B) Document vital signs that are the same as those obtained earlier. C) Make a reminder note to be more diligent when returning the next day. D) Report this omission to the charge nurse and the nurse on the next shift
Report this omission to the charge nurse and the nurse on the next shift
A nurse manager is providing education to a group of newly licensed nurses about various nursing organizations. Which of the following information should the nurse manager include? A) The American Nurses Association's The Code of Ethics for Nurses with Interpretive Statements guides nurses through difficult decisions. B) The National Academy of Medicine developed the Healthy People campaign to improve the health of all Americans C) The American Academy of Nursing requires members to have a doctorate degree in nursing to join. D) The National Student Nurses' Association is an organization created to encourage students to enter nursing.
The American Nurses Association's The Code of Ethics for Nurses with Interpretive Statements guides nurses through difficult decisions.
A nurse is caring for a client who has kidney stones. Which of the following manifestations is an objective indicator of pain? a. The client is diaphoretic. b. The client is experiencing stabbing pain. c. The client is nauseated. d. The client states feeling dizzy.
The client is diaphoretic.
A nurse is reviewing the health history of a client during a routine office visit. Which of the following observations by the nurse is an example of the client demonstrating health literacy? A) The client states they want to improve their current knowledge about their health. B) The client asks for information that will help them improve their eating habits. C) The client states they understand their health care information and treatments. D) The client requests a meeting with the nurse, the physical therapist, and the provider.
The client states they understand their health care information and treatments.
A nurse is caring for a client who is receiving palliative care. Which of the following non-pharmacological nursing interventions should the nurse provide the client?
Therapeutic touch
A nurse is planning care for a client who has incontinence. Which of the following information should the nurse consider when providing skin care for the client?
Urinary incontinence can cause a yeast infection.
A nurse is discussing culturally competent care with another nurse. Which of the following statements should the nurse include? A) "Use a medical interpreter for a client who does not speak the same language." B) "Provide the client with information in print only so they can have it as a resource." C) "Provide standard educational materials to all clients for continuity." D) "Limit communication with the client if there is a language barrier."
Use a medical interpreter for a client who does not speak the same language
A nurse is performing foot care for a client. Which of the following actions should the nurse take?
Use a towel to completely dry between the toes.
A nurse is assisting with teaching a newly licensed nurse about holistic nursing. Which of the following information should the nurse include? (Select all that apply.)
Use deep breathing to promote relaxation in clients .Encourage clients to use guided imagery to decrease pain .Apply essential oils to treat anxiety in clients.
A nurse is reviewing the vital signs fir four clients. The nurse should identify that which of the following clients has a vital sign outside of the reference range? a) a 52 year old client who has a fever due to a would infection and a pulse rate of 100/min b) a 76 year old client who reports moderate pain and has a RR of 20/min c) a 46 year old client who is postoperative following a hysterectomy and has an SaO2 of 95% d) a 23 year old client who runs marathons and has a BP of 82/54 mm Hg
a 23 year old client who runs marathons and has a BP of 82/54 mm Hg
A nurse is evaluating the effectiveness of interventions provided to four clients who have unexpected findings for vital signs. Which of the following findings requires follow up? a) a client has an 8 mm Hg difference in systolic BP when moving from a sitting to a standing position b) a client has a radial pulse of +4 bilateral c) an older adult client has a tympanic temperature of 35.9 degrees c (96.6 degrees f) d) a newborn has a RR of 56/min while sleeping
a client has a radial pulse of +4 bilateral
A nurse working on a medical-surgical unit is caring for a group of clients. Which of the following clients' vitals should the nurse identify is outside the expected reference range and notify the provider? a) a client who has an apical pulse rate of 120/min b) a client who has a BP of 100/74 mm Hg c) a client who has an apical pulse rate of 84/min d) a client who has a BP of 110/68 mm Hg
a client who has an apical pulse rate of 120/min
A charge nurse is reviewing orthostatic hypotension with a group of newly licensed nurses. Which of the following statements should the charge nurse make? a) the first step in checking for checking orthostatic hypotension is obtaining a client's BP while they are standing b) an increase of 5 mm of Hg in the diastolic pressure with a position change indicates orthostatic hypotension c) a decrease of 20 mm of Hg in the diastolic pressure with a position change indicates orthostatic hypotension d) wait 5 minutes to check the client's BP after each position change
a decrease of 20 mm of Hg in the diastolic pressure with a position change indicates orthostatic hypotension
A nurse is preparing an in-service for a group of newly hired APs about body temperature. Which of the following information should the nurse include? a) wait 5 min after a client has consumed a hot drink to obtain an oral temperature b) place a tape of patch thermometer over a client's scapula c) a tympanic thermometer reflects a client's body surface temperature d) a temporal probe thermometer uses infrared scanning to determine a client's temperature
a temporal probe thermometer uses infrared scanning to determine a client's temperature
A nurse is assisting with teaching a class about hospital-acquired injuries. The nurse should include which of the following? Select all that apply a) blood transfusion incompatibility b) wrong-site surgery c) ineffective insulin usage d) dysphagia following a stroke e) dehydration due to diarrhea
a) blood transfusion incompatibility b) wrong-site surgery c) ineffective insulin usage
A nurse is reviewing a new prescription with a client who reports difficulty managing their chronic pain. Which of the following statements should the nurse include? a. "You should write down the pain interventions you use and your pain rating before and after. "b. "You should understand that it is impossible to fix everyone's pain." c. "Your provider is best at determining whether your pain treatments are effective." d. "Your care partner should manage your pain control because you are unable."
a. "You should write down the pain interventions you use and your pain rating before and after."
A nurse is caring for a client who is going to require 7 days of IV antibiotics and dressing changes for cellulitis. Where is this client going to be admitted to?
acute care hospital
a nurse in a long-term care facility is caring for an older adult client and notes their muscles have become smaller and weaker. which go the following should the nurse suspect the client is experiencing? - sarcopenia - disuse osteoporosis - atrophy - joint contracture
atrophy
A nurse is assisting with teaching a class about evidence-based protocols established by the CDC to prevent healthcare-associated infections (HAIs). Which of the following infections should the nurse include? Select all that apply a) influenza infection b) catheter-associated urinary tract infection c) Mycobacterium tuberculosis infection d) central line-associated bloodstream infection e) surgical site infection
b) catheter-associated urinary tract infection d) central line-associated bloodstream infection e) surgical site infection
A charge nurse is providing an in-service for a group of nurses about cardiac output. Which of the following statements should the nurse include? a) cardiac output is the amount of blood flow through the heart in 1 minute b) cardiac output is the amount of blood ejected from the atria c) cardiac output is the ability of the muscle fibers in the ventricles to stretch d) cardiac output is the resistance of the ventricles to pump blood through the heart
cardiac output is the amount of blood flow through the heart in 1 minute
A charge nurse in a clinic is preparing an in-service about blood pressure measurements for a group of staff members. Which of the following should the nurse include? a) A client diagnosed with an elevated BP when the measurement is greater than 130/80 mm Hg b) A client us experiencing a hypertensive crisis when their BP is greater than 150/90 mm Hg c) A client who has a BP of 128/86 mm Hg has stage I hypertension d) A client who has a blood pressure of 162/102 mm Hg has stage II hypertension
d)) A client who has a blood pressure of 162/102 mm Hg has stage II hypertension
a nurse is performing a skin assessment on a client who has a wound on their heel that is blistered and lighter in color than the client's skin tone. the nurse should identify that the wound is in which of the following stages of damage? - deep damage through the skin and tissue - damage beyond the skin layer - damage into the skin layer - damage with the skin intact
damage into the skin layer
A nurse is caring for a client who has hypotension. Which of the following factors should the nurse identify as a contributing factor to the client's condition? a) decrease in contractility b) increase in blood viscosity c) decrease in RR d) increase in preload
decrease in contractility
a nurse is caring for a client who had a stroke and reports having difficulty with proprioception. the nurse should plan to assess the client for which of the following? A. restricted movement due to abnormal fixation of a joint B. a drop in blood pressure that occurs with a change in position C. altered gait with dragging of the toes while ambulating D. diminished awareness of body position and balance
diminished awareness of body position and balance
To decontaminate their hands with an alcohol-based gel, the nurse should rub their hands together until all of the gel has been evaporated and their hands are dry. Which of the following is the correct rationale for why hands should be rubbed together until dry?
drying provides the full antiseptic effect
A nurse is evaluating the effectiveness of interventions provided to a client who has an SaO2 below the expected reference range. Which of the following manifestations requires a follow up by the nurse? a) eupnea b) dyspnea c) heart rate of 84/min d) Sao2 of 96%
dyspnea
A nurse is planning care for a client who is experiencing tachycardia. Which of the following interventions should the nurse plan to make? a) instruct the client to increase exercise b) instruct the client to consume no more than four caffeinated beverages per day c) encourage the client to practice relaxation techniques each day d) encourage the client to engage in pattern paced breathing by panting
encourage the client to practice relaxation techniques each day
A nurse s caring for a client who has a HR of 118/min. Which of the following actions should the nurse take to improve the client's HR? a) encourages the client to reduce the amount of caffeinated soft drinks b) inform the client to ambulate in the hallway for 10 min prior to taking vitals c) increase the room temperature and add blankets to warm the client d) withold the client's anti-anxiety medication
encourages the client to reduce the amount of caffeinated soft drinks
A nurse is caring for a client who reports experiencing chills and not feeling well. The nurse informs the client that they will need to have theirtemperature taken to monitor the manifestations. Which of the following terms describes that the nurse's action is grounded in research? A) Evidence-based practice B) Competencies C) Lifelong learning D) Change agent
evidence based practice
a nurse is assessing a client's mobility and notes one of the client's feet drags behind them when ambulating. which of the following conditions should the nurse suspect the client is experiencing?- atrophy- foot drop- joint contracture- disuse osteoporosis
foot drop
A nurse is assisting with teaching about warning signs from a co-worker that might indicate future workplace violence. Which of the following behaviors should the nurse include? a) legitimate absenteeism b) strict adherence to facility policies c) consistent adequate work performance d) frequent reports of not being treated fairly
frequent reports of not being treated fairly
A nurse is caring for a client who tells the nurse they want to quit smoking. The nurse provides the client with information about smokingcessation and other ways to improve their health. Which of the following nursing roles is the nurse demonstrating? (Select all that apply.) A) advocate B) collaborator C) change manager D) health promoter E) nurse educator
health promoter nurse educator
A nurse is caring for a client who asks about healthy choices to lose weight. The nurse shares information from Healthy People 2030 to address theclient's questions. Which of the following describes the Healthy People initiative? A) it is a program for health care practitioners to get healthy B) it is a social media platform for nurses C) it is a set of objectives for improving the health of American lives D) It is a rehabilitation program for clients who have substance use disorders
it is a set of objectives for improving the health of American lives
A nurse is reviewing the licensing laws in their state of residence. Which of the following statements should the nurse use to define licensure?
licensure protects the health and welfare of the public
a nurse is preparing to transfer a client from a bed to a wheelchair. which of the following actions by the nurse demonstrates proper use of body mechanics? - twisting the torso when transferring the client - bending at the waist when transferring the client - placing the bed in the high position before transferring the client- looking at the client face-to-face when transferring the client
looking at the client face-to-face when transferring the client
a nurse is preparing a presentation about muscle function for a group of newly licenses nurses. which of the following information should the nurse plan to include? - muscles store calcium and magnesium - muscles produce red blood cells and platelets - muscles assist with thermoregulation in the body - muscles provide protection of internal organs
muscles assist with thermoregulation in the body
A nurse is discussing oxygen saturation with a client. Which of the following information should the nurse include? a) oxygen saturation is determined by the amount of oxygen bound to WBCs b) oxygen saturation reflects the amount of oxygen being delivered to body tissues c) the expected reference range for oxygen saturation s 90% to 100% d) a capillary refill time of less than 5 seconds ensures a reliable oxygen saturation measurement
oxygen saturation reflects the amount of oxygen being delivered to body tissues
A nurse in a provider's office is calling a client's insurance company to obtain permission prior to scheduling a magnetic resonance imaging (MRI) test. Which of the following is the nurse obtaining?
precertification
A nurse is planning care for a client who has hypertension. Which of the following interventions should the nurse include in the plan? Select all that apply a) provide the client with low-sodium meals and snacks b) encourage the client to participate in physical activity each day c) instruct the client in the use of relaxation techniques d) inform the client of the importance of abstaining from using products that contain nicotine e) anticipate a prescription for a 1L fluid bolus
provide the client with low-sodium meals and snacks encourage the client to participate in physical activity each day instruct the client in the use of relaxation techniques inform the client of the importance of abstaining from using products that contain nicotine
A nurse is reviewing blood flow through the heart with a group of APs. The nurse should identify that blood flows to which of the following parts of the heart as it leaves the right ventricle? a) tricuspid valve b) pulmonary artery c) right atrium d) vena cava
pulmonary artery
A charge nurse is teaching a group of AP the importance of documenting accurate vital signs. Which of the following information should the charge nurse include in the teaching? a) record vital signs at the end of the shift b) recording vital signs provides critical information regarding a client's condition c) obtaining and documenting baseline vital signs is the responsibility of the AP d) it is not necessary to record electronic BP measurements
recording vital signs provides critical information regarding a client's condition
a nurse is caring for a client who is at risk for developing atelectasis. which of the following actions should the nurse take? - reposition the client every 2 hours while in bed - remind the client to use the incentive spirometer - obtain the client's weight daily - encourage the client to eat foods that are high in fiber
remind the client to use the incentive spirometer
A nurse is caring for a client who has a prescription for wrist restraints. Which of the following actions should the nurse take? a) tie the restraints to the siderails on the client's bed b) remove the restraints with each vital sign check c) use the square knot to secure the restraints d) make sure one finger can fit under the restraints
remove the restraints with each vital sign check
A home health nurse is caring for a client who is receiving hospice care. The clients partner reports feeling overwhelmed from care for the client. What facility should the nurse recommend?
respite care
A nurse us caring for a client who asks about factors that could cause their pulse rate to increase. Which of the following factors should the nurse include in their response? a) hypothermia b) smoking c) sleeping d) aging
smoking
A nurse is educating a group of nurses about the Nurse Practice Act (NPA). Which of the following statements should the nurse include?
the NPA contains current laws and regulation for nursing practice the npa contains standards and scope of practice the nurse is responsible to know current roles and responsibilities as defined by the NPA
a nurse is preparing a presentation for a group of clients who are scheduled for joint replacement surgery. which of the following information should the nurse plan to include regarding flexion of a joint? - synovial joints contain sensory receptors that trigger flexion - the contraction of a muscle results in flexion of a joint - neurotransmitters coordinate with cartilage to intake flexion - ligaments extend to enable flexion of a joint
the contraction of a muscle results on flexion of a joint
A nurse has accepted a position at a hospital in the state where they live. The nurse should identify that which of the following regulates thenurse's actions when they begin working? A) American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements B) The state Nurse Practice Act C) The National Student Nurses Association (NSNA) D) The National League for Nursing
the state nurse practice act
a nurse is planning to implement the Transforming Care at the Bedside plan on a med-surg unit. Which of the following interventions should the nurse include in the plan? a) require nurses to spend 50% of their time at the bedside of the clients b) perform change-of-shift report at the nurses' station c) complete the client rounds every 4 hours d) use a standardized communication tool
use of standardized communication tool
A nurse is teaching a patient who has a new ileostomy about preventing the excoriation and breakdown of the peristomal skin after they have returned home. Which of the following instructions should the nurse include? A. Apply hydrocortisone cream to the skin when changing the appliance .B. Empty the pouch when it is less than half full. C. Wash the peristomal skin frequently with deodorizing soap and water . D. Choose a time shortly after a meal for replacing the pouch.
B. Empty the pouch when it is less than half full. Rationale: Nurse should instruct pt to empty pouch when it is between 1/3 to 1/2 full because waiting to empty pouch until it is more than 1/2 full increases risk of leakage. Leakage of Ileostomy effluent is irritating to peristomal skin.
A nurse is evaluating a client's pain level using the PQRST mnemonic. Which of the following questions should the nurse ask to evaluate the letter "R"? a. "Can you rate your pain on a scale of 0 to10, with 0 being no pain and 10 being the worst pain you can imagine?" b. "Can you point to where you are having your pain?" c. "What does your pain feel like?" d. "What were you doing when your pain started?"
"Can you point to where you are having your pain?"
A nurse is planning care for a group of clients and is reviewing the recent vitals obtained by an AP. Which of the following clients should the nurse assess and recheck the vital signs prior to notifying the provider? a) 16 year old female; RR 18/min, SaO2 98% b) 8 year old male; RR 34/min, SaO2 97% c) 11 year old male; RR 28/min, 99% d) 3 year old female; RR 32/min, SaO2 96%
8 year old male; RR 34/min, SaO2 97%
A nurse is obtaining health history from a patient who has a colostomy. The patient reports frequent episodes of loose stools over the last month but has no signs of infection or bowel obstruction. The patient reports that they have avoided participation in social activities because they are concerned about leakage. Which of the following should the nurse recommend? A. Consume foods that are low in fiber content. B. Take an ounce of mineral oil twice a day. C. Add buttermilk and cranberry juice to the diet. D. Increase water intake to 3 to 3.5 L per day.
A. Consume foods that are low in fiber content. Rationale: The nurse should recommend that pt consume foods low in fiber to help thicken stool.Ex: rice, noodles, white bread, & cheese
A nurse is talking with a client who arrived at the clinic over an hour ago and states, "Doesn't anyone care that I am sick? Why do I have to wait so long?" The nurse listens to the client and notifies the provider, relaying the needs of the client. In which of the following roles is the nurse performing? A) Educator B) Case Manager C) Advocate D) Leader
Advocate
A nurse is reinforcing teaching with a patient who has colon cancer & is scheduled for a procedure to remove their entire large intestine & rectum. The nurse should reinforce with the client that they are scheduled for which of the following types of ostomy procedure? A. Cecostomy B. Loop colostomy C. Ileostomy D. Descending colostomy
C. Ileostomy Rationale: After removing the entire large intestine & rectum, provider will create an ileostomy to divert feces from the small intestine to the abdominal surface & into an ostomy pouch.
What should the nurse do to maintain standard protocols?
Disinfect hands immediately after removing gloves.
A nurse is preparing an in-service about factors affecting RR for a group of APs. Which of the following information should the nurse include? a) anxiety can decrease a client's RR b) opioid analgesics can increase a client's RR c) pain can decrease a client's RR d) Fever can increase a client's RR
Fever can increase a client's RR
A charge nurse is reviewing factors that can affect a client's perception of pain with a newly licensed nurse. Which of the following should the charge nurse include? (Select all that apply.) Stress Dietary practices Culture Social support Disease severity
Stress Culture Social support Disease severity
A newly lived nurse is reviewing information about the National Council of State Board of Nursing (NCSBN) Transition to Practice (TTP) program. Which of the following factors should the nurse expect?
TTP programs increase job retention
A nurse is reviewing the contributions of various nursing organizations that provide support in caring for clients. The nurse should identify that which of the following agencies provides The Nursing Scope and Standards of Practice? A) The American Nurses Association (ANA )B) The American Academy of Nursing C) The National Student Nurses Association (NSNA) D) The National Academy of Medicine
The American Nurses Association (ANA)
A nursing student expresses a desire to become more involved with the nursing profession on a national level. Which of the following organizations should the student join? A) The National League for Nursing B) The National Student Nurses' Association C) The National Academy of Medicine D) The International Council of Nurses
The national student nurses association
A nurse is evaluating the effectiveness of interventions used for clients who had alterations in vital signs. Which of the following clients' vital signs indicate that interventions were effective? a) a preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 26/min b) an older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min c) a young adult who had hypotension after receiving an opioid analgesic now has a blood pressure of 98/68 mm Hg d) an adult client who had tachycardia 1 hr ago due to postoperative pain and has an apical pulse rate of 106/min
a preschooler who was exhibiting tachypnea 2 hr postoperative and now has a respiratory rate of 26/min an older adult client who had bradycardia while sleeping and now has an apical pulse rate of 66/min a young adult who had hypotension after receiving an opioid analgesic now has a blood pressure of 98/68 mm Hg
A nurse is caring for a client who has a heart rate of 120/min. Which of the following actions should the nurse take? a) instruct the client to bear down like they are having a bowel movement b) offer the client hot caffeinated tea to drink early in the morning c) hold the client's thyroid medication d) encourage the client to take a warm shower
instruct the client to bear down like they are having a bowel movement
Which of the following is an advantage of using alcohol-based gel?
it takes less time to use than washing with soap and water
a nurse is providing teaching for a client who has kyphosis. which of the following information should the nurse include? - kyphosis is when the upper back extends posteriorly to the lower back - kyphosis is an inward curvature of the lower back - kyphosis is a sideways curvature of the spine - kyphosis is a rounded upper back with the pelvis tilted forward
kyphosis is a rounded upper back with the pelvis tilted forward
A nurse is explaining to a newly licensed nurse that caring for clients involves lifelong learning by the nurse. The nurse should include which of the following as examples of learning opportunities for nurses? (Select all that apply) A) nursing blogs or opinions B) online continuing education journal articles C) nursing skill refresher opportunities D) continuing education presentations E) participating in healthcare research
online continuing education journal articles nursing skill refresher opportunities continuing education presentations participating in healthcare research
A nurse is assessing a three month old infant during a well-child visit. Which of the following actions should the nurse take when assessing the apical pulse? a) count the number of beats heard in 15 seconds and multiply by 4 b) notify the provider if the apical pulse rate is greater than 110/min c) place the stethoscope over the 4th intercostal space to the left of the sternum d) auscultate the apical pulse for an S4 heart sound
place the stethoscope over the 4th intercostal space to the left of the sternum
A community health nurse is teaching about social determinants of health. What should she identify as a physical determinant or health?
poor air quality
A nurse is discussing hospice care. What is the goal of hospice care?
provide care for a client who has less than 6 months to live
A nurse is assisting with emergency care of a client who has been exposed to a chemical toxin, Which of the following actions should the nurse take? a) rinse the client's skin with water b) remove the client's clothing by pulling it over their head c) dispose of the client's clothing in a single biohazard bag d) prepare to administer potassium iodide to the client
rinse the client's skin with water
a nurse is completing the Mobility Assessment Tool (MAT) for a client and determines that the client is at Level 1 Mobility. the nurse should identify that the client is unable to perform which of the following tasks? - sit on the edge of the bed for 1 minute - stand in place for 5 seconds - walk in place - step forward and backward
sit on the edge of the bed for 1 minute
A nurse is providing teaching about thermoregulation to a group of newly licensed nurses. Which of the following statements should the nurse include? a) the body increases body temperature through the process known as vasodilation b) the body loses heat through shivering c) the body lowers body temperature through sweating d) the body generates heat through evaporation
the body lowers body temperature through sweating
a nurse is evaluating a client who has a broken leg and is using crutches. which of the following actions by the client demonstrates proper use of the crutches? - the hand grips of the crutches are at the level of the client's umbilicus - the client's elbows are bent 45 degrees when holding the crutches - the client places their weight on their axilla when using the crutches - the client has the crutches resting 5 cm (2 in) below their axilla
the client has the crutches resting 5 cm (2 in) below their axilla
A nurse is reviewing the vital signs obtained by an AP at 1200. For which of the following clients should the nurse plan to intervene? a) adult male who has a RR of 18/min b) toddler who has a RR of 44/min c) newborn who has a RR of 56/min d) adolescent female who has a RR of 16/min
toddler who has a RR of 44/min
a nurse is teaching a newly hired assistive personnel (AP) about working with clients who require assistance with ADLs. which of the following activities should the nurse include as an ADL? - toileting - writing- ambulating- talking
toileting
A graduate nurse is offered a position in the emergency department upon the granting of initial licensure. Which of the following information should the graduate nurse identify as a requirement during the initial licensure process
verification of graduation criminal background check in certain states passing score on nclex examination self disclose of any substance use in the past 5 years
a nurse is discussing proper body mechanics with a group of assistive personnel. which of the following information should the nurse include? (select all that apply) - a stable center of gravity increases stability and balance - a wide base lowers the center of gravity - proper body alignment involves tightening the abdomen - leaning slightly back while carrying an object equalizes the center of gravity - bending at the waist when picking up objects stabilizes the spine
- a stable center of gravity increases stability and balance - a wide base lowers the center of gravity - proper body alignment involves tightening the abdomen
A nurse is teaching a client about food choices that promote immunity and healing. Which of the following foods is the best source of vitamin C?
1 cup strawberries
A nurse is caring for a client who has a prescription for heat therapy for knee pain. The nurse should apply heat therapy to the client's knee for how long? a. 60 min b. 20 min c. 30 min d. 45 min
20 min
A nurse is planning to teach coworkers about the legal and ethical principles used with pain management. Which of the following examples should the nurse include as an example of autonomy? a. A nurse allows a client to wait longer for their pain medication than other clients. b. A nurse does not properly clean a vial of pain medication prior to withdrawing medication from the vial, which results in the client contracting an infection .c. A nurse administers scheduled pain medication and provides therapeutic distraction techniques for a client in pain. d. A nurse provides a client with the opportunity to take an intramuscular injection or oral medication for pain relief.
A nurse provides a client with the opportunity to take an intramuscular injection or oral medication for pain relief.
A nurse is discussing social determinants of health with a newly licensed nurse. The nurse should include that which of the following factors contribute to the neighborhood and built environment determinant category?
Access to foods that support healthy eating patterns. Crime and violence. Environment conditions.
A nurse is caring for an older adult client who has a cognitive impairment and is postoperative. Which of the following actions should the nurse take? a. Use the Crying, Requires Oxygen, Increases Vital Signs, Expression, Sleeplessness (CRIES) pain scale .b. Reassure family members that older adult clients have a decreased ability to sense pain .c. Evaluate the client for pain by observing their behavior .d. Assign a pain scale number based on the FACES pain scale.
Evaluate the client for pain by observing their behavior.
A nurse is teaching a newly licensed nurse about Medicare reimbursement. What should she include?
Reimbursement amounts will be adjusted for clients who contract HACs.
A nurse is assisting in recommending clients for chiropractic treatment. Which of the following clients should the nurse recommend?
a client who has shoulder pain
A nurse is describing to another nurse how to use social media in client care. Which of the following examples should the nurse include as an acceptable use of social media? A) Posting a comment on social media about facility staffing shortages B) Accepting a social media friend request from a client C) Reviewing the use of a fitness application with a client D) Sharing client information with a coworker in a private social media message
Reviewing the use of a fitness application with a client
A charge nurse is discussing the physiology of the heart with a newly licensed nurse. Which of the following anatomical sites should the newly licensed nurse identify as the pacemaker of the heart? a) AV node b) left ventricle c) SA node d) right ventricle
SA NODE
A nurse is discussing cutaneous stimulation with a client who has back pain. Which of the following methods should the nurse include? (Select all that apply.) Transcutaneous electronic stimulating unit (TENS unit) Distraction techniques Massage Acupuncture Cold therapy
Transcutaneous electronic stimulating unit (TENS unit) Massage Acupuncture Cold therapy
A nurse in a long-term care facility took a picture of a client and posted it on the internet. This action by the nurse is an example of which of the following? A) Serving as an advocate for the client B) Violating the code of ethics for nurses C) Participating in the Healthy People 2030 program D) Demonstrating collaboration
Violating the code of ethics for nurses
A nurse on a pediatric unit is reviewing the medical records for a group of clients. Which of the following clients has a vital sign outside the expected reference range and requires intervention? a) a 1 month old infant who has a RR of 58/min b) a 3 year old preschooler who has an apical pulse of 144/min c) an 8 year old child who has a RR of 25/min d) an 18 month old toddler who has an apical pulse rate of 120/min
a 3 year old preschooler who has an apical pulse of 144/min
a nurse is planning care for a group of clients and is delegating to the AP to take the client's vitals. For which of the following clients should the nurse obtain the vitals signs rather than the AP? a) a client who just received the fourth dose of antibiotics for an infection b) a client who has heart failure and is scheduled for a discharge later in the day c) a client who is 24 hr post-op and is visiting with friends d) a client who was recently admitted and reports chest pain
a client who was recently admitted and reports chest pain
A nurse is teaching a group of nurses and asks which of the NLN integrating competencies is defined as having respect for diversity, holistic care, client-centered approach, and client advocacy. Which competencies does this describe?
human flourishing
A charge nurse is reviewing the expected reference ranges of BP in adult clients with a newly licensed nurse. Which of the following statements should the charge nurse include? a) hypertension is diagnosed with two elevated measurements on two separate occasions b) successive BP measurements of 126 over 78 is classified as stage I hypertension c) stage II hypertension is diagnosed when the BP measurement is 132 over 86 d) a BP measurement of 176 over 102 is classified as hypertensive crisis
hypertension is diagnosed with two elevated measurements on two separate occasions
A nurse is caring for a client who has an increase in cardiac afterload. Which of the following findings should the nurse expect? a) increase in BP b) increase in RR c) decrease in cardiac output d) decrease in preload
increase in BP
A nurse is caring for a client who has an increase n cardiac output. Which of the following findings should the nurse expect? a) increase in BP b) decrease in RR c) decrease in HR d) increase in stroke volume
increase in BP
a nurse is performing a focused assessment on an older adult client's mobility. which of the following findings should indicate to the nurse that the client is experiencing an age-related change to their musculoskeletal system?- increased curvature of the thoracic spine - reduced depth perception- narrower stance when standing - quick steps when ambulating
increased curvature of the thoracic spine
contact precautions should be implemented for an adult client who has been hospitalized and has which of the following?
infectious diarrhea
A nurse is providing care to a client who has an apical pulse rate of 54/min and is experiencing dizziness. Which of the following is the nurse's priority action? a) teach the client how to take their pulse so they can keep the provider informed of variations b) inform the client to ask for assistance with getting out of bed c) educate the client on medications, including therapeutic effects and potential adverse effects d) ensure the client has been taking medications as prescribes
inform the client to ask for assistance with getting out of bed
A nurse is completing the Minimum Data Set assessment for a resident in a skilled nursing facility. Which of the following information should the nurse include in the assessment?
input from members of the interdisciplinary team clients cognitive status each physical therapy visit clients need for assistance with adls
A nurse obtains a client's electronic BP reading of 188/96 mm Hg. Which of the following actions should the nurse take next? a) provide client teaching regarding medications to control BP b) notify the provider of the clients BP reading c) provide the client education on measurements to decrease BP d) obtain a manual BP reading from the client
obtain a manual BP reading from the client
a nurse is caring for a client who requires assistance with ADLs. which of the following referrals should the nurse recommend for this client? - speech therapist - physical therapist - respiratory therapist - occupational therapist
occupational therapist
A nurse is caring for a client who has an indwelling urinary catheter in place. Which of the following actions is the priority for the nurse to take to reduce the client's risk of developing a healthcare-associated infection? a) wipe down the client's bedside table with an antiseptic wipe b) conduct informal audits of medical records to identify the number of healthcare-associated infections c) perform hand hygiene d) instruct the client on ways to reduce the risk for infection
perform hand hygiene
A nurse is reviewing the contributions made by various nursing organizations that have impacted the nursing profession. The nurse should identify that which of the following are contributions made by The American Nurses Association (ANA)? (Select all that apply.) A) providing a definition of nursing B) lobbying for whistle blower protection C) provide objective data to improve the health of society D) providing all registered nurses with competency expectations E) providing the nursing magazine imprint
providing a definition of nursing lobbying for whistle blower protection providing all registered nurses with competency expectations
a nurse is caring for a recently admitted client and as a part of the plan of care, two nurses obtained simultaneous pulse rates. the client's auscultated apical pulse was 106/min and the palpated radial pulse was 93/min. The nurse should document the findings as which of the following? a) pulse deficit less than 10 b) radial pulse irregular c) apical pulse greater than radial d) pulse deficit of 13/min
pulse deficit of 13/min
After completing a procedure that required donning personal protective equipment (PPE) consisting of a gown, an N95 respirator, a face shield, and gloves, which of the following should the nurse remove first when removing PPE Separately.
the gloves
A charge nurse is reviewing oral care and hygiene practices with another nurse for a client who has glaucoma. Which of the following information should the charge nurse include?
the nurse should educate the client and caregivers about the importance of routine dental visits to maintain oral health
A nurse is assisting with teaching a client, who has a history of alcohol use disorder and is to be discharged following cataract surgery, about non-pharmacological therapies. Which of the following client statements indicates an understanding of the teaching?
"I will practice meditating when I feel stressed."
A nurse is discussing the use of a client's thigh for BP measurements with an AP. Which of the following information should the nurse include? a) select a blood pressure cuff width that is 25% of the circumference of the client's thigh b) palpate the femoral pulse when obtaining BP in the thigh c) expect BP in the thigh to be 10 to 15 mm Hg less than in the arm d) Use the thigh to obtain blood pressure when a client has severe edema in their arms
Use the thigh to obtain blood pressure when a client has severe edema in their arms
A nurse is assisting with teaching a newly licensed nurse about using a lift device to transfer a client. Which of the following actions by the nurse indicates an understanding of the teaching? Select all that apply a) locks the brakes on the client's bed b) checks the max weight on the lift before using it c) places the client on the edge of the sling d) uses the lift without assistance from another team member e) performs a safety check before lifting the client
a) locks the brakes on the client's bed b) checks the max weight on the lift before using it e) performs a safety check before lifting the client
A nurse is assisting with teaching a client about homeopathy. Which of the following client statements indicates an understanding of the teaching?
"Homeopathy believes a substance that can cause a disease can also cure it."
A nurse is caring for a client who has a prescription for hydromorphone 1 to 2 mg IM every 4 hr as needed for a pain rating of 4 to 6 on a 0 to 10 scale. The client has never taken hydromorphone before. Which of the following actions should the nurse plan to take? a. Administer 1 mg IM .b. Request a prescription to give the medication IV instead. c. Request a prescription for a different medication. d. Administer 2 mg IM.
Administer 1 mg IM
A nurse is preparing an in-service about peripheral pulses for a group of staff nurses. Which of the following information should the nurse include? a) a pulse strength of +4 indicates that the pulse is of normal strength upon palpation b) a femoral pules that is bounding upon palpation is an expected finding in a young adult c) a pulse strength of +1 indicates that the pulse is weak or diminished upon palpation d) a pedal pulse that is weak upon palpation is an expected finding in an older adult
a pulse strength of +1 indicates that the pulse is weak or diminished upon palpation
A nurse is reviewing documentation of vital signs by a newly licensed nurse for an assigned client. Which of the following entries in the chart requires follow up by the nurse? a) BP 130/82 mm Hg left arm, lying. Client reports experiencing post-op pain as 7 on a scale of 0-10. Prescribed analgesic administered and will re-evaluate BP in 30 min b) Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in the hall c) SaO2 93% left index finger, client sleeping, nasal O2 dislodged. Nasal O2 readjusted and SaO2 increased to 95% d) RR 18/min via observation, client sitting in chair
Pulse rate 116/min, left radial, standing, immediately following 10 min of ambulating in the hall
A nurse is teaching a newly licensed nurse about The Joint Commission (TJC). Which of the following information should the nurse include?
TJC ensures organizations remain up-to-date with state guidelines.
A nurse is performing a bed bath for a client. Which of the following should the nurse remember when preparing to bathe the client?
Washing the client in bed is less effective than taking a shower.
A nurse is preparing to conduct a fall risk screening on a client. Which of the following variables will the nurse use to evaluate the client? Select all that apply a) fall history b) medical diagnosis c) use of assistive devices d) mental status e) do-not-resuscitate status
a) fall history b) medical diagnosis c) use of assistive devices d) mental status
A nurse is reinforcing teaching about traditional Chinese medicine (TCM) to a client. Which of the following statements by the client demonstrates an understanding of the teaching?
"I will practice Tai Chi every day."
A nurse is assisting with teaching a newly licensed nurse about electrical safety. Which of the following actions by the newly licensed nurse indicated an understanding of the teaching? a) the nurse plugs in a sequential compression device with wet hands b) the nurse holds onto the plug to unplug a client's electronic bp machine c) the nurse rolls the client's bed over an electrical cord d) the nurse uses an extension cord to plug in a client's smart infusion pump
the nurse holds onto the plug to unplug a client's electronic bp machine
a nurse is teaching a client who has an unsteady gait about how to use a walker. which of the following instructions should the nurse include? - the top of the walker should be at the level of your wrist - when using the stairs, place the walker before taking a step - when holding the walker, bend your elbows 30 degrees - take a step first before moving the walker
the top of the walker should be at the level of your wrist
A nurse is reviewing discharge instructions for a client who has a prescription for morphine oral solution 10 to 20 mg every 4 hr PRN. Which of the following statements by the client indicates an understanding of the instructions? a. "I can use the morphine as needed as long as I don't take it more than six times a day." b. "I will use my household teaspoon to measure the correct amount of morphine." c. "I will monitor for high blood pressure while taking the morphine." d. "I will keep the morphine bottle in a locked cabinet in my kitchen."
"I will keep the morphine bottle in a locked cabinet in my kitchen."
A nurse is assisting a massage therapist to identify the best client for massage therapy. Which of the following clients should the nurse recommend?
A client who has postpartum depression
A nurse is discussing the role of tooth enamel with a client. Which of the following information should the nurse include in the discussion?
Enamel protects the teeth from pathogens.
A nurse is completing a preoperative health history for a client who reports taking several herbal supplements. Which of the following herbal supplements is the priority for the nurse to report?
Ginkgo biloba
A nurse is caring for a client who follows a vegan diet and reports lethargy. Which of the following interventions should the nurse implement?
Request a prescription for vitamin B12 supplements.
A nurse is reviewing information for several clients on the unit. The nurse should recognize that which of the following clients is at greatest risk for respiratory depression? a. A client who has chronic pain and recently started taking paroxetine b. A client who has cancer and has taken oxycodone PRN for several months c. A client who has been accidentally taking twice the amount of prednisone as prescribed d. A client who had surgery 3 hr ago and is receiving IV hydromorphone PRN
A client who had surgery 3 hr ago and is receiving IV hydromorphone PRN
A nurse is reviewing the plan of care for several clients who are receiving treatment for pain. Which of the following actions should the nurse plan to take to evaluate the clients' pain control? (Select all that apply.) Consider each client's cultural preferences. Determine the effectiveness of nonpharmacological strategies. Record the clients' subjective reports rather than the nurse's objective observations. Recognize that older adult clients over-report their pain level. Use a pain scale specific to each client's cognitive abilities.
Consider each client's cultural preferences. Determine the effectiveness of nonpharmacological strategies. Use a pain scale specific to each client's cognitive abilities.
A nurse is monitoring a client who is 2 hr postoperative and is receiving morphine via PCA pump. Which of the following findings should the nurse plan to monitor to detect opioid-induced ventilatory impairment (OIVI)? (Select all that apply.) Bowel sounds Deep tendon reflexes Respiratory rate Capnography Oxygen saturation
Respiratory rate Capnography Oxygen saturation
A nurse is reviewing handwashing skills with a newly licensed nurse. In which order should the nurse plan to perform this task using soap and water? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Wet hands with warm water is the first step. Apply the amount of soap recommended by the manufacture Rub hands together vigorously for at least 15 seconds is the third step. Rinse hands with water Use a disposable towel to dry Use a towel to turn off the faucet
A nurse is discussing transcutaneous electrical nerve stimulation (TENS) treatment with a client who has chronic lower back pain. Which of the following statements should the nurse include? (Select all that apply.) "You can be taught how to use TENS therapy at home." "We will insert very small sterile needles into your skin to block your pain." "This therapy may result in you having some temporary bruising at the site of application." "The TENS therapy delivers low-voltage electrical impulses to the skin over the painful areas." "We will adjust the intensity, pulse rate, and duration of the electrical pulses during your therapy."
"You can be taught how to use TENS therapy at home." "The TENS therapy delivers low-voltage electrical impulses to the skin over the painful areas." "We will adjust the intensity, pulse rate, and duration of the electrical pulses during your therapy."
A charge nurse is reviewing the technique for obtaining SaO2 with a group of newly hired nurses. Identify the order of the steps the nurse should include.
1) select the site for obtaining the measurement 2) apply the sensor probe on the chosen site 3) confirm the pulse rate displayed o the oximeter by palpating the radial pulse 4) wait 15 seconds and observer the SaO2 percentage displayed on the pulse oximeter
A nurse is reviewing vitals for a group of clients to determine the effectiveness of interventions. Which of the following findings indicates an intervention was effective? a) an adult client who received medication for pan 30 min ago now has a RR of 18/min b) a school-age child who received two units of packed RBCs now has a BP of 76/54 mm Hg c) a toddler who received an antibiotic injection has a heart rate of 148/min while sleeping in their parent's arms
an adult client who received medication for pan 30 min ago now has a RR of 18/min
A nurse is assisting with conducting a home hazard assessment for a client who has dementia. Which of the following findings indicates an understanding of home safety? a) an extension cord is secured under a rug b) the edges of stairs are marked with brightly colored tape c) a toaster is plugged in when not in use d) the water heater is set to 55 degrees C
the edges of stairs are marked with brightly colored tape
A graduate nurse notes that a hospital with Pathway to Excellence recognition is hiring staff. What should the nurse expect from this facility
the facility has practices in place that lead to a health workplace environment the facility emphasizes shared governance the facility emphasizes shared governance the facility emphasizes practices that positively affect the nurse well being
a nurse is preparing to lift a heavy object off the floor. in which order should the nurse perform the following steps to demonstrate the proper use of body mechanics. (place in order) - push up from the knees when lifting the object - stand as close to the object as possible - look straight ahead with shoulders raised up - bend hips slightly and squat- keep abdominal muscles contracted and the lower back straight
-stand as close to the object as possible - keep abdominal muscles contracted and the lower back straight - look straight ahead with shoulders raised up - bend hips slightly and squat - push up from the knees when lifting the object
A nurse is reviewing the recent vitals of a group of clients. Which of the following clients should the nurse see first? a) a 45 year old client who is post-op and has a BP of 130/82 b) a 28 year old client who runs marathons and has a HR of 54/min c) a 52 year old client who has an SaO2 of 92% d) a 78 year old client who has a temperature of 35.9 degrees c (96.6 degrees f)
52 year old client who has an SaO2 of 92%
A nurse is preparing to obtain a young adult client's apical pulse. In which of the following locations should the nurse place their stethoscope to auscultate the client's pulse? a) apex of the heart b) right side of the sternum c) 4th intercostal space d) midclavicular line below right clavicle
apex of the heart
A nurse is teaching a patient who has bladder cancer about urinary diversion options. The nurse should inform the patient that which of the following options will allow them to have some control over urinary elimination? A. Kock's pouch B. Ileal conduit C. Cutaneous ureterostomy D. Nephrostomy
A. Kock's pouch Rationale: A Kock's pouch is a continent ileal bladder conduit that does not require an external drainage collection device because pt self-catheterizes every 2-4 hrs to remove urine. This device will allow pt to have some control over urinary elimination
A charge nurse is evaluating a newly licensed nurse's documentation of vitals for several clients. Which of the following documentation should the charge nurse identify as being incomplete? a) radial pulse regular at 84/min b) respirations observed as even, nonlabored at 20/min with client in supine position c) BP 124/82 mm Hg lying in bed d) temporal temperature 36.9 degrees C (98.4 degrees F)
BP 124/82 mm Hg lying in bed
A nurse is reviewing information about performing oral hygiene with an assistive personnel (AP). Which of the following information should the nurse include?
"Clean the tongue with the toothbrush or tongue scraper during oral hygiene."
A charge nurse is discussing mechanisms of loss of body heat with a newly licensed nurse. Which of the following statements should the nurse include? a) "Convection is the loss of body heat when a client is in contact with a cooler surface." b) "Conduction is the loss of body heat when sweat dries from a client's skin." c) "Evaporation is the loss of body heat when a client is near a current of cool air." d) "Radiation is the loss of body heat when a client is in close proximity to a cooler surface."
"Radiation is the loss of body heat when a client is in close proximity to a cooler surface."
A nurse is teaching a client about the function of mucous membranes in protecting the body from pathogens. Which of the following statements should the nurse include?
"The mucous membranes in the nose contain cilia that trap particles, preventing them from invading the body."
A nurse is caring for a group of clients on the pediatric unit. For which of the following clients should the nurse use the FLACC Pain Scale to determine their pain level? (Select all that apply.) A 12-year-old client who has had an appendectomy A 3-year-old toddler who has a fractured femur A 6-day-old infant who had a surgical repair of a heart defect A 14-year-old client who has severe cognitive and developmental delays A 5-year-old preschooler who is experiencing pain during a sickle cell crisis
A 3-year-old toddler who has a fractured femur A 14-year-old client who has severe cognitive and developmental delays A 5-year-old preschooler who is experiencing pain during a sickle cell crisis
A nurse is caring for a client who has a Health care-associated Infection (HAI). Which of the following describes an exogenous HAI?
A Salmonella infection that occurs after eating contaminated food at the cafeteria.
A nurse is evaluating a group of clients who are experiencing pain. Which of the following clients should the nurse identify as experiencing neuropathic pain? a. A client who has osteoarthritis and reports difficulty ambulating for the past 6 months b. A client who had surgery to repair a fractured tibia and reports incisional pain c. A client who has diabetes mellitus and reports bilateral burning foot pain without signs of injury d. A hospice client who has prostate cancer and reports pelvic pain
A client who has diabetes mellitus and reports bilateral burning foot pain without signs of injury
A nurse is reviewing oral hygiene practices with an assistive personnel. Which of the following should the nurse include? (Select all that apply.)
A fluoride mouthwash should be used to promote oral health.The teeth should be brushed twice daily for 2 min.Poor oral hygiene can lead to gingivitis.Use a soft-bristled toothbrush for brushing the teeth.
A nurse is replacing the ostomy appliance for a patient whose newly created colostomy is functioning. After removing the pouch, which of the following actions should the nurse take first? A. Measure the stoma .B. Cover the stoma with gauze .C. Remove the backing on the skin barrier D. Cleanse the stoma and the peristomal skin.
A. Cleanse the stoma and the peristomal skin. Rationale: First action nurse should take is to remove any effluent adhering to the stoma & peristomal skin to facilitate assessment of area
A nurse is providing preoperative teaching for a patient who is scheduled for creation of a sigmoid colostomy. Which of the following info should the nurse include in the teaching? A. Expect the effluent from the sigmoid colostomy to be loose and continuous .B. Use irrigation to help establish a regular bowel pattern. C. Change the stoma's appliance every other day. D. Expect effluent from the newly created stoma within 24 hr after surgery.
B. Use irrigation to help establish a regular bowel pattern. Rationale: Clients with sigmoid colostomies can use irrigation to help control the passage of stool. Once the client has established a regular bowel pattern, the they can wear a stoma cap over the site, but they do not need an external appliance.
A nurse is discussing the physiology of BP. Which of the following information should the nurse include? a) Diastolic BP reflects the pressure exerted during contraction of the heart b) BP is measured and documented in mm Hg c) BP decreases when blood viscosity increases d) systolic BP reflects the pressure when the heart is relaxed
BP is measured and documented in mm Hg
A nurse is reinforcing teaching w/ a pt about replacing an ostomy pouching system. The client reports that they occasionally experience pain when removing the skin barrier. Which of the following techniques should the nurse suggest? A. Lift up on both sides of the skin barrier simultaneously. B. Release one corner of the barrier and pull it quickly over the stoma .C. Push the skin away from the barrier while removing it. D. Gently roll the barrier end-over-end across the stoma.
C. Push the skin away from the barrier while removing it. Rationale: If pt is experiencing pain w/ initial release of barrier, nurse should suggest removing barrier by starting in one corner & gently pulling it across the stoma while pushing skin away from barrier. This technique can help prevent skin stripping.
A nurse is caring for a client who reports muscle pain to the lower back that has persisted for over a year after a motor-vehicle crash. In which way should the nurse categorize this client's pain? a. Cancer pain b. Acute pain c. Chronic pain d. Neuropathic pain
Chronic pain
Which of the following ways is the Press Ganey survey conducted?
A nurse is discussing end-of-life pain management with a group of coworkers. Which of the following should the nurse include as barriers to end-of life pain management? (Select all that apply.) Fear of addiction Belief that pain is an expected part of their illness Inability to sleep Lack of support Inadequate pain assessment
Fear of addiction Belief that pain is an expected part of their illness Inadequate pain assessment
A nurse is reviewing historical nursing data and how it has impacted nursing care. The nurse should identify that which of the following nursing pioneers is credited with first using evidence-based practice in caring for clients? A) Clara Barton B) Dorothea Dix C) Eddie Bernice Johnson D) Florence Nightingale
Florence nightingale
A nurse is teaching about the Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS). What should she include?
HCAHPS measures the client satisfaction with health care services.
A nurse is teaching about hospice care to a client. What statement shows that the client understands?
I understand that services provided will include just what is needed to keep me comfortable.
A nurse working in an acute care facility is caring for a client who has a total brain injury and is receiving mechanical ventilation. Which of the following facilities should the nurse anticipate the client to be transferred for further treatment?
Long-term care hospital
A nurse is discussing the use of heat therapy with a newly licensed nurse. The nurse should include that heat therapy is effective for which of the following conditions? (Select all that apply.) Muscular pain Active bleeding Backache Menstrual discomfort Swollen extremity
Muscular pain Backache Menstrual discomfort
A nurse is caring for a client who has a prescription for oxycodone 5 to 10 mg PO every 4 to 6 hr as needed for pain rating 7 to 10 on a 0 to 10 scale. Fifteen minutes after receiving the dose, the client reports to the nurse their pain is still a 7 and has not changed. Which of the following actions should the nurse take? a. Administer another 5-mg dose of the oral opioid now. b. Administer 10 mg of oxycodone every 2 hr. c. Inform the provider that the client's pain medication is not effective .d. Offer to assist the client with nonpharmacological relief strategies.
Offer to assist the client with nonpharmacological relief strategies.
Which of the following products can affect the permeability of latex gloves?
Petroleum-based hand lotion
A charge nurse is reviewing documentation of vital signs by a newly licensed nurse. Which of the following pieces of documentation is correct? a) pulse 52/min b) RR 24 c) SaO2 97% right index finger, room air d) BP 132/86 mm Hg
SaO2 97% right index finger, room air
A nurse is responsible for their actions with whom they interact professionally, including clients, colleagues, and society as a whole. Which of the following components of the practice of nursing addresses this expected behavior?
Standards of professional performance
A nurse is reviewing the anatomy of the skin with a newly licensed nurse. Which of the following information should the nurse include as a characteristic of the epidermis?
The epidermis consists of squamous epithelial cells.
A nurse discovers a small fire in a client's room. After removing the client to safety, which of the following actions should the nurse take next? a) extinguish the fire b) close the windows in the client's room c) close the client's door d) activate the fire alarm
activate the fire alarm
A nurse is planning to use the identify, situation, background, assessment, recommendation, read-back (ISBARR) tool to communicate with a provider about a client. Which of the following information is included in the assessment component of ISBARR? a) the client's admitting diagnosis b) the client's medical history c) the client's lab test results d) the client's response to treatment
the client's lab test results
A nurse is assisting with a staff in-service regarding pain control. Which of the following statements by a staff member indicates an understanding of the information? (Select all that apply.) "A client's religious beliefs might affect the way they respond to pain." "Herbal therapies are not permitted for a client receiving prescription pain medication." "The client's past pain experiences are not related to their current pain and pain management." "If a client can rate their pain using a numeric pain scale, there is no need to note nonverbal findings." "Pain control might be harder to achieve if the nurse and client speak different primary languages."
"A client's religious beliefs might affect the way they respond to pain." "Pain control might be harder to achieve if the nurse and client speak different primary languages." "The client's past pain experiences are not related to their current pain and pain management."
A nurse is discussing health promotion programs with a client. Which of the following information should the nurse include?
Health promotion programs emphasize behavior changes in relation to prevention of illness.
A nurse is planning complementary therapy for a client who has breast cancer. Which of the following treatments is a complementary therapy that the nurse can implement?
Massage therapy
A nurse is teaching a class about the Hospital-Acquired Condition Reduction Program (HACRP). Which of the following information should the nurse include?
The HACRP links Medicare payments to health care quality
A nurse is evaluating the effectiveness of interventions used to address clients' vitals that were outside of the expected reference ranges. Which of the following findings indicates the intervention was effective? a) an older adult client who has pneumonia and a RR of 26/min after a position change b) an adolescent who is postoperative and has an SaO2 of 93% after receiving an opioid analgesics c) a young adult who is experiencing an asthma attack and has a BP of 116/72 mm Hg after using an inhaler d) an older adult client who has an infection and a pulse rate of 110/min after using relaxation techniques
a young adult who is experiencing an asthma attack and has a BP of 116/72 mm Hg after using an inhaler
A nurse is assisting with teaching a class about events that require an occurrence report. Which of the following events should the nurse include? Select all that apply a) a client's visitor falls in the hallway b) a nurse forgets their computer password c) a client develops an unexpected reaction to a medication d) a client's dentures are lost e) an antibiotic was administered to a client 30 min after the scheduled time
a) a client's visitor falls in the hallway c) a client develops an unexpected reaction to a medication d) a client's dentures are lost
A nurse is caring for a client who is at risk for suicide. Which of the following actions should the nurse take? Select all that apply a) place the client on round-the-clock surveillance b) remove the objects from the room that the client could use to arm themselves c) search items brought into the client's room by visitors d) refrain from asking the client if they intend to harm themselves e) screen the client for suicide ideation
a) place the client on round-the-clock surveillance b) remove the objects from the room that the client could use to arm themselves c) search items brought into the client's room by visitors e) screen the client for suicide ideation
A nurse is preparing to administer medications to a client. Which of the following information should the nurse use to identify the client? Select all that apply a) the client's full name b) the client's DOB c) the client's telephone number d) the client's diagnosis e) the client's room number
a) the client's full name b) the client's DOB c) the client's telephone number
A nurse is preparing to administer a premixed medication to a client. The nurse should check the label for which of the following information? Select all that apply a) the date the med was mixed b) the client's age c) the client's room number d) the dose of the mixed med e) the time the medication was mixed
a) the date the med was mixed d) the dose of the mixed med e) the time the medication was mixed
A nurse is teaching a group of newly licensed nurses about vital sign measurements. Which of the following factors should the nurse include in the teaching? a) anxiety can cause a decrease in RR b) body temperature is typically lower in olde adults c) caffeine can cause a temporary decrease in pulse rate in adolescents d) BP can slightly decrease immediately following the use of NICOTINE
body temperature is typically lower in older adults
A newly licensed nurse is reviewing Benner's Novice to Expert Model for nursing competence. At which of the following stages does the nurse first develop the ability to prioritize tasks by drawing on experience? A) advanced beginner B) proficient C) competent D) novice
competent
A nurse is preparing a poster about fire safety for a community health fair. The nurse should include on the poster that which of the following components contains needed elements for a fire to occur? Select all that apply a) CO2 b) Nitrogen c) cooking oil d) oxygen e) heat
cooking oil d) oxygen e) heat
A nurse is reviewing a report by the Institute of Medicine. Which of the following competencies should the nurse identify health care professionals need in order to reduce errors?
cooperation communication coordination
A charge nurse is discussing a client's RR data with a newly licensed nurse. Which of the following statements should the nurse include? a) clients will exhibit an increase in their RR after using a bronchodilator b) count the RR for 1 min who have a respiratory infection c) expect clients who have a brainstem injury to exhibit rapid respirations d) clients who are experiencing acute pain will have slow, deep respirations
count the RR for 1 min who have a respiratory infection
A nurse is teaching the importance of handwashing to a client. Which of the following statements should the nurse make about hand hygiene in a health care setting?
effective handwashing can decrease hospital infection rates
A nurse is checking a client's allergy bracelet before administering a medication and finds the client is allergic to that medication. The nurse does not administer the medication to the client. This is an example of which of the following unexpected events? a) near-miss event b) client safety event c) adverse event d) sentinel event
near-miss event
A nurse is preparing an in-service about vital signs for a group of newly hired APs. Which of the following information should the nurse include about measuring body temperature? a) tympanic temperature can be affected by environmental temperature b) temporal temperature is inaccurate in children under 3 years old c) axillary temperature reflects rapid changes in a client's core body temperature d) oral temperature is easily accessible despite a client's position
oral temperature is easily accessible despite a client's position
A nurse holds a single state nursing license and is preparing to move to another state. For the nurse to apply for reciprocity, which of the following actions should the nurse take?
present a current and valid nursing license submit an application pay the fees for new license
a nurse is caring for a client who has pneumonia. in which of the following positions should the nurse place the client to promote postural drainage? A. lateral B. supine C. prone D. Fowler's
prone
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? a) record the time and length of the seizure b) restrain the client's extremities c) place the client in the prone position d) monitor the client's hemoglobin level
record the time and length of the seizure
a nurse is caring for a client who requires maximum assistance to transfer from the bed to a chair. which of the following pieces of equipment should the nurse use? - pivot disc - slide board- sit-to-stand lift- gait belt
slide board
a nurse receives a license renewal notification from the board of nursing. the nurse should identify that a license renewal requires the disclosure of which of the following
substance use within the past 5 years
A nurse is delivering client care in partnership with multidisciplinary members of the health care team. This is an example of which of the following QSEN competencies?
teamwork and collaboration
A nurse is observing an AP obtain vital signs from an adult client. Which of the following actions by the AP requires follow up by the nurse? a) the AP pulls the pinna up and back when obtaining a tympanic temperature b) the AP informs the client when they are counting the respirations c) the AP gently presses down with the pads of two or three fingers over the radial pulse site d) the AP selects a blood pressure cuff that is 40% the circumference of the client's arm
the AP informs the client when they are counting the respirations
A nurse is observing an AP who is obtaining BP reading from a client. Which of the following actions by the AP requires follow up by the nurse? a) the AP uses a cuff width that is 40% of the circumference of the client's arm b) he AP provides support for the client's arm while taking the BP c) the AP waits to take the client's BP 45 minutes after the client ambulates in the hallway d) the AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second
the AP loosens the valve to reduce pressure within the bladder cuff at a rate of 5 mm Hg per second(Recommended rate is 2 mm Hg per second)
A newly licensed nurse is reviewing electronic information about the NCLEX exam from the National Council of State Board of Nursing (NCSBN) website. Which of the following information should the nurse identify as passing criteria for the NCLEX computerized adaptive test (CAT)?
the computer will stop giving items using the 95% confidence interval rule
a nurse is teaching an in-service about the nurse of ergonomics to a group of staff members. which of the following information should the nurse include? - the use of ergonomics improves blood circulation in the body - the use of ergonomics eliminated costs related to workers' compensation - the use of ergonomics increases job satisfaction - the use of ergonomics maintains the body's balance and a lower center of gravity
the use of ergonomics increases job satisfaction
