ATI PN FUNDAMENTALS 2022
A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give to the client?
"We need to document the exact medication you were taking because you might be allergic to it." b. If there is any possibility that the client is allergic to a medication, it is imperative that the provider does not prescribe the same medication again.
A nurse is educating a client who has a terminal illness about her request to decline resuscitation in her living will. The client asks what would happen if she arrived at the emergency department and had difficulty breathing. Which of the following responses should the nurse provide?
"We will apply oxygen through a tube in your nose." Oxygen can provide comfort and is not resuscitative when the nurse delivers it via nasal cannula.
A nurse is preparing to administer intermittent enteral tube feedings to a client. In what order should the nurse perform the following actions before beginning the feeding?
1. place client in fowlers. 2. Verify tube placement. 3. Check gastric residual. 4. Flush the tubing.
A nurse is preparing to administer gentamicin 2mg/kg via IV bolus to a client who weighs 220lb. How many mg should the nurse administer?
200mg
RhoGAM is administered at __ weeks of gestation
28 weeks of pregnancy
A nurse providing dietary teaching for a client who has chronic skin ulcers of the lower extremities. Which of the following foods should the nurse recommend as containing the highest amount of ZINC?
4 oz of ground beef patty.
A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply. a. "I need to check my medications for expiration dates." b. "I will use the grab bars when getting in and out of the bathtub." c. "I need to have a fire escape plan with my family." d. "I need to set my hot water heater to 140 degrees Fahrenheit."- no more than 120 degrees e. "I will apply tapes over frayed areas of electrical cord."
A, B, C, E a. "I need to check my medications for expiration dates." b. "I will use the grab bars when getting in and out of the bathtub." c. "I need to have a fire escape plan with my family." e. "I will apply tapes over frayed areas of electrical cord."
A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take? A. Allow the client to slide down his outstretched leg. B. Place his arms around the client to prevent her fall. C. Remain upright as the client falls toward him D. Move quickly to a position in front of the client.
A. Allow the client to slide down his outstretched leg.
A nurse is caring for a client who is scheduled for hip surgery in hr. Which of the following actions is the nurse's priority? A. Ensure that the client has signed the consent form. B. Lock the client's valuable in a safe location C. Verify that the client's lab values are in the medical record. D. Administer the prescribed preoperative sedative.
A. Ensure that the client has signed the consent form.
A nurse is preparing to use the Z-track method to administer iron dextran to a client who has iron-deficiency anemia. The client asks why this method of injection is necessary. Which of the following responses should the nurse make? A. It decreases the risk of injecting medication into a blood vessel. B. It delays medication absorption C. It minimizes tissue irrigation D. It accelerates medication excretion
A. It decreases the risk of injecting medication into a blood vessel.
A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse take? A. Place The Shallow End Of The Fracture Pan Under The Client's Buttocks. b. Hyperextend the client's back while the fracture pan is in place. c. Keep the bed flat while the client is on the fracture pan d. Encourage the client to try to defecate for 20 min while on the fracture pan.
A. Place The Shallow End Of The Fracture Pan Under The Client's Buttocks.
A nurse is planning care for a client who has prescription of knee-length antibolic stockings. Which of the following actions should the nurse take? A. Remove the client's stockings at least once each shift. B. Roll the top of the client's stocking down to just below the knee. C. Seat the client in a chair for 30min prior to applying stockings D. Measure the length of the client's leg from the heel to gluteal fold.
A. Remove the client's stockings at least once each shift.
A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse make?
A: "All of this equipment can be frightening."
A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching?
A: "Bear weight on both of your legs."
A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make?
A: "I can see that this is upsetting you."
A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?
A: "I keep having nightmares about my upcoming surgery."
A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?
A: "Tell me what I can do to help you overcome your fear of giving yourself injections."
A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP
A: "Using a cuff that is too small will result in an inaccurately high reading."
A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make?
A: "What worries you about being without your teeth?"
A nurse is caring for several clients who are receiving O2 therapy. Which client should the nurse assess most frequently for manifestations of oxygen toxicity?
A: 100% oxygen via partial rebreathing mask
A client is recovering from gallbladder surgery performed under general anesthesia. The nurse should encourage the client to use the incentive spirometer how many times per hour?
A: 4-5 times per hour
A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include?
A: A 10-month-old infant can pull up to a standing position.
A client is recovering from an appendectomy for a ruptured appendix has a surgical wound healing by secondary intention. When changing the client's dressing, which observation should the nurse report to the client's surgeon?
A: A halo of erythemia on the surrounding skin
A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the following abdominal assessments should the nurse expect?
A: Absent bowel sounds with distention
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take?
A: Administer analgesics to the child on a routine schedule throughout the day and night.
A nurse is in a public building when someone cries out "Help! I think he is having a heart attack!" The nurse responds to the scene and finds the unconscious adult lying on the floor. Another bystander has obtained an AED. The nurse's first action, after making certain someone has called for EMS, should be to
A: Administer cardiac compressions.
A nurse is assisting a client with a meal. The client suddenly grabs at her neck with both hands and appears frightened. The appropriate nursing action is to
A: Ask if the patient is choking
A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report?
A: Assessment
A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first?
A: Assessment
In planning care for a client with surgical wound heating by secondary intention, the nurse can anticipate that the client will
A: Be at an increased susceptibility for infection
A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess?
A: Bounding pulse
A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?
A: Carefully remove the gloves and follow with hand hygiene
A nurse is caring for a client who is incontinent of loose stool and is reporting a painful perineum. Which of the following is the priority nursing action?
A: Check the client's perineum
A post-op nurse has an indwelling catheter in place to gravity drainage. The nurse notes that the client's urine bag has been empty for 2 hours. The first action the nurse should take is to:
A: Check to see if the tubing was kinked.
When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should:
A: Cleanse the entry port priot to withdrawing urine.
A nurse is caring for a client who has just had a mastectomy and has a closed wound suction device (hemovac) in place. Which nursing action will ensure proper operation of the device?
A: Collapsing the device whenever its 1/2-2/3 full of air.
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR?
A: Confirm unresponsiveness
A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take?
A: Consult the medication reference book available on the unit.
A nurse is teaching a client who is postoperative how to use a flow-oriented incentive pyrometer. Which of the following instructions should the nurse include?
A: Cough deeply after each use.
A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated?
A: Cover the incision with a moist sterile dressing.
A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status?
A: Daily weight
A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect?
A: Decreased calcium
A client being discharged following abdominal surgery will be performing his own dressing changes at home. It is most important for the nurse to include which of the following in the discharge plan?
A: Demonstration of appropriate hand hygiene
A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take?
A: Discontinue the machine, and measure the blood pressure manually every 15 min
When replacing a client's surgical dressing, the nurse should:
A: Don clean gloves to remove the old dressing
A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client?
A: Donate autologous blood before the surgery
A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration?
A: Edema at the infusion site
A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention?
A: Educating clients about the recommended immunization schedule for adults
A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take?
A: Encourage the client to express his thoughts about death and dying
A client is admitted for evaluation and control of HTN. Several hours after the client's admission, the nurse discovers the client supine on the floor, unresponsive to verbal or painful stimuli. The nurse's first reaction at this time is to:
A: Establish an airway
An older adult client has been hospitalized on bed rest for 1 week. The client reports elbow pain. Which of the following is an appropriate initial action for the nurse caring for this client to take
A: Examine the elbow
A nurse is preparing to insert a NG tube for a client admitted with bowel obstruction. Which of the following should the nurse do first?
A: Explain the procedure to the client.
When communicating with a client who is hearing impaired, the nurse should?
A: Face the client and speak slowly
A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take?
A: Fill the bag two-thirds full with ice.
A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching?
A: Gelatin
A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?
A: Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back
A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning?
A: Have the client demonstrate the procedure.
A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions?
A: Hemolytic
While changing the linen on the client's bed, the nurse should
A: Hold the linen away from his body and clothing.
Which nursing action prevents injury to a client's eye during the administration of eye drops
A: Holding the tip of the container above the conjunctival sac
A client returning from the surgical suite following a vaginal hysterectomy is awake and asking for something to drink. Her post-op diet prescription reads: " clear liquids, advance diet as tolerated." Which of the following is appropriate for the nurse to tell the patient?
A: I am going to listen to your abdomen
A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first?
A: Identify the client using two identifiers
A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the per umbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?
A: Impaired peristalsis of the intestines
A client's provider has ordered that sputum specimen be collected for culture and sensitivity. The nurse plans to collect this specimen...
A: In the morning upon rising.
The mother of a toddler calls the nurse "Help! My baby is choking on his food!" The nurse determines that the Heimlich maneuver is necessary based on which finding:
A: Inability of the toddler to cry or speak
A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment.
A: Inspect, Auscultate, Percuss, Palpate
A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first?
A: Inspection
A nurse is caring for a client who has a new prescription for tube feeding. The nurse understands that the provider prescribed tube feeding because the client:
A: Is unable to swallow foods by mouth
A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make?
A: It must be difficult to care for someone who is confined to bed."
. A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from stretcher to the bed?
A: Lock the wheels on the bed and stretcher
A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship?
A: Loss
A nurse has inserted an indwelling catheter for a male patient. Where should the nurse tape the catheter to prevent pressure on the client's urethra at the pen scrotal junction?
A: Lower abdomen
A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take?
A: Lower the client the floor and place a pad under the client's head.
A client who is post-op following laparotomy is reporting pain and dry mouth. The client has morphine sulfate ordered to control the pain. Before administering the morphine sulfate prescribed for the client the nurse should first
A: Measure the client's vital signs.
. A client returns from surgery with two penrose drains in place. Anticipating frequent dressing changes, what should the nurse use around the incision site?
A: Montgomery straps
A nurse is preparing a client who is scheduled for hysterectomy for transport to the operating room when the client states she no longer wants to have surgery. Which of the following actions should the nurse take?
A: Notify the provider about the client's decision
A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next?
A: Observe the rate, depth, and character of the client's respirations.
A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process?
A: Obtain client information
A nurse takes an older adult lient who has dysphagia following a CVA to the dining room for dinner. When assisting the client at mealtime, the nurse should:
A: Offer the client tart or sour foods. (This makes it easier for them to swallow)
A client develops a fecal impaction. Before digital removal of the mass, which type of enema should the nurse give to loosen the feces?
A: Oil Retention
A nurse is caring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces?
A: Oil retention
A nurse is providing education about cultural and religious traditions and rituals related to death for the assistive personnel on the unit. Which of the following information should the nurse include?
A: People who practice Judaism status with the body of the deceased until burial
A nurse is preparing to provide tracheotomy care for a client. Which of the following actions should the nurse take first?
A: Perform hand hygiene
A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take?
A: Place the client in Trendelenburg's position.
A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take?
A: Place the client in a lateral position with the head turned to the side before beginning the procedure
A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take?
A: Position the client on his left side.
A nurse is teaching a client with a new colostomy about how to irrigate the stormy. The nurse realizes that the client needs further teaching when the client
A: Positions the irrigating solution bag 30 inches above the stomach.
A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing?
A: Provide a protein intake of 1.5 g/kg of body weight per day.
A nurse is caring for a client who is 3 days post-op following a cholecystectomy. The nurse suspects a wound infection because the drainage on the dressing is yellow and thick. The nurse identifies this type of drainage as:
A: Purulent
CPR has been initiated for the client in the ER. The nurse understands that a critical concept related to effective cardiac chest compressions is the need to:
A: Push hard and deep on the chest
A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take?
A: Raise the level of the bed
A nurse is planning to collect a liquid stool specimen from a client for ova and parasites. Inaccurate test results may result if the nurse:
A: Refrigerates the collected specimen
A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?
A: Remove the restraints one at a time
A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first?
A: Remove the safety pin from the extinguisher.
A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take?
A: Repeat each joint motion five times during each session.
A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance?
A: Romberg test
A nurse is caring for a client who is in terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying?
A: Sit and hold the client's hand
A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding?
A: Sit at the bedside while feeding the client.
A nurse is collecting a urine specimen for a client to test via urine dipstick the urine's specific gravity. The nurse knows the result will indicate the amount of:
A: Solutes in the urine
A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock?
A: Tachycardia
A nurse is assessing a client admitted with sudden onset of severe back pain of unknown origin. Which statement would be most effective for the nurse to use to elicit further information from this client about his pain?
A: Tell me how you are feeling right now.
An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make?
A: Tell me more about how your friends discourage you."
A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take?
A: Tie the restraint with a quick-release knot.
A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client?
A: Ventrogluteal
A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection?
A: WBC 15,000 mm3
A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client?
A: Washing dishes
A client is being discharged home with oxygen therapy via a nasal cannel. Which of the following instructions should the nurse provide to the client and family?
A: Wear cotton clothing to avoid static electricity.
A nurse is caring for a client who has Clostridium difficult (C. Diff.) and is in contact isolation. Which of the following actions should the nurse take?
A: Wear gloves when changing the client's gown.
A nurse is performing eye irrigation for the client who has been exposed to smoke and ash. Which of the following nursing actions should receive the highest priority during the irrigation?
A: Wearing gloves during the procedure.
The nurse is caring for an adult who has fluid volume excess. When weighing the client, the nurse should
A: Weight the client upon rising.
A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include?
A: When lifting an object, spread your feet apart to provide a wide base of support.
A nurse is caring for a client who is post-op following a partial colectomy. The patient has a NG tube set on low continuous suction. The client tells his nurse that his throat is sore and asks the nurse when the NG tube will be taken out. Which of the following responses by the nurse is appropriate at this time?
A: When the GI tract is working again, in about three to five days, the tube can be removed.
Before donning gloves to perform a procedure, proper hand hygiene is essential. The nurse understands that the most important aspect of had hygiene is the amount of
A: friction
A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft contender abdomen, and census overdue by 2 days. Which of the following findings should be the nurse's priority?
A:Temperature
A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits?
A:The involvement of the client in planning the change
A client is hospitalized for an infection of a surgical wound following abdominal surgery surgery. To promote healing and fight wound infection the nurse plans to arrange to increase the client's intake of:
A:Vitamin C and Zinc
A nurse is caring for a client who consumed 4 oz of juice, 16 oz of milk, 8 oz of coffee, and 200 mL of water over an 8-hr period. Calculate the client‟s intake for that 8-hr period using millilters. (nearest whole number) 1oz=30mL
Answer;; 120mL (juice) + 480mL (milk) + 240mL (coffee) + 200mL (water) = 1,040mL
A nurse is preparing to administer metoprolol 25 mg PO every 12 hr. Available is metoprolol 50 mg/scored tablet. How many tablets should the nurse administer with each dose? (nearest tenth)
Answer;; 25mg x (1 tablet/50mg) = 0.5 tablet
When admitting a client, the nurse records which information in the client's record first?
Assessment of the client
A nurse is planning to perform ear irrigation on an adult client who has impacted cerumen. Which of the following should the nurse plan to take? A. Wear sterile gloves while performing irrigation B. Position the client with the affected side down following irrigation C. Use cool fluid to irrigate the ear canal. D. Pull the pinna downward during irrigation.
B. Position the client with the affected side down following irrigation
A nurse is developing an educational program about the glycemic index of foods for clients who have diabetes. Which of the following foods should the nurse identify as having the highest glycemic index?
Baked Potato
A nurse is conducting a health assessment for a client who take herbal supplements. Which of the following statement by the client indicates an understand of the use of the supplements? A. I use garlic for my menopausal symptoms. B. I use ginger when I get car sick C. I take ginkgo biloba for headache D. I take Echinacea to control cholesterol
C. I take ginkgo biloba for headache 11 Proven Ginkgo Biloba Benefits - Increases Concentration. .. - Reduces Risk for Dementia and Alzheimer's. ... - Helps Fight Anxiety and Depression. ... - Fights Symptoms of PMS. ... - Helps Maintain Vision and Eye Health. ... - Helps Prevent or Treat ADHD. ... - Improves Libido. ... - Helps Treat Headaches and Migraines.
A nurse is delegating client care to assistive personnel. Which of the following tasks should the nurse delegate? A. Evaluating healing of an incision B. Inserting a NG Tube C. Performing a simple dressing change D. Changing IV tubing.
C. Performing a simple dressing change.
A client reports constipation during a routine check up. The client was previously encouraged to increase his intake of mineral supplements. Which of the following minerals should the nurse identify as the cause of the constipation?
CALCIUM
A nurse is providing education to an adolescent about making nutrient-dense food choices. Which of the following statements by the client indicates an understanding of the teaching?
Canned pinto beans are a better choice than refried beans.
A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein?
Cheddar cheese b. Complete proteins contain enough of all nine of the essential amino acids that help maintain and promote nitrogen balance. Cheese, poultry, and fish are good sources of complete protein.
A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-yearold child who has difficulty swallowing pills. Available is diphenhydramine 12.5 mg/5 mL oral syrup. Which of the following images shows the correct # of mL the nurse should administer? (Round the answer to the nearest whole number.)
Click on the syringe that has 8 mL of med. 20 mg x (5mL/12.5mg) = 8 mL
A nurse is screening several clients at a neighborhood health fair. Which of the following assessment findings is the priority for referral for further care? A. HR 105/min B. BMI 25 kg/m2 C. BP 148/92 D. Glucose 45mg/dl
D. Glucose 45mg/dl
A nurse is caring for a client who has C-diff infection Which of the following actions should the nurse take? A. Give the client chlorhexidine gluconate for hand hygiene. B. Remove the protective gown first when exiting the client's room C. Use alcohol-based hand rub when caring for the client D. Initiate contact precautions when providing client care
D. Initiate contact precautions when providing client care
A nurse is caring for a client who reports a pain level of 5 on a scale from 0-10. The client informs the nurse that pain medication are not option for managing pain. Which of the following is an appropriate response by the nurse? A. I'm sure it will work if you just give it a chance? B. You may take any herbal remedies you bring from home C. Why do you think pain medication is not going to help you D. Would you like me to give you a back massage?
D. Would you like me to give you a back massage?
A nurse is assessing a patient who has diabetes. Which of the following findings should the nurse identify as hypoglycemia?
Diaphoresis= sweating sign and symptoms: sweating, irritability, and tremors, tachycardia and hunger.
A client who is unstable and requires frequent vital signs has an electronic blood pressure machine automatically measuring his blood pressure every 15 min. However, the machine is reading the client‟s blood pressure at more frequent intervals, and the readings are not similar. The nurse checks the machine settings and observes the additional readings, but the problem continues. Which of the following is the appropriate nursing action?
Disconnect the machine, and measure the blood pressure manually every 15 min.
A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?
Evaluate electrolytes b. Assess the client's electrolytes first/lab results, including sodium, potassium, BUN, Hgb, Hct, and protein, to guide the planning of interventions to correct the imbalances. You should not restrict intake of oral fluids first.
A nurse in a clinic is reviewing the laboratory findings of a client who has type 2 diabetes. which of the following findings indicates the client's plan or care is effective?
HBA1C of 6.5%
A nurse teaching a client who is newly diagnosed with type 1 diabetes how to count carbohydrates. Which of the following statements made by the client indicates an understanding of the teaching?
I know the serving size can affect the number of carbs I can eat
A nurse is providing teaching to a client who reports nausea during pregnancy. Which of the following statements by the client indicates and understanding of the teaching?
I will eat dry cereal before I get out of bed
A nurse is providing teaching to a client who has Crohn's disease. Which of the following statements by the client indicates an understanding of the teaching?
I will eat eggs for breakfast. Crohn's patients -want a low-fiber , high-protein diet.
A nurse is teaching a female client about healthy diet to control hypertension. Which of the following client statements indicates understanding of the teaching?
I will eat four servings of unsalted nuts per week
A nurse in a clinic is providing nutritional counseling to a client who wants to lose weight. The nurse should identify that which of the following statements indications the client understanding?
I will make a list before I go grocery shopping
A home health nurse is providing dietary teaching to the parent of a 3 year old. Which of the following statements by the parents should the nurse identify as understanding the teaching?
I will put low-fat milk in her cup for her to drink. Children consume whole milk for up to their 2 years old and when they become 3 they can consume low fat milk. prevent children from consuming foods that are easily to swallow such as popcorn and pretzels until they are 4 year of age to prevent shocking. -avoid giving children high amounts of celery and peanut butter because of the risk of aspiration, and should spread the peanut butter on a thin piece.
A nurse teaching a client about stress management. Which of the following statements should indicate to the nurse that the client understands the teaching?
I will take long walk every evening. Exercise is good stress relief
A nurse is performing dietary teaching with a client who has a family history of cardiovascular disease. which of the following statements should the nurse include in the teaching?
Increase your dietary fiber intake.
A nurse is reviewing the lab findings for a client who has acute pancreatitis. Which of the following is an expected finding?
Increased serum glucose -an increased glucose is an expecting finding. -increased serum bilirubin. -decreased serum calcium. -increased alkaline phosphate.
A nurse is caring for a client who is receiving total parenteral nutrition through a peripherally inserted central catheter. The pharmacist informs the nurse that there will be a delay in delivering the next bag of TPN solution. Which of the following actions should the nurse take?
Infuse dextrose 10% in water when current infusion ends.
An assistive personnel says to the nurse, "This client is incontinent of stool three or four times a day. I get angry, and I think that the client is doing it just to get attention. I think we should put adult diapers on her." Which is the appropriate nursing response?
It is very upsetting to see an adult client regress.
A nurse is caring for an adolescent who has type 1 diabetes. Which of the following actions should the nurse take to assess for somgyi phenomenon?
Monitor blood glucose levels during the night.
A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minute and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?
Notify the nursing manager. b. The greatest risk to the client is not receiving timely intervention for his deterioration in physiological status; therefore the nurse should activate the chain of command to ensure proper patient care.
When a nurse makes an initial assessment of a client who is post-op following gastric resection, the client's NG tube is not draining. The nurse's attempt to irrigate the tube with 10ml 0.9% NaCl was unsuccessful, so she determines that the tube was obstructed. Which of the following actions should the nurse take?
Notify the surgeon.
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
Pad the client's wrist before applying the restraints. b. Restraints w/o padding can abrade the client's skin. The nurse should remove the restraints at least every 2 hours to reposition the client and assess his need for hygiene and toileting.
A nurse is caring for a client who is receiving total parenteral nutrition. Which of the following laboratory findings indicates that the total parenteral nutrition is effective?
Prealbumin 30 mg/dL *normal values: -prealbumin 20-40 mg/dL -Calcium 8.5-10.5 -hemoglbin 14-18 -cholesterol less than 200
A nurse is in an acute care facility is planning care for a client who has chosen to follow Islamic dietary laws during Ramadan. Which of the following actions should the nurse plan to take?
Provide a snack for the client after sunset.
A nurse in a long term care facility is monitoring a client who has Parkinson's disease during mealtime. Which of the following findings should the nurse identify as the priority?
The client drools while eating. Drooling could lead to a great risk of aspiration.
RhoGAM is administered to
a mother who is Rh-negative and gives birth to a Rh-positive infant.
A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make?
a. "I am available to talk if you should change your mind."
A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective? a. "I should expect my heart rate to take longer to return to normal after excessive as I get older." b. Urinary incontinence is something I will have to live with as I grow older. c. I can expect to have less ear was as I get older. d. My stomach will empty more quickly after meals as I get older
a. "I should expect my heart rate to take longer to return to normal after excessive as I get older." Older adults experience decreased cardiac output, which causes increased pulse rate during exercise. The pulse rate also takes longer to return to normal after exercise.
A nurse is teaching a client who has diabetes mellitus about mixing regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching. a. "I should roll the NPH between my hands before drawing it up." b. "I should wait 10 minutes after mixing the insulin to inject it." c. "I should draw up the NPH insulin before the regular insulin." d. "I should inject air into the vial of regular insulin first."-
a. "I should roll the NPH between my hands before drawing it up."- it says ROLL so that makes sense , this would be wrong if it said SHAKE because that will break up the proteins.
A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?
a. "We can talk about advance directives, and I can also give you some brochures about them."
A nurse on a medical surgical unit is receiving a change-of-shift report for four clients. Which of the following clients should the nurse see first? a. ) A client who has new onset of dyspnea 24 hr after a total hip arthroplasty0 can mean dvt b.) A client who has acute abdominal pain of 4 on a scale from 0 to 10 c.) A client who has a UTI and low-grade fever d.) A client who has pneumonia and an oxygen saturation of 96%
a. ) A client who has new onset of dyspnea 24 hr after a total hip arthroplasty0 can mean dvt always look for new onset of anything, other findings are normal also
A nurse is preparing to administer 750 mL of 0.9% sodium chloride IV to infuse over 7 hours. The nurse should set the pump to deliver how many mL/Hr?
a. 107 ml/hr
A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following should the nurse plan to document on the client's intake and output record as 120 mL of fluid?
a. 8 oz of ice chips
A home health nurse who has attended a training session for the therapeutic use of aromatherapy with essential oils is planning to use this modality with some of her clients. For which of the following clients should the nurse consult the provider before using this complementary therapy?
a. A client who has asthma.
A nurse on the newborn unit is planning discharge for four clients. Which of the following will require care beyond that of a standard follow-up visit with the provider after delivery? a. A newborn being sent home after 22 hr after birth. b. A new born at 38 weeks of gestational age c. A new born who is bottle feeding d. Twin newborns with Apgar scores of 8 &9
a. A newborn being sent home after 22 hr after birth-screening tests must be repeated if they were performed before the newborn was 24 hrs old.
A nurse is caring for a client who has a sodium level of 125mEq/L. Which of the following findings should the nurse expect?
a. Abdominal cramping The client has hyponatremia, manifestations include abdominal cramping, weakness, headache, and nausea.
A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should be the nurse assess? a. Abruptio placenta. b. Placenta previa c. Preeclampsia d. Maternal bradycardia
a. Abruptio placenta-Cocaine increases the risk for vasoconstriction and possible abruption placenta
A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?
a. Administer the medication with the needle at a 45 degree angle.
A nurse is caring for a client who has TB. Which of the following precautions should the nurse plan to implement when working with the client? Chapter 11 fundamentals 9.0 infection control page 52 a. Airborne b. Droplet c. Protective d. Contact
a. Airborne Rationale: measles, varicella, pulmonary or laryngeal tuberculosis
A nurse is performing a skin assessment of a client who has a lesion on his anterior thigh and expresses concern about skin cancer. Which of the following findings should the nurse report to the provider as a possible indication of a skin malignancy?
a. An uneven shape
A nurse is planning to use non formal logical pain methods for a client who reports still having mild back pain after receiving analgesia 1 hour ago. Which of the following actions should the nurse include in the plan? a. Apply an ice pack to the client's back for 1 hr. b. Remove distractions from the client's room. c. Instruct the client to take deep rhythmic breaths. d. Encourage the client to apply a heating pad for 2 hr at a time.- 2 hours seems too long
a. Apply an ice pack to the client's back for 1 hr. Cold therapy = reduced inflammation & slows down nerve impulse Heat therapy = stimulates blood flow & inhibits pain messages Avoid long applications of either cold or heat b/c results in tissue damage
A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client?
a. Apply intermittent suction when withdrawing the catheter
A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take? Chapter 27 Vitals signs page 244 a. Apply the cuff above the clients antecubital fossa. b. Use a cuff with a width that is about 60% of the client's arm circumference.- width of the cuff should be 40 % of arm circumference c. How the clients sit with his arm resting above the level of his heart.- MUST BE AT HEART LEVEL d. Release the pressure on the client's arm 5 to 6 mm per second.- pressure release should not be more than 2 to 3 mm hg per second
a. Apply the cuff above the clients antecubital fossa. Rationale: ATI FUNDA says 40% of the arm circumference pg. 139. Release the pressure no faster than 2 to 3 mm Hg per second. Apply the BP cuff 2.5 cm (1 in) above the antecubital space with the brachial artery in line with the marking on the cuff. Apply the BP cuff 2.5 cm (1 in) above the antecubital space with the brachial artery in line with the marking on the cuff
A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphasia. Which of the following tasks should the nurse assign to assistive personnel (select all that apply)?
a. Assist the client with a partial bed bath b. Measure the client's BP after the nurse administers an antihypertensive medication c. Use a communication board to ask what the client wants for lunch
A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? a. Attempt to increase the client's self-motivation b. Keep detailed records of each client's progress. c. Test client learning after each teaching session d. Avoid discussing areas that might cause client anxiety.
a. Attempt to increase the client's self-motivation motivation to learn is important in improving a client's commitment to achievement of a health goal, as well as increasing the amount and speed of learning.
A nurse in an emergency department is assessing a client who reports RIGHT lower quadrant pain, nausea and vomiting for the past 48 hr. Which of the following actions should the nurse take first? a. Auscultate bowel sounds. b. Administer an antiemetic. c. Offer a pain med. d. Palpate the abdomen.
a. Auscultate bowel sounds. Possible appendicitis "nausea/vomiting" with RLQ pain. (IAPP) INSPECTION. AUSCULTATE. PERCUSS. PALPATE- FOR BOWEL
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?
a. Bladder scan shows 525 mL or urine b. A client who has an indwelling catheter should have continuous urine flow w/o an accumulation of urine in the bladder
A nurse is screening several clients at a neighborhood health fair. Which of the following assessments findings is the priority for referral for further care? a. Blood glucose 45 mg/dL b. Blood pressure 148/92 mm Hg c. Body mass index 28 kg/m2 d. Heart rate 105/min
a. Blood glucose 45 mg/dL Rationale: low/hypoglycemia may lead to shock
During an admission history a client tells a nurse that she is under a lot of stress. Which of the following physiological responses should the nurse expect to increase as a result of stress? a. Blood glucose b. Intestinal peristalsis c. Peripheral blood vessels diameter . d. Urine output
a. Blood glucose- common stress response. Tiamson said it
A nurse is giving a change-of-shift report about a client he admitted earlier that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?
a. Breath sounds
A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessments findings should the nurse identify as a contraindication to the application of cold? a. Cap refill 4 seconds b. 7.5 cm (3 in) diameter bruise on the ankle c. Warts on the affected ankle d. 2+ pitting edema
a. Cap refill 4 seconds- ITS CONTRAINDICATED TO USE APPLICATION OF COLD
To ensure client safety a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is a nurse manager functioning? a. Case manager b. Client educator c. Client advocate
a. Case manager- they do no provide direct client care ,over see case load of clients
A nurse receives a report about a client who has 0.9% sodium chloride infusing IV at 125 mL/hr. When the nurse performs the initial assessment, he notes that the client has received only 80 mL over the last 2 hrs. Which of the following actions should the nurse take first?
a. Check the IV tubing for obstruction
A nurse is providing discharge teaching to a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family?
a. Check the cord routinely for frays or tearing b. Consider purchasing a generator for power backup c. Observe for signs of hypoxia d. Clothing and bedding should not be made from synthetic fabric b/c it can generate static electricity, the client should wear cotton instead. Oxygen equipment should be at least 10 feet away from open flames (gas stove, fireplace).
A nurse is caring from a client who has a tracheostomy. Which of the following actions should the nurse take? a. Clean the skin around the stoma with normal saline. b. Secure the tracheostomy ties with one finger to fit snugly underneath. → 2 snug fingers widths under neck strap c. Soak the outer cannula in warm tap water. STERILE NS d. Use a cotton tip applicator to clean the inside in the inner cannula. ean the inside with the faci
a. Clean the skin around the stoma with normal saline. Rationale: according to POTTER, funda pg. 866 using NS-saturated cotton-tipped sterile swabs and 4x4 gauze, clean exposed outer cannula surfaces and soma under faceplate, extending 5-10cm (2-4in) in all directions from stoma.
A nurse is providing teaching about nonpharmacological pain management for a postpartum client who is breastfeed and has engorgement. Which of the following methods should the nurse recommend? a. Cold cabbage leaves. b. Modified lanolin cream c. A breast binder d. Breast shells
a. Cold cabbage leaves-Application of this is an effective nonpharmacological method to relieve pain associated with engorgement.
A nurse is caring for a client who has a terminal illness and is approaching death. The client's respirations are noisy from secretions in her airway and she is short of breath. Which of the following actions should the nurse take?
a. Elevate the head of the client's bed
A nurse is monitoring a client who is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis the IV site? a. Erythema along the path of the vein b. Pitting edema at the insertion site c. Coolness of the client's left forearm d. Pallor of the client's left forearm
a. Erythema along the path of the vein
A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? a. Evaluate pedal pulse b. Obtain medical history c. Measure vital signs d. Assess for leg pain
a. Evaluate pedal pulses. For a client who has decreased circulation in the leg, evaluating pedal pulses is critical in order to determine adequate blood supply to the foot.
A nurse is providing dietary teaching with a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching? a. I should eat to taste instead of trying to balance my meals. b. I will avoid having a snack at bedtime. c. I will have 8 oz of hot tea with each meal. d. I should pair my sweets with a starch instead of eating them alone.
a. I should eat to taste instead of trying to balance my meals-Eat to taste to avoid nausea.
A nurse is providing dietary teaching about reducing the risk of infection to a client who has cancer and is receiving chemotherapy. Which of the followings statements made by the client indicates an understanding of the teaching?
a. I will discard leftovers after 3 days.. *thaw foods in the refrigerator -use home canned goods within a year -keep cooked food at a temp greater than 140
A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the following statements by the client indicates an understanding of the teaching? a. I will perform ankle and knee exercises every hour b. I will hold my breath when rising from a sitting position c. I will remove my antiembolic stockings while I am in bed d. I will have my partner help me change positions every 4 hours
a. I will perform ankle and knee exercises every hour- ROM is needed to prevent contractures .
A nurse is providing teaching to a newly licensed nurse about the care of a client who has MRSA. Which of the following statements by the newly licensed nurse indicates an understanding of teaching? a. I will place the client in a private room b. I will tell the client's visitors to wear a mask when they are within 3 feet of the client c. I will remove my gown after leaving the client's room d. I will wear an N95 respirator mask when caring for the client
a. I will place the client in a private room
A nurse is assessing a client's extraocular eye movements. Which of the following should the nurse take? a. Instruct the clients to follow a finger through the six cardinal fields of gaze. b. Hold a finger 46 cm (18 in) in front of the client‟s eyes. c. Ask the clients to cover her right eye during assessment of her left eye. d. Position the client‟s 6.1 m (20 feet) away from the Snellen chart. (This is for cranial nerve 2)
a. Instruct the clients to follow a finger through the six cardinal fields of gaze. Rationale: Cardinal fields of gaze test for cranial nerves 3, 4, and 6 which are for eye movement
A nurse is caring for a client who is to receive oxytocin (Pitocin) to augment her labor. Which of the following contraindicates the initiation of the oxytocin infusion and requires notification of the provider? a. Late decelerations b. Baseline variability c. Cessation of uterine dilation d. Prolonged active phase of labor
a. Late decelerations-Oxytocin is contraindicated based on late decelerations noted on fetal assessment findings because they indicate uteroplacental insufficiency.
A nurse is caring for a client who is postoperative following knee arthroplasty and requires the use of a thigh-length sequential compression device. Which of the following actions should the nurse take?
a. Make sure two fingers can fit under the sleeves
A nurse is caring for a client who has restraints to each extremity. Which of the following assessments should the nurse perform first? a. Peripheral pulses b. Comfort level c. Elimination needs d. Skin integrity
a. Peripheral pulses ABCS always first
A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?
a. Practice sessions
. A nurse is caring for a client who has a closed wound drainage system. Which of the following actions should the nurse take? a. Press straight down on the container to create a vacuum b. Wear sterile gloves when emptying the container c. Reset the container with the drainage port closed d. Maintain the drain in a dependent position to facilitate drainage
a. Press straight down on the container to create a vacuum
A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
a. Regulate oxygen via nasal cannula at a flow rate no more than 6l/min
A nurse is caring for a client who has a heart murmur. The nurse is preparing to auscultate the pulmonary valve. Over which of the following locations should the nurse place the bell of the stethoscope?
a. Second intercostal space at the left sternal border
A nurse is caring for a client who has a surgical wound. Which of the following laboratory values places the client at risk for poor wound healing? Ch a. Serum albumin 3 g/dL b. Total lymphocyte count 2400 mm3 c. HCT 42% d. HGB 16g/dL
a. Serum albumin 3 g/dL Rationale: Albumin in low. Normal range is 3.5 to 5.5 g/dL. Low albumin places the client at risk for poor wound healing. The other lab values are within normal limits.
A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. After which of the following observations should the nurse remove the IV catheter?
a. Swelling and coolness are observed at the IV site.
A nurse is caring for a client who does not speak the same language as the nurse. When working with the client through an interpreter, which of the following actions should the nurse take?
a. Talk directly to the client, instead of the interpreter, when speaking.
A nurse is teaching a client who requires maximal support about how to use a two wheeled walker. Which of the following actions by the client indicates an understanding of teaching. a. The client moves the walker ahead 25.4cm with each step b. The client picks up the walker with each step c. The client stands with her elbow slightly while holding the walker d. The client stoops slightly forward when moving the walker
a. The client moves the walker ahead 25.4cm with each step
A nurse is providing a teaching to a client who had a new medication prescription. Which of the following manifestations of a mild allergic reaction should the nurse include? a. Urticaria b. Ptosis c. Nausea d. Hematuria
a. Urticaria
A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching?
a. Use tracheostomy covers when outdoors. Tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles. In the home environment, medical asepsis with clean technique is appropriate.
A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?
a. Wrap blankets around all four sides of the bed.
A nurse is providing discharge teaching to a client who is postpartum about resuming sexual activity. Which of the following instructions should the nurse include in the teaching? a. You should use a water soluble gel for lubrication. b. You can resume sexual activity in 10 days c. You physical reaction to sexual stimulation will not be altered d. You will not ovulate for 3 months after delivery.
a. You should use a water soluble gel for lubrication-This will prevent discomfort.
A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity? a. a client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. b. a client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes c. a client who has a DNR order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family d. a client who is about to undergo a painful procedure receives pain medication 30 minutes before the procedure that the nurse previously promised to administer
a. a client who is unaware of her recent cancer diagnosis asks the nurse if she has cancer, and the nurse responds affirmatively. Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others. A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client's wishes. When stopping a procedure that the client refuses, the nurse is following the ethical principle of autonomy and is recognizing the client's right to refuse treatment. A client who has a do-not-resuscitate (DNR) order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family. A DNR order requires a request on the part of the client or the client's designated power of attorney for health care decisions. Enforcing a client's DNR order supports the ethical principle of autonomy by following the client's end-of-life wishes. A client who is about to undergo a painful procedure receives pain medication 30 min before the procedure that the nurse previously promised to administer. This is an example of the ethical principle of fidelity, which means keeping promises.
A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care? a. wrap blankets around all 4 sides of the bed b. apply restraints during seizure activity c. place the client in a supine position during seizure activity d. have a tongue depressor at the client's bedside
a. wrap blankets around all 4 sides of the bed
A nurse is teaching a client who has diabetes mellitus about mixing regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching? a.) "I should roll the NPH vial between my hands before drawing it up" b.) "I should draw up the NPH insulin before the regular insulin" c.) "I should inject air into the vial of regular insulin first" d.) "I should wait 10 minutes after mixing the insulin to inject it"
a.) "I should roll the NPH vial between my hands before drawing it up"
A nurse is providing teaching to an older adult client about home safety. Which of the following information should the nurse include? a.) "Keep a nightlight on the bathroom" b.) "Set room temperature to 68 degrees Fahrenheit" c.) "Place throw rugs over electrical cords" d.) "Use chairs without arm rests"
a.) "Keep a nightlight on the bathroom"
A nurse is caring for an adolescent client who has full-thickness burns on his leg. The client expresses concern about his future. Which of the following is therapeutic response by the nurse? a.) "You're concerned about what will happen when you leave the hospital?" b.) "If you work hard on your physical therapy, you won't need to worry" c.) "You shouldn't worry about the future so you can concentrate on getting well" d.) "Why are you concerned even though everyone is here to help you?"
a.) "You're concerned about what will happen when you leave the hospital?"
A nurse on a med-surg unit is providing care for four clients. The nurse should identify which of the following situations as an ethical dilemma? a.) A surgeon who removed the wrong kidney during a surgical procedures refuses to take responsibility of her actions b.) A client who has a new colostomy refuses to take instructions from the ostomy therapist because she "doesn't like him" c.) The family of a client who has a terminal illness asks that the provider not tell the client the diagnosis d.) A client who has Cohn's disease reports that his prescription drug plan will not pay for his medications
a.) A surgeon who removed the wrong kidney during a surgical procedures refuses to take responsibility of her actions- please double check anyone
A nurse is caring for a client who is 6 hr postoperative following abdominal surgery and is having difficulty voiding. Which of the following actions should the nurse take? a.) Allow the client to hear running water while attempting to void b.) Provide the client a bedpan while lying supine c.) Insert an indwelling urinary catheter and connect it to gravity drainage d.) Encourage fluid intake up to 1,000 mL daily
a.) Allow the client to hear running water while attempting to void least invasive first, bedpan doesn't promote independence, fluid intake more than 21>
A nurse is caring for a client who will receive intermittent entreat feedings through a gastrostomy tube. Which of the following actions should the nurse take when administering a feeding? (select ALL) a.) Keep the client sitting upright for 15 min following administration b.) Instill the formula over a period of 30 to 45 min c.) Heat the formula to 80F prior to administration d.) Check for residual volumes by aspirating stomach contents e.) Place the client into the Fowler's position
a.) Keep the client sitting upright for 15 min following administration b.) Instill the formula over a period of 30 to 45 min d.) Check for residual volumes by aspirating stomach contents e.) Place the client into the Fowler's position
A nurse is assessing a client who is receiving tube feedings via NG tube. Which of the following findings should the nurse report to the provider? a.) Potassium 5.5 mEq/L b.) Irritation of nasal mucosa c.) Sodium 144 mEq/L d.) Loose stools
a.) Potassium 5.5 mEq/L
A nurse is planning interventions for a group of clients who are obese. What can the nurse do to improve their commitment to a long-term goal of weight loss?
attempt to develop the client's self-motivation
. A nurse is documenting client care. Which of the following abbreviations should the nurse use? ati book was not thorough so I had to go on different sites for charts - not confident with this, please double check. a. "SS" for sliding scale b. "BRP" for bathroom privileges c. "OJ" for orange juice- do not d. "SQ" for subcutaneous- do not
b. "BRP" for bathroom privileges
A nurse is caring for clients who is prescribed a buccal medication. Which of the following client statements indicates that the client understands how to take this medication? a. "I will first dissolve the tablet in water." b. "I will insert the tablet between my cheek and teeth." c. "I will place the tablet under my tongue." d. "I will chew the tablet."
b. "I will insert the tablet between my cheek and teeth."
A home health nurse is teaching a new caregiver how to care for a client who has had a tracheostomy for 1 year. Which of the following instructions should the nurse include? a. "Use tracheostomy covers when going outdoors." Google b. "Maintain sterile technique when performing tracheostomy care." c. "Remove the outer cannula for routine cleaning." d. "Clean around the stoma with povidone-iodine." NS
b. "Maintain sterile technique when performing tracheostomy care."
A nurse is teaching a group of newly licensed nurses about the Braden Scale. Which of the following responses by the newly licensed nurse indicates an understanding of the teaching? a. "The client's age is part of the measurement." b. "The scale measures six elements." c. "The higher the score, the higher the pressure ulcer risk." d. "Each element has a range from 1 to 5 points."
b. "The scale measures six elements." Rationale: The six elements are 1. Sensory Perception, 2. Moisture, 4. activity, 5. mobility ,6. nutrition , 7. friction and shear.
A nurse is assessing a newborn who has a weak cry and is grimacing. The nurse notes the newborn has a heart rate of 102/min. blueish extremities, and a flaccid muscle tone. Which of the following reflects the appropriate APGAR score? a. 4 b. 5 c. 6 d. 7
b. 5
A nurse is auscultating a client's abdomen. The nurse hears a blowing sound over the aorta. The nurse should identify this sound as which of the following? a. Gallop b. Bruit c. Thrill d. Murmur
b. Bruit Rationale: Bruit- turbulent blood flow within the aorta.
A nurse is caring for a client who has right-sided paralysis following a cerebrovascular accident. which of the following prescriptions should the nurse anticipate to prevent a plantar flexion contracture of the affected extremity? P .222 chapter 40 mobility and immobility a. Ankle b. Continuous passive motion machine c. Abduction splint d. Sequential compression device
b. Continuous passive motion machine- range of motion prevents ankylosis ( permanant fixation of a joint ).
A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend? a. Exercise 1 hr before bedtime. b. Eat a light carbohydrate snack before bedtime. c. Drink a cup of hot cocoa before bedtime. d. Take a 30 min nap daily.
b. Eat a light carbohydrate snack before bedtime. This was on the fundamentals practice test on ATI funds 2013
A nurse is providing care for a client who is to undergo total laryngectomy. which of the following interventions is the nurse's priority? a. Schedule a support session for the client. b. Explain the techniques of esophageal speech. c. Review the use of artificial larynx with the client. d. Determine the client's reading ability.
b. Explain the techniques of esophageal speech.
A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?
b. Fluid volume deficit causes tachycardia
A nurse is providing teaching about preventing back strain to the caregiver of a client who is immobile and requires assistance to reposition in bed. Which of the following statements by the caregiver indicates an understanding of the teaching a. I will place the bed in the lowest position b. I will tighten my abdominal muscles prior to moving c. I will keep my legs straight to provide more power in the lift d. I will twist at the waist while pulling the draw sheet
b. I will tighten my abdominal muscles prior to moving Rationale : Avoid twisting your thoracic spine and bending your back while your hips and knees are straight; When lifting an object from the floor, flex your hips, knees, and back; tighten the abdominal muscles to increase support to the back muscles
A nurse is caring for a client who has a history of rheumatic disease, but no physical symptoms prior to pregnancy. The client begins to experience dyspnea, orthopnea, and pulmonary edema. Which of the following biological alterations explains this change? a. Increased maternal weight b. Increased blood volume c. Change in hematocrit levels d. Change in heart size
b. Increased blood volume- Increase in blood volume during pregnancy increase the workload of the heart, which causes the symptoms.
A nurse is caring for a client who is on bed rest following an abdominal surgery. Which of the following findings indicates the need to increase the frequency of position changes? Sacrum , buttock and heals are prone for ulcers. NON blanckingerthyema in merks manual . blanching is considered good since that means tissue perfusion a. Flat rash on the client's ankle b. Non blanching red area over my clients trochanter c. Ecchymosis on the clients left shoulder d. Petechiae on the client's right anterior thigh
b. Non blanching red area over my clients trochanter
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? a. Obtaining hydrogen peroxide for tracheostomy care. b. Obtaining cotton balls for the tracheostomy care. c. Obtaining sterile gloves for tracheostomy care. d. Obtaining a sterile brush for tracheostomy care.
b. Obtaining cotton balls for the tracheostomy care. Cotton ball particles can be aspirated into the tracheostomy opening, possibly cause an tracheal abscess. The charge nurse should intervein for this action.
A nurse is caring for a client who had a stroke and requires assistance with morning ADLs. Which of the following interprofessional team members should the nurse consult? a. Registered dietician b. Occupational therapist . c. Speech-language pathologist d. Physical therapist
b. Occupational therapist .
. A nurse is planning care for a client who reports insomnia. Which of the following actions should the nurse perform shortly before bedtime? a. Provide a late supper b. Offer a wet washcloth for the client to wash her face c. Perform range of motion exercise d. Prepare a hot cocoa or tea for the client
b. Offer a wet washcloth for the client to wash her face
A nurse is conducting a Weber test on a client. Which of the following is an appropriate action for the nurse to take? a. Deliver a series of high-pitched sounds at random intervals. b. Place an activated tuning fork in the middle of the client's forehead. c. Hold and activated tuning fork against the client's mastoid process. d. Whisper a series of words softly into one ear.
b. Place an activated tuning fork in the middle of the client's forehead.
A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse take? a.) Place the shallow end of the fracture pan under the client's buttocks b.) Encourage the client to try to defecate for 20 min while on the fracture pan c.) Keep the bed flat while the client is on the fracture pan d.) Hyperextend the client's back while the fracture pan is in place
b. Place the shallow end of the fracture pan under the client's buttocks Head of the bed to 30, never leave a client lying flat on bedpan.
. A client who is non-ambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the fire, which of the following actions should the nurse take next? a. Evacuate the client
b. RACE mnemonic (Rescue first)
A nurse is caring for a client who has left lower atelectasis. in which of the following positions should the nurse place the client for postural drainage? Chapter 53 Airway Management page 562 a. Supine and low-Fowler's position b. Right lateral in Trendelenburg position c. Side lying with the right side of the chest elevated d. Prone with pillows under the extremities
b. Right lateral in Trendelenburg position
A nurse is caring for a client who has left lower atelectasis in which of the following positions should the nurse place the client for postural drainage? a. Supine and low-Fowler's position. b. Right lateral in Trendelenburg position. c. Side lying with the right side of the chest elevated. d. Prone with pillows under the extremities.
b. Right lateral in Trendelenburg position. (Atelectasis: Partial or complete collapse lung)
A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention? a. Holding a community clinic to administer influenza immunizations. b. Screening groups of older adults in nursing care facilities for early influenza manifestations c. Educating parents of young children about the dangers of influenza. d. Finding rehabilitation programs for older adults who have complications from influenza.
b. Screening groups of older adults in nursing care facilities for early influenza manifestations Screening older adults who have some manifestations of illness to determine if they have influenza is an example of secondary prevention. Secondary prevention is focused on preventing complications of an illness or providing care to prevent illness from becoming severe.
A nurse is admitting an older adult client who is Hispanic. Which of the following cultural should the nurse include when developing the plan of care? a. The Hispanic culture views late adulthood as a negative time in the client's life b. The Hispanic culture identifies the eldest female family member as the decision maker c. The Hispanic culture expects individuals to make their own decisions when death is imminent. d. The Hispanic culture expects adult children to care for older adult parents.
b. The Hispanic culture identifies the eldest female family member as the decision maker
A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? a. The client asks the nurse to repeat the instructions before attempting the exercise. b. The client reports severe pain. c. The client asks the nurse how often deep breathing should be done after surgery. d. The client tells the nurse that this exercise will be painful after surgery.
b. The client reports severe pain. A client who is experiencing severe pain is not able to concentrate and therefore, is not ready to learn a new activity.
A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely increase the client's motivation to learn? a. The nurse empathy about the client having to self-inject b. The client's belief that his needs will be met through education c. The client seeking family approval by agreeing to a teaching plan d. The nurse explaining the need for education to the client
b. The client's belief that his needs will be met through education
A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?
b. The first action should be to assess the patient and determine if the patient is at risk for falling or fainting during the transfer.
A nurse is performing a dressing change on a client and observes granulation tissue. Which of the following findings should the nurse document? Chapter 55 Pressure ulcers, wounds and wound management? fundamentals pdf page 330 a. Stringy, white tissue- same as slough. Means that it is separated from the body. b. Translucent, red tissue- red means healthy and its healing. c. Soft, yellow tissue= means presence of slough and drainage. d. Thick, black tissue- black is necrotic = eschar is present and needs removal
b. Translucent, red tissue- red means healthy and its healing
A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first? a. Label the pump with a defective equipment sticker. b. Unplug the pump. c. Obtain a replacement pump. d. Notified the biomedical department to fix the pump.
b. Unplug the pump. Rationale: Prioritization question. YOU WILL FIRST UNPLUG the IV pump to avoid causing a fire.
A nurse is teaching about home safety with a client. Which of the following instructions should the nurse include? a. Unplug electronics by grasping the cord b. Use electrical tape to secure extension cords next to baseboards on the floor c. To use a fire extinguisher, aim high at the top of the flames. d. Replace carpeted floors with tile
b. Use electrical tape to secure extension cords next to baseboards on the floor
A nurse is caring for a client preoperatively who has given informed consent for an appendectomy. Which of the following statements by the client should the nurse address first? a.) "I am afraid to walk if it hurts too much" b.) "I don't understand why I need this surgery" c.) "I don't want my family helping me after the surgery" d.) "I am afraid the scar will make me look disfigured"
b.) "I don't understand why I need this surgery"
A home health nurse is teaching a client about home safety. Which of the following statements by the client indicates an understanding of the teaching? (select ALL) a.) "I need to set my hot water heater to 140 degrees Fahrenheit" b.) "I will use the grab bars when getting in and out of the bathtub" c) "I will apply tape over frayed areas of electrical cords" d.) "I need to have a fire escape plan with my family" e.) "I need to check my medications for expiration dates"
b.) "I will use the grab bars when getting in and out of the bathtub" d.) "I need to have a fire escape plan with my family" e.) "I need to check my medications for expiration dates"
A nurse is assessing the breath sounds of an adult client who has pneumonia. Which of the following actions should the nurse take? a.) Follow a systematic pattern from side-to-side moving down the client's chest b.) Ask the client to breathe in deeply through his nose c.) Instruct the client to sit erect with his head tilted slightly backward d.) Place the bell of the stethoscope on the client's chest
b.) Ask the client to breathe in deeply through his nose
A nurse is preparing to perform an admission assessment for a client who reports abdominal pain. Which of the following actions should the nurse take? a.) Perform deep palpation at the end of the admission assessment b.) Auscultate the client's abdomen before palpation c.) Begin palpation of the abdomen at the site of pain d.) Assess the client's bowel sounds using the bell of the stethoscope
b.) Auscultate the client's abdomen before palpation inspect, auscultate, palpate, percuss
A nurse is planning care for a client who has a prescription for extremity restraints to both wrists. Which of the following actions should the nurse include in the plan of care" (select ALL) a.) Secure restrains to allow three fingers to slide under the restrains (1-2 fingers) b.) Ensure that the bed is in the lowest position c.) Tie each restraint with a quick-release knot d.) Attach the client's restraints to the bed rail. e.) Remove the client's restraints every 2 hr
b.) Ensure that the bed is in the lowest position c.) Tie each restraint with a quick-release knot e.) Remove the client's restraints every 2 hr
A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse take to verify proper placement of the tube? a.) Assess the client for a gag reflex b.) Measure the pH of the gastric aspirate c.) Place the end of the NG tube in water to observe for bubbling d.) Auscultator 2.5cm (1 in) above the umbilicus while injecting 15 mL of sterile water
b.) Measure the pH of the gastric aspirate
A nurse is preparing to perform a sterile dressing change for a client. Which of the following actions should the nurse plan to take? a.) Don sterile gloves prior to opening sterile dressing supplies b.) Set up the sterile field above waist level c.) Consider 5.08cm (2 in) of the sterile field's border to be contaminated d.) Place the cap of a sterile solution inside the sterile field
b.) Set up the sterile field above waist level
A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the nurse include? a. "Use full-length side rails on the client's bed." b. "Check on the client frequently while he is in the restroom." c. "Encourage physical activity throughout the day to expand energy." d. "Remove clocks from the client's room."
c. "Encourage physical activity throughout the day to expand energy."
A nurse is providing teaching about health promotion guidelines to a group of young adult male clients. Which of the following guidelines should the nurse include? a. "Obtain a tetanus booster every 5 years." b. "Obtain a herpes zoster immunization by age 50." c. "Have a dental examination every 6 months." d. "Have a testicular examination every 2 years."
c. "Have a dental examination every 6 months."(funds atipg 201 says they need dental cause they are prone to infection)
A nurse is providing discharge teaching about safety considerations to an older adult client who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching? Chapter 19 pharm p. 145 a. "I will take a hot bath before going to bed." b. "I will take my new medication in the evening." c. "I will leave a light on in my bathroom at night." d. "I will weigh myself once weekly."
c. "I will leave a light on in my bathroom at night."-some clients might have to take it twice per day usually last dose taken before 1400. You leave a light on in the bathroom because they might have to go urinate at night time ( since nocturia is a possible side effect )
A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? a. "Drink a minimum of 1,000 mL of fluid daily. b. "Increase your intake of refined-fiber foods" c. "Sit on the toilet 30 minutes after eating a meal." d. "Take a laxative every day to maintain regularity"
c. "Sit on the toilet 30 minutes after eating a meal." " Increased peristalsis occurs after food enters the stomach. Sitting on the toilet 30 minutes after eating a meal, regardless of feeling the urge to defecate, is a recommended method of bowel retraining to treat constipation.
A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse? a. "This test will indicate if you are at risk for developing blood clots b. "This test will determine if your heart is performing properly" c. "This test will provide information about the function of your liver" d. "This test is used to check how your kidneys are working"
c. "This test will provide information about the function of your liver" Rationale: Leadership 7.0. ALT and AST measure you liver function. Creatinine and BUN measure your kidney function.
A nurse is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the nurse plan to initiate? a. Contact b. Droplets c. Airborne d. Protective environment
c. Airborne
A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include? a. Remove clocks from the client's room b. Use full length side rails on the client's bed c. Check on the client frequently while he is in the restroom d. Encourage physical activity throughout the day to expend energy
c. Check on the client frequently while he is in the restroom
A nurse is performing an admission assessment of a client. Which of the following actions should the nurse take when recording the client's medication? a. Council the client about medication adherence. b. Assess the client for medication reactions. c. Compile a list of the client's current medications. d. Evaluate the client's understanding of medications.
c. Compile a list of the client's current medications
A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? a. Measure the pulse using a Doppler ultrasound stethoscope b. Check the client's pedal pulses. c. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. d. Take the pulse at each peripheral site and count rate for 30 seconds.
c. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart. If the peripheral pulse is irregular, the nurse should auscultate the apical pulse for 60 seconds to obtain an accurate rate. The nurse should document the irregularity in the client's medical record.
A nurse is caring for a client who has a new diagnosis of terminal cancer. Which of the following interventions is a priority? a. Teach the client to use progressive relaxation techniques. b. Help the client to find a local support group. c. Discuss the client's prior coping mechanism. d. Develop a list of goals with the client.
c. Discuss the client's prior coping mechanism.
A nurse is providing teaching to a client who has diabetes mellitus about performing a capillary blood glucose test. Which of the following instructions should the nurse include in the teaching? a. Don sterile gloves prior to puncturing the site b. Puncture site after cleansing and before antiseptic dries. c. Gently squeeze the puncture site until a large droplet of blood forms d. Hold the finger to puncture above the level of the heart
c. Gently squeeze the puncture site until a large droplet of blood forms
A nurse is assessing a client's ability to balance. Which of the following actions is appropriate when the nurse conducts a Romberg test? Page 168 chapter 31 musculosketal and neuro systems a. Ask the client to extend her arms in front of her body. b. Ask the client to walk in a straight line heel To toe. c. Have the client stand with her feet together. d. How the client place her hands on her hips.
c. Have the client stand with her feet together.- also with eyes closed. There should not be swaying
A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corn And calluses on her toes. Which of the following statements by the client indicates an understanding of the teaching? a. I can place an oval corn pad over toes that have corns as long as I remove the pad weekly b. I should soak my feet in warm water daily to soften corns and calluses c. I can apply lotion to soften calluses as long as I don't put lotion between my toes d. I should use an over the counter liquid medication to remove corns
c. I can apply lotion to soften calluses as long as I don't put lotion between my toes Rationale : A qualified professional should perform foot care for clients who have diabetes mellitus to evaluate the feet and prevent injury. Instruct clients at risk for injury to do the following: inspect the feet daily, paying specific attention to the area between the toes; Use lukewarm water, and dry the feet thoroughly; Apply moisturizer to the feet, but avoid applying it between the toes; Avoid over‑the‑counter products that contain alcohol or other strong chemicals; Avoid self‑treating corns or calluses; Do not apply heat unless prescribed.
A nurse in a provider's office is caring for a client who states "I always have trouble sleeping". Which of the following actions should the nurse take first? a. Teach the client stress reduction techniques b. Recommend that the client avoid caffeine intake in the evening c. Identify the client typical bedtime routine d. Encourage the client to exercise regularly during day time hours.
c. Identify the client typical bedtime routine
A nurse is interviewing a family as part of a family assessment. The nurse identifies the family unit as a husband, a wife, and three children. One child is biological from this marriage and the other two are from the wife's previous marriage. The nurse should identify this as which of the following family forms? a. Extended b. Blended c. Nuclear d. Alternative
c. Nuclear
A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? a. BT for bedtime b. SC for subcutaneously c. PC for after meals d. HS for half-strength
c. PC for after meals-The nurse can use this abbreviation because it is approved and not error-prone; a. The nurse should avoid using this abbreviation because it can be mistaken for BID, which means twice daily, instead the nurse should use word "bedtime" b. Avoid using this abbreviation because it can be mistaken for sublingual, instead use "subcut" d. avoid this abbreviation and use half-strength instead.
A nurse is assessing a client's bowel sounds. Which of the following actions should the nurse take? a. Listen to the bowel sounds after performing abdominal palpation b. Auscultate for 2 min to determine if bowel sounds are absent c. Place the diaphragm of the stethoscope over each quadrant d. Ask the client to cough upon auscultation
c. Place the diaphragm of the stethoscope over each quadrant
A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use? a. Stand toward the client's stronger side. b. Instruct the client to lean backward from the hips. c. Place the wheelchair at 45" angle to the bed. d. Assume a narrow stance with feet 15 cm (6 inch) apart.
c. Place the wheelchair at a 45 degree angle to the bed. Positioning the wheelchair at a 45* allows the client to pivot, lessening the amount of rotation required.
A nurse is collecting A blood pressure reading from a client who is sitting in a chair period the nurse determines that the clients BP is 158/96 mmhg. which of the following actions should the nurse take? a. Ensure that the width of the BP cuff is 50% of the client‟s upper arm circumference. It says 40% b. Reposition the client Supine and recheck her BP. BP. → ORTHOSTATIC HYPOTENSION c. Recheck the clients BP and her other arm for comparison. d. Request that another nurse check the the clients BP in 30 minutes. → 15 minutes
c. Recheck the clients BP and her other arm for comparison.
A nurse is preparing to insert IV catheter for an adult client. Which of the following actions should the nurse take? a. Choose the most proximal site on the extremity selected b. Apply a cool compress for several minutes before insertion of the IV catheter c. Stroke the extremity for several minutes before insertion of the IV catheter d. Place the tourniquet below the proposed insertion site
c. Stroke the extremity for several minutes before insertion of the IV catheter
A nurse on a medical-surgical unit is dividing care for four clients. The nurse should identify which of the following situations as an ethical dilemma? a. A client who has a new colostomy refuses to take instructions from the ostomy therapist because she "doesn't like him." b. A surgeon who removed the wrong kidney during a surgical procedure refuses to take responsibility for her actions. c. The family of a client who has a terminal illness as the provider not to tell the client the diagnosis. d. A client who has Crohn's disease reports that his prescription drug plan will not pay for his medications.
c. The family of a client who has a terminal illness as the provider not to tell the client the diagnosis.
A nurse overhears a colleague informing a client that he will administer her medication by injection if she refuses to swallow her pills. The nurse should recognize that the colleague is committing which of the following torts? a.) Defamation b.) Malpractice c.) Assault d.) Battery
c.) Assault- verbal threatening
A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. Which of the following actions should the nurse take? a.) Use proper medical terms when giving instructions to the client. b.) Offer written instructions in the client's language c.) Direct verbal discharge instructions to the interpreter d.) Request that an assistive personnel interpret that instructions for the
c.) Direct verbal discharge instructions to the interpreter
A nurse is caring for a client who is confused and pulling at the tubing of her IV. Which of the following actions should the nurse take before requesting a prescription for restraints from the provider? a.) Place the client in a room away from the nurses‟ station b.) Limit the client's visitors c.) Give the client washcloths to fold d.) Close the door of the client's room
c.) Give the client washcloths to fold
A nurse is caring for a client who begins to experience a generalized seizure while standing in her room. Which of the following actions should the nurse take? a.) Place a pad under the client's head b.) Hold the client's limbs tightly to prevent injury c.) Lift the client into bed with the help of other staff members .d) Insert a bite block into the client's mouth
c.) Lift the client into bed with the help of other staff members (You assist them to fall) Rationale: Advise all caregivers and family not to restrain the client during a seizure but to lower him to the floor or bed, protect his head, remove nearby furniture, provide privacy, put him on his side with his head flexed slightly forward if possible, and loosen his clothing.
A nurse is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse include in the plan? a.) Empty the drainage bag at least every 8 hr b.) Keep the drainage bag at the level of the bladder c.) Use the clean technique to collect a specimen from the drainage system d.) Tape the catheter to the lower abdomen
c.) Use the clean technique to collect a specimen from the drainage system
A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature? a. rectal b. Tympanic c. Oral d. Temporal
d :Temporal- The temporal artery route, while not as accurate as the rectal route for obtaining a precise body temperature, is noninvasive and can be used to obtain a temperature in a toddler who might have an ear infection and who is having diarrhea. The nurse should place the probe behind the ear if the client is diaphoretic but should avoid placing it over and area covered with hair.
A nurse is documenting in a client's medical record . Which of the following entries should the nurse record? a. "Incision without redness or drainage." b. "Drink adequate amounts of fluid with meals." WHATS THE AMOUNT c. "Oral temperature slightly elevated at 0800." WHATS THE TEMP d. "Administered pain medication.
d. "Administered pain medication. Any action & change to the client's condition should be recorded.
A nurse is preparing change of shift report after the night shift using one sbar communication tool. which of the following data should the nurse include when reporting background information? a. "Blood pressure 160/92 mm Hg" b. "Start first dose of penicillin at 1200"- c. "Pain rating of 5 on a scale from 0 to 10" d. "Code status: do-not-resuscitate"
d. "Code status: do-not-resuscitate"
A nurse is admitting a client who is malnourished. The client states my wedding ring is loose and I'm worried I will lose it if it falls off. Which of the following is an appropriate response by the nurse? a. "I can pin it to your hospital gown, so you won't lose it." b. "I will place it in your drawer, so it won't get lost." c. "I will hold onto it until a family member can take it home."
d. "I can put it in a locked storage unit for you."
A community health nurse is caring for a group of families. The nurse should identify that which of the following families is experiencing a maturational loss? a. A family whose only child recently died due to cancer. b. A family whose head of household lost her job. c. A family whose house was destroyed in a fire. d. A family whose oldest child is moving away for college
d. A family whose oldest child is moving away for college Rationale: Flashcardmachine: Maturational loss- experienced as a result of natural developmental processes. E.g. The first child may experience a loss of status when her sibling is born. Also, happens when sending children off to kindergarten or college.
A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care? a. Obtain a random blood glucose daily. b. Change the PN infusion bag every 48 hr. CHANGE Q24HR c. Prepare the client for a central venous line. d. Administer the PN and fat emulsion separately.
d. Administer the PN and fat emulsion separately. ATI FUNDA PG. 298 Administer separate IV line below the filter using a Y-connector or as a admixture to PN solution (3-in-1 admixture consisting dextrose, AA, and Lipids
. A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG Tube. Which of the following actions should the nurse take? a. Remove the restraints every 4 hr. b. Attach the restraints securely to the side of the client's bed. c. Apply the restraints to allow as little movement as possible. d. Allow room for two fingers to fit between the client's skin and the restraints.
d. Allow room for two fingers to fit between the client's skin and the restraints.- for circulation
A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include? a. Monitor the client for pain in the suprapubic region. b. Ensure the client is free of metal objects. c. Administer 240 mL (8 oz) of oral contrast before the procedure. d. Assist the client with a bowel cleansing
d. Assist the client with a bowel cleansing. Fundamentals Textbook pg 1114 IVP = imaging of the urinary tract after iv injection of iodine Prep - assess allergies & dehydration, cleanse bowel, restrict food 4 hrs prior
A nurse is caring for a client who has extracellular fluid volume deficit. Which of the following findings should the nurse expect? a. Postural hypotension b. Distended neck veins c. Dependent edema d. Bradycardia
d. Bradycardia - would be TACHY since SNS system kicks in when detects low blood volume TACHYCARDIA is for fluid overload. Isnt wherever the water goes the sodium follows. The lady on ati gave me a remediation hw about manifestation of hypernatremia: hyperthermia, tachycardia, and orthostatic hypotension. Therefore it‟s opposite→ bradycardia. TBC by the group
A nurse is caring for a client who has chronic back pain and asked about receiving acupuncture for relief. Which of the following findings should the nurse identify as a contraindication to receiving this shipment? a. Obesity b. Hypertension c. Migraines d. Cellulitis
d. Cellulitis
. A nurse is receiving the prescription for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify? a. Dietitian consult b. Speech therapy referral c. Oral suction at the bedside d. Clear liquids
d. Clear liquids liquids must be THICK. Clear liquids can cause aspiration Rationale: ATI MS. Pg. 83 food levels for dysphagia include pureed, mechanically altered, advanced/mechanically soft, and regular.
. A nurse at an assisted living facility is preparing an in-service for residents about electrical safety. Which of the following instructions should the nurse include? a. Avoid taping electrical cords to the floor. b. Clean electrical equipment prior to disconnection. c. Cover exposed wires with tape before used. d. Disconnect electrical equipment by grasping the plug.
d. Disconnect electrical equipment by grasping the plug.
A nurse is caring for a client who has a tracheostomy collar. As the nurse is performing tracheal suctioning, the client's heart rate and oxygen saturation decrease. which of the following actions should the nurse take? a. Elevate the head of the bed. b. Remove the inner cannula. c. Irrigate the stoma. d. Discontinued suctioning.
d. Discontinued suctioning.
A nurse in an acute care facility is preparing to transfer a client to a long term care facility. Which of the following information should the nurse include in the hand off report? a. Frequency of previous vital sign measurement b. Number of family members who have visited c. Time of the clients last bath d. Effectiveness of the last dose of pain medication
d. Effectiveness of the last dose of pain medication Rational : Transfer documentation: -Medical diagnosis and care providers - Demographic information -Overview of health status, plan of care, and recent progress - Alterations that can precipitate an immediate concern -Notification of assessments or care essential within the next few hours -Most recent vital signs and medications, including PRN - Allergies - Diet and activity orders -Specific equipment or adaptive devices (oxygen, suction, wheelchair) -Advance directives and emergency code status - Family involvement in care and health care proxy, if applicable
A nurse is changing a client's colostomy pouch and notices peristomal skin irritation. Which of the following actions should the nurse take? a. Change the pouch once every 24 hour. b. Apply the pouch while the skin Barrier is still damp. c. Rub the peristomal skin dry after cleaning. d. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma
d. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma.
A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? a. Beneficence b. Justice c. Veracity d. Fidelitty
d. Fidelity -The duty to do what one has promised.
A nurse is teaching a client about Rho(D) immunoglobulin (RhoGAM). Which of the following statements by the client indicates an understanding of the teaching? a. I will receive this medication if my baby is Rh-negative. b. I will receive this medication at time of delivery. c. I will need a second dose of this medication when my baby is 6 weeks old. d. I will need this medication if I have an amniocentesis.
d. I will need this medication if I have an amniocentesis-Recommended because of the potential of fetal RBC's entering the maternal circulation.
A nurse is teaching a client how to use an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching? a. I will try not to cough after using the spirometer (it's good to cough up sputum) b. I will use the spirometer three times a day (3-5x an hour) c. I will initially hold my breath for 15 seconds (for inhalers) d. I will seal my lips around the mouthpiece
d. I will seal my lips around the mouthpiece
A nurse is planning to use nonpharmacological pain methods for a client who reports still having mild back pain after receiving analgesia 1 hour ago. Which of the following actions should the nurse include in the plan? a. Encourage the client to apply a heating pad for 2 hours at a time b. Apply an ice pack to the clients back for 1 hour c. Remove distractions from the client's room d. Instruct the client to take deep, rhythmic breaths
d. Instruct the client to take deep, rhythmic breaths Rationale : Avoid long applications of either heat or cold because this can result in tissue damage, burns, and reflex vasodilatation (with cold therapy). Breath work: Reduces stress and increases relaxation through various breathing patterns
A nurse is assessing a client whose therapy has included bed rest for several weeks. Which of the following findings should the nurse identify as the priority? a. Musculoskeletal weakness b. Loss of appetite c. Increased heart rate during physical activity d. Left lower extremity tenderness
d. Left lower extremity tenderness- warmth and tenderness = DVT= PE if it dislodges!!! Effects on the heart and blood Like the muscular system, the cardiovascular system functions best when the body is in an upright position, working against gravity. After just a few days of bed rest, blood starts to pool in the legs. On standing, this can lead to dizziness and falls.
A nurse is caring for a client who has a prescription for morphine 5mg IM accidentally administers the whole 10 mg from the single-dose vial. Which of the following actions should the nurse take first? a. Notify the client's provider. b. Report the incident to the pharmacy. c. Complete an incident report. d. Measure the client's respiratory rate.
d. Measure the client's respiratory rate. Rationale: Morphine can cause respiratory depression if given too much. Also you should ALWAYS ASSESS the patient first when a med error is performed to make sure med error doesn't put the client's health in risk.
A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse take to verify proper placement of the tube? a. Place the end of the NG tube in water to observe for bubbling. b. Auscultate 2.5 cm (1 in) above the umbilicus while injecting 15 mL of sterile water. AIR NOT WATER OR BY ASPIRATING GASTRIC FOR PH. c. Assess the client's gag reflex. d. Measure the pH of the gastric aspirate.
d. Measure the pH of the gastric aspirate.
A charge nurse is assigning tasks to nurse and assistive personnel for a group of clients. Which of the following tasks should the charge nurse delegate to the AP? a. Report ABG results to the provider b. Instruct a client about how to use an incentive spirometer c. Administer an enteral feeding to a client who has an established gastrostomy tube d. Monitor the color of a client's urinary output
d. Monitor the color of a client's urinary output
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. the nurse auscultators a high-pitched scratching sound during both systole and diastole with diaphragm of the stethoscope positioned at the left sterna border. Which of the following heart sounds should the nurse document? a. Audible click b. Murmur c. Third heart sound d. Pericardial friction rub
d. Pericardial friction rubs high pitched scratching, grating or squeaking leathery sound best heard at the diaphragm of the stethoscope at the left sternal border. It is relieved by sitting up and leaning forward.
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? a. Auscultate for the blood pressure at the dorsalis pedis artery. b. Measure the blood pressure with the client sitting on the side of the bed. c. Place the cuff 7.6cm (3 in) above the popliteal artery. d. Place bladder of the cuff over the posterior aspect of the thigh.
d. Place the bladder of the cuff over the posterior aspect of the thigh
A nurse is caring for a client who has a prescription for a stool specimen to be sent to the laboratory to be tested for ova and parasites. Which of the following instructions regarding specimen collection should the nurse provide to the assistive personnel? a. Collect at least 2 inches of formed stool. b. Wear sterile gloves while obtaining the specimen. c. Use a culture for specimen collection. d. Record the date and time the stool was collected.(funds ati pg423)
d. Record the date and time the stool was collected.(funds ati pg423)
A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? a. Fifth intercostal space just medial to the midclavicular b. Second intercostal space to the left of the sternum. c. Fifth intercostal space to the left of the sternum d. Second intercostal space to the right of the sternum.
d. Second intercostal space to the right of the sternum The aortic valve is located in the second intercostal space to the right to the right of the sternum Aortic stenosis produces a midsystolic ejection murmur that can be heard clearly at the aortic area with the client leaning forward.
A nurse is preparing to collect a blood specimen from a newborn via a heal stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? a. Warm the heel prior to the puncture. b. Request a prescription for IM analgesic. c. Use a manual lance blade to pierce the skin. d. Swaddle the newborn after the heel puncture.
d. Swaddle the newborn after the heel puncture-Effective technique to diminish the pain experience for the newborn.
A charge nurse is observing a newly licensed nurse prepare a sterile field. Which of the following actions should the charge nurse identify as contaminating the sterile field?
d. The nurse opens the sterile field on a wet surface.
A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first? a. Obtain a replacement pump b. Notify the biomedical department to fix the pump c. Label the pump with a defective equipment sticker d. Unplug the pump.
d. Unplug the pump- unplugging will remove the source of potential fire started .
A nurse is preparing to perform nasal tracheal suctioning for a client. Which of the following is an appropriate action for the nurse to take? Chapter 53 Airway management page 563 a. Hold the suction catheter with the clean non-dominant hand. b. Apply suctioning for 20 to 30 seconds.- 10 -15 seconds is the maximum. c. Place the catheter in a location that is clean and dry for later use new line.- NEVER EVER REUSE THE SUCTION CATHETER . you throw it away after being used. d. Use surgical asepsis when performing the procedure.
d. Use surgical asepsis when performing the procedure. Rationale: ATI FUNDA. PG. 316 Use surgical asepsis for all types of suctioning. No longer than 10-15 seconds to avoid hypoxemia (STERIL TECHNIQUE FOR TRACHEA)
A charge nurse is discussing the responsibility of nurses caring for clients who have Clostridium difficile infection. Which of the following information should the nurse include in the teaching? a. assign the client to a room with a negative airflow system b. use alcohol-based hand sanitizer when leaving the client's room c. clean contaminated surfaces in the client's room with a phenol solution d. have family members wear a gown and gloves when visiting
d. have family members wear a gown and gloves when visiting A client who has a Clostridium difficile infection requires a private room, but a negative airflow system is not necessary. Use alcohol-based hand sanitizer when leaving the client's room. The nurse should use soap and water for hand hygiene because alcohol-based hand sanitizer does not kill Clostridium difficile spores. Clean contaminated surfaces in the client's room with a phenol solution. The nurse should use a phenol solution to clean surfaces contaminated with bacteria and fungi. However, phenol does not kill Clostridium difficile spores. Chlorine bleach is an example of a disinfectant that kills spores. Have family members wear a gown and gloves when visiting. Nurses are responsible for ensuring that family members wear a gown and gloves to prevent the transmission of Clostridium difficile spores. Staff must also wear gowns and gloves.
. A nurse on a med-surg unit is teaching newly licensed nurse about tasks to delegate to AP. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a.) "An AP may take orthostatic blood pressure measurements from a client who reports dizziness" b.) "An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids" c.) "An AP may perform a central line dressing change for a client who is ready for discharge" d.) "An AP may count the respirations of a client who is going to have surgery later the same day"
d.) "An AP may count the respirations of a client who is going to have surgery later the same day"- the client has surgery LATER that day, so this should mean that the patients condition is not that urgent
A nurse is caring for a client who has brain cancer and is transferring to hospice care. The client's son tells the nurse, "I don't know what to tell my dad if he asks how he is going to die." Which of the following is an appropriate response by the nurse? a.) "Let's talk more about your dad's condition" b.) "The social worker will help you answer those questions" c.) "I think that you should discuss this with the hospice nurse" d.) "Try to help your dad enjoy this time as much as he can"
d.) "Try to help your dad enjoy this time as much as he can"
A charge nurse on an acute care unit is planning care for a client. Which of the following actions should the nurse take to promote the client's continuity of care? a.) Plan to assign a different nurse to the client each shift b.) Limit the number of interdisciplinary team members managing the client's care c.) Request that the client complete a satisfaction survey at discharge d.) Start discharge planning on the day of admission
d.) Start discharge planning on the day of admission
A nurse at a long-term facility is providing a change-of-shift report to an oncoming nurse about an older adult client who has shingles. Which of the following information should the nurse include in the report? a.) Where the client ate his breakfast b.) The times for routine vital sign measurements c.) The exact times the client had visitors d.) The type of transmission-based precautions in place
d.) The type of transmission-based precautions in place
A nurse is providing dietary teaching for a client who has COPD. which of the following instructions should the nurse include in the teaching?
eat foods that are soft and easy to swallow. add gravy and sauces. drink high protein-and should eat small meals instead of large meals.
A client is admitted to the hospital with decreased circulation in the left leg. During the admission assessment, which is the most important nursing action initially?
evaluate the pedal pulses
A client comes to the emergency department reporting that he has had diarrhea for 4 days and is urinating less than usual. When assessing the client's skin turgor, the nurse should
grasp a fold of the skin on the chest under the clavicle, release it, and not the depth of the impression
A nurse tells a client that the provider has prescribed IV fluids. The client appears to be upset about the IV catheter insertion, but says nothing to the nurse. Which of the following is an appropriate nursing response?
is there something about this procedure that concerns you?
A nurse is caring for a client who requires rectal temperature monitoring. Available at the client's bedside is a thermometer is with a long, slender tip. Which of the following is the appropriate action for the nurse to take?
obtain a thermometer with a short, blunt insertion end
RhoGAM is recommended following an amniocentesis because
of the potential of fetal RBCs entering the maternal circulation.
A nurse is demonstrating postoperative deep breathing and coughing exercise to a client about to undergo emergency abdominal surgery for appendicitis. The nurse realizes the client may be unprepared to learn if the client
reports severe pain
A nurse is caring for an older adult client who is confused and continually grabs at the nurses. Which of the following is a nursing action?
🡪 firmly tell the client not to grab
A nurse is updating a plan of care for a client who is receiving intermittent enteral feeding and is experiencing diarrhea. which of the following interventions should the nurse include in the plan?
Feed the client in small, frequent volumes.
A nurse is assessing a client who is suspected of having lactose intolerance. which of the following is an expected finding?
Flatulence
A nurse is caring for a group of clients. Which of the following should the nurse take to prevent the spread of infection.
b. A client who has TB requires airborne precautions
A nurse in the emergency department is measuring a client's oral temperature using an electronic thermometer. Which of the following actions should the nurse take? a. Provide oral hygiene prior to measuring the client's temperature. b. Ask the client if he has smoked within the past 30 min c. Attach the red tip probe to the thermometer unit. d. Place the tip of the probe along the client's buccal mucosa.
b. Ask the client if he has smoked within the past 30 min
A nurse is caring for a client who is grieving the loss of her partner. The client states I don't see the point of living anymore. which of the following actions should the nurse take? a. Request the client's family provide additional support. b. Ask the client if she plans to harm herself. c. Tell the client that this is a normal response to grief. d. Recommend that the client seek spiritual guidance.
b. Ask the client if she plans to harm herself.- safety first
A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following tasks should the nurse delegate to an assistive personnel? a. Teach deep breathing and coughing to the client b. Assist the client to select food choices from the menu. c. Evaluate the client's response to pain medication. d. Monitor the characteristics of the client's chest tube drainage.
b. Assist the client to select food choices from the menu.
A nurse is teaching a client about dietary management of hypercholesterolemia. Which of the following foods should the nurse suggest that the client add to his diet?
b. Avocados contain no cholesterol
A nurse is caring for a client who is nauseated and unable to eat after taking her antibiotic. Identify the steps the nurse should take to address the nausea. a.) Identify possible nursing interventions that address the client's nausea b.) Review the potential benefits and consequences of each intervention c.) Select an intervention that provides the greatest benefit and least risk d.) Determine the probability of intervention-related complications
(3) a.) Identify possible nursing interventions that address the client's nausea (1) b.) Review the potential benefits and consequences of each intervention (2) c.) Select an intervention that provides the greatest benefit and least risk (4) d.) Determine the probability of intervention-related complications
A nurse is preparing to provide foot care for a client. Identify the order in which the nurse should perform the steps of foot care
- Test the temperature of the water - Soak the client's feet in warm water - Use an orange stick to clean under the nails - Apply lotion to the client's feet
A nurse is administering a large volume enema to a client. Identify the sequence of steps the nurse should follow after preparation and lubricating the enema set.(ati funds video enema) 1. Insert the enema tube into the client's rectum 2. Administer the enema solution 3. Clamp the enema tube. 4. Remove the enema tube from the clients rectum. 5. Wrap the end of the enema tube with a disposable tissue
1. Administer the enema solution.(2) 2. Remove the enema tube from the clients rectum.(4) 3. Wrap the end of the enema tube with a disposable tissue.(5) 4. Insert the enema tube into the client's rectum.(1) 5. Clamp the enema tube.(3)
A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply)
1. Provide oral hygiene frequently 2. Measure the drainage from the NG tube every shift 3. Secure the NG tube to the client's gown
A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients?
A : A client who has a prescription for a transfusion of packed red blood cells.
A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching?
A :"There are times I should use soap and water rather than alcohol based hand rub to clean my hands."
A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. the stop should include that the nurse signature on the form confirms which of the following requirements? (Select all that apply.) a. The client was not coerced. b. The client does not have a mental health condition. c. The client Signed in the nurse's presence. d. The client speaks the same language as the nurse. e. The client has legal authority to do so.
A, B. C. E a. The client was not coerced. b. The client does not have a mental health condition. c. The client Signed in the nurse's presence. e. The client has legal authority to do so.
A nurse is assessing a client's oculomotor nerve functions. Which of the following actions should the nurse take? A. Check the client's pupillary reaction to light B. Ask the client to read print from the Snellen chart C. Ask the client to identify diff scents D. Use cotton to touch the client's cornea lightly.
A. Check the client's pupillary reaction to light
A nurse on a surgical unit is receiving a client who had abdominal surgery from the post anesthesia care unit. Which of the following assessments should the nurse make first?
A: Airway
An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?
A: The AP hangs the collection bag at the level of the bladder.
A nurse is caring for a client who is receiving an IV that has infiltrated. Which of the following would be an unexpected finding when the nurse assesses the client's infusion line and insertion site?
A: The area around the injection site feels warm when touched.
A nurse on a medical-surgical unit is washing her hands prior to assisting with surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique?
A: The nurse washes with her hands held higher than her elbows
A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?
A: The signature on the preoperative consent form is the client's
When ambulating a frail, older adult client, the nurse should
A:Use the transfer belt if the client is unsteady
A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the nurse expect?
Albumin level of 3 g/dL b. An albumin level below 3.5 indicates protein deficiency, placing the client at risk for pressure ulcer formation and poor wound healing. The braden scale measures the patient's risk for developing a pressure ulcer.
A nurse is assessing a client's extraocular eye movements. Which of the following actions should the nurse take? A. Position the client 6.1m(20ft) away from the Snellen chart. B. Instruct the client to follow finger through the six cardinal position of gaze, C. Ask the client to cover her right eye during assessment of her left eye. D. Hold a finger 46cm (18inch) in front of the client's eye.
B. Instruct the client to follow finger through the six cardinal position of gaze,
A nurse is caring for a client who has prescription for morphine 5mg IM accidentally administers the whole 10mg from the single dose vial. Which of the following actions should the nurse take first? A. Complete an incident report B. Measure the client's respiratory rate C. Report the incident to the pharmacy. D. Notify the client's provider
B. Measure the client's respiratory rate
A nurse is providing information regarding breastfeeding to the parents of a newborn. Which of the following statements should the nurse make?
Breast mils is nutritionally complete for an infant up to 6 months of age.
A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent?
Cold extremities
A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process?
Compare prescriptions with medications the client received during hospitalization. b. When performing reconciliation, the nurse should create a current, accurate list of every medication the client is or should be taking.
A nurse is planning to discharge a client who has diabetes mellitus and a new prescription for insulin. Which of the following actions should the nurse plan to complete first? A. Provide the client with contact number for diabetes education specialist. B. Obtain printed information on insulin self-administration C. Make a copy of the medication reconciliation from for the client D. Determine whether the client can afford the insulin administration supplies
D. Determine whether the client can afford the insulin administration supplies
. A nurse is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the nurse take?
Examine personal values about the issue. b. The nurse should examine her own personal values about the issue to help her provide care that is w/o bias.
A nurse is providing teaching for a client who has a new prescription for NIFEDIPINE. Which of the following foods should the nurse instruct the client to avoid?
Grapefruit juice NIFEDIPINE is a calcium channel blocker and antihypertensive drug. It can treat high blood pressure and chest pain (angina).
A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take?
Insert the IV catheter w/o using a tourniquet. b. The nurse should use the tourniquet minimally or not at all to avoid injury to fragile skin or veins.
A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?
Is your pain sharp or dull? b. Asking this type of question helps determine the quality of the pain.
A nurse in a provider's office is collecting information from an older adult who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects?
Liver damage
A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from stretcher to the bed?
Lock the wheels on the bed and stretcher
. A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?
Make sure the client wears a mask when outside her room if there is construction in the area. b. An allogeneic stem cell transplant compromises the client's immune system, putting her at risk for infection.
A nurse is leading a discussion at a prenatal education class with a group of expectant mothers who plan to breastfeed. Which of the following instructions should the nurse include?
Plan on 5 minute feeding on each breast on the first day after birth
A nurse is caring for a client who is receiving continuous enteral feedings via an NG tube. Which of the following actions should the nurse take to reduce the risk for aspiration if the client develops abdominal distention?
Position the client on their side. -assist the client to ambulate. -avoid increasing the rate. -request a change to a lower fat formula.
A nurse is planning a dietary teaching for a client who has dumping syndrome following a gastrectomy. Which of the following interventions should the nurse include in the clients plan of care?
Select grains with less than 2 g fiber per serving. -select foods low in fiber. -eat small frequent meals. -lie down after eating to slow the movement of food. -and avoid sugars.
A nurse is reviewing the lab results of a client who has a pressure ulcer. which of the following findings should indicate to the nurse that the client is at risk for impaired wound healing?
Serum Albumin 3. g/dl Serum albumin range is 3.5-5.0 anything less will decrease wound healing.
A nurse is caring for a 6-year-old child who has a new prescription for cefoxitin 80 mg/kg/day administered intravenously every 6 hour. The child weighs 20 kg. How much cefoxitin should the nurse administer with each dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
So it says each dose for the final answer, but we are given 80 mg/kg/day. 80 x 20 = 1600 / 4 (dose is given every 6 hours a day) = 400 mg
A nurse is teaching a client about managing irritable bowel syndrome. which of the following information should the nurse include in the teaching?
Take peppermint oil during exacerbations. decrease fresh fruit. increase foods that contain probiotics. -avoid sugar.
A nurse is caring for a client just diagnosed with type 1 diabetes mellitus. The client is resistant to learning self-injection of insulin and asks the nurse to administer all the injections. The nurse explains the importance of learning self-care and appropriately adds which of the following statements?
Tell me what I can do to help you overcome your fear of giving yourself injections.
A nurse is completing an admission assessment of an older adult client. Which of the following findings should the nurse identify as a potential indication of abuse?
a. Bruised on the arms in various stages of healing.
A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection?
Thread the catheter up to the hub reduces the risk of contamination along the length of the catheter. b. Inserting the catheter up to the hub reduces the risk of contamination along the length of the catheter
A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take?
Wash her hands before and after contact with the client b. Shigella requires the nurse to perform contact precautions to prevent the transmission of the bacteria
A nurse is documenting in a client's medical record. Which of the following entries should the nurse record? a.) "Incision without redness or drainage" b.) "Drank adequate amounts of fluid with meals" c.) "Administered pain medication" d.) "Oral temperature slightly elevated at 0800"
c.) "Administered pain medication"
A nurse is caring for a client who is grieving the loss of her partner. The client states, "I don't see the point of living anymore." Which of the following actions should the nurse take? a.) Recommend that the client seek spiritual guidance b.) Request that the client's family provide additional support c.) Tell the client that this is a normal response to grief d.) Ask the client if she plans to harm herself
d.) Ask the client if she plans to harm herself
A nurse's neighbor is scheduled for elective surgery. The neighbor's provider indicated that a moderate amount of blood loss is expected during the surgery, and the neighbor is anxious about acquiring an infection from a blood transfusion. Which of the following is appropriate for the nurse to suggest?
donating autologous blood before the surgery
An assistive personnel tells the nurse, "I am unable to find a large blood pressure cuff for a client who is obese. Can I just use the regular cuff if I can get it to stay on?" The nurse replies that taking the blood pressure of a morbidly obese client with a regular blood pressure cuff will result in a reading that is
🡪 high
. A nurse is teaching a client who has cardiovascular disease how to reduce his intake of sodium and cholesterol. The nurse understands that the most significant factor in planning dietary changes for this client is the
🡪 involvement of the client in planning the change
At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart murmur due to aortic stenosis. To auscultate the aortic valve, the nurse should place the stethoscope at which location?
🡪Second intercostals space to the right of the sternum