ATI RN Concept-Based Assessment Level 1 Online Practice A

A nurse enters a client's room and finds the client lying on the floor. The client states that on the way to the bathroom her, "knee locked", causing her to fall. What action should the nurse take first? Ask an assistive personnel to help return the client to her bed. Complete an incident report. Check the client for injuries. Document objective details about the client's condition in the medical record.

Check the client for injuries. Rat: The first action the nurse should take when using the nursing process is to assess the client. The nurse should first check the client for injuries and measure vital signs to help determine physiologic stability. The nurse should also inform the provider of the client's fall and of the assessment findings.

A nurse is asked by a provider to perform an invasive procedure for which he has not received training. What action should the nurse take to ensure that it is within his legal scope of practice to perform this procedure? Ask the provider for instructions on how to perform the procedure. Check the state's nurse practice act before performing the procedure. Request that the charge nurse assist him to perform the procedure. Obtain informed consent from the client before performing the procedure.

Check the state's nurse practice act before performing the procedure. Rat: The nurse should check the state's nurse practice act to verify that performance of the procedure is within his scope of practice. This will ensure that the nurse follows legal guidelines for his scope of practice. If the nurse works in more than one state, he should check the nurse practice act for each state, because guidelines for this procedure might differ from state to state. If the procedure is within the nurse's scope of practice, he should take necessary steps to gain competence in the procedure before performing it on a client.

A nurse is preparing to collect a stool specimen from a client who has had diarrhea for 3 days, with fever and abdominal cramping. When reviewing the client's recent medication administration record, the nurse should recognize that treatment with what medication increases the clients risk of developing a Clostridium difficile infection? Fidaxomicin Metronidazole Vancomycin Ciprofloxacin

Ciprofloxacin Rat: Recently, a virulent strain of C. difficile, a bacterium that causes diarrhea and potentially life-threatening colon inflammation, has emerged as a result of antibiotic therapy with fluoroquinolones, such as ciprofloxacin. A stool culture confirms the diagnosis. Medications that treat a C. difficile infection include fidaxomicin, metronidazole, and vancomycin.

A nurse in a long term care facility is admitting a new client following a brief stay in acute care. In adherence with the Joint Commission National Patient Safety Goals regarding medication administration, which of the following actions should the nurse take? A. Inform the client that he will not be receiving the medications he took prior to his hospitalization. B. Compare a list of the client's current medications with the ones he will take in long-term care. C. Eliminate any over-the-counter products from the client's current medication list. D. Omit the medication indications when listing the client's medication dose information.

Compare a list of the client's current medications with the ones he will take in long-term care. Rat: The Joint Commission National Patient Safety Goals regarding medication reconciliation includes maintaining and communicating accurate client medication information. The nurse should complete a medication reconciliation to identify and resolve any discrepancies by comparing the client's list of current medications with the medications he will take in the long-term care facility and addressing any duplications, omissions, or interactions.

A nurse is preparing to administer three medications to a client who has an NG tube: A levothyroxine tablet, an ibuprofen gel cap, and a delayed-release omeprazole capsule. What action should the nurse take? Dissolve all three medications in 30 mL of warm water and instill them through the NG tube. Crush the levothyroxine tablet into a powder and dissolve it in 30 mL of warm sterile water. Ask the provider to prescribe a different formulation of ibuprofen. Open the omeprazole capsule and dissolve it in 30 mL of warm sterile water.

Crush the levothyroxine tablet into a powder and dissolve it in 30 mL of warm sterile water. Rat: The nurse should prepare simple tablets for NG administration by crushing them into a fine powder and dissolving them in at least 30 mL of warm sterile water. Cold water can cause discomfort. Sterile water eliminates the possible problem of chemicals in tap water interacting with the medication.

A nurse is searching electronic databases for clinical research about behavioral indicators of pain in an infant. Which of the following online sources should the nurse select to research this infant care issue? 1. Cumulative Index to Nursing and Allied Health Literature (CINAHL) 2. The Nursing Minimum Data Set 3. The Omaha System 4. The Nursing Interventions Classification (NIC)

Cumulative Index to Nursing and Allied Health Literature (CINAHL) Rat: The nurse should select the Cumulative Index to Nursing and Allied Health Literature (CINAHL) to locate clinical research about health-related client care issues. CINAHL is a cumulative index that the nurse can search electronically to locate reliable data related to the specific topic being researched.

A nurse is beginning nutrition counseling with a client who has a BMI of 34.2. What question should the nurse ask first to address the client's excessive nutrition and obesity.? "What are some strategies you use to reduce the portion sizes of the foods you eat?" "Should we begin with a discussion of healthy versus unhealthy food choices?" "Are you ready to make a lifelong commitment to a healthier lifestyle?" "Did you know that you need to consume 500 fewer calories every day to lose a pound per week?

"Are you ready to make a lifelong commitment to a healthier lifestyle?" Rat: The first action the nurse should take when using the nursing process is to assess the client. The nurse should ask questions to determine the client's level of motivation for making the lifestyle changes that will result in weight loss and maintaining a healthy weight over time. Without motivation, the client is unlikely to lose weight.

A nurse is preparing to document care in a client's medical record. In adherence with the Joint Commission National Patient Safety Goals regarding communication errors, what entries should the nurse make? "Client fell to the floor." "Client medicated with morphine 5 mg IM for pain." "Physical therapy consult recommended for the client." "Client reported pain relief."

"Client medicated with morphine 5 mg IM for pain." Rat: The nurse is using approved abbreviations and providing accurate and detailed information, which should reduce communication errors according to the Joint Commission National Patient Safety Goals.

A nurse is teaching sleep hygiene to a client who has insomnia. What statement should the nurse make? "Plan to catch up on sleep during the weekend." "Limit watching television in bed to 1 hour." "Get out of bed if you are unable to fall asleep within 10 minutes." "Exercise in the morning after arising."

"Exercise in the morning after arising." Rat: Daily exercise has many benefits, including enhancing cardiovascular, psychological, and musculoskeletal health. The nurse should recommend that the client avoid exercising within 2 hr of bedtime to limit stimulation and enhance sleep.

A nurse is providing teaching to the parent of a child who is receiving chemotherapy and experiencing nausea. Which of the following statements should the nurse make? "Have your child rest with his head elevated after meals." "Administer the antiemetic at least 4 hours before chemotherapy." "Increase your child's intake of favorite foods when he feels nauseated." "Wait until your child vomits to give the antiemetic after chemotherapy."

"Have your child rest with his head elevated after meals" Rat: The nurse should instruct the parent to have the child rest with his head elevated after meals. This will allow for easier digestion and help to decrease the nausea associated with eating.

A nurse is talking with a client who reports difficulty adjusting to the death of her partner. Which of the following responses by the nurse demonstrates the therapeutic communication technique of reflecting? "I am here to listen if you'd like to talk about your current situation." "What do you think would help you cope with your loss?" "You've expressed that you are having difficulty adjusting to the loss of your partner." "Can you please provide an example of how you're having difficulty adjusting?"

"I am here to listen if you'd like to talk about your current situation." Rat: The nurse uses the technique of reflecting when asking this question. Reflecting encourages the client to explore her personal thoughts about a situation so that a plan can be developed to meet the client's individual needs.

A nurse is teaching the parent of a toddler about home injury prevention. When discussing snacks, which of the following statements by the parent indicates an understanding of the teaching? 1. "I can offer her grapes as long as I peel them first." 2. "I can give her watermelon pieces after I remove the seeds." 3. "I should give her popcorn that is air-popped and without salt or butter." 4. "I should cut hot dogs into thin, round slices before giving them to her."

"I can give her watermelon pieces after I remove the seeds." Rat: The nurse should inform the parent that toddlers can easily choke on seeds from fruits, such as watermelon seeds or cherry pits, because of their round shape and size. Removing the seeds and cutting the watermelon into pieces provides the toddler with a nutritious snack that does not increase the toddler's risk of foreign body obstruction.

A nurse is teaching a young adult female clients about health screening for breast cancer. Which of the following statements by the client indicates an understanding of breast self-examination (BSE)? 1. "I should perform a BSE about 1 week before my period each month." 2. "I should use the fingers of my right hand to feel for lumps in my right breast." 3. "I should report a lump in my breast if it remains for two consecutive BSEs." 4. "I should expect to feel a firm ridge along the bottom curve of each breast."

"I should expect to feel a firm ridge along the bottom curve of each breast." Rat: The nurse should instruct the client that a firm ridge is expected along the bottom curve of each breast. The client should be able to feel this area during the BSE. Performing a BSE promotes breast self-awareness so that the client knows how her breasts normally feel. This awareness increases the client's ability to identify changes that require further evaluation and treatment.

A nurse is teaching a client who has rheumatoid arthritis about chronic pain management. Which of the following statements by the client indicates an understanding of the teaching? 1. "I should stop participating in my bowling league." 2. "I should take a cool shower in the morning to relieve stiffness." 3. "I should decrease my intake of foods containing purine." 4. "I should use a warm paraffin dip for my hands and feet."

"I should use a warm paraffin dip for my hands and feet." Rat: The nurse should instruct the client to dip her hands and feet in warm paraffin to alleviate pain and stiffness. The client can more easily perform hand and finger exercises following the treatment.

A nurse is providing teaching to the parent of a 6 year old girl about preventing urinary tract infections. Which of the following statements by the parent indicates an understanding of the teaching? "I will have her wear panties made of nylon." "I will teach her how to wipe from back to front." "I will increase her intake of foods high in fiber." "I will limit her fluid intake in the evenings."

"I will increase her intake of foods high in fiber." Rat: Constipation increases the risk of development of a urinary tract infection. Therefore, the nurse should instruct the parent to increase the child's daily intake of fiber to prevent constipation. Other interventions include increasing physical activity and using a stool softener as needed.

A nurse is caring for a client who has cancer and is planning discharge to home with hospice care. Which of the following statements by the client indicates that he is experiencing spiritual distress? 1. "I am thankful for what I have, because things could be worse." 2. "I wish God had not allowed this cancer to invade my body." 3. "I will have to ask my son to read the Torah to me." 4. "I would like to speak to the rabbi at my synagogue."

"I wish God had not allowed this cancer to invade my body." Rat: The nurse should identify that this statement indicates the client is experiencing spiritual distress, which occurs when there is a disturbance in a client's belief system. This client is expressing spiritual anger and not accepting his condition.

A nurse is providing dietary teaching to a client who has diarrhea. What instructions should the nurse include? 1. "Decrease your intake of soluble fiber while you are experiencing diarrhea." 2. "Decrease your intake of sodium while you are experiencing diarrhea." 3. "Increase your intake of potassium-rich foods while you are experiencing diarrhea." 4. "Increase your intake of caffeinated beverages while you are experiencing diarrhea."

"Increase your intake of potassium-rich foods while you are experiencing diarrhea." Rat: The nurse should instruct the client to increase his intake of foods containing potassium, such as tomatoes and potatoes, while he is experiencing diarrhea. The increased intake of potassium helps reduce the risk of electrolyte imbalance due to fluid loss.

A nurse is talking with a client who has major depressive disorder. The client states: "Nobody cares if I'm around or not". What response should the nurse make? "Let's talk about the medications you're taking." "You know you really shouldn't talk like that." "You will feel much better after group therapy." "It sounds as though you're feeling hopeless."

"It sounds as though you're feeling hopeless." Rat: This statement by the nurse is an example of restating, which is a therapeutic response. This technique restates the main idea the client has expressed and allows the client to clarify any misunderstanding

A nurse is assessing the spiritual wellbeing and development of a preschooler. The nurse asks the preschooler, "Why is it wrong to kick our baby sister?" Which of the following responses should the nurse expect? 1. "It's not wrong because she made me mad." 2. "It's wrong because my dad said I can't kick her." 3. "It's wrong to kick her because the gods won't like it." 4. "It's wrong because she would get hurt and be sad."

"It's wrong because my dad said I can't kick her." Rat: The nurse should expect the preschooler to be motivated to choose right from wrong because of rules taught to him by his parents. The nurse should understand that, even though the preschooler might know the rules, he is not yet able to understand the rationale for the rules.

A nurse is teaching a client about strategies to prevent recurrent constipation. Which of the folllowing instructions should the nurse include? Perform moderate exercises daily Add more whole grains to your diet Increase your fluid intake Consume a dose of castor oil every day Take an iron supplement every day

"Perform moderate exercises daily" is correct. Physical activity helps increase peristalsis, which helps prevent constipation. "Add more whole grains to your diet" is correct. Whole grains, fresh fruits and vegetables, and legumes promote regular defecation by adding fiber to the diet, which helps prevent constipation. "Increase your fluid intake" is correct. Consuming at least 1,500 mL of water and fruit juice each day helps soften stool and prevent constipation.

A nurse at a providers office is counseling a client who reports insomnia. Which of the following statements should the nurse make to include the clients preferences into a sleep promotion plan? 1. "If alcoholic beverages are desired, consume them in the early evenings" 2. "Sleep in the location of your home where you feel your rest best" 3. "Turn on a favorite television show just before going to bed" 4. "Allow your sleep and wake times to vary depending on how you feel each day"

"Sleep in the location of your home where you feel your rest best" Rat: The nurse should encourage the client to sleep wherever she feels she gets the most rest, whether it be a bed, couch, or chair.

A nurse is using therapeutic communication to attempt de-escalation with a client who is yelling at staff members. What statement should the nurse make? "You need to stop yelling at the staff, okay?" "If you don't calm down, you will lose your privileges." "Tell me what is causing your anger at this moment." "Why do you feel it is acceptable to take out your anger on staff?"

"Tell me what is causing your anger at this moment." Rat: This statement uses the therapeutic communication technique of exploring, which promotes client communication. Exploring and the use of open-ended statements encourage the client to talk about his feelings and emotions at this time. Talking about his feelings can help the client calm down, and the information is used to help prevent further episodes of anger.

A charge nurse is educating unit staff about the cultural aspects of client care following death. What statement by an assistive personnel indicates an understanding of the teaching? 1. "The body of a client who practices Islam is washed and wrapped in a cloth following death." 2. "The body of a client who practices Judaism is left alone for 24 hr following death." 3. "The youngest child of a client who is Chinese might want to stay with the body for 12 hr following death." 4. "The body of a client who practices Buddhism is prepared by the oldest female family member."

"The body of a client who practices Judaism is left alone for 24 hr following death." Rat: The body of a client who practices Islam is washed, wrapped, prayed over, and buried as soon as possible following death. The client's head should be turned toward Mecca.

A nurse is providing change-of-shift report about a group of clients to the oncoming nurse at the end of the shift. Which of the following statements should the nurse include? 1. "The client received a PRN dose of pain medication this morning." 2. "The client has been very tearful since finding out he has diabetes mellitus." 3. "The client's routine vital signs were obtained at 0700, 1100, and 1500." 4. "The client's husband visited during lunch as he has done each day."

"The client has been very tearful since finding out he has diabetes mellitus." Rat: The nurse should include significant information such as a new diagnosis in the change-of-shift report. The nurse should also identify changes in the client's emotional status that might indicate a need for additional client support and teaching.

A nurse is preparing to contact a client's provider regarding the need for a prescription for pain medications. When using the SBAR communication tool, the nurse should provide what information in the assessment portion of the tool? "The client is a 75-year-old female who has a hip fracture and is reporting pain." "The client is in need of a prescription for pain medication at this time." "The client was admitted this afternoon and is scheduled for surgery in the morning." "The client is in audible distress and rates her pain as an 8 on a scale from 0 to 10."

"The client is in audible distress and rates her pain as an 8 on a scale from 0 to 10."

A newly licensed nurse asks a charge nurse where to find information about scope of practice for registered nurses. What responses should the charge nurse make? 1. "The National Institutes of Health website contains this information." 2. "The state board of nursing can provide this information." 3. "The facility's legal department writes a summary of scope of practice." 4. "The Nurse Licensure Compact defines a nurse's scope of practice."

"The state board of nursing can provide this information." Rat: Each state develops a nurse practice act, which defines scope of practice for nurses in that state. This practice act is available on the board of nursing website for each state.

A nurse is caring for a child who has contact dermatitis due to poison ivy. The parent asks the nurse how to prevent further reactions. Which of the following responses should the nurse make? 1. "Rinse your child's skin with hot water within 30 min of contact with the poison ivy plant." 2. "Wash your child's exposed clothing with hot water and detergent." 3. "Scrub your child's exposed skin with warm water and antibacterial soap." 4. "Don't allow your child to have contact with other children who have poison ivy."

"Wash your child's exposed clothing with hot water and detergent." Rat: The nurse should instruct the parent to wash the child's clothing in hot water and detergent after exposure to the poison ivy plant. This will remove the oil, urushiol, which causes the skin reaction.

A nurse is teaching an older adult client about accessing electronic resources for health care information on the internet. What statement should the nurse include in the teaching? "Websites that are evidence-based avoid placing direct links to other evidence-based websites on their home pages." "Websites that market products are credible as long as the products are beneficial for health care." "Websites ending in 'dot-gov' are reliable sites for obtaining health information from government agencies." "Website forums with the opinions of other clients provide factual and trustworthy

"Websites ending in 'dot-gov' are reliable sites for obtaining health information from government agencies." Rat: The nurse should teach the client how to select reliable internet websites when researching health care information. The nurse should identify that websites ending in ".gov" (government agencies) and ".edu" (educational organizations) are considered reliable and credible sources for health information. Websites ending in ".com" should not be used for researching credible health care information.

A nurse is preparing a client for an elective vaginal hysterectomy when the client states, "My doctor said there are more conservative ways to treat my problem. I realize now that I don't want this surgery, but I already singed that consent form" What response should the nurse make? "Why would you question yourself when it is clear that you've weighed the risks and benefits already?" "Perhaps you should talk with your family about this issue. They might be able to help you decide what's best for you." "I think you made the best decision you could and should go ahead with the surgery." "You have the right to refuse this and any other procedure, even after you have signed the consent form."

"You have the right to refuse this and any other procedure, even after you have signed the consent form." Rat: The client has the right to refuse treatment, even after signing the informed consent document. The nurse should inform the client of that right, notify the surgeon about the refusal to continue with the procedure, and document the refusal in the client's medical record.

A nurse is teaching about advice directives with an older adult client who has a terminal illness. Which of the following statements should the nurse make? 1. "Having advance directives means that you don't want to receive CPR." 2. "Your next of kin can amend your advance directives for you if you are unconscious." 3. "Advance directives are verbal or written instructions." 4. "Your advance directives can designate a friend to make your health care decisions."

"Your advance directives can designate a friend to make your health care decisions." Rat: The nurse should inform the client that he may include a health care proxy or durable power of attorney for health care as part of his advance directives. This form designates a person of the client's choosing to make health care decisions for him if he becomes unable to do so for himself. This may be a relative, personal friend, or anyone the client designates. The nurse should ensure that this form is witnessed or notarized according to state law.

A nurse is caring for a client who has dysphagia following a stroke. Which of the following actions should the nurse take to facilitate safe swallowing and decrease the risk of aspiration? 1. Delay the client's meal-time if he is fatigued. 2. Instruct the client to tilt his head to the side when swallowing. 3. Assist the client with fluid intake by inserting it into the client's mouth with a syringe. 4. Encourage the client to focus on a television program during meal time.

Delay the client's meal-time if he is fatigued. Rat: To facilitate safe swallowing and decrease the risk of aspiration, the nurse should encourage the client to rest prior to meal-time. If the client is fatigued, the nurse should delay the meal-time and give the client time to rest.

A community health nurse is planning interventions to promote Healthy People 2020 initiatives in the community. What action should the nurse plan to take first? Collaborate with community environmental resources to decrease pollutants. Educate adolescents in the community about diseases caused by tobacco use. Promote healthy development of infants and toddlers in the community. Determine the level of health equity among groups in the community.

Determine the level of health equity among groups in the community. Rat: Determine the level of health equity among groups in the community.

A nurse is preparing to admit a client to the hospital. Which of the following actions should the nurse take first? Determine the need for an interpreter. Orient the client to the room. Obtain a health history. Perform a physical examination.

Determine the need for an interpreter. Rat: The first action the nurse should take using the nursing process is to determine the need for an interpreter. If the client and the nurse do not speak the same language, information gathered can be inaccurate.

A nurse in a mental health facility is caring for a client who is exhibiting violent behavior and has been placed in seclusion. What actions should the nurse take? Provide the client with food every 3 hr. Ensure the provider evaluates the secluded client within 8 hr. Document the client's status every 15 min. Explain to the client that seclusion is punishment for violent behavior.

Document the client's status every 15 min. Rat:

A nurse on a pediatric unit is admitting an infant who has pertussis, what isolation precautions should the nurse initiate? 1. Protective environment 2. Airborne 3. Droplet 4. Contact

Droplet Rat: The nurse should initiate droplet precautions for an infant who has pertussis. The nurse should initiate droplet precautions for micro-organisms that are transmitted via droplets larger than 5 microns, including rubella, streptococcal pharyngitis, and diphtheria. Droplet precautions include a private room and a mask or respirator.

A nurse is caring for a client who is morbidly obese and is 3 days postoperative following bariatric surgery. What dietary recommendations should the nurse take? Restrict fluid intake to no more than 1,000 mL (34 oz) each day. Eat foods that are high in protein. Avoid drinking fluids that contain sodium. Begin adding soft foods one to two times a day.

Eat foods that are high in protein. Rat: The nurse should recommend that the client increase protein intake to promote healing from surgery. A client who is 3 days postoperative following bariatric surgery should limit foods to clear and full liquids. The nurse should recommend food items such as Greek yogurt. This full-liquid food also meets the dietary requirement for protein-rich foods.

A nurse is caring for an older adult who has a leg wound following a fall on the stairs. The nurse should identify what factors as an expected, age-related change in older adults that can impair wound healing? Collagen tissue expands and is more flexible. Antibody formation increases. Skin capillaries enlarge. Elastin fibers separate and thicken.

Elastin fibers separate and thicken. Rat: The nurse should identify that elastin fibers in an older adult client thicken and separate, which can cause delayed wound healing and lead to a "saggy" appearance due to decreased skin elasticity.

The nurse should instruct the parent to wash the child's clothing in hot water and detergent after exposure to the poison ivy plant. This will remove the oil, urushiol, which causes the skin reaction.

1. First, the nurse should assist the client into high Fowler's position or raise the head of the bed at least 30° to help prevent aspiration. 2. Then, the nurse should verify the tube's placement by aspirating 5 mL of gastric contents and then testing the aspirate pH. 3. Then, the nurse should check for gastric residual volume (GRV). 4. Excessive GRV is an indication of delayed gastric emptying, which places the client at risk of aspiration if additional formula is given. 5. Finally, the nurse should flush the tubing with 30 mL of water to ensure the tube is clear and patent.

A nurse is reviewing a client's new prescriptions that were just documented in the client's medical record by the provider. What abbreviation should the nurse classify with the provider? Enoxaparin 40 mg SQ QD Clindamycin 500 mg IM q 8hr Furosemide 40 mg IV STAT Acetaminophen 650 mg PO q 6 hr PRN pain

Enoxaparin 40 mg SQ QD Rat: The nurse should clarify this prescription with the provider. The abbreviations "SQ" and "QD" are considered error-prone and should not be used in documentation. The nurse should clarify that the provider intends the prescription to be administered subcutaneously once daily. "Subcutaneous" or "subcut" should be used instead of "SQ" and "daily" should be used instead of "QD."

A nurse is planning to use an interpreter to assist her when interviewing a client who does not speak the same language as the nurse. What action should the nurse plan to take? Direct the interview questions to the interpreter. Ensure the client and the interpreter are compatible. Ask the client's partner to act as the interpreter. Ask the interpreter to translate questions word for word.

Ensure the client and the interpreter are compatible. Rat: The nurse should ensure that the client is comfortable with the interpreter. The nurse should consider the client's age, gender, and culture when using an interpreter.

A nurse is caring for a 2yr old toddler who is immedietely postoperative. Which of the following pain scales should the nurse use to assess the toddler's pain level? FACES scale COMFORT scale Visual analog scale FLACC scale

FLACC scale The nurse should use the FLACC scale to assess pain for a 2-year-old child. The FLACC scale assesses facial expression, leg movement, activity, cry, and consolability in children 2 months to 7 years of age. The nurse assigns a score of 0 to 2 for each area.

A nurse is counseling a client who has a family history of colorectal cancer about management of nutrition to help prevent gastrointestinal (GI) cancers. Which of the following images indicates a food or beverage the nurse should encourage the client to include liberally in his diet?

Fruits and Veggies Rat: To help reduce the risk of cancers of the GI system, the nurse should instruct the client to consume at least 2.5 cups of fruits and vegetables per day.

A nurse is planning to implement bladder retraining for a client who has urge incontinence. Which of the following actions should the nurse plan to take? 1. Assist the client to the toilet as soon as the urge to void is reported. 2. Apply an adult diaper to the client during nighttime hours. 3. Gradually lengthen the time between the client's scheduled voids. 4. Decrease the client's fluid intake beginning at 2000.

Gradually lengthen the time between the client's scheduled voids. Rat: The nurse should gradually lengthen the time between scheduled voids when implementing bladder retraining. The client is encouraged and taught to suppress the urge to void between scheduled voids through the use of pelvic exercises, distraction, and abdominal breathing. When the client is successfully able to suppress the urge, the time between voids is slightly increased. This process of scheduled voiding promotes retraining of the bladder and decreases urge incontinence.

A nurse is providing discharge teaching about nutrition management to a client who has COPD. What instruction should the nurse include in the teaching? Limit the use of gravy or sauces on foods. Have a high-calorie protein drink between meals. Increase intake of beverages during meals. Use a bronchodilator 15 min after each meal.

Have a high-calorie protein drink between meals. Rat: The nurse should encourage a client who has COPD to drink a high-calorie protein drink between meals. Anorexia is a manifestation of COPD and this added nutritional intake promotes weight gain.

A nurse is preparing to administer morphine 5 mg IM from a 10 mg/mL viral to help manage a client's acute pain. What action should the nurse plan to take after administering a controlled substance? Crush the vial between paper towels and discard it in a sharps container. Lock the remaining medication in the vial in a secure location for future use. Have a second nurse witness and initial the disposal of the remaining medication. Return the unused portion of the medication in its original vial to the pharmacy.

Have a second nurse witness and initial the disposal of the remaining medication. Rat: When nurses administer a portion of a vial's amount of a controlled substance, they must discard the rest safely, such as by injecting it out of the syringe into a sink or toilet, while a second nurse witnesses the first nurse discarding it. The second nurse must then initial the waste of the medication in the client's medication administration record.

A nurse is administering ophthalmic solution to a client who has bacterial conjunctivitis. What action should the nurse take? 1. Have the client lie supine. 2. Tell the client to look down toward the floor. 3. Place a finger on the upper eyelid to pull it outward. 4. Instill the drops onto the client's cornea.

Have the client lie supine. Rat:

A nurse is caring for an adolescent client who is in critical condition following a motor vehicle crash in which he was the passenger. The clients parents shouts at the nurse, asking why her son is dying instead of the driver. Which of the following actions should the nurse take to provide emotional support to the patient? 1. Encourage the parent to speak with the family of the driver of the car. 2. Inform the parent that anger is a natural response when dealing with loss. 3. Ask the parent to leave and come back later after she has calmed down. 4. Contact a clergy member to come and speak with the parent.

Inform the parent that anger is a natural response when dealing with loss. Rat: The nurse should identify that the parent is in the anger stage of grief. The nurse should assist the parent to understand that anger is a natural response to loss and encourage her to talk about her feelings.

A nurse in a provider's office is caring for a male client who just turned 50 years old. The client has no significant health problems or family history of health problems. What preventive health screening should the nurse recommend? Initial screening colonoscopy Digital rectal examination Yearly glaucoma screening Monthly testicular self-examination Annual skin examination

Initial screening colonoscopy Digital rectal examination Monthly testicular self-examination Annual skin examination

A nurse is teaching a client who is postpartum about preventing injury when using a car seat for her newborn. What instructions should the nurse include? Place the retainer clip at the level of the newborn's abdomen. Keep the air bag on if the car seat must be placed in a front seat. Install the car seat so that it is facing the rear of the vehicle. Position the newborn at a 60º angle in the car seat.

Install the car seat so that it is facing the rear of the vehicle. Rat: The client should install the car seat so that it is rear-facing in the back seat. This position also protects the newborn's head and neck during a sudden stop or a crash. The back of the car seat protects the newborn's spine.

A nurse in an orthopedic clinic is documenting data about several clients. What actions should the nurse take to comply with the regulations of HIPAA? Lock or log off computers whenever he leaves the area. Discard hard copies of client-specific data in wastebaskets in "staff only" areas. Place clients' flow sheets in racks outside the examination room. Ask the provider to log into the system and document on the provider's behalf.

Lock or log off computers whenever he leaves the area. Rat: To prevent unauthorized access to clients' protected health information, all clinic staff should lock or log off computer terminals and turn off the monitor anytime they leave the computer unattended. This action demonstrates compliance with the HIPAA Security Rule.

A nurse is caring for a child who has celiac disease. Which of the following items should the nurse remove from the child's meal tray? 1. Corn-flake cereal 2. Orange juice 3. Scrambled eggs 4. Oatmeal with raisins

Oatmeal with raisins Rat: Celiac disease is the intolerance to dietary gluten, which is a protein in wheat, rye, oats, and barley. This intolerance causes diarrhea, weight loss, abdominal pain, and fatigue. Therefore, the nurse should remove oatmeal from the child's meal tray.

A nurse in a long term care facility is performing a fall risk assessment on a newly admitted client using the Timed Up and Go (TUG) test. The client reports using a tripod cane for ambulation. Which of the following actions should the nurse take when using this test? 1. Observe the client ambulating a distance of 3 m (10 feet) during the TUG test. 2. Instruct the client to perform the TUG test without the use of the cane. 3. Assist the client to stand up from the chair when starting the TUG test. 4. Advise the client to use the arms of the chair to stand when starting the TUG test.

Observe the client ambulating a distance of 3 m (10 feet) during the TUG test. Rat:The nurse should mark a spot 3 m (10 feet) away from the client's sitting location. The nurse should instruct the client to stand, ambulate to the marked spot, turn, ambulate back to the chair, and sit down. The nurse should observe the client's ability to perform the test and use a stopwatch to time the client. The nurse should identify that the client is at increased risk of falls if it takes longer than 14 seconds to complete the test.

A nurse is creating a plan of care for a client who is nonambulatory and has bladder and bowel incontinence. What interventions should the nurse include to prevent skin break down? 1. Use a sheepskin device to pad the client's pressure points. 2. Apply cornstarch to the perineal area after bathing the client. 3. Massage the client's skin and pressure points every 12 hr. 4. Offer the client a glass of water every 2 hr when repositioning.

Offer the client a glass of water every 2 hr when repositioning. Rat: The nurse should offer the client a glass of water every 2 hr on the client's repositioning schedule. This helps prevent dehydration, which increases the risk of skin breakdown.

A nurse is planning care to prevent a catheter-related blood stream infection for a client who is receiving IV fluid therapy. Which of the following interventions should the nurse include in the plan? 1. Change bags of IV solution every 72 hr. 2. Perform hand hygiene before touching the IV tubing. 3. Use hydrogen peroxide to cleanse the IV insertion site. 4. Assess the IV insertion site every 12 hr for redness.

Perform hand hygiene before touching the IV tubing. Rat: The nurse should perform thorough hand hygiene before touching any part of the infusion system or the client to reduce the risk of catheter-related blood stream infections.

A nurse is planning care for a client who has bacterial meningitis caused by Haemophilus influenza. What of the following infection control interventions should the nurse include in the plan? Stand at least 0.3 m (1 foot) from the client unless wearing a mask. Apply a N95 respirator before entering the client's room. Place a mask on the client during transport out of the room. Assign the client to a room with negative air flow.

Place a mask on the client during transport out of the room. Rat: The nurse should implement droplet precautions and standard precautions when caring for a client who has bacterial meningitis caused by H. influenza. The nurse should avoid transporting the client out of the room, if possible. However, if transport is necessary, then placing a mask on the client is an effective infection control intervention.

A nurse is developing a plan of care for an older adult client who is experiencing functional incontinence following hip arthroplasty, what interventions should the nurse include? Dress the client in pants with a zipper. Measure residual after each void. Insert a urinary catheter. Place grab bars by the toilet.

Place grab bars by the toilet. Rat: The nurse should place grab bars by the toilet and install a raised toilet seat. These aid the client in reaching and sitting on the toilet, decreasing the chance of incontinence.

A nurse is reviewing the medication administration record of a client who is 2 days post operative following abdominal surgery. The nurse should identify that what medications can result in delayed wound healing? Metoprolol Prednisone Vitamin C Ropinirole

Prednisone Rat: The nurse should identify that taking prednisone can result in delayed wound healing. Prednisone is a corticosteroid used in the treatment of inflammatory disorders. It can mask the manifestations of infection due to its ability to impair the inflammatory response. Other medications, such as anticoagulants and broad-spectrum antibiotics, can also play a role in delayed wound healing.

A nurse is assessing a client who has fibromyalgia. What treatment modality prescription should the nurse expect for the clients mixed pain? Referral for a nutritional consult PCA infusion pump with morphine Pregabalin PO twice daily Progressive exercise plan leading to running three times per week

Pregabalin PO twice daily Rat: The nurse should expect a prescription for an antidepressant medication such as pregabalin. The mixed pain experienced by a client who has fibromyalgia has components of both nociceptive and neuropathic pain, which responds best to adjunctive treatment modalities such as antidepressants. These medications work to increase the release of serotonin and norepinephrine neurotransmitters in the brain.

A nurse in a long-term care facility discovers a small fire a client's trash can. After moving the client to safety, which of the following actions should the nurse take next? 1. Return to the room to extinguish the fire. 2. Close the doors and windows on the unit. 3. Pull the alarm to notify emergency services. 4. Turn off oxygen and electrical equipment.

Pull the alarm to notify emergency services. Rat: Evidence-based practice indicates the nurse should first rescue and remove clients in immediate danger and then activate the alarm to notify authorities of the situation.

A nurse is administering enoxaparin subcutaneously to a client who is postoperative and is at risk of thromboembolic events. What following actions should the nurse take? 1. Insert the needle at a 15º angle after cleansing the site. 2. Pull up a small amount of skin using the thumb and forefinger of the nondominant hand. 3. Insert about half of the needle length into the tissue. 4. Pull back on the plunger to check for blood return before administering the medication.

Pull up a small amount of skin using the thumb and forefinger of the nondominant hand. Rat: Pulling up or pinching the skin brings the subcutaneous tissue upward and helps reduce the pain of the injection.

A nurse is assessing for acute pain in a client who is postoperative. The client has dementia and is nonverbal. What finding should the nurse identify as a need for administration of a PRN pain medication? Hypoactive reflexes Increased sleep time Pupils constricted bilaterally Rapid breathing

Rapid breathing Rat: The nurse should identify shallow, rapid breathing as a nonverbal indicator of acute pain. This change in breathing is a sympathetic nervous system response to acute pain. The nurse should further assess the client's respiratory status and administer a PRN pain medication. Other nonverbal indicators of pain include muscle tension, restlessness, and moaning.

A home health nurse manager is assisting in the implementation of an electronic medical record (EMR) system for client care. What actions should the nurse manager take the promote interoperability. Scan each client's prescribed medications into the individual EMR. Recommend a single coding system for each department to use. Seek reimbursement opportunities for the use of an EMR system. Establish a personal health record (PHR) for each client.

Recommend a single coding system for each department to use. Rat: The nurse manager should recommend a unified coding system for each department to use when documenting in the EMR system. This use of a single coding system ensures that data is shared accurately among interprofessional departments and that each department's system is able to process the coded information. This continuity of shared data and the ability to use the data is referred to interoperability.

A nurse is preparing to leave the room of a client who is on isolation precautions. Which of the following actions should the nurse take when removing a tied surgical mask? 1. Take the mask off immediately after leaving the client's room. 2. Perform hand hygiene prior to removing the mask. 3. Untie the top strings of the mask and then untie the lower strings. 4. Remove the mask by securely holding the ties and moving it away from the face.

Remove the mask by securely holding the ties and moving it away from the face. Rat: The nurse should untie the bottom strings and then the top strings. Finally, while still holding the strings, the nurse should remove the mask from her face. This action prevents the nurse from touching the front of the mask, which is contaminated.

A nurse is documenting an assessment in a client's electronic health record who an assistive personnel (AP) asks to enter the morning blood glucose for the client. What actions should the nurse take? Allow the AP to use the computer while the nurse is still logged in. Enter the data in the computer for the AP. Instruct the AP to come back later to use the computer. Request that the AP use another computer to enter the data.

Request that the AP use another computer to enter the data. Rat: The nurse should request that the AP to go to another computer that is not in use to enter the morning blood glucose from the client. This is time-sensitive data that needs to be entered in the computer as soon as possible.

A nurse is caring for an older adult client who has osteoarthritis and plans to go to an assisted living facility due to decreased mobility. What actions should the nurse take when acting in the role of client advocate. Research facilities for the client that best meet her specific needs. Inform the client about the discharge plan for treatment of her osteoarthritis. Assist the client as needed while encouraging independence with her ADLs. Coordinate the prescriptions from the health care team into the discharge plan.

Research facilities for the client that best meet her specific needs. The nurse is acting in the role of a client advocate when identifying the client's specific needs and then advocating for those needs by researching assisted living facilities that best meet those needs. The nurse's research findings support the client's autonomy by providing her with information needed to make an informed decision when selecting a facility.

A nurse is preparing to administer acetaminophen 120 mg PO to a toddler. Available is acetaminophen drops 80 mg/0.8mL. How many mL, should the nurse administer?

STEP 1: What is the unit of measurement the nurse should calculate? mL STEP 2: What is the quantity of the dose available? 0.8 mL STEP 3: What is the dose available? Dose available = Have 80 mg STEP 4: What is the dose the nurse should administer? Dose to administer = Desired 120 mg STEP 5: Should the nurse convert the units of measurement? No STEP 6: Set up an equation and solve for X. X = Quantity/Have x Conversion (Have)/Conversion (Desired) x Desired/ X mL = 0.8 mL/80 mg x 120 mg/ X = 1.2 STEP 7: Round if necessary. STEP 8: Reassess to determine whether the amount to give makes sense. If there are 80 mg/0.8 mL and the amount prescribed is 120 mg, it makes sense to administer 1.2 mL. The nurse should administer acetaminophen 1.2 mL PO.

A nurse is preparing to administer 0.9% sodium chloride 1000ml over 9hr IV

STEP 1: What is the unit of measurement the nurse should calculate? mL/hr STEP 2: What is the volume the nurse should infuse? 1,000 mL STEP 3: What is the total infusion time? 8 hr STEP 4: Should the nurse convert the units of measurement? No STEP 5: Set up an equation and solve for X. Volume (mL)/Time (hr) = X mL/hr 1,000 mL/8 hr = X mL/hr X = 125 STEP 6: Round if necessary. STEP 7: Reassess to determine if the amount to administer makes sense. If the amount prescribed is 1,000 mL to infuse over 8 hr, it makes sense to administer 125 mL/hr. The nurse should set the IV pump to deliver 0.9% sodium chloride at 125 mL/hr for 8 hr.

A nurse is planning a menu for a client who practices Seventh-Day Adventism. What food selection should the nurse take? Shellfish Scrambled eggs Pork chop Tuna fish

Scrambled eggs Rat: The nurse should select scrambled eggs in the client's dietary meal plan for a client who practices Seventh-Day Adventism. Most clients who practice Seventh-Day Adventistism are lacto-ovo vegetarians who consume vegetables, eggs, and dairy, but not meat. Clients who practice this religion also do not consume caffeine or alcohol.

A nurse is planning care for a client who has an indwelling urinary catheter. What interventions should the nurse include in the plan to prevent the development of a catheter-associated urinary tract infection (CAUTI). Ensure that the catheter tubing has a dependent loop. Empty the urinary collection bag when it is 75% full. Secure the catheter tubing to the client's leg. Use an open method for catheter irrigation.

Secure the catheter tubing to the client's leg. Rat: The nurse should assess the client's need for urinary catheterization and should follow evidence-based practice to prevent or reduce the risk of CAUTI development. This includes securing the catheter tubing to the client's leg so that the catheter does not move, reducing the risk of urethral trauma and introduction of bacteria into the urinary system.

A nurse is preparing to administer an immunization via IM injection into an adult client's deltoid muscle. What actions should the nurse take? 1. Limit the volume of fluid injected to 3 mL. 2. Aspirate and check for blood prior to injection of the vaccine. 3. Pinch the client's skin with the nondominant hand while inserting the needle. 4. Select a 1-inch needle for the injection.

Select a 1-inch needle for the injection. Rat: The nurse should select a 1-inch needle for an IM injection into the deltoid muscle. Depending on the client's weight, the nurse might need to use a 1 ½-inch needle to ensure injection of the vaccine into the muscle.

A nurse is preparing to extinguish a small fire in a clients room. Which of the following actions should the nurse take when using the fire extinguisher? 1. Aim the fire extinguisher at the top of the flames. 2. Pump the handles of the fire extinguisher up and down three times. 3. Sweep the fire extinguisher in a circular motion until the fire is extinguished. 4. Slide the pin on top of the fire extinguisher straight out.

Slide the pin on top of the fire extinguisher straight out. Rat: The nurse should pull the pin on the top of the fire extinguisher to allow for use to extinguish the fire.

A community health nurse is developing a brochure about the use of smokeless tobacco. What information should the nurse plan to include? Smokeless tobacco provides a higher dose of nicotine than cigarettes. Smokeless tobacco users are at an increased risk for lung cancer. Smokeless tobacco is more addictive than cigarettes. Smokeless tobacco users have a lower risk for developing stomach cancer.

Smokeless tobacco provides a higher dose of nicotine than cigarettes. Rat: Smokeless tobacco is placed in the mouth, where nicotine is then absorbed sublingually. A higher dose of nicotine is delivered with the use of smokeless tobacco compared to smoking cigarettes, because heat destroys nicotine.

A nurse on the medical-surgical unit is caring for a group of clients. The nurse should identify that what type of pain is classified as neuropathic? Spinal nerve pain Postherpetic neuralgia pain Phantom limb pain Fractured hip pain Osteoarthritic pain

Spinal nerve pain Postherpetic neuralgia pain Phantom limb pain Rat: Spinal nerve pain is correct. Neuropathic pain occurs when there is damage to or impaired function of nerves due to an injury or illness. Spinal nerve pain is a type of neuropathic pain. Postherpetic neuralgia pain is correct. Neuropathic pain occurs when there is damage to or impaired function of nerves due to an injury or illness. Postherpetic neuralgia pain is a type of neuropathic pain. Phantom limb pain is correct. Neuropathic pain occurs when there is damage to or impaired function of nerves due to an injury or illness. Phantom limb pain is a type of neuropathic pain.

A community health nurse is participating in a task force initiative to reduce the incidence of disease from injection drug use among the city's homeless population. What plan should the nurse recommend as part of tertiary prevention? Offer HIV testing. Start a needle-exchange program. Screen clients who are homeless for drug use. Provide community education about needle sharing.

Start a needle-exchange program. Rat: Initiating a program for needle exchange and treating clients who are homeless for any diseases they may have already acquired are examples of tertiary prevention.

A nurse is preparing to administer intermittent enteral nutrition via a client's NG tube. In what order should the nurse take action? Flush the injection port with 10ml of 0.9% sodium chloride solution Administer the intermitted IV bolus medication through the injection port Clamp the intravenous tubing proximal to the injection port Stop the continuous IV infusion

Stop the continuous IV infusion Rat: According to evidence-based practice, the nurse should first stop the continuous IV infusion. This action prevents the solution from flowing through the tubing while the nurse administers the medication. An infusion pump will alarm if the tubing is clamped before the pump is stopped.

A nurse is providing teaching to a client who has chronic fatigue syndrome. Which of the following statements should the nurse make?

Take NSAIDs for body aches and paim Rat: The nurse should instruct the client that NSAIDs can alleviate the body aches and pain that are associated with chronic fatigue syndrome. Alternative therapies, such as tai chi and massage, can also be helpful.

A nurse is planning meals for a client who practices judaism and reports that she strictly adheres to orthodox dietary laws. The nurse should recognize that what dietary practices applies to the client's beliefs? The client should avoid honey or products that contain honey. The client needs to wait 15 min after eating meat before consuming a dairy product. The client is permitted to eat fish that have scales. The client can eat chicken but should avoid eating their eggs.

The client is permitted to eat fish that have scales. Rat: The nurse should recognize that Orthodox Jewish dietary laws permit the client to eat fish that have fins and scales, such as tuna. However, fish that do not have scales, such as catfish, are considered unclean and are not permitted.

Post void residuals 0620: 22ml 1630: 18ml 2330: 40ml

The first action the nurse should take when using the nursing process is assessment. The nurse should obtain a urine specimen from the client to rule out a urinary tract infection. If it is determined the client has RBCs and/or WBCs in the urine, the specimen will require a culture. If it is determined that the client has a UTI, this will require treatment before any further assessment of incontinence would be indicated.

A charge nurse is observing a newly licensed nurse prepare medications for a client. What actions by the newly licensed nurse adheres to safe medication administration practices? The nurse breaks a non-scored caplet in half to administer a prescribed dose. The nurse uses the client's room number as an identifier for medication administration. The nurse compares the medication label with the client's medication administration record. The nurse prepares to administer an antibiotic 1 hr prior to the scheduled time.

The nurse compares the medication label with the client's medication administration record. When preparing medications for administration, safe practice includes comparing the medication label with the client's medication administration record a minimum of three times: prior to removing the medication from the drawer, when removing medication from the drawer, and at the client's bedside prior to administering the medication.

A nurse is preparing to administer enoxaparin subcutaneously to a client where will this be located for the patient? The Top arm Side of stomach Umbillical cord center

Top Arm Rat: The outer posterior aspect of the upper arms is a site commonly used for subcutaneous injections. However, it is not recommended for administration of low molecular weight heparins such as enoxaparin. The nurse should select another subcutaneous injection site to promote absorption of the enoxaparin. Side of stomach Rat: The nurse should administer low molecular weight heparins, such as enoxaparin, into the anterolateral aspect of the client's abdomen to promote absorption of the medication. Other recommended subcutaneous sites for this medication include the posterolateral aspect of the client's abdomen, the buttocks, and the upper thighs.

A nurse manager is developing a facility policy about the use of a fax machine to communicate information from a client's electronic medical record (EMR). What should the nurse include in the policy?

Use a cover sheet when sending a fax from the health care unit Rat: The nurse manager should recommend the use of a cover sheet whenever sending a fax of a client's EMR. The use of a cover sheet protects the client's private health information by providing an information sheet that allows the receiver to identify the intended recipient without reading the actual document.

A charge nurse is teaching a group of newly licensed nurses how to prevent errors during administration of blood transfusions. What actions should the nurse include? Complete the administration of 1 unit of packed RBCs within 6 hr of initiation of the transfusion. Infuse 500 mL of lactated Ringer's when administering whole blood. Vigorously massage the blood bag to mix the cells prior to administration. Use a new blood administration tubing set for each blood bag infused.

Use a new blood administration tubing set for each blood bag infused. Rat: The nurse should use a new blood infusion tubing set for each component of blood. A blood infusion set should not be reused, even for the same client.

A nurse is preparing to administer a unit of packed RBCs to a client. In adherence with the Joint Commission Nation Patient Safety Goals regarding blood administration, what actions should the nurse plan to take? 1. Review the client's medical record for previous transfusion information. 2. Administer premedication to the client as prescribed by the provider. 3. Verify the client and blood component using a two-person process. 4. Educate the client about manifestations to report to the nurse immediately.

Verify the client and blood component using a two-person process. Rat: The Joint Commission National Patient Safety Goals regarding blood transfusions includes improving the accuracy of client identification. The nurse should eliminate transfusion errors related to client misidentification by using a two-person verification process to identify the client and the blood component.

A nurse is caring for a client who has Clostridium difficile infection and is incontinent of stool following long-term antibiotic therapy. What action should the nurse make? Place the client in a room with a client who has Shigella. Clean hands with alcohol-based hand rub after caring for the client. Wear a gown when providing care for the client. Remain within 1 m (3 ft) while caring for the client.

Wear a gown when providing care for the client. Rat: The nurse should wear a gown when providing care for a client who has a C. difficile infection and is incontinent of stool. Applying a clean, water-resistant gown prior to entering the client's room prevents the nurse's clothing from becoming contaminated while caring for the client. The nurse should remove the gown prior to exiting the client's room.

A nurse on a medical-surgical unit is caring for a group of clients. What clients should the nurse monitor for the development of reflex urinary incontinence. A client who has a T12 spinal cord injury A client who has an acute bladder infection A client who has Alzheimer's disease A client who is receiving IV diuretics

A client who has a T12 spinal cord injury Rat: The nurse should identify that a client who has a C1 to S2 spinal cord injury is at risk of developing reflex urinary incontinence. With this type of incontinence, the client is unaware that the bladder is full and therefore lacks the urge to void, resulting in the involuntary loss of urine. The nurse should monitor for this form of incontinence and implement interventions such as intermittent catheterization.

A nurse is planning a community health program about substance use disorders. What information should the nurse include when discussing the guidelines for safe limits of alcohol consumption? A healthy man under the age of 65 years should consume no more than five drinks each day. A healthy woman of any age should consume no more than four drinks each day. A healthy man over the age of 65 years should consume no more than 14 drinks in a week. A healthy woman of any age should consume no more than seven drinks in a week.

A healthy woman of any age should consume no more than seven drinks in a week. Rat: Recommendations for safe limits of alcohol consumption for a healthy woman include consuming no more than seven drinks in a week.

A nurse in an emergency is caring for an infant who requires emergency surgery. The infant is accompanied by his 16-year-old mother and his maternal grandfather. Which of the following actions should the nurse take when assisting with informed consent? 1. Witness consent obtained from the infant's mother. 2. Inform the family that informed consent is not needed due to emergency surgery. 3. Notify the maternal grandfather that he is required to give informed consent. 4. Request that a court-appointed representative provide informed consent.

Witness consent obtained from the infant's mother. Rat: The nurse should assist in obtaining informed consent from the infant's mother by witnessing her signature. Statutory guidelines indicate that a minor, even if unemancipated, can provide consent for her infant. Unemancipated minors can also legally provide informed consent for STI treatment, substance use treatment, and care related to pregnancy in some states.

A nurse is assessing a preschooler who has a urinary tract infection (UTI). Which of the following findings should the nurse expect? 1. Diarrhea 2. Abdominal pain 3. Increased thirst 4. Skin rash

Abdominal Pain Rat: The nurse should expect a preschooler who has a UTI to experience abdominal pain. Other manifestations include constipation, dysuria, foul-smelling urine, and fever.

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. The client states he is experiencing a dull, burning pain in the leg that was amputated. Which of the following actions should the nurse take to treat the client's neuropathic pain? A. Inform the client that phantom limb pain is not real. B. Administer a beta-blocking medication to the client. C. Place the client on a soft mattress. D. Loosen the bandage on the client's residual limb.

Administer a beta-blocking medication to the client Rat: The nurse should administer a beta-blocking medication to the client. This classification of medication has been shown to relieve the phantom limb pain manifestations of constant dull and burning type pain.

A nurse is planning care for a client who has breast cancer and is scheduled for chemotherapy. The client reports experiencing chemotherapy-induced nausea and vomiting (CINV) during her previous round of treatment. What intervention should the nurse include in the patient's plan of care? Administer ondansetron to the client prior to chemotherapy administration. Provide the client with a small meal 30 min prior to chemotherapy. Offer the client an 8 oz glass of orange juice after chemotherapy administration. Implement NPO status for the client while the chemotherapy is infusing.

Administer ondansetron to the client prior to chemotherapy administration. The nurse should incorporate evidence-based practice interventions into the client's plan of care to prevent and treat CINV. Evidence-based research indicates that prevention of CINV is best achieved when antiemetics, such as ondansetron, are given prior to the administration of chemotherapy.

A community health nurse is planning prevention strategies for hypertension among members of her community. The nurse should identify which ethnic groups in the community is at greatest risk for developing hypertension? African Americans Hispanic Americans European Americans Native Americans

African Americans Rat: Evidence-based practice indicates that individuals of African-American ethnicity have the highest prevalence of hypertension. Therefore, the nurse should identify community members of this ethnicity are at greatest risk of developing hypertension.

A nurse is admitting a client who has pulmonary tuberculosis. What transmission-based precautions should the nurse initiate? Airborne Droplet Contact Protective environment

Airborne Rat: Pulmonary tuberculosis is an infection that is transmitted by airborne droplets smaller than 5 microns in diameter. Therefore, this client requires airborne precautions to prevent communicating this infection to others.

A nurse is planning care for a newly-admitted school-age child who has rubeola. Which of the following isolation precautions should the nurse plan to initiate? 1. Droplet 2. Airborne 3. Contact 4. Protective environment

Airborne Rat: The nurse should initiate airborne precautions for a client who has varicella, measles (rubeola), or pulmonary tuberculosis. Airborne precautions include a private room with negative pressure airflow, with 6 to 12 air exchanges/hr via a high-efficiency particulate air (HEPA) filtration system.

A hospice nurse is planning care for a client who has terminal cancer. The client tells the nurse that she practices the Hindu religion. What interventions should the nurse include in the plan of care to support the client's cultural beliefs? Position the client's bed in her home so that she faces east. Arrange for the Sacrament of the Sick when the client nears death. Allow time for a family member to perform a ritual bath after the client dies. Coordinate with the funeral home for burial within 24 hr of the client's death.

Allow time for a family member to perform a ritual bath after the client dies. Rat: The nurse should recognize a client who practices the Jewish, Muslim, or Hindu religions might want a ritual bath after death. This ritual bath can be performed by a family member or by certain members of the client's faith.

A nurse in a mental health facility is preparing an educational program for a group of staff nurses about the proper use of restraints. What information should the nurse plan to include? An adult client may be in a mechanical restraint for up to 4 hr. Documentation of the client's status should be performed hourly. The provider can write a client prescription for an as-needed restraint. The client should be offered toileting privileges every 2 hr.

An adult client may be in a mechanical restraint for up to 4 hr. Rat: The nurse should specify that a client who is 18 years or older may be in a restraint for no more than 4 hr. Children who are 9 to 17 years old are limited to 2 hr and children who are younger than 9 years old are limited to 1 hr.

A nurse is developing a plan of care for a client who has urinary incontinence. What actions should the nurse include? Gently massage reddened areas of the client's skin. Inspect the client's skin every other day. Change the client's position every 4 hr. Apply a moisture barrier cream to the client's skin.

Apply a moisture barrier cream to the client's skin. The nurse should apply a moisture barrier cream to protect the client's skin from urine. Urine is acidic and can lead to maceration of the skin.

A nurse is developing a plan of care for an older adult client who is at risk of falling. What fall prevention measures should the nurse include in the plan? Ask the client to demonstrate how to use the call light. Place wool socks on the client prior to ambulation. Store the client's eyeglasses in the bathroom at night time. Keep the bed in a flat position when the client is sleeping.

Ask the client to demonstrate how to use the call light. Rat: The nurse should include asking the client for a demonstration of how to use the call light in the plan of care. By ensuring the client understands the use of the call light and teaching the client to call for assistance when getting out of bed, the nurse will promote client safety and reduce the risk of falling.

A nurse is providing teaching about nutrition management to the parent of an 18-month old toddler who has phenylketonuria. What foods should the nurse recommend? Strawberry yogurt Refried beans Cheddar cheese Baked potato

Baked Potatoes Rat: Strawberry yogurt Refried beans Cheddar cheese Baked potato

A nurse in a community health clinic is screening a 10-yr old girl for scoliosis. What instructions should the nurse give the child for this examination. "Walk across the room with the heel of one foot against the toes of your other foot." "Lie on your back on the examination table." "Bend forward at the waist and let your arms hang down." "Close your eyes and stand with your heels together."

Bend forward at the waist and let your arms hand down Rat: During a scoliosis screening, the nurse should have the child bend forward at the waist, keeping her back parallel with the floor and having her arms dangle freely. In this position, the nurse can observe asymmetry of the ribs and flanks.

A nurse is performing a focused assessment on a client who has chronic pain die to fibromyalgia. What should the nurse ask to assess the quality of the client's pain? 1. "How long do your episodes of pain typically last?" 2. "Do you have nausea when you're in pain?" 3. "Can you describe what your pain feels like?" 4. "Could you rate your pain on a scale of 0 to 10?"

Can you describe what your pain feels like? Rat: The nurse should ask the client to describe her pain when assessing pain quality. The quality of a client's pain can be expressed using adjectives such as "piercing," "stabbing," and "aching."