ATI RN Fundamentals Online Practice 2019 A, ATI RN Fundamentals Online Practice 2019 B

A nurse is preparing to obtain a lower extremity BP from a client and no longer palpates the popliteal pulse after 92 mmHg. Which of the following images displays the measurement in mmHg to which the nurse should inflate the cuff when obtaining the BP?

122 mmHg

A nurse is planning care for a client who has TB. The nurse should use which of the following pieces of PPE when providing care for the client?

N95 respirator

A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first? a. check the client for injuries b. move hazardous objects away from the client c. notify the provider d. ask the client to describe how she fell prior to the fall

a. check the client for injuries -the first action the nurse should take when using the nursing process is to assess the client for injuries -all of these options need to be done, but checking the client for injuries comes first

A nurse is preparing to delegate client care tasks to an AP. Which of the following tasks should the nurse delegate?

ambulating a client who is postoperative

A nurse has just inserted an NG tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement?

an x-ray shows the end of the tube above the pylorus

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation?

bladder scan shows 525 mL of urine

A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy? a. a lesion with uniform pigmentation b. a new appearance of petechiae c. a mole with an asymmetrical appearance d. the presence of a papule

c. a mole with an asymmetrical appearance -an uneven or asymmetrical shape is a potential indication of a skin malignancy. This is manifested when part of a lesion or mole looks different from the other part. -variations in pigmentation are a possible indication of a skin malignancy. A lesion with uniform pigmentation is not an expected indication of a skin malignancy. -petechiae are capillaries that have bust under the skin and appear as small spots on the skin. Although they can be indications of other conditions, petechiae are not an expected indication of a skin malignancy. -papules are solid elevations that are palpable in the skin and are less than 1 cm in size. They are not an expected indication of a skin malignancy.

A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?

cleanse the wound from the center outward

A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the side rail onto the floor. Which of the following statements should the nurse document about this incident?

client found lying on the floor

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate? a. protective environment b. airborne precautions c. droplet precautions d. contact precautions

d. contact precautions -major wound infections require contact precautions, which means the nurse should admit the client to a private room. All caregivers should wear a gown and gloves during direct contact with this client.

A nurse is assessing an adult client who has been immobile for the past 3 weeks. For which of the following findings should the nurse intervene?

erythema on pressure points

A client who is nonambulatory notifies the nurse that his trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

evacuate the client

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse plan to take?

select a suction catheter that is half the size of the lumen

A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse?

the newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field

A nurse is caring for a client who requires an informed consent for a surgical procedure. Which of the following actions is the nurse's responsibility?

witness the client's signature on the consent form

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?

wrap blankets around all 4 sides of the bed

A nurse is planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?

you should receive a pneumococcal vaccine when you are 65 y/o

A nurse is providing discharge teaching for 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?

-check the cord routinely for frays or tearing -consider purchasing a generator for power backup -observe for signs of hypoxia

A nurse in a long-term care facility is caring for a client who dies during the nurse's shift. Identify the sequence in which the nurse should perform the following steps. -place a name tag on the body -ask the client's family members if they would like to view the body -obtain the pronouncement of death from the provider -wash the client's body -remove tubes and indwelling lines

-obtain the pronouncement of death from the provider -remove tubes and indwelling lines -wash the client's body -ask the client's family if they would like to view the body -place a name tag on the body

A nurse is caring for a client who has TB. Which of the following actions should the nurse take?

-place the client in a negative-pressure room -wear gloves when assisting the client with oral care -use antimicrobial sanitizer for hand hygiene

A nurse in a provider's office is assessing the deep tendon reflexes of a client. What should the nurse identify as the correct technique for eliciting the client's patellar reflex?

-to elicit the expected response of lower leg extension, the nurse should allow the client's legs to hang freely over the side of the examination table while seated and quickly tap the patellar tendon just below the kneecap using a reflex hammer

A nurse has accepted a verbal prescription for "3/10 of a mg of levothyroxine IV stat" for a client who has myxedema coma. How should the nurse transcribe the dosage of this medication in the client's medical record?

0.3 mg

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

107

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output as 120 mL of fluid?

8 oz of ice chips

A nurse is discussing the use of herbal supplements for health promotion with a client. Which of the following client statements indicates an understanding of herbal supplement use?

I can take echinacea to improve my immune system

A nurse is caring for a client who requires a 24 hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?

I flushed what I urinated at 7:00 am and have saved all urine since

A nurse is caring for a client who has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device?

I will be sure to remove my hearing aid before taking a shower

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should include in the teaching that this therapy might be contraindicated for which of the following clients?

a client who has asthma

A nurse is caring for a group of clients on a med-surg unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity?

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

A community health nurse is checking BPs for a group of clients at a community health screening. Which of the following clients is at an increased risk for HTN?

a client who smokes one pack of cigarettes each day

A nurse manager is overseeing the care activities on a unit. For which of the following situations should the nurse manager intervene due to a violation of HIPAA guidelines?

a nurse asks a nurse from another unit to assist with documentation for a client

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

a. "I can concentrate best in the morning." -the client's statement indicates a readiness to learn because he is verbalizing the best time for him to learn

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

a. "Use the complete name of the medication magnesium sulfate." -the Institute for Safe Medication Practices designates that nurses and providers write the complete medication name for magnesium sulfate when documenting medications to avoid any misinterpretation of MgSO4 as MSO4, which means morphine sulfate -"unit(s)" is the correct term for use in medication documentation -"subcut" or "subcutaneously" as the correct term for use in medication documentation

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 b. administer the medication into the client's nondominant arm c. pull the client's skin laterally or downward prior to administration d. massage the injection site after administration

a. administer the medication with the needle at a 45 degree angle -the nurse should insert the needle at a 45-90 degree angle for a subQ injection -the nurse should administer enoxaparin into the abdomen at least 2 inches from the umbilicus -the nurse should not massage the injection site following the injection of an anticoagulant due to the risk for bruising

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

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

A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following nursing actions should the nurse take? a. ask another nurse to observe the medication wastage b. notify the pharmacy when wasting the medication c. lock the remaining medication in the controlled substances cabinet d. dispose of the vial with the remaining medication in the sharps container

a. ask another nurse to observe the medication wastage -a second nurse must witness the disposal of any portion of a dose of a controlled substance

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel? (Select all that apply.) a. assist the client with a partial bed bath b. measure the client's BP after the nurse administers an antihypertensive medication c. test the client's swallowing ability by providing thickened liquids d. use a communication board to ask what the client wants for lunch e. irrigate the client's indwelling urinary catheter

a. assist the client with a partial bed bath, b. measure the client's BP after the nurse administers an antihypertensive medication, d. use a communication board to ask what the client wants for lunch

A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning? a. during the admission process b. as soon as the client's condition is stable c. during the initial team conference d. after consulting with the client's family

a. during the admission process -discharge planning should begin as soon as the client is undergoing the admission process. The nurse should begin to assess the client's needs and plan for care both during and after the client's time in the facility -the nurse should only consult with the client's family if the client gives the nurse permission to share that information

A nurse is caring for a patient who has a prescription for a blood transfusion. The child's parents have refused the treatment due to their religious beliefs. What of the following actions should the nurse take? a. examine personal values about the issue b. tell the parents that this is a necessary procedure c. inform the parents that the staff does not require their consent d. contact a spiritual support person to explain the importance of the procedure

a. examine personal values about the issue -nurses should examine their own personal values about the issue in question in order to provide care that is without bias -parents must give consent for a child to receive a blood transfusion -the nurse or provider should provide information about the procedure. Spiritual support people attend to clients' and families' spiritual needs, not their physiological needs.

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? a. pad the client's wrist before applying the restraints b. evaluate the client's circulation every 8 hr after application c. remove the restraints every 4 hr to evaluate the client's status d. secure the restraint ties to the bed's side rails

a. pad the client's wrist before applying the restraints -the use of restraints without padding can abrade the client's skin, resulting in client injury

A nurse is administering an otic medication to an older adult. Which of the following actions should the nurse take to ensure that the medication reaches the inner ear? a. press gently on the tragus of the client's ear b. pack a small piece of cotton deep into the client's ear canal c. move the client's auricle down and back toward her head d. tilt the clients head backward for 5 min

a. press gently on the tragus of the client's ear -pressing gently on the tragus of the ear will help the medication get into the inner ear

A nurse is caring for a client who has a terminal illness and is approaching death. The client is short of breath and has noisy respirations from secretions in their airway. Which of the following actions should the nurse take? a. turn the client every 2 hr b. administer an antiemetic every 6 hr c. hold oral care d. increase the room's temperature

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

A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client? a. use a bed exit alarm system b. raise four side rails while the client is in bed c. apply one soft wrist restraint d. dim the lights in the client's room

a. use a bed exit alarm system -the nurse should identify that the client who has dementia requires assistance when exiting their bed and might be unable to remember to ask for help. The client's condition places them at risk for falling; therefore, a bed alarm system can alert staff members that the client is trying to get out of bed and requires assistance

A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures?

apply an ankle-foot orthotic device to the client's feet

A nurse is planning care for a client who has vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

arrange food in a consistent pattern on the client's plate

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?

assess the client for orthostatic hypotension

A nurse is administering IV fluids to a client. When monitoring for adverse effects, which of the following assessments should the nurse identify as the priority?

auscultate lung sounds

A nurse is caring for a client who has a terminal illness and is at the end of life. The nurse should recognize that which of the following statements by the client's partner indicates effective coping? a. "I am not worried because I still have hope that he will be okay." b. "I am relying on support from our family during this time." c. "We can plan our family reunion once he recovers and comes home." d. "We don't see any reason to start discussing funeral arrangements right now."

b. "I am relying on support from our family during this time." -this statement indicates effective coping because the partner is relying on other members of the family for support during a time of crisis

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

b. "I will hire someone to trim that tree that hangs low over the stairs of my front porch." -clearing stairs of any object that could cause the client to trip or require them to bend over while walking will decrease the risk for falls

A nurse is caring for a client who asks about the purpose of advance directives. Which of the following statements should the nurse make? a. "They allow the court to overrule an adult client's refusal of medical treatment." b. "They indicate the form of treatment a client is willing to accept in the event of a serious illness." c. "They permit a client to withhold medical information from health care professional." d. "They allow health care personnel in the emergency department to stabilize a client's condition."

b. "They indicate the form of treatment a client is willing to accept in the event of a serious illness." -advance directives include a living will, which permits clients to direct the treatment they will receive in the event of a medical emergency or serious illness -a court can only overrule an adult client's refusal of medical treatment if the client is legally incompetent -The Americans with Disabilities Act protects the privacy of a client who chooses not to disclose a medical disability -The Emergency Medical Treatment and Active Labor Act directs emergency personnel to provide screening and stabilizing care before discharging or transferring clients to another facility

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

b. "We would give you oxygen through a tube in your nose." -oxygen can provide comfort and is not considered a resuscitative measure when the nurse delivers it via nasal cannula -intubation is a resuscitative measure. The staff should not implement this intervention for a client who declines resuscitation in their living will -clients determine advance directives ahead of time to guide decision-making at the time of an emergency event. If the client initiates a change, the staff must honor it. Otherwise, staff must honor the decisions the client has documented in the advance directives

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? a. insert the suction catheter while the client is swallowing b. apply intermittent suction when withdrawing the catheter c. place the catheter in a location that is clean and dry for later use d. hold the suction catheter with her clean, nondominant hand

b. apply intermittent suction when withdrawing the catheter -the nurse should apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. However, suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority? a. request that a respiratory therapist discuss the technique for incentive spirometry with the client b. determine the reasons why the client is refusing to use the incentive spirometer c. document the client's refusal to participate in health restorative activities d. administer a pain medication to the client

b. determine the reasons why the client is refusing to use the incentive spirometer -the first action the nurse should take when using the nursing process is to assess the client; therefore, the priority action for the nurse to take is to determine why the client is refusing the treatment

A nurse is caring for a client who has pharyngeal diphtheria. Which of the following types of transmission precautions should the nurse initiate? a. contact b. droplet c. airborne d. protective

b. droplet -droplet precautions are a requirement for clients who have infections that spread via droplet nuclei that are larger than 5 microns in diameter, including rubella, meningococcal pneumonia, and streptococcal pharyngitis. The nurse should wear a mask when providing care or when within 3 feet of the client who has a disorder requiring droplet precautions

A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use? a. use the Face, Legs, Activity, Cry, and Consolability (FLACC) pain rating scale for a client who is experiencing pain b. ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm c. obtain an apical heart rate by auscultating at the third intercostal space left of the sternum d. palpate the client's abdomen before auscultating bowel sounds

b. ensure the bladder of the BP cuff surrounds 80% of the client's arm -the nurse should use a blood pressure cuff with a bladder that surrounds 80% of the client's arm circumference to give an accurate reading -the FLACC pain rating scale is used for clients ages from 2 months to 7 years old -the nurse should place the stethoscope at the point of maximal impulse for an apical heart rate, which is at the fifth intercostal space at the midclavicular line left of the sternum -the nurse should auscultate bowel sounds before performing palpation in order not to change the character of the sounds

A nurse is initiating a protective environment for a client who has an allogenic stem cell transplant. Which of the following precautions should the nurse plan for this client? a. make sure the client's room has at least six air exchanges per hour b. make sure the client wears a mask when outside her room if there is construction in the area c. place the client in a private room with negative-pressure airflow d. wear an N95 respirator when giving the client direct care

b. make sure the client wears a mask when outside her room if there is construction in the area -an allogenic stem cell transplant compromises the client's immune system, greatly increasing the risk for infection. The client will need protection from breathing in any pathogens in the environment -a protective environment requires at least 12 air exchanges per hour -the nurse should place the client in a private room that provides positive-pressure airflow -the nurse should wear a N95 respirator mask when caring for clients who require airborne precautions, not a protective environment.

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? a. carry a client's soiled linens out of the room in a mesh linen bag b. place a client who has tuberculosis in a room with negative-pressure airflow c. provide disposable plates and utensils for a client who is HIV positive d. dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag

b. place a client who has tuberculosis in a room with negative-pressure airflow -a client who has tuberculosis requires airborne precautions, which include placing the client in a room that has negative-pressure airflow to reduce the risk of infection transmission -the nurse should place soiled linens in a fluid-resistant bag to reduce the risk of infection transmission -the nurse should dispose of items that have a large amount of blood in a biohazard bag that is impervious to micro-organisms

A nurse is planning to insert a peripheral IV catheter for an older adult. Which of the following actions should the nurse plan to take? a. insert the catheter at a 45 degree angle b. place the client's arm in a dependent position c. shave excess hair from the insertion site d. initiate IV therapy in the veins of the hand

b. place the client's arm in a dependent position -the nurse should place the client's arm in a dependent position because the veins will dilate due to gravity. -generally, the nurse should insert the catheter at a 10-30 degree angle; for an older adult 10-15 degrees is preferable because veins are closer to the skin surface as aging diminishes subcutaneous tissue -the nurse should clip excess hair from the IV insertion site and avoid shaving the area because shaving can cause breaks and cuts in the skin that could place the client at risk for infection. -the nurse should avoid using the fragile veins of an older adult's hands because the loss of subQ tissue can allow those veins to roll away from the needle. Also, having an IV in the client's hand can interfere with the client's performance of ADLs and can diminish the older adult's sense of independence and mobility.

A nurse is assessing an older adult client's risk for falls. Which of the following assessments should the nurse use to identify the client's safety needs? (Select all that apply.) a. lacrimal apparatus b. pupil clarity c. appearance of bulbar conjunctivae d. visual fields e. visual acuity

b. pupil clarity, d. visual fields, e. visual acuity -cloudy pupils mean that the client has cataracts. This makes vision cloudy and creates halos around lights, which can increase the risk for falls because the clients cannot see items in their path clearly -clients who have impaired visual fields and acuity are at an increased risk for falls because they might not see objects outside of their central vision and trip over them or bump into them and fall

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

b. regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min -evidence-based practice supports a flow rate of 1-6 L/min via nasal cannula. Rates above 6 L/min have a drying effect and force clients to swallow air excessively without increasing their fraction of inspired oxygen. -the reservoir bag should inflate one-third to one-half with inspiration. If it remains deflated, it indicates that clients are breathing in too much of the carbon dioxide they exhale -evidence-based practice supports the use of a water-soluble lubricant to protect the client's skin from the drying effects of oxygen

A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care? a. critical pathway b. situation, background, assessment, and recommendation (SBAR) c. transfer report d. medication administration record (MAR)

b. situation, background, assessment, and recommendation (SBAR) -SBAR is a communication tool nurses use to relate a client's status during a change-of-shift report -the nurse should use a transfer report when the client is moving from one health care area or facility to another

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? a. the client uses a wool blanket on their bed b. the client identifies the location of a fire extinguisher. c. the client stores an extra oxygen tank on its side under their bed d. the client has a weekly inspection checklist for oxygen equipment

b. the client identifies the location of a fire extinguisher. - The client should be able to identify the location of fire extinguishers in the home and be aware of how to use them

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol? a. the client uses a wool blanket on their bed b. the client uses nonacetone nail polish remover c. the client stores an extra oxygen tank on its side under their bed d. the client has a weekly inspection checklist for oxygen equipment

b. the client uses nonacetone nail polish remover -the client should use nonflammable materials, such as nonacetone nail polish remover, while using supplemental oxygen

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? a. remove the outer cannula cautiously for routine cleaning b. use tracheostomy covers when outdoors c. use sterile technique when performing tracheostomy care at home d. cleanse irritated skin with full-strength hydrogen peroxide

b. use tracheostomy covers when outdoors -tracheostomy covers protect the client's airway from cold air, dust, and other airborne particles

A nurse is giving change-of-shift report about a client they admitted early that day who has pneumonia. Which of the following pieces of information is the priority for the nurse to provide?

breath sounds

A nurse is caring for a client who has an aggressive form of prostate cancer. The provider briefly discusses treatment options and leaves the client's room. When the nurse asks if the client would like to discuss any concerns, the client declines. Which of the following statements should the nurse make? a. "I will return shortly after I document this in your record." b. "Most men live a long time with prostate cancer." c. "I am available to talk if you should change your mind." d. "I will make a referral to a cancer support group for you."

c. "I am available to talk if you should change your mind." -when a client does not wish to share his feelings with the nurse, it is important for the nurse to convey a willingness to be available for the client

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

c. "It might help me to listen to music while I'm lying in bed." -listening to music is an effective nonpharmacological intervention for the management of mild pain

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

c. "Let's talk about how the change in your job status will affect you." -this response is therapeutic because the nurse is encouraging the client to verbalize feelings about the life transition of retirement

A nurse is providing discharge teaching to a client about self-administering heparin. Which of the following instructions should the nurse include in the teaching? a. insert the needle at a 15 degree angle b. aspirate for blood return prior to administration c. administer the medication into the abdomen d. massage the site following the injection

c. administer the medication into the abdomen -the nurse should instruct the client to administer the medication into the abdomen at least 5 cm from the umbilicus. The client should pinch or spread the skin at the injection site to administer the medication into the subQ tissue -the nurse should instruct the client to insert the needle at a 45-90 degree angle to administer the medication into the subQ tissue -the nurse should instruct the client not to aspirate for blood return because this can cause tissue damage and bruising -the nurse should instruct the client not to massage the site because this can cause tissue damage and bruising

A nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis? a. bladder distention b. decreased blood pressure c. calf swelling d. diminished bowel sounds

c. calf swelling -swelling, redness, and tenderness in a calf muscle are manifestations of thrombophlebitis, a common complication of immobility

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation? a. verify the client's name on their ID bracelet with the medication administration record b. call the pharmacy to determine whether the client's medications are available c. compare the client's home medications with the provider's prescriptions d. place the client's home medication bottles in a secure location

c. compare the client's home medications with the provider's prescriptions -the nurse should compare the client's home medications with the provider's prescriptions when performing medication reconciliation

A nurse is administering 1 L of 0.9% NS to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful? a. increase in hematocrit b. increase in respiratory rate c. decrease in heart rate d. decrease in capillary refill time

c. decrease in heart rate -fluid volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range.

A nurse is caring for a client who is postoperative following a knee arthroplasty and requires the use of thigh-length sequential compression sleeves. Which of the following actions should the nurse take? a. assist the client into a prone position b. place a sleeve over the top of each leg with the opening at the knee c. make sure two fingers can fit under the sleeves d. set the ankle pressure at 65 mm Hg

c. make sure two fingers can fit under the sleeves -the nurse should ensure that there is enough space for two fingers to fit under the sleeve because any less space between the sleeves and the legs can inhibit circulation when the sleeves inflate -the nurse should place the client in a dorsal recumbent or semi-fowler's position to facilitate application of the sleeves -the nurse should place the sleeve under each leg with the opening at the knee and then wrap the sleeve around the leg so that it is secure -the nurse should set the ankle pressure between 35-55 mm Hg to achieve a therapeutic effect while also preventing damage to the client's skin and circulation

A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner id experiencing which of the following types of role-performance stress? a. role ambiguity b. sick role c. role overload d. role conflict

c. role overload -the partner's expression of frustration is an example of role overload, which refers to having more responsibilities within a role than one person can manage -role ambiguity occurs when people are unclear about the expectations of their role in a given situation -sick role refers to the expectations placed on the individual who has the alteration in health, rather than the caregiver -role conflict develops when a person must assume multiple roles that have opposing expectations

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take? a. place the client in a side-lying position b. instill 15 mL or irrigation fluid into the catheter with each flush c. subtract the amount of irrigant used from the clients urinary output d. perform the irrigation using a 20 mL syringe

c. subtract the amount of irrigant used from the client's urine output -the nurse should calculate the fluid used for irrigation and subtract it from the client's total urinary output -for a catheter irrigation, the nurse should place the client in a supine or dorsal recumbent position for maximal access to the catheter -open irrigation technique requires instilling 30-40 mL of irrigation fluid -the nurse should use a 30-50 mL syringe to perform open irrigation

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

c. the client holds the cane on the stronger side of her body -the client should hold the cane on the stronger side of her body to increase support and maintain alignment -to maintain balance, the client should advance the cane about 15-30 cm (6-12 in) at a time -the client should move her weaker leg forward with the cane. This divides the client's body weight between the cane and the stronger leg

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

c. the client's caregiver washes out the feeding bag with warm water once every 24 hr -feeding bags should be washed out after each feeding and replaced with a new feeding bag every 24 hr to prevent bacterial contamination. The nurse should reinforce this information with the client's caregiver to avoid future contamination

A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement? a. combine client care tasks when caring for multiple clients b. wait until the end of the shift to document care c. use the planning step of the nursing process to prioritize client care delivery d. allow for interruptions in tasks to discuss client care issues with colleagues

c. use the planning step of the nursing process to prioritize client care delivery -setting up a list of goals and tasks to perform for clients can help the nurse set care priorities and plan tasks accordingly. The priority to-do list is an efficient tool for optimal time management

A nurse 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 while at the facility

A nurse in an acute care facility is preparing a discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include?

current medications

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? a. "Is your pain constant or intermittent?" b. "What would you rate your pain on a scale of 0 to 10." c. "Does the pain radiate?" d. "Is your pain sharp or dull?"

d. "Is your pain sharp or dull?" -asking the client whether the pain is sharp, dull, crushing, throbbing, aching, burning, electric-like, or shooting helps determine the quality of the pain.

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? a. numbness of the extremities b. bradycardia c. positive Chvostek's sign d. abdominal cramping

d. abdominal cramping -this client has hyponatremia, which is a low sodium level. Manifestations include abdominal cramping, weakness, confusion, lethargy, headache, and nausea. -numbness of the extremities is a manifestation of hyperkalemia -tachycardia is a manifestation of hyponatremia along with hypovolemia -a positive Chvostek's sign is a manifestation of hypomagnesemia and hypocalcemia

A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies? a. biofeedback b. aloe c. feverfew d. acupuncture

d. acupuncture -the nurse should inform the client that herpes zoster, or any skin infection, is a contraindication for the use of acupuncture. An open portal on the skin's surface could increase the risk of further infection -biofeedback is a complementary and alternative therapy to assist clients with stroke recovery, smoking cessation, headaches, and many other disorders -aloe is a complementary and alternative therapy that can help improve disorders and can have wound healing effects -feverfew is a complementary and alternative therapy that helps promote wound healing. Anticoagulation therapy is contraindicated for taking feverfew.

A nurse is caring for a client who is postoperative. When the nurse prepares to change her dressing, she says, "Every time you change my bandage, it hurts so much." Which of the following interventions is the nurse's priority action? a. encourage the client to relax and take deep breaths during the dressing change b. educate the client about the importance of the dressing change to prevent infection c. assist the client to a comfortable position for the dressing change d. administer pain medication 45 min before changing the client's dressing

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

A nurse receives report about a client who has 0.9% NaCl 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 hr. Which of the following actions should the nurse take first? a. reposition the client b. document the client's IV intake in the medical record c. request a new IV fluid prescription d. check the IV tubing for obstruction

d. check the IV tubing for obstruction -the first action the nurse should take using the nursing process is to assess the client. If checking the IV tubing and verifying an obstruction, the nurse might be able to facilitate the flow of fluid through the tubing. This could re-establish the infusion rate the provider prescribed.

A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching? a. assign the client to a room with a negative 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 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 is caring for a client who requires an NG tube for stomach decompression. Which of the following actions should the nurse take when inserting the NG tube? a. position the client with the head of the bed elevated to 30 degrees prior to insertion of the NG tube b. remove the NG tube if the client begins to gag or choke c. apply suction to the NG tube prior to insertion d. have the client take sips of water to promote insertion of the NG tube into the esophagus

d. have the client take sips of water to promote insertion of the NG tube into the esophagus -taking sips of water as the NG tube passes through the oropharynx will close the epiglottis over the trachea and prevent the tube from passing into the trachea -the client should be sitting in high-fowlers position with the end of the bed elevated to 90 degrees to reduce the risk of aspiration -the nurse should withdraw the NG tube slightly, not remove it, if the client gags or chokes to reduce the risk of injury to the client -the nurse should not apply suction to until the NG tube is in place with x-ray verification of its position in order to reduce the risk of injury to the client

A nurse is preparing to apply a dressing for a client who has a stage 2 pressure injury. Which of the following types of dressing should the nurse use? a. alginate b. gauze c. transparent d. hydrocolloid

d. hydrocolloid -hydrocolloid dressings promote healing in stage 2 pressure injuries by creating a moist wound bed -alginate dressings are used to treat stage 3 and 4 pressure injuries to absorb drainage. Alginate forms a soft gel when it comes in contact with drainage. -moistened gauze promotes healing in stage 4 or unstageable pressure injuries by causing debridement and allowing granulation of the wound bed -transparent dressings promote healing in stage 1 pressure injuries by preventing further friction and shearing

A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vitals every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next? a. document the provider's statement in the medical record b. complete an incident report c. consult the facilities risk manager d. notify the nursing manager

d. notify the nursing manager -the greatest risk to the client is not receiving timely intervention for a deterioration in physiological status; therefore, the next action should the nurse should take is to activate the chain of command to ensure that the client receives the necessary care

A nurse is reviewing a client's fluid and electrolyte status. Which of the following findings should the nurse report to the provider? a. BUN 15 mg/dL b. creatinine 0.8 mg/dL c. sodium 143 mEq/L d. potassium 5.4 mEq/L

d. potassium 5.4 mEq/L -this value is above the expected range of 3.5-5 mEq/L, so the nurse should report this finding to the provider. This client is at risk for dysrhythmias -sodium 135-145 mEq/L -creatinine 0.6-1.2 mg/dL -BUN 10-20 mg/dL

A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take? a. discuss the risk factors of colon cancer b. focus teaching on what the client will need to do in the future to manage his illness c. provide the client with written information about the phases of loss and grief d. reassure the client that this is an expected response to grief

d. reassure the client that this is an expected response to grief -during the anger stage of the client's psychosocial adaptation to illness, the nurse should support the client and explain that this is an expected reaction to a cancer diagnosis

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

d. stand close to the cabinet when lifting it -this action keep the cabinet close to the nurse's center of gravity and decreases back strain from horizontal reaching

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client? a. have the client wear a mask when receiving visitors b. limit the client's time with visitors to no more than 30 mins per day c. assign the client to a room with negative-pressure airflow exchange d. wear a down when caring for the client

d. wear a gown when caring for the client -the nurse should implement contact precautions for a client who has shigella to prevent the transmission of bacteria. The nurse should wear a gown when providing care for a client who requires contract precautions due to the risk of contact with bodily fluids and contaminated surfaces

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?

distended neck veins

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?

droplet

A nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. Which of the following actions should the nurse plan to take?

flush the tube with 15 mL of sterile water

A nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take?

gently shake the container of medication prior to administration

A charge nurse is discussing the responsibility of nurses caring for clients who have a C. diff infection. Which of the following information should the nurse include in the teaching?

have family members wear a gown and gloves when visiting

A nurse is performing a Romberg test during the physical assessment of a client. Which of the following techniques should the nurse use?

have the client stand with their arms at their sides and their feet together

A nurse is caring for a client who has limited mobility in his lower extremities. Which of the following actions should the nurse take to prevent skin breakdown?

have the client use a trapeze bar when changing position

A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?

initiate an enteral feeding through a gastrostomy tube

A nurse is caring for a client who is receiving pain medication through a PCA pump. Which of the following actions should the nurse take?

instruct the family to refrain from pushing the button for the client while she is asleep

A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?

maintain a consistent time to wake up each day

A nurse is reviewing a client's medication prescription that reads, "digoxin 0.25 by mouth every day." Which of the following components of the prescription should the nurse verify with the provider?

medication dose

A middle adult client tells the nurse, "I feel so useless now that my children do not need me anymore." Which of the following responses should the nurse make?

people in middle adulthood often find satisfaction in nurturing and guiding young people

A nurse is planning teaching for a group of adolescents who each recently has surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning?

practice sessions

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?

rapid HR

A nurse is caring for a client who is receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as indicating infiltration?

skin blanching

A nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. Which of the following actions should the nurse take first?

tell the client to keep the HOB elevated at least 30 degrees

A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as a potential indication of elder abuse?

the caregiver insists on remaining in the room

A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

the pain is like a dull ache in my stomach

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend?

walking briskly

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?

we can talk about advance directives, and I can also give you some brochures about them

A nurse is caring for a client who has terminal liver cancer. Which of the following statements should the nurse identify as an indication that the client is experiencing spiritual distress?

what could I have done to deserve this illness?

A nurse is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

when descending stairs, I will first shift my weight to my right leg

A nurse is caring for a client who is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take?

withhold the blood transfusion

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take?

wrap monitoring cords with stockinette and tape them in place

A nurse in a clinic is caring for a middle adult client who states, "The doctor says that, since I am at an average risk for colon cancer, I should have a routine screening. What does that involve?" Which of the following responses should the nurse make?

you should have a fecal occult blood test every year