BADNAP Unit 1 Review

A nurse is preparing to administer methylnaltrexone 12 mg subcutaneously to a client who has opioid-induced constipation. Available is methylnaltrexone 8 mg/0.4 mL. How many mL should the nurse administer?

0.6 mL

A nurse is preparing to administer hydrocortisone 100 mg IM daily to a client. Available is hydrocortisone 250 mg/2 mL. How many mL should the nurse administer per dose?

0.8 mL

A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?

"Documentation is a communication tool for the interprofessional health care team."

A nurse is reinforcing teaching with a client about using transdermal patches at home. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

"I will clean and dry the area before applying the patch."

A nurse is providing care to a client who is on strict bed rest following surgery. The nurse assists the patient to the bedside commode and the client sustains an injury to the operative area. Which of the following types of tors has the nurse committed?

-negligence Negligence is the failure to provide the expected standard of care. The expected standard of care was strict bedrest.

A nurse is preparing to administer penicillin IM to an adult client. Which of the following angles should the nurse use for injection into the client's ventrogluteal muscle?

90

A nurse administers an incorrect medication to a client. Following an assessment of the client, the nurse determines that the client has experienced no untoward effects as a result of the medication. The nurse does not complete an accident report because no harm came to the client. Which of the following ethical principals did the nurse violate?

veracity

A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

"Information about a client can be disclosed to family members at any time."

A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching?

"It is a good idea to use the handrails in the bathroom."

A nurse at an extended-care facility is instructing a class of AP about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the clients' use of a cane?

"When the client moves, he should move the cane forward first."

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

-Use a transfer device to lift the client up in bed. Using a lifting device prevents dragging the client's skin across the bed linens, which can cause abrasions.

A nurse is calculating a client's fluid output for a 12-hr period. It includes a Jackson-Pratt (JP) drainage 35 mL, NG suction 120 mL, and incontinence pads weighing 240 g, 275 g, 310 g, and 270 g. The dry weight of the incontinence pads is 90 g. The nurse should record how many mL of output on the client's record?

890 mL

A nurse is caring for a client who is receiving oxygen at 2 L/min via nasal cannula. The nurse recognizes the client is receiving which of the following inspired oxygen concentration?

28%

A nurse is assessing a client for pitting edema and notes an indentation of 6 mm (0.25 in.) at the point of pressure. Which of the following notations should the nurse use to document the severity of the client's edema?

3+

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse?

3rd spot down

A nurse is admitting a client who reports anorexia and is experiencing malnutrition. Which of the following laboratory findings should the nurse expect to be altered?

Albumin A low albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time. Creatine kinase is a cardiac enzyme which is useful in the diagnosis of a myocardial infarction. It is not a laboratory test that supports a diagnosis of malnutrition. Troponin is a cardiac enzyme which indicates a client has experienced a myocardial infarction. It is not a laboratory test that supports a diagnosis of malnutrition. Total bilirubin is altered in clients who are experiencing hepatobiliary disease. It is not a laboratory test that supports a diagnosis of malnutrition.

Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use?

Ask the client's full name and date of birth.

A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?

Assess the apical pulse for a full minute.

A nurse is preparing to administer a pre-packaged oral medication to a client and complete the final medication check. At which of the following times or places should the nurse perform this final check?

At the client's bedside before administration

A nurse is providing hygiene care for a client who is immobile. Which of the following actions should the nurse take?

Check for personal items when changing the bed linens. Keep the bath water temperature between 43.3° C (110° F) and 46.1° C (115° F). Wash the client's extremities from proximal to distal.

A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound-drainage specimen for culture?

Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen.

A nurse is caring for a client who is postoperative following abdominal surgery. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse include on the client's lunch tray?

Cranberry Juice is an acceptable component of a cler liquid diet. The other three options are components of a full liquid diet, not a clear.

A nurse is preparing to administer three liquid medications to a client who has an NG tube with continuous enteral feedings. Which of the following actions should the nurse take?

D. Flush the NG feeding tube with 30 mL of water immediately following medication administration Rationale: The nurse should flush the NG feeding tube with 15 to 60 mL of sterile water following medication administration to ensure the feeding tube is cleared of the medications.

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Elevate the head of the client's bed 30° to 45°.

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation?

Excessive laxative use. Ignoring the urge to defecate. Inadequate fluid intake.

A nurse is preparing to administer ophthalmic solution to a client. Which of the following actions should the nurse take?

Hold the ophthalmic solution 2 cm (3/4 in) above the lower conjunctival sac.

A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hours. Which of the following actions should the nurse take as directed by the plan of care?

Instruct the client to tighten muscle groups for a short period, and then relax.

A charge nurse is observing a newly licensed nurse insert an indwelling urinary catheter for a male client. Which of the following actions by the newly-licensed nurse requires intervention by the charge nurse?

Lubricates the first 2.5 to 5 cm (2 in) of the catheter. The nurse should lubricate the first 2.5 to 5 cm (1 to 2 in) of the catheter when inserting a catheter into a female client. The nurse should lubricate the first 15 to 17.5 cm (6 to 7 in) when inserting a catheter into a male client. cleaning the client's meatus.

A nurse is measuring a client for knee-high antiembolic stockings to help prevent venous stasis. Which of the following actions should the nurse take?

Measure from the heel to the popliteal space.

A nurse in an acute care setting is planning care for a group of clients at the beginning of the shift. Which of the following tasks should the nurse assign to the AP?

Monitoring vital signs of a client who had an appendectomy 12 hr ago

A nurse is caring for a client who has a Clostridium difficile infection. Which of the following cleansing agents should the nurse use for hand hygiene?

Nonantimicrobial soap--- The Centers for Disease Control recommends that hands should be washed with nonantimicrobial soap and water if in contact with spore-forming organisms such as Clostridium difficile or Bacillus anthracis. Proper hand hygiene includes using soapy lather and friction under running water for at least 15 seconds.

A nurse is assisting a provider with a sterile procedure and prepares to pour solution onto a piece of sterile gauze. In what order should the nurse perform the following steps when pouring sterile solution?

Perform hand hygiene. Remove the bottle cap Place the bottle cap face up on a clean surface Pick up the bottle with the label facing his palm Pour 1 to 2 mL into a receptacle Pour the solution onto the gauze

A nurse is preparing to perform would irrigation on a client who has a puncture to the left leg. Identify the sequence of steps the nurse should take to perform the irrigation.

Place a waterproof pad under the client's leg Apply clean gloves to remove dressing Clean site using circular motion, Open sterile kit Irrigate wound

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include?

Relief of urinary retention Measurement of residual urine after urination Presence of an open perineal wound

A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

Reposition the client at least every 2 hr. The nurse should plan to reposition the client at least every 2 hr and to make a schedule to record position changes for the client's medical record.

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Secure the restraints using a quick-release tie.

A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes client confidentiality?

Sharing computer passwords with coworkers

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect?

Tachycardia Hypoxia is low levels of oxygen in your body tissues. It causes symptoms like confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin

A nurse removes an indwelling catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

Temporary urinary retention

A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?

The client's hand is cool and pale.

A nurse is preparing to assist a client who can partially bear weight and is cooperative with transfer from the bed to a chair. Which of the following actions should the nurse take to maintain safety during the transfer?

Use a powered standing-assist lift.

A nurse is reviewing the lab results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following lab values as an indication that the client has developed an infection?

WBC count An elevation in the WBC count (leukocytosis) indicates that the client's immune system is defending him against the pathogens causing an infection.

A nurse is planning care for a client who requires airborne precautions. Which of the following actions should the nurse take?

Wear an N95 respirator mask.

A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take?

Withdraw 3 to 5 mL of urine from the port.

A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?

blood

A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

carotid

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect?

contractures of the extremities crackles in the lungs pressure ulcers

A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations?

earlobe

A nurse is removing PPE after giving direct care to a client who requires isolation. Which of the following items should the nurse remove first?

gloves

A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs the client's hospitalization. The client could rightfully sue the nurse for which of the following?

malpractice