Basic Care

The nurse is administering oxygen by face mask to a client. Which action will the nurse include? A) Secure the elastic band tightly around the client's head. B) Assist the client to the semi-Fowler's position if possible. C) Loosen the connectors between the oxygen equipment and humidifier. D) Place the elastic straps below the client's ears.

B

The nurse is writing a medication order that a health care provider provided by telephone. Which should be included when writing the order? Select all that apply. A) medication ordered B) date the order is written C) code status D) client allergies E) medication dosage F) route of administration

A, B, E, and F

The nurse needs to administer heparin 10,000 units subcutaneously twice a day on a client who had a colon resection prophylactically for deep vein thrombosis. The dose on hand is 20,000 units per mL. How many milliliters will the nurse give?

0.5

A nurse is instructing a client who had abdominal surgery that day to do deep-breathing exercises. In which order from first to last should the nurse teach the client to perform diaphragmatic breathing and coughing? All options must be used. 1) Exhale through pursed lips. 2) Inhale through the nose. 3) Cough deeply from the lungs. 4) Splint the incisional site.

4, 2, 1, then 3

The nurse is recording the intake and output for a client: D5NS 1,000 ml, urine 450 ml, emesis 125 ml, Jackson-Pratt drain #1 35 ml, Jackson-Pratt drain #2 32 ml, and Jackson-Pratt drain #3 12 ml. How many milliliters would the nurse document as the client's output? Record your answer using a whole number.

654

A client has an indwelling urinary catheter and is prescribed physical therapy. As the client is being placed in a wheelchair, which action by the assistant would need further clarification by the nurse? A) The catheter bag is placed on the client's lap for safe transport. B) The assistant brings a container to drain the urine from the bag. C) The assistant checks to make sure the tubing is not kinked. D) The catheter drainage bag is placed on the lower side of the wheelchair.

A

A client has just returned to bed following the first ambulation since abdominal surgery. The client's heart rate and blood pressure are slightly elevated; oxygen saturation is 91% on room air. The client reports being "a little short of breath" but does not have dizziness or pain. What should the nurse do next? A) Allow the client to rest for a few minutes, then reassess. B) Request new activity prescriptions from the health care provider. C) Administer pain medication. D) Obtain a 12-lead electrocardiogram (ECG).

A

A client in a long-term care facility has signed a form stating that the client does not want to be resuscitated. The client develops an upper respiratory infection that progresses to pneumonia. The client's health rapidly deteriorates and is no longer competent. The client's family states that they want everything possible done for the client. What should happen in this case? A) The client should be treated with antibiotics for pneumonia. B) Pharmacologic interventions should not be initiated. C) The wishes of the client's family should be followed. D) The client should be resuscitated if the client experiences respiratory arrest.

A

A client recovering from an acute illness is extremely weak and unable to assist with transferring from the bed to a chair. Which action should the nurse take to ensure safety for both the client and nurse? A) Obtain an assistive device to help with the transfer. B) Apply a back belt before beginning the transfer. C) Recommend the client remain in bed until strength returns. D) Break the transfer down into smaller steps.

A

A client who's scheduled for open-heart surgery in 2 days has been having circulation problems in the feet and legs. The physician orders antiembolism stockings. The nurse is teaching the client about this treatment. What is the purpose of antiembolism stockings? A) to reduce or prevent edema of the legs and feet B) to decrease arterial blood circulation to the legs and feet C) to decrease venous blood circulation from the legs and feet D) to maintain warmth in the legs

A

A nurse has just removed an I.V. catheter from a client's arm because fluid has infiltrated the arm. The physician orders warm soaks for the area. Based on the principles of heat and cold application, the nurse should A) remove the warm compress for at least 15 minutes after each 20-minute application. B) keep the area covered with the warm soaks. C) question the order because heat increases edema. D) alternate warm compresses with cold compresses.

A

A nurse is required to irrigate a client's nasogastric tube, a procedure the nurse has not performed before. What is the most appropriate action by the nurse? A) Contact the nurse educator for an in-service and support in performing the skill. B) Ask another nurse to irrigate the nasogastric tube each time it is required. C) Refuse the assignment because of a lack of experience in irrigating a nasogastric tube. D) Irrigate the nasogastric tube by following the steps outlined in the procedure manual.

A

A nurse prepares to transfer a client from a bed to a chair. Which principle demonstrates safe body mechanics? A) The nurse uses a rocking motion while helping the client to stand. B) The nurse stands an arm's length away from the client. C) The nurse keeps knees straight and stiff and bends at the waist. D) The nurse keeps feet as close together as possible.

A

The nurse is suctioning a client's tracheostomy. For what reason during the procedure does the nurse complete the above action? A) to loosen the client's thick, tracheal secretions B) to clear secretions from the tubing C) to lubricate the outside of the suction catheter D) to regulate the suction pressure

B

A nurse-manager has decided to delegate responsibility for the review and revision of the surgical unit's client-education materials. Which statement illustrates the best method of delegation? A) Ask the two most proficient staff nurses to form a task force to review and revise client-education materials within the next 6 weeks. Have these nurses solicit input from clients and staff members. B) Tell the nursing staff that the client education materials need revision. Ask the staff to select people to review the materials and make suggestions for change. C) Tell the nursing staff they're responsible for the review and revision and welcome their recommendations for improving the materials. D) Ask the assistant manager to develop a plan for the review and revision of client-education materials.

A

A nurse-manager in the office of a group of surgeons has received complaints from discharged clients about inadequate instructions for performing home care. Knowing the importance of good, timely client education, the nurse-manager should take which steps? A) Work with the surgeons' staff and the nursing staff in the hospital and outpatient surgical center to evaluate current client education practices and make revisions as needed. B) Inform the nurses who work in the facility that client education should be implemented as soon as the client is admitted to either the hospital or the outpatient surgical center. C) Because none of the clients suffered any serious damage, the nurse-manager can safely ignore their complaints. D) Review and revise the way client education is conducted in the surgeons' office.

A

An employer establishes a physical exercise area in the workplace and encourages all employees to use it. This is an example of which level of health promotion? A) primary prevention B) tertiary prevention C) passive prevention D) secondary prevention

A

Following an education session on proper hand hygiene, the nurse educator observes a nurse washing hands before entering a client's room. Which observation would alert the nurse educator to the need for further education? A) The nurse dries from forearms up toward fingers. B) The nurse uses at least 3 to 5 mL of liquid soap. C) The nurse dries from finger tips down toward elbows. D) The nurse keeps hands lower than elbows while washing.

A

In the delivery of care, the nurse acts in accordance with nursing standards and the code of ethics and reports a medication error that the nurse has made. The nurse is most clearly demonstrating which professional values? A) integrity B) altruism C) human dignity D) social justice

A

Nurse researchers have proposed a study to examine the efficacy of a new wound care product. Which aspect of the methodology demonstrates that the nurses are attempting to maintain the ethical principle of nonmaleficence? A) The nurses are taking every responsible measure to ensure that no participants experience impaired wound healing as a result of the study intervention. B) The nurses have given multiple opportunities for potential participants to ask questions and have been following the informed consent process systematically. C) The nurses have organized the study in such a way that the foreseeable risks and benefits are distributed as fairly as possible. D) The nurses have completed a literature review that suggests the new treatment may result in decreased wound healing time.

A

The health care provider (HCP) has prescribed hydrocodone/APAP 1 tablet by mouth every 4 to 6 hours as needed for pain for a client who underwent right total knee replacement. When the nurse reassesses pain following administration, the client reports pain is still a 9 on a 10-point scale. When the nurse informs the HCP, the HCP states that one hydrocodone/APAP tablet should be sufficient and refuses to issue a new prescription. Which measure should the nurse select to act as an advocate for the client? A) Follow the chain of command to obtain adequate pain relief for the client. B) Give the client 1 hydrocodone/APAP tablet every 3 hours. C) Give the client 2 hydrocodone/APAP tablets every 4 hours. D) Document that the HCP was notified of the client's pain and continue to administer hydrocodone/APAP as prescribed.

A

The nurse has completed instilling fluid with a bladder irrigation and does not have a return of the fluid into the catheter bag. What is the next action the nurse should do? A) Ensure there are no kinks in the catheter tubing. B) Change the urinary catheter. C) Palpate the client's bladder for distention. D) Notify the healthcare provider about the lack of drainage.

A

The nurse instructs a group of colleagues on actions to take to prevent back injuries when providing client care. Which statement by a colleague indicates that additional teaching is required? A) "A back belt prevents injuries." B) "An assistive device reduces the risk of client injury." C) "A lift team will help prevent back injuries." D) "It is safer to use an assistive device."

A

The nurse is caring for a client who has a prescription for antiembolism stockings. The client is confused and begins kicking at the nurse during the measurement of the client's legs. What is the next action by the nurse? A) Ask an unlicensed assistive personnel to assist with the application of the antiembolism stockings. B) Place the antiembolism stockings without measuring the client's legs. C) Administer prescribed lorazepam 1 mg by mouth. D) Contact the health care provider to make aware that the antiembolism stockings cannot be applied.

A

The nurse is planning care for a hospitalized client who is blind. What should the nurse do to ensure safety for this client? A) Orient the client to the room environment. B) Request that the client stays in bed until the nurse can assist them. C) Require that the client has a sitter for each shift. D) Keep the side rails up when the client is alone.

A

The nurse-manager of a 20-bed coronary care unit is not on duty when a staff nurse makes a serious medication error that results in a client's overdose. The client nearly dies. Which statement accurately reflects the accountability of the nurse-manager? A) The nurse-manager would receive a call at home from the on-duty nursing supervisor, apprising the nurse-manager of the problem as soon as possible. B) Because the nurse-manager is off duty and not accountable for incidents that occur in their absence, the nurse-manager need not be notified. C) Although the nurse-manager is off duty and not responsible for what happened, the nursing supervisor would call the nurse-manager only if time permits. D) The nurse-manager only needs to be informed of the incident when the nurse-manager reports to work on the next scheduled day.

A

The staff of an outpatient clinic has formed a task force to develop new procedures for swift, safe evacuation of the unit. The new procedures haven't been reviewed, approved, or shared with all personnel. When a nurse-manager receives word of a bomb threat, the task force members push for evacuating the unit using the new procedures. Which action should the nurse-manager take? A) Determine that the procedures currently in place must be followed and direct staff to follow them without question. B) Ask staff members to quickly meet among themselves and decide what procedures to follow. C) Tell staff members to assemble in the staff lounge, where she will quickly gather opinions about evacuation procedures before deciding what to do. D) Tell staff members to use whatever procedures they feel are best.

A

Three individuals with gunshot wounds are brought to the emergency department. The nurse should take which action to preserve forensic evidence on the clients' clothing? A) Place each item of clothing in a separate paper bag. B) Request that a police officer observe the removal of clothing. C) Cut around bloodstains to remove clothing. D) Place all wet clothing in a plastic bag.

A

What should the nurse do to prevent pressure ulcers in an older adult? A) Perform a systematic skin assessment at least once a day. B) Massage bony prominences gently every shift. C) Encourage the client to sit in a chair as much as possible. D) Clean the skin daily using mild soap and hot water.

A

Which assessment factors would indicate a need for oropharyngeal suctioning? A) breathing rate of 36 breaths/min and noisy, gurgling respirations B) auscultation of crackles in the lower lobes of the lungs C) oxygen saturation levels of 95% and diaphragmatic breathing patterns D) thin sputum, weak cough, and enlargement of the tonsils

A

A nurse is working with an unlicensed assistive personnel (UAP). Which client(s) should the nurse assign to the UAP? Select all that apply. A) adult client who had a hysterectomy 3 days ago and requires vital sign checks every 4 hours B) young adult client who requires tube feedings C) older adult client who had hip replacement surgery and needs to walk in the hall with a walker D) adult client newly diagnosed with diabetes who is learning to administer insulin E) adult client who had abdominal surgery yesterday and requires a dressing change

A and C

A nursing student sees a nurse self-injecting medication in the nurses' locker room. The nurse tells the nursing student that students are not allowed to be the nursing staff locker room. What are the best actions for the nursing student? Select all that apply. A) Talk with the nursing instructor about what happened on that same day. B) Send an email to the nurse manager after the clinical experience. C) Discuss the experience with other students during post-conference at the end of the day. D) Ask the nurse manager what to do about what happened on that same day. E) Try to forget the experience since students should not be on the locker room.

A and D

A nurse is collecting an initial assessment for a client in early labor. During the health history portion of the assessment, the client tells the nurse that they had an elective abortion, but they do not want their spouse to find out. How should the nurse proceed? Select all that apply. A) List the elective abortion under past surgeries in the client's chart. B) Carefully omit this information in the client's electronic health record. C) Tell the client to share this important information with her spouse or you will. D) Leave the room to call a colleague and ask how to proceed. E) Uphold the client's wishes and ensure the client's confidentiality.

A and E

A nurse manager identifies fall prevention as a unit priority. Which actions can the nurses implement to meet these goals? Select all that apply. A) Maintain a clear path to client bathrooms. B) Close doors to client rooms at night. C) Make hourly rounds to client rooms. D) Apply soft waist restraint to confused clients. E) Use bed alarms to remind clients to call for help getting up.

A, C, and E

The nurse needs to pick up a large object that is sitting on the floor in a client's room. Which action most increases the nurse's risk of a back injury? A) bringing the body close to the level of the object B) leaning forward toward the object C) using the arms and legs to lift the object D) moving close to the object

B

A client says to the nurse, "My intravenous line hurts." The nurse assesses the client's peripheral intravenous line and suspects phlebitis. What assessment data confirm the nurse's suspicion? Select all that apply. A) redness B) warmth C) edema above the insertion site D) respiratory distress E) pain around the infusion site

A, B, C, and E

When giving a change-of-shift report, which statement by the nurse should be included? Select all that apply. A) "Client A is a 38-year-old female client of Dr. Born with cholecystitis and cholelithiasis." B) "Client B's pain is best relieved in the left lateral Sims' position." C) "Client C is just contrary today, and nothing is going to please him." D) "Client D was able to walk around the unit twice today with no dizziness." E) "Client E had visitors most of the day." F) "Client F has had 100 mL drainage from the nasogastric tube."

A, B, D, and F

When preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing? A) in the middle of the wound B) at the base of the wound C) over the total wound D) at the top of the wound

B

The client is to receive antibiotic intravenous (IV) therapy in the home. The nurse should develop a teaching plan to ensure that the client and family can manage the IV fluid and infusion correctly and avoid complications. What should the nurse instruct the client to do? Select all that apply. A) Cleanse the port with alcohol wipes. B) Wear sterile gloves to change the fluids. C) Report signs of redness or inflammation at the site. D) Place the IV bag on a table level with the client's arm. E) Call the health care provider (HCP) for a temperature above 100° F (37.8° C).

A, C, and E

A client is ordered to receive a sodium phosphate enema for relief of constipation. Proper administration of the enema includes which steps? Select all that apply. A) Assisting the client into Sims' position. B) allowing gravity to instill the solution C) Washing hands and putting on gloves. D) Chilling the solution by placing it in the refrigerator for 10 minutes. E) inserting the tip of the container 1/2 inch (1.25 cm) into the rectum F) encouraging the client to retain the solution for 5 to 15 minutes

A, C, and F

A nurse is discussing end of life care with a client's family in a skilled nursing facility. The client's advanced directive states the client wants no life support treatments. What are important nursing considerations to determine the efficacy of the advanced directive? Select all that apply. A) The client signed the form. B) The family wants to transfer the client to the hospital for ventilation. C) The healthcare provider is following the advanced directive. D) The advanced directive has a durable power of attorney. E) The advanced directive has two signatures.

A, D, and E

The nurse evaluates the effectiveness of the client's postoperative plan of care. Which outcome is expected for a client with an ileal conduit? The client: A) verbalizes the understanding that physical activity must be curtailed. B) will empty the drainage pouch frequently throughout the day. C) demonstrates how to catheterize the stoma. D)will place an aspirin in the drainage pouch to help control odor.

B

A charge nurse is preparing client care assignments for the next shift. A client who underwent femoral-popliteal bypass surgery is scheduled to return from the postanesthesia care unit. Which staff member would best receive this client? A) registered nurse who just completed orientation B) registered nurse (RN) with 2 years of experience C) charge nurse with 10 years of experience D) registered practical nurse/licensed practical or vocational nurse with 5 years of experience

B

A client is being discharged after abdominal surgery and colostomy formation to treat colon cancer. Which nursing action is most likely to promote continuity of care? A) asking an occupational therapist to evaluate the client at home B) asking the physician to write an order for home skilled nursing assessments and interventions C) notifying the American Cancer Society (Canadian Cancer Society) of the client's diagnosis D) advocating for the client by ordering Meals on Wheels 5 days a week

B

A client with a leg incision has a prescription for graduated compression stockings. The client rates the incision pain at 8/10. What is the best action by the nurse prior to applying the graduated compression stockings? A) Apply an ice pack to the incision for 15 minutes prior to application. B) Premedicate the client with prescribed morphine 1 mg I.V. 15 minutes prior to application. C) Premedicate the client with prescribed acetaminophen 500 mg PO 15 minutes prior to application. D) Cover the incision with a gauze bandage to provide cushion to the incision.

B

A diabetic client with peripheral vascular disease is ordered to wear knee-high elastic compression stockings continuously until discharge. Which would be the priority after the stockings are applied? A) Elevate the client's legs while out of bed. B) Remove elastic stockings once per day and observe lower extremities. C) Order a second pair of stockings to be rotated each day. D) Teach the client isotonic leg exercises.

B

A nurse is providing home care to a client with a foot ulcer related to diabetes. The client needs daily insulin injections. Family caregivers do not possess the technical skills to inject insulin. Which should the nurse keep in mind? A) Nurses should avoid asking the family caregivers to conduct the skilled task. B) The nurse needs to be creative in integrating the technical and relational aspects of care. C) Family caregivers are always perceived to be supportive of good care. D) The current reimbursement system recognizes the family's nontechnical value priorities.

B

A nurse should question an order for a heating pad for a client who has A) purulent wound drainage. B) active bleeding. C) a reddened abscess. D) tight back muscles.

B

A nurse-manager appropriately behaves as an autocrat in which situation? A) planning vacation time for staff B) directing staff activities if a client experiences a cardiac arrest C) identifying the strengths and weaknesses of a client-education video D) evaluating a new medication-administration process

B

Which consideration is the most important when performing tracheotomy suctioning? A) Suctioning should be done routinely and frequently to prevent accumulation of secretions. B) The client should be hyperoxygenated, then suctioned for 10 to 15 seconds. C) Fluid intake should be limited to reduce the amount of secretions produced. D) Oxygen should be provided after each suctioning episode if desaturation occurs.

B

Which example may illustrate a breach of confidentiality and security of client information? A) The nurse accesses client information on the computer at the nurse's station then logs off before answering a client's call bell. B) The nurse provides information over the phone to the client's family member who lives in a neighboring state. C) The nurse informs a colleague that the colleague should not be discussing client information in the hospital cafeteria. D) The nurse provides information to a professional caregiver involved in the care of the client.

B

A parent presents with a toddler to the clinic because the toddler is pulling at their left ear. When undressed, the nurse notices burn areas in varying stages of healing over the toddlers' body. Which nurse assessment findings should be reported to the healthcare provider? Select all that apply. A) burns only on one side of the body B) burns that have identifiable shapes C) burns that display an erratic pattern D) burns in places that can be easily seen E) the number of scars

B and E

The nurse overhears two nursing assistants saying that they think it is ridiculous that a female client of the Islamic culture insists that only female nurses care for her. What should the nurse do? Select all that apply. A) Report the conversation to the nursing supervisor so that they are immediately punished. B) Remind the nursing assistants that it is inappropriate to talk about clients in any way that does not involve them providing care. C) Explain to the nursing assistants that it is wrong in the client's culture for a male to touch a female that is not their wife. D) Speak to the nursing assistants about the importance of culturally competent care on the unit. E) Discuss the situation with another nurse from another unit over lunch to decide the best course of action.

B, C, and D

The nurse finds a small fire in the linen closet. Which action(s) should the nurse take to minimize the consequences of the fire? Select all that apply. A) Leave closet door open to facilitate access to the fire. B) Rescue clients who are at risk. C) Use a fire extinguisher. D) Step on burning embers to extinguish them. E) Activate the alarm. F) Contain the fire.

B, C, E, and F

A nurse is teaching a client about home safety after experiencing a third-degree body burn of the face, head, and neck. The client was smoking while cooking dinner with a gas stove. What are important teaching points for the nurse to cover during the teaching session? Select all that apply. A) Wear loose clothing when cooking over an open flame. B) Place a fire extinguisher in the home. C) Avoid smoking at all times. D) Resume activities slowly when discharged. E) Limit smoking times when doing other activities.

B, D, and E

A client is 2 hours postoperative after an appendectomy. The nurse recognizes a priority is to teach the client potential pulmonary postoperative complications. What action by the client demonstrates understanding of the teaching? A) passive range of motion exercises with the physiotherapist B) incisional splinting to assist with pain management C) diaphragmatic breathing and use of incentive spirometry 4-8 times an hour while awake D) continued bed rest for 24-48 hours postoperatively to protect the incision site

C

A client is being discharged with nasal packing in place. What should the nurse instruct the client to do? A) Gargle every 4 hours with salt water. B) Use normal saline nose drops daily. C) Perform frequent mouth care. D) Sneeze and cough with the mouth closed.

C

A client is scheduled for an appendectomy. What is the nurse's highest priority when planning preoperative teaching for this client? A) Surgical wound infection is most likely to occur during the first postoperative day. B) The client's skin should be assessed hourly. C) The client should begin coughing and deep-breathing exercises as soon as the client is able to follow instructions. D) The client should be encouraged to take food and fluids to prevent dehydration and malnutrition.

C

A client with ascites and peripheral edema is at risk for impaired skin integrity. To prevent skin breakdown, the nurse should perform which action? A) Institute range-of-motion (ROM) exercises every 4 hours. B) Elevate the lower extremities. C) Use an alternating air pressure mattress. D) Massage the abdomen once a shift.

C

A day-shift nurse gives a client an injection of pain medication. The nurse forgets to document the injection on the medication administration record (MAR). The day-shift nurse tells the evening-shift nurse that she gave the client 4 mg of morphine at 2 p.m. for postoperative pain but didn't document the injection. The evening-shift nurse puts the day-shift nurse's initials and the date and time the dose was administered in the appropriate area of the MAR. The evening-shift nurse's action is considered to be which type of documentation error? A) improper correction B) omission C) unauthorized entry D) late entry

C

A nurse enters a client's room and finds a pillowcase on fire where it was placed over a table lamp. Which action should the nurse perform first? A) Use the fire extinguisher. B) Call for help. C) Remove the client from the room. D) Put a heavy blanket over the lamp.

C

A nurse is preparing a client for bronchoscopy. Which instruction is appropriate for the nurse to give to the client? A) "Don't cough after the procedure." B) "You will not be able to talk for 4 hours following the procedure." C) "Don't eat for 6 hours prior to the procedure." D) "You will need to stay flat after the procedure."

C

A physician orders an intestinal tube to decompress a client's GI tract. When gathering equipment for this procedure, a nurse should obtain a: A) Sengstaken-Blakemore tube. B) Salem sump tube. C) Miller-Abbott tube. D) Levin tube.

C

A staff nurse would like to effect change to increase staffing levels on the nursing unit. What strategy should the nurse use to begin to create change on the unit? A) Assess the institutional resources available to increase staffing. B) Assess the effect increased staffing will have on nursing recruitment. C) Assess the impact of staffing on client-care quality. D) Assess the current standards of practice related to staffing.

C

An alert and oriented older adult client with metastatic lung cancer is admitted to the medical-surgical unit for treatment of heart failure. The client was given 80 mg of furosemide in the emergency department. The nurse is instructing the unlicensed assistive personnel (UAP) to implement a nursing plan to manage potential incontinence. Which instruction will be most effective for this client? A) prescribing incontinence briefs for the client so they will not have to worry about incontinence B) requesting an indwelling urinary catheter to avoid incontinence C) placing a commode at the bedside and instructing the client in its use D) padding the bed with extra absorbent linens

C

Before assisting a client to ambulate after surgery, the nurse helps the client dangle their feet over the side of the bed. Which action will best prepare the client to dangle their feet over the side of the bed? A) Position the client on their side for 5 minutes. B) Administer a prescribed analgesic medication 10 minutes before getting out of bed. C) Place the client in a high Fowler position. D) Have the client flex and extend the feet while in a recumbent position.

C

The nurse and physical therapist have planned for an unconscious client to receive passive range-of-motion (ROM) exercises. What indicates these exercises are having their intended outcome? A) preservation of muscle mass B) increase in muscle tone C) maintenance of joint mobility D) prevention of bone demineralization

C

The nurse is caring for a client who has been admitted from a situation involving domestic abuse. Which action is a correct component in the nursing plan of care? A) counseling the victim B) protecting the client's safety by completing an incident or occurrence report C) documenting the situation and providing support for the victim D) counseling the person committing the abuse

C

The nurse is recording a client's intake and output at the end of an 8-hour shift. The client had 300 ml in nasogastric suction container and 200 ml of urine in the foley bag. There was 300 ml of D5W infused from a 1000-ml bag during the shift, and the client was documented to have consumed 500 ml of liquids. What conclusion should the nurse reach regarding the client's intake and output? A) The client's intake and output are equal. B) The client's output is 300 ml greater than intake. C) The client's intake was 300 ml greater than output. D) The client's intake is 900 ml greater than output.

C

Which is the correct technique when the nurse is applying an elastic bandage to a leg? A) Increase tension with each successive turn of the bandage. B) Secure the bandage with clips over the area of the inner thigh. C) Start at the distal end of the extremity and move toward the trunk. D) Overlap each layer twice when wrapping.

C

A client recovering from a stroke has slid down in bed and needs to be repositioned. Which action should the nurse take to ensure safety for both the client and the nurse? A) Stand at the head of the bed and slide the client toward the pillow. B) Roll the client side to side. C) Raise the head of the bed before repositioning. D) Ask for assistance from the lift team.

D

A nurse is obtaining a sterile urine specimen from a client's indwelling urinary catheter. During the procedure, the nurse should A) wear sterile gloves when collecting urine. B) open the drainage bag and pour out some urine. C) disconnect the catheter from the tubing and collect urine. D) aspirate urine from the tubing port, using a sterile syringe and needle.

D

A nurse is reviewing a client's laboratory test results. Which electrolyte is the major cation controlling a client's extracellular fluid (ECF) osmolality? A) calcium B) chloride C) potassium D) sodium

D

A nurse must apply a wet-to-damp dressing over an ulcer on a client's left ankle. How should the nurse proceed? A) Apply the saturated fine-mesh gauze dressings over the wound. B) Apply an occlusive dressing over the saturated fine-mesh gauze dressings. C) Cover the saturated fine-mesh gauze dressings with an elastic bandage. D) Pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound.

D

A nurse needs to obtain an accurate blood pressure on a client. Which action is most important for the nurse to take to ensure an accurate reading? A) Have the client lie in a supine position while the blood pressure is taken. B) Raise the client's arm above the level of the heart before taking the blood pressure. C) Encourage the client to make a fist several times before taking the blood pressure. D) Palpate the brachial artery and then place the arrow on the cuff over the palpated artery.

D

A charge nurse tells a new nurse, "You really need to get your skills up to speed." The statement hurts and embarrasses the new nurse. How can the new nurse best handle the situation? A) Tell the charge nurse that the statement is hurtful. B) The new nurse should discuss feelings with a coworker in order to vent. C) Tell the charge nurse to be more specific about what is meant. D) Ask for a private meeting to explore the charge nurse's concerns in detail.

D

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? A) turning the client every 2 hours B) maintaining a cool room temperature C) elevating the head of the bed 30 degrees D) encouraging increased fluid intake

D

A nurse revises the care plan for a client who has difficulty dealing with a crying neonate. Which strategy should the new care plan implement early in this mother's hospital stay? A) referring the client for anger-management therapy upon discharge B) when the infant is crying always offer the bottle or breast first C) proper methods for dealing with stressful situations such as crying infants D) assessment of the mother's coping strengths and weaknesses and the presence or absence of support systems

D

A physician orders supplemental oxygen for a client with a respiratory problem. Which oxygen delivery device should the nurse use to provide the highest possible oxygen concentration? A) simple mask B) venturi mask C) nasal cannula D) nonrebreather mask

D

After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. What is an expected outcome of these exercises? A) There is increased blood flow to the lungs to allow them to recover from the trauma of surgery. B) The elevated diaphragm enlarges the thorax and increases the lung surface available for gas exchange. C) The rate of air flow to the remaining lobe is controlled so that it will not become hyperinflated. D) The alveoli expand and increase the lung surface available for ventilation.

D

The nurse is developing a care plan for a client who had abdominal surgery today. Which nursing action will be most important in preventing postoperative complications? A) progressive diet planning B) pain management C) bowel and elimination monitoring D) early ambulation

D

The nurse is educating a client who works with chemicals on immediate emergency care in the event of eye exposure. Which statement reflects correct teaching by the nurse? A) "You need to treat both eyes by flushing with water even if only one has been chemically exposed." B) "You can flush your eyes briefly with sterile water to try to remove the chemical." C) "You should not attempt to do anything at home - come directly to the emergency department." D) "You should flush your eyes for about 15 minutes with tap water to remove the chemical."

D

The nurse is measuring a client for thigh high antiembolism stockings. The client's thigh measurements are outside the guidelines for available sizes. What is the next action by the nurse? A) Use the client's calf measurements to determine the size. B) Place knee high antiembolism stockings. C) Place the largest thigh high stockings available. D) Notify the provider.

D

The nurse observes that the right eye of an unconscious client does not close completely. Which nursing intervention is most appropriate? A) Clean the eyelid with a washcloth every shift. B) Have the client wear eyeglasses at all times. C) Instill artificial tears once every shift. D) Lightly tape the eyelid shut.

D

The nurse was unsuccessful starting a peripheral intravenous line in the right forearm of a client with a history of a left axillary lymph node removal. What should the nurse do next? A) Try to start the peripheral intravenous line in the left forearm. B) Set up for placement of a triple-lumen central venous catheter. C) Notify the health care provider. D) Ask another nurse to attempt to start a peripheral intravenous line.

D

When bandaging a client's ankle, the nurse should use which technique? A) recurrent B) circular C) spiral reverse D) figure-eight

D

When preparing a client for a diagnostic study of the colon, the nurse teaches the client how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching? A) "I will administer the enema while lying on my right side with my left knee flexed." B) "I will administer the enema while sitting on the toilet." C) "I will administer the enema while lying on my back with both knees flexed." D) "I will administer the enema while lying on my left side with my right knee flexed."

D

Which assessment is most supportive of the nursing diagnosis, impaired skin integrity related to purulent inflammation of dermal layers as evidenced by purulent drainage and erythema? A) wound healing by primary intention B) dry and intact wound dressing C) a heart rate of 88 beats/minute D) oral temperature of 101° F (38.3° C)

D

Which guidelines define and regulate what the nurse may and may not do as a professional? A) state legislature B) facility policies and procedures C) standards of care D) nurse practice act

D

Which theory of ethics most highly prioritizes the nurse's relationship with clients and the nurse's character in the practice of ethical nursing? A) utilitarianism B) principle-based ethics C) deontology D) care-based ethics

D

While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply? A) sterile petroleum gauze B) dry sterile dressing C) povidone-iodine-soaked gauze D) moist sterile saline gauze

D

The nurse is completing discharge teaching with a client who had a long hospital stay. The client gives the nurse a handmade sweater for the personal nursing care. What is the best response by the nurse? Select all that apply. A) "Thank you for recognizing my work, I will enjoy wearing this sweater." B) "Maybe I can meet you for coffee next week." C) "I cannot take this gift while I am at work." D) "I appreciate the gift but it not appropriate for me to take a personal gift." E) "My hospital has a policy that does not allow a nurse to accept gifts."

D and E