Care Management 1: Final Practice

A nurse is orienting a newly licensed nurse about the documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates an understanding of the purpose of documentation? a. "Documentation is a communication tool for the interprofessional health care team" b. "Documentation provides information to the client about financial charges for care provided" c. "Documentation provides information for a client audit" d. "Documentation allows providers to monitor the nurse's activities."

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

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority? a. Administer antibiotics when available. b. Reduce environmental stimuli. c. Document intake and output.

a. Administer antibiotics when available.

A nurse is caring for a client who is postoperative following an appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the client? (Select all that apply.) a. Broth b. Grape juice c. Nonfat milk d. Custard e. Lemon gelatin

a. Broth b. Grape juice e. Lemon gelatin

A nurse is having difficulty caring for a client due to variables affecting the communication process. Which of the following should the nurse identify as an interpersonal variable? (Select all that apply.) a. Education. b. Feedback. c. Gender. d. Perception. e. Time.

a. Education. c. Gender. d. Perception.

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.) A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.) a. Excessive laxative use b. Ignoring the urge to defecate c. Inadequate fluid intake d. Increased fiber in the diet e. Increased activity

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

A nurse is caring for a client who is desiring their wound care to be provided at 1400. The nurse returns at 1400 to perform wound care for the client. Which of the following ethical principles is the nurse demonstrating? a. Fidelity. b. Justice. c. Veracity. d. Autonomy.

a. Fidelity.

A charge nurse is providing an in-service to a group of nurses on the different levels of illness prevention. The nurse should include which of the following as an example of secondary prevention? a. A client is scheduled to receive an influenza vaccination. b. A client who has a family history of breast cancer is scheduled for a mammogram. c. A client who is asymptomatic is not scheduled for a series of tests. d. A client who has heart failure is scheduled for an echocardiogram.

b. A client who has a family history of breast cancer is scheduled for a mammogram.

A nurse is assessing a client who is receiving total parenteral nutrition (TP) therapy via an infusion pump. Which of the following actions should the nurse take? a. Obtain the clients blood glucose every 12 hr. b. Change the IV tubing every 24 hr. c. Change the IV site dressing every 4 days. d. Weigh the client every other day.

b. Change the IV tubing every 24 hr.

A nurse is receiving a change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process? a. Critically analyze client data to determine priorities. b. Collect and organize patient data. c. Set client-centered, measurable and realistic goals. d. Determine effectiveness of interventions.

b. Collect and organize patient data.

A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of personal protective equipment (PPE) should the nurse remove first? a. Mask. b. Gloves. c. Gown. d. Goggles.

b. Gloves.

The nurse has notitied the provider of the client's 0700 assessment data pain, nausea, and lab results. Which of the following prescriptions should the nurse anticipate? a. Obtain informed consent for surgery b. Initiate IV antibiotics c. Obtain abdominal ultrasound d. Administer enemas until clear e. Give promethazine 50 mg intermittent IV bolus f. Maintain NPO status g. Administer acetaminophen 800 mg

b. Initiate IV antibiotics c. Obtain abdominal ultrasound e. Give promethazine 50 mg intermittent IV bolus f. Maintain NPO status g. Administer acetaminophen 800 mg

A nurse is admitting a new client. Which of the followings steps of the nursing process is the nurse performing when formulating goals for a positive outcome? a. Evaluation b. Planning c. Assessment. d. Implementation.

b. Planning

A nurse is caring for a client whose partner has recently died. The client states, "I am learning how to pay my own bills." The nurse should identify that the client is experiencing which of the following tasks in Worden's Four Tasks of Grieving? a. Experiencing the pain of grief. b. Accepting the reality of the loss. c. Adjusting to an environment without the deceased. d. Finding an enduring connection while embarking on a new life.

c. Adjusting to an environment without the deceased.

A nurse is bathing a toddler and notices that she has several bruises. Which of the following actions should the nurse take first? a. Ask the toddler what caused the bruises. b. Notify the provider. c. Ask the parents what caused the bruises. d. Notify social services.

c. Ask the parents what caused the bruises.

A nurse is giving change-of-shift report using BAR to the oncoming nurse on a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR? a. Glasgow results. b. Intracranial pressure readings. c. Code status. d. Plan of care changes for upcoming shift.

c. Code status.

A nurse is measuring a client for knee-high anti-embolic stockings to help prevent venous stasis. Which of the following actions should the nurse take? a. Measure from the heel to the gluteal fold. b. Measure the length of the feet. c. Measure from the hell to the popliteal space. d. Measure the ankle circumference.

c. Measure from the hell to the popliteal space.

A nurse is caring for a client who acquired hepatitis A from consuming contaminated food. The client's mouth is an example of which of the following links in the chain of infection? a. Reservoir. b. Infectious agent. c. Portal of entry. d. Susceptible host.

c. Portal of entry.

A nurse is developing a plan of care for a client who practices Islam. Which of the following actions should the nurse include in the plan? a. Serve foods that have a hot/cold balance. b. Serve milk products separately from meals. c. Request a meal tray without pork. d. Remove tea and coffee from meal trays.

c. Request a meal tray without pork.

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations? a. Pernicious anemia. b. Dehydration. c. Prostate enlargement. d. Bladder infection.

d. Bladder infection.

A nurse is caring for a client who is scheduled for surgery and has a history of alcohol abuse. The nurse should identify that alcohol abuse increases the client's risk for which of the following postoperative complications? a. Malignant hyperthermia. b. Blood clots. c. Nausea. d. Bleeding.

d. Bleeding.

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse? a. Speak using his usual tone of voice. b. Stand directly in front of the client. c. Rephrase statements the client does not hear. d. Determine if the client uses hearing aids.

d. Determine if the client uses hearing aids.

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation of the phase of injury? a. Initiate fluid resuscitation. b. Medicate for pain. c. Insert an indwelling urinary catheter. d. Maintain the airway.

d. Maintain the airway.

A nurse is caring for a client is who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500 mL D5W. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)

24 mL/hr.

A nurse is caring for a client who states, "My doctor was just here, but I still do not understand my diagnosis." The nurse contacts the provider to return to speak with the client. Which of the following principles is the nurse demonstrating? a. Confidentiality. b. Accountability. c. Advocacy. d. Fidelity.

c. Advocacy.

A nurse is caring for a client who is receiving an IV infusion of dextrose 10% in water. The nurse should monitor the client for which of the following adverse effects? a. Hypovolemia. b. Hypokalemia. c. Hypercalcemia. d. Hyperglycemia.

d. Hyperglycemia.

A nurse is caring for a client who is postoperative following an appendectomy and is prescribed D5 lactated Ringer's at 150 mL/hr by continuous IV infusion for 12 hr. The drop factor of the manual IV tubing is 20 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

50 gtt/min.

A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) Inspection Superficial palpatation Ascultation Deep palpatation

Inspection Ascultation Superficial palpatation Deep palpatation

A nurse is performing triage for a group of clients following a mass casualty incident (MCI). Which of the following clients should the nurse plan to care for first? a. A client is experiencing a tension pneumothorax. b. A client who has a closed upper extremity fracture. c. A client who has a full-thickness burn over 80% of his body. d. A client who has agonal respirations.

a. A client is experiencing a tension pneumothorax.

A nurse is assessing a client who has a cast in place for a fractured tibia. Which of the following actions should the nurse take first? a. Checking capillary refill. b. Discussing cast care. c. Managing pain. d. Performing range of motion.

a. Checking capillary refill.

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? a. Cleanse the wound with 0.9% sodium chloride saline irrigation before obtaining the specimen. b. Irrigate the wound with an antiseptic prior to obtaining the specimen. c. Include intact skin at the wound edges in the culture. d. Swab an area of skin away from the wound to identify the usual flora.

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

Which of the following factors could present a barrier to the nurse effectively communicating with the client? Select all that apply. a. Client's hearing deficit b. Volume of the client's television c. Numerous visitors in the client's room d. Increase in pain after ambulation e. Adverse effects of opioid analgesic f. Using earphones while listening to music

a. Client's hearing deficit b. Volume of the client's television c. Numerous visitors in the client's room f. Using earphones while listening to music

A nurse is preparing to perform a cranial nerve examination on a client. Which of the following actions should the nurse take to check cranial nerve I? a. Have the client identify specific smells. b. Observe facial symmetry while the client smiles. c. Check the client's visual acuity. d. Whisper in one of the client's east while occluding the other.

a. Have the client identify specific smells.

A nurse is teaching a newly licensed nurse about incident reports. Which of the following information should the nurse include? a. Identify other people involved with the event in the incident report. b. Identify the person responsible for the error in the incident report. c. Include note in the medical record that an incident report was completed. d. Include personal opinions regarding an event in an incident report.

a. Identify other people involved with the event in the incident report.

A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client? a. Identify the client's nutritional status. b. Request a mental health consult. c. Plan a therapeutic diet for the client. d. Provide a structured environment for the client.

a. Identify the client's nutritional status.

A nurse is implementing the ventilator care bundle for a client who is receiving mechanical ventilation. Which of the following should the nurse expect to find in the bundle? a. Instructions on mouth care. b. Instructions to place the client in a supine position. c. Instructions on how to change ventilator settings. d. Instructions to suction the clients' tracheostomy every 2hrs.

a. Instructions on mouth care.

For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client. a. Assist the client in completing their food selections for the next day. b. Apply wrist restraints. c. Administer olanzapine d. 10 mg |M stat. e. Assign assistive personnel (AP) to remain with the client. f. Ensure the client's room is brightly lit.

a. Non- essential. b. Anticipated. c. Anticipated. d. Anticipated. e. Contradicted.

A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (Select all that apply.) a. Offer the client a back rub. b. Remind the client to use incisional splinting. c. Identify the client's pain level. d. Assist the client to ambulate. e. Change the client's position.

a. Offer the client a back rub. b. Remind the client to use incisional splinting. c. Identify the client's pain level. e. Change the client's position.

A nurse is providing teaching to a client who has a terminal illness and is considering palliative care services. Which of the following statements by the client indicates an understanding of the teaching? a. "I will need to go to a skilled facility to receive these services." b. "This service assists with making me comfortable during my illness." c. "I will receive help with managing my meals with this service." d. "This service provides my caregiver the opportunity to take time for themselves."

b. "This service assists with making me comfortable during my illness."

A nurse is teaching a client who is preoperative for an ileostomy. Which of the following statements should the nurse include? a. "You should expect your stoma to be a purple color." b. "You will have a stoma placed in your right lower abdomen." c. "The end of the stoma will be painful after this procedure." d. "You will have solid stool pass through your stoma."

b. "You will have a stoma placed in your right lower abdomen."

A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, Pa02 60 mm Hg, HCO3 20 mEq/L, and Sa02 86%. Which of the following is the priority nursing intervention? a. Prepare for mechanical ventilation. b. Administer oxygen via face mask. c. Prepare to administer a sedative d. Assess for indications of pulmonary embolism.

b. Administer oxygen via face mask.

A charge nurse is providing an in-service for staff nurses on the use of new IV pumps. Which of the following actions should the charge nurse take to best evaluate staff competency with the new equipment? a. Ask each nurse to read the procedure and sign a form acknowledging competency. b. Allow time during the workday when each nurse can demonstrate proficiency. c. Require each nurse to take a written examination about new equipment. d. Verbally question the staff about the new equipment.

b. Allow time during the workday when each nurse can demonstrate proficiency.

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority? a. Increase the oxygen flow to 3L/min. b. Assess the client's respiratory status. c. Call emergency services for the client. d. Have the client cough and expectorate secretions.

b. Assess the client's respiratory status.

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? a. Steatorrhea. b. Blood c. Bacteria d. Parasites

b. Blood

A nurse is teaching a class about vulnerable populations that are at risk for health disparities. The nurse should include that which of the following populations are at risk for health disparities? a. Clients who have employer-provided health insurance. b. Clients experiencing poverty. c. Clients who are fluent inn the primary language of the health care team. d. Clients who have a college education.

b. Clients experiencing poverty.

The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? (Select All That Apply) a. Hyperlipidemia. b. Diabetes Mellitus. c. Medication history. d. Cholesterol level. e. Prealbumin level.

b. Diabetes Mellitus. c. Medication history. e. Prealbumin level.

Click to highlight the information from the nurse's notes that indicate the client is actively dying. a. Temperature 35.3° C (95.5° F) b. Heart rate 42/min c. Blood pressure 62/ mm Hg palpated d. Called by family requesting visit to client. e. Client does not arouse to verbal. tactile, or painful stimulation. f. Cheyne-stokes breathing, noisy respirations. g. Bowel sounds × 4 quadrants. h. Family reports no urine output in last 4 hr. i. Skin intact.

b. Heart rate 42/min c. Blood pressure 62/ mm Hg palpated e. Client does not arouse to verbal. tactile, or painful stimulation. f. Cheyne-stokes breathing, noisy respirations. h. Family reports no urine output in last 4 hr.

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take? a. Keep the container of solution at a level to maintain comfort. b. Hold the container of solution 30cm (12 in) above the anus. c. Hold the container of solution level with the client's upper hip. d. Hold the container of solution 15cm (6in) above the anus, then lower it 15cm below the anus.

b. Hold the container of solution 30cm (12 in) above the anus.

A nurse identifies a pressure ulcer after a client had a long, extensive recovery following a surgical procedure. When completing an incident report about the pressure ulcer, the nurse should take which of the following actions? a. Document what the nurse believes was the cause of ulcer development. b. Include any relevant statements the client made about the ulcer. c. Document in the client's medical record that she completed an incident report. d. Question the charge nurse about care deficits that might have contributed the ulcer development.

b. Include any relevant statements the client made about the ulcer.

A nurse is answering questions at a school meeting about government entities that regulate health care. The nurse should include that which of the following organizations advocates for the delivery of culturally competent health care? a. Center of Medicare and Medicaid services (CMS). b. Indian Health Service (IHS). c. Administration of Children and Families (ACF). d. Administration of Aging (AoA).

b. Indian Health Service (IHS).

A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect? a. Abdominal pain. b. Lethargy. c. Dry skin. d. Numbness of fingers.

b. Lethargy.

A nurse has completed an informed consent form with a client. The client then states, "I have changed my mind and do not want to have the procedure done." Which of the following actions should the nurse take? a. Remind the client that a signed informed consent form is a legally binding document. b. Notify the surgeon that the client wishes to withdraw informed consent for the procedure. c. Inform the surgical term to cancel the client's surgery. d. Proceed with the preparation of the patient for the surgical procedure.

b. Notify the surgeon that the client wishes to withdraw informed consent for the procedure.

A charge nurse is providing teaching to a newly licensed nurse on the advantages of electronic documentation. Which of the following information should the nurse include in the teaching? a. Decrease in the coordination of client care. b. Portal that allows clients to interact with providers. c. Same-day access to a client health record. d. Increase of duplicate tests performed on client.

b. Portal that allows clients to interact with providers.

A nurse is preparing a sterile field. Which of the following actions should the nurse perform when opening the sterile pack? a. Place the pack on a sterile surface. b. Reach around the pack and open the top flap away from the body. c. Open the right flap with the left hand. d. Move the opposite side of the pack to open the fourth flap.

b. Reach around the pack and open the top flap away from the body.

A nurse is gathering evidence-based practice on catheter-associated urinary tract infections (CAUTI). Which of the following roles is the nurse performing? a. Educator. b. Researcher. c. Case manager. d. Nurse manager.

b. Researcher.

A nurse is teaching a group of clients about the HIPAA Enforcement Rule. Which of the following information should the nurse include? a. The Enforcement Rule covers the process of reporting data breaches. b. The Enforcement Rule covers the administration of financial penalties. c. The Enforcement Rule addresses the use od disclosure of ePHI. d. The Enforcement Rule defines protected health information.

b. The Enforcement Rule covers the administration of financial penalties.

A nurse is teaching a client about nail care. Which of the following information should the nurse include? a. Wear rubber-lined gloves to wash dishes. b. Use acetone-free nail polish remover. c. Soak nails in hot water. d. Trim nails in a curved shape.

b. Use acetone-free nail polish remover.

A charge nurse is conducting an in-service for a group of nurses on the seven pillars of self-care created by the International Self-Care Foundation. Which of the following pieces of information should the nurse include? a. Avoid immunizations. b. Wash foods prior to eating. c. Consume a high-calorie diet. d. Perform low-level exercise once a week.

b. Wash foods prior to eating.

A charge nurse is observing a nurse performing a Mantoux tuberculin skin test for a client. Which of the following actions should prompt the charge nurse to intervene? a. Creating a 6 mm (1/4 in) bleb in the intradermal space of the forearm. b. Withdrawing the needle and massaging the site gently. c. Stretching the skin tightly before injection. d. Visualizing the tip of the needle under the skin.

b. Withdrawing the needle and massaging the site gently.

A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client? a. "Are there any specific factors that you think are affecting your ability to sleep?" b. "Can you describe your bedtime routine to me?" c. "Do you have difficulty staying awake when you are driving?" d. "When did you begin to have trouble sleeping?"

c. "Do you have difficulty staying awake when you are driving?"

A nurse is teaching a class about the stages of general adaptive syndrome (GAS). The nurse should include that which of the following is the first physiological response that occurs during GAS? a. Prolonged exposure to stress can result in illness. b. The body remains alert, while blood pressure, and heart rate return to prestress levels. c. A perceived stressor stimulates the central nervous system. d. An increase in hormones cause an increase in blood pressure and heart rate.

c. A perceived stressor stimulates the central nervous system.

A director of nursing is reviewing a new nursing program curriculum. Which of the following governing bodies should the nurse identify as providing program accreditation? a. Nurse Practice Act (NPA). b. Quality and Safety Education of Nurses (QSEN). c. Commission on Collegiate Nursing Education (CCNE). d. Board of Nursing (BON).

c. Commission on Collegiate Nursing Education (CCNE).

A nurse overhears two assistive personnel (APs) disagreeing about client care assignments. Which of the following actions by the nurse demonstrates conflict resolution? a. Report the APs to the charge nurse. b. Allow the APs to resolve their issues. c. Confront the APs to discuss their argument. d. Tell the APs they are acting immature.

c. Confront the APs to discuss their argument.

The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the client's behavior? a. He is hard of hearing. b. Pain. c. Confusion. d. Language barrier.

c. Confusion.

A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following? a. Delivers a constant rate of specific concentration of oxygen. b. Delivers a high concentration of oxygen. c. Delivers a low concentration of oxygen. d. Restricts the clients ability to eat, speak, or drink

c. Delivers a low concentration of oxygen.

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? a. Encourage the client to ambulate frequently. b. Encourage coughing and deep breathing. c. Encourage the client to increase fluid intake. d. Encourage regular use of the incentive spirometer.

c. Encourage the client to increase fluid intake.

A nurse is teaching a class about routes of medication administration. The nurse should include that which of the following routes has the fastest rate of absorption? a. Topical. b. Intramuscular. c. Intravenous. d. Enteral.

c. Intravenous.

A nurse is providing change-of-shift report to another nurse for a client using the Introduction, Situation, Background, Assessment and Recommendation (ISBARR) communication tool. Which of the following information should the nurse include as part of the situation component of this communication tool? a. Vital signs. b. Treatment. c. Medical condition. d. List of medications.

c. Medical condition.

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data? a. Blood pressure. b. Cyanosis c. Nausea. d. Petechiae.

c. Nausea.

A nurse is teaching a class about sleep disorders. The nurse should include that which of the following conditions can cause central sleep apnea (CSA)? a. Enlarged tonsils. b. Deviated septum. c. Opioid overdose. d. Obesity.

c. Opioid overdose.

A nurse is caring for a client who has metabolic alkalosis. Which of the following actions should the nurse take? a. Plan to administer sodium bicarbonate to the client. b. Have the client breathe into a paper bag. c. Place the client on continuous cardiac monitoring. d. Obtain a prescription for insulin for the client.

c. Place the client on continuous cardiac monitoring.

A nurse is contributing to the plan of care for clients who have rheumatoid arthritis. Which of the following plans incorporates integrative health? a. Monitor C-reactive protein and joint x-rays on clients. b. Request a referral for surgery and physical therapy for clients. c. Provide massage therapy and corticosteroid medications to clients. d. Offer nonsteroidal anti-inflammatory medications and occupational therapy to clients.

c. Provide massage therapy and corticosteroid medications to clients.

A nurse is teaching a class about the physiology of sleep. The nurse should include which of the following occurs as a result of sleep? a. Decreased ability to concentrate. b. Increase in basal metabolic rate. c. Transfer of memory from short-term to long-term memory. d. Weakened immune system.

c. Transfer of memory from short-term to long-term memory.

A nurse is assessing a client after administering IV vancomycin. Which of the following findings is the nurse's priority to report to the provider? a. Localized redness at the catheter insertion site. b. Client report of a headache. c. Client report of tinnitus. d. Audible inspiratory stridor.

d. Audible inspiratory stridor.

A nurse is planning care for a client who has a superficial wound with no exudate. The nurse should plan to use which of the following dressings to cover the wound? a. Alginate dressing. b. Foam dressing. c. Hydrofiber dressing. d. Film dressing.

d. Film dressing.

A charge nurse is determining client acuity levels. The nurse should consider the time spent completing which of the following tasks when determining acuity? a. Charting. b. Assisting others. c. Meal breaks. d. Medication administration.

d. Medication administration.

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse? a. Clamps the NG tube during auscultation. b. Performs auscultation between meals. c. Auscultates bowel sounds for 3 to 5 min. d. Palpates the abdomen prior to performing auscultation.

d. Palpates the abdomen prior to performing auscultation.

A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first? a. Deflate the catheter balloon using a sterile syringe. b. Measure and document the urine in the drainage bag. c. Remove the tape or device securing the catheter to the client's thigh. d. Position the client supine.

d. Position the client supine.

A nurse is caring for a client who has a radiation injury. Which of the following actions should the nurse take? a. Keep a distance of within 0.3 meters (1 foot) of the client. b. Place the client in a semi-private room. c. Have the client shower within 8hr. d. Remove the clients clothing.

d. Remove the clients clothing.

A nurse is calculating a client's body mass index (BMI). Which of the following information does the nurse require? a. The client's skinfold thickness. b. The clients waist circumference. c. The clients daily calorie intake. d. The clients height.

d. The client's height.

A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include? a. Perform catheterization when you recognize the urge to void. b. Hold the penis at a 30-degree to 45-degree angle when inserting the catheter. c. Inflate the ballon when the urine flow stops. d. Use soap and water to wash the catheter after each use.

d. Use soap and water to wash the catheter after each use.

A nurse is preparing to administer a soapsuds enema to an adult client. Which of the following actions should the nurse take? a. Put sterile gloves on. b. Assist the client to the left Sims' position. c. Hang the enema container 60cm (24in) above the anus. d. Insert the tubing about 15cm (6in) into the anus.

b. Assist the client to the left Sims' position.

A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the nurse delegate to the licensed practical nurse (LPN)? a. Admission assessment of a new client. b. Scheduling a diagnostic study for a client. c. Evaluating changes to a client's pressure ulcer. d. Teaching a client insulin injection technique.

b. Scheduling a diagnostic study for a client.

A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition (TP) solution is not infusing. The nurse should monitor the client for which of the following conditions? a. Excessive thirst and urination. b. Shakiness and diaphoresis. c. Fever and chills. d. Hypertension and crackles.

b. Shakiness and diaphoresis.

A nurse on an obstetrics-gynecology unit is planning care for four clients after receiving change of shift report. Which of the following clients should the nurse assess first? a. A client who is 1 day postpartum after a late-term miscarriage. b. A client who had a bilateral tubal ligation 12 hr previously. c. A client who is 4 days postpartum and has mastitis. d. A client was admitted 1 hr ago for an ectopic pregnancy.

d. A client was admitted 1 hr ago for an ectopic pregnancy.

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first? a. Clean and dress the wound. b. Administer pain medication. c. Administer a tetanus booster. d. Administer IV fluids.

d. Administer IV fluids.

A nurse in the emergency department is assessing a newly admitted client who has facial trauma. Which of the following assessments is the nurse's priority? a. Soft tissue edema. b. Facial asymmetry. c. Active bleeding. d. Altered respirations.

d. Altered respirations.

A nurse is teaching a class on ethical principles. The nurse should include that protecting a client's safety by not causing harm refers to which of the following ethical principles? a. Beneficence. b. Fidelity. c. Nonmaleficence. d. Justice.

c. Nonmaleficence.

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of following indications should the nurse include? (Select all that apply). a. Relief of urinary retention. b. Convenience of the nursing staff or clients' families. c. Measurement of the residual urine after urination. d. Routine acquisition of a urine specimen. e. An open perineal wound.

a. Relief of urinary retention. c. Measurement of the residual urine after urination. e. An open perineal wound.

A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.) a. Repeat the order back to the provider. b. Question any part of the order that is unclear or inappropriate. c. Transcribe the order into the client's health record. d. Obtain the provider's signature within 8 hr. e. Implement a recorded order message if the nurse can hear and understand it clearly.

a. Repeat the order back to the provider. b. Question any part of the order that is unclear or inappropriate. c. Transcribe the order into the client's health record.

Click to highlight the findings that indicate the interventions were effective. To deselect a finding, click on the finding again. a. T 38° C (100.4)°F, oral. b. BP 106/60 mm Hg, supine c. HR 99/min d. R 20/min e. Pulse oximetry 95% on room air

a. T 38° C (100.4)°F, oral. b. BP 106/60 mm Hg, supine c. HR 99/min

A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should base her actions on which of the following information? (Select all that apply.) a. The student should use his quick-relief inhaler. b. The student's asthma is not well controlled. c. The student's peak flow is 50% to 80% of his best peak flow. d. The student needs to go to the hospital. e. The nurse should obtain a second expiratory flow rate.

a. The student should use his quick-relief inhaler. b. The student's asthma is not well controlled. c. The student's peak flow is 50% to 80% of his best peak flow. e. The nurse should obtain a second expiratory flow rate.

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? a. Battery. b. Assult. c. Malpractice. d. Abuse

c. Malpractice.