Content Test 1

A nurse in an outpatient clinic is assessing a middle adult client as part of a routine physical examination. His BP is 142/88 mmHG, his BMI is 31, and he is a current smoker. The nurse should identify that this client has multiple risk factors for which of the following disorders? -Depression -Testicular cancer -Cardiovascular disease -Thyroid disease

Cardiovascular disease

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take first? -Secure the restraints using a quick-release tie -Ensure four finger fit under the restraints to prevent constriction -Secure restraints to the lowest bar of the side rail -Anticipate removing the restraints every four hours

Secure the restraints using quick-release tie

A nurse is teaching newly-hired group of assistant personnel about infection-control measures on the unit. It is crucial for the nurse to remind the APs that which of the following is the most effective way to prevent the spread of pathogens during client care?

Performing hand hygiene frequently and consistently

Steps for irrigating a wound on leg

Place waterproof pad underneath client's leg Don clean gloves and remove client's dressing Clean the wound using a circular motion Open a sterile dressing set and supplies Irrigate the wound until the solution becomes clear

A nurse is teaching a client's partner about how to obtain a proper blood pressure reading. Which of the following actions by the partner indicates a need for further teaching?

Places the client's arm above the level of the heart

A nurse in a provider's office is caring for a client who has a new diagnosis of tinea pedis. Which of the following findings should the nurse expect? -report of recent exposure to poison ivy -scaling and redness between the toes -circular, erythematous patches on the scalp -report of a recent prescription for an anti-seizure medicaiton

Scaling and redness between the toes

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection? -BUN -Potassium -RBC count -WBC count

WBC count

A nurse accidentally sticks her hand with a syringe needle after administering an IM injection to a client. Which of the following actions should the nurse take first?

Wash the area thoroughly with soap and water.

A nurse is orienting a new AP to the unit. For which of the following actions should a nurse intervene? -Wears a gown when entering the room of a client who requires contact precautions -Dons gloves to empty a urinary drainage device -Washes and rinses her hands for 10 seconds -Wears a respirator masks when entering the room of a client who requires airborne precautions

Washes and rinses hand for 10 seconds

A charge nurse is teaching a new nurse how to initiate IV access on a client. Which of the following actions of the new nurse indicate understanding of the teaching?

Washes hands with soap and water before the procedure

A nurse is caring for a client who has sustained blood loss. Which of the following is a manifestation of hypovolemia? -Decreased heart rate -Dyspnea -Increased blood pressure -Weak pulse

Weak pulse

A nurse is admitting a client who requires droplet precaution for influenza. Which of the following actions should the nurse take? -Place the client in a room with negative airflow -Wear a mask when providing care to the client -Ensure the client's room has HEPA filtration -Wear a gown when providing care to the client

Wear a mask when providing care to the client

A nurse is planning the care of a client who requires airborne precautions. Which of the following actions should the nurse take? -Provide a positive-pressure airflow room -Wear a N95 respirator mask -Allow the client to ambulate in the hall -Stand 6 ft away from the client

Wear an N95 respirator mask

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds?

Wheezes

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as an indication of infection? -Bradycardia -an increase in neutrophils -an increase in RBCs -an increase in platelets -localized edema

an increase in neutrophils localized edema

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days . The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions? -upper respiratory infection -pulmonary edema -atelectasis -delayed gastric emptying

atelectasis

A clinical nurse educator is preparing an educational program about transmission of MRSA in hospitalized clients. Which of the following information should the nurse include in the program? -Place clients who have MRSA on airborne precautions -MRSA can be effectively treated with an antiviral medication -MRSA can live on the hands for 1 hour -Bathe clients with water and chlorhexidine gluconate

bathe clients with water and chlorhexidine gluconate

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? -brachial -carotid -femoral -popliteal

carotid

A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full-thickness wound with jagged edges and muscle tissue visible. The nurse should document this as which of the following types of wounds? -abrasion -contusion -laceration -puncture

laceration

A nurse is caring for a client in the ED who, 2 hrs earlier, had severed the tip of their finger. During the assessment, the nurse detects a strong smell of alcohol from the client's breath. Which of the following findings should the nurse assess first? -history of past accidents -last tetanus immunization -blood alcohol level -signs of wound infection

last tetanus immunization

A nurse is obtaining a medical history from a client who is requesting the herpes zoster vaccine. The nurse should identify which of the following findings as a contraindication for receiving this vaccine? -postoperative hip arthroplasty -long-term use of prednisone for COPD -History of varicella as an adolescent -recent travel to the middle east

long-term use of prednisone

A nurse is providing discharge teaching to a client who has a new prescription for a metered dose inhaler. Which of the following instructions should the nurse include with the teaching? -Shake the inhaler for 3-5 seconds -rinse the mouth with mouthwash after inhaling the medication -wait 2 mins between the inhalations -press down twice on the MDI canister

shake the inhaler for 3-5 seconds

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 teaching AP about using PPE while caring for clients. Which of the following statements should the nurse identify as an indication that the AP understands the instructions?

"I will wear gloves and a gown while bathing a client who has open skin lesions"

A nurse is providing discharge teaching for a client who requires home oxygen therapy. Which of the following statements should the nurse identify as an indication that the client needs further teaching? -"i will be able to tell how much oxygen i'm getting by looking at the flow meter" -"i should call my doctor if i find it hard to concentrate" -"i will make sure my visitors smoke outside" -"i will wear synthetic clothing and woolen socks when using my oxygen"

"I will wear synthetic clothing and woolen socks when using my oxygen"

A nurse is caring for a client who is dying. The client says, "My mother died in a hospital, but I did not get there before she died." Which of the following statements should the nurse make? -"We will call your family in time for them to get here" -"I wonder if you are fearful of dying alone" -"I will make sure a staff member is in the room at all times' -"I will tell your family of your concern so they can be here."

"I wonder if you are fearful of dying alone"

A nurse enters an older adult client's room to insert a saline lock. The client asks the nurse, "Why do I need that? I am drinking plenty of fluids." Which of the following responses should the nurse provide?

"Your provider has prescribed antibiotic therapy to be administered intravenously every 6 hours."

A nurse is teaching a client who has a new diagnosis of atopic dermatitis. Which of the following statements should the nurse include in the teaching? _"You will need to take the entire prescription of antibiotics even if your condition improves" -"Your provider may recommend a daily antihistamine to help control your symptoms" -"You should cleanse your mouth daily with prescribed mouthwash" -"Your provider will remove the lesions with solid carbon dioxide"

"Your provider may recommend a daily antihistamine to help control your symptoms"

A nurse is reviewing HIPAA with a newly-licensed nurse. Which of the following statements reveals a need for further teaching? "information about a client can be disclosed to family members at any given time" -"HIPAA established regulations of individually identifiable health information in verbal, written or electronic form. -" a client's address would be considered and example of personally identifiable information" -"HIPAA is a federal law, not a state law"

"information about a client can be disclosed to family members at any given time"

A nurse is teaching the parents of a child who is to start using a metered-dose inhaler (MDI) to treat asthma. Which of the following information should the nurse include in the teaching? -"the spacer increases the amount of medication delivered to the oropharynx." -"the spacer increases the amount of medication delivered to the lungs." -"inhale rapidly using the spacer with the MDI" -"cover exhalation slots with lips while inhaling"

"the spacer increases the amount of medication delivered to the lungs"

A nurse is conducting a health promotion class for clients and their children about sun protection. The nurse should identify which of the following client responses as an indication that the teaching was effective? -"I will avoid sitting in the sun from 10 AM to 3 PM" -"I should use sunblock with the lowest sun protective factor number" -"I should use sunscreen instead of sunblock for my toddler" -"I can expose my 3-month old infant to the sun if I apply sunscreen"

-"I will avoid sitting in the sun from 10 AM to 3 PM"

A nurse is instructing a client who has a new diagnosis of Reynaud's disease about preventing the onset of manifestations. Which of the following statements should indicate to the nurse the need of additional teaching? -"I will wear gloves when removing items from the freezer" -" I will try to avoid stressful situations when possible" -"I will complete the smoking cessation program i started" -"I will take my medications at the first sign of an attack"

-"I will take my medications at the first sign of an attack"

A nurse is working with an LPN to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site? -"the infusion rate has stopped but the tubing is not kinked" -"the area surrounding the insertion site feels warm to the touch" -"there is fluid leaking around the insertion site" -"there is no blood return when the tubing is aspirated"

-"the area surrounding the insertion site feels warm to the touch"

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? -4+ -3+ -2+ -1+

-4+ (more than 7mm) -3+ (5-7 mm) -2+ (2-4 mm) -1+ (less than 2 mm)

A nurse is caring for an adult client who is scheduled for surgery. Which of the following sites should the nurse assess for possible placement of an IV catheter? -Great saphenous vein -Cephalic vein -Dorsal Plexus -Basilic vein -External jugular vein

-Cephalic -Basilic

A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take? -Assure the client there will be no discomfort during the procedure -Clean the surgical site -Lift the staple remover when squeezing the handle -Examine the incision -Verify the prescription for staple removal

-Clean the surgical site -Examine the incision -Verify the prescription for staple removal

Steps to remove PPE

-Gloves first -Face shield or goggles -Gown -Mask

A nurse is providing post-mortem care for a client. Identify the sequence of steps the nurse should follow:

-Make sure the provider has certified the client's death -Verify the client's tissue and organ donor status -Remove medical equipment from the client. -Cleanse the body while adhering to body-fluid precautions -Attach identification tags to the body

A nurse is receiving shift report about a group of assigned clients. Which of the following actions should the nurse plan to take first? -Ask the provider about an advancing a client's diet -Reinsert a catheter that was removed due to infiltration -Suction the tracheostomy of a client who has copious secretions -Check the laboratory findings of a preoperative client who is scheduled for surgery later on in the shift

-Suction the tracheostomy of a client who has copious secretions

A nurse in a clinic is caring for a female client who has a new diagnosis of acne vulgaris on her cheeks. Which of the following should the nurse include in the teaching plan for this client? -Use friction when washing the affected area -Use an oil-based soap to wash affected areas daily -Express the larger comedones periodically -Use a new cosmetic pad with each limited application of makeup

-Use a new cosmetic pad with each limited application of makeup

Which of the following clients should the nurse identify as having an increased risk of aspiration while eating? -a client who has lactose intolerance -a client who has had a cerebrovascular accident -a client who is 4 hr postoperative for leg amputation with general anesthesia - a client with prolonged diarrhea -a client who has had radiation therapy for head and neck cancer

-cerebrovascular accident -postoperative with general anesthesia -radiation therapy on head and neck

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 while changing the bed linens -keep the bath water temperature between 110 f and 115 f. -shave the client's hair in the direction of the growth

A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy via nasal cannula. Which of the following should the nurse include in the teaching? -verify the oxygen flow rate every other day -check the cannula position on a regular basis -check the tops of the ears for skin breakdown -post "no smoking" signs in a prominent location in the home -apply petroleum ointment to the nares to prevent dryness

-check the cannula position on a regular basis -check the tops of the ears for skin breakdown -post "no smoking" signs in a prominent location in the home

A nurse is providing postmortem care for an adult client. Which of the following items should the nurse take? -Place the client lying flat on the bed -determine whether the client will have an autopsy -cover the body with a clean sheet, and place the arms outside of the sheet -If the client has had significant trauma, discourage the friends and family from viewing the body -Give the client's personal belongings to the family

-determine whether the client will have an autopsy -cover the body with a clean sheet, and place the arms outside of the sheet -Give the client's personal belongings to the family

A nurse is caring for a group of clients on the med-surge unit. Which of the following situations should the nurse wear gloves? -emptying urine from the indwelling catheter drainage bag -providing oral care -changing an ostomy pouch -delivering a food tray to a client who has AIDS -placing oral medication tablets into a client's hand

-emptying urine from the indwelling catheter drainage bag -providing oral care -changing an ostomy pouch

A nurse is adhering to standard precautions while caring for a group of clients. For which of the following tasks should the nurse wear protective eye equipment? -providing hygiene care for a patient who is HIV-positive -emptying a urinary drainage bag for a client who has pneumonia -irrigating a client's abdominal wound -transporting a cerebrospinal fluid specimen -suctioning a client's new tracheostomy tube

-irrigating a client's abdominal wound -suctioning a client's tracheostomy tube

A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of the following actions is the nurse's priority? -instruct the client about. home disposal of contaminated dressings -schedule a follow-up visit by a home health nurse for dressing changes -provide a dietary list of foods that promote healing -establish a follow up apt with client's provider

-schedule a follow-up visit by a home health nurse for dressing changes

A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? -Lactated Ringer's - Dextrose 5% in 0.9% NaCl -0.45% NaCl -Dextrose 10% in water

0.45% NaCl (hypotonic)

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 concentrations?

28%

A nurse is caring for four clients. Which of the following clients should the nurse identify as having the highest risk of aspiration? -chest tube following a fall from a ladder -hemi-colectomy and placement of a colostomy -receiving continuous enteral feeding from NG tube -Crohn's disease and has an ileostomy

A client receiving continuous enteral feeding from NG tube

A nurse in the med-surge unit is assigning client care to a nurse is floating from the PACU. The nurse should recognize that the float nurse is most qualified to care for which of the following clients? -postoperative following a lobectomy and has a chest tube - is being discharged to a long-term facility -needs teaching about insulin self-administration -needs teaching prior to initiating cardiac rehabilitation activities

A client who is postoperative following a lobectomy and has a chest tube

A nurse is reviewing medical records of four older adult clients. The nurse should plan to administer the herpes zoster vaccine to which of the following clients?

A client who takes omeprazole for a peptic ulcer

While auscultating a client's breath sounds, the nurse hears turbulence between the S1 and S2 heart sounds. The nurse should document this finding as which of the following? -A systolic murmur -A third heart sound (S3) -An expected heart sound -A fourth heart sound (S4)

A systolic murmur

A nurse is presenting information to the public about preventative measures to reduce the risk for contracting the West Nile Virus. Which of the following instructions should the nurse include?

Encourage the use of mosquito repellent

Steps for tracheostomy care

Adjust suction Don sterile gloves Check the function of the catheter Hyper-oxygenate client Insert catheter without suction Apply suction while rotating catheter Assess for secretion clearance

A nurse is assessing a client with hypoxia. Which of the following findings should a nurse expect? -Bradypnea -Somnolence -Pallor -Tachycardia

Tachycardia

A nurse is caring for a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?

Airborne

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

Assess the apical pulse for one minute

A nurse is caring for a client who has pneumonia and prescription for oxygen therapy at 5L/min at nasal cannula. Which of the following actions should the nurse take? -Attach a humidifier at the base of the flow meter - Remove the nasal cannula while the client eats -Secure the oxygen tubing to bed sheets -Apply petroleum jelly to the client's nares as needed to soothe mucous membranes

Attach humidifier to the base of the flow meter

A nurse is caring for a client who is postoperative and has a prescription for anti-embolic stockings. Which of the following actions should the nurse take?

Check the stocking for wrinkles

A nurse is preparing to insert a peripheral IV catheter. Which of the following antiseptics is the nurse's best options for preparing the client's skin at the insertion site? -Alcohol -Chlorhexidine -Tincture of iodine -Povidone-iodine

Chlorhexidine

Steps to insert an IV catheter

Cleanse site with antiseptic Apply tourniquet or BP cuff Dilate the vein Insert catheter Flush catheter

A nurse is caring for a client who has a wound infection. Which of the following actions should a nurse take when obtaining a wound-drainage specimen for culture? -Cleanse the wound with NS irrigation before collecting -Irrigate the wound with antiseptic before collecting -Include intact skin at the wound edges in the culture - Swab an area of skin away from the wound to identify the usual flora

Cleanse the wound with NS (the nurse remove all wound exudate and any antimicrobial cream to avoid altering the culture results)

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as a result of the long-term inadequate oxygenation? -Restlessness -Retractions -Dependent edema -Clubbing of the fingers

Clubbing of the fingers

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client? -Pinnae of the ears -Dorsal surface of the hands -Conjunctivae -Dorsal surface of the foot

Conjunctivae

A nurse is admitting a client who has a wound infected with vancomycin resistant enterococci. Which of the following precautions should the nurse plan to initiate? -Droplet -Contact -Airborne -Protective

Contact

A nurse in the providers office is caring for a client who reports pruritus and reddened, oozing lesions on her lower leg. The nurse should suspect which of the following disorders? -Alopecia -Contact dermatitis -Pediculosis -Tinea pedis

Contact dermatitis

A nurse is caring for a client who requires removal of surgical sutures. Which of the following actions should the nurse take first? -Remove sutures by starting in the middle of the wound and working outward -Cut the suture as close to the skin as possible -Remove the sutures using clean bandage scissors -Apply clean gloves prior to the removal of the sutures

Cut the suture as close to the skin as possible

A nurse caring for a client with an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing?

Dispose of the dressing in a biohazard container

A nurse is assessing an IV infusion site on an infant's left hand. Which of the following findings should the nurse identify as an indication of an infiltration?

Edema in the palm of the hand

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

Elevate the head of the client's bed 30/45 degrees

A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of PPE should the nurse doff first?

Gloves

A nurse is caring for a client who has active pulmonary TB. The client requires airborne precautions and is receiving multi-drug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray? -Ask the xray technician to come to the client's room to obtain a portable x-ray -Have the client wear a mask -Notify the x-ray department that the client requires airborne precautions -Wear a filtration mask and gloves during transportation

Have the client wear a mask

A nurse is providing discharge teaching to a client with a new diagnosis of latex allergy. Which of the following statements indicates an understanding of the teaching? -"I will apply elastic bandages to cuts" -"I will use rubber gloves when washing the dishes" -"I will buy balloons for my son's birthday" -" I will use a pen with ink to write"

I will use ink pens for writing (pencil erasers have latex)

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? -Encourage the client to ambulate frequently -Encourage coughing and deep breathing -Encourage the client to increase fluid intake -Encourage the regular use of incentive spirometer

Increase fluid intake

A nurse has completed care procedures for a client who requires airborne precautions. Which of the following items of PPE should the nurse remove last?

Mask

A nurse is caring for a client who requires droplet precaution. Which of the following personal protective equipment should the nurse wear while setting up the client's meal tray?

Mask

A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following veins should the nurse select? -Dorsal Metacarpal Vein -Radial vein in the wrist -Antecubital vein -Median vein in the forearm

Median vein in the forearm

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the comfort of the client? -Obtain a pair of slipper-socks for the client -Rub the client's feet briskly for several minutes - Increase the client's oral fluid intake -Place a moist heating pad under the client's feet

Obtain a pair of slipper-socks

A nurse is preparing a sterile field. Which of the following actions should the nurse identify as contaminating the field?

Opening a sterile package over the middle of the sterile field (the nurse should approach the field from an angle)

A nurse is attending a social event when another guest coughs weakly once, grasps his throat with his hands, and cannot talk. Which of the following actions should the nurse take?

Perform the Heimlich maneuver

A nurse sees an AP entering the room of a client who requires transmission based precautions without using the appropriate PPE. Which of the following actions should the nurse take first? -Provide the appropriate PPE to the AP -Notify the charge nurse about the AP's need for training -Volunteer to provide an inservice about infection control -Speak with the AP when he exits the room about the appropriate protocol

Provide the appropriate PPE to the AP

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

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

A nurse is attempting to flush the IV saline lock for a client. The client reports pain above the catheter site. Which of the following actions should the nurse take? -Inject the solutions more slowly when trying to flush the saline lock -Apply warm compress to the site -Apply firm pressure to the plunger of the syringe during the IV flush to improve patency -Remove the IV saline lock

Remove the IV saline lock

A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, The client reports pain in the insertion site. Which of the following actions should the nurse take? -Remove the catheter and insert another into a new site -Administer an analgesic PO -Request a prescription for placement of a central venous access device -Administer a local anesthetic

Remove the catheter and insert another into a new site

A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take? -repeat auscultation after asking the client to take a deep breath and cough -instruct the client to limit fluid intake to 2000 mL/day -prepare to administer antibiotics -place the client on bed rest in semi-fowler's position

Repeat auscultation after asking client to breathe deeply and cough

A nurse is developing a plan of care for a client who has stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan? -Apply a heat lamp twice a day -Reposition the client at least every 2 hours -Clean the wound with a hydrogen peroxide solution -Massage reddened area with dressing changes

Reposition the client at least every 2 hours

A nurse is planning the discharge of a client who has sleep apnea and requires BiPAP at night. The nurse should plan to consult with which of the following health care team members to help educate the client?

Respiratory Therapist

A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? -Hypotension -Numbness _Shivering -Reduced blood viscosity

Shivering

A nurse is admitting a client with Hep C. Which of the following precautions should the nurse implement? -Droplet -Contact -Airborne -Standard

Standard

A nurse is teaching with a group of nurses about the administration of nitroglycerin. Which of the following routes of administration provides the most rapid onset for the client? - Transdermal patch - Sublingual - Suspended-release - Topical ointment

Sublingual

A nurse is reviewing the medical record for a client who has a HAI. The nurse should identify which of the following as a risk factor for acquiring an HAI? -The client had an appendectomy 6 months ago -The client has bipolar disorder -The client is a male -The client is 71 years old

The client is 71 years old

A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraints? -full capillary refill of 2 seconds or less -full ROM in her wrist -attempting to remove the restraints -hand is cool and pale

The client's hand is cool and pale

A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?

The left second intercostal space

A nurse manager is observing an AP applying wrist restrains on a client. Which of the following actions should the nurse identify as an indication the AP understands the procedure?

The padding of the restraints is against the client's bony prominences

A nurse in a community health clinic is caring for a client with a new diagnosis of plantar warts. The nurse should include which of the following in the teaching plan for this client?

They may be painful with ambulation

A nurse on a medical unit is teaching assistant personnel about handling clients' bed linens safely. Which of the following instructions should the nurse include?

Tie linen bags securely at the top

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

Turn the client on their side before starting oral care

A nurse is caring for client who has a single lumen central venous catheter. Which of the following actions should the nurse take when assessing the catheter? -Use a 10-mL syringe to flush the catheter -Flush the lumen with sterile water after each use -Use clean technique when accessing catheter -Apply firm pressure to the syringe plunger when flushing the lumen

Use a 10-mL syringe to flush the catheter

A nurse is planning care for an older client who is at risk of 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 client up in bed

A nurse is planning to perform a sterile dressing change for a client. Which of the following actions should the nurse plan to take?

Use sterile forceps to move the sterile items on the sterile field

A nurse is preparing a presentation about valerian to a group of clients. Which of the following information should the nurse include in the teaching?

Valerian is used to promote sleep

A nurse is performing chest physiotherapy on a client who has a respiratory infection. To increase the velocity of the air the client exhales, which of the following techniques should the nurse use? -Postural drainage -Percussion -Vibration -Nebulization

Vibration

A charge nurse is observing a nurse perform a Mantoux tuberculin skin test for a client. Which of the following actions should prompt the charge nurse to intervene?

Withdrawing the needle and massaging the site gently

A nurse is receiving change-of-shift report on a group of clients. Which of the following clients should the nurse assess first? -client who had a blood glucose reading of 70mg/dL after receiving 50% dextrose after a hypoglycemic episode -client admitted for chest pain and is reporting a new onset of indigestion -client with pneumonia and was treated for a temperature of 38.9 at 0400 -client who has pulled out peripheral IV catheter and is scheduled for a dose of famotidine at 0800

client admitted for chest pain and is reporting new onset of indigestion

A nurse is administering an IM injection to a client who has hep C. Before placing the syringe and needle into the sharps container, which of the following actions should the nurse take first? -Recap the needle -Place the cap on the bedside table and slide the needle into the cap -wrap the needle with gauze -dispose of the needle uncapped

dispose of the needle uncapped

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, Which of the following actions should the nurse take? -document what the nurse believes to be the cause of ulcer development. -include any relevant statements the client made about the ulcer -document in the client's medical record that she completed an incident report -question the charge nurse about care deficits that might have contributed to the ulcer's development

include any relevant statements the client made about the ulcer

A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate? -initiate low-residue diet -pantoprazole 80 mg IV bolus twice daily -ambulate twice daily -pancrelipase 500 units/kg PO three times daily with meals

pantoprazole (the nurse should anticipate a provider's prescription for a proton pump inhibitor to decrease gastric acid production, which ultimately decrease pancreatic secretions)

A nurse is caring for a client who is experiencing an infection at the insertion site of her IV catheter. Which of the following findings should the nurse expect? -the client reports numbness at the site -prurulent drainage is noted from the site -the vein appears cordlike -skin over the site is sloughing

prurulent drainage is noted from the site

As part of an annual physical examination, a nurse is preparing a client to undergo a chest x-ray. Which of the following instructions should the nurse give the client prior to the procedure? -remove all metal necklaces -take several shallow breaths during the procedure -do not eat or drink anything the morning of the test -expect minor discomfort after the procedure

remove all metal necklaces

A nurse is caring for a client who has contact dermatitis of the neck and upper chest. Which of the following are expected findings? -report of an exposure to a skin irritant -denial of pruritus -systemic symptoms such as elevated body temperature -report of generalized joint discomfort

report of an exposure to a skin irritant

A nurse is administering a nasal decongestant for a client. Which of the following actions should the nurse take? -tell a client to gently blow their nose before instillation -assist the client to a side-lying position -hold the dropper 2 cm (1 in) above the nares -instruct the client to stay in the same position for 2 min

tell the client to gently blow their nose before the instillation

A nurse is caring for a client who has MRSA in an abdominal wound. Which of the following actions should the nurse take? -Wear N95 respirator mask -Wear sterile gloves -wear clean gloves -wear protective eye wear

wear clean gloves