Dinamic Quizzes
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A nurse is discussing fire safety with newly hired nurses. Which of the following actions is the priority if a fire occurs in the healthcare facility?
Evacuate clients from the unit
A nurse is preparing to insert an NG tube for a client who has a bowel obstruction. Which of the following actions should the nurse take first?
Explain the procedure to the client
A nurse is administering 3 liquid medications through a client's nasogastric tube. Which of the following actions should the nurse take?
Flush the tube with water before and after instilling each medication
A nurse is collecting data from a client who is having difficulty breathing. The nurse should assist the client into which of the following positions?
Fowler's
A nurse is collecting data from a client who requires hygiene care. Which of the following pieces of information is the nurse's priority to determine before preparing to bathe the client?
How much the client can assist with bathing
A nurse is caring for a client who has a stage Il pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer?
Hydrocolloid
A nurse is monitoring a client's laboratory results. Which of the following results should the nurse report to the provider?
Potassium 3.0 mEq/L
A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection insulin methods. Which of the following statements should the nurse provide?
"Tell me what I can do to help you overcome your fear of giving yourself injections."
A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use?
Place the wheelchair at a 45° angle to the bed.
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention?
Obtaining cotton balls for the tracheostomy care
A nurse is assisting with preparing a client for discharge and providing instructions about performing dressing changes at home. Which of the following statements indicates that the client understands medical asepsis?
"I'll wash my hands before I remove the old dressing and again before putting on the new one."
A nurse is reinforcing teaching with a client who is postoperative about the importance of turning, coughing, and breathing deeply. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
"If I do this often, I won't get pneumonia."
A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP indicates that further instruction is required?
"If the client seems confused, I'll raise all 4 side rails to prevent C. injury."
A nurse is collecting data from a client. Which of the following statements by the nurse reflects the communication technique of clarifying?
"It sounds like your pain is intermittent."
A nurse is preparing to administer ondansetron 4 mg IM to a client who has postoperative nausea. Ondansetron injection 2 mg/mL is available. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if applicable but do not use a trailing zero.)
2
A client has 1 L of dextrose 5% in 0.45% sodium chloride infusing IV at 125 mL/hr. How many hours will it take for the liter to infuse? (Fill in the blank with the numeric value only. Round to the nearest whole number. Use a leading zero if applicable but do not use a trailing zero.)
8
A nurse is preparing to insert an NG tube for a client. Which of the following actions will help facilitate the insertion of the tube? (Select all that apply.) A. Coat the tip of the tube with a water-soluble
A. Coat the tip of the tube with a water-soluble lubricant B. Ask the client to swallow water while the tube enters her throat D. Tell the client to tilt her head backward as insertion begins
A nurse is preparing to administer timolol eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take?
Apply pressure to the bridge of the nose after instillation of the medication.
A nurse is collecting data from a client whose potassium level is 2.8 mE/L. Which of the following findings should the nurse expect?
A. Decreased bowel sounds
nurse is caring for a client who is unconscious. Which of the following actions should the nurse take when providing oral care for the client?
A. Test for the presence of the client's gag reflex
A nurse is contributing to the plan of care for a client who has a wound infection following abdominal surgery. To promote healing and fight infection, which of the following vitamins and/or minerals should the nurse plan to increase in the client's diet?
A. Vitamin C and zinc
A nurse on a medical unit is caring for a client who has difficulty sleeping. Which of the following actions should the nurse take to promote the client's ability to fall asleep?
Allow the client to maintain the same bedtime routine as at home
A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription reads as follows: "clear liquids; advance diet as tolerated." Which of the following responses should the nurse make?
B. "I am going to listen to your abdomen."
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed with a nasal cannula delivering oxygen. Which of the following interventions is the nurse's priority?
B. Assist the client to an upright position
A nurse is preparing to administer an intramuscular injection to a client who is overweight. Which of the following sites should the nurse select for the injection?
B. The side hip between the iliac crest and anterior iliac spine
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse have the client perform just before inserting the catheter?
Bear down gently
A nurse is assisting with the care of a client who requires ventilatory assistance with breathing following a motor vehicle crash. The nurse should suspect that the client has an injury to which of the following parts of the brain?
Brainstem
A nurse in an oncology clinic is collecting data for a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?
C. "I keep having nightmares about my upcoming surgery."
A nurse is teaching a client who has asthma about the proper use of an albuterol inhaler. Which of the following client statements indicates an understanding of the teaching?
C. "I will shake the inhaler well right before I use it."
A nurse is reinforcing teaching with an older adult client who has constipation. Which of the following statements should the nurse include in the teaching?
C. "Sit on the toilet 30 minutes after eating a meal."
A nurse is collecting data about a client's pulses of the lower extremities. The nurse should identify which of the following as the location of the most distal pulse?
C. Dorsalis pedis
A nurse is collecting baseline data about a client's chest as part of a physical examination. Which of the following actions should the nurse take first?
C. Inspect the thorax
nurse is reinforcing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks both the client's native language and the nurse's, arrives to drive the client home. Which of the following actions should the nurse take?
C. Obtain the services of an interpreter
A nurse documents clubbing of the fingernails for a client who has emphysema. The nurse should identify that which of the following is the underlying cause of this finding?
Chronic hypoxemia
A nurse is preparing to administer a tuberculin skin test to a client. After performing hand hygiene, which of the following actions should the nurse take?
Circle the area of the injection with a pen
A nurse is collecting data from a client who has fluid-volume excess. Which of the following findings should the nurse expect?
Crackles in the lung fields.
A nurse is performing a mental-status examination for a client who has manifestations of dementia. Which of the following directions should the nurse give the client when evaluating the client's ability to think abstractly?
Discuss the meaning of a common proverb
A nurse is reinforcing teaching for a client who has a new prescription for home oxygen therapy. Which of the following instructions should the nurse include?
Do not use any materials containing oil or alcohol when using oxygen.
A nurse is collecting data from a client who reports nausea and vomiting for 2 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?
Increased heart rate
A nurse in a provider's office is caring for a client who has blepharitis. Which of the following actions should the nurse take first?
Inspect the eyes for drainage or redness
A nurse in an acute-care facility is assisting with planning care for a client who is alert but is temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse suggest to prevent a complication of immobility?
Instruct the client to perform foot and leg exercises every 1 to 2 hours while awake to help prevent thrombophlebitis
A nurse is cleaning a client's wound by swabbing from the area of least contamination to an area of greater contamination. Which of the following rationales should the nurse identify for using this technique?
Keeping microorganisms from entering the wound
A nurse is assisting with the planning of an in-service training session about various dietary practices. Which of the following pieces of information should the nurse recommend including in the teaching?
Kosher diets involve restrictions regarding how food must be prepared
A nurse is planning to reinforce teaching for a client who is learning to self-inject a medication subcutaneously. The nurse does not speak the client's language, so arrangements are made for a medical interpreter from the facility to assist. Which of the following actions should the nurse take when working with the interpreter and the client?
Make sure the client and the interpreter are culturally compatible
A nurse is preparing to administer a bolus feeding to a client through an NG tube and observes that the exit mark on the tube has moved since the last feeding. Which of the following actions should the nurse plan to take?
Request an X-ray of the client's abdomen
A nurse is collecting baseline data about a client's respirations as part of a comprehensive physical examination. Which of the following types of breath sounds should the nurse report to the provider?
Rhonchi
A nurse is caring for a client who is dehydrated. An insensible fluid loss of approximately 500 to 600 mL occurs each day through which of the following organ?
Skin
A nurse is collecting data during a neurological examination of a client. When asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing?
The nurse checks the functioning of cranial nerve XII (hypoglossal), which innervates the tongue, by observing a range of tongue movements.
A nurse is witnessing a client signing an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action?
The signature on the preoperative consent form is the client's
A nurse finds a client sitting on the floor by the toilet in the bathroom adjacent to his room. He states that he is fine after slipping on the tile floor but is having difficulty getting up. Which of the following actions should the nurse?
data from the client about any health alterations before, during, or after the fall
A nurse is caring for a client who is producing large amounts of urine. The nurse should document this finding as which of the following?
diuresis
A nurse is caring for a group of clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?
oral care to a client who cannot take oral fluids
A nurse is collecting data from a client who is postoperative following abdominal surgery. Which of the following findings is the nurse's priority to report to the surgeon immediately?
C. Warm, tender area on the right calf
A nurse is contributing to the plan of care for a client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight?
C. Weigh the client on arising in the morning
A nurse is measuring a client's vital signs. The clients resting radial pulse rate is 55/min. Which of the following actions should the nurse take next?
Measure the client's apical pulse rate
A nurse is caring for a client who has an NG tube for intermittent enteral feedings. Which of the following actions should the nurse take?
Elevate the clients head of the bed 45 degrees before the feeding
A nurse is providing palliative care for a client who is at the end of life. The client is having difficulty breathing and has audible respiratory gurgling. Which of the following actions should the nurse take?
Elevate the head of the client's bed
A nurse is caring for a client who has injuries from a motor-vehicle crash. Which of the following client statements should the nurse address first?
I can't sleep well because whenever I move in my sleep, the pain wakes me up."
A nurse is conducting a health promotion class for a group of college students. Which of the following statements by a student indicates a potential problem with achieving Erikson's developmental task for this age group?
go home on the weekends to be with my family because I don't have any good friends here on campus."