Dynamic Quizzes | BP Integration (ATI)

A nurse is caring for a client who has a tracheostomy and requires suctioning. Which of the following actions should the nurse take? A. Hyperoxygenate the client before suctioning B. Insert the catheter during exhalation C. Apply suction during insertion of the catheter D. Apply suction for no more than 15 sec

A. Hyperoxygenate the client before suctioning

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? A. Retention B. Oliguria C. Diuresis D. Dysuria

C. Diuresis

A nurse is preparing to remove an NG tube for a client who had a partial colectomy. Which of the following actions should the nurse take? A. Maintain suction while removing the NG tube B. Instill 100 mL of air into the NG tube before removal C. Pinch the NG tube while removing the tube D. Instruct the client to breathe in and out during the removal of the NG tube

C. Pinch the NG tube while removing the tube

A nurse is preparing to assist an older adult client with ambulation following bed rest for 3 days. Which of the following actions should the nurse take to decrease the risk of a fall? A. Use a gait belt during ambulation B. Ensure the client is wearing socks before ambulating C. Instruct the client to sit on the edge of the bed for 15 sec before ambulating D. Walk 2 ft behind the client during ambulation

A. Use a gait belt during ambulation

A nurse is inserting an NG tube into a client who begins to cough and gag. Which of the following actions should the nurse take? A. Remove the NG tube B. Advance the NG tube quickly C. Pull the NG tube back slightly D. Ask the client to tilt his head backward

C. Pull the NG tube back slightly

A nurse is measuring the blood pressure of several clients. Which of the following results is within the expected reference range for blood pressure? A. 142/85 mmHg B. 116/70 mmHg C. 130/76 mmHg D. 124/82 mmHg

B. 116/70 mmHg Any value <120 mmHg systolic and <80 mmHg diastolic

A nurse is monitoring a client's laboratory results. Which of the following results should the nurse report to the provider? A. Sodium 140 mEq/L B. Potassium 3.0 mEq/L C. Chloride 100 mEq/L D. Magnesium 2.0 mEq/L

B. Potassium 3.0 mEq/L

A nurse is performing a straight urinary catheterization for a female client who has urinary retention. Which of the following actions indicates the nurse is maintaining sterile technique? A. Applying sterile gloves to open catheter package B. Wiping the labia minora in an anteroposterior direction C. Spreading the labia with the dominant hand D. Using a cotton ball to wipe the right and left labia majora

B. Wiping the labia minora in an anteroposterior direction

A nurse is caring for a client who is receiving continuous enteral feedings through an NG tube and develops diarrhea. Which of the following actions should the nurse take? A. Change the tube feeding bag every 48 hours B. Chill the formula prior to administration C. Increase the infusion rate D. Request a prescription for an isotonic enteral nutrition formula

D. Request a prescription for an isotonic enteral nutrition formula

A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to ease the passage of the catheter through the urinary meatus? A. "Bear down." B. "Perform Kegel exercises." C. "Hold your breath." D. "Raise your head off of the pillow."

A. "Bear down."

A nurse is caring for a client who has peripheral edema. The nurse should identify that which of the following nutrients regulates extracellular fluid volume? A. Sodium B. Calcium C. Potassium D. Magnesium

A. Sodium

A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse perform first after discovering that the client's wound has eviscerated? A. Cover the incision with a moist sterile dressing B. Have the client lie on his back with his knees flexed C. Call the client's surgeon D. Reassure the client

A. Cover the incision with a moist sterile dressing

A nurse is caring for a client who is exhibiting confusion. The nurse should identify that which of the following laboratory values can cause confusion? A. Sodium 123 mEq/L B. Blood glucose 100 mg/dL C. Potassium 3.5 mEq/L D. Hemoglobin 13 g/dL

A. Sodium 123 mEq/L

A nurse is administering an IM injection to a 5-month-old infant. Which of the following injection sites should the nurse use? A. Deltoid B. Ventrogluteal C. Vastus lateralis D. Dorsogluteal

C. Vastus lateralis

A nurse is assessing a client who is experiencing stress following a near fall out of bed. Which of the following physiological responses should the nurse expect due to the fight-or-flight response? A. Decreased respiratory rate B. Pinpoint pupils C. Increased blood pressure D. Bronchiolar construction

C. Increased blood pressure

A nurse is assessing 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? A. Decreased urine specific gravity B. Increased heart rate C. Decreased hematocrit D. Increased skin turgor

B. Increased heart rate

A nurse is caring for a client who reports feeling a pop after coughing without properly splinting an abdominal incision. On assessment, the nurse notes that the client's wound has eviscerated. Which of the following actions should the nurse take? (Select all that apply.) A. Carefully reinsert the intestine through the opening in the wound B. Place the client in a supine position with the hips and knees flexed C. Leave the room to call the surgeon D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

B. Place the client in a supine position with the hips and knees flexed D. Cover the wound and intestine with a sterile, moistened dressing E. Monitor the client for manifestations of shock

A nurse is reviewing the laboratory data of a client who has a fever and watery diarrhea. Which of the following results should the nurse report to the provider? A. Calcium 9.5 mg/dL B. Sodium 150 mEq/L C. Potassium 4 mEq/L D. Magnesium 1.5 mEq/L

B. Sodium 150 mEq/L

A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? A. Fifth intercostal space just medial to the midclavicular line B. Second intercostal space to the left of the sternum C. Fifth intercostal space to the left of the sternum D. Second intercostal space to the right of the sternum

D. Second intercostal space to the right of the sternum

A nurse is admitting a client who has measles. Which of the following types of transmission precautions should the nurse initiate? Graded Response: A. Airborne B. Droplet C. Contact D. Protective environment

A. Airborne

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following pieces of information must the nurse verify with another nurse prior to the administration? A. The client's ID number B. The client's room number C. The client's name D. ABO compatibility E. Rh compatibility

A. The client's ID number C. The client's name D. ABO compatibility E. Rh compatibility

An assistive personnel (AP) is helping a nurse care for a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? A. The AP uses soap and water to clean the perineal area. B. The AP tapes the catheter to the client's inner thigh. C. The AP hangs the collection bag at the level of the bladder. D. The AP ensures there are no kinks in the drainage tubing

C. The AP hangs the collection bag at the level of the bladder.

A nurse is planning care for an adult client who has fluid volume excess. Which of the following interventions should the nurse plan to include to monitor the client's weight? A. Calibrate the scales weekly B. Use a different scale each time C. Weigh the client on arising D. Weigh the client without clothing

C. Weigh the client on arising

A nurse is assessing the pH of a client's gastric fluid to confirm the placement of an NG tube in the stomach. Which of the following pH values should the nurse expect? A. 6 B. 2 C. 10 D. 8

B. 2

A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client? A. Vastus lateralis B. Dorsogluteal C. Deltoid D. Ventrogluteal

D. Ventrogluteal

A nurse is caring for a client who has chronic kidney disease. The kidneys regulate body fluids as well as assisting with which of the following functions? A. Regulation of acid-base balance B. Reabsorption of nutrients for cellular growth C. Regulation of body temperature D. Secretion of hormones needed for growth

A. Regulation of acid-base balance

A nurse is explaining the use of written consent forms to a newly licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? A. A client who has a prescription for a transfusion of packed red blood cells B. A client who is being transported for a radiograph of the kidneys, ureters, and bladder C. A client who has a prescription for a tuberculin skin test D. A client who has a distended bladder and needs urinary catheterization

A. A client who has a prescription for a transfusion of packed red blood cells

A nurse is reviewing a client's laboratory report. The client's ABG levels are pH 7.5, PaCO2 32 mmHg, and HCO3- 24 mEq/L. The nurse should determine that the client has which of the following acidbase imbalances? A. Respiratory alkalosis B. Metabolic acidosis C. Respiratory acidosis D. Metabolic alkalosis

A. Respiratory alkalosis

A nurse is caring for a client who has a history of dysrhythmias. Upon entering the room, the nurse discovers the client is unresponsive to verbal or painful stimuli, has no respirations, and is pulseless. Which of the following actions should the nurse take first? A. Start chest compressions B. Provide breaths with a manual resuscitation bag C. Administer oxygen D. Establish an airway

A. Start chest compressions

A nurse on a medical-surgical unit is caring for a client who is at risk of experiencing seizures. Which of the following pieces of equipment must be available at the client's bedside at all times? A. Suction equipment B. Clean gloves C. Blankets D. Oxygen

A. Suction equipment

A nurse is caring for a client who is postoperative following a vaginal hysterectomy and asks for a drink. Her postoperative diet prescription states "clear liquids; advance diet as tolerated." Which of the following responses should the nurse make? A. "Lunch trays should be here within the hour." B. "I am going to listen to your abdomen." C. "I'll get you some water to drink." D. "Let's wait a bit so you don't feel sick."

B. "I am going to listen to your abdomen."

A nurse is caring for a client who is receiving intermittent enteral feedings through an NG tube. The specific gravity of the client's urine is 1.035. Which of the following actions should the nurse take? A. Deliver the formula at a slower rate B. Request a lower-fat formula C. Provide more water with feedings D. Instill a lactose-free formula

C. Provide more water with feedings

A nurse is preparing to administer a partial dose of a prefilled opioid analgesic parenterally to a client. Which of the following actions should the nurse plan to take? A. Return the unused portion of the medication to the pharmacy B. Dispose of the wasted medication into a sharps container C. Record the amount of medication wasted on the controlled substance inventory record D. Ask an assistive personnel (AP) to witness the wasting of the controlled substance

C. Record the amount of medication wasted on the controlled substance inventory record

A nurse is caring for a client who is hospitalized and has a new tracheostomy. Which of the following actions should the nurse take when performing tracheostomy care for the client? A. Perform tracheostomy care using medical asepsis B. Allow enough slack under the tracheostomy ties to insert three fingers C. Soak the inner cannula of the tracheostomy tube in normal saline D. Cut a sterile gauze pad to place between the neck and tracheostomy tube

C. Soak the inner cannula of the tracheostomy tube in normal saline

A nurse is caring for a client who is receiving IV fluid replacement. Which of the following findings should the nurse identify as infiltration of the IV infusion site? A. Redness at the IV catheter entry site B. Palpable cord along the vein used for the infusion C. Taut skin around the IV catheter site that is cool to the touch D. Bleeding at the IV insertion site

C. Taut skin around the IV catheter site that is cool to the touch

A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2°C (102.6°F), a heart rate of 105/min, a soft nontender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority? A. Heart rate of 105/min B. Soft nontender abdomen C. Temperature D. Overdue menses

C. Temperature

A nurse is caring for a client who is postoperative following vascular surgery on the left femoral artery. The nurse should identify that the surgical wound should be cleansed in which of the following directions? A. From the middle of the thigh toward the wound B. From the left lower abdominal quadrant toward the wound C. From the left hip toward the wound D. From the wound toward the surrounding skin

D. From the wound toward the surrounding skin

A nurse on an oncology unit receives report at the beginning of her shift about 4 clients who are postoperative. Which of the following clients should the nurse see first? A. A client who is 1 day postoperative following a lobectomy for small-cell carcinoma and has a chest tube with 35 mL/hr of bright red, bloody drainage B. A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage C. A client who is 2 days postoperative following the excision of an abdominal mass and has a portable wound suction device with 20 mL/hr of serosanguinous drainage D. A client who is 1 day postoperative following the excision of a bladder wall tumor and prostate and has continuous bladder irrigation with 300 mL/hr reddish-pink urine

B. A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage

A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Set the suction machine at 120 mmHg B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown E. Apply petroleum jelly to the client's nares

B. Provide oral hygiene frequently C. Measure the amount of drainage from the NG tube every shift D. Secure the NG tube to the client's gown

A nurse is assisting a client who is eating at mealtime. Suddenly, the client grabs her neck with both hands and appears frightened. Which of the following actions should the nurse take first? A. Place an oxygen mask on the client B. Check the client's pulse C. Determine whether the client is able to breathe D. Wrap arms around the client from behind

C. Determine whether the client is able to breathe

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give to the dietary assistant? A. Don a gown before entering the room and remove it before exiting. B. Wear a mask while in the client's room. C. Don gloves when entering the room and use hand sanitizer when exiting. D. Take no special precautions unless engaging in direct contact with the client.

C. Don gloves when entering the room and use hand sanitizer when exiting. (Contact precautions)

A nurse is caring for a client who requires a dressing change. Which of the following actions should the nurse take? A. Clean the incision from bottom to top B. Apply sterile gloves prior to opening dressing packages C. Remove the tape by pulling away from the wound D. Clean the drain site from the center outward

D. Clean the drain site from the center outward

A nurse is planning to collect a stool specimen for ova and parasites from a client who has diarrhea. Which of the following actions should the nurse take when collecting the specimen? A. Instruct the client to defecate into the toilet bowl B. Transfer the specimen to a sterile container C. Refrigerate the collected specimen D. Place the stool specimen collection container in a biohazard bag

D. Place the stool specimen collection container in a biohazard bag

A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? A. Evaluate pedal pulses B. Obtain a medical history C. Measure vital signs D. Assess for leg pain

A. Evaluate pedal pulses

A nurse is admitting a client who has tuberculosis. In addition to standard precautions, which of the following transmission-based precautions should the nurse add to the client's plan of care? A. Protective B. Airborne C. Droplet D. Contact

B. Airborne

A nurse is teaching a group of unit nurses about the experiences of clients who are having surgery. In which phase of care is the client transferred to the surgical suite table before being transferred to the PACU? A. Preoperative B. Postoperative C. Intraoperative D. Admission

C. Intraoperative

During the insertion of a urinary catheter for a client, the tip of the catheter brushes against the nurse's arm. Which of the following actions should the nurse take? A. Wipe the catheter with povidone-iodine and continue the catheter insertion. B. Soak the catheter in chlorhexidine for 15 min and then reattempt insertion. C. Continue with the catheter insertion. D. Obtain a new catheter and reattempt insertion.

D. Obtain a new catheter and reattempt insertion.

A nurse is caring for a client who has a stage II pressure ulcer. Which of the following wound dressings should the nurse apply to the ulcer? A. Hydrocolloid B. Collagen C. Calcium alginate D. Proteolytic enzyme

A. Hydrocolloid

A nurse is instructing a client about collecting a 24-hr urine specimen for creatinine clearance. Which of the following statements should the nurse identify as an indication that the client understands the procedure? A. "The next time I urinate will be the first specimen of the collection." B. "I'll make sure to keep the collection bottle in the container of ice they gave me." C. "Once the container is half full, I no longer have to add any more urine." D. "It's okay if a piece of toilet paper gets in the bottle. The lab people will remove it when they do the test "

B. "I'll make sure to keep the collection bottle in the container of ice they gave me."

A nurse is caring for a client with dehydration who has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for this client? A. BUN 18 mg/dL B. Capillary refill 1.5 sec C. Hct 55% D. Urine specific gravity 1.001

C. Hct 55% An elevated hematocrit indicates hypovolemia. Other indications of hypovolemia are a weak pulse, tachycardia, hypotension, tachypnea, slow capillary refill, elevated BUN, increased urine specific gravity, and decreased urine output

A nurse is administering a cleansing enema to a client who is scheduled for a diagnostic procedure. Which of the following actions should the nurse take? A. Lubricate up to 3.2 cm (1.25 in) of the tip of the rectal tube B. Position the client on the right side C. Insert the tip of the tubing 8 cm (3.1 in) D. Hold the enema container 61 cm (24 in) above the rectum

C. Insert the tip of the tubing 8 cm (3.1 in)

A nurse is applying antiembolitic stockings for a client who has a history of deep vein thrombosis. Which of the following actions should the nurse take when applying the stockings? A. Roll the stocking partially down if too long B. Remove the stocking once per day C. Bunch and pull the stocking halfway up the calf D. Turn the stocking inside out up to the heel before applying

D. Turn the stocking inside out up to the heel before applying

A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first? A. Provide oxygen B. Place the client in a side-lying position C. Provide privacy D. Lower the client to the floor

D. Lower the client to the floor

A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following locations should the nurse secure the urinary catheter tubing? A. Lateral thigh B. Lower abdomen C. Mid-abdominal region D. Medial thigh

B. Lower abdomen

A nurse is planning care for a group of clients receiving oxygen therapy. Which of the following clients should the nurse plan to see first? A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask B. A client who has emphysema and is receiving oxygen at 3L/min via transtracheal oxygen cannula C. A client who has an old tracheostomy and is receiving 40% humidified oxygen via tracheostomy collar D. A client who has COPD and is receiving oxygen at 2 L/min via nasal cannul

A. A client who has heart failure and is receiving 100% oxygen via partial rebreather mask

A nurse is caring for a postoperative client who has an indwelling urinary catheter for gravity drainage. The nurse notes no urine output in the past 2 hr. Which of the following actions should the nurse take first? A. Check to determine if the catheter tubing is kinked B. Palpate the bladder C. Obtain a prescription to irrigate the catheter with 0.9% sodium chloride D. Encourage the client to drink more fluids

A. Check to determine if the catheter tubing is kinked

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 lubricant B. Ask the client to swallow water while the tube enters her throat C. Place the coiled tube in ice chips prior to insertion D. Tell the client to tilt her head backward as insertion begins E. Instruct the client to bear down during insertion

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 newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to him. Which of the following actions should the nurse take? A. Consult the medication reference book available on the unit B. Ask a more experienced nurse for information about the medication C. Call the client's provider and verify the prescription D. Ask the client if she takes this medication at home

A. Consult the medication reference book available on the unit

A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? A. Daily weight B. Blood pressure C. Specific gravity D. Intake and output

A. Daily weight

A nurse is reviewing the laboratory values of a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? A. Decreased calcium B. Decreased potassium C. Increased potassium D. Increased calcium

A. Decreased calcium

A nurse is admitting a client who will undergo a craniotomy. During the planning phase of the nursing process, which of the following actions should the nurse take? A. Establish client outcomes. B. Collect information about past health problems. C. Determine whether the client has met specific goals. D. Identify the client's specific health problems.

A. Establish client outcomes.

A nurse is removing personal protective equipment (PPE) after performing a procedure for a client who requires isolation precautions. Which of the following items of PPE should the nurse remove first? A. Gloves B. Gown C. Eyewear D. Mask

A. Gloves

A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) items should the nurse don prior to providing client care? (Select all that apply.) A. Gown B. Gloves C. Mask D. Hair cover E. Goggles

A. Gown B. Gloves

A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain, and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? A. Hemolytic B. Febrile C. Circulatory overload D. Sepsis

A. Hemolytic

As a nurse is preparing to administer liquid medication from a bottle to a client. Which of the following actions should the nurse take? A. Hold the medication bottle with the label against the palm of the hand when pouring B. Place the cap with the inside facing down on a hard surface C. Fill the cup until the medication is even with the edge of the dosage scale D. Pour any excess liquid back into the bottle after measuring

A. Hold the medication bottle with the label against the palm of the hand when pouring

A nurse is performing suctioning for a client who has a tracheostomy. Which of the following actions should the nurse take? A. Pull suction catheter back 1 cm (0.5 in) if the client starts coughing B. Allow 30 sec between suctioning passes C. Hyperventilate the client with 50% oxygen for 30 sec D. Perform a maximum of 4 passes with the suction catheter

A. Pull suction catheter back 1 cm (0.5 in) if the client starts coughing

A nurse is providing teaching about proper care to a client who has a new colostomy. Which of the following pieces of information should the nurse include in the teaching? A. Change the colostomy bag following breakfast B. Cleanse the skin around the stoma with warm water C. Change the pouch every day D. Place an aspirin in the ostomy pouch to decrease odor

B. Cleanse the skin around the stoma with warm water

A nurse is collecting a specimen for culture from a client's infected wound. Which of the following actions should the nurse perform? A. Wear sterile gloves when collecting the specimen B. Cleanse the wound with 0.9% sodium chloride irrigation C. Allow the collection swab to absorb old exudate D. Rotate the collection swab over the edges of the wound

B. Cleanse the wound with 0.9% sodium chloride irrigation

A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following abdominal assessments should the nurse expect? A. Frequent bowel sounds with flatus B. Absent bowel sounds with distention C. Hyperactive bowel sounds with diarrhea D. Normal bowel sounds with increased peristalsis

B. Absent bowel sounds with distention

A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? A. Blow into the spirometer to elevate the balls in the device B. Cough deeply after each use C. Clean the mouthpiece with an alcohol swab after each use D. Use the spirometer every 8 hr

B. Cough deeply after each use

A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? A. Push on a fingernail bed until it blanches, release it, and observe how long it takes the skin to become pink B. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back C. Press the skin above the ankle for 5 seconds, release it, and note the depth of the impression D. Measure the skinfold thickness on the upper arm using a pair of calibrated skinfold calipers

B. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back

A nurse is caring for a client who has a temperature of 38.7°C(101.7°F). Which of the following actions should the nurse take? A. Apply an alcohol-water solution to the client's skin B. Keep the client's bed linens dry C. Apply ice packs to the groin D. Limit the client's fluid intake to 1183 mL (40 oz) of fluid per day

B. Keep the client's bed linens dry

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube and has a gastrostomy tube for enteral feedings. Which pieces of information are critical to communicate to the next nurse who will be caring for this client? (Select all that apply.) A. Room temperature B. New prescriptions C. Number of visitors D. Arterial blood gas results E. Tracheal secretion characteristics

B. New prescriptions D. Arterial blood gas results E. Tracheal secretion characteristics

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? A. Obtaining hydrogen peroxide for tracheostomy care B. Obtaining cotton balls for tracheostomy care C. Obtaining sterile gloves for tracheostomy care D. Obtaining a sterile brush for tracheostomy care

B. Obtaining cotton balls for tracheostomy care

A nurse is caring for a client who has a cuffed endotracheal tube in place. The nurse should identify that the purpose of inflating the cuff includes which of the following? (Select all that apply.) A. Allowing the client to speak B. Stabilizing the position of the tube C. Preventing aspiration of secretions D. Preventing air leaks E. Preventing tracheal injury

B. Stabilizing the position of the tube C. Preventing aspiration of secretions D. Preventing air leaks

A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take? A. Continue the teaching, but check afterward with the surgeon about informed consent. B. Stop the teaching and check with the surgeon about informed consent. C. Stop the teaching and ask the client to sign an informed consent form. D. Continue the teaching and check the client's medical record afterward for a signed consent form.

B. Stop the teaching and check with the surgeon about informed consent.

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? A. "I should rinse my mouth out right before I use the inhaler." B. "After the first puff, I will wait 10 seconds before taking the second puff." C. "I will shake the inhaler well right before I use it." D. "I will tilt my head forward while inhaling the medication."

C. "I will shake the inhaler well right before I use it."

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 teaching is required? A. "I should not leave all 4 side rails up unless there is a prescription for restraints." B. "An alert client will be safest if I raise the 2 upper side rails at the head of the bed." C. "If the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself." D. "If a client is sedated, I should raise all 4 side rails to prevent a fall out of bed."

C. "If the client seems confused, I'll raise all 4 side rails so that he doesn't hurt himself."

A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? A. "Drink a minimum of 1,000 mL of fluid daily." B. "Increase your intake of refined-fiber foods." C. "Sit on the toilet 30 min after eating a meal." D. "Take a laxative every day to maintain regularity

C. "Sit on the toilet 30 min after eating a meal."

A nurse is teaching a client who has urinary incontinence about bladder retraining. Which of the following instructions should the nurse include? A. "Wake up every 2 hr to urinate during the night." B. "Drink citrus juices throughout the day." C. "Try to block the urge to urinate until the next scheduled time." D. "Limit fluids to no more than 1 L (34 oz) during waking hours."

C. "Try to block the urge to urinate until the next scheduled time."

A nurse is assisting a client who has dysphagia at mealtimes. Which of the following actions should the nurse take? A. Assist the client into a semi-sitting position B. Have the client lean slightly backward C. Advise the client to tuck his chin downward D. Instruct the client to tilt his head slightly backward

C. Advise the client to tuck his chin downward

A nurse in a provider's office is teaching a client about foods that are high in fiber. Which of the following food choices made by the client indicate an understanding of the teaching? (Select all that apply.) A. Canned peaches B. White rice C. Black beans D. Whole-grain bread E. Tomato juice

C. Black beans D. Whole-grain bread

A nurse is caring for a client who is immobile. The nurse should recognize that immobility places the client at risk of which of the following health alterations? A. Increased intestinal motility B. Respiratory alkalosis C. Decreased cardiac output D. Hypocalcemia

C. Decreased cardiac output

A nurse is assessing a client who has a total calcium level of 12.7 mg/dL. Which of the following findings should the nurse expect? A. Muscle tremors B. Positive Chvostek's sign C. Depressed deep-tendon reflexes D. Numbness around the mouth

C. Depressed deep-tendon reflexes

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? A. Auscultate bowel sounds after each feeding B. Ensure the formula is cold before administering C. Elevate the head of the client's bed to 45° before the feeding D. Flush the tubing with 15 mL of water after the enteral feeding

C. Elevate the head of the client's bed to 45° before the feeding

A nurse is using the Braden scale to predict the pressure ulcer risk of a client in a longterm care facility. Using this scale, which of the following parameters should the nurse evaluate? A. Incontinence B. Mental state C. Nutrition D. General physical condition

C. Nutrition

A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take? A. Raise the enema bag if the client experiences cramping B. Lubricate 2.54 cm (1 in) of the tip of the rectal tube prior to insertion C. Place the client in a left Sims' position D. Don sterile gloves prior to the procedure

C. Place the client in a left Sims' position

A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month and may require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse share with the client? A. "Ask your provider to prescribe epoetin before the surgery." B. "You should ask your provider about taking iron supplements prior to the surgery." C. "Ask a family member to donate blood for you." D. "Donate autologous blood before the surgery

D. "Donate autologous blood before the surgery Autologous blood transfusion is the collection and reinfusion of the client's blood. With preoperative autologous blood donation, the blood is drawn from the client 3 to 5 weeks before the surgery.

A nurse is teaching a client who is using a patient-controlled analgesia (PCA) pump to deliver morphine for pain management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I'll limit pushing the button so I don't get an overdose." B. "If I push the button and still have pain after 2 minutes, I'll push it again." C. "I'll ask my niece to push the button when I am sleeping." D. "I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button."

D. "I can still use my transcutaneous electrical nerve stimulation unit while I'm pushing the PCA button."

A charge nurse is providing teaching to a newly licensed nurse about removing sutures from a client's laceration. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? A. "I will use a staple remover and remove each suture individually." B. "Bandage scissors are used to cut the sutures." C. "Tweezers are necessary only for removing retention sutures." D. "I will clip each suture close to the skin and pull it through from the other side."

D. "I will clip each suture close to the skin and pull it through from the other side."

A nurse in an urgent-care center is caring for a 15-year-old client whose symptoms suggest a sexually transmitted infection (STI). The client's parent is unavailable, but the client's grandmother accompanied the client to the clinic. Which of the following actions should the nurse take? A. Explain that the treatment can wait until the parent is available. B. Inform the grandmother that she may give consent for the treatment. C. Invoke the principle of implied consent and prepare the client for treatment. D. Ask the adolescent to sign the consent form.

D. Ask the adolescent to sign the consent form.

A nurse is taking a client's vital signs. Which of the following findings should the nurse identify as outside the expected reference range? A. Pulse rate 90/min B. Rectal temperature 38°C (100.4°F) C. Pulse oximetry 95% D. BP 145/90 mmHg

D. BP 145/90 mmHg

A nurse is preparing to insert an indwelling urinary catheter for a female client. Which of the following actions should the nurse have the client perform just before inserting the catheter? A. Swallow water B. Prepare for a painful sensation C. Hold her breath D. Bear down gently

D. Bear down gently

A nurse is caring for a client who has major fecal incontinence and reports irritation in the perianal area. Which of the following actions should the nurse take first? A. Apply a fecal collection system B. Apply a barrier cream C. Cleanse and dry the area D. Check the client's perineum

D. Check the client's perineum

A nurse is providing teaching to a group of unit nurses about wound healing by secondary intention. Which of the following pieces of information should the nurse include in the teaching? A. The wound edges are well-approximated. B. The wound is closed at a later date. C. A skin graft is placed over the wound bed. D. Granulation tissue fills the wound during healing.

D. Granulation tissue fills the wound during healing.

A nurse is witnessing a client sign an informed consent form for surgery. What is the nurse affirming by this action? A. The client fully understands the provider's explanation of the procedure. B. The client has been informed about the risks and benefits of the procedure. C. The nurse witnessed the provider's explanation of the procedure. D. The signature on the preoperative consent form is the client's.

D. The signature on the preoperative consent form is the client's.

A nurse in an acute care facility is planning care for a client who is alert but temporarily immobile due to a total hip arthroplasty. Which of the following interventions should the nurse plan to take to prevent a complication of immobility? A. Move the client from supine to a low Fowler's position every 2-3 hr to help prevent orthostatic hypotension B. Limit fluid intake to 1 L (33.8 oz) in 24 hr to help prevent dependent edema C. Encourage the client to turn from side to side every 3-4 hr to help prevent respiratory complications D. Instruct the client to perform foot and leg exercises every 1-2 hr while awake to help prevent thrombophlebitis

D. Instruct the client to perform foot and leg exercises every 1-2 hr while awake to help prevent thrombophlebitis

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse perform first? A. Open all sterile supplies and solutions. B. Stabilize the tracheostomy tube. C. Put on sterile gloves. D. Perform hand hygiene.

D. Perform hand hygiene.

A nurse is leading an education session about disposing of biohazardous materials. Which of the following instructions should the nurse include in the teaching? A. Use isopropyl alcohol to clean blood spills. B. Discard empty blood bags in a bedside trash can. C. Break used needles before discarding. D. Place soiled linen in a single linen bag.

D. Place soiled linen in a single linen bag.

A nurse delegates the collection of a client's temperature to an assistive personnel (AP). The nurse notes in the documentation that the AP obtained the client's axillary temperature; however, the nurse wanted an oral temperature. The nurse should identify that which of the following rights of delegation should have prevented this situation from occurring? A. Right task B. Right circumstance C. Right person D. Right communication

D. Right communication